Ambitious expansion plans contributing to Dubai's competitive health care sector

With new hospitals under construction, existing facilities expanding, and ambitious plans to improve the quality of treatment available not only for residents but also the growing number of medical tourists, Dubai has a competitive health care sector. Included in its expansion is the introduction of the universal health insurance programme in 2017, providing a sustainable safety net for the over 4m people who live or work in the city and their dependants. Looking ahead, Dubai aims to implement 15 strategic programmes encompassing 100 health care initiatives through its the Dubai Health Strategy (2016-21), an overarching project of reform involving both the public and private sectors (see analysis).

A Decade Of Growth

Dubai’s medical landscape has been transformed in the last decade. From 2006 to 2016 the number of patients treated in the city’s hospitals doubled, with the private sector playing an increasingly important role, according to the “Dubai Annual Health Statistical Report 2016” published by the Dubai Health Authority (DHA).

In 2006 private hospitals saw 3m, or 60%, of the total 5m outpatients treated at local hospitals; and 46,000, or 37.7%, of the total 122,000 inpatients. By 2016 private hospitals saw 7.1m outpatients from a total of 10m; and treated almost 199,000, or 70%, of the emirate’s 287,000 inpatients. From 2010 to 2016 the number of physicians working in Dubai increased from 4766 to 8614, and the nursing workforce grew from 9302 to 18,493. In 2016 almost 6000 doctors and more than 12,000 nurses were employed in private hospitals, equivalent to 70% and 65% of the total workforce, respectively.

Hospitals

DHA runs four hospitals: Rashid Hospital, Dubai Hospital, Latifa Hospital for Women and Children, and Hatta Hospital have 1451 beds between them, according to the latest DHA data. A fifth publicly funded infirmary is the 200-bed Al Jalila Specialist Children’s Hospital (AJCSH), which officially opened in 2016. At the federal level, the Ministry of Health and Prevention (MoHP) also operates Al Baraha Hospital and Al Amal Hospital, which together account for 470 beds.

The DHA’s 2016 report showed that construction on 12 new private hospitals was currently under way, which would add 1800 new beds to the 26 private hospitals and 2500 beds already in operation. These figures tally with Dubai’s stated aim to meet 70% of its health care needs through the private sector.

Regulators

There are two emirate-level regulatory bodies governing the health care sector. DHA was created in 2007 and is headed by Sheikh Hamdan bin Rashid Al Maktoum, the deputy ruler of Dubai and minister of finance of the UAE. In 2011 Dubai Healthcare City Authority (DHCA), chaired by Princess Haya bint Al Hussein, was formed to regulate Dubai Healthcare City (DHCC), the sector’s free economic zone. DHCA licenses all practitioners and institutions in the free zone, a role tasked to DHA in the rest of the emirate.

In an effort to prevent any potential conflicts of interest, in November 2016 DHCA created a clearer administrative split between its function as a regulator and its roles in research, commercial activities and provision of medicine and education. DHA is also responsible for strategic planning and the monitoring of key performance indicators.

Vital Statistics

Dubai is looking to provide its residents with a first-rate health care system, and by many measures its results and facilities compare favourably with regional and international standards. In the GCC area, Dubai has the lowest mortality rate for infants and children under the age of five, the highest female life expectancy and the second highest male life expectancy after Qatar.

Dubai has an impressive 33.5 physicians per 10,000 people, the highest number of any GCC territory, and above those of the UK (28.1) and the US (25). The emirate’s nursing numbers, 72 per 10,000, are lower than those of Qatar (73.7) and the UAE (77), and some way below the figures for the UK, US and Germany, with 94.7, 98.2 and 113.8 nurses per 10,000 people, respectively. There are 19.6 hospital beds per 10,000 people in Dubai compared with a respective 20 and 23 in Kuwait and Abu Dhabi, 30 in the US and the UK, and 82 in Germany.

From 2011 to 2016 the population has grown from 1.95m to 2.6m. Over the same period, male life expectancy has increased by 5.4 years to reach 78.4, while female life expectancy in 2016 was 81.4, five years higher than in 2011. Childbirth has also become safer; from 2010 to 2016 the infant mortality rate fell from 7.2 to 5.1 per 1000 live births. There is room for improvement if Dubai is to match Germany and the UK, with respective infant mortality rates of 3.2 and 3.9, but the emirate’s comes in ahead of the US with an infant mortality rate of 5.9.

