Health Systems Performance Assessment and Sustainable Improvement in Bahrain, Kuwait and Qatar

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

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.

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.

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.

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.

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.

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.

Contents

Declaration of originality ...... 2

Acknowledgements ...... 3

Abstract...... 4

Contents ...... 7

List of Tables ...... 11

List of Figures ...... 14

List of Abbreviations ...... 16

Chapter 1: Introduction to the thesis ...... 19

Introduction ...... 19

Overview of the importance of addressing HSPA in the GCC...... 19

Research of HSPA ...... 19

Applications of HSPA ...... 20

Synthesis of the evidence ...... 20

Aim and Objectives ...... 20

Chapter 2 Background ...... 25

Background ...... 25

Health Systems Globally ...... 25

Defining Health systems ...... 26

Health Systems and Health Determinants ...... 28

Healthcare accessibility and barriers ...... 29

Health System Performance Assessment ...... 30

International frameworks for HSPA ...... 31

The World Health Organisation ...... 31

The Organisation for Economic Co-operation and Development (OECD) ...... 33

European Observatory on Health Systems and Policies ...... 33

Health Consumer Powerhouse ...... 34

The UK NHS Performance Assessment Framework ...... 34

The Commonwealth Fund ...... 34

Institute of Health Metric and Evaluation, University of Washington (IHME) ...... 35

The GCC Context in Health System Performance Assessment ...... 36

Individual Country Profile of the three study countries ...... 37

1. The Kingdom of Bahrain ...... 38

2. The State of Kuwait...... 49

3. The State of Qatar ...... 61

Chapter 3 Aim, Objectives and Methods ...... 73

Aim: ...... 73

Objectives ...... 73

Hypothesis ...... 74

Research Questions ...... 75

Research design ...... 75

Quantitative Methods ...... 76

Qualitative Methods ...... 79

Statistical Methods ...... 81

Synthesizing the evidence and Data Limitations ...... 82

Reporting ...... 82

Chapter 4 Literature and Systematic Review ...... 85

Literature review ...... 85

Quality Assessment ...... 90

Results ...... 90

Quality Assessment ...... 93

Chapter 5 The Health Status of the GCC Population with a focus on Bahrain, Kuwait and Qatar...... 96

Introduction ...... 96

The Gulf Corporation Council (GCC) Countries ...... 97

The GCC Population (Nationals and non-nationals) ...... 97

GCC Population’s Health Profile ...... 99

Healthy Life Expectancy ...... 101

Disability-Adjusted Life Years ...... 101

Leading Causes of Deaths ...... 102

Risks to Health ...... 104

The health systems ...... 105

Chapter Discussion ...... 108

Chapter 6 Health System Building Blocks: Finance and Human Resources for Health ...... 112

Introduction ...... 112

Health System Performance: Health Finance ...... 113

Health System Performance: Human Resources for Health ...... 119

Chapter Discussion ...... 123

Chapter 7 Quantitative assessment Health Access and Quality Index (HAQ Index) ...... 129

Introduction ...... 129

Results ...... 131

HAQ Index and total health spending per capita ...... 133

Chapter Discussion ...... 136

Chapter 8: The views of health leaders and senior managers on health system performance assessment and its application ...... 139

Introduction ...... 139

Face-to-Face interview ...... 141

Findings ...... 142

Chapter Discussion ...... 162

Limitations of the study (Survey and 1-1 Interviews) ...... 166

Chapter 9 General Discussion and Recommendations ...... 168

Discussion ...... 168

Health Status ...... 169

Financial Protection ...... 170

Workforce (Human Resources for Health)...... 171

Health Access and Quality of Service...... 173

Limitations ...... 174

Added Value of this Study ...... 175

In Conclusion ...... 175

Recommendations ...... 176

Recommendation 1: HSPA ...... 176

Recommendation 2: Health Finance ...... 177

Recommendation 3: Human Resources for Health ...... 177

Recommendation 4: Health System and service Research ...... 178

Recommendation 5: Governance ...... 178

References: ...... 179

Appendix 1 ...... 192

Appendix 2 ...... 207

Appendix 3 ...... 210

List of Tables

TABLE 1: POPULATION DEMOGRAPHICS, BAHRAIN 2014 ...... 40

TABLE 2: BAHRAIN POPULATION HEALTH (NATIONALS ONLY), FROM 2004 TO 2014...... 42

TABLE 3: HEALTH INSTITUTIONS IN BAHRAIN: NUMBER OF VISITS AND BEDS, 2014

STATISTICS...... 46

TABLE 4: HEALTH WORKFORCE IN BAHRAIN 2008-2014. [53] ...... 48

TABLE 5: HEALTHCARE EXPENDITURE IN BAHRAIN 2014 ...... 49

TABLE 6: POPULATION DEMOGRAPHICS IN KUWAIT, 2014 ...... 51

TABLE 7: POPULATION HEALTH INDICATORS IN KUWAIT (NATIONALS ONLY) FROM 2004-2014

...... 54

TABLE 8: HEALTH SERVICE DELIVERY IN KUWAIT ...... 59

TABLE 9: NUMBER OF HEALTH PROFESSIONALS IN KUWAIT BETWEEN 2007 AND 2011...... 60

TABLE 10: HEALTHCARE EXPENDITURE IN KUWAIT, 2014 ...... 61

TABLE 11: POPULATION DEMOGRAPHICS IN QATAR 2014 ...... 63

TABLE 12: POPULATION HEALTH INDICTORS IN QATAR 2004 - 2014 ...... 66

TABLE 13: HEALTH INFRASTRUCTURE AND PLANS FOR DEVELOPMENT (QATAR) (2012-2019)

...... 69

TABLE 14: HEALTH WORKFORCE (QATAR) FROM 2006 TO 2014 (RATES PER 1,000) ...... 70

TABLE 15: HEALTHCARE EXPENDITURE (QATAR) 2014 ...... 71

TABLE 16: CHARACTERISTICS OF THE INCLUDED STUDIES ...... 92

TABLE 17: MEAN QUALITY SCORE OF THE THREE REVIEWERS ON CASP CHECKLIST ...... 93

TABLE 18: THE GCC TOTAL POPULATION DISTRIBUTED BY COUNTRIES ...... 98

TABLE 19: HEALTHY LIFE EXPECTANCY AT BIRTH (HALE) ...... 101

TABLE 20: DISABILITY-ADJUSTED LIFE YEARS (DALYS) PER 100, 00 FOR BOTH SEXES ...... 102

TABLE 21: THE HEALTH FINANCE OF THE GCC COUNTRIES ...... 106

TABLE 22: HEALTH SPENDING IN BAHRAIN, KUWAIT AND QATAR...... 115

TABLE 23: GCC HEALTH SPENDING COMPARED WITH NEIGHBOURING COUNTRIES IN 2014

AND PROJECTED TO 2040. SOURCE: IHME, WHO, WORLD BANK...... 117

TABLE 24: NUMBER OF ALL TYPES OF PHYSICIAN PER 1,000 POPULATIONS 2014 AND EXPAT

PHYSICIANS AND NURSES IN GCC AS A PERCENTAGE OF THE TOTAL WORKFORCE . 120

TABLE 25: THE STATUS OF FAMILY MEDICINE SPECIALTY IN THE GCC ...... 122

TABLE 26: REGIONAL (EMRO) AND STUDY COUNTRIES (BAHRAIN, KUWAIT QATAR)

ESTIMATES OF THE HAQ INDEX FROM 1990 TO 2015 ...... 135

TABLE 27: PROFILE OF RESPONDING PARTICIPANTS FROM BAHRAIN, KUWAIT AND QATAR.

...... 143

TABLE 28: KNOWLEDGE OF HEALTH SYSTEM PERFORMANCE ASSESSMENT IN THE THREE

GCC ...... 144

TABLE 29: AVAILABILITY, USE AND APPLICATIONS OF HEALTH SYSTEM AND HEALTH DATA

...... 148

TABLE 30: BETWEEN-COUNTRY ORDINAL HETEROGENEITY TESTS OF ORDINAL ANSWERS

TO QUESTIONS ...... 152

TABLE 31: SUMMARY (1) OF THE KEY FINDINGS FACE-TO-FACE INTERVIEW ...... 156

TABLE 31: SUMMARY OF THE KEY FINDINGS FACE-TO-FACE INTERVIEW (CONTINUATION)

...... 157

List of Figures

FIGURE 1: WHO HEALTH SYSTEM FRAMEWORK...... 27

FIGURE 2: DETERMINANTS OF HEALTH AND WELL-BEING ...... 29

FIGURE 3: BAHRAIN, POPULATION PYRAMID FOR THE LAST POPULATION ESTIMATES, 2014

...... 41

FIGURE 4: THE TEN TOP CAUSES OF DEATHS BETWEEN 2005 AND 2016...... 43

FIGURE 5: ORGANISATIONAL CHART OF THE MINISTRY OF HEALTH IN BAHRAIN...... 44

FIGURE 6: AGE GROUPS IN KUWAIT 2014...... 52

FIGURE 7: THE TEN TOP CAUSES OF DEATHS BETWEEN 2005 AND 2016 IN KUWAIT...... 55

FIGURE 8: ORGANISATIONAL CHART OF THE MINISTRY OF HEALTH IN KUWAIT ...... 57

FIGURE 9: THE STRUCTURE OF THE QATARI POPULATION, 2014 ...... 64

FIGURE 10: THE TEN TOP CAUSES OF DEATHS BETWEEN 2005 AND 2016 IN QATAR...... 67

FIGURE 11: MINISTRY OF HEALTH STRUCTURE 2016 ...... 68

FIGURE 12: A SUMMARY OF THE RESEARCH DESIGN AND THE METHODS...... 76

FIGURE 13: EXAMPLE OF SEARCH STRATEGY ...... 89

FIGURE 14: PRISMA CHART FOR THE SYSTEMATIC SEARCH OF THE LITERATURE ...... 90

FIGURE 15: LIFE EXPECTANCY AT BIRTH IN GCC COUNTRIES (POPULATION OVER 410

MILLION) COMPARED WITH THE UK FOR THE PERIOD 1960 TO 2016...... 100

FIGURE 16: GOVERNMENTAL AND OUT-OF-POCKET HEALTH EXPENDITURE (2014)...... 106

FIGURE 17: GOVERNMENT HEALTH EXPENDITURE AS A PERCENTAGE OF THE TOTAL

HEALTH EXPENDITURE IN GCC ...... 118

FIGURE 18: PHYSICIANS (ALL TYPES) PER 1000 POPULATION 2013 IN THE GCC (AVERAGE)

COMPARED WITH EUROPEAN REGION OF WHO (MOST COUNTRIES OF SIMILAR WEALTH)

AND THE WHO PAN AMERICAN (WITH SOME COUNTRIES OF SIMILAR WEALTH). (2014)

...... 121

FIGURE 19: PERFORMANCE OF THE HAQ INDEX AND 25 INDIVIDUAL CAUSES IN 2015...... 131

FIGURE 20: PERFORMANCE OF THE HAQ INDEX (25 INDIVIDUAL CAUSES) BETWEEN 1990 AND

2015 (ROUNDED VALUES)...... 132

FIGURE 21: COMPARING THE HAQ INDEX TO THE LOG OF TOTAL HEALTH SPENDING PER

CAPITA IN GCC...... 133

FIGURE 22: PERFORMANCE OF THE HAQ INDEX (TOTAL OF 25 INDIVIDUAL CAUSES) FOR 1990

AND 2015 VALUE, IN BAHRAIN, KUWAIT AND QATAR...... 134

List of Abbreviations

BDF Bahrain Defence Force Hospital CAGR Compound Annual Growth Rate CASP Critical Appraisal Skills Programme CHI Commission for Health Improvement CQC Care Quality Commission DALY Disability Adjusted Life Years GCC Gulf Co-operation Council GDP Gross Domestic Product HALE Healthy Adjusted Life Expectancy HAQ Index Health Access and Quality Index HC Health Center HDR Human Development Rank HIV Human Immunodeficiency Virus HMC Hamad Medical Corporation HRH Human Resources for Health HS Health System HSPA Health System Performance Assessment Institute of Health Metric and Evaluation, University of IHME Washington ILO International Labour Organisation IT Information Technology LEB Life Expectancy at Birth MENA Middle East and North Africa MOH Ministry of Health MoPH Ministry of public Health NCDs Non-Communicable Diseases NHA National Health Authority NHS National Health Strategy OECD Organisation for Economic Co-operation and Development OOP Out-Of-Pocket PA Performance Assessment PCC Primary Care Corporation PHCC The Primary HealthCare Corporation PPC Public-Private Partnerships or Collaboration PPP Public and Private Partnerships QALY Quality-Adjusted Life Year QCHP Qatar Council for Healthcare Practitioners SCH Supreme Council of Health

SDGs Sustainable Development Goals SMC Salmanyia Medical Complex THE Total Health Expenditure UHC Universal Health Coverage UAE United Arab Emirates UK United Kingdom UN United Nations US$ United States dollar WB World Bank WHO World Health Organisation WHO EMRO WHO Eastern Mediterranean Regional Office YLD Years Lost due to Disability YLL Years of Life Lost

Chapter 1 Introduction to the thesis

Chapter 1: Introduction to the thesis

Introduction

The current thesis starts by presenting an overview of the health system performance assessment (HSPA) and the issues surrounding the topic of my research. My research project was broadly aimed at enhancing our understanding of health systems and their performances in the GCC countries, with particular emphasis on the study of three countries; Bahrain, Kuwait and Qatar. The GCC countries are unique in the world in their rapid economic and social development, and population growth and structure[1]. This work is designed to provide better insights for politicians, policymakers and health professionals in achieving sustainable improvement in population health in the GCC.

Overview of the importance of addressing HSPA in the GCC

Firstly, research on how health systems are performing in serving its population is essential for funders (mainly government) to ensure sustainability especially at a time when all health systems worldwide are under a great deal of pressure due to population growth, ageing and technological advances. It is also important for practitioners and policymakers to evaluate their health system to assess if it is meeting population health needs and securing good health for the entire population, irrespective of their backgrounds. This is vital for GCC countries with unplanned population growth, mainly through migration, and rapid unplanned expansion of health services purely to meet demands.

Research of HSPA

Since the 1990s and following the WHO initiative and its World Health Report [2] comparing all member states health system performance, some key research was undertaken to develop the best approach for assessing health system performance exclusively in high-income countries. The absence of such research in low and middle-income countries may be a

reflection of the complexity of health systems and the costs of researching and developing an assessment framework [3].

Applications of HSPA

The frameworks for HSPA were created mainly by international organisations and the UK.

These are designed for countries with good reliable baseline data on inputs, process and outputs of health systems. Limitations in the sources and type of data in low and middle- income countries, including the GCC are a major obstacle to conduct reliable and timely assessments of their health systems [4].

The 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.

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

[5],[6].

Synthesis of the evidence

A major limitation in data sources in the GCC is related to the health status, utilization and outcome of interventions of the migrant population who constitute around 50% of the 51 million population of the six countries [6],[7]. They do not have the right to settle and are described legally as ‘contract’ workers: the majority of whom are unskilled on short-term contracts [8].

Aim and Objectives

The main aim of the study is to enhance our understanding of the health systems and their performances in the GCC countries of Bahrain, Kuwait and Qatar.

This purpose, in addition to the respective research questions, (Chapter 3) shall be addressed by:

I. An extensive review of the relevant literature including a systematic review,

II. A review of each of the three study health systems (Bahrain, Kuwait and Qatar) and

comparison with the rest of the GCC countries,

III. Surveys and face-to-face interviews with policy and decision makers; including senior

managers at all levels of the three health systems of Bahrain, Kuwait and Qatar.

IV. Introducing comparative health system assessments using a new index: Healthcare

access and Quality Index (HAQ Index). This PhD thesis was undertaken to address

the aim and research questions according to the chapters listed below:

Chapter 2 Background

This chapter is designed to

1. Explore the current frameworks of health system performance assessment around the world.

This was achieved through an extensive review of the literature and seeking expert opinion

from colleagues at WHO Geneva.

2. Analyse each of the relevant frameworks.

3. Research the availability and use of any frameworks in the GCC and other countries in the

region of Eastern Mediterranean Region of the WHO.

4. Introduce the overall picture of the GCC and each individual country in term of population

dynamics, the burden of disease, workforce, finance in general and the structure, function and

governance of the health system,

Chapter 3 Aim and Objectives and Methods

Based on the aim and objectives, including the research questions,

5. The methods needed for this research have been identified, which include both quantitative

and qualitative methods. The systematic review and additional review of the literature on the

GCC helped to refine the methods used in the study.

Results:

Chapter 4 Systematic Review: Health system performance assessment in the GCC

6. A systematic review was conducted using all available search engines through a well-defined

search protocol.

7. Additional targeted search was performed through “snowballing,” based on the bibliographies

of the retrieved articles. The findings in this chapter were used to shape and refine the methods

used in this study.

Chapter 5 GCC-wide and Country Profiles

8. Compares and contrasts the six Gulf States in terms of their population, disease burden and

health service provision. These will be related to comparable health systems outcomes in later

chapters,

9. The chapter also analysed the unique population of the GCC and their impact on health

system performance and ability to secure the health of the entire population.

Chapter 6 Health System Building Blocks: Finance and Human Resources for Health

10. The key health system building blocks in the three GCC countries studied, compared with the

other countries and countries in the region.

Analysis of the current and projected the future needs for the scaling up of family physicians

in the GCC. This is based on the recognition of the value of primary care in achieving universal

health coverage (UHC).

Chapter 7 Quantitative assessment: Health Access and Quality Index (HAQ Index)

11. The novel extension of the Global Burden of Disease data by demonstrating the untapped

potential for personal healthcare access and quality improvement in assessing health system

performance.

12. Assesses the three GCC health system performances compared with other GCC and

neighbouring countries, for the first time in the region.

Chapter 8 The views of health leaders and senior managers on health system

performance assessment and its application

13. Questions the methods used in the GCC for assessing their health systems performance.

14. Explores the knowledge and attitude of health leaders and senior managers working within

these systems of HSPA, its application and benefits.

15. Identifies the current strengths and weaknesses, future projections and their impact on

population health.

Chapter 9 Discussion and recommendations

16. The overall findings from the various methods used in this thesis and triangulating the findings.

17. The feasibility of using healthcare access and quality index in the GCC.

18. The implications for other countries in the region and low and middle-income countries.

19. The final recommendations for the GCC and WHO EMR.

Chapter 2 Background

Background

This chapter presents the context and the background of the topic of this thesis, health system performance assessment, and an extensive review of the literature. The background information will firstly focus on health systems and its building blocks. It will then highlight the development of health system performance assessment globally, and the rationale for such development. Next, the chapter will describe the current approaches and frameworks in health system performance assessments around the world. Each approach/framework will be assessed and compared with other ones and how health system performance assessments link to health system building blocks. Finally, it will conclude by looking at the rationale for this research and its main aim.

Health Systems Globally

The global healthcare expenditure is estimated to increase from US$9.21 trillion in 2014 to

$24.24 trillion in 2040[4]. However, large health inequalities continue to persist all over the world; even within wealthy countries, life expectancy still varies across the population by over

20 years [9],[10]. This is largely due to the complexity of health systems, the intricate relationship between the supply and demand of healthcare, demographic complexity, the ageing population, and impacts of social determinants of health.

In addition, resources for health and healthcare are often not used efficiently or are misappropriated at different stages of the health production process [11]. Healthcare involves a high level of resource inputs that must be used efficiently for attaining the highest possible level of health with the available resources. Misappropriation distorts the flow of inputs into the

health system and consequently compromises the capacity of the health system to attain the goals it sets for itself [12]. WHO estimated that about 40% of the resources are wasted.(12_

The differences in the design, content and management of health systems translate into various levels of socially valued outcomes, such as health, responsiveness, or fairness.

Decision-makers at all levels need to quantify the variations in health system performance, identify factors that influence the system, both positively and negatively, and articulate policies that would improve the health of the population by bringing better outcomes in a variety of settings. Stakeholders and the public raise many questions about the performance of their health systems [11]. Governments are focused on improving their health systems and demand evidence that investments are effective in improving health outcome for their citizens [13].

Therefore, what do we mean by health system?

Defining Health systems

Health systems have been defined in numerous ways. The most widely used definition is from the World Health Organisation’s World Health Report [2] which defines health systems functionally as “all the activities whose primary purpose is to promote, restore or maintain health”. [2] This definition implies that the boundaries of health systems encompass broader government policies aiming primarily at improving health, as well as broader health determinants directly actionable by the health system.

The functional activities referred to in the WHO definition are grouped into six categories or building blocks that operate jointly to support an integrated organisation that aims to secure the health of the population it serves. This thesis will mainly focus on two of these building blocks (health workforce and financing). The building blocks are displayed in figure 1 [9] :

Figure 1: WHO Health System Framework.

Source: World Health Organisation. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action [9]. The two studied building blocks are highlighted in red

The health of the population should reflect the health of individuals throughout their lifespan and include both premature mortality and non-fatal health outcomes as key components.

These key components, alongside the average level of population health and health disparities within the population, are some of the concerns among governments and the authorities in the health sector [14]. Regarding health equity as a social determinant of health, implies that health systems aim both at enhancing the health of the population in general and to achieve better health status for those who have been in poor health [15]. It is important to recognize overall that health equity is a result of the interaction of diverse socioeconomic systems and determinants of health that lie outside the health system [16] such as living and working conditions, education, the working environment, healthcare services, and housing [16],[17].

To relate health system architecture to performance, it is important to understand and analyse the way in which the six health system building blocks (See Figure 1) operate and interrelate.

The first step towards achieving this result is to include all elements in the architecture of the system. The second step involves deciding upon how to measure these elements and which indicators to map onto the framework. Lastly, the third – and most difficult step, is to relate the indicators back to the assessment of performance and establish empirical links, which in turn provide evidence on how changes in these elements can affect performance, have been previously identified, and are actually carried out. Analysing this information permits variations in performance to be traced back to one or more of these elements and will ultimately serve as a driver of health system improvements. As per the political and societal dynamics in the three selected countries of the GCC and their relevance, for the purpose of this thesis only two of the six building blocks were researched: health workforce and financing.

Health Systems and Health Determinants

The health map (Figure 2) demonstrates how individual characteristics including a person’s age, sex, and hereditary factors are nested within the wider determinants of health, which include lifestyle factors, social and community influences, living and working conditions and general socio-economic cultural and environmental conditions. The map exhibits how people are placed at the centre but sets them within the global ecosystem. All these social determinants are intertwined with social forces that affect population health, patient care and health outcomes. Health systems intervene on social determinants of health preventing disease and protecting population health, early diagnosis and treatment, continuity of care and addressing health inequalities, healthcare driven interventions targeting social determinants

[18].

Figure 2: Determinants of health and well-being Source: Barton, H. and M. Grant, A health map for the local human habitat [19].

Healthcare accessibility and barriers

Health systems that deliver high quality and safer health services that can be accessed without barriers are responsive ones. Access to high-quality healthcare services is also critical for achieving improved health. Barriers to accessing healthcare services take different forms, for example, the limited supply of services, including limitations related to regional or geographical areas and restricted opening hours: excessive cost/unaffordability of private health services; lack of information about services and how, and where, to obtain them. These limitations influence access denial, prolonged waiting times for services, the length of stay in the hospital and unexpected or unplanned hospital admissions or procedures. There are also financial barriers to primary care services and limited providers in primary care might drive individuals to the relatively higher utilization of hospital emergency services; (if free); this excessive use of emergency services negatively impacts on day to day planned hospital healthcare services, and indeed total cost [20].

In summary, decision-makers should focus on efficiency and articulate the three main goals for the health system: better health, responsiveness, and fairness in financial contribution.

These intrinsic goals of delivering improved healthcare can be measured through routine monitoring to the health systems.

From the above descriptions, the lives and well being of populations in any given country lie in the hands of health systems. ‘From the safe delivery of a healthy baby to the care with the dignity of the frail elderly, health systems have a vital and continuing responsibility to people throughout the lifespan’ [2].

Good performance of health systems, therefore, is essential to the healthy development of individuals, families and societies everywhere across the globe. The question is how to measure/ assess good performance. In the next section, I will explore in detail the approaches and framework for assessing health system performance worldwide.

Health System Performance Assessment

Population health at national, regional and local levels is widely influenced by differences in health systems performance. Countries increasingly strive to find ways to assess the performance of their health systems to identify good practice and benchmark their results against those of others. This comparative assessment, often international, allows decision- makers to understand potential pitfalls of health systems and generate solutions to tackle them. It also provides decision-makers the opportunity to explore various options and learn from successes and mistakes of others [6],[21]

Health System Performance Assessment (HSPA) is a process used to establish and evaluate performance to improve health outcomes against expected standards. Performance measurement is usually conducted with the help of a framework, which provides qualitative and quantitative targets [21]; and assesses mainly five main dimensions: population health, health service outcomes, equity, fairness in financing and responsiveness [22].

International frameworks for HSPA

Since the mid 1990’s the WHO has invested in the defining and developing framework standards for assessing health system performance[17]. This resulted in the publication of the

World Health Report [2] Health Systems: Improving Performance [2], ranking of the health system performance of 192 WHO member states. Most of the report was based on modelling as only a minority of countries have a functioning system of vital registration (births, deaths, etc.). The report was unique and ‘remarkably courageous’ [23]. Yet, many countries expressed displeasure with the report [24]. Criticism was directed to the ‘perceived underlying pro-market ideology in many of the solutions proposed and the language used to justify them. In particular, a seeming conflation of tax-funded national health services with the discredited Soviet system

[23],[25], the unjustified dismissal of primary care model set in Alma Ata [26] and whether there are any universally agreed goals for health systems [27]. Nevertheless, despite all criticisms from member’s states and researchers, the World Health Report 2000 stimulated the emergence of a community of researchers working on health systems assessment and placed health system performance on the political agenda. The Report provided the impetus for the development of acceptable approaches and frameworks of assessment of health system performance. To date, few frameworks have been developed that systematise the evaluation of how health systems meet their objectives and to clarify the meaning of health systems. The following outline summarises the work of some institutions in developing frameworks for health system performance assessment:. They used various tools such as statistical comparisons, achievements of defined goals, indicators of quality of care, comparing best practices, or comparing against set of proposed standards.

The World Health Organisation

As described above, the ‘World Health Report on Health Systems: Improving performance” initiated international discussion on HSPA among academia and politicians [2]. The report sets

out one of the first frameworks for HSPA, which defined, assessed and analysed health systems and their performance. In 2003, the WHO summarised all the information available on HSPA: “Health System Performance Assessment: Debates, Methods, and Empiricism” [28].

However, what really placed health systems back on the political agenda was the 2008 Tallinn conference, organised by WHO EURO [29], which aimed to improve the understanding of how health systems affect health and financial growth and thereby how countries can improve the performance of their health systems [30].

The WHO Framework to evaluate health system performance is based on measurement of the three main health system goals described in the World Health Report: improved health, responsiveness and fairness in financing [2]. It includes cross-system goals, which link health to sectors such as education, housing or economic production. Health refers to achieving good health throughout life, from pregnancy to death and includes equal distribution of good health across populations. Responsiveness is the health system’s response to a population’s needs and expectations and focuses on respect for patients in terms of dignity, autonomy, confidentiality, access to social support and choice of care. It also includes an ethical dimension. Fairness in financing addresses how households should not suffer financially from obtaining needed healthcare, and how every household should pay a fair share to access health systems, based on income rather than usage [28]. In order to achieve these three goals, every health system needs to be accessible, innovation-oriented, and sustainable and should involve communities [2], [28]. Accessibility and quality therefore are key dimensions in the WHO framework.

After establishing a definition of the health system and strengthening assessment measurements, WHO renamed and regrouped the instrumental goals of the [2] framework into six building blocks of health systems (figure 1 Chapter 2): service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance (stewardship) [9].

National policymakers are expected to provide an integrated response, which combines all building blocks and recognises their interdependence in their health systems performance assessment.

