With more physicians per head than the UK and a lower mortality rate for children under five than the US, Dubai can boast of a world-class health care system by some measures. However, in the face of rapid population growth and the quest for a more comprehensive offering of clinical specialities, much is left to be done in Dubai’s health care system. As of the first quarter of 2015, health officials said 18 private hospitals were under construction, and it has been predicted that if the pace of growth in the commercial health sector is maintained, an additional 1500 beds will be required by 2020. In September 2016 Dubai will welcome its first co-educational cohort of students to a new university medical college. The year will also mark the final stage of the introduction of the emirate’s mandatory health insurance scheme.

NEW STRATEGY: In an effort to align Dubai’s health sector with the national UAE Vision 2021, feedback was gathered from private and public sector health partners, local authorities and 11,000 Dubai Health Authority (DHA) staff. The result was the Dubai Healthcare Strategy 2016-21. The plan encompasses some 93 initiatives which fall under 15 programmes, each of which comprises three milestone horizons: immediate, medium and long term. Two main focuses of the plan are the improvement of primary and urgent care, and preventive medicine. The improvements to urgent care are aimed at freeing emergency rooms in hospitals from handling non-emergency cases. It is hoped this will enable them to optimise services to address actual emergencies. Meanwhile, prevention and lifestyle medicines are also being focused on via initiatives aimed at educating the public. It is hoped that these efforts will reduce the burden of non-communicable “lifestyle” diseases.

GLOBAL COMPARISONS: The most recent set of comprehensive health sector data published by DHA covers 2014. The report includes comparisons with Germany, the US, the UK, Abu Dhabi and other GCC countries. It shows that Dubai’s under-five mortality rate was seven per 1000 live births, compared to eight in the US, Qatar and Abu Dhabi, five in the UK and four in Germany. The infant mortality rate was 6.3 per 1000 live births in Dubai, compared to six in the US and Qatar, four in the UK and three in Germany. By both measures Dubai fared better than Oman, Saudi Arabia, Bahrain and Kuwait. Life expectancy for men and women in Dubai was 76 and 77.4, respectively, which was higher than Saudi Arabia and Oman, but below other GCC states, with Qatari men and women likely to live to 83. There were 29.9 physicians per 10,000 people in Dubai, lower than Germany’s 36.9, but higher than any of its GCC neighbours and ahead of the UK (27.7) and the US (24.2). Dubai had 6559 registered physicians in 2013, a 58.5% increase on 2008. However, 79.7% of all doctors in Dubai were consultants or specialists. In 2014 there were 59.7 nurses per 10,000 people in Dubai, below Qatar on 73.7, but a higher figure than any other GCC country. However, the emirate still has some way to go to match Germany with 113.8 nurses per 10,000 people, the US with 98.2 and the UK at 94.7. Abu Dhabi, Saudi Arabia and Kuwait all have more beds per 1000 people, with 2.3, 2.2 and 2, respectively, compared to Dubai’s 1.8. The data shows that the UK and US each have three beds per 1000 people, while Germany once again leads with 8.2 beds.

DEMOGRAPHIC CHALLENGES: For some demographic segments, Dubai’s residents experience health outcomes similar to European nations. However, the challenges faced by developed Western countries, with well-established public health systems, are very different from those in Dubai. The high number of young expatriate men working in Dubai’s construction industry and other manual occupations is just one factor that creates a unique demographic profile in the emirate and so generates complex challenges when managing health care provision. What is more, in a city where the majority of the population are workers on temporary visas, the demographic distribution can change quite rapidly. For instance, in its report in 2013, DHA reported that 24.1% of Dubai’s 2.16m population was female, which suggested a female population of 520,256, and yet by the end of 2014, Dubai Statistics Centre was reporting that the proportion had risen to 30.7%, an increase of 193,919 female residents in the space of a year.

AGE FACTORS: Another feature of an economy relying on such a high proportion of working-age males on short-term visas is that the demographic profile will not evolve over time in the same way as it would in a society with a more conventional demographic structure. This is particularly striking when the 25-49 age bracket in Dubai is compared to that in EU countries. Official data published by Eurostat shows that people in that age group constitute 34.7% of the average population in the 28 member states, 33.6% in Germany and 33.9% in the UK. In Dubai there were 1,559,401 people in this age group in 2014, according to DHA data, or 72.2% of the total population. A very small proportion of those relatively young expatriate men will retire in Dubai, as they would in most other economies. Instead, they will return home when their visas expire and be replaced by a new group of young men. When the 2014 data on age and nationality of those who died in Dubai is considered, it can be seen that expatriate males accounted for 78% of all deaths of people aged 25 to 55 in the emirate, while national citizens represented 38% of deaths among people aged 75 to 79. As a result, any planning for future geriatric medical care must focus on a segment of the population where a higher proportion of patients are Emirati. Overall, it is estimated that approximately 12% of Dubai’s population are national citizens.

