How Abu Dhabi is revitalising its medical offerings

Abu Dhabi’s health care sector has witnessed significant expansion in recent years, with health services improving and an increasing number of hospitals, clinics and specialised facilities coming on-line. Both private and public entities are investing heavily in the sector, ensuring a steady stream of new facilities. However, while new and high-tech facilities are improving access to and quality of care, the sector continues to be challenged by high incidences of lifestyle-related illnesses such as obesity, diabetes and cardiovascular diseases. Like the rest of the world, the sector came under additional pressure in early 2020 as a result of the Covid-19 pandemic. Although the authorities were quick to respond with a series of measures designed to slow the spread of the virus, its full impact had yet to be seen as of June that year. The government has rolled out a number of public-private partnerships (PPPs) to assist with the sector’s expansion and further enhance the quality of health care services. Recent trends have included greater digitisation and innovation, with the emirate positioning itself to become a global leader in digital health. It has also taken steps to build upon its reputation as a regional centre for health services and medical tourism.

Structure & Oversight

Abu Dhabi has both a government-funded health service and a large private health sector. Private care accounts for over 75% of the market, according to the Department of Health (DoH). Much of the sector’s recent expansion has been centred on the private sector due to the government’s strategy to encourage investment, and the pace of growth has introduced the challenge of managing potential oversupply, as well as rebalancing in certain areas and specialisations.

In Abu Dhabi the health sector is regulated and administered at both the national and emirate level. At the federal level the Ministry of Health and Prevention presides over health-related issues. Previously titled the Ministry of Health, it was rebranded in 2016 to place greater emphasis on disease prevention and healthy lifestyles. The ministry is responsible for licensing companies that provide health-related services; building and managing facilities; and regulating medicine, nursing, pharmacy and dentistry in the Northern Emirates.

Abu Dhabi has regulated and operated its own public health sector since 2001. DoH is responsible for defining the strategy for the health system in the emirate, and regulating and licensing all sector actors, including public and private providers, and health care professionals. Before the establishment of DoH in 2017, the health sector was regulated by the General Authority of Health Services from 2001 to 2007, followed by the Health Authority - Abu Dhabi from 2007 to 2017. The Abu Dhabi Health Services Company (SEHA) is the largest public provider, managing and operating all public hospitals and clinics in the emirate. SEHA is an independent, public joint-stock company that delivers services to both nationals and expatriates. It has entered into a number of partnerships with international institutions, such as Johns Hopkins Medicine International. According to SEHA, each year its facilities treat over 5m outpatients, accommodate 100,000 inpatients and conduct 41,000 surgeries. The company employs more than 18,700 individuals, 14,000 of whom are non-UAE nationals. This figure includes around 3450 doctors, 7600 nurses and 3000 technicians. SEHA operates at least 12 hospitals with 2644 beds, 46 primary care clinics, 10 disease prevention and screening centres, four dental clinics, three mobile clinics, two blood banks, two employee health care centres, one school clinic and one vaccination centre.

Available Resources

As of April 2020 there were a total of 3114 health facilities in the emirate, according to DoH statistics. Abu Dhabi has 64 hospitals, 40 of which were in Abu Dhabi City, 17 in Al Ain and seven in Al Dhafra. There were also 746 health centres, with 493 centred in Abu Dhabi City, 227 in Al Ain and 26 in Al Dhafra; 759 clinics, with 393 in Abu Dhabi City, 223 in Al Ain and 143 in Al Dhafra; and 291 other types of health facilities, 198 of which were in Abu Dhabi City, 85 in Al Ain and 8 in Al Dhafra. Abu Dhabi City was home to the majority of pharmacies in the emirate as of April 2020 (594 out of a total of 880) as well as the largest number of drug stores (67 out of a total of 77). The number of health care facilities has grown at a compound annual growth rate of 9.6% between 2011 and 2020. For comparison, in 2015 there were 52 hospitals, 757 health centres, 423 clinics, 637 pharmacies, 76 drug stores and 192 other types of facilities.