The Organisation for Economic Co-operation and Development (OECD)

The OECD published three documents within the field of health system performance assessment [22]. Immediately after the publication of WHO Report 2000 [2] they released

“Performance measurement and performance management in OECD health systems”. This provided with a framework for the analysis of health systems and included indicators to assess the quality of healthcare across countries. This was followed by the “Health at a Glance” report, which compared indicators of health and health systems across OECD countries [13],[22]. These indicators were produced jointly with the European Commission and are available, as the

“Heidi Data Tool” [31]. In 2010, the OECD identified strengths and weaknesses of health systems by comparing performance data in its document “Healthcare systems: efficiency and policy settings” [32]. The three reports used key indicators from the WHO Report in 2000 expanded to include primary care and prevention [33, 34].

European Observatory on Health Systems and Policies

Health System Performance Assessment is a key area of this institution following the 2008

WHO Tallinn conference on “Health Systems, health and wealth” [29]. Drawing from the experience of health systems around the world, it provides a framework for the measurement of performance that covers both technical and political aspects of HSPA. The Observatory’s new book on “Health System performance comparison: an agenda for policy, information and research” identifies best practice in health system comparison, as well as current methodological caveats[6], 34].

Health Consumer Powerhouse

This private Swedish organisation undertakes benchmarking of the health systems of 35 countries, based on 38 indicators in areas including quality of care, patient engagement, e- health and innovation, health outcomes or medicines. It publishes an annual report, the

“EuroHealth Consumer Index”, which contains a summary of their analysis [35].

The UK NHS Performance Assessment Framework

While WHO was working on the development of ‘reasonable’ performance assessment measures of health systems the NHS Executive of the UK Department of Health published its first ‘NHS Performance Assessment Framework’ in 1999 [36, 37]. The UK was a pioneer country in this regard.

The framework sets standards (high-level performance indicators) for delivery and monitoring at the local level. The latter was the nucleus of the creation of regulatory bodies for monitoring providers of health and healthcare service (Commission for Health Improvement (CHI) 2001-

2004; Commission for Health Improvement (CHI) 2004-2009; and Care Quality Commission

(CQC) from 2009) [37]. The NHS Framework was not designed to assess interventions, access and quality merely to address high-level indicators, which were refined over the years[38]. The

UK is the only country that has published this type of framework.

The Commonwealth Fund

The Commonwealth Fund is a private fund focusing on two programmes: improving health insurance coverage and access, and improving the quality of healthcare. Without a defined framework, the Commonwealth Fund based their comparative assessments on surveys of patients and primary care physicians. Information was collected for a standardized set of

metrics on health system performance and comparative data was drawn from the most recent reports of the Organisation for Economic Cooperation and Development (OECD), the

European Observatory on Health Systems and Policies, and the World Health Organization

(WHO) in collaboration with partners in ten advanced countries comparable with the USA [40,

41]. The 2017 survey found that of 11 high-income countries surveyed, people in Britain have among the fastest access to GPs; the best coordinated care and suffer from the fewest medical errors. The service substantially out-performs the USA on a per capita expenditure of less than half, rivalled only by Switzerland in Europe. This comparative approach is useful mainly for developed countries but it may help low and middle-income countries assess their health systems [40, 41].

Institute of Health Metric and Evaluation, University of Washington (IHME)

The IHME through a comprehensive approach to mortality and risk factors data assessment developed a reliable index of access to and quality of healthcare provision across 195 countries between1990-2015. Based on Nolte and McKee studies [42], which measures death rates due to causes considered amenable to healthcare to approximate average levels of personal healthcare access and quality. These analyses of access and quality were used in high-income countries. As part of the Global Burden of Diseases, Injuries, and Risk Factors

Study 2015, [43] the IHME constructed the HAQ Index to quantify personal healthcare access and quality in the 195 countries and territories with the aim of addressing ‘amenable deaths’ to prevention and treatment.

After I reviewed the available GCC data and in discussion with colleagues at IHME, data from the HAQ Index, available through the Institute of Health Metrics and Evaluation data visualization tool was incorporated. The HAQ Index is an excellent proxy for assessing the performance of the health system in any given country and compare to other countries of similar economic status. Details of the use of this method in comparative assessment of health systems are described in the methods chapter 7.

The GCC Context in Health System Performance Assessment

The accurate diagnosis of the performance shortcomings in a health system is a prerequisite for successfully sustainable improvements to achieve the objectives for better health. Many factors may hamper an accurate assessment of health system performance. Amongst these are: lack of health information systems; lack of clear strategies and policies; lack of clarity on financing; service fragmentation; absence of regulatory bodies lack of data; and above all the strong tendency for privatisation, shifting responsibility from government to individuals, and a profit-driven and unregulated private sector [44],[45],[46].

The GCC is a group of six countries of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United

Arab Emirates that share the same language, culture, religion and economy with a population of more than fifty-one million people. Nearly half of whom are non-nationals (expats), mainly short-term contract (See Chapter 6). The population and economic growth over the past two decades has been rapid, as has been the social transition from ‘basic desert living’ to highly urbanised cities. These changes coupled with much higher population expectations for their health have led to unprecedented demands for modern health service. It expected that health expenditure by 2025 would exceed $60 billion, up from $12 billion in 2012 [1]. Shortage of health professionals, uncoordinated service development, combined with an increase in disease burden, especially non-communicable diseases such as diabetes and cancer are of concern to health leaders in the region with the unplanned expansion of service [47],[48],[49].

Health-care system improvement has become a priority in the GCC to reduce the poor quality of health-care provision compared with non-GCC high-income countries. Health system performance assessment is needed more than ever and the GCC Ministers of health recognised this in 2015, when the Ministers passed a resolution on “Assessment of Health

System Performance in the GCC: The road to excellence” [50].

Today, there is growing consensus among the GCC Health Ministers that better and stronger health systems are essential to achieve the most needed improved health outcomes. While

past economic and social developments were remarkable and have contributed significantly to the health of the population, compared with countries of similar economic standards the health systems are not matching these developments [51]. The GCC population perceives differences between levels of care within their own countries and countries abroad, therefore they are demanding change [52], while responses are patchy and services are fragmented.

Taking into account the aforementioned background, the primary aim of the study was to enhance our understanding of the health systems and their performances in the GCC countries. The question to be addressed, is whether health systems in the GCC are in a position to achieve sustainable improvements in population health. In this thesis, various possible scenarios have been postulated to assess the current health systems operation, management and performance using both quantitative and qualitative research methods.

Extensive literature searches and discussions with key health leaders suggest this study is the first of its kind.

The next chapter will describe the research methods implemented to address the aim and research questions and testing the proposed hypothesis (Chapter 3).

The systematic reviews and additional scoping reviews helped to reshape the initial research methods and the progression of this research project.

Individual Country Profile of the three study countries

Data for this section was collected directly by corresponding with the Ministry of Health. As described in the methods section, out of six countries of the GCC three were selected for in- depth analysis. This is based on the advice given by examiners at the first year of the research.

The six countries have similar population, culture, development and health systems and hence three were selected randomly to represent the population and health systems in the GCC.

1. The Kingdom of Bahrain

Bahrain is an island situated centrally, on the southern shores of the Arabian Gulf, to the east of Saudi Arabia and to the north of Qatar. The Kingdom of Bahrain is an archipelago of 40 islands, with a total area of 757.50 km2 inhabited by 1.3 million people. The largest island is the island of Bahrain, which includes the capital Manama, representing 80.68% of the total area of the Kingdom. The King Fahad Causeway connects the country with the Kingdom of

Saudi Arabia.

Political, cultural and economic history

Bahrain has been an independent country since 1971 and was declared a “Kingdom” in 2002.

The Al Khalifa Royal Family is now in power, following successive treaties with Great Britain.

The Kingdom of Bahrain, for many years, has strived to become one of the best health service providers in the Gulf region. The government sees healthcare as paramount to the Kingdom’s evolution into a service-oriented economy, a place where high skilled practitioners and comprehensive facilities are the norms. The Bahrain ethnic group is the indigenous people of the Bahrain and Eastern Province of Saudi Arabia, while the Najrdis are Arabs from Najd, including Iraq, as well as Persians in central Arabia. Indians represent the largest non- nationals community.

The Kingdom of Bahrain is composed of five governorates, each with a municipal council elected every four years: Al Manamah (Capital), al Muharraq, Ash Shamaliyyah (Northern), Al

Wusta (Central), and Al Janubiyah (Southern), which is the largest governorate with a surface area of around 441 km2. Ash Shamaliyyah is the most densely populated governorate. The main language spoken is Arabic, but English is also spoken throughout the country, and although the state religion is Islam, the country is tolerant towards other religions. Bahrain has a very similar culture to its Arab neighbours in the GCC and is a highly cosmopolitan country.

Bahrain is one of the most diversified economies in the Arabian Gulf. Highly developed communication and transport facilities make the country home to numerous multinational business firms. However, Bahrain continues to depend heavily on oil. Petroleum production and refining account for more than 60% of Bahrain's export receipts, 70% of government revenues, and 11% of Gross Domestic Product (GDP) (exclusive of allied industries). Other major economic activities are the production of aluminium - Bahrain's second biggest export after oil - finance, and construction. Since the late 20th century, Bahrain has sought to diversify its economy and become less dependent on oil by investing in the banking and tourism sectors. Bahrain continues to seek new natural gas supplies as feedstock to support its expanding petrochemical and aluminium industries.

The country's capital, Manama, is home to many large financial structures, including the

Bahrain World Trade Centre and the Bahrain Financial Harbour. The Bahrain Economic Vision

2030, published in 2010, lays special emphasis on health and aims to transform Bahrain into a leading centre for modern medicine that offers high-quality and sustainable healthcare in the region. In 2011-2012, $852 million was allocated from the national budget towards the

Sustainable improvement of health projects and services.

Population demographics

The population of Bahrain was 1,314,562 in July 2014. This includes 683,818i non-nationals

(52%) from countries such as India, Pakistan, Iran, Egypt, Malaysia and others. A large number of migrants were nationalized in recent years to balance the sectorial (mainly religious) groups in the country. With a rapid population growth (Table 1), the population pyramid shows

that the majority of the population are between the age of 25 and 54 years old, and the percentage of the elderly population is low, although higher than the rest of the GCC countries

(Figure 3). The adult literacy rate is high.

Table 1: Population demographics, Bahrain 2014

Indicator Value

Total population (in millions) 1.314 Population growth rate (%) 2.49 Birth rate (per 1,000 population) 13.50 Median age of the population 31.6 Adult literacy rate (%) 94.6 Citizens (%) 59.6

Residents/Migrant Workers (%) 40.4

Source: WHO Database

Figure 3 shows that the male population outnumbers the female population in all age groups, except the elderly, where the female population is slightly higher.. The high proportion of the male in the age group 25-54 years old is mainly due to non-nationals migrant workers.

Figure 3: Bahrain, population pyramid for the last population estimates, 2014

Source: MoH Bahrain, 2016

A brief history of health services

The structured health system of the Kingdom of Bahrain was first established in the early

1900s when the American Mission Hospital started treating Bahrainis and patients from neighbouring countries. The rapid growth in the population required the development of additional hospital services. In 1929, the government started offering preventive and public health services. Al Salmaniya Hospital, the first public hospital, was established in 1957 and is now known as the Salmaniya Medical Complex (SMC), which is the main secondary care facility providing a wide range of healthcare facilities. The first National health policy for

Bahrain was launched in 1961. The first primary healthcare centre was opened in 1977.

Currently, there are three public hospitals (one military) and 26 health centres across the country.

Population health

Health status indicators of the nationals in Bahrain are comparable to those of developed countries. This is manifested by a life expectancy of

78.5 years and an infant mortality rate of 9.6 /1000 live births. Of the three selected countries, Bahrain has the highest life expectancy among

nationals. It increased from 73.98 years in 2004 to 78.58 in 2014. (Table 2)

Table 2: Bahrain population health (Nationals only), from 2004 to 2014.

Calendar Year Indicator 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Life Expectancy at Birth(Years) 73.98 74.23 74.45 74.68 74.92 76.12 75.04 78.15 78.29 78.43 78.58

Mortality rate (deaths/1,000 population) 4.03 4.08 4.14 4.21 4.29 4.37 4.37 2.61 2.63 2.65 2.67

Infant Mortality Rate (per 10,000 live births) 17.91 17.27 16.08 16.18 15.64 15.25 14.76 10.43 10.02 9.93 9.68

Under five mortality rate (per 1,000) 11.40 11.20 11.00 10.80 10.60 10.30 10.10 9.80 9.60 9.00 8.72

Source: WHO Database and IHME visualization (Data for Non-nationals is not available)

Over the years, Bahrain has managed to control communicable diseases and to reach 100% coverage of basic vaccines in line with developed countries. However, Bahrain has witnessed a continued rise in chronic diseases such as Ischemic heart disease, Diabetes (ranked the

10th in the world), Road injuries, Stroke, Alzheimer disease, COPD, and Lung cancers. Non- communicable diseases are the leading cause of mortality among nationals (Figure 4).

Figure 4: The ten top causes of deaths between 2005 and 2016.

It shows that Ischemic heart disease, diabetes and road traffic injuries are constantly the top three causes of death over the last decade (IHME; WHO HEA Database; National Data). The data related to nationals as data for non- nationals is not available.

Health System Structure

The Ministry of Health is responsible for the provision of health service for the population of

Bahrain. It is also responsible for the regulatory mechanism of health services, including health policies, planning, implementation and evaluation of health service delivery. Management is centralised through the Minister of Health who is appointed by the King. An undersecretary and five assistant undersecretaries support the Minister of Health in running the service, each of who manages a separate department. Primary care, hospitals and public health, training and planning, finance and technical resources and human resources are the key functions within the Ministry (Figure 5). The Ministry undertakes many other functions including emergency preparedness and response, international relations and GCC wide coordination through the GCC Health Ministers Council.

Public & International Minister of Health Relations Directorate

Internal Audit Unit Medical Commission

Undersecretary Legal Affairs Office

Health Promotion Directorate

Nursing Development Section

Asst. U/Secretary Asst. U/Secretary Hospitals Training & Planning

Admin. Services of SMC Medical Services of SMC Directorate of Training Medical Review Office

Admin. Services of Nursing Services of Hospital Quality Management Section Health Planning Directorate External Hospital

Health Information Directorate

Asst. U/Secretary Financial & Technical Primary Care & Public Health Resources

Medical Equipment Directorate of Finance Health Centres Public Health Directorate Medical Services Directorate

Directorate of Engineering & Health Centres Dental & Oral Maintenance Directorate Health Services

Nursing Services of Primary Care & Public Health

Asst. U/Secretary Human Resource & Services

Directorate of Directorate of Human Resources Services

Directorate of Materials Management

Figure 5: Organisational chart of the ministry of Health in Bahrain.

Sources: Kingdom of Bahrain Ministry of Health, Organisation Structure, http://www.moh.gov.bh/EN/aboutMOH/aboutMinistry/OrganisationStructure.aspx

Health service delivery

The Ministry of Health in Bahrain provides comprehensive health services for the entire population. Universal coverage was achieved through free services offered to the population, both nationals and non-nationals via a well-established network of 27 primary care health centres and clinics. The average number of people living in the catchment area of each centre is around 35,000. Primary care centres act as the first point of contact and a well-structured referral process, together with accident and emergency services, allows the patient to access secondary care. Due to the small size of the country, most areas are considered to be urban, and the distribution of health centres, therefore, spreads across the totality of the country.

Secondary and tertiary healthcare is provided through Salmaniya Medical Complex (the main hospital in the country), a psychiatric hospital, a geriatric hospital and four maternity hospitals

(Table 3). The Bahrain Defence Force Hospital (BDF), managed by the Ministry of Defence, provides healthcare services to members of the Bahrain Defence and their families, as well as emergency care and cardiac care services to the whole population. Several highly specialised services and advanced cardiac care services are offered at the Shaikh

Mohammed Al-Khalifa Cardiac Centre.[53].

Table 3: Health institutions in Bahrain: number of visits and beds, 2014 Statistics.

Indicator Value

HEALTH CENTRES VISITS 3,787,365

HOSPITAL INPATIENT ADMISSIONS 192,008

Salmaniya Medical Complex 50,799

King Hamad University Hospital 8,620

Bahrain Defence Force Royal Medical Services 21,462

Public hospitals 80,881

Private hospitals 111,127

HOSPITAL OUTPATIENT ADMISSIONS 6,531,407

Salmaniya Medical Complex 4,386,687

King Hamad University Hospital 202,155

Bahrain Defence Force Royal Medical Services 529,075

Directorate of Health & Social Affairs 183,485

Public hospitals 5,301,402

Private hospitals 1,230,005

HOSPITAL BEDS 4,544

Salmaniya Medical Complex 1,320

King Hamad University Hospital 373

Bahrain Defence Force Royal Medical Service 353

Total Public Hospital 2,046

Total Private Hospital 2,498

Source: Health Statistics 2012, Ministry of Health, Bahrain.

Primary care is well developed compared with other GCC countries. The service is run by around 500 family physicians, all of them are fully trained [54]. Services under the umbrella of maternal and child healthcare include, but are not limited to, antenatal and postnatal care, family planning, periodic women screening, premarital counselling, child screening and immunisation, home visits and health education. Additionally, dentists and dental hygienists are offering many curative and preventive dental services. Health centres provide medical and other health services such as nursing, pharmacy; clerical and medical record services, laboratory and radiological services. Physiotherapy services have also been introduced at four health centres each across the country.

Healthcare is available through both private and public systems that are not coordinated and government regulation is weak. Public medical services are free or subsidised. Currently, the private sector is relatively limited in comparison with publicly offered health services. However, it is growing rapidly, and the aspiration of the government is to generate more revenue by expanding the private health sector, taking a major role in the future as a key provider of healthcare services, while public services will function as regulatory and policy-making bodies

[55]. This is an important issue across all GCC countries as governments are gradually shifting the costs of health care to individuals through private insurance and out-of-pocket expenditure

(See the Discussion chapter).

Health workforce

Bahrain has four medical and health universities: the Arab Gulf University, the Royal College of Surgeons of Ireland, the College of Health Science, and AMA International University. The number of physicians has increased from 2,332 in 2008 to 3,324 in 2014. The number of nurses has increased from 4,652 in 2008 to 6,584 in 2014. Currently, about 40% of all physicians and 20% of all nurses’ work in the private sector (Table 4). Majority of the physicians work in both public and private sectors (dual practice), including family physicians.

Table 4: Health workforce in Bahrain 2008-2014. [53]

Source: Health Statistics 2012,[53] Calendar Year Indicator 2008 2009 2010 2011 2012 2013 2014

Public 1,409 1,475 1,536 1,575 2,061 1932 1957

Physicians Private 923 1,006 1,034 1,335 1,363 1385 1367

Total 2,332 2,481 2,570 2,910 3,424 3317 3324

Public 140 141 149 153 165 162 265

Dentists Private 214 211 217 373 391 393 393

Total 352 352 366 526 556 555 558

Public 3,510 3,708 3,841 3,988 4,918 5066 510

Nurses Private 1,142 1,210 1,267 1,310 1,372 1476 1484

Total 4,652 4,918 5,108 5,298 6,290 6542 6584

Public Pharmacist 237 241 253 256 308 299 324 s & Private 426 431 433 442 448 447 444

Technicians Total 663 672 686 698 756 746 768

Health financing

Bahrain spends 5% of its GDP on health, amounting to $2258 per capita (Table 5). Around

63% of expenditure on health comes from the government as a percentage of the total health

expenditure. The government plans to introduce compulsory health insurance for expatriate workers, but the plan is delayed for political reasons at the present time.

Table 5: Healthcare expenditure in Bahrain 2014

Source: The World Bank, WHO[9]

Indicator Value

HealthCare Expenditure Per Capita (USD) 2258

Government Expenditure on Health as % Expenditure on Health 65.3

Private Expenditure on Health as % of Total Expenditure on Health 10.6

GDP Growth 2014 % 5.3

Prepaid and Risk-Pooling Plans (Private) Expenditure on Health as % 26.2

OPP (Private) Expenditure on Health as % 24.1

Out of the total health expenditure, 59% was spent on secondary care, 27% of primary care and public health, and 11% on administrative and support services.

2. The State of Kuwait

Kuwait is an Arab country in Western Asia, situated in the north-eastern edge of the Arabian

Peninsula at the tip of the Arabian Gulf. It shares a border with Iraq in the north and with Saudi

Arabia in the south. The name "Kuwait" means fortress in Arabic. The country covers an area of 17,820 km2 and had a population of 4.3 million in 2014.

Political, cultural and economic history

In 1962, Kuwait became a constitutional monarchy with a parliamentary system and with

Kuwait City serving as the country's political and economic capital. After Kuwait gained independence from the United Kingdom in 1961, the state's oil industry saw unprecedented economic growth. The country has the world's fifth largest oil reserves and petroleum products

now account for nearly 95% of export revenues and 80% of government income. The state is now the seventh richest country in the world per capita.

Kuwait has the highest literacy rate in the Arab World at 96.3 percent, and education standards are high. Kuwait provides free education from elementary to university for all citizens. It is delivered equally to all nationals, regardless of social classes, and is one of the government’s priorities especially further improvements of primary education.

Although over 95% of the population is Muslim, there is high religious tolerance. Churches can practice freely and Kuwait is the only Gulf Country to have established relations with the

Vatican.

Kuwait currently has an annual population growth rate of 1.8% per year and if this trend continues, Kuwait’s population will grow to 5.2 million by 2050 from 4.3 million in 2016. The majority are non-nationals (69.4%), most of them are on short-term contracts from Asia (two thirds of all non-nationals). This trend is increasing as the proportion of national Kuwaitis decreases. In addition, there are more than 100,000 people living in Kuwait, who are classified as ‘Bedoon’ (which means without a status or any citizenship) [56].(See table 6) .

The government and people of Kuwait view the high level of non-national workers in the country as a serious challenge, which led to an attempt in 2014 to reduce the number of expatriates in the country by 100,000 every year over the next decade.

Population demographics

The population of Kuwait is currently over 4.3 million and is growing at a rate of 1.8%. A very high percentage of the population is literate and there are almost as many citizens as there are residents in the country (Table 14).

Table 6: Population demographics in Kuwait, 2014

Indicator Value

Total population (in millions) 4.1

Population growth rate (%) 1.8

Birth rate (per 1,000 population) 20.2

Median age of the population 28.9

Adult literacy rate (%) 95.8

Citizens (%) 31

Residents (%) 69

The median age in Kuwait is 28.9 years with the structure in favour of the working-age groups

(Table 14), which can be explained by the high immigration rates and a large reliance on foreign labour. In 2014, 25.7% of the population was under the age of 15, 15.5% were between the age of 15 and 24, 52.3% were between 25 and 54, 4.5% were between 55 and 64 and only 2.1% of the population was 65 and older. The male population outnumbers the female population in all age groups, except the elderly, where the female population is slightly higher.

The high proportion of the male in the age group 25-54 years old is mainly due to non-nationals migrant workers.

Figure 6 shows that Kuwait has almost the same population structure as Bahrain. Out of the three study countries, Kuwait has the highest percentage of children (age 0-14) and the lowest percentage of the adult population.

Figure 6: Age Groups in Kuwait 2014.

Brief history of health services

The history of healthcare in Kuwait dates to the beginning of the 20th century, when the ruler,

Ameer of Kuwait Shaykh Mubarak Al Sabah, invited American missionaries to establish a health clinic, years before independence from the British rules was declared. By 1911 the group had set up a hospital for men and by 1919, a small hospital for women. In 1934 the 34- bed Al Cott Memorial Hospital was opened. Since independence in 1962, the health services have government funds, with new primary care and hospital services.

Population health

Kuwait achieved high life expectancy among nationals, as well as low maternal and infant mortality rates (Table 7). In addition, the total fertility rate is 2.56 children per woman and contraceptive use is relatively high. It is estimated that fertility will decline to 2.1 by 2035, together with a decline in the youth population. All mortality indicators are good and

comparable with developed countries (Table 7).

Calendar Year

Indicator 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Life expectancy at birth (Years) 76.84 77.03 77.02 77.36 77.53 77.71 77.89 77.09 77.28 77.46 77.64

Mortality rate (deaths/1,000 population) 2.44 2.42 2.410 2.39 2.37 2.35 2.29 2.11 2.13 2.14 2.16

Infant mortality rate (per 10,000 live births) 10.26 9.95 9.71 9.47 9.22 9.96 8.75 8. 07 7.87 7.68 7.51

Under five mortality rate (per 1,000) 12.20 11.90 11.70 11.50 11.40 11.40 11.30 11.20 11.10 11.00 10.86

Table 7: Population health indicators in Kuwait (nationals only) from 2004-2014

Source: WHO Database and IHME Visualization

In line with other GCC countries, Kuwait is facing a substantial increase in the number of people with one or more non-communicable diseases (NCDs) (Table 6). These are mainly attributed to lifestyle behaviours including smoking, obesity and inactive life style. Ischemic heart diseases, road traffic injuries and cerebrovascular diseases are consistently the top three causes of death from 2005 - 2016. Qatar and Kuwait have road traffic injuries as the first and second cause of deaths, while diabetes-related mortality in Kuwait is not as high as the other two countries.

Figure 7: The ten top causes of deaths between 2005 and 2016 in Kuwait.

It shows that Ischemic heart disease, road traffic injuries, and cerebrovascular disease are constantly the top three causes of death over the last decade (IHME; WHO HEA Database; National Data). The data related to nationals.

Health system structure

The Ministry of Health (MOH) is responsible for health policy, planning, financing, resource allocation, regulation, monitoring and evaluation as well as healthcare service delivery. It is the third largest public employer, after the Ministry of Education and the Ministry of Interior. In

2014, a proposal to set up a National Health Authority within the parliament was put forward for it to assume overall responsibility for the licensing, certification and accreditation of healthcare facilities in Kuwait.

The undersecretary and twelve assistant undersecretaries assist the Minister of Health. The

Ministry operates through an administrative and a technical workforce and has an extensive

central organisational structure. Central departments under the direct supervision of the undersecretary include technical department, legal advisor, planning and follow up, public relations, treatment abroad, medical council and department of medical services. The Ministry overall structure, therefore, consists of twelve functional divisions embracing 42 central departments and offices at the central level (Figure 14). It is a centralised system through the

Ministry and six regional offices located in the six provinces.

Figure 8: Organisational chart of the ministry of Health in Kuwait

Source: Ministry of Health Kuwait

Health service delivery

Kuwait has a relatively high standard of public and private healthcare within the region, accessible to the entire population. The public sector is controlled by the central Ministry of

Health, as well as by regional health offices. The private sector is rapidly expanding and is predominantly used by the wealthiest Kuwaitis and expatriates. However, the government has recently introduced a law restricting the number of visits non-nationals can make to public hospitals and clinics. Expatriates are now unable to attend public hospitals in the morning, except for emergencies [8].

Currently, Kuwait has 19 hospital beds per 10,000 people (Table 16). The government operates 15 general and specialised hospitals, with the private sector expected to grow moderately in the coming years. In 2011, Kuwait announced plans to add 3,500 hospital beds to the current capacity as well as to expand laboratories and surgical sites.

Table 8: Health service delivery in Kuwait

Calendar Year

Indicator 2009 2010 2011 2012

Government Sector

Number of healthcare centres 85 86 92 92

Number of visits to healthcare 14.2 15.6 16.8 17.6 centres million million million million

Hospitals

Number of hospitals 15 15 15 15

Number of hospital beds 6075 6338 6703 6703

Number of hospital (inpatient) visits 203,822 215,3417 216,658

Number of hospital (outpatient) 2,117149 2,294,882 2,432,773 visits

Private Sector

Number of hospitals 9 9 12 12

Number of hospital beds 802 808 1,038

Number of hospital (inpatient) visits 84012

Number of hospital (outpatient) 1,617,847 1,750,690 2,141,661 visits

Oil Companies

Number of hospitals 3 3 3 3

Number of hospital beds 197 209 209 209

Number of hospital (inpatient) visits 9267

Number of hospital (outpatient) 638,309 581,769 483,680 visits

Source: Statistical Review, 2013[57]

Health workforce

The health workforce in Kuwait, like other GCC countries, relies heavily on the expatriate health workforce. About 40% of all physicians and 20% of all nurses work in the private sector: many of the doctors are in dual practice. The number of physicians in the country has increased from 5607 in 2007 to 7781 in 2011 (39%). However, the number of nurses has fallen from 13162 in 2007 and declined to 12096 in 2011, an average annual decline of 3.3 % (Table

17) this affects the quality healthcare provided.

