Qatar National Health Accounts Report A Trend with a New Classification

Transcription

1 دولة قطر State Of Qatar المجلس األعلى للصحة Supreme Council Of Health Policy Affairs Directorate Qatar National Health Accounts Report A Trend with a New Classification June - 212

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3 دولة قطر State Of Qatar المجلس األعلى للصحة Supreme Council Of Health Policy Affairs Directorate Qatar National Health Accounts Report A Trend with a New Classification June - 212

4 212 General Secretariat, Supreme Council of Health, Qatar First published June Supreme Council of Health, Qatar P.O. Box 42 Doha, Qatar Qatar National Health Accounts - Report The content of this publication may be freely reproduced for noncommercial purposes with attribution directed to the copyright holder.

5 Contents Tables And Figures... II Qatar National Health Accounts Glossary...III Abbreviations... IV Foreword...V Acknowlegdements... VI Executive Summary Introduction Qatar Health Accounts Report, SHA Qatar s Healthcare System Methodologies and Data Collection QHAR-2 Activities QHAR-2 and SHA Data Sources, Strategy, and Assumptions Used Limitations QHA Results Financing Dimensions Uses of Funds Factors of Healthcare Provision Gross Capital Formation Beneficiary Characteristics Policy Implications Annex 1: Second Online Health Survey Introduction Purpose Methodology The Survey Results Pattern of Participation Sociodemographic Characteristics Household Structure and Health Expenditure...5 Annex 2: NHA Tables References... 62

6 II Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 1 Table 11 Table 12 Table 13 Table 14 and Figures Selected Qatar indicators compared to regional and international countries....1 Revenues of the financing schemes received by the financing schemes Health expenditure by type of financing schemes and type of providers...25 Health expenditure by type of financing schemes and health care functions...28 Health care expenditure for the health care providers by health care functions...32 Factors of health care provision Gross Capital Formation of government and other public organizations Current health expenditures by the beneficiaries characteristics Sociodemographic characteristics of respondents Detailed flow of funds from the financing sources to the financing agents Detailed health expenditure by type of financing schemes and type of providers Detailed health expenditure by type of financing schemes and health care functions Detailed health care expenditure for the health care providers by health care functions....6 Detailed gross Capital Formation of government and other public organizations Supreme Council Of Health Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 1 Figure 11 Figure 12 Figure 13 Governance structure of the health care system in Qatar Actual and Adjusted Population, Qatar, Medical equipment per million population, OECD and Qatar Trend of current and capital health expenditure by financing sources, Qatar 29 to Distribution of current and capital health expenditure by revenue, Qatar and OECD Trend of current and capital health expenditure by health provider, 29 to Distribution of current and capital health expenditure by provider, Qatar and OECD Trend of current and capital health expenditure by health care function, 29 to Distribution of current and capital health expenditure on healthcare functions, Qatar and OECD....3 Distribution of current health expenditure by age and gender, Qatar and selected countries Participants number of completed by rounds and by nationality [N=2,472] Participants distribution by nationality [N=2,472]....5 Participants average household size, by nationality [N=2,472]....5

7 Qatar National Health Accounts Glossary Ancillary services Capital formation (investment) Curative care Current and capital health expenditure Current health expenditure (CHE) Factors of provision (FP) Financing agents (FA) Revenues of financing schemes (FS) Financing schemes (HF) A variety of services such as laboratory tests, diagnostic imaging and patient transport, mainly performed by paramedical or medical technical personnel with or without the direct supervision of a medical doctor. Investment in health care facilities and equipment that creates assets that are typically used over a long period of time. Medical and paramedical services delivered during an episode of curative care. An episode of curative care is when principal medical intent is to relieve the symptoms of injury or illness; to reduce severity of an illness or injury; or to protect against exacerbation and/or injury which could threaten life or normal function. Expenditure that arises out of the addition of investment expenditures to current health expenditures (CHE + investment). Comprises all services such as curative care, rehabilitative care, prevention and public health, and ancillary health care. It also includes expenditures made for the administration of these services and drugs, medical goods that are provided for the public, and salaries and fees of health personnel. It excludes investment expenditures. The types of inputs used in producing the goods and services consumed or the activities conducted in the health accounts boundary. Institutional units that manage health financing schemes. The revenues of the health financing schemes received or collected through specific contribution mechanisms. Components of a country s health financial system that channel revenues received and use those funds to pay for, or purchase, the activities inside the health accounts boundary. III General government expenditure on health (GGEH) Gross capital formation (HK) Gross domestic product (GDP) Covers all general government entities to produce or purchase health care goods and services. the types of the assets that health providers have acquired during the accounting period and that are used repeatedly or continuously for more than one year in the production of health services. The value of all goods and services provided in a country by residents and non-residents without regard to their allocation among domestic and foreign claims. National Health Accounts Health care functions (HC) Health care providers (HP) Long-term care Not specified by kind (nsk) Out-Of-Pocket (OOP) spending System of Health Accounts (SHA) Voluntary prepayment schemes The types of goods and services provided and activities performed within the health accounts boundary. Entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary. Ongoing health and nursing care given to inpatients who need assistance on an ongoing basis because of chronic impairments that reduced their degree of independence and ability to perform daily activities. A category used to reflect those activities or transactions that fall within the boundaries of the health accounts but which cannot be definitively allocated to a specific category because of insufficient documentation. The direct outlays of households, including gratuities and payments in-kind, made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups. Includes household payments to public services, nonprofit institutions or non-governmental organizations. A system developed by the OECD to provide international comparability for member and nonmember countries. Schemes that receive payments from the insuree or other institutional units on behalf of the insure, to secure entitlement to benefits of the voluntary health insurance schemes. 212

8 Abbreviations IV Supreme Council Of Health CHE Current Health Expenditure FP Factors of Provision FS Revenues of Financing Schemes GCC Gulf Cooperation Council GDP Gross Domestic Product GGEH General Government Expenditure on Health HC Health care functions HF Financing schemes HMC Hamad Medical Corporation HP Healthcare Providers MOEF Ministry of Economy and Finance MOI Ministry of Interior n.e.c. Not elsewhere classified NHA National Health Accounts NHS National Health Strategy NSK Not Specified by Kind OECD Organization for Economic Co-operation and Development OGO Other Government Organizations OHS Online Health Survey OOP Out-Of-Pocket PHCC Primary Health Care Corporation PHI Private Health Insurance QAF Qatar Armed Forces QAR Qatari Riyal QF Qatar Foundation for Education, Science and Community Development QHA Qatar Health Accounts QHAR-1 Qatar National Health Accounts Report QHAR-2 Qatar National Health Accounts Report QP Qatar Petroleum SCH Supreme Council of Health SHA 1. Initial System of Health Accounts, developed in 2 SHA 211 First revision of System of Health Accounts, completed in 211 SHI Social Health Insurance TA Treatment Abroad US$ United States Dollar WHO World Health Organization WHS World Health Survey

9 Foreword Following the successful release of Qatar s first National Health Accounts 1st Report in June 211, a first in the Gulf Cooperation Council region, it is my pleasure to release, the Qatar National Health Accounts 2nd Report 211,the first in the world to utilize the new classification system created by the Organization for Economic Cooperation and Development, Eurostat and the World Health Organization (WHO). Qatar s decision to move to the new classification system is based on our fundamental belief that decision making should be based on evidence-based measures. The new classifications provide a refined conceptual framework for health accounting, and an extended set of classifications to describe the flow of funds within the health system. With these new classifications, Qatar s policymakers and stakeholders will have a more precise description of the role of the health sector within the national economy. This report also adds new information about the granularity of health care financing in Qatar, by offering an enhanced opportunity to study the trend of health care expenditure in the last few years. This information helps us to answer three additional questions: Who benefited from current health expenditures? ; What was spent for investment on health? ; and What resources were used to provide these services?. Qatar is experiencing significant developments, particularly in the health sector. This report shows that the money spent on health increased by 27% from 21 to 211, and 84% of this increase was funded by the government. This increase illustrates the government commitment to advancing the health of its people. The Qatar National Health Accounts Report 211 is the realization of close collaboration between the Supreme Council of Health and its partners. I would like to thank the National Health Accounts team at the Supreme Council of Health headed by Dr. Faleh Mohamed Hussain Ali, Assistant Secretary General for Policy Affairs for their excellent work. This report would not have been possible without the contribution of various organizations, particularly the contribution of the Steering Committee member organizations. I also gratefully acknowledge the data and qualitative information provided by respondents to the online health survey, private health insurance companies, and health care providers. V National Health Accounts Lastly, and in our effort to institutionalize National Health Accounts in Qatar, I look forward to continuing support from all stakeholder organizations in the production of future reports. His Excellency Abdulla bin Khalid Al Qahtani Minister of Health, and Secretary General Supreme Council of Health 212

10 VI Supreme Council Of Health Acknowledgements Production of the Qatar National Health Accounts Report was realized by the support of various individuals and organizations. This Report could not have been done without the support of His Excellency Mr. Abdulla bin Khalid Al Qahtani, Minister of Health, and Secretary General of the Supreme Council of Health. His Excellency Mr. Al Qahtani secured political support at the highest level, issued a Ministerial Decree to form the Steering Committee, and revised and approved the final version of this report. The National Health Accounts also benefited tremendously from the support and guidance of Dr. Faleh Mohamed Hussain Ali, Assistant Secretary General for Policy Affairs. He supervised the entire process, and participated in all revisions of this report. The execution of the National Health Accounts in Qatar was carried out by the following team of technical staff from the Supreme Council of Health Policy Directorate: Mr. Altijani Hussin managed the technical team, supervised the analysis, and led the development of this report. Mrs. Eman Habib Sailani and Mrs. Fadlah Al-Mansouri provided the technical support and performed the data analysis. Mrs. Lolwa Al-Kuwari provided the administrative support. Mr. Husein Reka, Ms. Orsida Gjebrea, and Mr. Ahmad Fekri provided revisions to this report. In addition to the team in the Supreme Council of Health, the following organizations provided valuable information and data, which were used in this report: The World Health Organization, in particular Dr. Cornelis Van Mosseveld (HQ Office) and Dr. Awad Mataria (EMRO Office). Hamad Medical Corporation, in particular Mr. Saeed Bawazeer and Mr. Giyab Alaamri. Primary Health Care Corporation, in particular Dr. Mariyam Abdulmalik (A/Managing Director) and Mr. Amir Megahed. Ministry of Economy and Finance, in particular Mr. Ahmad Bokshisha. Qatar Statistics Authority, in particular Ms. Wadha Al-Jabor. Ministry of Interior Medical Services, in particular Captain Sabt Al Kuwari. Qatar Orthopedic and Sports Medicines Hospital (Aspetar), in particular Mr. Mouhamed Kayal and Mrs. Ailsa Lord. Sidra Medical & Research Center, in particular Mr. Llew Werner. Qatar Petroleum, in particular Mr. Saleem Kapoorwala. The private hospitals (in alphabetical order): Al Ahli, Al Emadi, American, and Doha Clinics Hospitals. The private health insurance companies (in alphabetical order): American Life Insurance, Al-Khaleej Takaful Group, Al Koot Insurance & Reinsurance, Doha Bank Assurance, Doha Insurance, Libano- Suisse Insurance, Qatar General Insurance and Reinsurance, Qatar Life And Medical Insurance Company, and SEIB Insurance and Reinsurance. The respondents to the Online Health Survey 211.

