A regional pioneer in the provision of both health care and medical insurance, Abu Dhabi continued to lay the foundations in 2018 for a more robust model of primary care and achieved new milestones in transplant surgery. Driven by the construction of new hospitals, clinics and specialised facilities, there is a strong pipeline of public and private sector investment in new facilities, especially regarding specialised care. The health system’s administrators have worked hard over the last decade to fill capacity shortages and attract qualified human resources, acknowledging that more can be done to ensure the achievement of the level of health care services envisaged in Abu Dhabi Economic Vision 2030, especially as medical challenges related to the high incidences of lifestyle-related illness, such as obesity, diabetes and cardiovascular diseases, continue to pressure service provision.
“Opportunities within health care lie on two fronts,” Salem Al Noaimi, chairman of the Abu Dhabi Health Services Company (SEHA) and Waha Capital, told OBG. “The first involves investing in specialisations, namely by building specialised centres focused on more complex issues that have a limited presence in the market; and second, there will be opportunities in acquisitions and consolidation across the region, especially from the larger players.”
The Abu Dhabi health sector is regulated and administered at both the national and emirate levels. At the federal level, the Ministry of Health was founded in 1972, and was rebranded as the Ministry of Health and Prevention in 2016 to place greater emphasis on the organisation’s focus on disease prevention and improving overall lifestyles. The ministry is responsible for licensing companies that provide health care services; building and managing facilities; and regulating the practice of medicine, nursing, pharmacy and dentistry in the Northern Emirates. Since 2001 Abu Dhabi has regulated and operated its own public health sector with the establishment of the General Authority of Health Services. Its functions were later divided in 2007, with the Health Authority - Abu Dhabi (HAAD), which became a government department called the Department of Health (DoH) in 2017, tasked with the regulation and administration of the sector, while SEHA became the operator of most of the government’s health care assets. Sheikh Abdulla Bin Mohamed Al Hamed is chairman of the DoH and a member of the Abu Dhabi Executive Council and the Abu Dhabi Executive Committee.
Since 2014 Abu Dhabi’s health sector strategy has prioritised seven aspects of public health: creating an integrated continuum of care; driving quality and safety; attracting, training and retaining a workforce, with an emphasis on Emirati staff; ensuring emergency preparedness and ambulance services; developing a public health approach to wellness and prevention; managing sustainable health care financial systems; and integrating health informatics and e-health.
The latest DoH data shows that public and private facilities made significant progress in many of these areas between 2011 and 2016. Over that period the number of hospital beds increased by 43.2% to 5240 with the opening of 21 new infirmaries and 565 new clinics. This brought the total number of licensed health care facilities to 2455. To meet the demand created by the uptick in care centres, the number of doctors per 10,000 people increased by 45.1%, from 20.4 to 29.6, and the number of nurses per 10,000 people nearly doubled, from 43.6 to 82.
Although it is harder to quantify improvements in service quality and disease prevention, a number of steps have been taken to provide measurements in both regards. As regards hospital performance, since the third quarter of 2014 DoH has gathered data on key metrics from health service providers under its Jawda programme, which translates to quality and excellence. This monitoring of various clinical indicators is reported on a quarterly basis, with the department working on plans to incentivise hospitals by approving funding allocations for high-quality health care providers and discouraging poor performance. “Quality assurance in health care has been a major current focus for the Abu Dhabi government, with pay-for-quality schemes being deployed to ensure quality in existing facilities, personnel and service,” Mohammed Ali Al Shorafa Al Hammadi, CEO and managing director of UEM edical, told OBG. “The system benefits not only from penalising underperforming providers if they do not reach their benchmark, but also incentivising those players that surpass it.”
The Weqaya (prevention) programme has propelled the movement on the part of the emirate’s authorities to begin tackling non-communicable diseases (NCDs) in a concerted manner by looking at lifestyle issues that contribute to poor health. The initiative concentrates on iterative screening, evidence-based care and coordinated actions across the sector to focus on nutrition, physical activity and curbing unhealthy habits. Screening for NCDs found that around 71% of citizens had at least one risk factor associated with cardiovascular disease. As part of the programme DoH is working with strategic partners, such as municipalities, schools and employers, to educate the public on smoking, workplace safety and nutrition.