Table 9: Number of health professionals in Kuwait between 2007 and 2011.

Calendar Year

Profession 2007 2008 2009 2010 2011

Doctors 5607 6298 6794 7269 7781

Dentists 1163 1480 1533 1634 1836

Nurses 13162 15788 17307 19535 12096

Pharmacists N/A N/A 1.14 1.08 1.01

Sources: World health Rankings, World health Rankings health profiles: Kuwait, 2011 http://www.worldlifeexpectancy.com/country-health-profile/kuwait 2. Health, Kuwait, 2011, Edition 48, Department of Health Information& Medical Records, ministry of health State of Kuwait http://www.moh.gov.kw/dih/2011.1.pdf,

Health financing

Kuwait has a state-funded public healthcare system. Health service is free for Kuwaiti nationals, but expatriates are required to contribute to the public health insurance scheme and are issued with a health card, which entitles them to treatment in public facilities for a subsidised cost. Health cardholders and Kuwaiti citizens are entitled to treatment at any public primary care clinics

The Ministry of Health has a budget of US $4 billion for 2012-13, which constitutes a 100% increase from the previous US $2 billion budget predicted to grow by 7.5% until the year 2020

[58]. The private sector expenditure on health accounts for 1.3% of total health expenditure

(Table 10).

Table 10: HealthCare Expenditure in Kuwait, 2014

Expenditure Type Value

Healthcare Expenditure as % of GDP 3.3

HealthCare Expenditure Per Capita (USD) 2075

Government Expenditure on Health as % Expenditure on Health 85.9

Private Expenditure on Health as % of Total Expenditure on Health 1.3

GDP Growth 2012 % 3.4

Prepaid and Risk-Pooling Plans (Private) Expenditure on Health as 19.6 %

OPP (Private) Expenditure on Health as % 12.8

Source: WHO Database, MoH Kuwait, IHME various years)

3. The State of Qatar

The state of Qatar is a sovereign Arab State, located in Western Asia, on the Arabian

Peninsula. The country is almost surrounded by the Arabian Gulf but shares a border with

Saudi Arabia in the south. A strait in the Arabian Gulf separates Qatar from the nearby island of Bahrain. It has an area of 11,437 km2 and most the land is a barren desert, leading to a high risk of dust and sandstorms. The country has an arid climate with mild winters and very hot, humid summers. The climate and topography of the country make Qatar highly dependent on desalination facilities to compensate for the limited availability of fresh water.

Political, cultural and economic history

Qatar is a constitutional monarchy, which has been ruled by the Al Thani family since the mid-

19th century. Between the First and Second World Wars, Qatar became a British Protectorate and stayed under the country’s influence until 1968. It remained in a federation together with

Bahrain and the U.A.E until independence in 1971.

The Emir of Qatar, Shaykh Hamad bin Khalifa Al Thani, has managed a course of major economic growth for the country and has undertaken several projects to capitalize on Qatar’s hydrocarbon resources, as well as to improve educational opportunities for Qatari citizens, and pursue economic diversification. Expatriates have benefited Qatar’s economy and have made the country more culturally diverse [59].

Petroleum and gas is the cornerstone of Qatar's economy and accounts for more than 70% of total government revenue, more than 60% of the gross domestic product, and roughly 85% of export earnings. Proved oil reserves of 15 billion barrels (588,000,000 m³) should ensure continued output at current levels for 23 years. Oil has given Qatar a per capita GDP that ranks among the highest in the world. Qatar's reserves of natural gas and oil exceed 7000 km³, which is more than 5% of the world total and the third largest reserve in the world.

Production and export of natural gas are becoming increasingly important. Long-term goals feature the development of offshore petroleum and the diversification of the economy. In 2011,

Qatar had the highest human development in the Arab World and it is now one of the wealthiest states in the world [60].

Population demographics

Between 2003 and 2014, Qatar's population has almost tripled, reaching 2.4 million people in

2016. The population is growing by 3.58% a year and most citizens live in urban areas. The adult literacy rate is high (Table 11).

Table 11: Population demographics in Qatar 2014

Indicator Value

Total population (in millions) 2.404

Population growth rate (%) 3.58

Birth rate (per 1,000 population) 09.95

Median age of the population 32.2

Adult literacy rate (%) 96.3

Urban population (%) 99.1

Citizens (%) 27

Residents (%) 73

Source: Qatar’s Ministry of Development Planning and Statistics; WHO Database; IHME.

Figure 9 shows the distribution of the population by age groups and gender. Qatar population is relatively young. The high proportion of the male in the age group 20-49 years old is mainly due to non-nationals migrant workers.

Figure 9: The structure of the Qatari population, 2014 The bulge in the age group 20-49 is mainly due to a large number of single male unskilled short term-term foreign labourers (SML) in the country. Source: WHO, Ministry of Health Qatar, 2016

Although a similar structure can be observed in Bahrain and Kuwait, out of the three countries,

Qatar has the highest percentage of the adult population and the lowest percentage of the older population. Males outnumber females in all age groups. (Figure 9)

Brief history of health services

Before the discovery of oil in the country, healthcare mostly consisted of traditional medicine: barbers performed circumcisions and other minor procedures, and herbalists dispensed natural remedies. The first hospital, operated by only one doctor, opened in Doha in 1945. In

1959, the Emir of Qatar, Shaykh Ali ibn Abd Allah, established the first state-run hospital.

Rumailah Hospital with 170 beds, one doctor and one staff member. In 1965, a second hospital, with 165 beds, opened for maternity services.

In 2002, two institutions shared organisation and management of healthcare: The Ministry of

Health and the Hamad Medical Corporation (HMC). The Ministry of Health was to play the role of a normative, regulatory, policy development and coordinating authority. However, in 2005, the Supreme Council of Health (SCH) was established to replace the ministry. Under the guidance of His Highness the Emir of Qatar, the SCH was given the responsibility to guide healthcare reform with the aim of establishing Qatar as one of the ‘most reputable and trusted health systems in the world’ [61]. The SCH was abolished in 2016 and the Ministry of Public

Health was created with responsibility for health policy, regulations, international health and public health in addition to monitoring and overseeing the functions of the two corporations:

Primary care Corporation and Hamad Corporation (mainly secondary and tertiary hospital care). Despite the well-defined functions, there are many areas of overlapping and lack of coordination.

Population health

By Western standards, the health status of the ‘national’ population in Qatar is high. Health status indicators of the nationals in Qatar are comparable to those of developed countries. Life expectancy has risen among nationals, mainly due to the socio-economic development and better access to health service, from 71.2 years in 1990 to 78.9 years in 2014 (Table 12). Rates of infant, child and maternal mortality are comparable to those of other industrialised nations. The death rate accurately indicates the current mortality impact on population growth. This indicator is affected by age distribution.

Table 12: Population health indicators in Qatar 2004 - 2014

Calendar Year

Indicator 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Life expectancy at birth (Years) 73.04 73.67 73.09 74.41 75.19 75.35 75.51 75.07 78.09 78.24 78.38

Mortality rate (deaths/1,000 population) 4.52 4.61 4.72 4.82 2.47 2.46 2.44 2.43 1.55 1.54 1.53

Infant mortality rate (per 10,000 live births) 19.32 18.61 18.04 17.46 13.09 12.66 12.34 12.05 6.81 6.06 6.42

Under five mortality rate (per 1,000) 12.20 11.90 11.70 11.50 11.40 11.40 11.30 11.20 11.10 11.00 10.86

Source: Qatar Ministry of Development, Planning and Statistics; WHO Database; IHME, World Bank

It is estimated that NCDs contribute to 75% of the total burden of disease among nationals in

Qatar.

Figure 10: The ten top causes of deaths between 2005 and 2016 in Qatar.

It shows that road traffic injuries superseded Ischemic heart disease and diabetes in 2016. (IHME; WHO HEA Database; National Data). The data related to nationals.

As Figure 16 shows, road traffic injuries are the number one cause of death in Qatar in 2016, despite measures to reduce speed on the road by the introduction of speed cameras and heavy fines [62],[63]. Self-harm has increased to be the 4th most common cause of death in 2016

(from 8th in 2005) [64].

Health system structure

The Ministry of Public Health regulates and monitors the country’s health system and provides services to address national priorities (Figure 11). This includes a wide range of public health functions such as environmental health tests, communicable disease screening for all migrants and privately operated primary care services. The Ministry of public Health (MoPH) funds and supervises Qatar’s largest network of public providers: Hamad Medical Corporation

(HMC), which is responsible for all secondary and tertiary healthcare; and Primary Care

Corporation (PCC), which is responsible for all primary care service.

In 2013 the Qatar Council for healthcare practitioners (QCHP), was established as a professional licensing organisation with the aim of enhancing accountability and effectiveness of health professionals.

Figure 11: Ministry of Health structure as 2016

A Director of Public Health leads the public health function, which is located within the Ministry of Public Health. The two Corporations are functioning with some independent financial control, although the overall responsibility is with the Minister of Public Health.

Health service delivery

In 2012, there were 8 hospitals in Qatar, along with 24 health centres. Within these, there was one maternal care unit and three specialised hospitals. There were 2,208 hospital beds in

2012, with plans to increase that number to 2,980 by 2019 (Table 13). Most healthcare

facilities are modern and based in urban areas, especially around the capital, Doha. Table 13

shows the current health infrastructure and plans for development (Qatar) (2012-2019).

Table 13: Health infrastructure and plans for development (Qatar) (2012-2019)

Calendar Year

Infrastructure 2012 2013 2014 2015 2016 2017 2018 2019

Maternal Care Centres/Units 1 2 3 3 7 7 7 7

Health Centres 24 25 26 29 40 43 43 43

Hospitals 8 8 8 9 13 13 13 13

Other Specialised hospitals 3 3 5 6 7 9 10 14

Total Facilities 36 38 42 47 67 72 73 77

Total Hospital Beds 2,208 2,100 2,100 2,223 2,629 2,629 2,629 2,980

Total Renovation Projects 0 0 6 15 15 28 28 28

Source: Ministry of Public Health Qatar. https://www.moph.gov.qa/home-en

In 2013, the Primary HealthCare Corporation (PCC) advanced the construction of 19 health

centres to replace some of the existing ones, as part of a program focused on enhancing

wellness, community and urgent care, as outlined in the National Primary Care Strategy 2013-

2018 [65]. The 24 health centres with 139 certified family physicians are located mainly in busy

suburban areas. The HMC runs 17 healthcare facilities including 7 general and specialised

hospitals and 10 specialised medical centres with 1,940 hospital beds (Table 13). An

additional 330 beds are available in private hospitals, which is expected to increase. In

addition, there are two governmental hospitals not linked to HMC: Sidra Medical and Research

Centre, which will mainly provide a referral only maternal and paediatric service, and Aspetar

Hospital, which is the first specialised Orthopaedic and Sports Medicine Hospital in the Gulf.

Health workforce

In recent years, Qatar’s health system was under strain mainly due to the rapid expansion of the population of migrant workers. The government through their National Health Strategy in

2011 have expanded the services and recruited a huge number of health professionals, almost doubling the number of physicians by 2014 (Table 14). In preparation for the 2022 World Cup and the huge construction projects across the country, it is expected that the number of health facilities and health professionals will expand further over the next few years.

Table 14: Health Workforce (Qatar) from 2006 to 2014 (rates per 1,000)

Year

Health workforce 2006 2010 2014

Physicians 3.11 4.03 7.7

Dentists 0.72 0.55 1.19

Nurses 6 6.19 8.5

Pharmacists 1.14 1.17 *

Source: SCH, MoPH, WHO Database, World Bank

*No data for Pharmacists in 2014.

Health financing

Since independent Qatar provided free healthcare to all nationals and expatriates. However, the falling oil prices, rising costs and increased pressure on the budget led the government to require expatriates to purchase health cards in recent years. The costs remain low and signal a shift in government policy. . To minimize the cost of healthcare service on public funds, the

Government explored the introduction of a national health insurance for nationals and non- nationals. This shift in the government’s attitude to the public provision of healthcare is also reflected in the establishment of several new private hospitals. Thus, under the National Health

Strategy (NHS) 2011–16 [66] the national health insurance (Seha) was introduced in 2014, first for the nationals and then non-nationals. By December 2015, the Government suspended the

Qatar mandatory health insurance, in favour of exploring private insurance schemes through the open market. Hence, the current funding of the health system continues to be mainly public with some of out-pocket –payments.

The country allocated £1.5 billion for health sustainable improvement projects and services transformation and, in 2011; the government mandated all private hospitals in the country to achieve international accreditation within the next three to four years.

Despite its wealth, Qatar spending on health is still low (2.3% of GDP) and more than 10% of the population seek healthcare outside Qatar.

Table 15 outlines healthcare expenditure in Qatar. The per capita healthcare expenditure of

USD 2,106 in 2014 was the highest in the GCC, although this represents just 2.3 per cent of

GDP. The government expenditure on health as a percentage of the total health expenditure is high (86%).

Table 15: HealthCare Expenditure (Qatar) 2014

Expenditure Value

HealthCare Expenditure as % of GDP 2.3

HealthCare Expenditure Per Capita (USD) 2663

Government Expenditure on Health as % Expenditure on Health 85.9

Private Expenditure on Health as % of Total Expenditure on Health 7.4

GDP Growth 2012 % 16.6

Prepaid and Risk-Pooling Plans (Private) Expenditure on Health as % 14.9

OPP (Private) Expenditure on Health as % 6.9

The high per capita expenditure is high because this for nationals only who represent 10.1% of the total population.

The profiles of the three GCC countries provide interesting findings which I will compare later to explore the differences in health systems performance in meeting population health needs (Chapter 6).

Chapter 3 Aim, Objectives and Methods

This chapter will examine the methods used in data collection, which incorporate both quantitative and qualitative elements. This approach will enable the research to explore the complex issues relating to the impact of performance assessment and to collect and quantify the information necessary to produce reliable findings. My particular focus will be on how to sustain health system performance in each of the three study countries through health financing policies and by producing, recruiting and retaining the right and competent workforce. These two health system building blocks were used in this research to assess the ability of three GCC countries (Bahrain, Kuwait and Qatar) in achieving their health system goals [2, 9, 47]. The six countries have similar population, culture, development and health systems and hence three were selected randomly to represent the population and health systems in the GCC.

Aim:

The main aim of the study is to enhance our understanding of the health systems and their performances in the GCC countries of Bahrain, Kuwait and Qatar.

Objectives

Objective 1:

To explore the socio-demographic fabric of each of the countries, and to draw parallels between the three countries (Bahrain, Kuwait and Qatar), the complexity of health systems, the intricate relationship between the supply and demand of health, demographic complexity and the social determinants of health.

Objective 2:

To investigate whether health system performance assessment (HSPA) policies and procedures are in place in any of the countries and to what extent these procedures have developed to accommodate for the particular population needs in each of these three countries

(Bahrain, Kuwait and Qatar). .

Objective 3:

To explore the impact of two health system building blocks on health and healthcare policies in three countries of the GCC (Bahrain, Kuwait and Qatar): Finance and Health Workforce

Hypothesis

H0: The health systems performance in three GCC countries is based on quality standards that address population health needs.

H1: The health systems performance in three GCC countries is not based on quality standards that address population health needs.

Research Questions

In line with the main aim of the study which is to ‘enhance our understanding of the health systems and their performances in the GCC countries of Bahrain, Kuwait and Qatar’, I have focused on answering the key research question:

What are the methods used to assess the health system performance of the health systems in Bahrain, Kuwait and Qatar?

Subsequent questions I aimed to address were:

1. Are current health systems designed to address the needs of the entire population?

2. Is current expenditure sustainable?

3. How can these systems address the most challenging elements of health worforce?

4. Can health systems in the three GCC countries of Bahrain, Kuwait and Qatar achieve sustainable improvements in population health?

Research design

A summary of the research design and the methods to address the aim and the research questions is given in (Figure 3).

After an initial review of the literature and my personal knowledge due to my work within a

GCC health system, it became evident how little research was conducted on health systems and its performance in the GCC. Indeed, in my informal discussions with experts in the field and through the experience of my supervisors in health system development, I decided that the most appropriate method would be to use a triangulation approach using both quantitative and qualitative data, despite the limitation of the latter [53]. I was also advised by external assessors of my project to focus on three out of the six GCC countries because of their

similarities and to manage the research project more effectively, including access to data and staff.

Figure 12: A summary of the research design and the methods.

Quantitative Methods

In addition to the review of the literature (Phase 1), I undertook extensive data collection to address the research questions: both primary and secondary questions (Phase 2). See figure

Phase 1:

In the first phase, I started with a review of the literature, which is discussed in sections below followed by a systematic review on HSPA in the GCC.

Phase 2

The second phase included collecting a mass of data on mortality, morbidity, the risk to health,

health access and quality of service, health finance and Human Recourses of Health (HRH)

in the countries of the GCC (with more detailed analysis for Bahrain, Kuwait and Qatar). For

this, I relied on multiple sources:

1. I accessed all published official data from the WHO, World Bank and other sources, but

also found other related but unpublished data (grey literature). In addition, data were collected

on the health expenditures over several years for the three countries and data on human

resources for health, with particular emphasis on migrant health workers, national training

programmes and workforce regulations. Data were collected from multiple sources: a. Ministry of Health and Ministry of Planning in each country. Some of these countries have a

Central Statistical Organisation/Office, which I have managed to contact and visit. b. WHO Eastern Mediterranean Regional Office (EMRO is responsible for 22 countries in the

Middle East and North Africa including the six GCC countries). c. World Bank Data related to the Middle East and North Africa d. The Executive of the GCC Council for Health Ministers (Riyadh, KSA) e. Google Search for any other relevant data

In addition, I obtained a large number of published and non-published official documents.

Many of these documents are with data on the health systems, the burden of disease and

planned development to improve service and health. Examples of these documents include a

National Health Strategy (Qatar), Bahrain Health Strategy, Health Service Development

Strategy (Kuwait), Cancer Strategy (Qatar), Primary care Strategy (Qatar), Mental Health

Strategy (Qatar), Health Insurance (Bahrain), and all WHO County Cooperation Documents

for the three countries.

During my visits to each country for the face-to-face interviews (see phase 3), I also collected

further unpublished information related to the research questions. Furthermore, the Office of

the GCC Executive Board of the Health Ministers Council provided extensive data collected across the GCC, both published and unpublished.

2. I obtained permission to access Global Burden of Disease Data (GBD) at the Institute of

Health Metric and Evaluation (IHME), Seattle. After training, I used the GBD Results Tools;

GDB compare/ Visualisation Hub: and direct contact with researchers at the IHME. The GBD data is the largest de facto source for global health accounting with data from 195 countries and territories, with substantial assessments of 12 countries, calculated for each year since

1990. It is comprehensive, and includes 333 diseases and injuries, 2982 sequels of diseases and injuries, and 84 risks or combinations of risks are included. The GBD data has been updated annually since 2005 [43].

In particular, I have used the HAQ index (Healthcare Access and Quality Index) as a proxy for

HSPA. I decided on the HAQ index as the only measure currently available that addresses the quality of specific interventions for 33 diseases. Other HSPA are mainly addressing high- level indicators.

HAQ Index was constructed by the IHME employing principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0.88), an index of

11 universal health coverage interventions (r=0.83), and human resources for health per 1000

(r=0.77). The free disposal full analysis with bootstrapping was used to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allows better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum. The methods of construction and application are fully described by [43].

3. It was essential during this phase to collect data on the complex nature of the population of

the GCC countries. Here, I encountered many difficulties in obtaining accurate data on the

number of nationals, long-term resident non-nationals, and short-term migrant workers.

National Statistical Offices in the countries were reluctant to share data on security grounds.

Qualitative Methods

Phase 3:

The third phase is the qualitative research seeking the opinion of the health leaders and

policymakers in the three countries and indeed within the GCC health leadership.

In this phase of the research, the plan was to collect all data available on the current health

systems in the three countries, on performance, and on outcomes (access, quality and

acceptance). For this phase of the research, I planned three possible approaches:

1. Structured interview with health leaders and key policymakers from the three countries,

mainly at the ministry of health, major hospitals and primary care services.

2. Face-to-face interviews during my visits exploring the state-of-art developments of the three

countries’ health systems, personal opinions and indeed their views about the future.

3. Focus groups to discuss and explore some of the gaps and issues raised during the

research.

For this part, I designed a self-administered questionnaire to be completed by policy makers.

The main aim of this questionnaire was to explore the knowledge and practice of health

systems assessments and monitoring of their performance to enhance decision-making and

influence health policies. The main aim of this questionnaire was developed to address the

following parameters:

 Profile of participants

 Individuals experiences of attaining the performance assessment

 Their reasons for training for the performance assessment

 How they thought the performance assessment has affected their work in practice

 How the training towards the performance assessment has enabled their work practice,

 The cost benefits of working towards the performance assessment, and personal benefits

they have achieved from undertaking the award the bounds at the end of the year,

 Access, coverage, quality and safety of health services as means of attaining the aims of

performance assessment.

The Questionnaire was piloted with three health leaders and policymakers within each of the

three GCC countries (Bahrain, Kuwait and Qatar). Questions were adjusted and the

questionnaire was translated into Arabic.

For the second part, I relied on face-to-face discussions with health leaders and policymakers

during my visits to the three countries and while meeting some of them during their visits to

London. I was fully aware of the wide range of opinions on the current and future developments

of the health systems in the GCC. In particular, I was keen to learn about issues related to

equity in health and healthcare providers to nationals and non-nationals, their views on health

finance and in particular the policies in some countries of shifting the responsibility from the

state to individuals. I wanted to learn more about the health leadership, the quality of migrant

health workforce, and about the lack of legislation to ensure high-quality workforce in health.

I also wanted to establish why GCC health systems were not successful in addressing the

‘epidemic’ of non-communicable diseases (NCD) such as diabetes cardiovascular disease

and associated risk factors while other countries were more successful.

For the third part, the plan was to conduct at least one focus group in each country during my

visit but I was only to conduct one group meeting in Qatar.

Statistical Methods

Statistical analyses used Version 13.1 of the Stata statistical software [67].

Various statistical methods were used with the support and advice from IHME to analysis the burden of disease data and health access and quality data. Most countries’ profile data; human resources data and financial data did not need significant statistical analysis.

For the manager’s questionnaire, a rank comparison was used. Therefore, a list of 15 ordinal or binary questions was put to 75 healthcare managers, comprising 25 in each of three countries (Bahrain, Kuwait and Qatar). These variables were compared between the three countries using the Somers’ D (a measure of agreement between pairs of ordinal variables).

Of each country indicator with respect to the ordinal/binary question [68]. Somers’ D is an asymmetric measure of ordinal association between variables. Given 2 random individuals with unequal answers to an ordinal question, Somers’ D of a specified country indicator with respect to the question is the difference between 2 probabilities, namely the probability that the individual with the higher answer is from the specified country (and the individual with the lower answer is from one of the 2 other countries) and the probability that the individual with the lower answer is from the specified country (and the individual with the higher answer is from one of the 2 other countries). Somers’ D, therefore, will be positive for a specified country when individuals from that country tend to give higher-ranking answers than individuals from the other 2 countries and will be negative when individuals from that country tend to give lower- ranking answers than individuals from the other 2 countries. We computed confidence intervals for each Somers’ D use the delta-jacknife method with Fisher’s z-transformation. For each ordinal question, we also used the test pram module of Stata to carry out an F-test of the hypothesis that all Somers’ D statistics for all 3 countries were zero, thereby defining an unequal-variability version of the Kruskal-Wallis test for rank heterogeneity.

Synthesizing the evidence and Data Limitations

One of the key elements of this research was to obtain accurate data on the complex populations of the three countries, as, despite their small size, there are huge variations in recording the population depending on the source.

Population data in the study countries and the GCC, in general, is essential for this study, as many of the health policies are shaped, by the way, policymakers decided, on how to meet the complex health needs of nationals, non-nationals long-term residents and non-national migrant workers (mainly unskilled construction, service industries and domestic workers).

Such policies also influence the local assessment of each health system performance, and whether there is a whole system approach or selected population targeted approaches.

Lack of baseline data and variation in data availability are common for all non-nationals especially for short-term migrant workers in all the GCC countries. Consequently, I had to rely on informal and newspaper reports and, on some occasions, the social media. Although a less traditional data source, the latter, provided clear indications of how some policymakers think, how the health system works and indeed how services are or are not responding to the populations’ health needs.

The lack of official data, mainly masked under security issues in the Arab region, which is characterized by the lack of stability (currently 12 countries out of 22 are in conflict), is frustrating, but at the same time it did make the work challenging and drove me to explore more informal channels of data collection and explore the power of social media in shaping health policies and sharing information otherwise not available.

Reporting

The results of the study are reported in four chapters: chapter 4 reports the results of the systematic review; chapter 5 details a GCC wide and country profile with some comparative results between the six countries; Chapter 6 Health System Blocks emphasises on finance

and human resources for health; Chapter 7 is a quantitative assessment of health access and quality using the HAQ Index; and Chapter 8 analyses the views of leaders and senior managers on HSPA and its applications.

Chapter 4 Systematic Review

Chapter 4 Literature and Systematic Review

Literature review

Methodology

The aim of this literature review is to examine evidence about performance assessment of health systems in the GCC countries and internationally.

In terms of global evidence, the literature relevant to the research focus was identified from various sources. An online search was carried out to locate evidence about the concept of

‘health system performance assessment’, as well as related issues such as ‘health system and human resource’, ‘health system and finance for health”. The search used a range of health-related literature databases with a focus on health systems. I performed a literature review of all English and Arabic language publications since 1980 identified using the search terms (health system Performance/assessment/evaluation) and obtained via the following databases: PUBMED, Medline, ELDIS, the World Bank library, WHO library, ID-21, EMBASE, and the Cochrane library. I also reviewed key articles, conference publications, and texts that were not included in the database search through discussion with experts and by consulting the reference lists of the papers identified. A manual search in the reference lists of the gathered literature was also utilized, and recent books on health system related issues were found and reviewed. Finally, some references were located because of communication with other researchers and specialists in the field of health system reforms. Whilst articles written in English were selected, no relevant Arabic articles were found.

The search for the study was initially focused on the period between 1980 and 2016. However,

I did an additional work appropriate for the aim and objective of the research in 2017 exploring possibilities of additional research that may contribute to HSPA. Most of the published papers on Health System Framework Building block were from 2000 onwards.

As mentioned in earlier chapters, I expected a bulk of health system literature from GCC but was disappointed. Health system literature related to GCC in general and performance assessment, in particular, was lacking at all levels: academic and service. Hence, the search was widened to cover worldwide literature on health system development and assessment within the study questions and focus. Most recent work on healthcare systems in the Middle

East, North Africa, and the Gulf countries consists of reports compiled by consulting firms such as Booz & Company, McKinsey & Company, and Alpen Capital. These reports focus on how existing healthcare structures can be transformed into modern healthcare systems and lack academic rigour and tend to ignore larger, policy-related issues. There has been a striking dearth of contributions addressing policies and practices of healthcare systems of different states, as other authors found from a social science perspective [62, 69].

The extensive search of worldwide literature resulted in 887 peer-reviewed publications from

PUBMED and 168 publications from the other databases including those published by multilateral organisations of academic institutions and civil societies.

