Kuwait Health Care System: Assessment and Reform Analysis

Introduction

As society grew and evolved, its focus on healthcare increased, and it has eventually reached a situation in which life expectancy at birth has doubled or even tripled. Macau, for instance, is the country with the highest life expectancy at birth at 84.36 years, followed by Andorra with 82.51 years, Japan with 82.12 years, and Singapore with 81.98 years. At the other end sit Angola with 38.20 years, Zambia with 38.63 years, Lesotho with 40.38 years, and Mozambique with 41.18 years (Central Intelligence Agency, 2010).

The past few decades have witnessed numerous processes of global change, one of the most important being the liberalization of markets and the globalization of not just economies but also cultures, technologies, and societies. These values began to transcend boundaries and influenced corresponding values in other global regions. Despite this process of globalization, however, differences remain obvious in various fields. One of the most relevant examples is offered by the healthcare sector. While the globally observable trend has been that of improving living conditions for populations and increasing life expectancy, the means by which countries approach this goal vary considerably.

A most relevant distinction is noticeable — as with many other elements — in terms of the western hemisphere versus the eastern hemisphere. While the West has strived to improve the health of its citizens through technological innovations, the East has focused on making medical services more easily accessible to the entire population. Unfortunately, the two approaches have proved rather mutually exclusive. A notable example is offered by Kuwait, where medical reform was conducted to increase the population's access to medical services, but in the process, innovation and technological advancement were neglected.

The current research endeavor strives to assess the status of the Kuwaiti health care system and produce a relevant picture of the situation. In order to accomplish this, it constructs a twofold approach. On the one hand, the research is grounded in an analysis of the available literature in order to identify the situation as presented in secondary sources. On the other hand, an attempt is made to assess the situation through primary sources of information. Specifically, the analysis is conducted through the lens of patient perceptions as well as medical staff perceptions regarding the status of the Kuwaiti health care system.

The assessment of primary sources — patients and medical staff — is accomplished through a survey of both categories of individuals. The selection of research tools and techniques was completed with the aid of the onion ring research methodology, which revolves around the gradual answering of several questions referring to elements such as research philosophy, research strategy, research choice, and so on.

The findings of the research process indicate issues such as technological limitations, training needs, and the required emphasis on prevention as well as treatment. In light of these findings, recommendations have been forwarded, including: offering training to staff members; providing better support for the educational system; focusing on disease prevention; and developing and implementing strategic courses of action originating from the private sector but with enhanced ability to support managerial advancement in the public sector.

The scope of this research endeavor is to objectively assess the status of the Kuwaiti health care system. In order to attain relevant findings, the research considers the standpoints of both patients and medical staff. As the condition of the Kuwaiti health care system is reviewed, specific recommendations are offered. The set of recommendations represents the practical significance of the research endeavor, while the study itself represents its theoretical significance.

Research Aims and Objectives

At a more specific level, there are five sub-themes associated with the research project. They also represent the key questions of the study:

Question 1: How can medical reporting errors be improved?
Question 2: How can performance management practices be improved?
Question 3: What is the patient perception of the services provided?
Question 4: What is the staff perception of the services provided?
Question 5: How does the media's portrayal of healthcare provision in Kuwait impact the perceptions of staff and patients regarding the healthcare system?

In order to answer these research questions, several smaller objectives are set. Initially, it is necessary to review the specialized literature in order to place the research questions in context. The literature review constitutes the starting point not only in the analysis but also in the creation of the survey, as it creates the background and identifies the issues that merit attention. Once the literature review is completed, the next sub-objective is to identify the most adequate research methodology. As with most research elements, the researcher cannot simply adopt a specific technique but must select one in accordance with the research's particular requirements.

The third objective is to combine the three research components — the information in the specialized literature, the sample, and the research tools and techniques — in order to generate findings through the process of data analysis. The final objective is the integration of all findings into a single, unified section restating the most important conclusions, followed by a series of recommendations.

Kuwait gained its independence in 1961, up until which point it had been ruled by the United Kingdom. In 1990, the country was invaded by Iraq, and a resolution of the conflict was only possible the following year, after the intervention of the United Nations (promoted by the United States). The 1990s decade witnessed a deeply challenged Kuwait, struggling to rebuild the country as its infrastructure had been severely impacted by the armed conflicts.