11 Executive Summary

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13 Executive Summary With the first anniversary of the National Health Strategy (NHS) that outlines 35 major health projects in Qatar, it is essential to observe and analyze the financial dimensions of health expenditure. The international tool used to monitor changes in the financial dimensions of healthcare systems is the National Health Accounts (NHA). The Supreme Council of Health (SCH), Qatar s highest authority for health care, launched the Qatar National Health Accounts Report (QHAR-1), in June 211, to help policy makers with several key objectives, such as giving a clear financial picture of the health system. Building on the same objectives, SCH produced Qatar National Health Accounts Report (QHAR-2), with updated classifications that follow the newly published A System of Health Accounts (SHA 211). These new classifications offer more complete coverage within the functional classification, a more concise picture of the universe of health care providers, and a precise approach for tracking financing in the health care sector. The key findings of QHAR-2 are summarized below, and are followed by the detailed findings and a list of policy implications. The report also includes two annexes. Annex 1 shows the methodology and main results of the second Online Health Survey (OHS-2). The responses from OHS-2 were used to estimate the household health expenditure used in this report. Annex 2 shows detailed NHA tables. KEY FINDINGS Current and capital health expenditure In 211, Qatar spent a total of 12,88m QAR (3,32m US$) on healthcare, up by 27% from 21 [9,53m QAR, (2,618m US$)]. The per capita expenditure, as a result, increased from 5,682 QAR to 7,28 QAR (1,92US$) in 211. Of the total 12,88m QAR spent, 9,966m QAR (82%) was spent on current health expenditure (CHE), and 2,122m QAR (18%) was spent on gross capital formation (investment). Flow of funds from the original sources (where the funds came from?) The total 12,88m QAR spent was funded by the government schemes,9,37m QAR (77%), and by the voluntary prepayment schemes, 2,781m QAR (23%). The 9,966m QAR spent on CHE was funded by the public sector (72%), households (17%), and employers (11%) (1). Financing Schemes(HF) (which funds are used?) The public portion of CHE (7,186m) was mainly managed by SCH, 6,732m QAR (94%) and then by Other Government Organizations (OGO), 454m QAR (6%). The private portion of CHE (2,781m QAR) was managed by: Households, 1,665m QAR (6%); Voluntary health insurance schemes in Qatar, 629m QAR (23%); Enterprise schemes, 291m QAR ; The rest of the world, in form of services in Qatar paid by international health insurance plans, 195m QAR (7%); and Zakat Fund, 15m QAR. 1 National Health Accounts 212 (1) Employers share was 9% direct services and enrollment in local private health insurance schemes, and 2% international health insurance plans.

14 2 Supreme Council Of Health Financing schemes to healthcare providers (HP) (which providers received the funds?) The 9,966mQAR spent on CHE was distributed to the following healthcare providers: Hospitals, 5,651m QAR (57%); Providers of ambulatory health care, 1,427m QAR (14%); Private providers of ancillary services and retailers of medical goods, 547m QAR (5%); Health care system administration, 77m QAR (8%); Rest of the world, in form of treatment abroad (TA), 97m QAR (9%); and Others not specified by kind (N.S.K.), 664m QAR (7%). Healthcare functions (HC) (what services were received for these funds?) The 9,966m QAR spent on CHE was paid for the following services: Inpatient, long term, and rehabilitative care services, 4,16mQAR (4%); Outpatient and day care services, 3,31m QAR (3%); Ancillary services and medical goods, 1,851m QAR (19%); and Collective care, such as governance and preventive care, 1,32mQAR. Factors of provision used (FP) (what sources were used to provide these services?) The 9,966m QAR spent on CHE was paid for the following resources: Compensation of employees and self-employed, 6,297m QAR (63%); Materials and services used, 2,562m QAR (26%); Treatment abroad, 97m QAR (9%); and Other items, 234m QAR. Beneficiary characteristics (who benefited from the CHE?) The 9,966m QAR spent on CHE was paid for services delivered to: Males, 5,631m QAR (57%); and Females, 4,335m QAR (43%). The age groups that benefited from these funds were as follows: -14 years old, 1,751m QAR (18%); Working age group years old, 7,378m QAR (74%); and Elderly population 65+, 836m QAR (8%). Gross capital formation (what was spent for investment on health?) The 2,122m QAR spent on gross capital formation was paid for infrastructure(74%), and machinery and equipment(26%).

15 Introduction

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17 1- Introduction With the demand for advanced technologies in the health care systems increasing, the financial implications are increasing rapidly. Policy makers, analysts, and the general public have increased expectations about the costs associated with the advancement of their healthcare systems. NHA depicts the flow of the costs related to the consumption of health care goods and services. NHA is thus an analytical tool to provide measurable inputs to monitor and assess health system performance. In addition, NHA supplies reliable and timely data that is comparable both across countries and over time. The trend in spending for healthcare can be tracked by the NHA to find the factors driving it, such as change in demographics, and can be used to predict the future growth of the healthcare funds. Thus, NHA is used in two main ways: internationally, where the emphasis is on a selection of internationally comparable expenditure data, and nationally, with more detailed analyses of health care spending and a greater emphasis on comparisons over time. Health accounts are crucial for both of these uses (SHA 211, 2).NHA allows countries to achieve these two uses by answering the following fundamental questions: How are revenues mobilized? Which schemes are used? Who is managing these schemes? Which healthcare providers do the health funds go to? Which healthcare services were bought for these funds? Who benefited from these funds, in terms of beneficiary characteristics such as age and gender? 1.1 Qatar Health Accounts Report, 21 The SCH produced its QHAR-1 in June, 211. The primary objective of the first report was to support the development and review of policies that are related to: Identifying the revenues of financing schemes. Reviewing the current allocation of resources to health services. Identifying additional resources needed for healthcare. Mobilizing funds and allocating them efficiently and effectively. The report was divided into two parts: the results of NHA in Qatar and the annexes which discuss the results of the OHS (used in several parts of the QHAR-1), and the methodological approach to adjust the population in Qatar. The results from QHAR-1 show the flow of funds in calendar years 29 and 21. In 21, Qatar spent 9,53m QAR (USD 2,618m) on healthcare. The per capita health expenditure was QAR 5,683 (USD 1,561). Of the total 9,53m QAR spent on healthcare in 21, 77.5% (QAR 7,382m) was funded by the public sector and 22.5% (QAR 2,148m) by the private sector. Other main findings include: The public funds were exclusively managed by the public agents (SCH, 77%, Qatar Foundation QF, 14%, other government organizations and parastatal companies (2), 9%). The private funds were mainly managed by the private agents (households, 17%, private health insurance companies (PHI), 28%, and charitable organizations, 1%). Hospitals received the majority of the healthcare funds, 67%, followed by ambulatory providers, 11%, private retail sale and other providers of medical goods, 5%, public health programs and general health administration and insurance, 9%, and other non specified sources, 8%. (2) Parastatal companies are state-owned companies that have a significant degree of autonomy from general government operations. 5 National Health Accounts 212

18 The services received for these funds in 21 were inpatient, long term, and rehabilitative care,26%, outpatient and daycare, 27%, ancillary services,12%, medical goods dispensed to outpatients, 9%, public health, and general administration and insurance, 9%, gross capital formation (investment) in health, 15%, and functions NSK, 1.5%. Cross-country comparisons were carried out for the main findings to show the relevant level of expenditure and utilization in Qatar compared to the region and countries of the Organization for Economic Cooperation and Development (OECD).The methodologies used in QHAR-1 were based on the international guidelines provided in the Guide to Producing National Health Accounts (WHO, 23). This Producer s Guide details the methodology to analyze the collected data, and the format for reporting the findings. In addition, the Qatar Health Accounts (QHA) team used the classification in A System of Health Accounts (OECD, 2) (SHA 1.). 6 Supreme Council Of Health 1.2 SHA 211 The healthcare systems around the globe have been developing rapidly since the production of SHA 1.. Driving these changes are innovations in interventions, pharmaceuticals, and medical technologies. As a result, the cost of healthcare is also becoming increasingly a pressing subject of interest to policy makers, analysts, and the general public. There is an increased expectation for more sophisticated information that can be gained through the greater volume of health expenditure data now available. With this increased interest in healthcare financing, OECD, the European Union, and the World Health Organization (WHO) produced A System of Health Accounts in 211 (SHA 211). SHA 211 built on SHA 1., but addressed the following issues in more details: SHA 211 develops the health care financing interface to allow for a systematic assessment of how finances are mobilized, managed and used, including the financing arrangements (Financing schemes), the institutional units (Financing agents) and the revenue-raising mechanisms (Revenues of financing schemes). SHA 211 delves into the cost structures of health care provision (Factors of provision) and provides a separate treatment of capital formation so as to avoid some of the past ambiguity regarding the links between current health spending and capital expenditure in health care systems. SHA 211 improves the study and further analysis of the functional dimension. SHA 211 improves the breakdown of health care expenditure according to beneficiary characteristics, such as disease, age, gender, region and socioeconomic status. In its effort to employ the improvements in the classification of the NHA, Qatar adopted SHA 211 in the development of QHAR Qatar s Health Care System Health care governance in Qatar is exercised through the SCH, which is mandated with a comprehensive range of powers for the administration and regulation of the health care system. The SCH supervises the two government owned organizations which are the country s principal health care providers: Hamad Medical Corporation (HMC) and Primary Health Care Corporation (PHCC). The SCH also supervises all private health care institutions, including hospitals, clinics, pharmacies, laboratories and auxiliary medical practices. Figure 1 depicts the governance structure of the health care system in Qatar. Health care services, especially for the lower paid, are most commonly provided via HMC. The PHI market in Qatar is relatively new but rapidly expanding. Although not mandatory, employers may purchase PHI coverage to attract and retain qualified employees. Over the past decade, the private healthcare sector in Qatar has increased rapidly in size and services provided. Its role is expected to increase even further with the planned healthcare reforms.