At the initial stage of the searching process, the concept “health system” was used in general and then later in combination with a human resource for health and health finance related concepts, themes and sub-themes. Most of the publications identified through the search reported the results of health system reforms or evaluated specific health programs rather than examining the measures used for evaluation; for example, focusing on the measures used (process) rather than the health outcomes. Only studies that offered examples of the actual application of the indicators in the field were included in the review. 118 papers on the health system’s effectiveness were selected for final review, 90 on equity, and 97 with efficiency.

From the above search results, two types of articles were selected for review. . The first set of papers was conceptual articles on health system performance measurement, which were used to assist in defining the various frameworks of health system performance assessment.

The second set of papers selected discussed actual indicators used in practice to assess health systems. The latter articles either assessed indicators used to measure the impact of health policy in countries and reforms or reported on direct trials of measurement tools that are used in practice. All published articles that met these criteria were reviewed in depth.

These reviews were reported in chapter 2 and will be discussed again at the end of this and later chapters. However, I thought it would be useful to reflect on how countries used various review and assessment approaches to strengthen health systems and hence improve the population’s health.

1. 'Functional Review' is a transformation of health based on its functions. In such transformation, the starting point is an in-depth analysis of the policy, structure, service delivery and regulations.

2. 'Performance Review': is a transformation based on the 3 health system goals of better health, responsiveness to health needs and financial protection. The Commonwealth Fund's assessment of high performing systems, described in chapter 2, is based on Quality (right, safe, coordinated and patient centred care), access, efficiency, and equity and healthy productive life.

3. 'Financial Review' is a transformation with emphasis on the search for efficiency and value for money. In many cases and in many transformations these reviews aim at cutting services or shifting the responsibilities from Government to individuals.

4. 'Service Review' a transformation based on its ability to meet emerging / changing population’s health needs. Good examples of changing needs are the HIV epidemic, non- communicable diseases (NCDs), the introduction of new technology etc.

In practice, many countries’ health transformation is a mixture of the above, although in recent years, due to the global financial crisis, the focus has mainly been financial rather than on public health needs including countries across Eastern Mediterranean Region of the WHO

(EMRO), which includes the six GCC.

Systematic Review

In the background chapter (Chapter 2), I described the various frameworks used worldwide in assessing health system performance assessments. These came from literature in the developed world and international organisations since the late 90s. The purpose of this review is to focus on health system performance in the GCC and the way governments, institutions and researchers are assessing performance in each country to explore how performance frameworks are developed, applied and used in the GCC to assess health systems and measure its main objectives to achieve better health for the entire population including both nationals and migrants (non-nationals).

Methodology

Online databases were searched for published materials, supplemented by literature reviews of reference lists and citation tracking of key authors and papers to generate additional articles that may have been missed in the database reviews. The search aimed to retrieve published articles on health system performance in the three study countries.

Data sources and search strategy

After a scoping exercise, I have conducted two systematic reviews on HSPA in GCC: the first one was at the start of my second year of study and was repeated with extended search criteria in 2017. Both reviews used the same databases, covering a period from 1980, with the second review having extended keywords. The Electronic databases: EMBASE Classic +

EMBASE (1980 – 2016), Ovid Medline (1980 – June 2016), HMIC Health Management

Information Consortium (1980 - 2016), and Global Health (1980 – 2016) were used to systematically review the literature in order to identify all available data up to end of 2016 from published and selected unpublished sources. The search aimed to identify literature that discussed Health System performance assessment, or evaluations, in Bahrain, Kuwait &

Qatar. A second review used the same databases and keywords, was repeated in June 2017 covering a period of 2000 to the end of June 2017. The selection of 2000 as the starting points as literature has shown most of the HSPA research were conducted following the publication of WHO World Health Report in 2000 [2]

Key words: Keywords (Bahrain OR Kuwait OR Qatar) AND (Health System Assessment OR

Health System Performance OR Health System Development OR Health System

Responsiveness OR Health System OR Health service [mesh] OR Healthcare Service* Or

“Academic Health System” OR Access to Healthcare OR Health delivery OR Health finance

Or Healthcare disparities [mesh] OR Healthcare inequality* OR Delivery to Healthcare

[mesh] OR Health Service Accessibility [mesh] OR Health Service Outcomes

Figure 13: Example of search strategy

Example of search strategy on EMBASE [2000-June 2017]: Second Systematic Review

Study selection and data extraction

A systematic search of the electronic online databases for published literature on Health

System performance assessment, or evaluations, in Bahrain, Kuwait & Qatar are using the

Keywords (Bahrain OR Kuwait OR Qatar) AND (Health System Assessment OR Health

System Performance OR Health System Development OR Health System Improvement OR health system sustainable improvement OR health system outcome (Figure 4). No language restriction was imposed. ZK and I had then independently reviewed all the retrieved articles by title and abstract to find the relevant papers (Figure 14). Full text of the remaining articles was scrutinised and screened for eligibility. SR and AM checked reviews (my two supervisors).

Quality Assessment

As the studies selected were ‘descriptive’ studies, the quality assessment was conducted for each using the Critical Appraisal Skills Programme (CASP) for observational studies checklist.

(CASP) [70].

Databases searched: EMBASE Classic + EMBASE, Ovid Medline In process and other non-indexed citations & Ovid Medline, HMIC Health Management Information Consortium, and Global Health. Keywords:(Bahrain OR Kuwait OR Qatar) AND (Health System Assessment OR Health System Performance OR Health System Development OR Health System Responsiveness OR Health System OR Health service [mesh] OR Healthcare Service* Or “Academic Health System” OR Access to Healthcare OR Health delivery OR Health finance Or Healthcare disparities [mesh] OR Healthcare inequality* OR Delivery to Healthcare [mesh] OR Health Service Accessibility [mesh] OR Health Service Outcomes

Potentially relevant papers identified Excluded – not (n=11) relevant to the GCC or referring to health system performance but Articles remaining after no health system screening by details; or title and described only abstract (n=6) part of the system and no performance details (n=4)

Articles included (n=2)

Figure 14: PRISMA Chart for the systematic search of the literature

Results

Although the first review identified 6 articles, all deemed irrelevant, the second review in 2017 identified a total of 11 articles, of which 2 met the criteria. Reasons for excluding other articles are presented in Figure 5. Data extracted from each study in the two articles is depicted in

Table 16. Some characteristics of these two studies are worth mentioning here. There are only

two studies and they have different methodological approaches to assess health systems. The first study by Ali et al in 2013[71] was a survey in Qatar (population at that time was 1.5 million) and restricted to hospital care in one hospital. It is difficult to generalise the findings. Some of the recommendations are general and not related to the findings of the study and nor supported by data (for example lowering co-payments and strengthening primary care).

The second study by Wang and Yazbeck in 2017[72] is based on analysis of World Bank data on 20 countries in the Middle East and North Africa (so-called MENA Region), which includes the six GCC countries. The focus of the article was on health systems outcome pinpointing only two: population health status, using high-level indicators of mortality, Quality-Adjusted

Life Year QALY and Disability-Adjusted Life Year DALY; and some measures of financial protection (mainly out-of-pocket payment). In doing so, they focused on the methods used by

Person in 1975 linking mortality to the level of economic development) [73].

Both articles show that health systems are very challenging to benchmark due to multiple outcomes. A regional framework for health system performance assessment is needed more than ever in this rapidly developing part of the world.

Table 16: Characteristics of the included studies Study: Design & Exposure Exposure Measured Year & Population Main Findings Population Implication Setting Variables Data Outcomes Country

Qatar Descriptive Qatari 2 Variables 5 options Satisfaction with Non-Nationals High - The study shades more light on the concepts of Survey (one Nationals & scale care IP/OP Satisfaction satisfactions with & responsiveness of service (2013) [73] month Non- -Satisfactions Sept/Oct Nationals OP/IP Yes/No Index of Nationals & Males found - Good dimensions to improve quality 2012) (36%)) Responsiven Responsiveness services less responsive ess IP/OP to their needs - More attention to males and nationals is needed F (47%) (Waiting Time/ - Lower co-payment could increases satisfactions Diagnosis Explained/Re spect/Privacy - Strengthen primary care to improve access /Decision involvement/ Cleanliness) USA Route Data 20 MENA Population Life Health Status No correlation between Health systems are challenging to benchmark due (WB) based Countries, Health Status expectancy LEB and per capita to multiple outcomes and complex operation (2017) [71] on World including the (Mortality/mor at birth Financial income LEB Vs Development 6 GCC out bidity/QALY/ Protection Spending on Health (to Comparative ‘benchmarking’ is important to guide 160 countries DALY) (LEB) be explored more). policy and prevent failure Cross-country data Many countries are comparisons Financial LEB spending less than Different measures of health system performance & Protection expected but produced representing different dimensions of health benchmarking (OOP) Per Capita higher LEB than system outcomes Income expected (Socio- economic? Out of Detailed assessments of drivers of performance Health pockets (POO) should be undertaken Expenditure payments? Qatar and (OOP) UAE constantly Benchmarking identifies areas or performance underperformed. that needs to be addressed through the health system reforms.

Quality Assessment

As the studies selected were ‘descriptive’ studies, the quality assessment was conducted for each using the Critical Appraisal Skills Programme (CASP) for observational studies checklist.

(CASP) [70]. (See Table 17)

Table 17: Mean quality score of the three reviewers on CASP Checklist Criteria Addressed Ali et al (2013) [59] Wang & Yazbeck (2017) [60] 1. Focused: Population, Risk Factors, Outcomes 1 1 2. Appropriateness of study design 1 1 3. Generalisability 1 0 4. Exposure: Objective measurements with validated instruments 1 1 5. Outcome: Objective measurement with validated instruments 1 1 6. Cofounders: identified 0 0 7. Cofounders: methodological control 0 0 8. Results: Reliability 1 1 9. Implication: local population 0 1 10. Implications: Regional 1 0 TOTAL QUALITY SCORE 7/10 6/10 1: Criteria evidently met 0: Criteria not accounted for/unclear Maximum Score=10 (10 out of 12 criteria selected for relevance of the reviewed studies). There were three reviewers (A.M, M.S, and S.R) that checked the results.

Chapter Discussion

This systematic review shows clearly the lack of interest in health system performance research in the

GCC.[74,75]

This is similar to the findings of Tashobya et al 2014, who showed that HSPA is a process mainly undertaken in upper-income countries and that low and middle-income countries approaches are limited to a service or a small scale surveys. [3]

The above findings revealed deficiencies in national health research systems in the areas of health system assessment (priorities, strategy, capacity, activity, access, quality, governance, and outcomes).

The lack of interest among health professionals and academia to generate the knowledge in GCC countries to inform their health systems despite the vast wealth is a serious issue and must be addressed by collective actions across the GCC six countries. [49]

Relaying on consultancy firms addressing policies and practices of health systems of these countries is a serious deficit in trained health leadership and senior management. These private firms lack academic rigour and tend to ignore larger, policy-related issues. The findings also confirm that our approaches to obtaining information from current policymakers and informers are the best possible method available to us to complement assessment of the health systems in the GCC.

Chapter 5 The Health Status of the GCC population with a focus on Bahrain, Kuwait and Qatar.

Chapter 5 The Health Status of the GCC Population with a focus on Bahrain, Kuwait and Qatar

Introduction

This chapter will introduce the overall picture of the GCC in terms of population dynamics, the burden of disease, workforce, finance in general and the structure, function and governance of the health system. This chapter compares and contrasts the six Gulf States with a focus on

Bahrain, Kuwait and Qatar in terms of their population, disease burden and health service provision. These will be related to comparable health systems outcomes in later chapters. The following dimensions were explored with a brief description for each of the three selected countries:

1. political, cultural and economic history;

2. population demographics;

3. risks to health;

4. burden of disease;

5. history of the health service;

6. health system structure;

7. health service delivery;

8. health workforce; and

9. health finance.

I relied mainly on official statistics published by the three governments. However, other international data (International Labour Organisation ILO, WHO, World Bank, and

International Organisation for Migration for example) may not correspond with the national official statistical organisations and published reports. In the discussion, I will explore this point further as it has some implications on the interpretation of the official data and health systems

performance assessments. Individual country data for the three study countries were analysed in detail.

The Gulf Corporation Council (GCC) Countries

The Gulf Cooperation Council, referred to as GCC, is a regional co-operation system between six countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. The

Council was formed in 1981 with the main principle of achieving a single culture and nation.

The establishment of this cooperation was highly facilitated by geographical proximity, common culture, language and religion, and similar regulations and economic and social conditions. The GCC, with a 2.55 million km2 area, has an estimated population (2016) of 51.5 million nearly half of whom are foreign nationals in long or short-term contract visas.

The GCC Population (Nationals and non-nationals)

In all six GCC countries, the demographic changes seen due to the influx of foreign labour, driven by an unprecedented economic boom, have occurred at an extraordinarily rapid rate, not observed in any other country during this modern era. The region’s aggregate population has increased more than tenfold in a little over half a century (from four million in 1950 to 40 million in 2005, and over 51 million in 2016).[76],[77] (Table 18)

Foreign nationals (described locally as non-nationals) outnumber citizens in four of the six

GCC states, and foreign national workers with short-term contracts represent between 83.7% in Saudi Arabia to 90.8% in Qatar (Table 18)

Table 18: The GCC total population distributed by countries

% in total Population % of Foreign Labour Nationals with Market Nationals Foreign short term % Foreign Total Foreign contacts Nationals Country Nationals Population Nationals Nationals

Bahrain 1,314,562 630,744 683,818 48.0 52.0 88.0 56.0 Kuwait 4,294,171 1,316,147 2,978,024 30.6 69.4 89.2 >65.0 Oman 4,419,193 2,412,624 2,006,569 54.6 45.4 87.1 73.1 Qatar 2,404,776 243,019 2,161,757 10.1 89.9 90.8 94.2 Saudi 30,770,375 20,702,536 10,067,839 67.3 32.7 83.7 56.0 Arabia UAE 8,264,070 947,997 7,316,073 11.5 88.5 85.2 >90.0 TOTAL 51,467,147 26,253,067 25,214,080 51,0 49.0 87.3 >72.4 Source: National Statistics Offices, ILO, WHO, UN, WB and Gulf Research Centre [http://gulfmigration.eu/gcc-total-population- percentage-nationals-foreign-nationals-gcc-countries-national-statistics-2010-2016-numbers]. [https://www.gccstat.org/en/]

Supplementary data on short-term contract foreign nationals in the six countries for the period

2015-2016 were collected from ILO, WHO, the United Nations (UN) and the World Bank (WB).

Data on the labour market, which has a direct impact on HRH, is also added to the table. The bold percentage figure highlights the high percentage of national and foreign nationals. The latter are divided into two groups: long-term or short-term contracts.

Foreign nationals are the backbone of the labour market in all six GCC countries with the lowest figure in Bahrain (56%) and the highest in Qatar (94.2%) this has implications for the stability and sustainability of workforce in general and the health service in particular (Table

18) . The vast majority of the short-term foreign national workers, from more than 90 countries with different backgrounds, culture and education tend to be employed in jobs characterized by low payment, long working hours, and, at times, a physically and mentally hazardous working environment [8]. These jobs include the construction industry, domestic service, manufacturing, fishery, entertainment, sports, education, health, management, and others such as hospitality or support services. Many of these workers experience poor housing conditions and have limited access to quality health service. Employer-based insurance is basic and typically covers only accidents at the workplace, thus many find it hard to access

the health services for other health problems [78]. Large companies directly employ the majority of labourers on short-term contracts for construction and manufacture while recruitment agencies employ domestic and entertainment workers. A large proportion of them are single male labourers (SML) in construction and the manufacturing industry and relatively few single women in the domestic and service industry, without accompanied families [79]. Long-term contracts are mainly for workers with government agencies (all ministries), banking, commercial sectors and small individual businesses. All foreign workers, except government- employed ones, are granted a work visa through Kafala (sponsorship) by an individual national or a national company [80]. In November 2017, and following sustained international criticism,

Qatar abolished the controversial Kafala (sponsorship) system for all workers [81]. Furthermore, new rules in 2017 in Qatar give domestic workers labour rights: rights which do not exist in all

GCC countries [82].

GCC Population’s Health Profile

Thanks to the vast oil and gas reserve and production, the six GCC countries have achieved impressive economic and social development over the last four decades. These have impacted positively on all aspects of life including the health services and population health.

Life Expectancy: Figure 15 shows the life expectancy of the six GCC countries compared with all other Arab countries and the UK. The GCC countries longevity has improved dramatically over this period, and has overtaken all other countries in the region except

Lebanon. This improvement can be attributed to the social and economic development of the six countries in almost all aspects of life [51].

In the 1970s in Oman, for example, there were only thirteen physicians (mostly British) and life expectancy was 49.3 years of age [71]. The dramatic improvements over a relatively short period of time [72] ranked the Omani health system as one of best performing by the controversial WHO World Report in 2000 [2].

In all Arab countries life expectancy at birth has continuously improved since 1960 with the exception of Iraq and Syria (mainly due to recent wars and civil conflicts). The six GCC countries (dotted lines), the wealthiest in the Arab world, are by far with much higher life expectancies than others (Figure 15).

Life Expectancy at Birth of GCC Arab Countries 1960-2016 90

UK 70 Qatar

Bahrain 60 Kuwait

UAE 50

KSA Oman 40

0 1960 1970 1980 1990 2000 2010 2016

Bahrain Kuwait Oman Qatar KSA UAE UK

Figure 15: Life expectancy at birth in GCC countries (Population over 410 million) compared with the UK for the period 1960 to 2016.

(Source: Countries National Statistics Offices, WHO, World Bank)

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Healthy Life Expectancy: The number of years of healthy life expected at birth (HALE

Healthy Life Expectancy) for each of the six GCC countries is summarised in Table 19.

Table 19: Healthy Life Expectancy at Birth (HALE)

Country 1990 1995 2000 2005 2010 2015

UAE 60.99 62.17 63.45 65.09 65.61 65.52

Bahrain 61.99 62.81 63.38 65.47 67.6 68

Saudi 64.39 65.75 66.89 67.80 68.68 69.36 Arabia

Oman 62.05 63.68 64.63 65.39 65.45 66.36

Qatar 64 64 65 66 68 69

Kuwait 66.69 66.57 67.49 67.64 68.32 69.82

Healthy Life Expectancy at Birth (HALE) in the six GCC countries with the three study countries (highlighted in blue) between 1990 and 2015. HALE is a measure of population health that takes into account mortality and morbidity. It adjusts overall life expectancy by the amount of time lived in less than perfect health.

HALE has increased in all countries. Kuwait, Oman and Qatar have the highest number of years lived without disease and disability (69.82, 69.36 and 69.0 respectively). This is higher than in neighbouring countries and above the world average of 63.1 years.

Disability-Adjusted Life Years: Looking at the DALY (Disability-Adjusted Life Years), which is calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences, in the six GCC countries between 1990 and 2015, shows an interesting picture (Table 20).

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Table 20: Disability-Adjusted Life Year (DALY) per 100, 00 for both sexes

Country 1990 1995 2000 2005 2010 2015

UAE 26,198.44 23,167.93 20,972.18 19,515.45 19,267.70 20,897.70

Bahrain 25,087.06 23,313.78 22,340.31 19,171.29 17.452.34 17,363.18

Saudi 29,755.24 24,192.56 20,433.59 18,409.36 17,427.65 17,055.55 Arabia

Oman 31,762.19 23,827.82 19,932.57 18,720.97 19,617.77 18,701

Qatar 21,511 21,498 21,269 19,318 16,336.92 15,600.45

Kuwait 18,753.71 18,545.34 17,304.38 17,278.57 16,195.49 15,155.21

Disability-Adjusted Life Year (DALY) per 100,00 for both sexes, all ages and all causes for the period of 1990 and 2015 in the six GCC countries highlighting the three study countries (blue). One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

So all GCC show a reduction in DALYs between 1990 and 2015, while total global DALYs trend shows small change from 1990 to 2016 (–2·3%), this is not the case for the GCC countries. With sharp decreases in communicable, maternal, neonatal, and nutritional disease, DALYs age-standardised rates in 2015 were lower in all GCC countries with more reduction in Saudi, while Kuwait started with lower rates than the other GCC countries. The decreases in communicable, maternal, neonatal and nutritional disease DALYs were offset by increased DALYs due to NCDs in all countries of the GCC as we have shown in Table 21.

Leading Causes of Deaths: Analysis of the data of the ten top leading causes of deaths in the six countries between 1990 and 2015 shows an interesting picture reflecting the development of these countries. Table 21 shows the impact of the epidemiological transition from infectious to non-communicable diseases and the demographic changes of population growth and ageing.

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Table 21: The ten top leading causes of deaths in the GCC between 1990 and 2015

Saudi Arabia Kuwait UAE Bahrain Qatar Oman 1. Neonatal 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular disorders 1. Cardiovascular Diseases Diseases Diseases 1. Cardiovascular 2. Cardiovascular Diseases 2. Transport injuries 2. Neoplasms 2. Transport injuries Diseases diseases 2. War & disaster 3. Unintentional 3. Diabetes, 3. Neoplasms 2. Neonatal 3. Diarrhoea, LRI, 3. Neoplasms injuries Urogenital, Blood, 4. Diabetes, disorders Other 4. Transport injuries 4. Neoplasms Endocrine Urogenital, Blood, 3. Transport injuries 4. Unintentional 5. Other non- 5. Neonatal 4. Neonatal Endocrine 4. Diarrhoea, LRI, injuries communicable Disorders Disorders 5. Neonatal Other 5. Other non- 6. Diabetes, 6. Diarrhoea, LRI, 5. Transport injuries Disorders 5. Neoplasms 1990 communicable Urogenital, Blood, Other 6. Diarrhoea, LRI, 6. Unintentional 6. Other non- 6. Transport injuries Endocrine 7. Diabetes, Other injuries communicable 7. Neoplasms 7. Diarrhoea, LRI, Urogenital, Blood, 7. Other non- 7. Other non- 7. Diabetes, 8. Diabetes, Other Endocrine communicable communicable Urogenital, Blood, Urogenital, Blood, 8. Neonatal 8. Chronic 8. Chronic 8. Diarrhoea, LRI, Endocrine Endocrine disorders respiratory respiratory Other 8. Unintentional 9. Neurological 9. Unintentional 9. Other non- 9. Unintentional 9. Self-harm and injuries disorders injuries communicable injuries violence 9. Neurological 10. Chronic 10. Neurological 10. Self-harm and 10. Neurological 10. Neurological Disorders respiratory Disorders violence Disorders Disorders 10. Other group 1 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular Diseases Diseases Diseases Diseases 1. Cardiovascular Diseases 2.Transport Injuries 2. Neoplasms 2. Transport injuries 2. Diabetes, Diseases 2. Transport injuries 3. Neonatal 3. Transport injuries 3. Neoplasms Urogenital, Blood, 2. Transport injuries 3. Diabetes, disorders 4. Diabetes, 4. Unintentional Endocrine 3. Neoplasms Urogenital, Blood, 4. Neoplasms Urogenital, Blood, injuries 3. Neoplasms 4. Diabetes, Endocrine 5. Unintentional Endocrine 5. Diabetes, 4. Transport injuries Urogenital, Blood, 4. Neoplasms injuries 5. Other non- Urogenital, Blood, 5. Other non- Endocrine 5. Diarrhoea, LRI, 6. Diabetes, communicable Endocrine communicable 5. Unintentional Other 2005 Urogenital, Blood, 6. Diarrhoea, LRI, 6. Chronic 6. Self-harm and injuries 6. Neurological Endocrine Other respiratory violence 6. Other non- Disorders 7. Diarrhoea, LRI, 7. Unintentional 7. Diarrhoea, LRI, 7. Diarrhoea, LRI, communicable 7. Neonatal Other injuries Other Other 7. Neonatal disorders 8. Other non- 8. Neonatal 8. Self-harm and 8. Chronic disorders 8. Other non- communicable Disorders violence respiratory 8. Self-harm and communicable 9. Neurological 9. Neurological 9. Other non- 9. Neurological violence 9. Unintentional disorders Disorders communicable Disorders 9. Neurological injuries 10. Chronic 10. Self-harm and 10. Neurological 10. Unintentional Disorders 10. Chronic respiratory violence Disorders injuries 10. Cirrhosis Respiratory 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular 1. Cardiovascular Diseases Diseases 1. Cardiovascular Diseases Diseases Diseases 2. Neoplasms 2. Neoplasms Diseases 2. Diabetes, 2. Transport injuries 2. Transport injuries 3. Transport Injuries 3. Transport injuries 2. Transport injuries Urogenital, Blood, 3. Neoplasms 3. Diabetes, 4. Diabetes, 4. Diabetes, 3. Neoplasms Endocrine 4. Diabetes, Urogenital, Blood, Urogenital, Blood, Urogenital, Blood, 4. Diabetes, 3. Neoplasms Urogenital, Blood, Endocrine Endocrine Endocrine Urogenital, Blood, 4. Transport injuries Endocrine 4. Neoplasms 5. Diarrhoea, LRI, 5. Diarrhoea, LRI, Endocrine 5. Neurological 5. Unintentional 5. Diarrhoea, LRI, Other Other 5. Unintentional Disorders injuries Other 2015 6. Unintentional 6. Other non- injuries 6. Other non- 6. Self-harm and 6. Neurological injuries communicable 6. Chronic communicable violence Disorders 7. Neurological 7. Neurological respiratory 7. Self-harm and 7. Other non- 7. Unintentional disorders Disorders 7. Diarrhoea, LRI, violence communicable injuries 8. Other non- 8. Unintentional Other 8. Diarrhoea, LRI, 8. Neurological 8. Other non- communicable injuries 8. Self-harm and Other Disorders communicable 9. Neonatal 9. Neonatal violence 9. Chronic 9. Neonatal 9. Neonatal disorders Disorders 9. Neurological respiratory disorders disorders 10. Chronic 10. Self-harm and Disorders 10. Unintentional 10. Diarrhoea, LRI, 10. Chronic respiratory violence 10. Cirrhosis injuries Other Respiratory

Source: IHME, WHO, National Statistical Offices

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Cardiovascular diseases are dominant in the three countries studied and were the top cause of death in five GCC countries over the last 30 years. Transport injuries, mainly due to road traffic accidents are in the top 4 causes of death in all GCC. Deaths attributed to diabetes are also in the top 4 causes of death in the 3 countries. This has been the constant in the last 25 years (except Saudi Arabia). Four of six countries have seen a rise in neoplasms, while neonatal disorders have decreased in all of them.

Risks to Health:

Analyses of the top risk factors that cause or lead to death in the six GCC countries are given in Table 22. It shows that dietary risks in the form of overweight and obesity are the main risks to health in all GCC countries since the 1990s and continued through 2015 except in

Oman, where obesity became second to high blood pressure since 2005.