The country's location in the Middle East — bordered by the Persian Gulf, Iraq, and Saudi Arabia — means that it is generally characterized by the problems of the region, such as relative resistance to globalization (understood as Americanization or Westernization), regional conflicts, and high income inequalities. The geographic conditions in Kuwait are rather harsh, with only 0.84 percent of the entire land being arable. The weather is generally dry due to the desert, with intense and hot summers and short, cool winters. The country's main natural resources are petroleum, fish, shrimp, and natural gas. Kuwait faces several environmental issues stemming from both natural hazards and human activity. Natural hazards include sudden cloudbursts, heavy rains, sandstorms, and dust storms. Environmental concerns include "limited natural fresh water resources; some of world's largest and most sophisticated desalination facilities provide much of the water; air and water pollution [and] desertification" (Central Intelligence Agency, 2010).

Literature Review

Officially entitled the State of Kuwait, the country is a constitutional emirate with its capital in Kuwait City. The country is territorially divided into six administrative regions, and the legal system is based on civil law with strong Islamic influences. Kuwait has yet to adopt the jurisdiction of the International Court of Justice. State representatives are elected by popular vote, and the suffrage age is 21; men in the military are not allowed to vote, and women's right to vote was only granted in 2005.

The Kuwaiti population totals approximately 2,692,526 individuals, making it the 140th largest population on the globe. In terms of ethnicity, the majority (45 percent) are Kuwaitis, followed by other Arabs at 35 percent, South Asians at 9 percent, Iranians at 4 percent, and other ethnicities at 7 percent. The predominant religion is Islam (85 percent of the entire population), followed by Christianity and Hinduism. The official language is Arabic, but English is widely used. The literacy rate is 93.3 percent, with the average Kuwaiti expected to spend 13 years in school, and 3.8 percent of national income is spent on education.

The largest proportion of the population (70 percent) is between the ages of 15 and 64, and the total median age is 26.4 years. Life expectancy at birth is 77.71 years — 76.51 years for males and 78.96 years for females. The Kuwaiti population grows at an annual rate of 3.549 percent; the net migration rate is 16.01 migrants per 1,000 individuals, and the large majority of the population (98 percent) lives in urban areas. The infant mortality rate is 8.97 deaths per 1,000 live births, and the adult HIV/AIDS prevalence rate is 0.1 percent.

In terms of economy, Kuwait is a relatively open, small, and wealthy economy relying extensively on oil exports — petroleum exports account for approximately 95 percent of total export revenues and 95 percent of federal income. Kuwaiti representatives have recently set goals to increase daily oil production. Kuwait is also facing pressure from the international economic crisis, although recent economic surpluses have limited its impact. Key economic indicators include:

Kuwait registers a gross domestic product of $142.1 billion, ranking as the 59th largest economy in the world. The GDP growth rate was a negative 1.7 percent. In a global context where the average income per capita is approximately $10,500, the Kuwaiti income per capita stands at $52,800, making Kuwaitis the seventh wealthiest population on the globe. The services sector generates 51.5 percent of GDP, industry generates 48.2 percent, and agriculture contributes only 0.3 percent. The labor force totals 2.04 million individuals, with an unemployment rate of 2.2 percent, an inflation rate of 4 percent, exports of $50.25 billion, and imports of $17.09 billion.

The telecommunications industry in Kuwait is relatively underdeveloped, with approximately 541,000 main telephone lines in use and fewer than 3 million mobile phones. Internet users do not exceed one million. There are seven airports and four heliports in Kuwait, as well as 5,740 kilometers of roadways. From this standpoint, the country's infrastructure remains relatively underdeveloped.

Regarding crime, Kuwait currently faces severe problems with human trafficking. The country is a desirable destination for South Asian immigrants seeking a better life, but these individuals are often abused upon arrival and employment. The Kuwaiti authorities have yet to efficiently address the problem (Central Intelligence Agency, 2010).