Health Concerns

Although there are clear signs of progress and improvement in some of health indicators, there are also causes for concern. In common with its GCC neighbours, Dubai reports a high incidence of non-communicable diseases, which health experts say are related to lifestyle choices, such as diet and exercise. At 33.4%, diseases of the circulatory system are the leading cause of death, followed by cancer (17.9%), respiratory system disorders (11.1%) and injuries (6.7%).

The prevalence rates of lifestyle-related conditions such as diabetes are among the highest in world. According to 2017 data from the International Diabetes Federation (IDF), 1.19m people, or 17.3% of the population between the ages 20 to 79, in the UAE have Type 2 diabetes. The IDF believes rapid economic growth, sedentary lifestyles and unhealthy diets are among the risk factors, and experts predict the number of people living with diabetes in the country will increase to 2.28m by 2045.

Recent medical research published in industry media in January 2017 found that among expatriate women living in the UAE, the longer they stay in the country, the greater their chances are of developing Type 2 diabetes. The study reports that 18.6% of the women, with a mean age of 34, had pre-diabetes and 10.7% had Type 2 diabetes, with prevalence highest among South-Asian women, 30.3% of whom had pre-diabetes and 16.7% with Type 2.

Obesity is also a significant cause for concern. A medical paper published in 2015 suggested 25.4% of adults in Dubai were obese, while 35.1% were overweight. More worrying still, the study found 26.7% of Dubai children were overweight and 12.2% were obese, with those under 15 more likely to be obese or overweight than those aged 15 to 18. “Obesity and diabetes are a significant concern in Dubai,” Mark Adams, founder and former CEO of Anglo Arabian Healthcare, told OBG. “The incidences of diabetes in the UK is at 7%, while in Dubai it is nearer to 20%. Many of these people may have been diagnosed quite recently, but when you consider the complications associated with the later stages of the condition, it is clear there is a ticking time bomb.”

Demographic Factors

A glance at Dubai’s demographic pyramid also reveals another key factor for health care planning and provision. The large influx of male expatriates in the emirate on work visas means that of a population of 2.6m people in Dubai, almost 1.5m, or 58%, are men aged 20-50 years old. It is estimated there were just over 233,400 Emirati citizens living in Dubai in 2016, a segment of the population with a more equal distribution of males and females in all age groups.

DHA data also shows Emirati women have more babies on average than their expatriate counterparts. The total fertility rate for Emiratis was 5.2 per woman, compared to 1.7 for expatriates. Emiratis account for 8.6% of Dubai’s population, but its citizens gave birth to 26% of babies in the city in 2016. In that year 71% of babies were born in Dubai’s private hospitals and 29% in government maternity units.

Government Hospitals

Of the four public hospitals run by DHA, all but one are situated within a few kilometres of each other in the Deira and Bur Dubai neighbourhoods. The exception is Hatta Hospital, which is located approximately 125 km from the centre of the city. All facilities in Dubai have developed different specialisms as can be seen by the distribution of inpatient beds in 2016.

Maternity services are concentrated at Dubai and Latifa hospitals, which have the most comprehensive facilities for obstetrics, gynaecology and post-natal care, with 49 and 126 beds, respectively. Dubai and Latifa hospitals also handled a majority of paediatric care. Dubai Hospital has children’s wards with the capacity to treat 38 patients, as well as four beds for paediatric surgery and 38 beds on a specialist care baby unit. Latifa Hospital has 38 children’s beds, 28 beds for paediatric surgery patients and a specialist care baby unit with a capacity of 64. Hatta Hospital has five beds for children, 16 maternity and gynaecology beds, plus 15 beds for internal medicine patients, four intensive care beds, a five-bed isolation unit and 15 private beds. Dubai Hospital has all 36 cardiology and cardiac surgery beds and a coronary care unit for nine patients. While Rashid Hospital also has a coronary care unit with 16 beds, and leads the field in provision of internal medicine with 89 beds, as well as in emergency surgery having all 64 trauma beds in the emirate. It also has 50 intensive care unit beds and the DHA’s only burns and plastic surgery units. Of these four DHA facilities, Rashid has the only wards treating patients with digestive diseases, psychiatric disorders, respiratory system problems and infectious diseases.