Table 22: The top ten risk factors that cause or lead to death in the GCC Saudi Arabia Kuwait UAE Bahrain Qatar Oman

1. Dietary risks 1. Dietary risks 2. High systolic 2. High systolic 1. Dietary risks 1. Dietary risks 1. Dietary risks 1. Dietary risks blood pressure blood pressure 2. High systolic 2. High systolic 2. High systolic 2. High body-mass 3. Air pollution 3. High body-mass blood pressure blood pressure blood pressure index 4. High total index 3. High body-mass 3. High body-mass 3. High body-mass 3. High systolic cholesterol 4. Air pollution index index index blood pressure 5. High body-mass 5. High fasting 4. High total 4. High total 4. High total 4. High fasting index plasma glucose cholesterol cholesterol cholesterol plasma glucose 6. High fasting 1990 6. High total 5. Tobacco 5. Tobacco 5. Tobacco 5. Air pollution plasma glucose cholesterol 6. Air pollution 6. Air pollution 6. High fasting 6. High total 7. Child and 7. Child and 7. High fasting 7. High fasting plasma glucose cholesterol maternal maternal plasma glucose plasma glucose 7. Air pollution 7. Tobacco malnutrition malnutrition 8. Low physical 8. Alcohol and drug 8. Low physical 8. Low physical 8. Tobacco 8. Tobacco activity use activity activity 9. Unsafe water, 9. Low glomerular 9. Low glomerular 9. Low physical 9. Low glomerular 9. Alcohol and drug sanitation and filtration rate filtration rate activity filtration rate use handwashing 10. Low physical 10. Occupational 10. Low glomerular 10. Alcohol and 10. Low glomerular 10. Low physical activity risks filtration rate drug use filtration rate activity

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1. Dietary risks 1. Dietary risks 1. Dietary risks 1. Dietary risks 1. Dietary risks 1. High systolic 2. High systolic 2. High systolic 2. High systolic 2. High systolic 2. High body-mass blood pressure blood pressure blood pressure blood pressure blood pressure index 2. Dietary risks 3. High body-mass 3. High body-mass 3. High body-mass 3. High body-mass 3. High systolic 3. High body-mass index index index index blood pressure index 4. High fasting 4. High total 4. High total 4. High fasting 4. High fasting 4. High fasting plasma glucose cholesterol cholesterol plasma glucose plasma glucose plasma glucose 2005 5. Air pollution 5. Tobacco 5. High fasting 5. High total 5. Air pollution 5. High total 6. High total 6. High fasting plasma glucose cholesterol 6. Tobacco cholesterol cholesterol plasma glucose 6. Tobacco 6. Tobacco 7. High total 6. Air pollution 7. Tobacco 7. Air pollution 7. Air pollution 7. Air pollution cholesterol 7. Tobacco 8. Low glomerular 8. Low physical 8. Alcohol and drug 8. Low physical 8. Low physical 8. Low physical filtration rate activity use activity activity activity 9. Low physical 9. Low glomerular 9. Low physical 9. Low glomerular 9. Alcohol and drug 9. Low glomerular activity filtration rate activity filtration rate use filtration rate 10. Alcohol and 10. Occupational 10. Low glomerular 10. Alcohol and 10. Low glomerular 10. Alcohol and drug use risks filtration rate drug use filtration rate drug use

1. Dietary risks 1. Dietary risks 1. Dietary risks 1. Dietary risks 1. Dietary risks 1. High systolic 2. High systolic 2. High systolic 2. High systolic 2. High fasting 2. High body-mass blood pressure blood pressure blood pressure blood pressure plasma glucose index 2. Dietary risks 3. High body-mass 3. High body-mass 3. High body-mass 3. High body-mass 3. High systolic 3. High body-mass index index index index blood pressure index 4. High fasting 4. High total 4. High total 4. High systolic 4. High fasting 4. High fasting plasma glucose cholesterol cholesterol blood pressure plasma glucose plasma glucose 2015 5. Air pollution 5. Tobacco 5. High fasting 5. High total 5. Air pollution 5. High total 6. High total 6. High fasting plasma glucose cholesterol 6. Tobacco cholesterol cholesterol plasma glucose 6. Air pollution 6. Tobacco 7. Occupational 6. Air pollution 7. Tobacco 7. Air pollution 7. Tobacco 7. Air pollution risks 7. Tobacco 8. Low glomerular 8. Low physical 8. Alcohol and drug 8. Low physical 8. High total 8. Low physical filtration rate activity use activity cholesterol activity 9. Low physical 9. Low glomerular 9. Low physical 9. Low glomerular 9. Alcohol and drug 9. Low glomerular activity filtration rate activity filtration rate use filtration rate 10. Alcohol and 10. Occupational 10. Low glomerular 10. Alcohol and 10. Low physical 10. Alcohol and drug use risks filtration rate drug use activity drug use

Source: IHME, WHO, National Statistical Offices

The health systems

All six GCC health systems are based on the ‘Beveridge model’, which is funded mainly through the government general fund, with variable out-of-pocket contributions (Figures 16, and Table 23). From the seventies until today there were substantial improvements in the six countries’ health services with investment in modern primary care centres and hospital facilities as well as improvement in public health infrastructure and functions.

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Governmental and out-of pocket health expenditure 0 20 40 60 80 100

Oman Kuwait Qatar UK Saudi Arabia UAE Bahrain % of governmental expenditure on health

Out-of-pocket expenditure on health and healthcare as a percentage of total health expenditure

Figure 16: Governmental and out-of-pocket health expenditure (2014).

Total Health Expenditure compared with the other GCC countries and the UK as a high social index country, 2015 (WHO 2016). The highest expenditure is that of Oman, Kuwait and Qatar, which are similar to the UK.

Furthermore, in recent years all countries experienced an expansion of the private health service providers (mainly hospitals and doctors’ private clinics). The six countries expenditure on health, which will be discussed in a later chapter in full, is below the 6% of GPD on health expected for achieving Universal Health Coverage (UHC) (Table 21).

Table 21: The health finance of the GCC countries

General General Total General Total Health General Government Government Health Government Expenditure Government Health Health Expendi Health (THE) % Health Expenditure Expenditure ture Expenditure Gross Expenditure (GGHE) as % (GGHE) as % of (THE) (GGHE) as % of Domestic (GGHE) per of Total General per Gross Product Capita in Health government Capita Domestic (GDP) US$ Expenditure expenditure (GGE) in US$ Product (GDP)

Bahrain 5 63 10 1,243 786 3 Kuwait 3 86 6 1,386 1,191 3 Qatar 2.3 86 6 2,106 1,806 2 Saudi Arabia 5 75 8 1,147 855 3 UAE 4 72 9 1,611 1,165 3 Oman 4 90 7 675 606 3 The health finance of the GCC countries (blue) compared with other countries in the region (data 2014-2016). None of the six countries spends over 6% of GDP on health. The highest are Bahrain and Saudi Arabia (5% of GDP).

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Prepaid health insurance based on annual premium, rather than a percentage of income, was introduced in Dubai and Abu Dhabi but not the rest of UAE [83]. Saudi Arabia introduced basic insurance for all foreign nationals, and in Qatar health insurance was abolished within one year of its introduction in 2014[84].

Data in Figure 16 show clearly that the higher the government expenditure on health, the less is the out-of-pocket (OOP) spending on health. With the high general government expenditure on health as a percentage of total health expenditure in Oman (90%), the OOP is the lowest in the GCC. The European Region of WHO showed that the higher the general government health expenditure as a percentage of general government expenditure the more it will reduce the premature NCDs mortality [85].

Primary care based on family medicine is well developed in Bahrain but not the rest of the

GCC. Fully qualified family physicians are around 20% in all GCC countries except Bahrain where it is 80% plus [86]. Qatar expanded their primary care services with modern health centres, but the trend shows that they are moving towards an ambulatory care model rather than primary care (holistic, with continuity of care) as the first contact with the health service

[87]. The gatekeeping function and continuity of care are not characteristics of the health systems in the GCC, although all have plans or intentions to do so[9]. WHO EMRO estimated that the shortage of family physicians in the 6 GCC countries is more than 14,000 fully trained family physicians (based on 3 family physicians/10,000 population) [76].

It is the case that all GCC countries, as with other Middle Eastern countries, are characterized by fragmentation of their health systems, with an expanding private health sector. This leads to fragmentation of government health financing[88],[61],[89],[90, 91] For example, the healthcare funding in Saudi Arabia is split amongst more than eight different government agency budgets, and each agency provides health services for its own-targeted population.

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Chapter Discussion

Economic and epidemiological changes in the GCC over the last four decades affected health systems as well as other ‘social’ services. The six countries have progressed their health system in this relatively short period of time in comparison to other countries in the region with a longer history of development; some are halted by conflict and civil wars. The comparative data, between GCC countries and neighbouring ones, show clearly that the health of the

Nationals has improved to a level comparable to developed countries (See figure 15). This chapter, also, provides some of the most interesting findings, which are not reported anywhere in the literature on the GCC and reveals some unique issues, which have a direct or indirect impact on the performance of the health systems in these countries. GCC governments should be keen to develop their health systems based on evidence, invest heavily in modern health infrastructure and widen medical and health professional education and training. However, many challenges have emerged taking into account the nature of the population, disease burden and systems’ capacity. First of these issues is the large proportion of migrant populations as a percentage of the total population. These migrant people are described as

‘guests’ with work permits: mainly short but some with long term-contracts[92]. The ‘guest’ workers amount to half of the total GCC population. In some countries, such as Qatar, non- nationals constitute about 89% of the population. Local authorities across the GCC states prefer to view ‘foreign workers’ as being strictly temporary in nature, even if reality belies the truth of this. GCC countries do not consider themselves to be destinations of choice for permanent settlement or immigration. The presence of ‘foreign workers’ in each country is tied to the labour market within a particular sector for a defined duration of time. There is no policy in place that allows migrants to work toward a permanent citizenship status. As mentioned, access to public funds by non-nationals in countries like Qatar, is limited [66]. Furthermore, there are no state-driven attempts to encourage social integration [93],[94]. There is no such high percentage of migrant workers recorded anywhere in the world. Switzerland reported that 23%

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of its workers were born outside the country. However, unlike the GCC countries, those working in Switzerland have the right of settlement and citizenship. [94]

Another concern is the health of the migrant workers, especially those in unskilled work. The data collected and analysed in this chapter did not reflect the health of the entire population.

Governmental statistics are mainly collected for nationals. There are few studies on the health of migrant workers, but these are based on small-scale surveys and cannot be generalised [78,

98, 99],[100]. All these issues have some direct and indirect impact on the health systems performance.

In particular, Qatar, UAE and Kuwait remain dependent on a foreign health workforce, especially physicians and nurses (Table 18). At present, even with 36 medical schools (70% in KSA), the GCC is unable to produce sufficient numbers of clinical staff to provide adequate healthcare for its population[1, 95]. As a result, foreign workers can comprise up to 90 percent of physicians in some countries (30% in Bahrain to 90% in UAE: in KSA more than 78%).

Despite the expansion in medical education, the numbers of new medical graduates becoming available in the foreseeable future will not fulfil the needs of the GCC’s population increase.

Hence, the reliance on foreign physicians and nurses will continue for some time to come.

This high percentage of foreign doctors poses many challenges to the health systems in the

GCC. Maintaining standards and quality is almost impossible when you have physicians from very different cultures, with differing medical practices and approaches to health and patient care. Brownie and colleagues reached a similar conclusion in their study of nurses in the UAE

[93], Quality and safety medical practice are raised by many and this may have a direct impact on health system performance [96]. In addition, few doctors and nurses view the GCC as a permanent home, leading to high turnover rates. Staff from developing countries, and in particular those from the Philippines and India, view the GCC as a stepping-stone to more lucrative and permanent careers in the West, whereas many staff from the West view work in the Gulf as an opportunity to save funds before returning home. Language barriers are also

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an issue. Furthermore, today you can observe a two-tier system emerging where foreign health workers who are “Western-trained” are valued higher, compensated better, placed in urban centres, granted more senior positions, and have greater opportunities/training at their disposal [97].

The next issue is related to health and healthcare statistics. These generally are drawn from nationals and thus only partially reflect the overall level of the health in the total population

(This is a limitation of the data. See methods chapter). Population-based health profiles exclude migrant workers and we do not have the detailed information needed for adequate stratification of data on the burden of disease, living circumstances, and access to healthcare services according to ethnicity, sex, and occupation [7]. I have encountered this problem at every step of this research.

The last issue is the burden of disease. The burden of disease is shifting towards non- communicable diseases. Conditions like road traffic injuries and self-harm are high, in addition to CVDs, cancer and diabetes, as this study results show. Only one study for the GCC by

Blair and Sharif in 2012 tried to link population structure to mortality in the UAE but concluded that better data are needed to generate health intelligence for health improvement [75].

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Chapter 6

Health System Building Blocks: Finance and Human Resources for Health

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Chapter 6 Health System Building Blocks: Finance and Human Resources for Health

Introduction

In assessing health system performance this study raised two research questions about health system inputs: sustainability of health systems finance and human resources for health. In this chapter, I will examine the impact of two health system building blocks on health and healthcare policies in the three countries of the GCC. These were identified as the key ‘input’ determinants of health policies and performances taking into account the rapid economic development of these countries thanks to hydrocarbon wealth, and the resulting huge influx of

‘temporary’ migrant workers (long and short-term contracts), which are shaping the unique nature of the GCC population today.

For this part of the study, I found very few scientific works of literature on the two buildings blocks in any of the GCC countries and I had to rely on official documents (both published and unpublished) from the three Ministries of Health, Supreme Councils for Health, Ministries of

Planning, Supreme Council for Planning, international organisation reports (WHO, World

Bank, International Labour Organisation and many others), private consultancy firm reports, and online public materials. In addition to this, I have interrogated the large database at the

Institute of Health Metric and Evaluation (IHME), Seattle.

There were variations between reports depending on the source. On one hand, national statistical data from countries exaggerate the total populations and attribute epidemiological studies and data collected from nationals (representing 10.1%, 30.6% and 48% of Qatar,

Kuwait and Bahrain total population respectively) to the entire population. On the other hand, international consultancy agencies exaggerate projected population health needs and hence projected financial investment needed for both public and private health sectors [55]

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I have also collected additional data on health finance in the GCC countries using the GBD

Results Tools; GDB compare/ Visualisation Hub: and direct contact with researchers at the

IHME in Seattle. As mentioned in the methodology chapter, GBD data collected is the largest de facto source for global health accounting with data from 195 countries and territories, calculated for each year since 1990.

Health System Performance: Health Finance

The three GCC countries of Bahrain, Kuwait and Qatar are amongst the wealthiest in the

Eastern Mediterranean region thanks to natural hydrocarbon resources. Qatar is a country with one of the highest per capita incomes in the world. The two questions to be considered are: first, with such wealth do these three countries spend enough on health services to meet the needs of their population, both nationals and non-nationals (long and short contact migrants workers)? And second, is the current spending sustainable?

Most of WHO Eastern Mediterranean Region (EMRO) countries have published at least one round of national health accounts, including all three of the study countries [130]. Data reported by the countries and WHO are sometimes different than those published by the World Bank and private health think tanks, and consultancy firms [5].

Despite standardization by WHO [10], there are, also, some differences at country level with concepts, definitions, financing policies, tracking healthcare expenditure, various financing schemes, data sources, and collection and analysis. Qatar is the first country in the WHO

EMR to move towards adoption of the new system of national health accounting with clarity of definitions and sources of funding [10]. Based on each countries’ GDP and government spending in 2014, estimates were made for the potential health spending for each country in the GCC, compared with the rest of the GCC and neighbouring countries, over the next 30+ years. These projected estimates were based on the current revenues (mainly oil), inflation, and rates of population growths.

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Estimation of future spending is inherently uncertain. Health spending is a complicated product of national, international, and subnational policy and decision-making, institutional factors, the supply and demand of the health system, economic development, and even war, civil strife, natural disaster, and other environmental issues potentially related to climate change. Many of these factors are not forecasted through the projection of health spending in the GCC for

2030 and 2040 (Tables 22 and 23). To make credible health spending estimates through 2040,

I relied on past global and country-specific spending trends and the relationships between these variables and economic development, government spending, and demographic variables. Use of these forecasting methods are far from exact, and accordingly a quantified uncertainty was calculated by estimating uncertainty intervals (UIs) that increased the further we projected into the future. Table 22 summarises the current health spending per capita and as a percentage of the GDP in 2014 projected for 2030 and 2040 in the study countries. Only

Bahrain is projected to reach above 5% spending on health as a percentage of the GDP by

2030, whilst both Qatar and Kuwait are projected to continue to spend below the 5% by 2040.

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Table 22: Health Spending in Bahrain, Kuwait and Qatar. Data analysed for current expenditure based on 2014 and projected expenditure for the years 2030 and 2040. Source: IHME, WHO, World Bank.

2014 2030 2040 2014-2040 Indicator

Health Annualised rate Health spending Health spending per Health spending per Health spending per Health spending of change, health spending per per capita capita ($) GDP (%) capita ($) per GDP (%) spending per GDP (%) Country ($) capita (%)

Bahrain 2258 4.8% 3289 (2738 to 4136) 5.3 %(4.4 to 6.7) 4380 (3426 to 6336) 5.8% (4.5-8.4) 2.4 (1.5 to 3.8)

Kuwait 2075 3.0% 3208 (2309 to 4950) 4.2% (3.0 to 6.5) 4368 (2792 to 8124) 4.9% (3.1-9.1) 2.6 (1.1 to 5.1)

Qatar 2663 2.3% 3785 (2922 to 5426) 2.7% (2.1 to 3.9) 5006 (3392 to 8591) 3.1% (2.1 -5.3) 2.2% (0.9 to 4.3)

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The differences in the health spending per capita among countries could be due to the level of national income and wealth for each country. In 2014, all GCC countries except Oman were spending over $2000 per head of population. Qatar was the highest with spending of $2663 per head of population. This level of spending is very high compared with the rest of the

Eastern Mediterranean Region of WHO. However, the high per capita spending does not match the low % of GDP spending. The most likely explanation is that in most GCC countries data relate to nationals only, as I have shown in the previous chapter. Hence, Qatar data for example, with the highest per capita expenditure and the lowest percentage of GDP allocation to health, will present a different picture if the spending is based on the total population of 2.4 million rather than 243,019 nationals.

The percentage of health spending per GDP in most of the GCC is similar to other countries in the region. However, all WHO EMRO countries including GCC ones are allocating less than the 6% of the GDP to health, which would be needed to achieve Universal Health

Coverage[101],[102],[103]. These results indicate the need for greater financial protection for the population of both nationals and non-nationals in the GCC. As out-of-pocket expenditures for healthcare are high, action is needed to reduce them and secure financial protection to prevent catastrophic events.

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2014 2040

Indicator Government Prepaid Out-of- Development Government Prepaid private Out-of- pocket Development spending as private pocket assistance spending as share spending as spending as share of assistance for share of total spending as spending for health as of total (%) share of total total (%) health as share of (%) share of as share share of total (%) total (%) Country total (%) of total (%) (%)

Bahrain 65.3% 10.6% 24.1% 0.0% 71.8% (64.1–81.2) 9.9% (6.3–14.3) 18.3% (12.1–24.1) 0.0% (0.0–0.0)

Kuwait 85.9% 1.3% 12.8% 0.0% 89.9% (83.0–95.2) 1.1% (0.6–1.7) 9.0% (4.1–15.6) 0.0% (0.0–0.0)

Oman 91.8% 2.3% 5.9% 0.0% 93.6% (89.8–97.2) 1.9% (0.8–3.1) 4.5% (1.8–7.8) 0.0% (0.0–0.0)

Qatar 85.7% 7.4% 6.9% 0.0% 89.1% (82.9–94.4) 6.1% (3.1–10.0) 4.8% (2.1–9.0) 0.0% (0.0–0.0)

Saudi Arabia 78.7% 6.2% 15.1% 0.0% 82.7% (74.4–91.2) 5.5% (2.7–8.7) 11.7% (5.8–18.7) 0.0% (0.0–0.0)

U A E 72.3% 9.9% 17.8% 0.0% 75.7% (66.9–84.9) 9.0% (5.4–13.5) 15.3% (9.1–22.7) 0.0% (0.0–0.0)

Table 23: GCC health spending compared with neighbouring countries in 2014 and projected to 2040. Source: IHME, WHO, World Bank.

Notes: Total expenditure includes both public and private expenditures. Public health expenditure consists of recurrent and capital spending from government budgets, Prepaid private spending as share of total (%) includes private insurance and non-governmental organizations. Out-of-pocket spending as share of total (%) is defined as direct payments made by individuals to health care providers at the time of service use. Development assistance for health as share of total (%) financial and in-kind contributions is made up by channels of development assistance that is, by institutions whose primary purpose is providing development assistance. to improve health in developing countries.

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Table 23 shows the share of the government expenditure on health in each country as a percentage of total expenditure (Government, private, out of pocket and development assistance for health). Both Kuwaiti and Qatari Governments spending on health are high

(above 85%) while Bahrain is spending 20% less than these two countries (65.3%). In the rest of the GCC, Oman tops the list of high Government spending on health (91.8%).

Figure 17 shows a trend of GCC governments’ commitment to health service funding between

1995 and 2014, Government health expenditure as a percentage of the total health expenditure in the six GCC countries, 1995-2014. Oman has remained the GCC country with the highest government health expenditure at the beginning and at the end of the study period, being exceeded by Qatar and Kuwait from 2003-2012. Saudi Arabia has seen the most dramatical change moving from the lowest expenditure in 1996 to the fourth position by 2014.

Figure 17: Government health expenditure as a percentage of the total health expenditure in GCC

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My further analysis of the health finance data also shows that between 10- 20% of the population, mainly nationals and a few wealthy expats, are seeking care outside the GCC countries, either through government budgets (some outside health budgets) or out-of-pocket payments [66]. There are no official figures for the numbers of those who sought medical treatment abroad on their own expenses. However, some data from Qatar in 2010, suggests that almost 10% of nationals were sent abroad by the government, mainly to the UK, Europe,

India, Lebanon and Jordan for treatment [66].

Furthermore, among the GCC nationals surveyed by Gallup in 2011, Kuwaitis (65%) are the most likely to prefer to receive medical care abroad, followed by Bahraini (47%) and Qatari

(43%). The high majority of nationals do not have one personal physician they see for continuous medical care. Kuwaitis, who are the most likely to prefer medical care abroad, are also the least likely to say that they have one physician they regularly see (16%) followed by the Bahraini (27%) and the Qatari (34%) [52].

Patients may choose to travel abroad because of the poor quality of care or the unavailability of some medical specialties at home, including some oncology treatments. Perceived quality of care is one of the parameters of the Health System Performance Assessment (HSPA).

Health System Performance: Human Resources for Health

In chapter 5, I showed the trend regarding the non-national workforce. Moreover, the infrastructures in GCC, especially human resources, are still relatively challenging compared to countries of similar wealth. In the GCC there are 1.5 Physicians per 1,000 of the population

(physicians density), compared with 3 in Europe (Table 24). Similarly, the numbers of beds per 10,000 population are 21 in the GCC compared to 30 in the UK. .

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Table 24: Number of all types of physician per 1,000 populations 2014 and expat physicians and nurses in GCC as a percentage of the total workforce

Hospital Physicians Expatriate Expatriate Nurses beds per Country (all types) Physicians % of total % of Total 10,000 /1,000 pop population Bahrain 0.9 30 48 n.a Kuwait 1.8 70 92 n.a Saudi Arabia 0.8 78 65 n.a Oman 2.2 79 80 n.a Qatar 2.8 75 95 n.a UAE 1.9 90 98 n.a GCC Average 1.5 78 82 21 30 UK 3 n.a n.a Source: WHO, World Bank, 2016; Adapted from Rawaf and Rawaf, 2016[69]. Updated information 2016 from WHO, Ministries of Health.

Table 24 shows that Qatar has the highest number of physicians per 1000 population and comparable to the UK. The GCC average is 1.5/1000 populations.

At present, even with five medical schools (2 in Bahrain, 1 in Kuwait and 2 in Qatar out of 36 in the GCC), and taking into account the reliance on the expat workforce, there is an inability to produce sufficient numbers of clinical staff to provide adequate healthcare for the population. As a result, foreign workers make up a significant proportion of all physicians in some countries: 30% in Bahrain; 70% in Kuwait and 75% in Qatar (Table 24 + Figure 18).

With the expansion of the private health sectors in these countries, national supplies at this rate will not meet the demands for more doctors and nurses. Hence, the reliance on ‘foreign’ physicians and nurses is likely to continue for some time to come (Figure 20). This high percentage of foreign doctors poses many challenges to the health systems in the GCC, which

I will explore further in the discussion below.

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Source:WHO

Figure 18: Physicians (all types) per 1000 population 2013 in the GCC (average) compared with European Region of WHO (most countries of similar wealth) and the WHO Pan American (with some countries of similar wealth). Source: WHO, 2016 [104]. (Data related to 2014)

The literature shows that most countries experience significant challenges to their health systems, due to increasing health costs and diminished returns on healthcare investment. Where primary healthcare (PHC) is well structured in the health system, and professionals are trained in family medicine in primary care settings, the system achieves better population health at lower costs [105] [106, 107].

This has made PHC a global strategy to secure sustainable healthcare [108] The PHC strategy has been reinforced by the universal health coverage (UHC) target within the

UN Sustainable Development Goals (SDGs) [109].

Taking the importance of such global strategy, I looked at the status of family medicine as one of the most important aspects of HRH in the GCC. In October 2016 The Regional

Committee of the WHO (EMRO) passed a resolution stating that all 22 member states, including the six GCC countries, should scale up a family practice in order to progress towards universal health coverage [86]. The aim of this major WHO initiative, in line with the global strategy mentioned above, is to increase the numbers of family physicians in the region, including the six GCC countries, to reach 3 per 10 000 population by 2030

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and also establish bridging programmes for ‘untrained’ general physicians in family medicine. Table 25 shows the current status of Family Medicine in the GCC.

The current numbers of fully trained family physicians in the GCC (the study countries in pink) estimated by the Ministries of Health is considerably below the numbers needed based on the figure of 3 family physicians /10,000 population. In the UK, the rate is 6 family physicians /10,000 population. It is estimated that in total, there is a shortage of

14,099 family physicians across the six GCC countries.

Table 25: The Status of Family Medicine in the GCC

Country Total Current FP Annual Family FP per 10,000 FP needed to

Population working at Physicians Population in meet the target

2016 MoH (2016) Outputs (2015) 2015 of 3/10,000

Bahrain 1,314,562 250 22 1.84 394 Kuwait 4,294,171 229 35 0.64 1,288 Oman 4,419,193 163 20 0.40 1,326 Qatar 2,404,776 151 12 0.64 721 KSA 30,770,375 740 140 0.25 9,231 UAE 8,264,070 46 10 0.05 2,479 TOTAL 51,467,147 1,579 239 0.31 15,439 The table shows the current fully trained family physicians in the GCC (the study countries in pink) working at the Ministries of Health compared with the number needed based on the lowest figure of 3 family physicians / 10,000 population (the UK rate is 6 family physicians (GPS)/10,000 population). Currently, there is a shortage of 14,099 family physicians across the 6 GCC countries. The three study countries of Bahrain, Kuwait and Qatar have shortages of 144 family physicians, 1,059 and 582 respectively.

The three study countries of Bahrain, Kuwait and Qatar have shortages of 144, 1059 and 570 family physicians respectively. Data from the six GCC countries show that only

20% of primary care doctors, both nationals and non-nationals are fully trained family physicians. The reminders are ‘untrained’ medical practitioners working in primary care without supervision. This raises many questions about the quality of primary care services and the consequent public confidence in such services.

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Such shortages in key HRH, who provide the first contact with the health system and ensure continuity of care, are a huge challenge to the GCC health systems in shaping their health services to meet current and future demographic and disease burden changes across the region.

Chapter Discussion

This chapter addressed two important ‘input’ pillars of health system building blocks, finance and human resources for health. The findings reveal an interesting picture about the three study countries as well as the GCC health systems in general.

First for health finance, economic growth leads to more spending across sectors as well as on health. With the decline in oil prices in recent years, the economic growth in 2017 was between zero and 0.3% in all GCC countries. All public services were subjected to an approximate 20% cut in their budgets in 2015-2017[49]. Furthermore, at least two GCC countries (Saudi and UAE) will introduced a tax to boost revenue in 2018; others, including the three study countries, will follow [110]. With such a decline in the national revenues, it is unlikely that the GCC countries will increase their allocation to health to reach the WHO target of over 5% of GDP for universal health coverage [102] in the foreseeable future. Furthermore, none of these countries have introduced efficiency measures including addressing the fragmentation of health services, strengthening of primary care (WHO EMRO, 2016) [111, 112], and improving the quality of health practitioners.

Second, the finding also raised the question of population financial protection and how the study countries (and all GCC) address the health of the foreign workers and their dependents, who constitutes about 50% of the total population. In some countries such as Qatar they are 90% of the population. As the findings in the previous chapter show, health statistics are drawn from nationals only and hence per capita expenditure appears erroneously high in GCC countries. While all nationals receive full health protection

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through government funds, this is not the case for non-nationals. A study by Hamidi

(2013)[113], in the UAE, showed that with the rising cost of providing healthcare for non- nationals, there is a trend to share ‘the burden’ with the private sector, which funds about

67% of THE . Some countries have introduced based health insurance to migrant workers outside government employment and many left the responsibility to employers without a clear protective regulatory mechanism [8].