19 Figure 1 Governance structure of the health care system in Qatar SCH Board of Directors SCH Executive Committee SCH General Secretariat Other Health Care Providers (Other gov t organizations; Private hospitals, polyclinics, clinics, pharmacies, labs and imaging, etc.) Hamad Medical Corporation Primary Health Care Corporation National Health Insurance Company Supervision and oversight Population Qatar s infrastructure, including the health care system, continues to adjust for the significant increase in its population over the last 1 years. The population in Qatar increased by 176% between 2 and 21 (from 616, to 1,7,). The high demand for oil and gas over the past 1 years, and the high cash revenues generated, resulted in a demand for labor, especially young expatriate males. The population in Qatar, as in other Gulf Cooperation Council (GCC) countries, of which Qatar is one of six member countries, is noted for its male composition. To cope with this rapid growth, laborers are brought in from other countries on short-term work visas. These laborers are mainly male, aged between 2 and 45, and screened for three communicable diseases upon entry to the country (3). Labor laws mandate employers to protect laborers against hazardous occupational health and work-related injuries. The laborers, which constitute about 54% of the population, have the lowest health utilization rates (due to their gender-age composition and selection based on screening), and, subsequently, the lowest health expenditure. Laborers live in large labor compounds located close to their working sites. The rest of the population in Qatar lives in standard household setups. This includes Qatari and non-qatari household members and non-qatari domestic workers. It is the regular household members (about 4% of the total population) who use the health care system the most and incur the highest share of health expenditure. Their health needs and utilization are comparable to those in other countries with a common gender-age distribution. Domestic workers, who receive their health care independently from their employers, are primarily covered by the HMC health cards. Although domestic workers are part of the household they live in, they have little impact on health care utilization and expenditure at the household level. (3) HIV, and Tuberculosis for all, in addition to Hepatitis (B and C) for the food handlers. National Health Accounts 212

20 To use comparable population denominators for Qatar, SCH used a statistical model, based on an imputation procedure, to estimate an adjusted male population aged 25 to 6 years. Population data from five regions were used (North Africa, Asia, Eastern Europe, Latin America, and the Caribbean). For more information see 56. The results are shown in Figure 2 below. The total population in 21 was 1.7 million, while the adjusted population results show that the total population is only 95,. Figure 2 Actual and Adjustedd Population, Qatar, 21 Adjusted Males Actual Males Actual Females 7+ yrs yrs yrs yrs yrs yrs 1 14 yrs. 4 yrs Population in 1,s 5 1 Supreme Council Of Health Key Indicators-Summary Table 1 below shows selected key macroeconomic and health care resources indicators for Qatar and compares it with three groups of countries: (4) I. Organization of Economic Cooperation and Development : a group of high income Western European countries; in addition to other non-european high income countries such as USA, Canada, Japan, and Australia. We chose this group of countries as our primary comparison throughout this report for two reasons. First, these countries have a comparable level of income to Qatar (both are high income countries). Second, these countries have updated and detailed health financing information. (5) II. Eastern Mediterranean Region (EMRO), including Qatar. One of the six regions of the WHO. It includes a group of 22 countries, most of which are in the Middle East and North Africa. Because Qatar is part of the EMRO group, it is thus important to compare Qatar to these countries. (6) III. Other GCC countries,not including Qatar. Qatar has the distinction of being part of this group of six, unique oil-rich countries. These countries share specific population structure, with the majority of the population consisting of expatriates, as well as specific economies with high dependency on oil and gas revenues. (4) Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom, and United States. (5) Afghanistan, Bahrain, Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. (6) Bahrain, Kuwait, Kingdom of Saudi Arabia, Oman, and United Arab Emirates.

21 Qatar s Data The economy in Qatar continued to increase in 211. The Gross Domestic Product (GDP) per capita increased by 35% since 21 (from 74,246 US$ to 1,3 US$). This dramatic growth is due to continuing increases in oil and gas prices worldwide. In the health sector, the government continues to play a major role in financing the services provided and the investment sought. Per capita current and capital health expenditure increased in 211 by 23% since 21 (from 1,561 US$ to 1,92 US$). The government s share in this amount is 79% (1,518 US$ per capita, which is a 28% increase compared to 21). The households share of the current and total health expenditure decreased from 16% in 21, to 13.8% in 211. As a result of the upward trend in health expenditure, healthcare resources indicators have continued to improve over the last three years. For example, hospital beds per 1, population edged up to 1.3, and is expected to reach 1.7 by the end of 212. Table 1: Selected Qatar indicators compared to regional and international countries Country OECD a EMRO b Other GCC b,c QATAR Year Population (Million) 1, GDP per capita (US$) 33,32 3,643 33,58 59,683 74,246 1,3 Per capita current and capital health expenditure (US$) 3, ,58 1,561 1,92 9 Per capita public current and capital health expenditure (US$) Current and capital health expenditure, as% of GDP Public expenditure on health, as % of current and capital health expenditure 2, ,233 1,183 1, % 4.2% 2.8% 2.6% 2.1% 1.9% 72.% 53.2% 71.4% 78% 77% 79% National Health Accounts OOP expenditure, as % of current and capital expenditure on health 2.% 41.6% 19.% 16.% 16.% 13.8% OOP expenditure, as % of CHE Not available in the old classifications 19.4% 18.7% 16.7% GGEH, as % of general government expenditure NA 6.9% 7.7% 6.% 6.9% 5.3% d Hospital Beds per 1, population Radiation therapy equipment per million population NA NA 2.3 Life expectancy at birth a: Health at a Glance OECD INDICATORS. All OECD monetary values are in US$ Purchasing Power Parity. b: World Health Statistics 211 c: Other GCC countries excluding Qatar. d: Preliminary results 212

22 1 Cross-country comparison Qatar s GDP is the highest compared to the other countries in Table 1, with 211 data showing 1,3 US$ per capita GDP. In the health care sector, Qatar s per capita current and capital health expenditure was more than twice the average in Other GCC countries, and more than 12 times the average in the EMRO countries. When contrasted with OECD countries Qatar s per capita current and capital health expenditure (1,92 US$) was lower than the average in OECD countries (3,233 US$) (7). However, when the expenditure was adjusted for population (results not shown in Table 1), Qatar s per capita current and capital health expenditure (3,321 US$) exceeded OECD average. The same was true with per capita public current and capital expenditure on health. In addition, public funds were the highest source for health expenditure when comparing Qatar with the other groups of countries. The percentage share of households was the lowest in Qatar (13.8%) compared with the other groups of countries: about 2% in Other GCC and OECD countries, and 42% in EMRO. General government expenditure on health (GGEH) was relatively the same in Qatar (5.3%) to Other GCC (7.7%) and EMRO (6.9%) countries. Life expectancy at birth in Qatar (78.6 years) was very close to OECD (79.3 years), 3 years higher than Other GCC (75. years), and 12.6 years higher than EMRO (66.). Figure 3 shows medical equipment per million population in Qatar, both at actual and adjusted population, compared with those in OECD. Qatar s adjusted population MRI units per million populations are similar to OECD. However, the CT scanners and mammography units are lower in Qatar. Qatar s results of lower than average OECD medical equipment, particularly radiation therapy and mammography units, should be interpreted with caution, and in context of Qatar s population structure. Although these results appear to indicate lower ratios, this equipment is used primarily to detect breast cancers among women and to treat cancer patients, who are primarily over 6 years old. Qatar s adjusted population is young and male biased. Supreme Council Of Health Figure 3 Medical equipment per million population, OECD and Qatar MRI units per million population CT Scanners per million population Mammograghs per million population OECD, 29 Qatar, 211 Qatar, 211 Adjusted population (7) Although the values for OECD are in US$ adjusted for Purchasing Power Parities (an economic method used to adjust for income and expenditure), these economies tend to have closer values between Purchasing Power Parities and US$ at exchange rates. For instance, the Purchasing Power Parities in national currencies per US$ in OECD was 1.6 for the GDP in 28. In addition, the health expenditure data published for OECD - as a group - is only available in Purchasing Power Parity (Health at a Glance 211).