However, the biggest demographic challenge for the health care sector, and the most significant opportunity for private providers, is population growth. The 2014 “Healthcare Market Review” report, published by global real estate services firm Colliers International, predicted the population of Dubai would reach 3.48m by 2020, noting that it grew from 1.3m in 2005 to 2.2m in 2013 at a compound annual growth rate (CAGR) of 7%. The Colliers report also points out that the population could rise to as much as 3.8m by 2020 as more workers are needed for the construction and staffing of Expo 2020 and associated hotels, but notes that while the CAGR was 13.3% for the four years before the financial crash, it fell to 5.1% for 2010-13. Indeed, the population declined from 2.17m in 2009 to 1.91m in 2010, an exceptional year in Dubai’s history, when many expatriate workers who lost their jobs and visas returned to their home countries.

PATIENT NUMBERS: To keep pace with population growth and its ambition to become a centre for medical tourism, the emirate needs to build new hospitals, or at the very least, additional wards. As of early 2016 there were 26 private hospitals in Dubai, plus four DHA infirmaries and two run by the federal Ministry of Health. Some 18 new private hospitals were due to be built in Dubai to meet demand in the near future.

The target in Dubai’s health strategy is to reach a point where 70% of care is provided by the private sector. According to DHA data, there were 148,239 inpatients in 2014, up 4.7% over 2013. Hospitals across all sectors dealt with 5.9m outpatient cases in 2014, a decline of 3.6% from the previous year. National citizens accounted for 14% of all outpatient visits, with female nationals accounting for 86% of national attendees. At DHA facilities, the highest proportion of patients were female and male Emirati patients, at 46% and 31%, respectively, while expatriate men and women represented 12% and 11% of patients, respectively.

NEW BEDS: The DHA’s 2014 report showed that, although three new private hospitals had been opened and seven expanded, the sum total of beds provided by the private sector’s 25 hospitals was 1707 by the end of the year, or 68 beds per hospital on average. DHA has four hospitals of its own: Rashid, Dubai, Latifa and Hatta, which have 1372 beds between them. In addition, Al Amal and Al Baraha hospitals, which are federal facilities, together have 470 beds, bringing the number of beds in the public sector to 1844, or 52% of the total. However, it is problematic to use the number of beds per 1000 people to compare Dubai to places with more conventional population profiles. With working-age men between 20 and 50 constituting 63.3% of the population, Dubai’s demand for inpatient beds is likely to reflect a distortion towards this demographic profile, caused by such an influx of mostly male migrant workers. In the private sector, just under half of all inpatients (46.4%) were aged 25-45. In addition, 57.3% of all inpatients in private hospitals were female.

The impact of migrant workers on health services in Dubai is further emphasised by the number of medical fitness tests carried out by DHA facilities in 2013. These tests must be passed by anyone applying for a residence or work visa, and in 2013, 1.7m people took these tests, equivalent to 80% of the population. In the first half of 2015, 1.03m people took medical tests, with 421,618 applying for new visas and the remainder renewing their paperwork. The DHA report found the typical bed occupancy rate in its hospitals was 75.7%, while in private hospitals it was 56.1%. The report said the optimal bed occupancy rate for a hospital was 75%.

INSURANCE REFORMS: Another key factor that has affected efforts to gauge health service needs based on the age, nationality and gender profile of Dubai’s population has been access to health insurance. Effective June 30, 2016, health insurance has become compulsory for all expatriate employees, although DHA has extended the grace period until the end of 2016. In 2016 almost 83% of population of Dubai were expatriates. In the public sector, the Government of Dubai Employee Healthcare Benefits Scheme (ENAYA) covers government employees and their families – a total of 90,000 beneficiaries. A Dubai health care survey conducted in 2009 found that 13% of all expatriates and 48% of nationals were covered by ENAYA, and in addition 14% of expatriates and 47% of nationals were covered by private health insurance.