There were 10,202 physicians in 2019, breaking down to 4 physicians per 1000 people, according to the “Statistical Yearbook of Abu Dhabi 2020” released by Statistics Centre - Abu Dhabi (SCAD). Abu Dhabi was served by 27,520 nurses in 2019, or 10.7 nurses per 1000 people. Both figures were higher than the 2019 national average for the UAE, which numbered 2.6 physicians and 5.9 nurses per 1000 people. Hospital beds totalled 7032 that year, providing 2.7 hospital beds per 1000 people, up from 2.2 in 2018. The total number of beds in government hospitals was approximately 3266 in 2019.

DoH’s “Health Statistics 2017” report estimated that by 2025 up to 3465 additional doctors and 11,979 nurses will be required based on the 2007-17 population growth rate of 5.4%. It also estimated 1346 additional acute hospital beds may be needed based on the current occupancy rate. However, this projection was not inclusive of the 468 additional hospital beds under construction at the time.

Strategies

Both national and emirate authorities have implemented a series of strategies aimed at improving health outcomes. UAE Vision 2021 identifies the achievement of a globally competitive health care system as one of its six national priorities. It focuses on accreditation, international quality standards and the importance of preventive medicine. It also aims to reduce the prevalence of smoking, and increase the system’s readiness to deal with epidemics and health risks – especially important given the Covid-19 pandemic in early 2020.

The National Nutrition Strategy 2017-21 aims to raise the nutritional status of the population throughout their life cycles, and reduce the incidence of illness and death resulting from diet-related, non-communicable diseases (NCDs). Maternal and infant health targets include achieving a 50% reduction of anaemia in women of reproductive age and increasing the rate of exclusive breastfeeding in the first six months up to at least 50%. Diet and physical activity-related targets include achieving a 10% reduction in the prevalence of insufficient physical activity, and a 2.4% reduction in the prevalence of obesity among children five to 17 years of age.

The National Strategy for Wellbeing 2031 was launched in 2019 and aims to make the UAE a leader in quality of life. Through an integrated concept of well-being, it aims to promote healthy and active lifestyles and good mental health. There are three levels to the framework: individuals; society; and country. One of its most important initiatives is the development of the National Wellbeing Observatory to support decision-making, monitor key well-being-related indicators and issue reports.

At the emirate level the Abu Dhabi Health Care Strategic Plan was launched in 2014 and identifies multiple priority areas, including quality of service, capabilities of staff, emergency preparedness, wellness and prevention, sustainability of spending, e-health and addressing gaps in capacity. The plan emphasises the need to collaborate with strategic stakeholders such as municipalities, schools, police and employers to address issues such as tobacco control, the importance of healthy eating and exercise, road safety and workplace health.

Both the UAE and Abu Dhabi swiftly enacted measures to combat the spread of Covid-19 in early 2020, including imposing social-distancing measures and ramping up testing and disinfection. Flights and tourist visas were temporarily halted; large gatherings were suspended; and many government offices and businesses shifted to remote work. Moreover, Strata Manufacturing, a subsidiary of Mubadala Investment Company, partnered with Honeywell to produce N95 masks in Al Ain.

Economic Contribution

Based on preliminary estimates for 2019 released by SCAD, human health and social work contributed Dh13.7bn ($3.7bn) to the economy, representing 1.5% of GDP at current prices, up from Dh13.4bn ($3.6) in 2018. The sector has experienced both positive and negative growth over the last decade. In real terms the sector grew by 2.8% between 2010 and 2015. In 2017 growth was negative, at -0.5%, while in 2018 the sector expanded by 7.5% and in 2019 it grew by 2.2%.

Some of the funding for health care comes from the federal government. Out of the UAE’s budget of Dh60.3bn ($16.4bn) for 2019, the health sector was allocated Dh4.4bn ($1.19bn), or 7.3% of the total. This was slightly down from the Dh4.5bn ($1.22bn), or 7.4% of all funding included in the 2018 budget. However, health expenditure is expected to rise significantly in the coming years. This is due to technological advances driving increased costs, people living longer and requiring more complex care, and the longer-term impact of sedentary lifestyle issues.