With the expansion of the private sector, it is likely that most if not all non-nationals outside government employment will be covered by some basic health insurance.

However, the workforce shortage and dependence on foreign supply may hinder any needed or planned transformation.

With the slowing economic growths, one can conclude from the above findings that the

3 study countries are unlikely to increase their share of THE. They, most probably, will aim to shift the so-called ‘burden’ to the individuals and employers outside government through expansion of the private sector, both insurance and providers. They will mandate employers to provide basic healthcare services, mainly through private insurance, to their foreign (expatriate) employees. This is in line with Hamidi’s (2013) conclusions [113].

Third, in the coming decades, the increase of disease burden due to non-communicable diseases, the ageing population, and the technological advancements (and its high costs) will generate more demands on services and higher expectations. It is unlikely that health systems in the GCC will be sustainable with the current slow economic growth, low level of funding and financial projections. Shifting responsibility to employers and individuals for health and healthcare will increase the unit costs and fuel wage escalation [114], and may deter people from accessing their doctor when they should, resulting in delayed diagnoses, fewer contacts for public health measures such as screening and vaccination, poor follow-up and worse clinical outcomes, with more costly subsequent treatment, and may prevent many people from seeking care or public health

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advice early[115] . Shifting the burden of healthcare was acceptable in Singapore despite the huge inequality it created but Singapore has a totally different immigrant population to the GCC [116]. As the findings from the previous chapter show population dynamics are dictating many ‘political’ current and future policy decisions including health system funding. While nationals may be willing to pay more to get better service and improved satisfaction as Al-Hanawi found in their study in KSA [117], this is not the case for non- nationals, especially short-term employees on low wages.

HRH is another major issue for health system sustainability as the findings in the chapter clearly illustrate. First, my analysis of the human resources for health data shows that the GCC are almost entirely reliant on foreign doctors, nurses, other healthcare professionals and technicians. These health professionals come from various medical backgrounds and cultures with very different levels of education and training; in addition, there is the issue of the language spoken by these staff. Data from one GCC country

(UAE) demonstrates that physicians come from more than 118 different countries [118].

This imposes once again a unique management and planning situation and various other challenges on HRH policies and strategies to the three of GCC study countries and all

GCC. .

Secondly, the findings show a potential gap in primary care, which can be solved by scaling up family medicine training. The size of the gap is such that the sustainability of the health system in providing a world-class first contact and continuity of care is questionable. This needs major reforms to the health system including investment in primary care and in particular national training programmes as Starfield and her colleagues advocated in 2005[106] and WHO in its World Report 2008 [108].

Third, in addition, the health workforce is not stable. Reliance on imported physicians and nurses will continue for some time to come, if not forever. This high percentage of foreign doctors poses many challenges to the health systems in the GCC, particularly to

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those who manage these systems and plan service delivery. Maintaining standards and quality is almost impossible when you have physicians from very different cultures, with differing medical practices and approaches to health and patient care. In addition, only a tiny minority of doctors and nurses view the GCC as a permanent home, leading to high turnover rates. Staff from developing countries and those from the Philippines and India, in particular, view the GCC as a stepping-stone to more lucrative and permanent careers in the West, whereas many staff from the West view works in the

Gulf as an opportunity to save funds before returning home. Language barriers are also an issue[69]. In today’s GCC you can observe a two-tier system emerging where foreign health workers who are “Western-trained” are valued higher, and subsequently compensated better, placed in urban centres, granted more senior positions, and have greater opportunities and training at their disposal; a conclusion supported by the view expressed by Shamsi in 2013[92].

Fourth, the lack of a mandatory regulation authority (an equivalent to the UK’s GMC), compounded by workforce shortages, is a serious issue as it is difficult to assure the public that their health is protected and services that are provided are safe and delivered by competent health professionals. There is much hesitation among GCC health policymakers to impose strict regulations on health professionals in the form of an independent General Medical and Health Professional Council and providers’ regulators, mainly due to the shortage of the health workforce. The fear is that market forces may inhibit private investments and restrict the availability of the numbers of professionals of the desired quality. Consultancy firms see the lack of regulatory mechanisms as an opportunity for private solutions for healthcare in the GCC.

Finance and human resources for health are key building blocks of GCC health systems and as I have shown in this chapter problems with both create enormous challenges for the health systems in the GCC countries. Health policies have to focus on re-designing the health system with more emphasis on population health needs. Strengthening

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primary care through family practice for better first contacts with the health system and continuity of care will be the gateway to addressing the increasing burden of NCDs, reduce inequalities and meet population health needs. With the identified gaps, there is a need for a proper health system assessment.

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Chapter 7 Quantitative assessment Health Access and Quality Index (HAQ Index)

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Chapter 7 Quantitative assessment Health Access and Quality Index (HAQ Index)

Introduction

The literature review, including the systematic review, shows clearly the absence of any systematic or pragmatic Health System Performance Assessment (HSPA) in the GCC countries.

In-depth analysis of the available frameworks for HSPA shows clearly that most of the data needed are not available in any of the GCC countries. For example, the WHO Framework to evaluate health system performance is based on measurement of the three main health system goals described in the World Health Report: improved health, responsiveness and fairness in financing. It also includes cross-system goals, which links health to sectors such as education, housing or economic production. While I found ‘high-level indicators’ data on health improvement and some data on health financing, no data are available for responsiveness, and links of health to education, housing and economic performance.

The OECD performance measurement and performance management in OECD health systems framework, however, focuses mainly on the quality of care and did not specify access to specific services and interventions.

The European Observatory provided its ‘own’ framework for the measurement of performance and covers both technical and political aspects of HSPA. While it focuses on best practices, some of it is not based on strong evidence, rather employing controversial political analysis, something which is too difficult to assess in the GCC, if not impossible in any scientific and valid way.

The other tool is the Health Consumer Powerhouse. While this private Swedish organisation framework provided some comprehensive analysis, there are many criticisms in the selection of the 38 indicators (quality of care, patient engagement, e-health and innovation, health outcomes or medicines). In particular, linking innovation and e-health to the outcome with many subjectivities and possible vested interest [35].

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In the previous chapters the findings showed the insufficient investment in health, the lack of recognising the impact of the non-national workforce, and the shortage of health workforce are serious issues, which have direct impact on the performance of these health systems. However, in getting the full picture of the current status of the systems in the study countries, I decided to use the HealthCare Access and Quality Index (HAQ Index) for the first time to assess and compare the GCC health systems performance. The HAQ Index is used by the Institute of Health

Metric and Evaluation (IHME) to assess mortality rates from conditions, which are considered amenable to personal healthcare [43]. It is believed that the use of the HAQ Index will provide a comprehensive tool for measuring performance while addressing both quality and access.

This novel extension of the Global Burden of Disease data enabled me to demonstrate the untapped potential for personal healthcare access and quality improvement in assessing health system performance: the application of this should improve and simplify the HSPA worldwide.

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Results

Different country patterns emerged for overall HAQ Index levels and gains from 1990 to 2015

(Figure 19) within and outside the GCC area.

Figure 19: Performance of the HAQ Index and 25 individual causes in 2015.

Data were taken from IHME, Seattle. 2015 and analysed by the author

Generally speaking, all GCC countries improved their HAQ index between 1990 and 2015 and in

2015 all showed high HAQ Index compared with their neighbouring countries as well as countries with highest HAQ Indices including as Switzerland and the UK, in 2015 (Figure 19). Within the

GCC, Qatar scored the highest HAQ (similar to the UK) followed by Kuwait, with a score of 85 and 82 respectively. The other 4 GCC countries HAQ index ranged 72-79.

However, further comparisons of the overall HAQ Index with its component parts showed substantial heterogeneity. . As such, the overall performance is not consistent across the 25 causes of disease burden and amenable mortality (preventable death). The findings of this study

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indicate that none of the GCC countries are managing congenital heart disease or chronic kidney disease (CKD) (See figure 19). Hence, it is raised many questions about access and quality of care for important conditions like CKD which is linked strongly to one of the prevalent NCD conditions over time such as diabetes [119]. There is a similar concern about ischemic heart disease, one of the major burdens of disease and cause of death. The UAE shows very low value

(3rd decile), as well as Oman, Kuwait and Saudi Arabia (5th decile).

Figure 20: Performance of the HAQ Index (25 individual causes) between 1990 and 2015 (rounded values). All causes presented in this figure are scaled 0 to 100, with 100 being the “best” value (i.e., lowest observed age-standardised risk-standardised mortality rate by cause) and 0 being the “worst value” (i.e., highest observed age-standardised risk-standardised mortality rate by cause) between 1990 and 2015. Their HAQ Index 1990-2015 orders GCC and neighbouring countries. HAQ Index=Healthcare Access and Quality Index.

Further comparisons of the overall HAQ Index within and between GCC countries (and their comparators) show a very interesting picture. Qatar shows faster progress in both access and quality and hence reduced amenable mortality, than the other GCC countries (Figures 20 and

22). Neither UAE nor Oman did not show the same speed of progress with Oman looking almost stationary since 2005.

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HAQ Index and total health spending per capita

In my analysis, I wanted to explore if there is any relationship between health spending and access and quality of health services. Figure 21 shows that health spending per capita was positively related to access to healthcare and the quality of the healthcare as measured by the

HAQ index. While Kuwait is spending less than UAE per capita on health, yet they score high on

HAQ index, which indicates better and more efficient use of the resources. Qatar performance and spending per capita exceeded all other GCC countries.

90 Qatar Kuwait 80 BahrainKSA Oman UAE 70

60 HAQ Index HAQ 50

30 2 2.2 2.4 2.6 2.8 3 3.2 3.4 3.6 log of cumulative total health spending per capita ($)

Figure 21: Comparing the HAQ Index to the log of total health spending per capita in GCC.

Comparing the HAQ Index to the log of total health spending per capita in GCC, 2016. (Per capita spending 2014-2016: Pakistan $132; Yemen $233; Iraq $828; Iran $1073; Oman $1467; Kuwait 2075; Bahrain $2258; KSA $2320; UAE $2561; Qatar $2663). Data Sources: National Statistics; IHME; WHO Database.

Overall performance of the three study countries 1990-2015

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Figure 22 shows the actual and potential improvement in health system performance in the three countries of Bahrain, Kuwait and Qatar.

Figure 22: Performance of the HAQ Index (Total of 25 individual causes) for 1990 and 2015 in actual value, in Bahrain, Kuwait and Qatar.

Data were taken from IHME, Seattle. 2015

All causes presented in this figure are scaled 0 to 100, with 100 being the “best” value (i.e., lowest observed age- standardised risk-standardised mortality rate by cause) and 0 being the “worst value” (i.e., highest observed age- standardised risk-standardised mortality rate by cause) between 1990 and 2015. Their HAQ Index 1990-2015 orders GCC and neighbouring countries. HAQ Index=Healthcare Access and Quality Index. "Best possible" represents the highest personal healthcare and access achieved at a given level of development. The gap between the HAQ Index and "best possible" represents how much the untapped potential exists for improving personal healthcare access and quality is given a location's resources and development status.

Unlike Bahrain and Kuwait, Qatar’s health system progressed steadily between 1990 and 2015 and indeed exceeded the expected best scenario for personal healthcare, including access to and quality of service received.

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Social and Economic Development and Health System Performance

In exploring the potential performance of the health systems in the three study countries of

Bahrain, Kuwait and Qatar and taking into account the wealth of the three countries due to oil and gas production and export since the 1970s, I used the HAQ Index frontiers i.e. the maximum HAQ

Index that can be reached in relation to their individual socio-demographic development. Table

26 summarises the comparison between the three countries and the region (the 22 countries of the Eastern Mediterranean Region of WHO). The findings suggest that Qatar has gained in personal healthcare access and quality much better than the other two health systems of Bahrain and Kuwait. Despite the fact that Kuwait was ahead of both Bahrain and Qatar in the 1990s. As we have seen in Figure 22, Qatar exceeded its expected performance and tapped fully on the potential of their health system. While Bahrain’s health system can improve further, the relative poorer performance of the Kuwaiti health system despite the huge available resources raises many questions.

HAQ Index Observed (95% UI) HAQ Index Frontier Difference between Observed & Frontier HAQ Index Value 1990 2015 1990 2015 1990 2015

EMRO 43.8 58.4 55.7 72.3 11.9 13.8

41.9-46.0 56.5-60.5

71.8 82.3 12.1 3.3 BAHRAIN 59.7 79.0

57.4-62.2 76.2-81.7

KUWAIT 71.7 82.0 76.0 88.5 4.3 6.4 70.1-73.3 79.9-84.0

QATAR 70.8 85.2

68.1-73.3 82.0-88.3 72.9 84.5 2.1 -0.7

Table 26: Regional (EMRO) and Study Countries (Bahrain, Kuwait Qatar) estimates of the HAQ Index from 1990 to 2015, on the basis of socio-demographic development and the difference between HAQ Index and the frontier value in 1990 and 2015 (data extracted with modification from IHME, 2017)

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Chapter Discussion

The Healthcare Access and Quality (HAQ) Index provides a summary measure of personal healthcare access and quality on a scale from 0 (lowest) to 100 (highest). This measure is based on risk-standardized mortality rates from causes that, in the presence of high-quality healthcare, should not result in death. It was produced by the IHME in 2016 and published in 2017 [43].

As a validated tool, I used it here for the first time to assess the health system performance in the

GCC. The results show that there were improvements in access to healthcare, as measured by

25 causes of ill health, and quality of care between1990 and 2015 across all the GCC countries and much higher than the regional (22 EMR countries) average. While the three study countries of Bahrain, Kuwait and Qatar have progressed very well in developing their health systems, the

Qatari’s health system progressed relatively better since 1990 and by 2015 even exceeded the best possible scenario, as measured by HAQ Index, compared with the other two countries. Qatar has invested heavily in recent years in policy development, capital building, human resources and service development, and has worked with clear strategic directions with the development in 2009 of the National Health Strategy [120], together with strategies for Primary Care, Public Health,

Mental Health and Cancer [87]. Progress in primary care was most notable in building and renovating 26 modern primary care centres with extended services including wellbeing clinics, increased workforce, and improved access for all including the much-criticized short-term construction workers (about 1 million of the Qatari population) [54].

The relatively slower development in both Bahrain and Kuwait (figure 22) may be attributed to the political upheaval in the two countries in recent years: The 1990 invasion of Kuwait did slow the developments on all fronts including health [121]. The civil unrests in Bahrain have slowed both the economy and development in this smallest GCC country [122]. Unlike Kuwait, Bahrain does not have a serious issue with workforce, and I believe that both countries can accelerate the development of their health systems performance through a critical review of their health system

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components focusing on efficiency and productivity, re-setting priorities on the greatest burden of disease, and investing in policy development, governance and leadership.

The positive correlation between health spending per capita and health access and quality suggests that cuts in the health spending will have a direct impact on access to and quality of the service and hence patient outcomes: a study in the USA reached to a similar conclusion [123].

While addressing waste and reducing unwarranted variations in care are essential, unplanned reduction in spending on health may have major implications for system sustainability and the ability to address the many challenges outlined in this work.

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Chapter 8 The views of health leaders and senior managers on health system performance assessment and its application

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Chapter 8: The views of health leaders and senior managers on health system performance assessment and its application

Introduction

The Systematic Review demonstrated a lack of adequate knowledge and research on health systems and health system performance assessments by the academic and service institutions across the GCC. Comparing the health systems of the three study countries is part of one of the study’s objectives and, while the Kingdom of Bahrain, State of Kuwait and the State of Qatar, are similar in terms of demography, geography, politics, economy, culture, language, religions and climate, there are limited empirical data on their health systems performance. This part of the thesis studies the understanding and methods used in the GCC for assessing their health systems’ performances. It also explores the knowledge and attitudes of health leaders and senior managers working within these HSPA systems, its application and benefits. It concludes by identifying the current strengths and weaknesses, future projections and their impact on population health.

To answer the research question, I will present the results of two studies I conducted: first, a survey among health leaders and managers in the three GCC countries, and second, face-to- face interviews with key identified leaders in Bahrain, Qatar and Kuwait. The interviews were essential for an in-depth exploration of HSPA as the survey revealed considerable lack of knowledge and understanding of this.

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A survey of health leaders and senior managers:

This survey was conducted in the three study countries using a pre-designed study questionnaire, which I developed and validated through a small pilot study, The pilot study was conducted among nine colleagues (not included in the final analysis). The questionnaire (Appendix 1) explored knowledge and understanding of: HSPA frameworks, their national application, the challenges in health system performance, and the views on the improvement needed. As a result of the pilot, some of the questions were modified, removed, and a new one was added. Terminologies were explained following the pilot study to avoid confusion and misunderstanding. The final questionnaire was organised into three sections. The first section addresses the respondent’s personal details (gender, age, education and years of service in the health system). The second section is about health system performance assessment (with 12 questions of health system performance). The third section is on the health system and health data (with 21 questions).

The survey questionnaire was posted to target policymakers and senior managers in the

Ministries of Health of the three study countries. To determine the correct sample size to yield meaningful results, I met with a number of senior staff in the MoH of the three countries to establish the approximate potential number of leaders and senior managers. Based on their advice, and using a purposive sample [124], I decided that 40 questionnaires per country would be appropriate for the sample size with an expected response rate of 40-45%. A total of 120 questionnaires were therefore sent out and followed up by three reminders to increase the response rate. Within the time frame, 79 (65.8%) questionnaires returned. Four of these were removed due to incomplete or no answers. The final response rate was 62% (75 valid questionnaires), which is considered to be very good. The high response is due to the commitment and involvement of colleagues at the three Ministries of Health in identifying the senior people that I should approach for this part of the study.

A framework analysis was conducted to answer key questions related to the five functional components of data management and reporting systems. Framework analysis links data to the

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source, enabling the visual presentation of data specific to the different health system levels and by sector (Hospitals and MoH). After reviewing the data, a standardized code list was developed to identify recurrent and important themes. Transcripts were reviewed to identify, code, and index responses. Brief summaries of the data were generated and synthesized using a framework focused on generating policy and practice-oriented findings.

All the statements within the survey form were coded for data entry. Following coding, each response in each form was entered into a MINITAB data worksheet for analysis. I analysed the data using MS-Excel and SPSS Statistics Version 22 software to present the data in an understandable format for the reader. Statistical analyses used Version 13.1 of the Stata statistical software 54.

Face-to-Face interview

A face-to-face interview was recorded with nine key health leaders in the three study countries, to further explore the knowledge, understanding and use of HSPA in the GCC. The face-to-face interview technique is a commonly used data collection method in health and social research [125].

Increasing attention has been given in the literature to the process of conducting an interview, particularly with respect to the role of the interviewer and the relationship between the interviewer and interviewee. The systematic review revealed very little quality academic or service research in HSPA, and the survey of GCC health leaders and senior managers also revealed a significant lack of knowledge, understanding and experience of HSPA.

Some, engaged in their own performance assessment, did not see the value of assessing the performance of their health system. I wanted to explore why this was the case. To this end, I supplemented my earlier efforts in this part of the study by conducting structured face-to-face interviews with a number of senior managers. These included Assistant Undersecretaries, and

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Directors of Service reporting to Undersecretaries in each of the three Ministries of Health:

Bahrain, Kuwait and Qatar.

As I am currently working in one of the GCC health systems, it was possible to identify key leaders in the three countries, including my own country (Qatar) and organised interviews in their own workplaces. I travelled to Bahrain and Kuwait and in total I had in-depth face-to-face interviews with 9 senior colleagues from the 3 study countries’ Ministry of Health

Findings

Findings from the survey questionnaire

Participants Profile

Table 27 summarises the profile of the respondents to the questionnaire from the three study

GCC countries 54.7% were females compared with 45.3 males, with age range between 36 and

65. More than two-thirds had a higher postgraduate degree (Masters and above) and the majority had been in post over 10 years (71 out of 75 respondents).

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Table 27: Profile of responding participants from Bahrain, Kuwait and Qatar.

Variable Total (n=75) Bahrain Kuwait Qatar

Male 34 11 14 9

Female 41 14 11 16

26-35 1 0 1 0

36-45 24 6 11 7

46-55 33 13 10 10

56-65 17 6 3 8

1st Degree (BSc, BA, BBA, MBBS, MBChB) 24 7 10 7

Higher Degree (MA, MBA, MSc, PhD) 51 18 15 18

Work duration

0 –5 years 3 2 0 1

5 - 10 years 1 0 1 0

Over 10 years 71 23 24 24

The second question was optional and was asked to determine the job title and role in the health sector. Out of these 28 identified themselves as follows: 2 as Chief Executive Officers, 5 as

Executive Directors, 8 Assistant Executive Directors, 4 Senior Administrators, 3 Finance

Directors, 1 Human Resources Manager, 4 Program Managers, and1 Chief of Group. The majority of health managers are medically qualified and many had spent time in medical training and practice before they moved to management. It was also observed that a small number were expats and recruitment had tended to concentrate on those with experience and track records in

US and European countries.

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Knowledge and experience of HSPA

One manager who said that he had knowledge and experience of HSPA (Table 28) mentioned the ‘performance scorecard’ had been developed in the country to assess performance on a regular basis.

Table 28: Knowledge of Health System Performance Assessment in the three GCC

Tool Total (n=75) Bahrain Kuwait Qatar

Knowledge / Experience of HSPA Frameworks / Tools

Do you have any Experience or Knowledge of HSPA, Frameworks or HSPA Tools?

No 53 17 21 15

Yes 22 8 4 10

The existence of specialized entity to assess health performance*

Does any entity in your health system provide regular performance assessment to the service they provide?

No 11 2 7 2

Yes with no insight to the procedure 46 15 18 13

Yes with a clear SOP 18 8 0 10

Assessment tools

Which of the following do you use to assess the performance of your health system?

Improvement of the health system 0 0 0 0

Effectiveness of the services provided 0 0 0 0

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Customer satisfaction 0 0 0 0

Mix of the above 18 8 0 10

Assessment tools

Which of the following do you think will be useful to assess the performance of your health system?

Improvement of the health system 8 2 3 3

Effectiveness of the services provided

Customer satisfaction 15 7 3 5

Mix of the above 34 8 19 7

Employee’s opinion of the assessment process

What do you think about the entire health system performance assessment process?

Poor 2 1 0 1

Good 9 3 0 6

Excellent 7 4 0 3

Employee’s satisfaction of the process

What did not satisfy you about the health system performance assessment process?

Time consuming 0 0 0 0

No set strategy in place 11 5 0 6

Does not give the full picture of the workforce 7 2 0 5 performance

Too much bureaucracy 0 0 0 0

Too costly 0 0 0 0

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All above 0 0 0 0

Employee’s satisfaction with the process

Which of the following do you think will not satisfy you in health system performance assessment process

Time consuming 0 0 0 0

No set strategy in place 17 6 6 5

Does not give the full picture of the 0 0 0 0 workforce performance

Too much bureaucracy 0 0 0 0

Too costly 0 0 0 0

All above 40 12 18 10

Budget for HSPA

What is the budget (estimation) assigned for the health system performance assessment that you are working for?

10 000 – 15000 USD 0 0 0 0

15500 – 20000 USD 2 1 0 1

20500 – 25000 USD 0 0 0 0

Budget Needed

In your opinion what is the appropriate budget (estimation) will be assigned to the health system performance assessment that you are working for?

10 000 – 15000 USD 0 0 0 0

15500 – 20000 USD 0 0 0 0

20500 – 25000 USD 0 0 0 0

Updated at least every 3 years

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Is the health system performance assessment updated at least every 3 years?

Yes 18 5 0 13

No 0 0 0 0

Updated at least every 3 years

Do you think to update the health system performance assessment every 3 years will be beneficial?

Yes 38 15 15 8

No 19 5 10 4

Knowledge, opinion and practice of Health System Performance Assessment in the three GCC countries of Bahrain, Kuwait and Qatar.

* Based on decision maker’s opinion

Respondents to the question ‘if any entity in their health system provides performance assessment of the service they provide’ gave a range of answers. Eighteen were aware of a specialized entity for this, whilst 11 said they do not assess the performance of system/service.

The remaining that said they have assessed performance did not know about the process. One can assume here that these managers were involved in assessing a specific service, a program or an initiative within the health system. Sixteen managers (21.3%) denied the existence of a clear strategy for performing HSPA. Despite this, 76% of the respondents considered that HSPA would be a useful tool for health system improvement by increasing service effectiveness and patient satisfaction. Only 18 (24%), none in Kuwait have used some assessment tools for system improvement, effectiveness and satisfaction. It is interesting to see that 7 respondents said that if there is an assessment it does not give a full picture of the workforce performance, and there is a need for training about the performance assessment process and the use of assessment tools.

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Table 29: Availability, use and applications of health system and health data

Tool Total Bahrain Kuwait Qatar (n=75)

Health System structure Do you consider the structure of your health Organisation (as a whole) to be: Simple and clear 4 1 0 3 Not very simple 26 18 5 3 Complicated and not clear 45 6 20 19

Frequency 25 25 25

Somers' D -0.433 0.272 0.161

(95% CI) (-0.621, -0.197) (0.082, 0.442) (-0.068, 0.374)

P 0.0008 0.0061 0.17

Health System activities What are the activities and capacities of the health system that you are working for? 1 We cover all health services in the country 58 20 20 18 including hospitals and clinics 2 We cover health services in some part of 17 5 5 7 the country 3 We only cover a few hospitals in the 0 0 0 0 country

Frequency 25 25 25

Somers' D -0.051 -0.051 0.101

(95%CI) (-0.300,0.205) (-0.300,0.205) (-0.172,0.360)

P 0.7 0.7 0.46

Health System opinion

How good (in your opinion) are the healthcare services in your region? 1 Not very good 19 6 8 5 2 Good 52 19 17 16 3 Very good 2 0 0 2 4 Excellent 2 0 0 2

Frequency 25 25 25

Somers' D -0.04 -0.151 0.191

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(95%CI) (-0.248,0.171) (-0.355,0.066) (-0.039,0.402)

P 0.71 0.17 0.1

Health System data

Do you collect and save data for the purpose of health system performance assessment?

Yes 45 20 6 19 No 30 5 19 6

Frequency 25 25 25

Somers' D -0.278 0.5 -0.222

(95%CI) (-0.468, -0.064) (0.267,0.678) (-0.420, -0.004)

P 0.012 0.00016 0.046

Health System data level

What level of data is being collected to assess the health system performance? Patient level data 37 6 21 10

Hospital level data 14 4 10

Area level data 24 19 5

Country level data

Frequency 25 25 25

Somers' D 0.425 -0.428 0.003

(95%CI) (0.229,0.589) (-0.560, -0.275) (-0.178,0.184)

P 0.00011 1.6x10-6 0.98

Health System data comparability

Are data from the health system performance assessment comparable to data from other comparative countries within and outside the GCC? Yes 55 22 10 23 No 20 3 15 2

Frequency 25 25 25

Somers' D -0.25 0.568 -0.318

(95%CI) (-0.446,-0.031) (0.305,0.751) (-0.496,-0.115)

P 0.026 0.00021 0.003

Health System data area

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Which of the following is comparable data do you collect? Neighbour (GCC) 75 25 25 25 The Region (EMRO) 0 0 0 0 International 0 0 0 0

Frequency 25 25 25

Somers' D 0 0 0

(95%CI) (0.000,0.000) (0.000,0.000) (0.000,0.000)

Health System data collection

Is there any national body approved by the ministry of health responsible for collecting and disseminating healthcare data?

