Reflections on Differences in Health Care Between a Kingdom and a Democracy

February 01, 2024

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

A hospital is often seen as a sanctuary—a bubble of refuge for local and migrant populations alike. However, in order for a hospital to provide care, it needs to rely on a health care system that governs daily operational functions and establishes rules and regulations to care. As an Egyptian-American licensed physician assistant (PA) in the United States currently conducting a clinical trial and an educational research curriculum in Bahrain, I have had a chance to reflect on the major differences, successes, and downfalls of these vastly different health care systems.

Bahrain is a small island located off Saudi Arabia in the Middle East on the coast of the Persian Gulf. Whereas the U.S. is approximately 9,833,520 km2, Bahrain is a mere 765 km2—a very tiny island in comparison. The government structure of Bahrain is also vastly different than that of the U.S. The Kingdom of Bahrain is a constitutional monarchy, meaning the king is the executive head of government, while the U.S. is a democracy. Generally, the mean income for Bahrainis is approximately $27,180 in comparison to the American mean income of $76,370. However, the cost of living in Bahrain is only 47% of what it is in the U.S. Compared to the U.S., Bahrain spends 84% less on health care per capita.

A difference you can see and smell

As I walked through King Hamad Hospital in Muharraq, Bahrain, I was instantly intrigued by the apparent differences in the design and resources of the hospital in comparison to hospitals in the U.S. The hospital atrium is dimly lit with neon pink and green lights. It has large glass windows with a nearby corridor leading to the “lifts” to take you up to one of five floors. Instantly, when you walk in, the sweet aroma of perfume hits your nose—most providers and patients alike wear perfume, or “otoor.” In the U.S., potent smells are discouraged in health care settings due to allergies or the potential to cause disease flares. Although these differences do not contribute substantially to the community’s overall health, they are still considerable contrasts to the West. 

(Dis)continuity of care

In Bahrain, patients and providers are friendly to each other but with a slight power dynamic. Patients eagerly but patiently await providers, and providers make the medical decisions for the patient that the patient is typically expected to follow. If patients are dissatisfied with their diagnosis or treatment, it is common for them to visit multiple providers until they feel that they have received adequate care. In the Bahraini health care system, patients don’t need primary care referrals to specialties—they are able to walk in at their convenience to receive testing or imaging without prior approval. In the U.S., this is often impossible or prohibitively expensive. Patients are generally limited to tests and imaging ordered by providers and, due to the primary care shortage, often have limited access to alternative providers. 

Reflecting on these differences, there are certainly several advantages and disadvantages to each. Bahraini patients have true autonomy and freedom to pursue what they think is most relevant to their health. They are empowered indirectly by the ability to switch providers at their convenience, receiving the care they believe they deserve and need. The disadvantage to this system is that, undeniably, many of the tests the patients may think they need—such as X-rays, labs, and imaging—may not be medically indicated. Obtaining unnecessary testing contributes to excessive radiation exposure, complications, and inefficient usage of health care dinars (Bahrain’s principal currency). Additionally, continuity of care is a struggle in Bahrain. As patients continue to switch providers and receive care at different hospitals, it is very difficult to assess the deterioration of their conditions and the effectiveness of their prescribed medications. This is a disadvantage that can be countered through building better rapport with patients and listening to their concerns and feelings regarding their conditions. This is why, in the U.S., provider decision-making is moving toward a collaborative “patient-centered” approach where the provider recommends options for treatment and works together with their patients to see what best fits their lifestyles and meet patients’ goals for their health. A common critique of this patient-centered model of care is the fact that many patients don’t feel well-equipped with medical knowledge to know what to choose or what to do, and some prefer the provider who definitively recommends what they personally think is best. 

Taking time to build trust

Depending on the specialty, the average provider-patient encounter in Bahrain can last up to 20 minutes from my experience at an outpatient clinic in King Hamad University Hospital, which is substantially more time than the average 18-minute encounter practiced in the U.S. More time allows for more accurate patient diagnoses and a chance for better communication and an intimate provider-patient relationship.