Some of the funding for health care comes from the federal government of the UAE. In 2018 the Cabinet approved a record Dh51.5bn ($14bn) budget, with Dh4.5bn ($1.2bn), or 7.4%, dedicated to health services in the UAE, an increase of 7.1% on the Dh4.2bn ($1.1bn) health budget in 2017.
Insurance is one of the central factors supporting the sustainability of Abu Dhabi’s health sector. The emirate became an early pioneer in instituting mandatory health insurance when it issued Law No. 23 of 2005, requiring employers to provide cover for their staff. Resolution No. 83 of 2007 mandated comprehensive coverage to all UAE nationals living in Abu Dhabi under the Thiqa (trust) programme, enabling them to claim 100% of treatment received in the emirate and 90% of overseas health care costs.
The Thiqa programme is managed exclusively by Daman, a public joint-stock company in which the government of Abu Dhabi owns an 80% stake, with the remainder held by the German reinsurance firm Munich Re. Daman also manages basic coverage policies for expatriates below a certain income threshold, while foreigners with higher incomes can select from enhanced policies, which are issued by approximately 40 private insurance providers.
DoH data shows that Thiqa covered 19% of all policyholders in 2016, while 45% were protected by basic insurance and 36% had enhanced insurance. Thiqa accounted for 38% of the claims made in 2016 and 56% of the value; enhanced policyholders accounted for 33% of the claims made and 30% of the value; while basic policyholders comprised 29% of the claim count and 14% of the value. The total number of claims rose by more than 120%, from 13m in 2010 to just under 29m in 2016.
The enhanced market remains dominated by Daman, which in 2016 held 48% of the enhanced policy market, followed by Al Dhafra Insurance (8.5%), Oman Insurance (5.1%) and Union Insurance (3.8%). The average enhanced premium cost Dh4804 ($1300) in 2016, up 4.3% from Dh4598 ($1250) the previous year. In 2016 there were 9.3 claims per enhanced member, up from 7.1 the year before, and the number of days it took to be reimbursed increased from 66 days to 80. It was reported in 2018 that DoH was working on ways to accelerate the claims and reimbursement process operated by hospitals and insurance companies. This comes on top of a series of changes over the course of 2016 and 2017, culminating in the government’s April 2017 decision to waive a 20% co-pay that had been established the previous year for Thiqa customers at private health care facilities.
As of July 2018 the SEHA administered 12 hospitals with 2,644 beds, 46 primary health care clinics, 10 disease prevention and screening centres, three mobile clinics, one school clinic, two blood banks, four dental centres, two employee health care centres and one vaccination centre. It employed more than 18,000 physicians, nurses, pharmacists and health auxiliaries, and treated 100,000 inpatients and more than 5m outpatients across the emirate.
Its largest infirmary by bed-count is Sheikh Shakhbout Medical City, which opened at the end of 2017 with 732 beds. Located near Abu Dhabi International Airport, the Dh4bn ($1.1bn) facility can provide care to patients without the need to travel to the city centre. The hospital employs 2200 doctors and nurses, in addition to other support staff, making it one of the largest health centres in the country. Other key SEHA facilities in the Abu Dhabi region include Sheikh Khalifa Medical City (654 beds), Mafraq Hospital (364 beds), Corniche Hospital (247 beds) and Al Rahba Hospital (140 beds).
There are three hospitals serving the Eastern Region of the emirate: Al Ain Hospital, Tawam Hospital and Al Wagan Hospital, with 356, 436 and 15 beds, respectively. The Western Region of Al Dhafra is served by six hospitals, the largest of which is Madinat Zayed Hospital (129 beds), followed by Liwa Hospital (40 beds), Marfa Hospital (40 beds), Delma Hospital (38 beds), Al Sila Hospital (36 beds) and Ghayathi Hospital (32 beds).