Health Indicators

The emirate has a diverse population that can be separated into two broad, but distinct, categories: nationals and expatriates. According to SCAD’s 2020 yearbook, the emirate’s total population was estimated to be 2.9m in mid-2016, the most recent year for which statistics are available. The population is weighted towards males (1.9m, or 63.9% of the total) and expatriates (2.4m, or 81% of the total). Among nationals, the distribution of men (282,632) and women (268,903) is more equal, representing 51.2% and 48.8% respectively. The median age for nationals in mid-2016 was 19, while that for expatriates was 31. That year, the emirate had a population density of 48.9 persons per sq km. Abu Dhabi City was the most dense, at more than 164 persons per sq km, while the Al Dhafra Region was the least, at 9.5 persons per sq km.

The emirate’s crude birth and death rate in 2019 was 14.5 births and 1.3 deaths per 1000 population, respectively. Both of these figures were higher for nationals. Citizens had a birth rate of 27.5 and death rate of 1.9 per 1000 persons, while expatriates had a birth rate of 10.4 and death rate of one per 1000. That year life expectancy at birth was 76 years for male citizens and 81.5 years for female citizens.

While the world’s average fertility rate was 2.4 around this time, according to the World Bank, Abu Dhabi’s fertility rate was an overall 1.5 per woman, broken down to 3.5 per citizen woman and one for non-citizens. The infant mortality rate stood at 6.4 deaths per 1000 live births in 2018, down from 6.8 in 2017. The infant mortality rate in Abu Dhabi has seen a significant improvement in recent decades, decreasing by more than half from the 14 infant deaths per 1000 births that occurred in 1990.

In 2019 the greatest number of deaths was caused by diseases of the circulatory system such as heart disease and stroke, representing 52.9 deaths per 100,000 population. Neoplasms and external causes of morbidity and mortality were the second- and third-highest causes of death, at 25.8 and 10.3 deaths per 100,000, respectively. High rates of mortality related to lifestyle-related diseases, including obesity, diabetes and cardiovascular diseases remain an area of concern. In 2017 cardiovascular diseases accounted for 36.7% of all death cases, according to DoH. The prevalence of diabetes among people aged 20-79 was 17.6% in 2016. This can be further broken down into 25.4% for nationals and 15.2% for expatriates. In 2016 the cancer incidence rate was 59.8 per 100,000 population, which can be further broken down to 41.3 for the male population and 103.6 for females. Cancer caused 15.2% of all deaths in 2017, with breast (11.5%), bronchus and lung (8.7%), and colon (8.5%) cancers standing as the causes of the most cancer-related deaths.

Respiratory infections were the most common non-life threatening conditions in 2016, representing 17.2% of treatment episodes in local health care facilities. Immunisation programmes for children aged five and below have helped rates of childhood communicable diseases to remain very low. To further reduce rates of transmission, expatriates are screened for communicable diseases before they are able to acquire residency status.

Treatment Patterns

In 2017, 49.1% of treatment episodes were provided by health centres, followed by 47.4% by hospitals and 3.4% by clinics. Some 93% of visits were outpatient, while 5% were in the emergency room and 1% inpatient. Records indicate that 124,773 patients were admitted to government hospitals in 2019, compared to 124,806 the year before. Bed occupancy rates in SEHA hospitals varied in 2017, from 16% at Delma Hospital to 85% at Tawam Hospital. The range is attributed to facility size and population density: Delma Hospital hosts 16 beds in the less-populated region of Al Dhafra, while Tawam Hospital is a 450-bed facility located in Al Ain, which is home to the emirate’s second-largest city. SEHA hospitals provided care in 44% of all inpatient treatment episodes and 25% of all outpatient visits that year. In 2019 there were 3474 beneficiaries of social aid offered to handicapped citizens and 3228 for those with a health disability.

Insurance Market

Health insurance is mandatory in Abu Dhabi and is provided under three programmes: Thiqa (trust); basic; and enhanced. Thiqa was introduced in 2007 and provides comprehensive coverage to all UAE nationals living in the emirate. It enables them to claim 100% of health care costs for treatment received in Abu Dhabi and 90% for treatment overseas. The programme is managed by Daman, a public joint-stock company in which the government holds a 80% stake, with German reinsurance firm Munich Re holding the remaining 20%.

