Universal Health Coverage in Gulf Cooperation Council (GCC) Countries: A Dream or a Nightmare?

Universal Health Coverage in Gulf Cooperation Council (GCC) Countries:  A Dream or a Nightmare?

Universal Health Coverage (UHC) is a key global goal, adopted by the World Health Organization (WHO), which means that all individuals are able to receive the healthcare that they require without enduring any financial hardship.  

There have been efforts in the six Gulf Cooperation Council (GCC) states – Saudi Arabia, Oman, Kuwait, Bahrain, United Arab Emirates (UAE), and Qatar – to achieve UHC for all their citizens and residents. The health sector in GCC countries has been undergoing a period of expansion and transformation, whereby healthcare reforms are meeting high demands of health services and a growing population. For example, in December 2021, The Expo 2020 Dubai hosted the WHO's celebration of the UHC Day, under the theme “Leave no one's health behind: invest in health systems for all”.

The GCC is well known globally for being a host of a high percentage of migrant groups (over 10% of all migrants globally), with Saudi Arabia and UAE respectively hosting the third and fifth largest migrant populations worldwide. Foreign nationals make up the majority of population in the six GCC countries, with an average of 70% (ranging from 56% to 93% in individual countries).

The abusive Kafala system is a form of modern day slavery, with no protection for workers in cases of abuse, trafficking, or unpaid wages. 

To what extent can GCC countries achieve UHC? What are the factors which influence UHC achievement for all the region’s residents?

Living Conditions Under the Kafala System

The Kafala, or ‘sponsorship’ is a system whereby a migrant worker’s visa, and legal status in the host country is tied to a sponsor or ‘Kafeel’. Upon the worker’s arrival to the GCC country, the Kafeel is fully responsible for his/her mobility, insurance, residency, medical tests and treatments. This makes the worker completely dependent on the Kafeel, and cannot transfer jobs or leave the country without the his/her consent.

The abusive Kafala system is a form of modern day slavery, with no protection for workers in cases of abuse, trafficking, or unpaid wages. Low-income female migrants in particular, face even more vulnerabilities. The majority of female migrants work as domestic workers in GCC countries, and are often isolated in their employer’s homes with their work unvalued.

Given the circumstances of the Kafala system, living conditions for migrant workers are dire in all GCC states. Domestic workers suffer from low salaries, long working hours and physical, verbal, sexual and psychological abuses in these countries. They are uncovered by labour laws since they are often considered a member of the Kafeel’s family. These workers are therefore unable to exercise their freedoms or complain through legal or protection systems. Moreover, most of the GCC states have no minimum wage policies in place, while others set a minimum wage as low as $ 200 per month. 

One study exploring the situation of Nepali domestic workers under the Kafala system in the GCC, mentioned that many harassment and rape incidents are reported among these workers. It is also predicted that these reports are an underestimation, as many workers are not able to report or may not know the legal way to report such incidents

Access to Healthcare

Health insurance schemes in the GCC countries are often granted by work employers, which are claimed to be available for everyone. Yet, legislations to provide everyone with complementary insurance schemes remain unfulfilled today. For example, insurance coverage for foreign employees in Bahrain and Kuwait remains un-determined and un-mandatory.

On the other hand, it is evident that all six GCC countries have different health insurance schemes for citizens and residents (non-nationals). For example, public hospitals in Kuwait serve only Kuwaiti nationals and GCC citizens. Saudi state-run health facilities are freely accessible by Saudi nationals only. Only Qatari nationals receive full subsidisation of healthcare, while foreigners residing in Qatar must purchase Hamad cards to access services.

New government insurance funding in Bahrain is intended to cover Bahraini citizens, GCC nationals and their domestic workers, without the mention of other domestic or migrant workers in the country. The UAE has insurance schemes for Dubai and Abu Dhabi only, and not in the remaining 5 emirates within the country. In both Dubai and Abu Dhabi, insurance plans depend on salaries (more basic plans for residents with lower salaries). Only UAE citizens are automatically insured, and enjoy a higher insurance coverage for healthcare services. Moreover, in the UAE, there is no requirement for employers to fund health coverage for their employees.

The Kafala system exacerbates migrant workers’ inability to access healthcare services. This can be directly, through lack of compulsory insurance schemes within the Kafala system, or indirectly through the extremely low wages, poor working conditions and absence of sick leaves. These in turn render migrant workers unable to access healthcare due to the lack of time and inability to pay for the often-uninsured services. Other barriers to accessing healthcare include language barriers, and lack of health awareness initiatives targeted for non-citizens.

The Kafala system also requires migrant workers to pass a pre-departure medical check-up, to assess for any infectious disease and avoid transmission to the host population. In addition to testing for pregnancy and psychiatric illness. These tests are only performed for certain nationalities and jobs (mainly those under the Kafala system). For example, a foreign worker from Europe or another Arab country does not undergo such tests. Yet, once migrant workers enter the country, their health is no longer a priority for GCC states.

What Next?

Evidence shows that despite GCC states’ efforts to achieve UHC, there remains large gaps in ensuring access to healthcare to the most vulnerable populations in the GCC; migrant workers. The Kafala system has been deeply rooted and widely applied in the six countries, leaving the majority of their residents in dire economic, social and health conditions. UHC can never be achieved where there is a Kafala system in place. GCC states should provide migrant workers with humane living and work conditions, and basic health insurance coverage at the least. Human rights organisations and advocacy groups must add pressure to protect migrant workers in the GCC and worldwide, in accessing their human right of living healthy and dignified lives.

To download the full report click HERE.


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