Under the new mandatory insurance regulations, companies with more than 1000 employees are required to ensure their workers had medical cover from October 2014, and those employing over 100 staff members had to begin providing cover as of July 2015. The gradual introduction of medical insurance for all workers has prevented a sudden spike in demand for treatment, similar to that which followed overnight introduction of compulsory health insurance in other Gulf countries. From the second half of 2016, all potential employees will have to demonstrate they are insured, as well as fit to work, in order to receive a visa.

SAFETY NET: For the first time there will be insurance for even the lowest-paid workers, and this has been a top priority for DHA. It is designed to balance both the cost to the economy and the health security of individuals. The cost of insurance is on average only 1.5% of an employee’s monthly salary, so if a company pays their employees Dh10,000 ($2722) per month, the additional expense will be only Dh150 ($40.83) per employee per month.

Insurance industry experts expect to see changes in consumer behaviour as residents adjust to a new system, and the variety of products on offer expands beyond basic cover. “After phase three of the compulsory insurance project has bedded in, and an insurance culture develops where claiming on insured benefits becomes more prevalent, we expect that policyholders will be able to see that the cheapest cover may not be the most efficient or the best choice,” Elie Tohme, general manager of GlobeMed Gulf Healthcare Solutions, told OBG. “Historically, there has been a tendency for policyholders to shop for the lowest premiums rather than the best cover to meet their needs.”

CLAIM CULTURE: The introduction of a more insurance-driven model of health care is expected to have an impact on the paperwork physicians and hospitals will have to complete, which could prove onerous particularly for smaller clinics. In addition, doctors will have to take into account the likelihood of receiving reimbursement from insurance companies when deciding on the type or frequency of treatment being recommended for their patients. “The implementation of health insurance is a key step that may lead to a more mature market, but there has to be a balance between insurance coverage and costs,” Mariano Gonzalez, managing director of Moorfields Eye Hospital Dubai, told OBG. “The cost-to-quality ratio will depend on the clinical models adopted and whether they are aligned with the health care needs of individual patients to take into account, plan and deliver the quality of services tailored to the population we serve.”

To smooth the process of transition, training courses are being run for medical professionals and hospital administration staff. “There may also have been a tendency in the past to for some providers to oversubscribe medications, or for overuse of tests and scans, but DHA is working very hard to educate market participants and to improve standards across the health insurance industry,” Tohme told OBG.

Hospitals hope a smooth adoption of insurance will be beneficial for health care in Dubai. “Compulsory health insurance has been really important in order to drive sustainability,” Mohaymen Abdelghany, CEO of Al Zahra Hospital, told OBG. “It is all about working in collaboration with providers and regulators to find the perfect formula in terms of payment and reimbursement of the services.”

MEDICAL EXPERTISE: As hospitals in both the public and private sector work to determine that formula, they are also faced with a number of challenges, not least of which is the recruitment and retention of top-quality staff. Al Zahra Hospital has ambitious plans including the completion of an oncology centre, expansion from 100 to 200 beds by 2017 and the establishment of a groundbreaking “gamma knife” brain surgery centre. However, the hospital’s CEO finds himself facing human resource challenges that are common across the region. “There is intense competition among the different health care providers, with the number of hospitals growing, and the problem is they all go back to the same pool of candidates,” Abdelghany said. “The rising demand and limited supply is creating inflation in salaries, which further drives costs up.”

TECHNOLOGY: Funding new technology and keeping up with the latest developments presents challenges for hospitals, and there are also human resource implications when it comes to adopting new equipment or processes. “Our GCC clients are often eager to acquire products that have the best and latest technology, but the challenge for them is often in finding people with the knowledge and skill set to operate the equipment,” Akram Azmy, managing director of Beckman Coulter International, a medical equipment supplier, told OBG.

Hospitals in Dubai are keen to adapt smart technologies that could enable more efficient sharing of patient notes, imagery and remote diagnostics. However, there are also ethical and patient confidentiality considerations. Agfa Healthcare Solutions Middle East has a contract to manage imaging service for 36 DHA centres and operates a system that enables doctors to access imagery from scans remotely. The company sees the potential for more efficient dissemination of medical records, but acknowledges that the issue of security must first be addressed. “There is enough infrastructure and technology within the health authority to make the information available, but decisions still have to be made about what can be disclosed and to whom,” Antonio Varela, regional business manager at Agfa Healthcare Solutions Middle East, told OBG.

Information collected on patients can also be a hugely valuable resource as researchers use data mining techniques as an epidemiological tool. “We are seeing a new generation of doctors and I believe it is important for us to develop a knowledge of health informatics in our professionals so that a cardiologist, for instance, knows how to make best use of the data that’s available,” Mohammad Abdulqader Al Redha, director of health data and information analysis at DHA, told OBG.

