The health care sector in Dubai is undergoing a period of transformation and expansion, driven by reforms in health care funding coupled with a growth in population. Construction projects are taking place at existing hospitals and on new sites, in both the public and private sectors, while new, smarter electronic systems are being introduced to improve patient care and health care administration.
The rollout of universal health insurance began in October 2014 and is due to be completed by mid-2016, offering improved treatment options for many of Dubai’s expatriate workers while enabling the government to make fundamental changes to funding mechanisms and priorities.
Dubai’s state hospitals treat all emergency cases, and the government foots the bill regardless of the patient’s ability to pay. For example, at Rashid Hospital, a 599-bed acute infirmary and trauma centre, 70% of all admissions come through the emergency room. The hospital accident and emergency department admits 160,000 patients a year, equivalent to the top 10% busiest accident and emergency (A&E) facilities in the US, according to Dr Moin Fikree, clinical director of Rashid Hospital’s Trauma Centre. Rashid Hospital has 68 intensive care beds dedicated to surgical, neurosurgical, burns, coronary care and cases requiring chronic ventilation. It is the only one of Dubai Health Authority’s (DHA’s) four hospitals to treat more non-nationals than Emiratis. DHA figures for 2012 show Rashid Hospital’s A&E department treated almost 105,000 non-nationals compared to just under 50,000 nationals. The hospital dispensed 169,893 days worth of care to its patients in that year. Of the hospital’s consultants and specialist doctors, 56 are emergency, 40 medical and surgical intensive care, and 33 are trauma specialists. While the state will continue its commitment to free health care for Emiratis, and many white-collar expatriates already have private health care insurance as part of their employment contracts, the vast majority of non-nationals arriving at Rashid Hospital have been uninsured and have not had the means to pay for their treatment.
Dubai’s new Health Insurance Law is designed to address this issue and its implementation began in October 2014, with the first of three deadlines for employers to ensure their staff are covered by health insurance. The deadlines are staged to reflect the number of staff employed by businesses. Phase one applied to companies employing more than 1000 staff; phase two, from June 2015, covers companies employing between 200 and 1000 staff; and the final phase covering all remaining companies is due to be introduced by June 2016. The DHA says the first phase covered about 200 large firms, many of which already had insurance in place for senior staff, and thousands of companies would join the scheme from June 2015.
“It’s not only just about covering people for health; it’s about improving the quality of service in the emirate of Dubai and that’s why a lot of our regulatory tools focus on improving the quality of all the different players in the market,” Dr Haidar Saeed Habib Al Yousuf, DHA’s director of health funding, told OBG. “It is about improving health care in the emirate of Dubai, making the system financially sustainable and, from the point of view of outcomes, to be bench-marked with some of the top systems in the world.” The new health insurance law does not state that employers must provide for the dependents of their staff; instead, employees will be expected to fund cover for their family members themselves. The implementation of the new insurance system coincides with the introduction of a raft of electronic data collection and management services across DHA. This means that from early 2015, new visas and ID cards will contain data showing up-to-date information on the owners’ health insurance status. Medical staff will also be able to process insurance claims via an electronic filing system introduced in 2013.
Officials at DHA are hoping that by phasing in the new insurance scheme, they will avoid any sudden pressure on the health care system. When Abu Dhabi introduced universal health insurance in 2006, it saw an immediate 40% increase in visits to hospitals and clinics by people able to afford treatment for the first time. “There may be a hump in terms of new health care users, because there is a group of the population who did not have access to health care coverage and now they will have access,” Al Yousuf told OBG. “That is standard whenever you implement a new system, but we’ve got tools to monitor unnecessary utilisation in the health sector such as spending by groups per age group, and so all of these patterns and parameters are being monitored.” The DHA has also been working with insurance companies and with insurance brokers. A system of permits has been introduced by the DHA for insurance companies and third-party administrators (TPAs) wishing to cater to 70% of Dubai’s population who previously had no coverage. The DHA is also publishing price and premium regulations to ensure the market is well regulated.