23 Methodologies and Data Collection

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25 2- Methodologies and Data Collection 2.1 QHAR-2 Activities Following the successful launch of QHAR-1, the NHA team organized a dissemination event that showed the main findings to the stakeholders (September, 211). The objective of the dissemination event was to inform the stakeholders of the importance of their participation in providing the needed datasets, and to inform them that the NHA exercise will be part of the decision making process in Qatar s health care system. Therefore, stakeholders were asked to provide periodic and detailed datasets to improve the accuracy of the NHA in Qatar. Soon after, the NHA team designed to capture the households health information for 211. The survey was conducted with repeated sample of participants for four consecutive months (September to December, 211). Annex-1 shows the details of OHS-2, and the key results. The team then designed various instruments to collect the needed information for QHAR-2. These instruments were built with SHA 211 as the adopted set of classifications and methodologies. Section 2.3 below shows the targeted organizations and the requested information in these instruments. T-Accounts and NHA tables in Microsoft Excel 27 were created to host the data. Once received, the information was entered in the relevant cells and the results were automated. Not all the needed information was received, and thus some assumptions were used to fill the missing information. These assumptions are also explained in Section 2.3 below. 2.2 QHAR-2 and SHA 211 The data collected for QHAR-2 was analyzed in accordance with the international guidelines provided in SHA 211 (OECD, Eurostat, WHO, 211). Once the decision to adopt SHA 211 in Qatar s NHA was made, the technical team drafted the list of NHA tables that correspond to QHAR-1. The team also expanded the list of tables with the SHA 211, based on the data availability and the policy needs. Thus, QHAR-2 repeats the following four tables reported in QHAR-1, but based on the new classifications. The first three of these tables are the following tri-axials: 1) Revenues of financing schemes BY Financing schemes [FSXHF] table. This table shows the revenues by type received by schemes and answers how are revenues mobilized, and which schemes are used. 2) Financing schemes BY Health care providers [HFXHP] table. This table shows the flow of funds from the managing schemes to the health care providers, and answers which schemes funds who? The classification of the healthcare providers in SHA 211 includes nine changes (see page , SHA 211). Thus, adjustments were made in QHAR-2 to match the changes in SHA 211. Financing schemes BY Health care functions 3) [HFXHC] table. This table shows the flow of funds from the financing schemes to the health care services purchased for these funds, and it answers which schemes are used? The healthcare functions in SHA 211 were not significantly changed, with two exceptions. First, the public health services are separated from preventive services. Second, some of the health care related parts in SHA 1. are now inside the CHE in SHA 211. Although major, these changes in classification caused limited adjustments in QHAR-2 to fit the new classification. 13 National Health Accounts 212

26 14 Supreme Council Of Health 4) Factors of provision BY Public and private provider group [FP] table, previously known as Resources Cost table in NHA Producer s Guide. This table shows the cost of resources used to produce the health care functions purchased. It is a key monitoring tool in determining overall system performance, and it provides a basis for the analysis of the efficiency of production and resource use (SHA 211, page 343). Due to the limited information available in 21, QHAR-1 included only the public sector expenditure on the cost of resources. SHA 211 classifications include small changes in the classification and definitions of this table s items, and the team adjusted these changes in QHAR-2 to fit the new classifications. In addition, QHAR-2 includes the following new set of tables, which were not developed in QHAR-1: 5) Health care providers BY Health care Functions [HPXHC] table. This table is the final table in the tri-axial system of the NHA, and shows the CHE by type of provider and by function. It shows how expenditures on different health functions are channeled through the various types of providers, and answers who provides what? This table provides a summary perspective of the health market in a country, i.e. what is the structure of its health care needs and who are the providers involved. This table has been shown to be valuable for validating the supply side of the CHE estimate (SHA 211, page 342). 6) Gross Capital Formation [HK] table. This table provides an overview of the finance of the capital goods in the health care system for the NHA year. It thus answers which investment goods are acquired? Because Qatar s government is injecting significant amount of investment in the health care system, it is imperative to include this table in QHAR-2. However, this table only provides investment classifications financed by the government and other public organizations. Data was not available from the private sector to include in this table. 7) Expenditure on health care by beneficiary characteristics: Gender and Age group. This table answers which segments of the population benefited from the current health care spending? With a unique population characteristics (see Section1.3.1), this table provides essential information on the uses of funds. It is thus considered one of the key outcomes of QHAR Data Sources, Strategy, and Assumptions Used This section lists the data sources used in QHAR-2 matrices, the strategy used to collect the necessary data, and the assumptions used Government MOEF MOEF provided the SCH with a breakdown of health expenditures paid by the government. Although the information received included all of the recipient organizations, the data only shows the expenditures at four categories: salaries and wages, operating expenses, capital expenses, and major projects. This breakdown was useful for the healthcare resources table, and was also useful to ensure consistency with reports from the recipients of the funds. SCH The SCH provided the breakdown of financial information based on the new budget classifications. Although the breakdown is more detailed than that received from MOEF, the allocation of funds was not given by programs. Assumptions were then used in allocating the expenditures to the healthcare function, health care resources, and health care providers tables. Because a significant amount of the public fund for health was spent on TA, an additional classification item was created in the health care functions table to allocate these expenditures: HC.1.1.M.

27 HMC A mapping exercise was conducted to improve the allocation of the HMC s 57 cost centers to the various QHA matrices. Data for 211 was available with the breakdown of the cost centers, and each cost center has further breakdowns of the various activities included, such as salaries and wages, equipment, etc. The QHA team allocated the administrative expenditure, proportionate to the size of the cost center, in consultation with the finance team from HMC. In addition, the team used HMC s annual reports such as Annual Hospital Costs Report, 211 in the factors of provision table. PHCC Similar breakdown to SCH expenditure was received from PHCC. Given the limited variety of services that PHCC provided, benchmarking was used to distribute the total expenditures into the needed QHA matrices. The benchmarking included the breakdown used in previous PHCC reports (FY 27/8). Employer clinics The five Qatar Petroleum (QP) clinics provided detailed information which was used to allocate the funds into the necessary matrices. The other employer clinics, MOI and Qatar Armed Forces (QAF), did not provide new information. Thus, a simple trend was used to calculate their expenditures for 211. Then, we benchmarked those expenditures to QP data to assert their health expenditures. Aspetar An instrument was sent and later filled by Aspetar. The instrument provided detailed information which allowed the mapping with QHA matrices with minimal assumptions. Sidra As Sidra does not yet provide services, all funds spent were placed into the capital formation sections of the QHA matrices Private health insurance companies Another instrument, tailored to PHI companies, was sent to the registered companies in Qatar. The instrument included four sections: 1) Person completing the instrument, and his position in the organization. 2) High level health insurance activities. For example, total number of enrollees, total amounts received in premiums, and total amounts paid in claims. 3) Details of total health expenditure for the services and goods provided to insured individuals. For example, inpatient care to public hospitals and inpatient care to private hospitals. 4) Details of the total health expenditure by beneficiary characteristics; i.e. age and gender. National Health Accounts Out-Of-Pocket spending The SCH administered the second OHS in 211 to evaluate the population s health utilization and health expenditure, the current PHI market, and to assess attitudes toward the current health insurance market and expectations of the upcoming SHI scheme. The results from the OHS built on existing data in 21 to help the SCH form an objective perspective on health financing issues pertaining to NHA and SHI projects, and to evaluate various economic and financial health care outcomes based on evidence-based methods. We added a new section in the survey about the children s health utilization and expenditures. 212

28 An important section of the second OHS is the OOP expenses paid by individual respondents. The findings from that section were used to estimate the national average OOP expenses and were used in the QHA matrices. See Annex 1 for further details Private health care providers A third instrument was sent to the four private hospitals operating in the country, with similar information to that requested from the private health insurance companies. Sources of income were classified as OOP, PHI, contracts, and others. The information received was then compared to that from the OHS and the PHI instruments. We found that the national PHI companies paid approximately 2m QAR to the private hospitals, while private hospitals received approximately 4m QAR from the PHI companies. Thus, we assumed that the difference, i.e. around 2m QAR, was received from the international PHI companies that operate in Qatar. These expenditures were then classified in the NHA tables as other domestic revenues in the financing sources classification, and as rest of the world in the financing schemes classifications Private firms Private firms provide health coverage to their employees either by purchasing private health insurance, providing direct contracts with the private health providers, or reimbursing their employees for services received. The latest establishment survey conducted by QSA, which is the appropriate method to collect the private firms information, did not include health expenditures information. To address this limitation, the data received from the private hospitals included direct contracts with the private institutions. These amounts were then used in the appropriate classification of the NHA tables. Supreme Council Of Health Charitable Organizations Aggregate information was received from the not-for-profit Zakat Fund. Thus, the expenditures were allocated to not specified by kind categories of the QHA matrices. For the next rounds of QHA, it is highly recommended that the charitable organizations and the recipients of its funds report these amounts to the QHA team. 2.4 Limitations The second report of the QHA addressed most of the limitations experienced in QHAR-1. However, few limitations remain to be addressed. First, the OOP estimate is derived from various sources, such as the OHS and the WHS, 26, which may introduce bias. Efforts should be made to conduct a national health expenditure survey. Second, health expenditure data was not available for the private clinics and polyclinics. A limited survey should be carried out to estimate the amount spent at these providers. Third, the data received from the public and private providers, as well as the insurance companies, was not to the needed details. A proper and consistent mapping exercise should be adopted by the stakeholders, in collaboration with SCH, to ensure that future data needs are produced t the needed details.