Rashid and Dubai hospitals share responsibility for general surgery with 144 beds. Dubai Hospital has the only provision for urology and nephrology, with 29 beds, haematology (16) and oncology (18), plus two beds for nuclear medicine. DHA also runs the Al Mamzar Community Care Centre for the Elderly, which has 33 geriatric beds and provision for seven inpatients with physical disabilities.

Of the doctors employed by DHA, 34.3% were at Rashid Hospital, 26.4% were at Dubai Hospital, 11.8% at Latifa Hospital and 7.4% at Hatta Hospital. A further 18.7% of DHA physicians were at primary health care centres and 1.4% at specialised health clinics.

Surgeons performed over 25,800 operations at DHA hospitals in 2016, with the most common procedures being orthopaedic (20.9%), obstetric and gynaecological (18.9%), and general (15.8%). Rashid, Dubai, Latifa and Hatta hospitals accounted for 30%, 40.6%, 25.2% and 3.2% of operations, respectively.

Ministry Facilities

The MoHP runs two hospitals in Dubai: Al Baraha tertiary hospital in Deira and Al Amal, a hospital offering psychiatric services. Until 2017 these two facilities were exclusively for Emirati patients, but with mandatory universal insurance now fully implemented, a change to this policy was announced. This will make better use of capacity as the two federal hospitals have been treating fewer people recently, with numbers of outpatients and inpatients falling from 447,296 and 7652, respectively, in 2010 to 284,782 and 6215 in 2016.

In November 2016 the new 50,000-sq-metre Al Amal Psychiatric Hospital opened. Patients were moved from the old site in Jumeirah to the new Dh419m ($114m) facilities off the Dubai-Al Ain road. Al Amal has 276 beds and will offer psychiatric care as well as treatment for substance abuse, and drug and alcohol rehabilitation for inpatients and outpatients, and both adults and adolescents.

Treatment Abroad

In addition to operating its own medical facilities, DHA pays for Emirati patients to travel abroad for specialist treatment. It covers medical expenses, travel and accommodation for patients, allowing its citizens to access the world’s best care. The policy also covers travel and the associated costs for accompanying family members. In 2016 Germany was the destination for 28.6% outbound patients, while 15.3% went to the UK and 8.3% to India. Of those travelling abroad in 2016, 21.8% travelled for oncology treatment, 17.2% for neurology or neurosurgery, 16.5% for orthopaedic surgery and 7.6% for heart surgery. On average, DHA sent around 2291 patients abroad per year between 2012 to 2016, paying an average annual fee of Dh410.7m ($111.8m), or Dh187,600 ($51,000) per patient. The kinds of treatments being sought are similar in each of those years, but the price of treatment varies. At Dh623m ($169.6m), or Dh312,300 ($85,900) per patient, the total bill in 2016 was more than twice the amount paid in 2015, while the number of patients comes in below the average at 1994. Over five years DHA spent more than Dh2bn ($544.4m) on treatments outside the emirate.

Over that five-year period DHA’s total expenditure including staffing, operational expenses, capital works and projects came to Dh19.4bn ($5.3bn), with yearly increases ranging from Dh3bn ($816.6m) to Dh5.3bn ($1.4bn), according to the authority’s statistics. The combined overseas medical bill was higher than the authority’s capital costs of Dh1.1bn ($299.4m) and its domestic project expenses of Dh852.4m ($232m) over the five-year period.

In February 2016 the investment banking advisory firm Alpen Capital estimated the overall health care market in the UAE would expand by 12.7% per annum from 2015 to 2020. By that time, it is expected that the entire sector will be worth around $19.5bn.

Improving Services

One of the 15 strategic programmes of the Dubai Health Strategy (2016-21) is to create centres of excellence where patients will be able to receive specialist treatment for many of the conditions currently covered by overseas medical care. The goal is to develop clinical research and training, as well as treatment for cardiovascular disease, cancer, trauma, ophthalmology and neurology.