Medical services in Kuwait are nearly as old as the country itself, but the evolution of the medical system only truly commenced in the early twentieth century. During the 1910s, the country was host to American missionaries who offered medical services to the population. These missionaries represented the earliest medical trainers and set the basis for the development of Kuwaiti health care. Their involvement was due to the fact that Shaykh Mubarak Al Sabah the Great — the ruler of Kuwait — had "invited doctors from the Arabian Mission of the Dutch Reformed Church in the United States to establish a clinic. By 1911 the group had organized a hospital for men and in 1919 a small hospital for women. In 1934 the thirty-four-bed Olcott Memorial Hospital opened. Between 1909 and 1946, Kuwait experienced gradual, albeit limited, improvement in health conditions. General mortality stood between twenty and twenty-five per 1,000 population and infant mortality between 100 and 125 per 1,000 live births" (Regional Health Systems Observatory EMRO).

By the 1940s, the country was beginning to register the first significant revenues from oil exports. State officials used this money to invest in the health care system, and by 1949 they had opened the Amiri Hospital. The Kuwait Oil Company also launched investments in health care, primarily opening several smaller medical clinics. By 1950, the mortality rate had fallen to between 17 and 23 per 1,000 individuals, and the infant mortality rate had also decreased to 80–100 deaths per 1,000 live births.

During the 1950s, the Kuwaiti authorities developed and implemented a comprehensive plan to expand the medical system. The primary goal was to ensure free medical assistance for the entire Kuwaiti population. The scope of free access was so broad that it even included veterinary services. These developments were made possible with the aid of foreign medical staff — especially Egyptian physicians — and the endeavor came to cost Kuwait one third of its entire national budget. The main criticism of the reform was that it focused on treating illness rather than preventing it. Nevertheless, the reform produced a series of positive outcomes: "The number of doctors grew from 362 in 1962 to 2,641 in 1988. The doctor-to-patient ratio improved from one to 1,200 to one to 600. Infant and child mortality rates dropped dramatically; in 1990 the infant mortality rate was fifteen per 1,000 live births. Life expectancy increased ten years in the post-independence years, putting Kuwait at a level comparable to most industrialized countries" (Regional Health Systems Observatory EMRO).

At the broadest level, the Kuwaiti health care system is divided into two categories — the public health care system and the private health care system.

The public health care system is organized into two tiers — the central Ministry of Health (MOH) and the regional health offices. The Ministry of Health is located in Kuwait City and has seven specific functions: planning, resource allocation, financing and budgeting, regulation, monitoring, evaluation, and delivery of health care services. The MOH is the third largest public employer, after the ministries of education and interior.

One of the most notable ministerial decrees divided the country's public health care sector into six administrative regions: Kuwait City, Hawali, Ahmadi, Jahra, Farwania, and Al Suabah. Each region is required to fulfill the following four functions: the implementation of medical action plans in accordance with ministerial specifications to ensure service provision to the local population; the offering of various types and levels of medical care; the implementation of training programs for medical, technical, and administrative staff; and the construction and implementation of a "comprehensive computerized system of health information in the area" (Regional Health Systems Observatory EMRO).

There are three categories of health care facilities — primary, secondary, and specialized health centers. There are 782 primary health centers, which offer "general practitioner services and childcare, family medicine, maternity care, diabetes patient care, dentistry, preventive medical care, nursing care and pharmaceuticals" (Regional Health Systems Observatory EMRO). Secondary health centers consist of a general hospital, a health center, and specialized clinics and dispensaries. Specialized medical facilities are organized into ten categories: maternity care, pulmonary ailments, mental disorders, neurosurgery, burns treatment, allergies, cancer diagnosis and treatment, hearing disorders, organ transplants, and physiotherapy and rehabilitation.