Bed occupancy at the emirate’s hospitals varied widely in 2016, ranging from 14% at Delma Hospital to 87% at Tawam Hospital. DoH reports that SEHA hospitals provided care in 50% of all inpatient treatment episodes and 28% of all outpatient visits in 2016. Johns Hopkins Medicine International manages both Al Rahba Hospital in Abu Dhabi and Tawam in Al Ain, and both are endorsed by Joint Commission International, a US-based, non-profit health care organisation that issues accreditation standards.
In July 2018 it was announced that construction on the Dh4.4bn ($1.2bn) New Al Ain Hospital was 66% complete. Development of the 719-bed facility began in 2014 through collaboration with developers Abu Dhabi General Services Company ( Musanada), SEHA and three other contractors.
Mubadala Healthcare, a division of the state-owned Mubadala Investment Company, has undertaken efforts to develop a commercially sustainable, private health care sector in the UAE. Through its two main hospitals and a network of facilities in Abu Dhabi, the company is increasing the emirate’s service capacity, addressing the country’s most pressing health care needs and reducing the need for patients to travel abroad to access complex services. Its flagship facility, the 364-bed Cleveland Clinic Abu Dhabi (CCAD), was developed in conjunction with the US-based Cleveland Clinic, a non-profit, academic medical centre, and is led and served by physicians certified by North American and European assessment boards or their equivalents. The facility, which is expandable to 490 beds, opened the UAE’s first and only multi-organ transplant centre in 2017, and went on to complete the country’s first kidney transplant in April 2017; its first full heart transplant and multiple kidney transplants in December 2017; its first deceased donor full liver and lung transplants in February 2018; and its first living, related, split-liver transplant in July 2018.
“We strive to be on the leading edge of health care value – providing the highest-quality, safest, patient-oriented care at the lowest cost,” Dr Rakesh Suri, CEO at CCAD, told OBG. “We have a clear role to play in the development of Abu Dhabi’s health care system, through innovation, the commitment of our caregivers, education and research, and by listening to the voices of our patients and working with the community for a healthier, happier future.”
Healthpoint Hospital, also part of Mubadala’s integrated network of health care providers, is a specialty hospital. Its three centres of excellence – the Abu Dhabi Knee & Sports Medicine Centre, the Bariatric and Metabolic Surgery Centre, and the Wooridul Spine Centre – cover paediatrics, family medicine and more. Care is provided by a multidisciplinary team of 900 physicians, nurses, pharmacists and allied health professionals. The hospital partners with some of the world’s leading health care organisations, including South Korea’s Wooridul and Children’s National and Fortius London, to meet the health care needs of the UAE.
“Healthpoint is guided by three principles, which work together to deliver high-quality health care,” Dr Jose Lopez, CEO at Healthpoint, told OBG. “First, we use evidence-based practices to provide the full cycle of care for each patient in an integrated manner that reduces costs and readmissions by streamlining each patient’s journey. Second, we work to improve patient experiences and outcomes for a safer hospital, improved timeliness, and higher quality and effectiveness of care. Lastly, we run our facilities according to an integrated practice unit model, meaning we provide treatment from start to finish by using a coordinated care model and a multidisciplinary team approach, all in one place.”
In recent years Mubadala Healthcare has identified opportunities to garner international expertise focused on specific medical needs. For instance, the International Diabetes Foundation calculated that 17.3% of the UAE’s adult population suffered from Type 2 diabetes in 2017, meaning the disease affected more than 1m people.
In 2006 Mubadala Development Company established its first health care facility, in partnership with Imperial College London. Imperial College London Diabetes Centre (ICLDC) now has three branches in the country – the newest of which, in Zayed Sports City, opened in November 2016 and broke even within three months. Overall, ICLDC saw an 18.5% increase in its caseload in 2017, with 326,684 patient visits to its three sites.
Lawrence Patrick, CEO of ICLDC, told OBG, “It is crucial to address population health, particularly in a market like the UAE, which exhibits high incidences of non-communicable diseases such as diabetes. To address these ailments, early detection is essential, as is allocating ample resources to preventive medicine to improve lives and keep people healthy.”
There were a total of 41 private hospitals in Abu Dhabi in 2016, providing 2447 beds, with 28 facilities in Abu Dhabi City, 12 in Al Ain and one in Ruwais in the Al Dhafrah Region. Collectively, private hospitals in the emirate employed 2637 doctors, 6539 nurses and midwives, and 1589 pharmacists and allied health care professionals.