DUBAI HEALTHCARE CITY: To attract leading physicians, as well as companies specialising in health and life sciences, a free zone was created in Dubai in 2002. Dubai Healthcare City (DHCC) has a phase-one, 380,000-sq-metre campus in the Oud Metha area of the emirate, where more than 300 clinical and non-clinical partners occupy 94% of units in DHCC’s main buildings. DHCC is governed by an independent regulatory body – Dubai Healthcare City Authority-Regulation (DHCR) – which has licensed more than 5400 health care professionals.

In 2015 DHCR increased the number of licensed health care professionals by 20%, bringing the total number from 4534 in 2014 to 5400 in 2015. It also increased specialties by 68% from 90 in 2014 to 152 in 2015. DHCC’s licensing framework covers 63 countries, and from 2015 its regulators introduced new health insurance rules for people using its facilities. Clinical offerings were increased from 124 in 2014 to 159 in December 2015. The free zone’s clinical facilities comprise JCI-accredited hospitals, outpatient medical centres and diagnostic laboratories. DHCC welcomed new support services,reaching a total of 192 non-clinical facilities up from 190 in 2014. “Patients are becoming increasingly aware and involved in their health; they want more control and faster treatment. This approach is possible today due to the significant advancement in health IT,” Arjen Radder, CEO of Philips Middle East and Turkey, told OBG. “One example of innovation is dedicated diagnostic centres. This will ensure accurate first time analysis along with comprehensive treatment options that take patients out of the hospital faster.”

Phase two of DHCC was launched in 2015, and the first hospital to be established there was announced in March 2016. This phase constitutes a 2.04m-sq-metre site at Al Jadaf, overlooking the historic Dubai Creek, and the focus is on wellness, with rehabilitation centres complimented by residential components providing rest, recuperation and recreation services. DHCC is talking to a number of investors interested in building hotels, health and rehabilitation centres in its expansion. “Wellness is about providing holistic services for the human being from cradle to grave,” Ramadan Alblooshi, CEO of DHCR, told OBG. “The [ wellness] approach will be about the entire lifestyle. For instance, there are several complications that can arise from diabetes, and there will be facilities where people can learn to manage their complications. There will also be evidence-based wellness services where people can come for treatments.”

FITNESS: As part of encouraging wellness, there is also a growing emphasis on fitness. “One of the main strategic goals of Dubai is to consolidate sports as a way of life,” Ibrahim Abdul Malik, secretary-general of the General Authority of Youth and Sports Welfare, told OBG. “Currently, the percentage of people who exercise regularly does not exceed 16% of the population. Our aim is to increase this figure to 25%. Moreover, another goal at a professional level is to achieve 20 medals at the 2020 Olympics by targeting eight different sports with high potential.”

Beyond the DHCC free zone, some multinational firms believe Dubai could do more to incentivise international pharmaceutical and medical device firms to base their activities in the emirate. “Dubai has done a great job in inviting multinational pharmaceutical companies to establish regional offices, but they could do more to encourage those companies to build warehouses and establish distribution hubs, and then introduce incentives to bring manufacturing here as Singapore has done,” Abboud Bejjani, regional vice-president of US bio-pharmaceutical company AbbVie, told OBG.

Pricing, however, remains a particular sticking point in the pharmaceuticals segment. “Pricing is a risk in the shadow. It is a worldwide phenomenon, and it is going to get tougher and tougher. Emerging markets have huge populations but no money, so the pharmaceuticals sector is heavily influenced by regional public policies that often differ from one GCC country to another,” Ahdy ElSayes, former managing director for the Middle East at Takeda, a Japanese pharmaceuticals firm, told OBG.

MEDICAL TOURISM: The two DHCC locations are within a 20-minute drive from Dubai International Airport, one of the world’s busiest international air hubs. This is an important pillar of the emirate’s medical tourism strategy, with just under 80m passengers passing through its terminals in 2015. DHA officials said that almost 631,000 medical tourists were treated in 2015, surpassing the 2020 target of attracting 500,000 medical tourists to Dubai, five years ahead of schedule. In that same year, DHA reported over Dh1bn ($272.2m) in revenue from medical tourists. One important stream of revenue is cosmetics, an industry segment that has seen a rise in the emirate in recent years. “Changes in lifestyle and demographics are affecting the cosmetic medicine sector,” Jeehan Abdul Qadir, executive chairperson at the American Academy of Cosmetic Surgery Hospital, at DHCC, told OBG. “The male segment, for instance, is a market with strong growth potential, with a 12% increase in patients last year alone.”