As medical practitioners and administrators adapt to this insurance model, a former dental surgeon with a background in health insurance has spotted a gap in the newly evolving market. Accumed, founded by Dr Ayham Refaat, is now working with 65 health care providers across Dubai, offering out-sourced revenue cycle management. The company has drawn on its expertise in filing and processing of insurance claims on behalf of medical facilities and has developed an app that draws on claims data to help physicians select courses of treatment that have a high probability of resulting in a successful claim for reimbursement. The company claims to have reduced the time it takes to file a claim from between 30 and 60 days to 10 days and the time it takes for the hospital to receive its payment from as much as 180 days to 72 days on average, and 30 days with its top five insurance companies. Accumed, which is processing 100,000 claims a month, also says its typical initial rejection rate for claims is 7% and its final rejection rate is 4%, compared to a more typical rejection rate of between 10% and 25% for claims submitted by hospital administrators. “The governmental facilities have been providing services for free, or against cash fees, for years, and if I’m a doctor, I don’t have to worry who is going to pay in the current system,” Refaat, who is also Accumed’s managing director, told OBG. “When moving to an insurance-oriented system, what we have to do is shift the mentality of all clinical and administrative staff and make sure they think efficiently and start considering the coverage of the policy and the protocols of the insurance company.” Refaat believes the service his company offers will enable hospitals to outsource revenue cycle management and so speed up their cash flows, in much the same way as insurance companies outsource to TPAs. “I think we have started an industry, not just a company,” he added. “Outsourcing your claims is a no-brainer. I believe hospitals should outsource the non-core processes they have so they can concentrate on their core process, which is to provide quality health care.”
For Dr Muna AbdulRazzaq Tahlak, CEO of the 345-bed Latifa Hospital for women and children, adaptation to the insurance model will present a challenge for health workers and back office staff. However, she believes training can help to overcome some of the teething troubles. “I think one way of addressing the mind set in DHA is that we are probably a lot better than private in doing the necessary test, but not the unnecessary test,” Tahlak told OBG. “Sometimes people do ask for the most expensive treatment and I think some training in that area will be necessary, at least in following the guidelines.”
Once Dubai’s insurance-funded treatment system is fully operational from 2016, health care administrators providing services through the emirate’s four DHA hospitals, two UAE Ministry of Health hospitals, and dozens of primary health care centres and clinics will be able to decide how to prioritise their expenditure.
From the middle of 2015, DHA staff will be able to make decisions informed by data gathered electronically from all its facilities, which will enable them to publish a three-year series of accounts for 2012, 2013 and 2014. A comprehensive analysis for 2012 has already been published, but this relied on data captured through voluntary compliance with providers and insurance companies rather than on the new electronic system. That study showed that of the Dh10.5bn ($2.86bn) spent on health care in 2012, Dh8.5bn ($2.31bn) was spent in Dubai, while Dh1.5bn ($408.3m) was spent on health care outside the emirate. The government funded 32% of the expenditure, while 68% was paid for privately, which adheres to DHA’s strategic aim of a 30:70 public, private model. The private funding component was further sub-divided, with private companies and institutions funding 45% of the total and families and individuals paying 22% of health care fees out of pocket. The findings show that of the Dh10bn ($2.72bn), Dubai’s hospitals received Dh4.8bn ($1.31bn), its clinics and dispensaries took Dh2.2bn ($598.8m) and Dh1.2bn ($326.6m) was spent on pharmacies and diagnostic services in the emirate. A further Dh1.5bn ($408.3m) was spent outside the emirate. It showed 74% of the total was spent on curative care, while 20% was spent on medicines and medical equipment, and 6% on preventive services.
The data being accessed electronically for 2012, 2013 and 2014 will be drawn together, analysed and used as a benchmark to judge changes in the system as universal insurance is introduced. This will help DHA to plan changes in the services it offers, to reduce any overlaps in care provided by different sectors and to re-structure health care provision more efficiently so that primary care facilities can play a larger role. “This is a primarily secondary market with a lot of people used to going to see a specialist first, and not necessarily the right one, and so ‘doctor-hopping’,” Al Yousuf told OBG. “Through controls, and also through awareness-building, we are trying to establish the role of primary care as an efficient, sustainable and at the same time clinically efficient way of utilising the health care system.”
The plan is to develop a general practitioner gatekeeper model so that patients would typically see their family physician first, who would be able to select an appropriate consultant or specialist. An electronic referral system will be created to monitor pathways and referral behaviour. For the medical teams dealing with emergency cases at Rashid Hospital, such a system offers potential when it comes to discharging patients into secondary or primary care when treatment at an acute unit is no longer appropriate.