Leading businesses have played a significant role in the growth of hospitals, clinics and services in Abu Dhabi. NMC Healthcare launched in 1975 and now runs 10 speciality hospitals and clinics in the emirate. Its flagship facility, the $200m NMC Royal Hospital in Khalifa City, opened in 2015 with 160 beds. Private provider Mediclinic formed in February 2016 when two private UAE providers merged in a reverse takeover by Al Noor Group of Mediclinic International, a health care company with operations in Switzerland and South Africa. Both Mediclinic and NMC Healthcare are listed on the London Stock Exchange. In December 2017 Prasanth Manghat, CEO of NMC Healthcare, told Reuters that the company was actively seeking acquisitions in the Gulf and other markets. Manghat said he saw opportunities with increased government expenditure in Abu Dhabi. The emirate’s second-largest private hospital, the 159-bed Burjeel Hospital, is owned by VPS Healthcare, another international provider that maintains a prominent footprint in Abu Dhabi. VPS Healthcare also plans to open the 400-bed Burjeel Medical City in Mohamed Bin Zayed City. The tertiary care facility will focus on oncology, long-term care and wellness. Top providers in the private sector also include UEM edical, which has run a number of hospitals and clinics that deal predominantly with family health, children’s health, diabetes and fertility under its HealthPlus Network of Specialty Centers, Danat Al Emarat Hospital for Women and Children, and Moorfields Eye Hospital Abu Dhabi since 2007.
“The Abu Dhabi health care sector remains very lucrative, particularly as the local government places emphasis on the private sector and its ability to build additional capacity for the delivery of services. This encourages international investors to participate in the market and local players to expand their business,” Mohammed Ali Al Shorafa Al Hammadi, CEO and managing director of UEM edical, told OBG.
DoH acknowledges that most of the growth in doctor numbers and new facilities has been in the private sector as businesses move to fill capacity gaps, especially in rural areas where services can be thin on the ground. “Home care in the past was implemented by paying providers to get people out of hospital beds, mostly in the Western Region and remote locations, as these areas did not have the needed capacity,” Nick Faselis, partner at home care services provider Via Medica International, told OBG. “Over time, private players like Mediclinic and VPS Healthcare have set up shop in these areas.”
Of the 8983 doctors working in Abu Dhabi in 2016, around 10.6% were Emirati citizens, while of the 24,915 nurses working in Abu Dhabi, just 157, or 0.6%, were UAE nationals. The emirate would like to encourage more citizens to train in the medical profession, but hospitals and clinics continue to recruit most of their staff from overseas. “We recruit significant numbers of emergency medical technicians from overseas, and we regularly visit the Philippines with a recruiting team,” Ahmed Al Hajeri, CEO of National Ambulance Company, which provides ambulance services for hospitals such as CCAD, told OBG. This poses additional problems regarding the human resource gap as foreign staff are usually temporary. Redempto Jimeno, CEO of Nightingale Group, which offers home care services as well as professional development courses for working nurses, told OBG, “Each nurse who has completed their training has the opportunity to work abroad in western countries, and about 20% of trained nurses leave Abu Dhabi each year.” This has led to calls from health experts to make nursing a more attractive profession for locals, especially after it was revealed that no Emiratis had applied to fill positions advertised by a nursing recruitment campaign in 2017, with thousands of applications coming from Asian candidates. At the International Council of Nurses conference held in Abu Dhabi in September 2018, Dr Anwar Sallam, the chief medical and clinical affairs officer at SEHA, commented that expanding the responsibilities given to nurses, as well as allowing them to undergo specialisation training could help make the profession more appealing to citizens. Sallam also told local media that SEHA was looking to hire up to 100 local nurses per year.
A number of industry players would also like to see the authority speed up the processing of job applications, and believe this would help bring in much needed health professionals, such as speech therapists and specialised physicians. “At the moment it can take a good doctor up to eight months to be licensed, and there is a danger that top physicians and other talented staff will be put off by the lengthy process in Abu Dhabi,” Faselis, told OBG.