Basic policies, meanwhile, provide coverage for expatriates with limited income, while enhanced policies cover expatriates with incomes above a certain threshold. Daman also manages both basic and enhanced policies, while the latter are issued by 42 private insurance providers as well. Mandatory health insurance for expatriates was first introduced in 2006 and is linked to resident permits. Employers are responsible for providing health insurance for all employees and their in-country family members, which includes a spouse and up to three children until they reach the age of 18.

At the end of 2017 Thiqa covered 20% of all policyholders, representing 600,000 members. Basic policies covered 43%, with 1.3m members, while enhanced policies covered 37%, with 1.1m members. In 2017, 41 licensed payers provided health insurance for the entire population. That year the majority of the enhanced insurance market was held by three payers: Daman (49.6%); Abu Dhabi National Insurance Company (7.1%); and National Life (7%).

There was a total of 28.6m claims made in 2017, representing an average of 9.5 claims per member, a substantial increase from 5.1 in 2013. Thiqa accounted for 44% of claims made, followed by enhanced (33%) and basic (29%). The average claim for Thiqa was Dh779 ($212), followed by Dh434 ($118) for basic and Dh234 ($63.69) for enhanced. The average enhanced premium per contract in 2017 was Dh5220 ($1420), while basic was Dh860 ($234). The average time it took for payers to remit a claim in 2017 was 67 days.

Screening

The Weqaya (prevention) programme offers screening for cardiovascular risk factors for all adult nationals. It was initiated in 2008 as part of enrolment in Thiqa. Screenings are conducted every year, and the first screenings for the programme showed that 71% of people had at least one risk factor related to cardiovascular disease. Education and awareness campaigns on cardiovascular disease risk factors are conducted annually, and target smoking, physical inactivity and unhealthy nutrition habits.

Meanwhile, the Abu Dhabi Central Cancer Registry, established in 2012, monitors incidence rates and effectiveness of screening programmes. Monitoring is supported by regular cancer screenings to detect and remove precancerous growths and treat cancers at an earlier stage. Available screening exams include mammograms for women aged 40 or above, pap tests for women aged 25 to 65 years, and colonoscopies for men and women aged 40 to 75 years.

Nutrition

Lifestyle-related diseases continue to present the most significant challenge to the emirate’s service provisions. The World Health Organisation estimates that one-third of adults in the UAE are obese and one out of five people live with diabetes. The problem is more acute among the citizen population. A study published by researchers at Zayed Military Hospital in July 2019 indicated that nearly 70% of male citizens between 18 and 30 years of age are overweight or obese.

The authorities are working actively to change this, as UAE Vision 2021 aims to reduce the childhood obesity rate from 14.5% in 2018 to 12% by 2021. A nationwide sugar tax targeting sweetened drinks, including carbonated and energy drinks, was introduced in December 2019. Reducing the availability of unhealthy food and making healthier food more available is also a priority. The government has therefore banned the sale of junk food in school canteens, and in 2019 DoH introduced a new weight management programme for overweight and obese children aged two to 18. It encourages individuals to adopt goals to monitor performance within a specific timeline. The Abu Dhabi Childhood Obesity Task Force, for its part, aims to eventually increase physical activity by 15%.

Primary Care

While the sector is weighted towards specialist care, DoH is beginning to expand primary care options. As of 2018 there were 46 SEHA-administered primary care clinics. Common practice in the emirate is to see a specialist first, rather than a general practitioner (GP), and seeing a GP for check-ups is uncommon. DoH is looking to upskill GPs and expand the function of primary care as a gatekeeper to ensure more efficient and personalised patient care. The July 2019 establishment of the electronic medical records central database is expected to help expand primary care offerings through more effective diagnosis and treatment.

Specialties

As part of efforts to establish Abu Dhabi as a global destination for health care, the emirate has been working to expand local capacity for complex care through international partnerships and investments. In November 2019 a new multi-specialty hospital, Sheikh Shakhbout Medical City, was opened in Al Mafraq district. A joint venture (JV) operated by SEHA and the Minnesota-based Mayo Clinic, the facility is now the largest tertiary hospital in the UAE as well as Mayo Clinic’s first JV to operate a hospital abroad.