“Patients can access tertiary care directly, and they tend to do that and come back to tertiary care for further treatment,” Fikree, the clinical director of Rashid Hospital’s trauma centre, told OBG. “That loop is not completed between primary and tertiary care, and if you are in tertiary care, you tend to stay within that system.” The hospital says that one of the reasons for this fragmented approach is that separate medical records are kept at the primary and tertiary level, but doctors hope to see a new recordkeeping system introduced shortly that will bridge that gap and allow for greater access to records.
Although it may be more efficient to enhance interaction between the different tiers of health care provision, the introduction of universal insurance will also give patients greater choice when they are seeking treatment. If the insurance companies are prepared to pay for treatment, private hospitals and primary care centres could start to offer more competitive alternatives to care in DHA and Ministry of Health facilities. For the first time those treatments and services could become affordable for expatriates receiving employer-funded health insurance. One measure of this can be seen in maternity units. DHA figures for 2012 show that 58% of births in Dubai took place in private hospitals with the remaining 42% divided between Dubai Hospital and Latifa Hospital. Of the 11,715 births at the two hospitals in that year, 2878, or 25% of babies born, were from non-national families. The specialist facilities available at the DHA units may have helped Emirati families to choose them over private alternatives, particularly in instances where complications were anticipated, but treatment at the state’s expense may have been the only option for families without health insurance cover. “There are many private hospitals where babies are born; especially low risk pregnancies, they go to private hospitals,” Tahlak told OBG. “What we are proud of is that the public trust the government and DHA hospitals, and we do have the resources and expertise to take care of the high-risk cases, and so actually we don’t mind women with low-risk cases delivering elsewhere. It’s the difficult cases we want to be able to help with.”
When it comes to planning for changes in health care provision, or for that matter making comparisons with other health care systems in the world, Dubai’s unique demographic composition presents its own peculiar difficulties. In its 2010 census, Dubai recorded a total of 168,029 nationals living in the emirate. Since then the DHA has published figures showing the natural increase in the national population, based on numbers of births and deaths, and this suggests annual growth in the Emirati population of 8230, 8339 and 8170 in 2011, 2012 and 2013, respectively. Although this does not take into account other factors such as migration by the national population, it suggests a figure of 192,768 nationals living in the emirate.
The official population of Dubai published in mid-2014 was 2.27m and based on those two numbers, nationals would constitute 8.5% of the total. The majority of the emirate’s residents are expatriate workers aged between 20 and 60, many of them male employees staying in Dubai without family, and by definition fit enough to work. The result is that 76% of Dubai’s population is male, and men in Dubai benefitted from 53% of health care expenditure. In contrast to this, children under five and people over 65 together constituted just 6% of the 2012 population, but accounted for 18% of health care spending. The contrast between use of health care by nationals and by non-nationals is even starker when statistics on outpatient visits are considered.
Of the 1.47m visits made to outpatient departments in 2012, 1.14m were made by nationals, according to DHA figures. Therefore, nationals, who together represent 8.7% of the population, made 78% of visits to outpatient clinics. The challenge for health care administrators is to assess whether this high utilisation of facilities results from nationals’ ability to afford treatment, or is a factor of the broader age range represented. If affordability is a dominant factor, it would suggest a high degree of dormant demand for treatment among the expatriate population, which could expose hospitals to a surge in patient numbers.
Refaat told OBG that universal insurance would lead to a change in patient behaviour. “Currently if you have a staff member with flu, he will go to the supermarket, get some flu treatment and get some sleep, but now he has insurance he will take one or two hours off work, go to a doctor for some medicine, who by default will give him 24 hours sick leave. We will initially see a hike in utilisation but it should stabilise afterwards,” said Refaat.
Although expatriate workers come to Dubai to work, those who have grown up in countries with poor levels of inoculation and high incidence of infectious diseases can be more susceptible to serious illness than the Emirati population.
Doctors & Nurses
DHA records for 2012, the most recent available, showed that there were 5618 registered physicians in Dubai, which translated to a ratio of 2.7 physicians per 1000 population. The rate for DHA physicians was 0.5 per 1000, while in the private sector there were 1.7 per 1000 people.