The private health care sector is characterized by modern institutions, both for-profit and not-for-profit. Not-for-profit health care facilities are specifically represented by the medical facilities belonging to oil companies, such as the Ahmadi Hospital, the Texaco Hospital, and the Kuwait National Petroleum Company (KNPC) hospital. The for-profit sector is also active in Kuwait, with clinics focused primarily on the treatment of illness rather than prevention. The actual number of private clinics is not precisely known, but the Ministry of Health is intensifying efforts to ensure an even geographic distribution. Currently, private facilities are concentrated in central and populated areas. "There are 5 private hospitals in Kuwait with a total bed capacity of 427. Total number of doctors in these hospitals is 254 and number of nurses 707. In 2004, total number of outpatient visits in private hospitals was 798,985 (compared to 1.75 million in public sector hospitals)" (Regional Health Systems Observatory EMRO). Medical care services provided by the private sector are generally perceived as higher quality compared to those offered by the public sector.

Typically, the healthcare system in Kuwait is under the control and supervision of the Ministry of Public Health, which provides almost 90 percent of available health care services. According to state records, there are over 6,000 hospital beds in six general hospitals and 65 clinics, 157 dental clinics, and emergency services. The Ministry of Health employs over 30,000 staff members, of whom 16 percent are doctors, nurses, and medical-technical personnel (Al-Ansari).

A discussion of the issues observable within the Kuwaiti health care system may begin with the recognition of varying perceptions of the system. During the 1990s, approximately 60 percent of the country's population comprised non-Kuwaiti expatriates. Their levels of satisfaction with the health care system were relatively higher, whereas the perceptions of Kuwaiti nationals were less favorable. It should also be noted that non-Kuwaiti individuals would more often visit hospitals than Kuwaiti nationals, who would need to explain any absence to their employer and therefore often sought to manage their illnesses independently. "Although the health services in Kuwait are free of charge for Kuwaiti nationals, some people might find it inconvenient to report for clinical examination during working hours since they would need to obtain permission for an absence from their work places" (Al-Awadhi, Olusi, Al-Saeid, Moussa, et al., 461).

In addition, like much of Arab culture, Kuwait is a land of social paradoxes. Vast symbols of wealth, modernization, and rapid urbanization often conflict with attitudes and behaviors that have been part of Bedouin culture for centuries. Modern healthcare has only a few decades of tradition for most Kuwaitis, and despite social and demographic improvements for the majority of the population, there are still issues surrounding access to healthcare. Among these are the gender and ethnicity of the healthcare professional — for example, men will rarely visit a female practitioner, and women are reluctant to share personal details with male practitioners. Social status also plays a significant role in whether a Kuwaiti individual accesses healthcare, and many report that even with purportedly "free" care, there remains a perception that those with greater financial resources have easier access to the medical field (Meleis).

In one study (Al-Kandari), there was a statistically significant difference in the perceived quality of care between nurses in medical and surgical areas, specifically in the areas of accountability, medical knowledge, and span of control. Most nurses in advanced units — such as specialized care or surgery — were considered competent and not perceived as different from those in other countries. However, basic LPN or staff nurses were perceived as less well trained and professional.

In a report authored by Tony Blair, cautious optimism was the central thesis, asserting that greater focus on quality of care and treatment could drastically improve the healthcare system by 2030. However, other medical scholars are concerned that it may take two decades to achieve the kind of improvement necessary to make the Kuwaiti system world-class. Several recommendations were made to support this plan: (1) restructuring and professionalizing the system; (2) promoting healthier lifestyles and preventive care through behavior change; and (3) using education to reduce tobacco use and improve infrastructure for pre-disease screening. The Blair Report also suggests an aggressive need for liaison with hospitals and medical organizations worldwide in order to improve the availability and training of Kuwaiti doctors and nurses and to upgrade the system so that individuals no longer need to travel abroad for riskier procedures (Agency).

A particular element to consider is the role of perception in relation to reality. Kuwaiti perspectives can easily be influenced by external elements such as the media, which has a significant ability to shape patient and staff perceptions. The media promotes both sides of the story — on one hand, that the Kuwaiti medical system is one of the best in the region, easily comparable with systems in Europe or the United States; on the other, that the system is deeply flawed and inefficient, with adequate care only accessible to the wealthy. Regardless of where the truth lies, it remains clear that the Kuwaiti medical system requires consolidation and improvement, even if some criticism reflects cultural sensitivities or expatriate pressures. As one recent report stated: "The state of the public healthcare system is a serious concern. Both men and women, urban and Bedouin, complained of the poor quality of healthcare service, especially when considering the country's wealth. Participants were particularly critical of the inadequate number of hospitals; poor equipment maintenance; unqualified doctors; shortages in medicines and the necessity to purchase them from private pharmacies; and the approval of overseas treatment trips based on connections rather than a fair selection of patients" (National Democratic Institute for International Affairs).