29 17 National Health Accounts 212 QHA Results

30

31 3 - QHA Results This section of the report shows the flow of funds in the following main NHA Tables: 1. Revenues of Financing Schemes (revenues) X Financing schemes [FSXHF]. 2. Financing schemes X Health care providers [HFXHP]. 3. Financing schemes X Health care functions [HFXHC]. 4. Health care providers X Health care functions [HPXHC]. 5. Factors of health care provisions [FP]. 6. Gross Capital Formation of government and other public organizations [HK]. 7. Beneficiary characteristics by gender, and by age group. 3.1 Financing Dimensions Revenues of Financing Schemes (FS) are defined in the SHA 211 (OECD, Eurostat, WHO, 211: 341) as: the revenues of the health financing schemes received or collected through specific contribution mechanisms. Financing schemes (HF) are defined in the SHA 211 (OECD, Eurostat, WHO, 211: 341) as: Components of a country s health financial system that channel revenues received and use those funds to pay for, or purchase, the activities inside the health accounts boundary. Financing agents (FA) are defined in SHA 211 (OECD, Eurostat, WHO, 211: 341) as: Institutional units that manage health financing schemes Main Findings: Where do the health funds come from? Table 2 shows the revenues of the financing schemes received by the financing schemes in 211: The current and capital health expenditures were 12,88m QAR. Of this amount, CHE was 9,966m QAR (82%), and the gross fixed capital formation was 2,122m QAR (18%). The gross fixed capital formation was exclusively funded by the government. The total CHE (9,966m QAR) was funded by: i. The government, 72% ii. Households, 16.7% iii. Employers, 9.2% iv. Other domestic revenues not elsewhere classified (n.e.c), 2%. The other domestic revenues n.e.c. are the amounts received by the private hospitals from the international health insurance schemes (see Section 2.3.4). The CHE from the public funds in 211 were managed as follows: SCH, 94% (6,732m QAR), and other government organizations, 6% (454m QAR). The CHE paid by voluntary prepayment schemes funded by the employers were managed as follows: voluntary health insurance schemes, 68% (629m QAR), and enterprise financing schemes, 32% (291m QAR). Public entities continue to exclusively manage the public funds, and private entities exclusively managed the private funds. 19 National Health Accounts 212

32 Trend analysis Figure 4 below shows the trend of the current and capital health expenditures by financing sources in Qatar for the last three years. The total current and capital expenditure increased by 27% (2,558m QAR) between 21 and 211 (from 9,53m QAR to 12,88m QAR). The increase was funded by: Government, 84% (2,141m QAR). Employers, 12% (32m QAR). Households, 4.5% (115m QAR). However, a direct comparison should be interpreted with caution for two reasons. First, the difference in classifications between SHA 1. and SHA 211. Second, the new detailed information that we received allowed a proper mapping of the schemes. Figure 4 Trend of current and capital health expenditure by financing sources, Qatar 29 to 211 (Million QAR) 2 Supreme Council Of Health 14, 12, 1, 8, 6, 4, 9,376 9, ,57 1,55 7,158 (76%) 7,166 (75%) 12,88 1,116 1,665 9,37 (77%) 2, Employers Households Government Total Health Expenditures Notes: Note: Institutional units used in previous NHA classifications are not identical to the schemes used in the new classifications.

33 Table 2 : Revenues of the financing schemes received by the financing schemes, 211 (Million QAR) Financing Sources (revenues), Million QR Total (% CHE) FS.5 Voluntary Prepayment FS.6 Other Domestic FS.5.2 From FS.5.1 From Households Revenues n.e.c. Employers Code Financing Schemes FS.1 Government * 7,186 HF.1 Government Schemes (72%) 6,732 6,732 HF SCH (94%) (68%) HF Other Government Organizations (MOI, AF, Aspetar) (6%) (5%) 935 HF.2 Voluntary Health Care Payment Schemes (9%) HF.2.1 Voluntary Health Insurance Schemes (68%) (6%) HF.2.2 NPISH (Zakat Fund) HF.2.3 Enterprise Financing Schemes (32%) (3%) 1,65 1,65 HF.3 Household Out-of-pocket Payment (99%) (17%) HF.4 Rest of the world Total Current Health Expenditure ** 7,186 1, ,966 (% from Total) (72.1%) (16.7%) (9.2%) (2.%) 2,122 HK.1.1 Gross Fixed Capital formation 2, Current and Capital Health Expenditures 9,37 2, ,88 Notes: As the focus of the new system shifted into current spending, the percentages shown are from the CHE, i.e. from the columns totals. * Revenue of the Government (FS.1) includes the household payments for enrollment in the public health system. ** Percentages shown are from total CHE, 9,966m QR. 21 National Health Accounts 212

34 Cross-country comparison Figure 5 shows the distribution of the current and capital health expenditure by revenue in Qatar in 211, and compares it with advanced economies (OECD in 29). The figure shows that the main source of revenues is the public funds both in Qatar and in OECD; however, the share is relatively higher in Qatar (77%). Households in Qatar contribute by 14%, compared to 19% in OECD, and employers have a higher share in Qatar (9%) compared to OECD (6%). Figure Figu ure 5 Distribution tion of current and capital health health expendituure expenditure by by revenu revenue, e, Qatar Qatar and and OECD OECD Qatar, 211 9% 14% 22 77% Supreme Council Of Health 3% 6% OECD, 29 19% 72% Public Sector Employers Households Others

35 3.2 Use Of Funds Health care providers Health care providers are defined in SHA 211 (OECD, Eurostat, WHO, 211: 341) as: Entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary. Main findings: Where do the health funds go to? Table 3 shows the flow of funds from the financing schemes to the healthcare providers in 211, as follows: The amount of funds spent on CHE in 211 was 9,966m QAR (last green column) and was distributed as follows: i. Hospitals received the lion s share of the CHE, 57% (5,651m QAR). The ratio from the total current and capital expenditure is even higher: 64% (7,773m QAR, from 12,88m QAR). ii. Providers of ambulatory healthcare services, 14%, (1,427m QAR). iii. Providers of ancillary services, 2%, (183m QAR). iv. Retailers and other providers of medical goods, 4%, (364m QAR). v. Providers of health care system administration and financing, 8%, (77m QAR). vi. Rest of the world, TA, 9%, (97m QAR). vii. Providers NSK, 7% (664m QAR). The public CHE (QAR 7,186m) was distributed to the following providers (first column): i. Hospitals, 68%, (4,914m QAR) mainly HMC. ii. Ambulatory health care, 12%, (845m QAR), which represents the expenditures on PHC and employer clinics. iii. Public health programs and government health administration, 8%, (553m QAR). iv. Rest of the world, TA, 12%, (874m QAR). The funds for voluntary health care payment schemes (936m QAR) were distributed to the following providers (second two columns): i. Hospitals, 24%, (222m QAR). ii. Ambulatory healthcare, 4%, (375m QAR). iii. Private retail sale and other providers of medical goods, 8%, (53m QAR). iv. PHI administration, 23% (217m QAR), which includes profit and future payments, because of the difference between the accrual and cash methods. This share was initially reported as 54% in 21, see SQHAR-1 Page 2, but now adjusted to (171m QAR 32%), where all future payments were liquidated. v. Rest of the world, TA, 4%, (33m QAR). vi. Providers n.s.k, the Zakat funds, 1.6%, (15m QAR). 23 National Health Accounts The public funds continue to be exclusively spent on public providers, and the private funds continue to be mainly spent on private funds. 212

36 Trend analysis Figure 5 below shows the trend of the current and capital health expenditures by health provider in Qatar for the last three years. The total current and capital expenditure increased by 27% (2,558m QAR) between 21 and 211 (from 9,53m QAR to 12,88m QAR). The increase was received by: Hospitals, 53%, (525m QAR in CHE and 74 in Gross Capital Formation). Ambulatory care, 13% (333m QAR). Ancillary, retailers and others, 36% (921m QAR). However, it is important to note that institutional units used in previous NHA classifications are not identical to the schemes used in the new classifications. Figure 6 Trend of current and capital health expenditure by health provider, 29 to 211 (Million QAR) 24 Supreme Council Of Health 14, 12, 1, 8, 6, 4, 2, 9,376 9,53 1,161 1,196 1,44 1,94 4,754 (51%) 5,36 (53%) 1,724 1,382 12,88 2,117 (18%) 1,427 5,651 (47%) 2,122 (18%) Adminstration and Financing Ancillary, Retailers, and Others Ambulatory Care Hospitals Gross Capital Formation Total Health Expenditures Notes: Note: Institutional units used in previous NHA classifications are not identical to the schemes used in the new classifications.

37 Table 3 : Health expenditure by type of financing schemes and type of providers, 211 (Million QAR) Financing Schemes, Million QR (% of CHE) TOTAL (% of CHE) Code Providers HF.4 Rest of the world HF.2 Voluntary health care payment schemes (other than OOP) HF.3 Household out-of-pocket HF.2.1Voluntary payment HF.2.3 Enterprises health insurance HF.1 Government schemes and compulsory contributory health care 5,651 (57%) 195 (12%) 32 (19%) 38 (13%) 184 (29%) 4,914 (68%) HP.1 Hospitals 3,135 (31%) 185 (11%) 16 (17%) 2,843 (4%) HP.1.1 General hospitals HP.1.2 Mental health and substance abuse hospitals 2,433 (24%) 195 (12%) 13 (8%) 38 (13%) 75 (12%) 1,995 (28%) Specialty (other than mental and substance abuse) hospitals HP.1.3 1,427 (14%) 28 (13%) 254 (87%) 121 (19%) 845 (12%) HP.3 Providers of ambulatory health care 441 (4%) 112 (7%) 254 (87%) 75 (12%) HP.3.1 Medical Practices (6%) 46 (7%) HP.3.2 Dental Practice (3%) HP.4 Providers of ancillary services 364 (4%) 311 (19%) 53 (8%) HP.5 Retailers and other providers of medical goods 77 (8%) 217 (35%) 553 (8%) Providers of health care system administration and financing HP.7 97 (9%) 33 (5%) 874 (12%) HP.9 Rest of the world (TA) 664 (7%) 649 (39%) HP.nsk Provider not specified by kind 9, ,65 (17%) 629 (6%) 291 (3%) 7,186 (72%) Total Current Health Expenditures* (% from Total) HK.1.1 Gross Fixed Capital formation 2, ,122 Total Current and Capital Health Expenditures 9, , ,88 Note: As the focus of the new system shifted into current spending, the percentages shown are from the CHE, i.e. from the columns totals. HP.nsk Totals include Zakat Fund (not shown). * Percentages shown are from total CHE, 9,966m QAR.. 25 National Health Accounts 212