Private health care providers are being encouraged to play a full role in these strategies, and some of the most influential companies in Dubai are investing in improvements to cancer care and facilities for patients with neuro-spinal issues (see analysis). At the same time, new treatment centres are being developed in hospitals run by DHA and funded by the government. In November 2016 Sheikh Mohammed bin Rashid Al Maktoum, vice-president and prime minister of the UAE, and ruler of Dubai, inaugurated AJCSH – a facility designed as a top-tier paediatric facility (see analysis). In 2016 administrative functions of AJCSH were transferred from DHA to DHCA, an arrangement that enables it to operate as a government hospital where co-payment for Emirati patients is waived, while also taking advantage of free zone conditions to attract the best staff and services. Under this arrangement, DHCA and the UAE Ministry of Finance fund AJCSH equally.

The Free Zone

Describing itself as the world’s largest health free zone, DHCC was launched in 2002 and has been developed over two phases. Phase 1 covers an area of 372,000 sq metres in the Oud Metha area, while Phase 2 occupies a 1.8m-sq-metre site in Al Jaddaf and is being developed as a wellness destination. DHCC is home to 166 clinical facilities including hospitals, outpatient centres and laboratories. Licensed professionals from 90 countries work in the zone, allowing staff to greet many medical tourists in their own language. There are also 200 retail and non-clinical facilities servicing the zone.

In November 2016 the management structure of DHCC was changed, and the DHCA board created a new medical cluster vertical, Dubai Healthcare City Medical (DHCM), reporting to a new CEO, Dr Amer Al Zarooni. Additionally, DHCM oversees Dubai Dental Clinic, and Dubai Bone and Joint.

Medical Tourism

DHCC plays a key role in another of Dubai’s strategic objectives, which is to promote and develop the city as a major destination for medical tourists. In 2014 DHA announced it hoped 500,000 medical tourists would be visiting Dubai annually by 2020, generating revenues of Dh2.6bn ($707.7m). “Medical tourism has significant potential, but health care facilities must work with the various airlines and hotels to encourage them to provide discounted packages,” Peter Makowski, CEO at American Hospital Dubai, told OBG. “Additionally, health care facilities must provide all the necessary services to make the process for international patients as seamless as possible.” Visas and package travel deals have been created to include hotel stays and activities for visitors seeking surgery, medical treatment or wellness experiences. From 2012 to 2016, the number of medical tourists grew from 107,000 to 326,600, with revenues increasing from Dh652m ($177.5m) to Dh1.4bn ($381.1m). Visitor numbers had grown by 9.5% since 2015 with 37% of medical visitors coming from Asia, 31% from Arab countries including the GCC, and 15% from Europe.

If DHA is to meet its ambitious 2020 target, visitor numbers will have to rise with a compound annual growth (CAGR) rate of 13.3% from 2016. There may be significant challenges in reaching this target given the downward pressure on consumer spending in oil-producing GCC countries created by sustained low global energy prices since mid-2014. In addition, Dubai will have to compete on quality with established markets in Europe and North America, and on price with destinations in parts of Asia. However, there are also factors working in Dubai’s favour, including new private health facilities which are set to open by 2020. These are being built to offer a broader range of specialist care, enabling the emirate’s hospitals and clinics to cater for a higher volume of patients with a wider range of conditions. In addition, the upcoming Expo 2020 event in Dubai is serving as an increased impetus for global marketing efforts to attract more visitors.

Dental Care

Dental work attracts a significant number of medical tourists. More than 1m dental treatments were performed in Dubai’s private sector clinics in 2016, a quarter of which were administered to Emirati citizens. DHA facilities treated 164,000 dental patients, performing 167,000 treatments in 15 dental clinics and 67 chairs. There were 0.8 dentists per 1000 people in Dubai in 2016, and the number of practitioners has grown from 1220 in 2010 to 2094. The private sector employs 1870 dental surgeons, including 38 Emiratis. However, in the public sector, dentistry is the only medical profession where nationals outnumber foreigners, with 112 nationals among the 177 DHA dentists and 95 of them Emirati women.