Mind the Gap
Data provided by DoH indicates that from the end of 2010 to 2016 there was a 16.1% compound annual growth in the number of clinicians, including physicians, dentists and nurses in Abu Dhabi, while the number of licensed facilities increased by a 12.5% compound annual growth rate. The authority estimates that by 2025, an additional 1789 doctors and 12,518 nurses will be required along with 1231 acute hospital beds.
Authorities have identified capacity gaps in several respects, including primary care, emergency care, psychiatry, obstetrics, neonatology, specialist paediatric care, orthopaedics and long-term care beds. “We have developed a capacity plan for the sector, and we have identified areas of concern. DoH is working with both public and private providers to close these gaps. Through our licensing of facilities we can determine what new services need to be provided,” Hamed Al Hashemi, director of strategy and corporate performance at DoH, told OBG.
To address shortages in primary care, in January 2018 DoH announced it would no longer issue new licences for general health care clinics in Abu Dhabi and would be implementing a family medicine model of care. The new standards for primary care place a greater emphasis on the role of the community physician. Health centres, with the exception of those located at construction sites, schools and a number of other facilities, were given until the end of December 2018 to register. The move has seen a number of facilities move to offer primary care services. Corniche Hospital, for example, which specialises in obstetrics and gynaecology, has also begun shifting its care model to one that is more in line with government goals. “We have just opened our family medicine centre here at the hospital, because it was clear that while there was plenty of acute and intensive care capacity, there was room to focus on primary care so that women can become healthier before they get pregnant and subsequently receive ongoing support,” Linda Clark, CEO of Corniche Hospital, told OBG.
Capacity gaps in long-term care are being filled by a number of firms, including UAEbased private equity firm TVM Capital Healthcare, which invested in Cambridge Medical Rehabilitation Center (CMRC) in 2012. As of October 2018, CMRC had two 90-bed facilities in Abu Dhabi and Al Ain, with Emiratis constituting between 95% and 98% of its patients. CMRC’s facilities are not run as long-term domiciliary care facilities, with each of its patients working towards a discharge plan. “A few years ago our investors were wise enough to see that post-acute, long-term care was a niche that needed to be filled,” Dr Howard Podolsky, group chief executive at CMRC, told OBG. “There are other gaps in the Abu Dhabi health landscape, however, marking an exciting time for the private sector as investors identify areas in need of better service.”
CMRC will face competition from the newly formed Capital Health. In April 2018 the group opened the Health Shield Medical Center in Abu Dhabi’s Al Qurm district. The facility will run specialist outpatient clinics across 12 areas and serve up to 350 patients per day. In May 2018 Capital Health signed an agreement with US rehabilitation centre Shirley Ryan AbilityLab, formerly the Rehabilitation Institute of Chicago, to build the region’s first purpose-built rehabilitation centre. The 166-bed Specialised Rehabilitation Hospital will provide acute and long-term rehabilitation care to both inpatients and outpatients.
The government has undertaken several programmes to emphasise preventative care, boost safety and improve overall population health. There are high rates of chronic diseases related to lifestyle, such as obesity, diabetes and cardiovascular disease, according to DoH. In 2016 circulatory diseases, including strokes and heart attacks, caused 37.1% of all deaths; followed by accidental injuries, including road accidents, poisoning and falls, which accounted for 19.9% of all deaths; and cancer with 12.8%. The pattern for non-fatal injuries saw falls account for 40% of total incidences, followed by stabs and cuts (17.2%), moving objects (11.4%) and traffic accidents (7.2%).
All nationals on the Thiqa insurance scheme have been screened for cardiovascular risk factors since 2008. In addition to the follow-up advice offered on smoking, physical inactivity and diet to at-risk individuals, the authority has established several education and public awareness campaigns. For instance, the evidence-based Care Pathways initiative helps professionals diagnose and manage the most common risk factors for cardiovascular disease, including diabetes, obesity, smoking, hypertension and hyperlipidaemia.