Consultants and specialists constituted 78.9% of physicians in Dubai. The rate of dentists was 0.7 per 1000 people, and there were 5.5 nurses per 1000. According to WHO comparisons, these ratios are above the regional average.
However, significant numbers of Emiratis seek treatment abroad. DHA figures released in January 2014 suggested that in 2012, a total of Dh1.5bn ($408.3m) was spent on treatment outside Dubai. While the majority of these treatments were privately funded, DHA paid for Dh338.2m ($92.1m) for overseas care for 1819 patients. Germany treated 35.5% of cases, Thailand 31% and the UK 11.9%. Oncology treatments were sought by more than one in five of the total number of patients, or 20.6%, while 12.9% saw orthopaedic surgeons, 12.6% saw neurosurgeons and 5.1% had heart surgery. According to Shoaib Khoory, managing director of Mir Hashem Khoory Group, expats also tend to travel home for treatment. “Implementation of mandatory employer-based health care insurance is expected to help reverse the trend of expats flying to their home countries seeking medical treatment. This expected reversal has prompted a flurry of investment by both new and existing health care operators,” Khoory told OBG.
Efforts to provide more of these services are being made by DHA hospitals and the UAE Ministry of Health. The latter runs two hospitals in Dubai, the Al Baraha Hospital and Al Amal psychiatric hospital, a 270-bed infirmary rebuilt at a cost of Dh419m ($114.1m) in 2014. Both public and private providers are also anticipating increased numbers of patients as Dubai’s population is forecast to grow in anticipation of Expo 2020. Another factor driving development of new facilities is the growth of new population centres. The newest of DHA’s hospitals is in Hatta. The 123-bed centre is almost 150 km from Dubai and serves the south-eastern portion of the emirate. The authority’s three biggest hospitals, Latifa, Rashid and Dubai, are situated within 10 km of each other. All three facilities are due to open new, or expanded, facilities in 2015.
A new Dh692m ($188.4m), 200-bed paediatric facility, Al Jalila Specialist Children’s Hospital, is also due to open on a 100,000-sq-metre campus adjacent to Latifa Hospital in 2015. Al Jalila will have 40 intensive care units, six dialysis units, eight operating theatres, a 40-bed emergency unit and 40 outpatient clinics among its facilities. This will allow Latifa Hospital, which has catered to both women and children, to sharpen its focus and the aim is that the two centres will complement each other. “We have around 6000 deliveries per year and so most of the wards are for women,” Tahlak told OBG. “Three wards are currently for paediatric, and each have 30 beds, and so we are talking about 90 paediatric beds and the rest are women, excluding our neo-natal intensive care unit, which has 43 beds.”
Latifa Hospital is also expanding its delivery suite and emergency area. In terms of specialised services, Latifa has seen demand for its minimally invasive surgery services increase dramatically. “We have gone from 50 or 60 cases five years ago to 300 cases per year now,” explained Tahlak. “We have developed and invested in the staff and more and more of them are trained to do these surgeries, and we have advanced our operating theatres with the latest hybrid integrated laparoscopic operating rooms. We have developed the team of nurses and physicians that work together for this sub-speciality, and so the process is very clear and efficient and patients are being discharged next day.”
Dubai Hospital provides a full range of general hospital services and has three specialist centres providing heart, kidney and cancer surgery and care facilities. The hospital’s dialysis centre has 50 beds, with plans to add 40 more in 2015, as well as to develop the emirate’s first renal transplant centre.
The hospital’s cancer centre sees 70 new paediatric cases and 500 adult cases a year. In 2015 Dubai Hospital plans to open its first bone marrow transplant centre, a treatment that has only been available abroad until now.
“Hospitals in the UAE have not had sufficient access to these services in the past, putting a great deal of stress on our limited resources,” Dubai Hospital’s CEO, Dr Abdulrahman Mohammad Al Jassmi, told OBG. “All these cases were sent abroad at great expense. For example, the DHA used to send cancer cases abroad, and around Dh250m ($68.1m) was spent on this treatment per year. This is not only a financial burden but also has a social toll on the families who have to travel abroad with a sick relative.” Construction work is under way on a two-year project to expand the trauma centre at Rashid Hospital, adding 160 beds and 116 treatment rooms.