38 Cross-country comparison Figure 7 shows the distribution of the current and capital health expenditure received by provider in Qatar in 211, and compares it with advanced economies (OECD in 29). The figure shows that the main recipients of the funds in Qatar were the tertiary care providers, mainly the public hospitals. For example, hospitals in Qatar received almost twice as much as in OECD countries (64% compared to 36%). As a result, the ambulatory care providers seem to have been the most affected by the domination of the tertiary care providers. Ambulatory care in Qatar received only 12%, while these providers in OECD countries received more than twice that percentage (28%). In addition, the ancillary services and retailers seem to be also affected by the concentration of the services in the hospitals. The share of the ancillary services and retailers in Qatar was only 6%, compared to 19% in OECD (figures not shown). To diversify the economy and to promote the consumer choice under the upcoming health insurance scheme, the Qatari health care system should support the ancillary services and retail sale at the private providers. Fig ure 7 Distribution of current and capital health expenditure by provider, Qatar and OECD Qatar, % 6% Supreme Council Of Health 12% 64% OECD, 29 6% 3% 36% 28% Hospitals Ambulatory Care Ancillary, Retailers, and Others Admin.. and Financing

39 3.2.3 Health Care Functions Health care functions are defined in SHA 211 (OECD, Eurostat, WHO, 211: 341) as: The types of goods and services provided and activities performed within the health accounts boundary. Main findings: What kinds of services and goods do health funds purchase? Table 4 shows the flow of funds from the financing schemes to the various health care functions. The 9,966m QAR spent on healthcare in 211 (last green column) was paid for the following services: i. Inpatient, 38% (3,746m QAR) of which 97m QAR was spent on TA services. ii. Outpatient, 3% (3,7m QAR) of which 524m QAR was spent on dental care. Dental care, however low overall, constitutes 14% (234m QAR) of the OOP expenditures. iii. Ancillary services such as clinical laboratories and diagnostic imaging, 6% (636m QAR). iv. Medical goods non-specified by function, such as pharmaceuticals, medical equipment, and therapeutic appliances, 12% (1,215m QAR). v. Preventive care, and general administration and insurance, 11% (3% and 8%, respectively or 1,32m QAR). Although the preventive care seems to appear very low, the financial information received from SCH does not distinguish the preventive care provided by SCH and the governance expenses. Efforts should be made to allocate expenditures by services provided by SCH. vi. All others, including rehabilitative care, long-term care, and n.e.c., 3% (35m QAR). The government financing schemes, 72% (7,186m QAR) of CHE, were paid for the following current health care functions (first column): i. Approximately 9% (6,352m QAR) was spent on personal care as follows: 2,348m QAR was spent on inpatient and long-term care inside Qatar; 874m QAR on TA; 2,84 QAR on outpatient and rehabilitative care; 672m QAR on medical goods; and 374m QAR on ancillary services. ii. About 1% (813m QAR) was spent on preventive care (26m QAR) and health care administration 553m QAR. The voluntary schemes (936m QAR) were paid for the following services i. Approximately 75% (7m QAR) was spent on personal care as follows: 89m QAR was spent on inpatient care inside Qatar; 33m QAR on TA, 42m QAR on outpatient care; 81m QAR) on medical goods; 43m QAR on rehabilitative care; and 52m QAR on ancillary services. ii. About 24% (218m QAR) was spent on collective care, mainly PHI administration (217m QAR). The details of the other two financing schemes, household OOP and rest of the world payments, are shown in columns HF.3 and HF.4 of Table National Health Accounts 212

40 28 Supreme Council Of Health Table 4: Health expenditure by type of financing schemes and health care functions, 211(Million QAR) Financing Schemes, Million QR (% of CHE) TOTAL (% of CHE) HF.4 Rest of the world HF.1 Government financing schemes Code Health care function HF.2 Voluntary health care payment schemes (other than OOP) HF.3 Household outof-pocket payment HF.2.3 Enterprise financing HF.2.1Voluntary health insurance 6,777 (68%) 151 (77%) 1,3 (61%) 2 (69%) 325 (52%) 5,99 (71%) HC.1 Services of curative care 3,746 (38%) 4 (21%) 398 (24%) 11 (4%) 111 (18%) 3,185 (44%) HC.1.1 Inpatient curative care 831 (8%) 132 (8%) 7 (3%) 691 HC General inpatient curative care 1,889 (19%) 266 (16%) 3 1,62 (23%) HC Specialized inpatient curative care 97 (9%) 33 (5%) 874 (12%) HC.1.1.M Treatment Abroad HC.1.2 Day curative care 3,7 (3%) 19 (56%) 62 (37%) 19 (65%) 212 (34%) 1,894 (26%) HC.1.3 Outpatient curative care 1,175 (12%) 52 (27%) 99 (6%) 158 (54%) 11 (16%) 765 (11%) HC General outpatient curative care 524 (5%) 27 (14%) 234 (14%) 24 (8%) 53 (8%) 185 (3%) HC Dental outpatient curative care 1,38 (13%) 3 (15%) 269 (16%) 8 (3%) 58 (9%) 944 (13%) HC Specialized outpatient curative care (15%) 19 (3%) HC.2 Rehabilitative care HC.3 Long-term care (health) 636 (6%) 17 (8%) 193 (12%) 2 (7%) 32 (5%) 374 (5%) Ancillary services (non-specified by function) HC.4 1,215 (12%) 27 (14%) 434 (26%) (8%) 672 (9%) Medical goods (non-specified by function) HC (3%) (4%) HC.6 Preventive care 77 (8%) 217 (35%) 553 (8%) Governance, and health system and financing administration HC Other health care services not elsewhere classified (n.e.c.) HC.9 9, ,65 (17%) 291 (3%) 629 (6%) 7,186 (72%) Total Current Health Expenditures (TCHE)* 2, ,122 Capital formation for health care provider institutions HK.1.1 Total Current and Capital Health Expenditures 9, , ,88 Note: As the focus of the new system shifted into current spending, the percentages shown are from the CHE, i.e. from the columns totals. * Percentages shown are from total CHE, 9,966m QAR.

41 Trend analysis Figure 8 below shows the trend of the current and capital health expenditures by health care function in Qatar for the last three years. The total current and capital expenditure increased by 27% (2,558m QAR) between 21 and 211 (from 9,53m QAR to 12,88m QAR). The increase in the total current and capital expenditure in 211 was distributed as follows: Personal care, which includes all the items except governance and gross capital formation, increased by 23% (from 7,466m QAR to 9,196m QAR). Health governance and gross capital formation increased by 4% (from 2,64m QAR to 2,892m QAR). Figure 8 also shows the share of each service provided from the total current and capital expenditures over the three-year period. However, a direct comparison should be interpreted with caution for two reasons. First, the difference in classifications between SHA 1. and SHA 211. Second, the new detailed information that we received from HMC, which allowed a proper mapping of the services provided. Nevertheless, the trend between 21 and 211 shows that: The share of the inpatient care increased from 23% to 31% (from 2,214m QAR to 3,746m QAR). The share of the outpatient care decreased from 27% to 25% (from 2,553m QAR to 3,7m QAR). (8) The share of the ancillary services decreased from 22% to 15% (2,83m QAR to 1,851m QAR). The share of gross capital formation increased from 15% to 18% (1,382m QAR to 2,122m QAR). The share of all other functions, including governance and administration, slightly decreased from 13% to 12% (1,299m QAR to 1,362m QAR). Figure 8 Trend of current and capital health expenditure by health care function, 29 to 211 (Million QAR) 29 14, 12, 1, 8, 6, 4, 2, 9,376 9,53 1,724 (18%) 55 2,15 (21%) 2,447 (26%) 2,97 (22%) 1,382 (14%) 683 2,83 (22% ) 2,553 (27%) 2,214 (23%) 12,88 2,122 (18%) 77 1,851 (15% ) 3,7 (25%) 3,746 (31%) All others Capital formation Governance & admin. Ancillary services & Medical goods Outpatient Inpatient Total National Health Accounts Notes: Note: Institutional units used in previous NHA classifications are not identical to the schemes used in the new classifications. (8) The data received from HMC for 21 assigned all the ancillary services provided by HMC (whether for inpatients or outpatients) to one category. The data for 211 was corrected for the ancillary services to include only outpatient care. Ancillary services received by patients admitted inside the hospital is classified as part of inpatient care expenditure. 212

42 Cross-country comparison Figure 9 shows the percentage distribution of current and total health expenditures by health care function in Qatar, and compares it to the OECD average in 29. The curative care (inpatient and outpatient care) is almost identical in Qatar and OECD, 63% and 62%, respectively. However, long term care in Qatar was almost non-existent (.3%), and it was 12% in OECD. There are two explanations to the variation in the long-term care between Qatar and OECD. First, Qatar has a relatively young population. The expatriate population, comprising a vast majority, is repatriated to their home countries once they reach retirement age. Second, most of the elderly population, exclusively Qataris, is provided the long-term care by their families in forms of social care. Hence, this care will not appear in the NHA classifications, and can only be estimated through other studies. Medical goods and ancillary services were lower in Qatar compared to OECD (19%). However, collective care was relatively the same, 9% and 7%, respectively. Capital formation in Qatar constituted 18% of the total, but should also be interpreted with caution due to the variation in the classification. A more accurate comparison can be conducted once OECD produce their expenditure reports with the SHA 211 classifications. Fig ure 9 Distribution of current and capital health expenditure on health care functions, Qatar and OECD Qatar, Supreme Council Of Health % 18% 9% 1% 31% 32% OECD, 29 19% 7% 29% 12% 33% Inpatient care Outpatient care Long term care Medical goods Collective caree Capital formation

43 3.2.3 Health Care Providers By Health Care Functions Table 5 is the final table in the tri-axial system of the NHA, and it is an additional table the previous QHA Report. The purpose of adding this table is to allocate more accurately some of the non-specified items. For instance, 39% of the households health expenditure is not specified by provider. Due to the lack of information provided by the providers for the functions offered, we made some estimates to ensure that the data is matching the other tri-axial tables. A small survey of providers should be carried in the future to allocate the health expenditure by functions more accurately. Main Findings: What services were produced by which providers? Table 5 shows new information about health care expenditure for the health care providers by health care functions, which can be summarized as follows: Hospitals received in total 7,77m QAR, and 5,651m QAR was spent on current services. About 74% (4,169m QAR) of the current expenditure was in curative care. Ancillary services cost the hospitals 7% (422m QAR), while medical goods cost the hospitals 1% (567m QAR). HP 4, 5, and 6 have a very small share in the health care market in Qatar, because the majority of these services is provided in the hospitals. For instance, the expenditure on ancillary services, 636m QAR, was mainly provided by the hospitals, 66% (422m QAR), and only 34% (214m QAR) by the private providers of ancillary services. This concentration of services in hospitals is rarely experienced in more diversified health care system, such as the majority of the high income countries. Due to the complexity of the table and the first time to produce it, the making of a trend analysis and cross-country comparison is not advised for the health care providers by health care functions table. 31 National Health Accounts 212