This followed a partnership between US-based Cleveland Clinic and Mubadala Investment Company to open the flagship 364-bed multi-specialty hospital Cleveland Clinic Abu Dhabi in 2015. Since its establishment it has expanded to include the UAE’s first multi-organ transplant centre in 2017. According to hospital officials, the facility is enhancing its services further by building a new oncology centre that will bring an integrated approach to diagnosing and treating cancer in the UAE. “A key focus of Abu Dhabi’s health care sector is to promote ourselves as both a regional and international resource,” Dr Rakesh Suri, CEO of Cleveland Clinic Abu Dhabi, told OBG. “That is why we are investing in developing treatments and therapies to service not just the local market, but the global market as well. Specifically, a key aim is to ensure that the emirate can match global standards in the treatment of cancer.”

Looking to the future, while the market has a number of multi-specialty providers, there is opportunity for growth in sub-specialty areas such as oncology, psychology and addiction centres. “The UAE’s health sector is starting to experience a steady specialisation in niche treatment areas such as oncology,” Aly Abdel Razek, chairman and executive director of the Gulf International Cancer Centre, told OBG. “Continuing with this trend, the country will need more health professionals including doctors and nurses, as well as advanced equipment and laboratories. In order for these specialised segments to develop efficiently and effectively, the regulatory environment will need to continue ensuring that quality is at the core of the decision-making process when it comes to licensing new medical centres.”

Pharmaceuticals

In addition to its focus on specialties, Abu Dhabi is working to increase the use of generic medications as part of efforts to make health care more affordable and reduce rising insurance costs that result from expensive branded medicines. Doctors are being encouraged to prescribe generic drugs considered just as effective as well-known brands. This follows a DoH ruling in 2018 that instructed health care facilities to dispense generic prescription medicines unless patients requested the brand names and were willing to pay the additional costs. A 2019 study by UK-based medical company Medbelle ranked the UAE, the US and Germany as the three countries with the highest cost for essential medicines out of 50 studied.

Medical Tourism

Leveraging its offerings, Abu Dhabi is taking steps to cement its position as a medical tourism destination. As the travel restrictions imposed in response to Covid-19 in early 2020 are progressively eased, it is a segment that could present significant earnings, given that the average medical tourist in Abu Dhabi spends between $800 and $2500 per day, compared to $500 by a general tourist, while the average stay of a medical tourist is estimated between seven to 10 days.

The emirate is well on its way in establishing itself as a leading centre for medical tourism. In November 2019 Abu Dhabi hosted the 12th World Medical Tourism and Global Health Care Congress. “Abu Dhabi is an ideal partner for our event because it is a rising star in the medical tourism community, with easy visa acquisition and a central location,” Jonathan Edelheit, co-founder of the Medical Tourism Association, said in a statement that same month. “With China, Russia and the Middle East being major sources of health care consumers and medical tourists, it made sense to forge a partnership with an up-and-coming destination like Abu Dhabi.” The event came after the launch of the Abu Dhabi Medical Tourism e-portal in December 2018, a collaborative initiative between DoH and the Department of Culture and Tourism - Abu Dhabi which enables tourists to book appointments and access medical and tourism information, such as treatment packages and medical tourism insurance. Abu Dhabi attracts patients from over 80 countries.

Digital Health

The focus on preventive care and specialisation is being complemented by a digital transformation. DoH is aiming to develop health care solutions through technologies such as blockchain, genomics and predictive analytics. In January 2019 Abu Dhabi unveiled a unified health information platform that allows electronic medical records to be instantly accessed and shared between facilities. The Abu Dhabi Health Information Exchange, or Malaffi (my file), became operational in July 2019 and is set to help improve health outcomes by enabling more efficient medical decisions and reducing duplication of services. Once all service providers are brought on board, it will centralise the records of Abu Dhabi’s approximately 3m people, and connect over 2000 public and private health care providers.

The portal is the first of its kind in the region and was developed as a PPP between DoH and Mubadala Investment Company’s Injazat Data Systems. The platform is operated by the Abu Dhabi Health Data Services company. While public health facilities have been using a centralised database since 2008, it was not accessible to those outside the SEHA network. “Digitalisation is the future of health care. By making information more easily accessible, we can dramatically improve the quality and speed of decision-making within the sector,” Atif Al Braiki, CEO of Malaffi, told OBG. “For this reason, investment in new technology needs to be a major focus.”