Yes 23 23 No 52 25 25 2

Frequency 25 25 25

Somers' D 0.481 0.481 -0.962

(95%CI) (0.328,0.609) (0.328,0.609) (-0.991, -0.847)

P 2.3x10-7 2.3x10-7 6.3x10-7

Health System data resources

Do any of the following institutions contribute to the national health data and/or facilitate as a resource for health data collection? 1 GCC wide 53 20 21 12

2 The Region (EMRO) 1 1 3 International 21 5 3 13

Frequency 25 25 25

Somers' D -0.143 -0.226 0.369

(95%CI) (-0.357,0.085) (-0.421, -0.011) (0.109,0.582)

P 0.21 0.04 0.007

Health System Data Access

Do all or some of the data contributors have free access to the national health database?

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Yes 39 19 0 20 No 36 6 25 5

Frequency 25 25 25

Somers' D -0.321 0.694 -0.374

(95%CI) (-0.509, -0.102) (0.504,0.820) (-0.555, -0.158)

P 0.0052 2.7x10-7 0.0012

Health System Statistics and the Public Are the health statistics easily accessible for the general public? Yes 22 18 4 0 No 53 7 21 25

Frequency 25 25 25

Somers' D -0.686 0.214 0.472

(95%CI) (-0.835, -0.444) (-0.009,0.417) (0.321,0.599)

P 0.000016 0.059 2.4x10-7

Health System MOH Does the MOH use latest technology to: 1 Collect health profile database Yes 70 25 23 22 No Frequency 25 25 25 Somers' D -0.357 0.071 0.286 (95%CI) (-0.468, -0.236) (-0.372,0.488) (-0.204,0.661) P 3.8x10-7 0.76 0.25 2 Manage health profile database Yes 0 0 0 5 No Frequency 25 25 25 Somers' D 0.357 0.357 -0.714 (95%CI) (0.236,0.468) (0.236,0.468) (-0.808, -0.586) P 3.8x10-7 3.8x10-7 1.5x10-11 3 Integrate health profile database. Yes 0 0 0 0 No Frequency 25 25 25 Somers' D 0 0 0 (95%CI) (0.000,0.000) (0.000,0.000) (0.000,0.000) P 4 Display health profile database

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Yes 0 0 0 0 No Frequency 25 25 25 Somers' D 0 0 0 (95%CI) (0.000,0.000) (0.000,0.000) (0.000,0.000) P

When I asked about the budget allocated to support system performance assessment only 2 (4%) responded to the questionnaire. One of them is a CEO, and the other a Director of Finance: one respondent from Bahrain and one from Qatar. It is interesting to note that responses from Kuwait without answering to many questions were higher than Bahrain or Kuwait.

Health Systems and health data

In this section of the questionnaire (Table 29), many questions were raised about the health systems structure, activities, and data sources, availability and use. The results are summarised in Table 30.

Table 30: Between-country ordinal heterogeneity tests of ordinal answers to questions

Question name N F Heterogeneity Residual Heterogeneity d.f. d.f. P Health System structure 75 7.483 2 74 .0011 Health System activities 75 0.272 2 74 .76 Health System opinion 75 1.553 2 74 .22 Health System data 75 8.204 2 74 .00061 Health System data level 75 16.119 2 74 1.5e-06 Health System data compare 75 8.451 2 74 .00049 Health System data area 75 0 74 Health System data collect 75 26.071 2 74 2.7e-09 Health System data resources 75 4.168 2 74 .019 Health System Data Access 75 17.067 2 74 8.0e-07 Health System Statistics and the 75 22.829 2 74 1.9e-08 Public Latest technology used to collect data 75 15.668 2 74 2.1e-06 Latest technology used to manage 75 33.843 2 74 3.7e-11 data Latest technology used to integrate 75 0 74 data Latest technology used to display 75 0 74 data

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We accepted the null hypothesis for the heterogeneity tests of ordinal answers between countries in all the questions but two (Health System Activities and Health System Opinion) as the questions-related parameters were zero. This means that professionals from all three countries are equally likely to have similar views in regards to the specific question.

Analysis from the above table shows with regard to ‘Health system structure’, that managers in

Bahrain think their system is not very simple, compared to those in the other two countries.

Managers in Kuwait tend to think their system is complex, compared to those in the other two countries. In addition, managers in Qatar do not think their system is simple or complex, compared to those in the other two countries.

With regards to ‘Health system activities’, managers in all 3 countries did not have a visible tendency (in their report of activities and capacities of the health system) covering all health services in the country including hospitals and clinics. Managers in Kuwait tend to think they do not collect and save data for the purpose of health system performance assessment, compared to those in the other 2 countries. Managers in Bahrain think they collect data to assess the health system performance at the area level, compared to those in the other two countries. Managers in

Kuwait think they collect data to assess the health system performance at the patient level, compared to managers in the other 2 countries. Moreover, those in Qatar do not have a visible tendency to report which level of data is being collected to assess the health system performance, compared to managers in the other 2 countries (Table 29).

Managers in Bahrain and Qatar think that the data they collect is comparable with that collected from other comparable countries within and outside the GCC. Managers in Bahrain and Kuwait think that there is no national body approved by their Ministries of Health responsible for collecting and disseminating healthcare data. Managers in Qatar think that there is such a national body. In addition, Managers in Bahrain did not have a clear position regarding the institutions contributing to the national health data and / or collection. Their counterparts in Kuwait thought that GCC-wide

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institutions were the ones contributing to national health data. Whilst in Qatar, they considered mostly international institutions played this role.

Managers in Bahrain and Qatar think that some or all or some of the data contributors have free access to the national health database, whereas managers in Kuwait disagree.

Managers believe the health statistics are easily accessible to the general public in Bahrain, compared to the other 2 countries, an observation that I experienced personally during this study.

Hence, the latest technology to collect health profile database is widely used in Bahrain, compared to Kuwait and Qatar. However, managers in the 3 countries do not think that their

MOH uses the latest technology to manage the health profile database, Integrate health profile database, and display the health profile database.

While 58 participants (77%) have responsibilities across the whole system in the three study countries, four (5%) believed that the structure and organisation of the systems was clear and easy to understand. This is an interesting observation, when the population sizes of these countries are relatively small (ranging from 1.3 to 4.2 million) (Table 3).

The same 4 managers reported that the service their systems provide was either very good or excellent. The remaining respondents (25%) did not get a feeling of quality from their health services. Contrasting views were given regarding data collection, availability and usage. While

45 managers confirmed that they collected data for HSPA, 27 of them denied the existence of

HSPA in their systems (Table 33). Furthermore, 55 respondents considered the data collected for HSPA was comparable to that from other countries within and outside the GCC. The numbers of people praising the comparability of data exceed the number of participants that confirmed existence of data collection. The mismatch in these related questions could reflect either misunderstanding of the questions or the concept of HSPA per se.

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The health statistics and data are not easily accessible to the general public as 53 out 75 managers indicated. This is certainly what I have experienced during my PhD studies. However, the majority of managers (89%) felt that the MOH use the latest technology to collect the health profile database. Employees clearly perceive a positive link between the technology and health profile database and the effect of this on the health system in general and their organisation in particular. Furthermore, some of the responses outlined the perceived benefits their organisations will gain from any performance assessment information on a regular basis.

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Findings from the Face-to-Face Interviews

My in-depth structured interviews of nine senior managers in the three countries revealed some interesting findings on health policy development, high-level decision-making, health system assessment, finance, workforce, governance, market regulations, public engagement and research. Table 31 gives a summary of the outcome of the interviews in the three study countries.

Table 31: Summary (1) of the key findings of the face-to-face interviews

Findings Bahrain Kuwait Qatar

Policy Development - is it:

Based on Health Needs Limited i No Limited ii Assessments

Reactive to events Yes Yes Yes

Ad hoc Mostly Mostly Mostly

Political Always Always Inputs iii

High Level Decision-Making:

Political influence V. High iv High V. High

Highly Centralised Strong Medium Corporations v

Based on Long Term Planning Limited vi Limited vii NHS 2011viii

Based on accurate /timely Poor Poor Poor information

Reactive/ Fire fighting Most of it Most of it Partly

Notes:

I. Bahrain: As a one-off exercise for primary care as part of the process of accreditation in 2010. II. Qatar: Some needs assessments were conducted in relation to Cancer Strategy and Mental Health Strategies[73, 74]. III. Qatar: The Prime Minister of Qatar heads the Supreme Council for Health (SCH). Much of the political direction in health is made at this forum.

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IV. Bahrain created a Supreme Council for Health: more political control on health policies [53]. This is headed by the Minister of Military Affairs (A physician)[61]. V. This devolved functions of some areas of primary care services and hospital services to two corporations. Although they have some independence they are members of the SCH and report to the Minister of Health. VI. The last Health Strategy in Bahrain was published in 2002 (Health Strategy: Framework for Action: 2002- 2010), and a Health Improvement Strategy was published in 2012 [53] Planning guidelines for service providers supported none of these strategies. VII. Vision Kuwait 2030: Assessment by Tony Blair and directions for health services, 2010. None of these was translated into specific planning guidelines [121] VIII. SCH published a National Health Strategy 2011-2016 [120]. A private firm who successfully negotiated a contract for monitoring the implementation developed this. This mainly concerned general high-level changes rather than service philosophies and developments.

Table 32: Summary of the key findings of the face-to-face interviews (continuation)

Findings Bahrain Kuwait Qatar

System Assessment, Building Blocks, Regulations, Research

Health System Assessment None None Public Health Scorecard i

Health System Financing Government Government Health Insurance Funded; No Funded mainly Qatari Only ii Health Insurance

Workforce Planning Poor Poor Poor iii

Quality & Patient Safety No No Independent No independent Independen Professional professional + t Provider Provider Regulators v Professiona Regulators l Provider Regulators iv

Governance No No definitive NHS defined but not definitive system applied ii system/ /framework framework

Market Regulations None None None

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Engaging the Public Medium Low Mainly Nationals

Health Service Research Weak vi Medium vi Weak vi

Notes:

I. Qatar has a strong Public Health Department, yet reporting is not at a high level and therefore is not a full member of the SCH (the Department of Public Health (DPH) reports to the Under-secretary and not the Minister). II. Qatar: National Health Insurance Company. (NHIC). 100% Government owned commercial entity established in July 2013 to implement and administer the Social Health Insurance (SHI) [84] scheme. Stopped one year after implementation III. Qatar: Some proactive planning: National Health Strategy; Public Health in Qatar [120] IV. One respondent reported that discussions had started but had not yet proved fruitful. V. Qatar declared that they are intending to develop a health professional regulation mechanism. As yet there have been no details and it is not known if it is independent. VI. Reference Kennedy et al 2008; Ismael Et al 2013: Blair et al, 2014 – all showing that health service research is weak in the GCC [61] [62] [63].

The respondents from the three countries agreed that health and healthcare policies are driven

mainly by two factors: political and public pressure. There was almost total agreement that

population health needs assessments were not driving policy because such assessments are

not conducted and also due to a lack of experience in this field. However, in Bahrain, (as

shown in the survey) they believe that some health needs assessments were conducted in

primary care as part of the Canadian Accreditation process. Respondents felt that perceptions

of the severity of and responsibility for the problem, and affected populations all influence

governmental responses. Very often Royal visits to certain parts of the country will culminate

with promises, which translate into policies--for example, building a new hospital in a low-

density population area. These ‘ad hoc’ reactive and ‘crisis-triggered’ approaches are very

common. There were some exceptions, such as the case in Qatar, where policies tend to

inform strategies-for example, the National Health Strategy, Cancer Strategy, and Mental

Health Strategies.

In exploring how major decisions are taken at a high level and what these decisions are

influenced by, most of the interviewees said that decisions are made without proper discussion

or a non-evidenced based approach to policy and hence lack of collective responsibility. They

reported that some discussions take place but these are normally following the decisions, not

prior to. On occasion, these may lead to modifications including enhancement of the

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subsequent strategy. The rapid expansion of the population in the three study countries is one of the key factors in driving the political agenda in health. While few interviewees from Qatar continued to reference the National Health Strategy[84], they remained unhappy with the direction and accuracy of other strategies including Primary Care and Mental Health. Various responses to the questions were given at length. These are summarized in the Table 31 above with some explanation to their background.

With regards to Health Systems Performance Assessments, almost all initial answers were:

“Yes we have it”, or “Yes, we perform it”. However, when enquiring which framework was in use (WHO, OECD or Commonwealth Fund, for example.), we received differing responses..

This reflects the importance of the interviews in addition to the survey. It was obvious that all but one of the interviewees were not aware of any of these frameworks and associated reports.

They did repeatedly refer to the ‘famous’ WHO report published in 2000, which provided some comparative data between members states and showed Oman to be one of the best- performing systems. Many countries and experts in health systems worldwide subsequently discredited this WHO Report.

While all interviewees expressed lack of knowledge and applications of HSPA, a senior executive from Qatar showed me the Public Health Scorecard, which measures and regularly reports key public health interventions against targets (Table 31). This practice was not extended to the other services (primary and hospital care).

Health system financing is currently a major issue in the GCC. All health leaders interviewed felt that, while the governments are the main source of health finance supplemented by out of pocket payments (OOP), the large influx of foreign workers due to the unprecedented economic boom, is dictating different unplanned health policies. This, in turn, is expanding the numbers of private healthcare providers and shifting ‘the burden’ away from government. In response, Qatar has developed a National Health Insurance Company (NHIC). This is a solely government-owned commercial entity, which was established in July 2013 to implement and

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administer the Social Health Insurance (SHI)[84] scheme for Qatari nationals (which account for less than 10.1% of the population). There was no clear decision about non-nationals. Within a year of its launch the SHI was abolished and no clear replacement has been introduced yet.

Kuwait has no clear policy at present on health insurance, despite specific advice from private consultancy firms for a fully-fledged private insurance system. Bahrain, however, following advice from private consultancy companies is planning on implementing private health insurance systems. This, however, was halted due to the political ‘instability’ in Bahrain and fear of a backlash.

Interviewees expressed the pressure that they are under (reactive systems), with a plethora of advice, especially from private consultancy firms, on how to finance their health systems, which are currently under strain due to the ‘unregulated’ expansion of their populations. In

Bahrain, this was due to developmental and political influences towards population expansion and in Kuwait as a result of recent geopolitical factors. Whilst in Qatar both economic and preparations for the 2020 football World Cup are having major influences on health policies and decisions. The example given by one manager was the international pressure to protect short contract workers on 2020 World Cup construction projects.

A lack of independent regulators is undoubtedly contributing to some poor quality services and concerns over patient safety. None of those interviewed were aware of the WHO Manual

‘Patient Safety Friendly Hospital Initiative’ [127], although most of them were aware of the WHO

Report published in 2000, When I shared with them the WHO (EMRO) work which revealed that up to 18% of hospital patients in the Eastern Mediterranean Region suffer an adverse event (3% of which are fatal) they were not aware of such figures neither have they collected any nature of data on medical errors [127].

With regard to the questions around ‘Health System Governance’, I introduced the concepts of ‘accountability’ and ‘responsibility’ as the main aspects of Governance[128]. This concerns the management of relationships between various stakeholders in health including individuals,

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households, communities, firms, governments, non-governmental Organisations, private firms, and other entities which have the responsibility to finance, monitor, deliver, and use health services’[129]. In particular, I referred to accountability involving: a) delegation or an understanding (either implicit or explicit) of how services will be supplied; b) financing to ensure that adequate resources are available to deliver services; c) performance around the actual supply of services; d) receipt of relevant information to evaluate or monitor performance; and, e) enforcement which concerns the imposition of sanctions or the provision of rewards for performance. I also described Clinical Governance and its dimension of ‘collective responsibility’.

All interviewees said that they have arrangements in place, which cover most of these aspects.

This included a small element of service delivery performance; however, it was not comprehensive, it was below the expected level. Despite this, no one could point out a specific framework or a document that I could refer to except Qatar[84]. With regard to Clinical

Governance, none had any arrangements (voluntary or mandatory) for clinical governance, yet all gave the impression that it forms part of the accreditation process for health service providers (both public and private). This is carried out by the Joint Commission Council (JCI) or Accreditation Canada and forms a one-off assessment of providers without any mechanisms for continuous systematic improvements in the quality of healthcare provided

[143].

In terms of the market regulations’ sets of questions, I was interested to learn how the rapidly expanding and unregulated market is managed in the three GCC countries. Marketing is fierce in the GCC and the notion of ‘fear of illnesses dominates’. Patients struggle to differentiate between services on offer due to the lack of referral systems through a trusted family doctor.

Almost all respondents felt that there were no clear market regulations, management or control in place. Indeed, none of the three countries has national bodies in place for monitoring and assessing providers of health services. This important function is left to Ministries of Health

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with the little available capacity to manage the expanding health providers especially the private sector.

All interviewees said that they were engaging the public through open forum and participation in “World Days” (for example HIV World Day or Anti-Smoking Week). In further questioning about involving the public in health systems management and decision-making, none of the three countries was involving the public or patients as members of the Boards or indeed the

Supreme Councils for Health in Bahrain and Qatar. There was some mention of ‘Patients

Surveys’ but these were mostly small scale surveys conducted by academic departments or were on specific health issues only. There were some small ad hoc surveys on patients satisfaction conducted by the three Ministries, but these were limited and conducted some while ago. I did not have access to any documentation around this issue

Chapter Discussion

This part of the study has demonstrated that policymakers and managers at the Ministries of

Health in the three GCC countries are not well versed with concept, framework and application of health system performance assessment. Both the survey and the face-to-face interviews with key players within the health systems revealed that while some performance assessment may exist, these are small and limited to specific services or procedures and not based on a well-defined framework. This finding is similar to that of Tashobya et al (2014) who found that

HSPA existed mainly in high-income countries while low and middle countries, for example in

Africa, assess small elements of their health systems and are normally donors-led [3].

Furthermore, discrepancies between the surveys and the face-to-face interviews exist regarding the existence of health system assessments. From the survey results, the majority of respondents in Bahrain and Qatar report having HSA whereas in the face-to-face interviews none said they were available. Regarding health data collection, results may seem heterogeneous about the perceptions of the existence of a national body approved by the

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Ministry of health responsible for collecting and disseminating healthcare data. However, the results show that the availability of free access to a national health database (survey questionnaire) does not necessarily translate into strong national health systems research

(face-to-face interviews).

Among the three country respondents, almost 79% (52/75) considered healthcare services as

“Good” in a scale that went from not very good, good, very good to excellent. I believe that a likely explanation for this is that despite having a good range of services available, there are still gaps in treatment options and most of all the quality perception is low. Many middle and low-income countries struggle with questions on how can stakeholders determine if the health system is or is not performing, as it should. How can the reasons for this be established? What tool(s) can help governments carry out their stewardship role? An appropriate HSPA framework can be such a tool, help answer these questions, and support evidence-based decision-making. Such tools are important in all circumstances but are particularly crucial in the GCC with such huge investments and unprecedented expansion of the unregulated private sector.

This lack of HSPA throughout the GCC was acknowledged by WHO EMRO in October 2014 in its report to the Regional Committee [130] and also by GCC Health Ministers. The GCC of

Health Ministers under the theme: ‘Measuring Health Systems: Way to Excellence’, announced that the ‘work’ comes as part of the continuation of the march and efforts of the

GCC health ministers council to boost and support plans and strategies aimed at developing the services provided to citizens in GCC countries in different health sectors” in a recent GCC

Health Ministers meeting in Riyadh in February 2015 [47],[131].

No reference to the health of non-citizens was given. In their 78th meeting in 2015, the GCC

Health Ministers passed a resolution to place particular emphasis on evidence-based indicators and arguments while setting up health and public health policies. They also urged the Executive Board of the GCC Health Ministers Council to strengthen cooperation with the

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WHO Regional Office for the Eastern Mediterranean and the different areas of experience to improve health systems performance. In the ‘Riyadh Declaration over Health Systems

Performance’, they stressed the need to seek technical support for the member states in the

GCC and strengthen the capacity and expertise in the field of measuring and evaluating health systems performance [132].

In this part of the research, I found little reference to the needs of the total population of the three studied countries by key policymakers. This may sound surprising, but official reports and statements used nationals only as the denominator of the total population. In a press release about the meeting of the GCC Health Ministers under the theme: ‘Measuring Health

Systems: Way to Excellence’, officials said “The conference comes as part of the continuation of the march and efforts of the GCC health ministers council to boost and support plans and strategies aimed at developing the services provided to citizens in GCC countries in different health sectors” [131]. This is in line with what Mamdani and Lowenfels (2017) reported in their book on health policies and politics in the GCC[62] .

The absence of training, lack of reliable data and high manager turnover has led to a serious deficit in the experience of HSPA in developing countries. Lack of research on HSPA in low and middle income countries and reliance on evidence mainly generated in developed countries is another dimension to the problem of HSPA [3]. However given the widely differing contexts, it is advisable for developing countries like the GCC to adopt a gradual introduction of HSPA and not just copy the western experiences, which has accumulated since the publication of the WHO 2000 Report [2]. In my study, I have found many hurdles that should be overcome in order to develop a meaningful HS performance assessment in the GCC.

Accepting a GCC-wide framework for HSPA is an essential first step: the current focus of simple and limited assessments will not help shape the future of the health systems in the

GCC. In Qatar, the Public Health ‘Scorecard’ attempts to measure performance against clearly specified health targets, but is limited to one service and is not a system-wide [133]. Similar

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efforts were made in Kuwait to ensure the observance of minimum standards but only in some services. Bahrain has introduced a system of ‘staff’ supervision as a tool for measuring performance [104].

Advancing information technology is another required step. While the three study countries have made some declarations that they will evolve their health systems through information technology and follow suit with Dubai in its electronic government philosophy, many of the respondents to this survey still highlighted the insufficient information technology (IT) and electronic systems at all levels. Respondents mentioned that information is often entered long after a client receives services, particularly if there are long queues at a facility. Lack of the seriousness with data collection is a common feature of health systems in developing countries [134].

Limited human resources and technical expertise is a major obstacle to introducing and implementing HSPA in the GCC. Even if key health system performance assessment processes and data management responsibilities at the country level were defined, there are limited human resources available for such activities. Non-nationals (foreign workers) fill most fixed-term posts. In competing demands for the well-trained workforce and sustained pressure on services, priorities are shifting away from allocating resources to routine data collection, analysis and interpretation for policy makers, service managers and the public. This is another factor in health system sustainability and is a major governance issue. Workforce planning is almost non-existent in the GCC countries. Although there have been many attempts to increase the national supply of healthcare professionals, according to all interviewees. Bahrain has added another medical school, and Qatar has just opened its first national medical school, in addition to the already existing Cornell University which enrolled only a very few Qatari students during its first 10 years of its existence. However, market forces dictate workforce policies and in the absence of independent regulators, the quality of many recruits is questionable.

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This study is the first of its kind in the GCC; approaching key official policy and decision- makers in countries described as ‘closed’ societies for an open opinion about their health systems is not easy. The face-to-face interviews were conducted with many prior rehearsals to ensure diplomatic approaches through building professional relationships and assuring them of absolute anonymity. It was interesting to note that initial interviewees’ responses to most of my questions were positive about the situation in their health systems, with two exceptions. Nevertheless, during the in-depth face-to-face discussions, the picture tended to change and the realities of the current situation were shared in a more honest and professional way.

Limitations of the study (Survey and face-to-face Interviews)

Lack of understanding of the concept and indeed the framework of HSPA by many managers in this sample was one of the limitations. I was not aware of this initially but after preliminary analysis of the data, I learnt that almost all of them were not trained in health service management. Learning on the job was the method of learning about ‘management’ and because HSPA is not part of the health system culture, the majority had no experience.

The number of key policy and decision-makers in the three GCC countries is relatively small.

However, despite the fact that the three Ministries of Health are not large, access to the key players at the Ministries was not easy. The task was made easier through the excellent network provided by my two supervisors and the frequent visits of many GCC health officials to the WHO Collaborating Centre and the Department of Primary Care and Public Health at

Imperial College London.

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Chapter 9

General Discussion and Recommendations

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Chapter 9 General Discussion and Recommendations

Discussion

A health system is the product of a country’s culture and the way nations are willing to fund it, to ensure equity and fairness. There is no ideal health system. Each system has its strengths and weaknesses [126]. However, the best systems are those able to secure good health outcomes for the whole population [135]. Securing good health for the whole population cannot be achieved without universal health coverage (UHC). Across the world governments, stakeholders and the public repeatedly pose the question of how their health system is performing. Despite pressure on health services, many countries are unwilling to inject further funds if the evidence on performance is not available. Since the 1990s, WHO has invested resources and expertise in developing a framework for health system performance assessment [17]. This culminated in the publication of the WHO World Health Report in 2000

[2]. The lifespan of the report was very short. Some high-income countries questioned the methods used and discredited its findings off the record.

Many middle and low-income countries struggle with questions on how can stakeholders determine if the health system is performing, as it should? How can the reasons for this be established? What tool(s) can help governments carry out their stewardship role? An appropriate health systems performance assessment framework can be such a tool, help answer these questions, and support evidence-based decision-making. Such tools are important in all circumstances but are particularly crucial in countries with huge investments and unprecedented expansion of their health systems including a large unregulated private sector, such as Bahrain, Kuwait and Qatar [136].

In this chapter, I will triangulate the main findings from the different chapters of the study on the three GCC health systems of Bahrain, Kuwait and Qatar in an attempt to address the research questions outlined in Chapter 4. Triangulation refers to the use of more than one

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approach to the investigation of a research question or in order to enhance confidence in the ensuing findings. The four result chapters plus the systematic review provided evidence on the strengths and weakness of the health systems in the GCC in meeting their populations’ health needs.

This is the first-ever substantial assessment of selected GCC health systems. The literature provides no evidence of such assessment. Further, this study provides new findings on health politics and policies in the GCC. The literature review shows that health systems are complex and not easy to benchmark. This is mainly because health sectors produce more than one outcome [2, 71]. Therefore, I clustered, for the purpose of discussion and recommendations, the study findings into the following health system outcomes: health status, financial protection, workforce, and access and quality.

Health Status

The three countries have progressed their health systems in this relatively short period of time in comparison to other countries in the region with a longer history of development. The comparative measures of mortality (causes of deaths and life expectancy (LEB)), morbidity

(burden of disease, risk factors, and HALE), and disability (DALY) in this study clearly indicate that health status of the GCC population is higher than the rest of the region, except Lebanon.

However, this assessment is only relevant to the nationals of these countries (only 51% of the total population) and no data for non-nationals are available (or included in the analysis)

[8],[78],[62, 75],. The lack of health statistics for non-nationals is of great concern and may indicate inequalities in access to health and healthcare services [8]. However, GCC health politics are largely governed by the social contract between Nationals and the Rulers in the six countries, which give nationals full priority on the countries resources [62].

While the overall health of the GCC population has improved over the last three decades, the study shows that new emerging risks to health are very challenging. Lifestyle diseases of wealthy countries, including diabetes, hypertension, cardiovascular diseases and cancer are

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on the increase in comparison with neighbouring countries. These will certainly put pressure on health systems and demand for more human and other resources for health. Such pressure on services will be compounded by population growth, ageing and technological advancement.

Financial Protection

All GCC countries are spending below the 5% of GDP on health: a lower limit recommended by WHO[101]. While government spending as a share of total expenditure on health is relatively high (from 65.3% in Bahrain to 91.8% in Oman) and projected to continue to be high in 2040, the out-of-pocket of contribution in Bahrain, Kuwait and Qatar is on average above 17% of total health expenditure. The per capita spending on health is higher than the neighbouring countries of Iraq, Iran and Pakistan. However, as health statistics are drawn from nationals only, the per capita expenditure ‘misleadingly’ appears high. The study shows that until now, the costs of health service for all GCC nationals have been primarily the responsibility of their respective governments as part of the oil wealth sharing, and this has become a major challenge for the states [62]. With the decline in oil prices and a slower economy, almost all

GCC countries cut their health budgets and two (Saudi and UAE) are introducing value added tax for all goods and services, including food, early 2018 [110]. The study shows, for the first time, the association between access to health services, quality and health spending per capita using the HAQ Index. Therefore, any further reduction in health spending will lower access to and the quality of healthcare, and reduce the confidence of the population in their health systems.

What is interesting in most GCC countries is that many nationals prefer to receive medical treatment abroad instead of relying on their national service. In most cases, the overseas treatment is funded by the state, substantially increasing further the burden on the health budget [52].