Local Talent

Another key programme in Dubai’s health strategy is to develop its local workforce by improving medical education and attracting more nationals to health care professions (see Education chapter). DHA employs 436 Emirati physicians, 339 of them women, and 1361 foreign doctors, 793 of whom are men. There are just 48 Emirati public sector nurses, all of them women, among 4557 expatriate nursing staff. There are 53 Emirati women working as public sector pharmacists and three men, compared to 145 male expatriate pharmacists and 74 foreign females in the profession.

In the private sector in 2016, 10.3% of health professionals were Emirati, including 142 doctors, 38 dentists, 40 nurses and 81 pharmacists.

Traditionally, nationals wishing to enter the medical profession would study abroad, with most attending schools in Ireland, the UK, the US, and to a lesser extent other countries. While there are a handful of medical schools in the UAE, plans to invest in the development of more teaching centres in the near future are under way.

Training Facilities

That is not to say Dubai is currently without medical education training institutions. The College of Medical and Health Sciences at UAE University was founded in 1984, with its first batch of students graduating in 1993. The school is accredited by the General Medical Council, accepted by the World Health Organisation, and recognised by Canadian and US universities. It offers bachelor’s and doctoral degrees in medicine as well as master’s programmes in pharmacology, toxicology, microbiology, immunology, biochemistry, molecular biology and public health. In the 2016/17 academic year, 623 students attended the faculty across all courses, 477 of them women.

Additionally, Harvard Medical School has been running a research and training centre at DHCC since 2015, with a focus on health capacity planning in a local and regional context.

In September 2016 the first cohort of students began their studies at a new medical school in DHCC, the Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU). At the end of their first year of studies, 24 MBRU students spent part of their summers on placements with medical and academic research institutes in the UK, Canada, Australia and Cuba, or in the UAE where they interned at New York University Abu Dhabi, the Biotechnology Centre at Khalifa University or at Harvard Medical School’s Centre for Global Health Delivery in Dubai.

In the 7.2-sq-km Dubai Silicon Oasis free zone, the first phase of the Fakeeh Academic Medical Centre was due to be finished in 2017, including three hospital buildings with a total 150-bed capacity. The second phase of the hospital will include a medical school and is planned to open in 2019 (see analysis).

Meeting Staffing Needs

When the Dubai Clinical Services Capacity Plan (2015-25) was launched in November 2014, it identified the need to build three new medical colleges and five schools of nursing by 2025. The medical schools at DHCC and Dubai Silicon Oasis free zone will go some way towards meeting this target, but there have been no further indications of progress in building colleges of nursing.

The Dubai Health Strategy (2016-21) stresses the need to offer ongoing professional development training and to foster more research by Emirati medical professionals and health scientists. Another goal for education providers is in attracting local talent to the sector (see Education chapter). With so few Emiratis working in the medical professions, educators are looking is to inspire new generations to consider health care careers.

Private Providers 

The UAE’s private health care sector ranges from individual medical practitioners operating small clinics, to mid-sized companies, to publicly listed international medical businesses employing tens of thousands of staff. It is a measure of the rapid pace of growth over the last 40 years, that three of today’s major providers started out as small businesses with one practitioner.

In 1974 Bavaguthu Raghuram Shetty, a pharmacist from Karnataka, India, opened the New Medical Centre (NMC) pharmacy and clinic in Abu Dhabi. By 2014 the company was listed on the London Stock Exchange (LSE), and by 2016 had grown into the UAE’s largest health care provider with two main branches of business, NMC Healthcare and NMC Trading. Its 2016 financial statement reported global revenues of $1.2bn and net profits of $151.4m, up 38.6% and 76.5% respectively, on 2015. This expansion continued into the first half of 2017, with global revenues increasing by 34% year-on-year (y-o-y) to $775.2m, and net profits rising by 56% y-o-y to $105.7m. The company operates three hospitals in Dubai, and is currently building two additional medical centres in the emirate. Shetty stood down as chairman of NMC in 2017.