Individual hospitals are also joining in the push for digitisation. In November 2019 Abu Dhabi’s Mediclinic Al Noor Hospital implemented a new electronic medical record system called TrakCare, from the global health IT platform provider InterSystems. It will allow the hospital to exchange data with Malaffi. The move was part of a rollout of the system across Mediclinic’s UAE facilities, and will give providers a holistic view of patient data including clinical, administrative and financial information to support medical staff in their decision-making.

Digital health platforms became even more important in early 2020 as a way of monitoring the spread of Covid-19 without making physical contact with patients. In April 2020 DoH launched a mobile application, TraceCovid, to help the authorities to identify and monitor potential cases by detecting whether someone has been in close contact with an infected person. At the same time, DoH added new features to the Istijaba e-system, which enables health care professionals from both the public and private sectors to exchange information and resources, as well as shows real-time information about the capacity of treatment facilities that can attend to Covid-19 patients. To advance digital health, in October 2019 DoH partnered with Plug and Play to initiate a health start-up accelerator programme. Due to commence in 2020, it will allow international and regional start-ups to pitch their solutions. Corporate health care partners will then vote which start-ups will participate in the programme.

Diseases Registry

In November 2019 the Abu Dhabi Central Chronic Diseases Registry was launched to improve monitoring of chronic diseases and their risk factors. As of January 2020 health care facilities were required to report chronic cardiovascular diseases diagnosed and being managed. With time, it will expand to include information on osteoporosis, chronic respiratory diseases and depression. The registry will be managed by DoH’s Public Health Centre (ADPHC) and will help to improve documentation of data on conditions including cancer and diabetes. “The registry will serve as a key tool not only to monitor the causes and associated risk factors of chronic diseases in the emirate, but also to evaluate current medical interventions and identify potential areas of improvement in health practices,” Omniyat Al Hajeri, director of public health at the ADPHC, told Gulf News in November 2019.

Artificial Intelligence

The authorities are looking beyond the digitisation of records to move the health sector to the next stage. Artificial intelligence (AI), in particular, is expected to offer new growth for the sector in the coming years. According to a 2018 report by Accenture, it is estimated that AI technologies will contribute Dh668.5bn ($182bn) to the UAE economy by 2035. To this end, in 2019 DoH launched the AI Lab, which uses AI and machine learning to advance health care solutions. Areas of focus include hospital care, drug development, disease detection and data analytics. The lab aims to serve as a platform for co-creation between DoH, providers, payers and technology companies to develop, test and launch solutions. Products under the AI Lab include the My Health Coach app, which syncs to a user’s fitness tracker, and provides personalised coaching and guidance based on data collected. The Cognitive Virtual Assistant was also developed under the AI Lab. Available on DoH’s website, the tool is able to answer queries in both Arabic and English to facilitate easy access to information.

DoH was the first entity in the region to develop an AI policy for the health care sector. In May 2018 it implemented a series of regulations regarding AI for all health care providers, drug producers, researchers and insurers in the market.

Genome Project

Efforts also are under way to improve the understanding of genetic variation. In December 2019 Abu Dhabi unveiled a genome project that will use the large-scale compilation of genomic data to enable advanced medical diagnosis and treatment. Aiming to be the first of its kind worldwide, the project serves to develop a comprehensive genome database and incorporate genomic data into health care management. It will produce a reference genome specific to emirati citizens. With the help of Abu Dhabi-based supercomputer Artemis by Group 42, the project will rely on big data analysis, AI and advanced sequencing technology. The aim is to produce customised genomic data for citizens and create preventive programmes tailored to each person’s genetic make-up.

Outlook

Abu Dhabi’s health sector has expanded significantly in recent years, both in terms of size and scope. Moving forward, it faces complex challenges, such as the treatment and prevention of Covid-19, as well as new opportunities. With greater centralisation of health data, cybersecurity and patient privacy will remain a priority, as will improving nutrition and reducing NCDs. Meanwhile, continued investment will help Abu Dhabi achieve its long-term vision and build up its advanced health care system, aligning with the UAE’s overall goals.