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Plans in all GCC countries under discussion is to shift sharing the burden of health costs to their nationals and non-nationals through privatisation programmes, which may affect the quality of health service and access to healthcare negatively [62]. The introduction of basic health insurance to non-nationals (migrant workers) outside government employment and put the responsibility to employers without clear protective regulatory mechanism[8] may create inequity in healthcare. This will lead to multitier health services and possible differentials in access to and quality of healthcare[69, 113, 137] Avoiding such unwelcomed negative outcomes of access, quality and equity, governments should aim at spending above 5% of GDP and plan to achieve universal health coverage as envisaged by the UN Sustainable Development Goals

(SDGs) [138]. International Consultancy Firms, who are the main source of reports compiled on health systems and future projections, without any academic rigor [62] [69] predict that health spending in the GCC will exceed $60 billion by 2025 [1]. That needs to be seen, but I found that the share of Governments percentage will continue to be high (Table 22 page 117) and it is unlikely that predicted ‘health tourism’ will expand to such an extent. The focus of the health policies and strategies should be on addressing the health needs (both nationals and non- nationals) and the challenges of population growth, ageing, technology and NCDs and mental health[139].

Workforce (Human Resources for Health)

Current analyses of the human resources for health (HRH) represent the culmination of past investment and policy actions to develop health services and offer an important entry to strengthening health systems in the GCC states in the future. The results of this study show

“exceptionally” high percentages of doctors and nurses trained outside the region, and most of them are non-nationals. This emphasises the long-term need to scale up undergraduate education and postgraduate training capacity for nationals in each of the six countries, as well as regional collaborations, especially in postgraduate training, in support of health system sustainability. However, quality should not be compromised. Demands on HRH will be

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increased even further, as the demographic and economic trends point to populations living longer, and with higher disease burden [140]. Despite the expansion in medical education and training, the GCC is currently an attractive market for doctors and nurses. Nevertheless, this may change, depending on the economic situation. With the acute shortages worldwide and lack of opportunity for long-term settlement in GCC countries, many view the GCC as a stepping-stone to a more permanent career in the West [1, 69]. These are difficult to resolve and a ‘de facto’ situation imposes itself on HRH policies and strategies in the Gulf. It will require strenuous efforts to be able to sustain a healthcare system in any GCC country without the help of foreign health professionals.

As primary care is the backbone of any health system [106], my analysis of the GCC current family medicine capacity and future needs, for the first time, shows acute shortages in the speciality in at least 5 countries (Bahrain has a shortage but can be addressed within a manageable timeframe). Such shortages, unless addressed through scaling up the training as envisaged by WHO[86] cannot be materialised in UHC and the cost of hospital care will escalate. This will put further pressure on health system finance. Similar shortages were reported among other health professionals.

In my face-to-face interviews with senior managers, many highlighted the shortages, even lack, of expertise in health service management. There are no training programmes in health service management in the GCC and senior managers and policymakers, are from a medical background without management training. This is not unique to Bahrain, Kuwait and Qatar but a problem across low and middle income countries as reported by WHO [141].

The major concern is when energy resources are depleted, how the GCC will be able to sustain health system funding and buy the expertise they need? The health workforce is a key element of the reform process and aligning the health workforce supply with the requirements of the reformed system to meet challenges and needs, is crucial to all GCC countries and the

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region. Any attempt to reform health system without proper human resources for health strategy is doomed to fail.

Health Access and Quality of Service

The HAQ Index, used for the first time to assess and compare health systems performance in the GCC, shows clearly a significant improvement between 1990 and 2015. Among the three study countries of Bahrain, Kuwait and Qatar, the Qatari’s health system progressed steadily and by 2015 even exceeded the predicted best possible scenario, as measured by HAQ Index, compared with the other two countries. This is mainly due to the heavy investment by Qatar in their health system in recent years in policy development, capital building, human resources and service development [54].

The political upheaval in the region in recent years may have impacted on the performance of the health systems in Kuwait due to the invasion in 1991[121] and Bahrain civil unrests[122].

The lack of health management expertise, as both the health managers’ survey and face-to- face interviews, have shown, may have hampered health systems development and progress in addressing the many challenges identified for better outcomes and better population’s health. Furthermore, managing the health needs also requires accurate, up-to-date statistics.

Such information is not always available in the three countries, which limits the ability to identify priorities, allocate resources, develop relevant policies and decision-making [142]].

The study also shows that health policy development and implementation in the region are largely lacking. The most recent work on health systems by the Eastern Mediterranean Region of the WHO, which includes the 6 GCC states, consists of reports compiled by consulting firms such as Booz & Company, McKinsey & Company, and Alpen Capital[62]. Though such reports focus on how existing healthcare structures can be transformed into modern healthcare systems, they lack academic rigour and tend to ignore larger, policy-related issues. As for the

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social scientists, there has been a striking dearth of contributions addressing policies and practices of health systems of different countries.

Limitations

The analysis of the findings from this study is subject to limitations beyond the control of the researcher. First, limitations experienced in literature availability on health systems in the GCC which is most probably the case for most developing countries. Second, the lack of accurate and reliable data and statistics is very frustrating in the GCC. Very limited data are available on the health of non-nationals and most of the published national statistics attribute data for the entire population incorrectly. Access to unpublished information and reports was not easy and I had to visit Ministries to obtain such data. Third, access to senior managers was not easy and the fear of sharing information without higher authority’s approval delayed and restricted my work. Fourth, the lack of understanding of the concept and indeed the framework of HSPA by many managers in the study sample was one of the limitations. I was not aware of this initially but after preliminary analysis of the data, I learnt that almost none of them were trained in health service management. Learning on the job was the only method of learning about ‘management’ and because HSPA is not part of the health system culture, the majority had no experience. Fifth, the number of key policy and decision-makers in the three GCC countries is relatively small. However, despite the fact that the three Ministries of Health are not large, access to key players at the Ministries was not easy. The task was made easier through the excellent network provided by my two supervisors and the frequent visits of many

GCC health officials to the WHO Collaborating Centre and the Department of Primary Care and Public Health at Imperial College London.

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Added Value of this Study

The study added value in several ways. First, this is the first study of health system performance in the Gulf Region. The findings will be of value and hopefully, drive and support the implementation of both GCC Health Ministers and WHO 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 reforming health services and defining priorities. Fourth, I conducted an exploratory analysis of national HAQ Index levels and potential determinants of performance. This method of HSPA is used for the first time in the

GCC. Fifth, I examined for the first time the relationship between HAQ Index and per capita spending in the selected GCC countries, highlighting the value of sustainable funding to address challenges and improve health. Finally, and sixth, the study provided, for the first time, data on primary care needs and the numbers 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 to secure good health for the whole population.

In Conclusion

This work is the first of its kind in addressing HSPA in the Gulf Region. The null hypothesis proposed is rejected, as the three health systems studied are not equitable. Although they share similarities, they show differences in accessibility and discriminate between nationals and non-nationals (guest workers). Despite the fact that the non-nationals were and still are the key players in economic developments and the running of these countries, they were not treated in equal ways. The analysis showed clear discrimination between the two distinct groups of the population in the three GCC countries studied. This study found that health systems performance assessments in the GCC and across the region do not exist, are poorly

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understood and attract little interest. Comparative data, between GCC countries and

neighbouring ones as well as the individual country profile, show clearly that the health of the

‘nationals’ has improved significantly in the last two decades. No information is available for

‘non-nationals’. UHC hinges upon ensuring that all populations have good access to high-

quality care across key health service areas. My findings show that while nationals have full

access, many found the quality is questionable and sought healthcare outside their countries.

None of the countries has any form of neither HSPA nor senior managers trained in

undertaking such assessments. The study found many challenging issues in health finance,

workforce and burden of disease; especially non-communicable diseases. While health

systems are evolving, many health policy decisions are taken without proper health system

assessments, or evidence of proper assessments of needs. Clear long-term strategies are

needed to address the huge challenges health systems are facing in the region. Qatar is

moving in the right direction, but more needs to be done and coordination between the six

countries is essential for better health for all those living and working in the GCC. Lack of

research in this area is a serious issue and must be addressed.

Recommendations

The situation of health and healthcare in the GCC states continues to evolve. The emergence

of lifestyle diseases, mental health conditions, population growth, the ageing population,

healthcare costs, health coverage, and a shortage of health professionals pose considerable

challenges as I have shown in his study. Based on the findings the following recommendations

should be taken into consideration by GCC Member states and WHO EMRO:

Recommendation 1: HSPA a. WHO EMRO should implement resolution C60/12-E and develop an appropriate framework

for HSPA inclusive for all the population served.

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b. GCC countries should implement GCC Health Ministers’ 2015 Resolution and work in

collaboration to strengthen the capacity and expertise in the field of measuring and evaluating

health systems’ performances. c. A conceptual framework should be developed for Health System Performance Assessment.

Such a framework could be based on some of the existing ones in developed countries

modified to the needs of the GCC countries and EMRO. d. Health Information Systems (HIS) should be strengthened to generate evidence, monitor

services and evaluate outcomes. e. Ministries of Health should invest in developing capacities at their ministries through training

and strengthening technology resources.

Recommendation 2: Health Finance f. The GCC, with the vast wealth they have, must invest in health with at least 6% of their

respective GDPs as recommended by WHO (10). Current policies, which are politically driven,

and triggered by private consultancy firms, and advise shifting the so-called ‘burden’ away

from the state to employers and individuals should be fully re-assessed. g. The governments should agree on measures to review the benefit of medical treatment abroad

and its impact on the health budgets.

Recommendation 3: Human Resources for Health h. Recruitment processes should be revised and based on developed standards.

i. National capacities for supplying doctors, nurses and other health professionals should be

increased. In addition, the places for higher specialization medical training programmes

should be increased. j. An independent regulatory body(s) for doctors, nurses and other health professionals should

be set up. Such a body(s) will help to protect patients and improve medical education and

practice in each member state of the GCC, by setting standards for students and doctors. It

177

will also help practitioners achieve and exceed those standards and take action when they are

not met. k. Ministries of Health should invest in health planning capacities, based on the use of the latest

evidence and performance data.

Recommendation 4: Health System and service Research l. Ministries of Health should identify resources to address the health system issues of concern. m. Universities should be encouraged to competitively develop their capacities in health system

research. n. Research is also needed on how to address the most prevalent diseases and risk factors and

how to protect the population’s health.

Recommendation 5: Governance o. Ministries of Health must be transparent with all policy formulation and decisions taken that

will have a direct impact on their population’s health (both nationals and non-nationals). They

should develop national standards for all services (National Service Frameworks), including

human resources, procedures, medical equipment, drug supply and procurements. p. Ministries and health organisations must produce Annual Health Reports of the state of the

health of their population, both nationals’ and non-nationals. Such reports should highlight any

gap and how to address it. q. Corporate Governance, Financial Governance, and Clinical Governance Frameworks and

operation need to be established. Clinical governance will ensure systematic improvements

in the quality of the service, and hence safety through collective responsibilities. It is by far a

much superior and effective method than the one-off costly and less effective accreditation

process by Joint Commission International (JCI) and similar organisations.

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r. Independent health professional’s regulatory body and service providers’ regulatory bodies

should be developed if not in existence, or existing ones strengthened in each country to

safeguard patients and the population and assure quality of services.

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Appendix 1

Health System Performance Assessment Questionnaire

The study questionnaire was tested through Crohnbach’s alpha testing for validity, and piloted in the other three GCC countries (non-study countries)

The Study Questionnaire

Dear Colleague

First let me first thank for agreeing to take part in this important study, which is aimed at understanding how health systems in the GCC are continuously assessed in term of its performance in achieving improvement in population health through better access and quality of service. This study is part of my PhD study at Imperial College London under the supervision of Professor Majeed and Professor Rawaf.

The questionnaire was piloted in Bahrain, Kuwait and Qatar questions were re-phrased and adjusted and some were removed to ensure validity of responses. Collected information will be anonymous and all information provided will be treated in strict confidence and no source will be identified. The overall aim of this study is to improve access and quality of the service to the GCC population.

Once again, we are most grateful for your participation in this important study.

Yours sincerely

Aisha Al Ghafri (PhD Student, Imperial College London)

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لقد تم تصميم هذا االستبيان لجمع البيانات التيسيتم إدخالها في التحليالت الكمية والنوعية على ٍّحد سواء

ويهدف االستبيان توفيرالمعلومات لتقييم النظمالصحية )إن وجدت( وألدواتالتي يتم من خاللها تقييم أداء هذهالنظم,

وتماالخذ بعيناالعتبار المعاييرالثقافية االجتماعية عند تصميم هذا الستبيان , وبموجبقانون االحصائيات إجابات كستكون

سريةللغاية وقد تم اختبار هذه االستماره في ثالث دولخليجيه هي البحرينوالكويت وقطر .والدراسه تحت اشرافالبرفسور

سلمان الروافوالبرفسور عظيم مجيد من جامعه امب لاير فيلندن.

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Section1: Profiles of participant

ذكر Male 1.1

Gender الجنس انثى Female

المسمى الوظيفي)اختياري( (Job Title (optional 1.2

…………………………………………………………………………………………

الفئهالعمريه Age range 1.3

18-25 26-35 36-45 46-55 56-65 65+

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1.4 What is your highest level of academic attainment to date? ما هي اخر درجة علمية حصلت علي ها؟

High school = A Level, ONC, OND, BTEC etc.

GCSE, O level, City & Guilds

HNC, HND, CMS, DMS,

1st Degree (BSc, BA, BBA, MBBS, MBChB)

Higher Degree (iMA, MBA, MSc, PhD)

None of the above

1.5 How long have you worked / been working in health care services? منذ متى وأنت تعمل / عملت في مجال خدمات الرعايةالصحية؟

0 –5 years 5 - 10 years over 10 years

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تقييم أداء النظام الصحي Section 2: Health System Performance Assessment

2.1 Do you have any Experience or Knowledge of HSPA, Frameworks or HSPA Tools?

Yes No

2.2 Does any entity in your health system provide regular performance assessment to the service they provide?

هل يوفر اي كيان في نظامكمالصحي تقيم مستمرالداء الخدماتالتي يقدمون ها

ال نحن ال نقيماألداء )انتقل الي No we do not assess the performance (go to 2.8 .1

2. Yes we assess the performance but I do not know about the process. (Go to 2.8)

نعم نحن نقييماألداء ولكن أناال أعرف عنالخطوات )انتقل الي 2.8(

3. Yes we assess the performance and there is clear process and governance for it.

)Continue 2.2(

نعم نحن نقييماألداء، وهناك طرق و نظام إداري واضحلذلك )أكمل 2.2

4. There is a procedure and policy for health system performance assessment but no one

uses it. (Continue 2.2)

هناك إجراءات وسياساتلتقييم أداء النظامالصحي ولكنال أحد يستخدمه )اكمل 2.2 (

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2.3 Which of the following do you use to assess the performance of your health system?

أي مما يلي تستخد مهالتقييم أداءالنظام الصحي

تحسين النظامالصحي (Improvement of the health system (outcomes .1

فعالية الخدمات (Effectiveness of the services provided (access, quality .2

رضاالعمالء Customer satisfaction .3

الشيء مماسبق None of the above .4

أشياء أخرى )الرجاء ذكر ها( (Other (please specify .5

………………………………………………………………………………………

2.4 What do you think about the entire health system performance assessment ما رأيك في عملية تقييم أداءالنظام الصحي بأكمله؟ ?process

Very poor Poor Good Excellent

ممتاز جيد سيئ سيئللغايه

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اي ?What did not satisfy you about health system performance assessment process 2.5 مما يليال يرضيكفي عملية تقييم أداء النظامالصحي

استهالك الوقت  Time consuming

 No set strategy in place to reward the outcome of performance assessment

ال توجداستراتيجية مجمعه في مكانلمكافأة نتائج تقييم

ألداء

 Does not give the full picture of the workforce performance

ال تعطي صورة كاملة عن أداء القوى العاملة

الكثير منالبيروقراطية  Too much bureaucracy

مكلفة جدا  Too costly

كل ماسبق  All the above

الشئ  None

2.6 What is the budget (estimation) assigned for the health system performance assessment that you are working for?

198

ماهي الميزانيه )بالتقدير( المخصصهلتقييم اداءالنظام الصحي في عملك

1. 10 000 – 15 000 USD

2. 15500 – 20000 USD

3. 20500 – 25000 USD

2.7 Is the health system performance assessment updated at least every 3 years?

هل يتم تحديث تقييم أداء النظامالصحي كل 3 سنوات على ألقل ؟

Yes No

If "yes" go to 3.1 If "No" continue 2.7

اذا كان "ال" اكمل 2.7 واذا كان "نعم" اذ هب الي سؤال3.1

2.8 How often does the health system performance assessment get updated? (In years) كم مرة يتم تحديث تقييم أداء النظامالصحي )بالسنوات( …………………………………………………………………………………

انتقل الي Go to 3.1 3.1

2.9 Which of the following do you think will be useful to assess the performance of your أي مما يلي في رأيكستكون مفيدة لتقييم أداء النظامالصحي ?health system

تحسينالنظام الصحي Improvement of the health system .1

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فعالية الخدمات المقدمة Effectiveness of the services provided .2

رضاالعمالء Customer satisfaction .3

الشيء مماسبق None of the above .4

أشياء أخرى )الرجاء ذكر ها( (Other (please specify .5

………………………………………………………………………………………

2.10 Which of the following do you think will not satisfy you in the health system performance assessment process

اي مما يلي تعتقد انه غير مجدي في عملية تقييم أداءالنظام الصحي

استهالك الوقت  Time consuming

 No set strategy in place to reward the outcome of performance assessment

ال توجداستراتيجية مجمعه في مكانلمكافأة نتائج تقييم

ألداء

 Does not give the full picture of the workforce performance

ال تعطي صورة كاملة عن أداء القوى العاملة

الكثير منالبيروقراطية  Too much bureaucracy

مكلفة جدا  Too costly

كل ماسبق  All the above

الشئ  None

2.11 In your opinion, what is the appropriate budget (estimation) assigned for the

health system performance assessment that you are working for?

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في رايك ماهي الميزانيه )بالتقدير( التي يمكن ان تخصصلتقييم اداء النظام الصحيفي عملك

1. 10 000 – 15 000 USD

2. 15500 – 20000 USD

3. 20500 – 25000 USD

2.12 How often do you think the health system performance assessment will get كم مرة يمكن ان يتم تحديث تقييم أداءالنظام الصحي )بالسنوات( (updated? (In years

…………………………………………………………………………………

2.13 At the end of this section, do you think that you have sufficient knowledge of

Health System Performance Assessment frameworks and tools?

Yes No

2.14 Do you need training in methods and applications of HSPA?

Yes No

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نظم الصحة والبيانات الصحية Section 3 Health Systems and health data

3.1 Do you consider the structure of your health Organisation (as whole) to be

هل يعتبر الهيكل التنظيميللمؤسستك بشكل عام

بسيط وواضح Simple and clear .1 ليس بسيط Not very simple .2

معقد وغير واضح Complicated and not clear .3

3.2 What are the activities and capacities of the health system that you are working ما هيالنشاطات وقدراتالنظام الصحي الذي تعمل فيه؟ ?for

1. We cover all health services in the country including hospitals and clinics. نحن نغطي جميع الخدمات الصحية فيالبلد بما فيذلك المستشفيات والعيادات

2. We cover health services in some part of the country

نحن نغطي الخدمات الصحيةفي جزء منالبالد

3. We only cover few hospitals in the country

نحنال نغطي سوى عدد قليل من المستشفيات فيالبالد

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3.3 How good (in your opinion) are the health care services in your region/Country? ما هو تقيمك للخدماتالرعاية الصحيةفي منطقتك ؟

ليست جيده Not very good .1

جيده Good .2

جيده جدا V ery good .3

ممتازه Excellent .4

3.4 Do you collect and save data for the purpose of health system performance assessment? هل تقومون بجمع وحفظ البيانات لغرض تقييم أداءالنظام الصحي؟

Yes No

3.5 What level of data is being collected to assess the health system performance? ما هو مستوى البياناتالتي يتم جمعهالتقييم أداءالنظام الصحي؟

بيانات على مستوى المريض  Patient level data

بيانات على مستوى المستشفى  Hospital level data

بيانات على مستوىالمنطقة  Area level data

بيانات على مستوىاالقليم  Regional level data

3.6 Are data from the health system performance assessment comparable to data from other comparative countries within and outside the GCC? هل بيانات تقييم أداء النظام الصحي لديكم قابلهللمقارنه مع بيانات النظم الصحيهفي المناطق المماثله ؟

Yes No

203

If yes continue to 3.7 If No go to 3.8

اذا كانال اذ هب الي سؤال 3.8 واذا كان نعم اكمل 3.7

3.7 Which of the following is comparable data you collect يتم مقارنه البياناتالتي تم جمع ها مع ما يلي

الدول المجاوره )مجلسالتعاون الخليجي (  GCC-wide

المنطقه )الشرق االوسط ( ( The Region (EMRO

عالميا  International

3.8 Is there any national body approved by the ministry of health responsible for collating and disseminating health care data? هل هناك أي هيئة وطنية معتمده من وزارةالصحة مسؤولة عن جمع ونشر بياناتالرعاية الصحية؟

Yes No

3.9 Do any of the following institutions contribute to the national health data and/or facilitate as a resource for health data collection? هل أي من المؤسساتالتالية تسا هم في بيانات الصحةالوطنية وتقوم كمصدر مساعد في عمليه جمعالبيانات الصحية؟

وزارةالصحة  Ministry of Health

جامعات أو مؤسسات أكاديميه ( University or academic institution(s

204

مقدمينالرعاية الصحية في القطاعالخاص ( Private health care provider(s

المراكزالصحية  Health center

وكاال تالقطاع ( Other public sector agency or governmental entity (ies العام أو هيئات حكومية اخرى و االت أومنظمات على مستوىالدول ( National level agency or Organisation(s

منظمات اجتماعية ( Community-based Organisation(s

غيرذلك )يرجى ذكر ها( ( Other (Please specify

…………………………………………………….………….…………………………

3.10 Do all or some of the data contributors have free access to the national health database? هل كل أو بعض المساهمين في البياناتلديهم حرية الوصول إلى قاعدة البيانات الوطنيةللصحة؟

Yes No

3.11 Are the health statistics easily accessible for the general public? هلاإلحصاءات الصحية يمكن الوصولإلي ها بسهولة لكلالناس

Yes No

3.12 Does the MOH use latest technology to: هل تستخدم وزارةالصحة أحدث التقنياتلـ :

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لجمعالبيانات المتعلقه بالصحه العامه Collect health profile database .1

الدارة هذه البيانات Manage health profile database .2

لدمج قواعدالبيانات المتعلقه بالصحة Integrate health profile database .3

لعرض قواعد بيانات الصحه بالكامل Display health profile database .4

Once again thank you for taking the time to complete this questionnaire. Please return the questionnaire using the enclosed pre-paid envelope to Aisha Al Ghafri

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Appendix 2

PRISMA

Reported Section/topic # Checklist item on page # TITLE Title 1 Health Systems Performance Assessment and Sustainable Improvement in Bahrain, 1 Kuwait and Qatar ABSTRACT Structured summary 2 The purpose of this review is to focus on health system performance in the three of 2 GCC countries (Bahrain, Kuwait and Qatar) and the way governments, institutions and researchers are assessing performance in each country. In it, I wanted to see how services are effective and efficient in serving the needs of the entire population, of the GCC, including both nationals and migrants (non-nationals) populations. INTRODUCTION Rationale 3 Described how important for health policy makers and senior managers to understand 4 the performance of their health systems to identify opportunities for improvement in effectiveness, efficiency and equity. Aim & Objectives 4 The aim of this literature review to examine evidence about performance assessment of 4 health systems in the GCC countries and well as on a global level.

METHODS Protocol and registration 5 In terms of the evidence base globally and not simply confined to the GCC countries in 4-5 question, the literature relevant to the research focus was identified from various sources. An online search was carried out to locate evidence about the concept of ‘health system performance assessment’, as well as related issues such as “health system and human resource’, ‘health system and finance for health”.

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Eligibility criteria 6 A systematic search of the electronic online databases for published literature on 5-6 Health System performance assessment, or evaluations, in Bahrain, Kuwait & Qatar are using the Keywords (Bahrain OR Kuwait OR Qatar) AND (Health System Assessment OR Health System Performance OR Health System Development OR Health System Improvement OR health system Sustainable improvement). No language restriction was imposed. Information sources 7 From PUBMED, Medline, ELDIS, the World Bank library, WHO library, ID-21, 4 EMBASE, and the Cochrane library(from inception to 1 July 2017) Search 8 A systematic search was conducted of the following electronic databases (from 5 inception to 1 July 2017): EMBASE Classic + EMBASE (1947 – 2017), Ovid Medline In process and other non-indexed citations & Ovid Medline (1946 – March 2017), HMIC Health Management Information Consortium (1979 - 2017), and Global Health (1973 – 2017) The Electronic databases were used to systematically review the literature in order to identify all available data up to July 2017 from published and selected unpublished sources. The search aimed to identify literature that discussed. The search covered all studies that reported on (Health System Assessment, Health System Performance, Health System Development, Health System Improvement, health System Sustainable Improvement. No restrictions were applied regarding study design, age, and language. The analysis was limited to studies conducted in Bahrain, Kuwait & Qatar Study selection 9 I expected to be faced with the huge bulk of health system literature from GCC but was 5 disappointed. Health system literature related to GCC in general and performance assessment, in particular, was lacking at all levels, academic and service reports. Hence, the search was widened to cover worldwide literature on health system development and assessment within the study questions and focus Data collection process 10 At the initial stage of the searching process, the concept “health system” was used in 7-8 general and then later in combination with a human resource for health and health finance related concepts, themes and sub-themes. Most of the publications identified through the search reported the results of health system reforms or evaluated specific health programs rather than examining the measures used for evaluation; for example, focusing on the measures used (process) rather than the result of health reforms. Only studies that offered examples of the actual application of the indicators in the field were included in the review. Selected for final review were 118 papers on the health system’s effectiveness, 90 on equity, and 97 dealing with efficiency.

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Data items 11 Bahrain OR Kuwait OR Qatar AND (Health System Assessment OR Health System Performance OR Health System Development OR Health System Improvement OR health system Sustainable improvement). Risk of bias in individual 12 Critical Appraisal Skills Programme (CASP) for observational studies checklist. (CASP) studies Summary measures 13 Health system’s effectiveness, equity, and efficiency Synthesis of results 14 Summary tables and narrative synthesis.

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Appendix 3

List of Publications from this study 1. Hamad A, Rawaf S. Health System Performance Assessment. In Sbaiti M (Ed) Global Health at Glance, 2016. 2. Khoja T, Rawaf S, Qidwai W, Hamad A, et al. (August 21, 2017) Health Care in Gulf Cooperation Council Countries: A Review of Challenges and Opportunities. Cureus 9(8): e1586. doi:10.7759/cureus.1586 3. Hamad A, Rawaf S, Dubois E, Mokdad A, Khoja T, Rawaf D, Althani, M, Majeed A. Comparing health system performance assessment and management in the Gulf Corporation Countries. WHO EMRO, Eastern Mediterranean Health Journal (submitted Jan 2018) 4. Rawaf S, Hamad A, Salah H, Majeed A, Dubois E, Khoja T, Al-Duwaisan H, Alnase F, Kurashi N, Abdulmalik M, Rawaf D. Scaling up family medicine training in the Gulf Corporation countries. Submitted to Family Medicine March 2018. 5. Rawaf, S. Hamad A, Dubois E, Rawaf D, Alsheikh M, Majeed A. Population dynamics, politics and health policies in the Gulf Corporation Council countries. April 2018 (under review) 6. Rawaf S, Mokdad A, Hamad A, Rawaf D, Majeed A. Health Access and Quality in Assessing Health System Performance in low and middle income countries. April 2018 (under review)

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