44 Table 5: Health care expenditure for the health care providers by health care functions, 211 (Million QAR)] Health Care Providers HP.1 HP.3 HP.4 HP.5 HP.6 HP.7 HP.nsk HP.9 Code Health Care Functions Hospitals Providers of ambulatory health care Providers of ancillary services Retailers and other providers of medical goods Providers of preventive care Providers of health care system administration and financing Provider not specified by kind/ balancing Item Rest of the world (TA) Total HC.1 Services of curative care 4,169 1, ,777 HC.2 Rehabilitative care HC.3 Long-term care (health) HC.4 HC.5 Ancillary services (nonspecified by function) Medical goods (non-specified by function) , HC.6 Preventive care Supreme Council Of Health HC.7 HC.9 Governance, and health system and financing administration Other health care services not elsewhere classified (n.e.c.) Total Current Health Expenditures (CHE) 5,651 1, ,966 HK.1.1 Capital formation for health care provider institutions 2, ,122 Total Current and Capital Health Expenditures 7,77 1, ,88

45 3.3 Factors of Health Care Provision Factors of provision (FP) is defined in SHA 211 (211:341) as: The types of inputs used in producing the goods and services or activities conducted inside the HA boundary. Thus, this definition implies that only CHE should be evaluated in this section. Because TA is a major item in the cost of provision of care in Qatar, we added an import classification to the FP table: FP.M Table 6 shows the detailed factors of provision by the public and the private providers. The compensation of employees was not available for the private clinics. Thus, the self-employed estimate is based on PHCC data, and should be interpreted as the minimal estimates. Main Findings: What resources used to provide these services? Compensation of employees was 61% of the public sector s resource cost, while it was 69% of the private providers (18% compensation of employees and 51% self-employed remuneration). TA was 12%, 874m QAR, of the public provision of care. The share of health care goods, mainly pharmaceuticals, was 14% from the public provision, and 22% of the private provision of care. Table 6 : Factors of health care provision, 211 (Million QAR) Code Description Public Provision Private Provision* Total (% of CHE) FP.1 Compensation of employees 4,626 (61%) 436 (18%) 5,62 (51%) 33 FP.2. FP.3 FP.3.2 FP.3.3 Self-employed professional remuneration Materials and services used Health care goods Non-health care services 1,868 (25%) 1,35 (14%) 75 (9%) 1,212 (51%) 684 (29%) 518 (22%) 146 (6%) 1,212 (12%) 2,552 (26%) 1,553 (16%) 851 (9%) National Health Accounts FP.3.4 Non-health care goods FP.4 Consumption of fixed capital FP.5 Other items of spending on inputs FP.M Treatment Abroad 874 (12%) (9%) Total Factors of Provision (% from Total) Notes: 7,576 (76%) 2,39 (24%) 9,966 1) FP does not include the capital formation. Expenditures on investment and major projects do not yet produce health care services and is thus excluded. 2) The total cost in the public sector is paid for by MOEF and OOP. Public provision includes HMC, PHCC, SCH, and other government organizations (Aspetar, MOI, QP, QAF). 212

46 3.4 Gross Capital Formation Qatar is experiencing major expansion projects in the health care system. The gross capital formation constituted 18% of the total current and capital expenditures in 211 (2,122m QAR). Thus, it is very important to evaluate these expenditures using the NHA classifications. The information on capital expenditures was collected only from the public institutions. The private providers also underwent expansion projects in 211, but to a much lesser extent. The data was not available from the private sector, and thus we only show the capital formation in the public sector. Main Findings: what was spent for investment on health? Table 7 shows the gross capital formation of government and other public organizations in 211, and the results can be summarized as follows: Infrastructure in total received 74% (1,574m QAR) of the investment amount. Medical equipment received 18% (386m QAR) from the total, and the majority of this amount was received by HMC (338m QAR). These figures indicate that HMC is developing their technical capabilities faster than the other providers. HMC received 27% of the total gross capital formation (578m QAR), while PHCC received only 2% (34m QAR). It is crucially important that PHCC increase their share of capital formation in future years, particularly in the medical equipment. Other Government Organization received 7% of the gross capital formation (1,479m QAR), and the infrastructure is taking 99% of that amount (1 463m QAR), i.e., Sidra Project. 34 Table 7: Gross Capital Formation of government and other public organizations, 211 (Million QAR)] Supreme Council Of Health HK Code Description HMC PHCC SCH OGO* HK HK HK HK HK HK HK Infrastructure Residential and non-residential buildings Other structures Machinery and equipment Medical equipment Transport equipment ICT equipment HK.1.1 Gross Fixed Capital Formation (% from Total)** Machinery and equipment n.e.c. Total (% CHE) ,463 1,574 (19%) (3%) (99%) (74%) 7.9 1,463 1,534 (12%) (3%) (99%) (72%) 4 4 (7%) (81%) (97%) (26%) (58%) (34%) (79%) (18%) (3%) (9%) (24%) (13%) (3%) (14%) (37%) (8%) (4%) ,479 2,122 (27%) 91%) (7%) Notes: No information available on capital formation in the private sector. * Other Government Organizations include Sidra, Aspetar, QP, MOI, and QAF. As the focus of the new system shifted into current spending, the percentages shown are from the CHE, i.e. from the columns totals. ** Percentages shown are from total capital expenditure, i.e. 2,122m QAR.

47 3.5 Beneficiary Characteristics Qatar has a unique structure of the gender and age characteristics (see section 1.3.1), and this structure is expected to influence the healthcare delivery. Therefore, the NHA team collected information from the providers on the characteristics of those who benefited from the services delivered. This breakdown enables the comparison of the health expenditures by gender and age groups of the beneficiaries. Main Findings: Who benefited from the current health expenditures? Table 8 shows the distribution of the CHE by the characteristics of the beneficiaries, as follows: Gender: i. Males received 57% of CHE (5,631m QAR). ii. Females received 43% of CHE (4,335m QAR). Age groups: i. Preschoolers, -4 years old, and school age, 5-14 years old, received 17% of CHE (815m QAR, and 935m QAR, respectively). ii. A significant share, 74%, of the CHE was spent on working age group, years old (7,378m QAR). iii. Elderly age group, 65+ years old, received the lowest share of the CHE, 8% (836m QAR). Table 8 : Current health expenditures by the beneficiaries characteristics, 211 (Million QAR) Characteristic Current Health Expenditure 35 Gender Males (all ages) Females (all ages) Totals 5,631 (57%) 4,335 (43%) 9,966 National Health Accounts Age 4 years old 5 14 years old years old years old 65+ years old Totals 815 (8%) 936 (9%) 5,182 (52%) 2,196 (22%) 836 (8%) 9,

48 36 Cross-country comparison Comparative data on health expenditures by beneficiary characteristics is quite scarce. Only few countries report the distribution of the health expenditure by age and gender. Thus, we only include three countries in this cross-country comparison: USA, 24, Germany, 28, and Austria, 27. Although the data for the comparative countries are not overlapping in time, the trend of health care expenditure by the age and gender groups would not vary within a short period of time, particularly in these selected countries. Figure 1 shows the distribution of current health expenditures by gender, and by age groups. Unlike the other countries, males in Qatar received higher CHE than females (57% in Qatar, compared to 43% in the comparative group of countries). However, the distribution is disproportionately higher than the actual population. Males in the comparative group constitute roughly 5% of the population. While in Qatar males constitute more than 76% (source QSA 21). The difference in distribution of CHE is even more pronounced by age groups in Qatar and the comparative countries. The age group received 52% of CHE in Qatar, while this group received only 21% in the comparative group of countries. These differences do not come at a surprise, given the population pyramids in Qatar and in the comparative group of countries. As shown in Figure 1, the population in Qatar is skewed toward male. Census data from 21 shows that 67% of the population was in the 2-44 age group in Qatar, while this age group composed only 42% of the population in Germany, for example. However, these findings further indicate that the per capita health indicators (including age and gender KPIs) must take into consideration the skewed distribution of the gender and age groups in Qatar. In addition, most of those males population reside in Qatar for short working contracts, and are screened upon their arrivals. Supreme Council Of Health

49 37 National Health Accounts 212

50

51 Policy Implications

52

53 4 - Policy Implications Funds available for health care Qatar s health care expenditure increased by 27% between 21 and 211. This significant increase is one of the highest in the world, given that most of the countries are imposing austerity measures, including their health sectors. The increase was mainly funded by the government, which indicates the government s commitment to improve health services in Qatar. Qatar s health care expenditure totaled 12,88m QAR. The lion s share of the health funds were secured through the government (77%), but the share funded privately is expected to increase with planned health care reforms, including the implementation of the SHI. A sizable share of the health funds (18%) was spent on capital formation (investment in health) to meet needed reforms, funded by the public sector. Public entities are exclusively responsible for managing the public funds, and private entities are exclusively responsible for managing the private funds. These exclusivities indicate that the health financing structure is fragmented, which may indicate duplication in efforts and services provided. It is expected that SHI will address these exclusivities, in order to improve the equity of the health care system in Qatar. 1 st Implication The share of the capital formation will start to fade gradually, and use of these investments will increase once operational. To avoid misleading drops in future health expenditure, the current funds directed to investments should be properly allocated in future health consumptions, i.e. proper amortization and depreciation nd Implication Although the OOP expenditure decreased in relative terms as a share of the total current and capital health expenditure between 21 and 211 (from 16% to 13.8%), the absolute share increased (from 1,55m QAR to 1,665m QAR). Until full implementation of SHI, the OOP may continue to increase. On the other hand, the opening of new public hospitals from this year, as well as an ongoing shift to a primary health care model of care should reduce unmet need, and OOP payments for alternative services (such as private or overseas services), particuarly in the secondary and tertiaty sectors. Nevertheless, short-term cost sharing adjustments should be studied and evaluated carefully. National Health Accounts Uses of health care funds The Qatari population is relatively young, and the non-qatari population is mainly composed of young expatriate males. Nevertheless, the main recipients of the health care funds were tertiary care hospitals (57% of the total money spent on health), which is very high compared to advanced economies (36% in OECD countries). The amount spent on care delivered at hospitals increased by 12% from 21 to 211. This increase can be explained by the opening of. These hospitals provide outpatient care, as well as tertiary care. The share of the hospitals is only expected to increase for the next few years. There are currently five to six new hospitals scheduled to open in the next five years, which will double bed capacity. This concentration of services in hospitals is rarely experienced in more diversified health care system, such as the majority of the high income countries. 212