In December 2017 the Abu Dhabi Children’s Obesity Task Force designed a comprehensive plan to reduce the average body mass index of children by 15% by 2020. Representatives of 12 different government entities are involved with the initiative, including DoH, SEHA, the Abu Dhabi Education Council and the Abu Dhabi Food Control Authority. On a systemic level officials have been urged to create safe, clean cities that are play-friendly, while individually, parents and families were encouraged to make healthier food choices and reduce the amount of time children spend idle. In October 2017 the UAE also introduced a 50% so-called “sin tax” on sugary drinks, sports drinks and cigarettes.
As the third-leading cause of death in the emirate, cancer accounted for 421 deaths in 2016. According to the latest available data from DoH, in 2015 the incidence rate of cancer per 100,000 people was highest among Emirati females (102.3), followed by female expatriates (95.3), national males (73) and foreign males (30.3). Breast cancer was the most common overall (325 cases) and the most common affliction for females (321 cases), while among male patients, colorectal cancer was the most prevalent with 117 cases. Breast cancer accounted for 12.1% of all cancer deaths in 2016 and 25.4% of female cancer deaths. Bronchial and lung cancers were the second most-common cause of overall deaths related to cancer (9.7%) and the most common cause among men (15.5%).
Starting in October 2017 DoH organised a sixmonth Live Healthily and Simply Check awareness campaign, focusing on a different cancer each month. According to government recommendations, women should have a mammogram screening biennially after the age of 40, and through information campaigns DoH encourages women to carry out monthly self-examinations. Women deemed to be at high risk due to their clinical or family history are recommended to have annual screenings, including MRI scans, and can arrange a meeting with a genetic counsellor. Regular screening and improved education are also helping the fight against colorectal cancer. In 2015, 42.5% of cases were detected early, compared to 37% the year before. DoH encourages men aged 40 and above and women aged 25 and above to go for regular screenings.
The country is also looking to mitigate contributing risk factors to deaths caused by accidents, with fatal injury figures growing from 587 in 2010 to 653 in 2016. Abu Dhabi Occupational Safety and Health Centre was formed in 2010, drawing on international best practices to develop standards, enforce regulations, spread awareness and ensure investigations into workplace accidents and injuries are conducted. DoH developed the Height Aware campaign to raise awareness of the dangers of working on tall structures and prevent falls, especially in the construction, agriculture, and oil and gas industries. The programme provides free resources to business owners and workers to encourage safety and prevent falls.
To address hazards in the home, the authority launched a home safety campaign in February 2018, warning that 77.5% of non-fatal injuries occurred at or near the home, with children up to age 17 accounting for 34.6% of non-fatal injuries and 19,900 accidents in 2015-16. The initiative aims to increase parents’ awareness and use of precautionary measures, such as childproofing tools, security devices and guards against common household dangers. DoH has also run a Drive Safe, Save Lives campaign since 2009, encouraging motorists to wear seatbelts, use child safety seats and drive more slowly. In 2016 Abu Dhabi’s traffic mortality rate was 11.6 per 100,000 people. That year 353 people died on the roads, including 220 in cars, 83 pedestrians, 14 on buses, 14 on motorcycles and 22 via other incidents. Efforts to tackle negligent driving and reduce accidents in 2017 entailed the introduction of additional traffic laws and stricter enforcement, including a law mandating seatbelt usage introduced in June, and increased monitoring and fining, with Abu Dhabi police handing out 4.6m fines to drivers over the course of 2017. Local media reported that in 2017 the number of traffic fatalities fell to 199, down 43.6%, with the overall number of accidents falling to 1533 from 1740 in 2016.
Health care in Abu Dhabi has expanded and matured considerably in recent years. The growing population is expected to enjoy access to increasingly sophisticated treatments and more services at a number of new or under-development hospitals. Public initiatives to reduce NCDs and increase awareness about safety should boost lifestyle-associated health and reduce the systemic burden. Investors and private health care providers are also engaged in identifying gaps in service provision and taking advantage of opportunities to develop new services. “The attractiveness of the emirate is centred on its stability, good economy, growing population and lack of tax,” Lawrence Patrick, CEO of ICLDC, told OBG. “Whereas in the past, the emirate’s health care system needed improvement, nowadays people want higher-quality services, and this is driving increased standards in the industry.”
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