Similarly, both scholarship and media coverage have shown that religious and cultural sensitivities mean certain medical issues are not part of "polite culture" — including STDs, contraception, and condom use. Forty-one percent of retail pharmacists believed that the use of contraception was religiously objectionable and that women who needed such products were irresponsible; 51 percent reported being unaware of available contraceptive drugs; and 35 percent stated that health providers in the country would not prescribe such drugs (Ball).

At almost every juncture, Kuwaitis perceive part of their healthcare problem to stem from inadequate training and competencies among general practitioners. This perception has become sufficiently embedded in popular culture that an ongoing program has been established to distinguish family practice and increase the competency level for new doctors and nurses. This program has been designed to increase core competencies, provide a wider range of training, additional sources of professional development, and — to engender public and media confidence — a rigorous set of review courses after degree and internship, as well as competency examinations (Al-Baho). Many scholars also believe that one of the more serious problems is the lack of, or inadequacy of, health sciences libraries for students and professionals. The large majority of medical libraries were not established until the 1980s, and some are unable to provide current, cutting-edge information. Research shows that not only are the collections relatively small, but the majority of library staff are neither trained librarians nor trained medical personnel.

The issue of supply and demand for professional nurses is another critical component of both the perception of healthcare and the improvements needed. Research shows a decline in indigenous Kuwaiti nurses of approximately 3.5 percent annually since the 1990s. "There is a gap between the numbers of native and migrant nurses, which will widen with time. In 2006, native nurses constitute only 6.6% of the nursing workforce; this affects the quality of provided care owing to language, religious, and socio-cultural barriers between foreign nurses and patients.... Improvement in recruitment and retention of indigenous nurses and nursing students" is a critical issue for the country (Al-Jarallah, Moussa, Hakeen, and Al-Khanfar).

At a broad level, the research methodology is composed of two specific directions: the analysis of the available literature — completed in the preceding section — and direct interaction with individuals through a questionnaire. The analysis of secondary research was conducted in order to create a starting point for the research project. Based on those findings, the survey was constructed to address the most critical issues within the Kuwaiti health care system. The literature review was built through the gradual analysis of available sources, including books, journal articles, and internet articles. Books and specialized journal articles are peer reviewed and thus highly reliable, but they can be outdated. Internet and magazine articles are seldom peer reviewed and may reflect editorial bias, but they address issues of contemporary interest.

The selection of the survey as a research tool was constructed gradually, through responses to the following questions:

(a) What is the research philosophy?
(b) What are the most appropriate approaches to the research?
(c) What are the research strategies to be used?
(d) What research choices have been made?
(e) What is the time availability and how does it influence the research tools?
(f) What techniques and procedures will be used in the data collection and analysis process?

These six questions represent the core of the onion ring research methodology. Just as an onion has layers, the research project is constructed in layers and stages. In order to move on to the next layer, it is necessary to complete the current one. The following sub-sections address each of these six questions in the context of the Kuwaiti health care system study.

Mark Saunders, Philip Lewis, and Adrian Thornhill (2009) identify ten research philosophies: positivism, realism, interpretivism, objectivism, subjectivism, pragmatism, functionalism, interpretative, radical humanism, and radical structuralism. The positivist philosophy is characterized by an objective researcher who observes phenomena and strives to form rules and theories of behavior based on observations. The objectivism approach strives to explain the observed phenomenon in the context of the social constructions that impact or are impacted by it. Subjectivism research observes the phenomenon from the standpoint of the individual and seeks to understand how the individual and the phenomenon mutually influence one another.

For purposes of objectivity and appropriateness with the study's objectives, the selected research philosophy is positivist. The researcher remains an objective observer of the health care system in Kuwait, documenting the context and constructing informed conclusions to explain the phenomenon.