54 3 rd Implication Policy interventions should be in place to ensure that the concentration of health services at the tertiary care facilities is robust, and the cost of these services is sustainable. In addition, health financing policies should foster the advancement of the primary health care model as specified in the NHS. The funding model should benefit from economies of scale. For instance, studies should be carried to measure the benefits of shifting more ancillary services and retail sales of pharmaceutical products to the private providers.economies of scale are situations in which the average cost declines as quantities of health services purchased increases. Beneficiaries of current funds Because Qatar s population structure is unique (75% male, and 82% in age-working group), analyzing health care funds by beneficiaries characteristics is paramount. The findings from this report show a potentially disproportionate distribution of funds: Males received only 57% of the current health funds, while the ageworking group received 75%. 4 th Implication It is expected that health expenditure for males will be smaller than their population share in Qatar. The majority of males living in Qatar are young and healthy. However, further health economics studies should investigate whether the services delivered to each population group are equal to their health needs. 42 Supreme Council Of Health Future directions The QHAR-2 report is informative and reveals important findings, which can be used as the beginning of a trend to gauge health care expenditures to benchmark costs pre- and post the ambitious planned health care reforms. 5 th Implication There are improvements in the data collection and data quality provided by the study s stakeholders. However, further improvements need to be made. A number of assumptions were used in this report due to lack of data (incomplete or not provided in time). Efforts should be made to promote and mandate the collection of data for future Qatar National Health Accounts.

55 Annex 1: Second Online Health Survey

56

57 1. Introduction 1.1 Purpose The SCH conducted OHS-2 in 211 as a follow up to the OHS-1 conducted in 21. The main purpose of OHS-2 was to evaluate the population s health utilization and health expenditure. The results from the OHS-2 will build on existing data to help the SCH form an objective perspective on health financing issues pertaining to the Health Insurance and this NHA report, and to evaluate various economic and financial health care outcomes based on evidence-based methods. The objectives of the OHS-2 are to: 1. Assess access to public and private health facilities by various subgroups of the population, and the common reason to visit these facilities. 2. Assess the health care system utilization of public and private health facilities, which include outpatient and inpatient visit ratios, the frequency of visits, and the reasons for the visits. In addition, assess patient satisfaction levels using international health satisfaction scales to identify areas for improvements in both the public and private sectors. 3. Obtain an updated OOP health expenditure for these households. 1.2 Methodology Format The technical team in SCH decided to conduct the second round of OHS-2 due to the delay in conducting a face-to-face survey within the calendar year 211. Respondents to OHS-1 were asked to provide their contact information for future health surveys. About 3,2 respondents (of the total 6,25 completed responses) provided their addresses. See for more details of the results. These respondents were contacted in 211 to participate in OHS-2, conducted in four consecutive months September through December 211. They were asked to record their household members health utilization and health expenditure. An invitation was sent to them at the beginning of each following month to complete the survey for the previous month. In addition to the participants from OHS-1, the team contacted additional organizations not approached in OHS-2, such as commercial banks and other major employers in the oil and gas industry. Each new recruited respondent was also asked to provide their contact information for future surveys. The same software used in 21 was used to collect the information in 211 ( Furthermore, all aspects of the survey (the invitations, the media campaign and the survey itself ) were in Arabic and English, the two most common languages of the target population. 45 National Health Accounts Sections of the survey The surveys were composed of the following sections: 1) Demographics: This part of the survey included standard demographic questions, such as age, gender, nationality, educational attainment, work status, and household structure. To ensure proper calculations of the adjustment in the analyses stages, these questions were compulsory. To diminish respondents fatigue, these questions were only asked at the first round of participation. 212

58 2) Household health care expenditure: This section included a breakdown of total household health expenditure categories (primary, secondary and tertiary care, medicines, laboratory tests, medical devices, treatment abroad, etc.) during the 3 days prior to the survey. 3) Insurance coverage: This section included questions about the respondents health coverage. 4) Respondents health care: This section included questions about: i. The respondents general health status (presence of chronic diseases, etc.), and presence of a regular health care provider. ii. Health care utilization: Two sections solicited the respondents health care utilization (outpatient and inpatient care) in the 3 days and 12 months, respectively, prior to the survey. The respondents were also asked about the cost associated with each episode, and their satisfaction of the services delivered. iii. Children s utilization: respondents were asked about the total number of children (16 years old or younger) that live in the household. They were then prompted to answer questions related to the youngest child only, if they have more than one child in the household. Two sections, similar to the adults sections, solicited the health care utilization and expenditure of that child. iv. Closing Section: In this section respondents were asked to keep records of the household s health expenditure and utilization for the then current month. 46 Supreme Council Of Health

59 2. Survey Results 2.1 Pattern Of Participation Respondents were asked to participate in multiple rounds, during the four months of data collection. Figure 11 shows distribution of the participants by the number of completed rounds and by nationality. Above half of the Qatari respondents participated only once (54%), while less than half of the Non-Qataris participated only once (48%). Qataris, however, have a higher all-round participation than Non-Qataris (14% and 9%, respectively). Fig ure Participants' number of completed rounds and by nationality [N= =2,472] Qataris 14% 15% 54% 47 17% Non Qataris National Health Accounts 9% 19% 48% 23% One round Two rounds Three roun ds All rounds 212

60 48 Supreme Council Of Health 2.2 Sociodemographic Characteristics Table 9 shows the sociodemographic characteristics of the respondents to OHS-2. Gender The gender distribution for the Qatari respondents is somewhat balanced (47% males and 53% females), but the non-qatari respondents have higher male representation (69% male and 31% female). This reflects the actual gender distribution in the targeted population of the non-qatari white-collar workers. The 21 Census data show that this cohort is mainly male (9). Age group Respondents were asked to choose from one of five age groups (18-24, 25-34, 35-44, 45-54, and 55+). Qatari respondents are younger (43% between the age of 18-34) compared to non-qatari respondents (27%). There were comparatively fewer respondents in the 55+ age group, particularly among Qatari respondents. Given the nature of the survey, this is to be expected: fewer elderly people are computer savvy. Educational attainment Given the age distribution discussed above, Qatari respondents are more concentrated in the lower educational attainment scale of the targeted sample for this survey (18% have attained high school or less). Non-Qatari respondents have a higher level of educational attainment (31% with a graduate degree) than their Qatari counterparts (18%). The distribution of college graduates possessing a bachelor s degree is balanced between the two groups. Occupational status Consistent with the respondents age group and educational attainment findings, the occupational status results show that Qatari respondents are more likely to be in senior (26%) and clerk (3%) positions compared to non-qatari respondents (11% and 14%, respectively). Professionals, however, are highly represented by the non-qatari respondents (54%). Sector of employment The government sector had the highest number of Qatari and non-qatari respondents (67% and 59%, respectively). Marital status Most respondents are married. There were more single Qatari respondents (22%) than non-qatari (11%). Nationality Figure 12 shows the respondents categorization into the five common nationality groups that live in Qatar. Qataris, who constitute a unique denomination both in health status and other socioeconomic characteristics, represent 27% of the total respondents. Non-Qataris from other Arab countries constitute the same number of respondents as Qataris (28%). The three other non- Qatari groups include those from Asian non-arab countries (34%), Westerners including Australians - (9%), and all other nationalities. (9) QSA Census 21 Results, Table 1.9

61 Table 9 Sociodemographic characteristics of respondents Qatari Non-Qatari Gender [N=2,472] Male 47% 69% Female 53% 31% Age group [N=2,472] % 2% % 25% % 4% % 23% % 1% Educational attainment [N=2,173] Less than high school 3% 1% High school 15% 7% Diploma 17% 17% Bachelor 47% 45% Graduate 18% 31% Occupational status [N=2,22] Senior position 26% 11% 49 Professional 23% 54% Technician 11% 14% Clerk 3% 14% Other 1% 3% Currently not working 9% 4% Employment sector [N=2,472] National Health Accounts Government 67% 59% Private 19% 32% Other 19% 32% Currently not working 6% 5% Marital status [N=2,1] Never married 22% 11% Currently married 71% 86% Separated/divorced 6% 2% Widowed 1% 1% Note: Column results may not add up to 1% due to rounding. 212

62 Figure Fig Participants cipants' distri distribution by by nationality [N=2,472] 2 2% 9% 27% 34% 28% 5 Supreme Council Of Health 2.3 Household Structure Qataris Arab countries Asian non Arabs Europe, North America, and Australia Other nationalities An important component of health care financing is household structure. Figure 13 shows the results of the information provided on household members. The average Qatari households are larger than Non-Qatari households by one child (3.3 versus 2. children) and by two domestic workers (2.3 versus.2 workers). Figure Participants' number of completed rounds and by nationality [N= =2,472] Qatari Non Qatari Adults, 1.9 Domestic Workers, 2.3 Others,.7 Adults, 1.7 Children, 2. Domestic Workers,..2 Others,.3 Children, Average number per household 3 4

63 Annex 2: NHA Tables