Officials expect revenues from medical tourism in 2020 to be 20% above the originally predicted Dh2.6bn ($707.7m). In 2015 Dubai also hosted the International Medical Travel Conference and Exhibition with delegates from 84 counties.

NEW UNIVERSITY: In September 2016 the first cohort of 50 undergraduate students is due to enrol at Mohammed bin Rashid University of Medicine and Health Science (MBRU), Dubai’s first co-educational undergraduate college of medicine, which is located in DHCC. The UK’s Queen’s University Belfast has signed an agreement to help develop the new medical school and will advise on curriculum development, recruitment and selection of staff and student admissions.

MBRU is licensed by the Federal Ministry of Higher Education and Scientific Research (MOHESR) and has two colleges: the undergraduate medical school and a postgraduate dental school, Hamdan bin Mohammed College of Dental Medicine. Formerly the Dubai College of Dental Medicine, it offers six MOHESR-accredited postgraduate programmes and in 2015 had 60 students, up from 52 in 2014. The majority of enrolled students are UAE nationals, but there are also international students from various Arab countries, India, Iran, Greece and the UK. MBRU is affiliated with the Royal College of Surgeons of Edinburgh, the Royal College of Surgeons in Ireland and the American Heart Association. The university campus also includes other learning resources. Al Maktoum Medical Library (AMML), which serves students as well as the wider community, saw its number of regular patrons increase from 1431 at the end of 2014 to more than 2700 in 2015. Close to 6500 individuals visited the library that year compared to 3500 in 2014, to access over 22 electronic databases and e-resources and 16,500 e-books and journal titles.

In 2015 around 2100 health care professionals attended training courses at the Khalaf Ahmad Al Habtoor Medical Simulation Centre. Since the centre’s opening in 2012, the total number of trainees has crossed 5000. The centre has two operating theatres, an adult and paediatric intensive care unit, as well as three wards, including a maternity suite with neonatal resuscitation equipment and a dental surgery training suite. The mannequins include a human patient simulator, with the ability to interface with patient monitors, and include lungs that respond to mechanical ventilation, and a METIM an wireless patient simulator, designed to withstand real-life indoor and outdoor environments and to enable students to practice defibrillation and chest tube placement techniques. There are also simulated paediatric, infant and maternity patients. “Students enrolling for our undergraduate and post-graduate courses will have access to these state-of-the-art learning resources and will be at the centre of a thriving medical community here in Dubai,” Amer Ahmad Sharif, CEO of the education sector at Dubai Healthcare City Authority (DHCA), the governing body of DHCC, told OBG.

GLOBAL CONNECTIONS: In January 2015 DHCA and Harvard Medical School signed an agreement to establish the Harvard Medical School Centre for Global Health Delivery-Dubai. The new centre is based at Mohammed bin Rashid Academic Medical Centre in DHCC and will be funded by the Dubai Harvard Foundation for Medical Research. Research scholarships are also being offered through Al Jalila Foundation, a philanthropic organisation founded by the ruler of Dubai, Sheikh Mohammed bin Rashid Al Maktoum, in 2013. In 2017 Al Jalila Foundation Research Centre will open in DHCC to promote and support medical and biomedical research. Princess Haya bint Hussein, the chairperson of DHCA and Sheikh Mohammed’s wife, has been president of the UAE Nursing and Midwifery Council since 2009, as well as assisting in the development of Al Jalila Children’s Speciality Hospital.

International medical firms based in Dubai say the emirate would also benefit from greater corporate investment in research. “Dubai has developed a legacy of building things fast, which has brought great success. Research and development (R&D) is something that requires a lot of time,” Moritz Hartmann, head of EMEA & LATAM Diabetes Care at Roche Diagnostics, told OBG. “Real innovation takes place through a combination of exchanging and challenging ideas. On the other hand, the emirate offers a very entrepreneurial environment that brings innovation quickly to the market.”

OUTLOOK: The sector looks set to pass some milestones in 2016. The launch of the new five-year strategy will focus the efforts of policymakers and health care providers. Additionally, the completion of health insurance reforms that should promote universal health care and underpin a more sustainable funding system for public care, the start of teaching at the first co-educational medical school and the construction of new private medical facilities should all play a part in improving standards in the sector. As these reforms take hold, Dubai should begin to see the quality of its offerings match standards found in Europe or North America.