In 1985 Syrian physician Dr Kassem Alom opened Al Noor Hospital in Abu Dhabi with the backing of Sheikh Mohammed bin Butti Al Hamed. In June 2016 Al Noor Group was floated on the LSE with a valuation of £1.2bn ($1.6m). In February 2016 the company was acquired by South Africa’s Mediclinic in a reverse takeover. Mediclinic Middle East operates six hospitals and 31 clinics with more than 700 inpatient beds across the UAE. At the end of 2017 Mediclinic reported global revenues of £2.75bn ($3.7bn), up 30.3% on £2.11bn ($2.9bn) in 2016. However, net profits were down 23.6% for the year, registering £220m ($300m) compared to £288m ($390m) the previous year. Mediclinic also operates in South Africa and Switzerland through its sister company Hirslanden. “We collaborate with our sister centre in Switzerland, and our configuration in Dubai is a mirror image of the Swiss clinic with the same protocols, treatments and equipment,” Sara Alom Ruiz, director of business performance improvement at Mediclinic Middle East, told OBG. “So, Mediclinic patients can be treated in Switzerland and continue their care here or vice-versa.”

In 1987 Dr Azad Moopen from Kerala, India opened his first polyclinic in Bur Dubai. Some 30 years later, Aster DM Healthcare employs just over 19,600 staff in 316 establishments across nine countries, including four hospitals in Dubai under the premium Medcare and mid-market Aster DM brands.

In March 2017 Aster announced it was considering an October 2018 initial public offering in London or Mumbai with some reports that it hoped to raise $300m by selling 10% of its shares.

While many smaller health care practices operating in Dubai may be hoping replicate the success of these firms, new health care entrepreneurs in the emirate are conducting business in a more fragmented and competitive marketplace (see analysis).

Health Insurance

In March 2017 DHA finalised the implementation of universal medical insurance, a process which it began in 2014, whereby employers are required to pay for their employees’ policies. The system was introduced in three phases based on the number of staff on payroll. The rule first applied to larger companies in 2014, then down to small businesses and finally to people employing domestic servants by 2016, a deadline that was extended to the end of March of the following year.

The result is that low-income earners are able to receive treatment in both private and government facilities, with providers able to recover the treatment costs from 12 approved insurance firms. To ensure claims are processed quickly and efficiently, and in an effort to prevent over-prescription of medicines or procedures, new hospital software is being introduced across the board (see analysis).

However, some of those in Dubai’s health care sector suspect that if increasing numbers of people with basic cover start to make claims, insurance companies may see their margins fall, which could have implications for smaller private health care providers. “The insurance companies will start shrinking their network and reducing the number of facilities they are prepared to deal with,” Adams told OBG. “The larger insurers will not want to deal with clinics with a 30% bed occupancy rate; they will focus on the larger established firms that are consolidating, such as NMC, Aster DM and Mediclinic,” he added.

Pharmaceuticals & Devices

The pharmaceuticals sector in the UAE is regulated by the MoHP, which issues licences for all medicines. Although more than 80% of pharmaceuticals are imported, manufacturing in Dubai is expected to grow. In 2016 the MoHP forecast the number of pharmaceuticals factories in the UAE would increase from 16 to 34 by 2020, driven by partnerships with international companies and a predicted average annual growth of 8% in expenditure on medicines. Joe Henein, president and CEO of NewBridge Pharmaceuticals, told OBG, “The pharmaceuticals market in the region and Dubai in particular offer considerable opportunities for growth, particularly in speciality areas such as immunology, oncology and neuroscience.”

Dozens of international pharmaceuticals companies are already operating in DHCC and the Dubai Science Park free zone, while Dubai Investment Park is the home of Globalpharma, a UAE business established in 1998 that produces 300m tablets, 150m capsules and 7m litres of dry syrup annually. In 2014 the French pharmaceuticals company Sanofi acquired a majority stake in the firm. LIFEP harma, part of VPS Healthcare, has a manufacturing facility in the Jebel Ali free zone. BMI Research has forecast a CAGR of 8.2% in the UAE medical device industry between 2015 and 2021, and this segment could grow to be worth $1.4bn by 2025.

Outlook

Dubai has made significant strides in the quality and quantity of health care available to its residents in the last decade, and there is every sign the pace of transformation will be maintained in the immediate future. However, in a sector with such a high proportion of private providers contributing to a competitive marketplace, one of the most pressing issues for the city will be balancing the medical needs of its constituents with market forces.