1. Dr. Bahaa Eldin Fateha, CEO, NHRA* * National Health Regulatory Authority Kingdom of Bahrain

2. National Health Regulatory Authority, NHRA Established by law in 2009. Became fully operational in September 2011. Responsible for regulation of healthcare services, public and private: Facilities and professionals. Registration, licensing and pricing of pharmaceuticals and health-related supplements. Investigating medical errors and handling patient complaints. Authorizing experimental medical research.

3. Bahrain experience, so far The task is huge, and therefore there must be a strategy to assure unified process of monitoring. The main objective of NHRA is to improve the health system. Therefore, we should have a common understanding of what we need to improve. We will also illustrate the dilemma facing National Health Insurance and NHRA proposed solution.

4. Resources Facility; Manpower Financial Components of The Dynamic Health Systems We put a lot of resources into the health systems: Buildings, equipment, all categories of manpower: Physicians, nurses, technicians, admin. In addition, financial resources to assure sustainability. Is this sufficient to have a functioning Health System?

5. Resources Facility; Manpower Financial Processes Direction Strategy & Planning Management Monitoring & Evaluation + The Dynamic Health Systems’ Model How to use the resources: Strategy, plans and programs, management inclusive of monitoring and evaluation. Is this sufficient? Probably – but something is missing!!

6. Resources Facility; Manpower Financial Processes Direction Strategy & Planning Management Monitoring & Evaluation Outcome Quality, Efficiency Safety + = The Dynamic Health Systems’ Model The third component is the outcome of the system. It needs something extra to call it DYNAMIC

7. Resources Facility; Manpower Financial Processes Direction Strategy & Planning Management Monitoring & Evaluation Outcome Quality, Efficiency Safety + = The Dynamic Health Systems’ Model Analysis Continuous Analysis to Improve the outcome through modifying Resources or the Process.

8. NHRA “wider” view of the Health Systems Management Oversight Dept. Section Unit DirectorateDept. Department

9. Leading system Others compare with it Excellent System Compare with others Good System Decisions supported by evidence Weak System Operating but No evaluation! Unknown Status Facility, Staffing, PPG Outstanding Achievement Extensive Achievement Moderate Achievement Some achievement Low achievement Performance Appraisal of healthcare organizations* *Modified from ACHS

10. Input Resources : Facility; Manpower Financial Failing Process 1, Poor monitoring 2, Loss of control 3, Loss of direction 4, Crisis Management 5, Dissociated System Outcome Poor Quality, Wastage Higher Risk + = The Failing Health Systems’ – Phase I Analysis Applies to individual department or to the hospital as a whole.

11. Input Resources : Facility; Manpower Financial Process Individual-based practices No evaluation No direction No integration Outcome Wastage Ill-health Unsafe Practice Dissociated from the community The Failed System – Phase II ??

12. “This is what we hope to have” Community Primary Care System Secondary Care Tertiary Care

13. This is what we must avoid: “Dysfunctional” Health Systems Community Primary Care System Secondary Care Tertiary Care

14. Repairing a failed system Once a system becomes dysfunctional, it is extremely difficult and too costly to repair it. Patients’ and community confidence in the system may be damaged. The best solution is prevention of failure.

15. Health Insurance Reimbursement Dilemma Reimbursement is based on DRG- or DRG-Derived system. The problem? If reimbursement is based on equal payment to all facilities: It will kill future quality improvement, as high-expense facilities will cease investing in development. If based on variable payment based on actual costing studies of each facility: Health insurance companies will channel patients to low-cost facilities, thus again killing future quality improvement.

16. NHRA Contribution to the Insurance Dilemma Ranking of healthcare facilities based on a unified system of appraisal. Reimbursement is based on DRG, but with an approved scale based on the ranking. The system is binding, and enforced by a strong governance. Insurance companies may use the system as an add-on privileges to their subscribers.

17. Leading system Others compare with it Excellent System Compare with others Good System Decisions supported by evidence Weak System Operating but No evaluation! Unknown Status Facility, Staffing, PPG Outstanding Achievement Extensive Achievement Moderate Achievement Some achievement Low achievement NHRA interpretation of an Appraisal System (based on ACHS/ACHSI)

18. Leading System Others compare with it Excellent System Compare with others Good System Decisions supported by evidence Weak System: Operating but No evaluation! Passes Minimum Requirements Outstanding Facility Excellent Facility Good Facility Mediocre Licensed - passable NHRA Categorization of healthcare organizations