The patient demographics in the hospitals are quite different as well. The Bahraini population is around 52.6% expats or migrants from other nearby Gulf countries, India, Bangladesh, and the Philippines. Despite this, in my experience Bahraini hospitals don’t have structured translation services, instead relying on bi- or tri-lingual medical students and nurses to communicate with patients. If the patient’s language is not understood by any of the available providers, a game of charades ensues. While in Bahrain, I was often reminded of an experience during my clinical training in New York. I was passing through the emergency room and encountered a woman screaming in agony surrounded by four providers all trying to understand what she was saying. They had a translational iPad available, but the woman was in too much pain for interpreters to adequately understand her speech amidst her screams. Thankfully, I knew enough Arabic to translate to the caring providers that she was having a burning reaction to intravenous contrast. I kept replaying that instance in my mind. If I wasn’t coincidentally passing by the emergency department for a consult, what would have happened to that patient? Similarly, in Bahrain, without proper translational services provided to patients, there may be pertinent medical history information missed or unreported resulting in incomplete or mistaken diagnoses. 

Balancing Ethical Responsibilities in a Capitalistic Society  

I cannot help but wonder whether these differences are largely due to the universal vs. capitalistic health care systems adopted by both countries respectively. In Bahrain, health care at governmental facilities is essentially free, with some caveats. Non-Bahrainis and expats have to pay a small fee for seeing providers. When health care is free, it is common for patients to wait several weeks or months for standard testing, surgeries, and overall care. 

Privatized clinics and hospitals in both Bahrain and the U.S. often charge a fee for their testing and elective procedures. They also offer expedited care, which is a priority for many patients.

The majority of patients in Bahrain can afford health care and routinely obtain testing and medications. In the capitalistic system of the U.S., about half of U.S. adults report that they are unable to afford health care. It is common for uninsured and underinsured patients to avoid hospitals and care until their illness or condition becomes life-threatening. In fact, a 2015 study aimed at assessing why people in the U.S. avoid medical care found that approximately one-fourth of participants specifically emphasized high costs. This trend worsened during the COVID pandemic, especially among uninsured adults, 60% of whom postponed or skipped health care in 2022 due to cost. This is all despite the fact that the U.S. spends the most money out of all other nations on health care. At the height of the COVID-19 global pandemic in 2020, the average health care spending per person in the U.S. was $11,945. In 2022, it was estimated to be $12,530 per person annually. This is a 4.89% increase in health care spending from 2020 to 2022, and it continues to rise. Other high-income countries spend about half of that amount per person on health care with similar or better health care results. Bahrain spends around $1,110 per person annually on health care. Despite these differences in spending, some issues are common. Both countries struggle with providing efficient patient care, alleviating provider burnout, addressing the needs of multilingual patients, and adequately allocating health care resources. 

How do we reach a balance in a capitalistic society with a just intent on healing, reducing disparities, and providing robust patient-provider relationships to overcome clinical hardships? I urge every patient to reflect on the ways they can best utilize their providers and to clearly and honestly communicate their needs and pain. I urge every health care professional to reflect on the ways, big or small, that they can contribute to bettering patient care and establishing patient trust once more—a step toward fixing our incomplete and broken system. 



About the author

Maria Marcos' HeadshotMaria Morcos is a certified Physician Assistant and Researcher in Rochester, New York. She has completed a Fulbright fellowship in Bahrain to help conduct an asthma clinical trial and an educational program for women with polycystic ovarian syndrome. In her free time, she loves to volunteer with her community and organizations such as Food for Life, domestic abuse centers, and mental health initiatives. She hopes to pursue a lifestyle and career always addressing the social determinants of health, as well as helping rural, refugee, immigrant, and underrepresented groups through medicine.


**Feature photo obtained with a standard license on Shutterstock. 

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