However, this is just the first stage of a Dh3bn ($816.6m) master plan for Rashid Hospital, which will feature six new specialist health centres in three seven-storey towers, each accommodating 300 patients, and the development of a campus to include a five-star and a four-star hotel on either side of a 500-bed rehabilitation centre. The blueprint for these plans was announced in May 2013 as part of the Dubai Health Strategy 2013-25. Also included in the plan are three new hospitals designed to serve growing communities in Dubai and to ensure that by 2025 there is a hospital within 8-12 km of every catchment area.
The three new planned hospitals are Sheikh Mohammad Bin Rashid Hospital on Sheikh Mohammad Bin Zayed Road near Arabian Ranches, Al Maktoum Hospital in Jebel Ali and Al Khawaneej Hospital. In addition, 40 new health care centres will also be built across the emirate as part of the plan.
There are six large hospitals in the private sector in Dubai. DHA figures show the Canadian Specialist Hospital has 200 beds, the American Hospital has 187, the Saudi German Hospital has 300, and the Iranian Hospital has 120. Mediclinic runs two hospitals, the 130-bed Welcare and Mediclinic City Hospital, which has 235 beds. Indian health care provider Medanta announced it will be opening its first UAE hospital in 2017, a 250-bed hospital in Dubai Healthcare City (DHCC).
At the start of 2014 there were 16 other private hospitals in Dubai providing 608 in-patient beds among them, or 38 beds on average. In July 2014, NMC Healthcare opened a new 60-bed multi-speciality hospital in Dubai Investment Park in order to serve the new communities of Arabian Ranches, Jumeirah Lake Towers, Al Barsha and Jebel Ali Village. NMC, which is listed on the London Stock Exchange, operates hospitals, day surgery centres, clinics and pharmacies in the UAE and also has a distribution arm for pharmaceutical, scientific, food and education products. Its NMC Speciality Hospital has 73 beds. Mediclinic City Hospital, which is in DHCC, is constructing a new building to provide oncology services. “We are busy building a new centre including a linear accelerator and PET scan and so it’s going to be a fully fledged oncology centre, going from diagnostics to therapeutic, to medical and radiotherapy as well,” Dr Tarek Fathey, hospital director of Mediclinic City Hospital and COO of Mediclinic Middle East, told OBG. “In the past people said cancer or heart disease affected the old age group, but now with lifestyle and food habits, we see a lot of cancer and cardiac patients at a very, very young age.”
Although the number of private facilities is increasing rapidly, private sector offerings for local health care in Dubai continue to lack a more affordable segment, with most investment currently being channelled into higher-end facilities.
In the UAE as a whole, World Health Organisation figures show non-communicable diseases (NCDs) account for 65% of total deaths and that the probability of dying from the four main NCDs – cancer, cardiovascular disease, diabetes and chronic respiratory diseases – is 19% for people aged 30 to 70. Adult risk factors include high blood pressure, which affected 21.1% of males and 13.3% of females in 2008, and obesity, which in the same year affected 30% of UAE males and 39.9% of UAE females.
“I think obesity is our number-one challenge,” Tahlak told OBG. “We do tend to see a lot of obese women and children, which gets reflected in their health, for example women with polycystic ovary syndrome. We are seeing more and more young girls with this condition, and obesity is one of the hallmarks of this disorder. There are also children with a high body mass index (BMI), and I see that as a culprit for everything else. Women getting diabetes during pregnancy, it is all falling back to high BMIs, unhealthy lifestyle and lack of exercise. People have a very sedentary lifestyle here.”
While hospitals may treat the symptoms of this disorder, the responsibility for promoting healthier lifestyles including nutrition, exercise and lifestyle rests with the primary health sector. Figures released by the DHA in January 2014 showed that 6% of the Dh10bn ($2.72bn) spent on health care for the people of Dubai was devoted to preventive medicine.
The introduction of mandatory health insurance promises to create firmer financial foundations for health care provision as Dubai braces itself for further population growth in the next 10 years. The DHA has chosen to phase in the introduction to smooth out the impact of any demand-side pressure triggered by residents who will find themselves with the means to access affordable care for the first time. In the meantime, short- and medium-term construction projects demonstrate the emirate’s desire to cater to a larger population and to provide all of its residents with standards of care benchmarked against some of the best systems in the world. It may be some way from this goal, but plans are in place, and in the case of mandatory insurance, those in authority have demonstrated a willingness to grasp the nettle of reform in order to make progress.