UAE Findings: Strength in Infrastructure

The UAE has one of the most interesting health provider and insurance systems I’ve seen to date. Based on the complexity of the patient population and varied forms of insurance, the health system here has unique challenges and opportunities for new diabetes programs. One of the most important influences on the system is the Expat population in the UAE: about 80% of the population is comprised of Expats (non-citizens) who do not benefit from the government healthcare programs. Not only does this mean the population is very diverse (Dubai and Abu Dhabi are considered two of the most international cities around the world) but only 20% of the population relies on government programs (and funding) for healthcare.

A Complex Infrastructure

So how does this impact care as a whole? The vast majority of health in the UAE is private: privately insured and privately provided. The result has been a significant investment in health infrastructure from both private and public funding to support the larger patient population (and in theory that of some of the region as well). In Dubai, the “Healthcare City” is a mini-city of some of the nicest healthcare facilities I have seen anywhere with top-of-the line technology, equipment, and information systems. However, this can be seen all over the UAE with a number of exemplary hospitals and clinics, many of which are international chains that have been “imported” to treat a specific patient population or affordability level. For example Mubadala, Abu Dhabi’s investment arm, is currently in the process of establishing a Cleveland Clinic in Abu Dhabi. The Expat population is comprised of several classes of patients: the low-class labor workforce (e.g. construction workers), the low/middle working class (e.g. taxi drivers), and high-end businessman (e.g. real estate / finance). This adds to the complexity of the health care and insurance needs / affordability of the patient segments.

I was able to meet with the Health Authorities of Abu Dhabi and Dubai to understand their perspectives on the system and needs for chronic care programs. In Abu Dhabi all residents are required to have insurance through their employers and in Dubai about 80% of the population is covered. All Emirati are 100% covered for all health services public or private through the government. I was extremely impressed by the quality of data from Abu Dhabi (as all people are covered the health data is tracked via insurance reimbursements) and we discussed the progression of diabetes in the population.

The graph below was one of the most frightening I’ve seen and demonstrates the “boom” of diabetes growth the population is destined to see without serious action.

Challenges in Talent Management

The UAE’s biggest challenge in healthcare is recruiting and retaining quality health care talent. One of the most interesting interviews I conducted was with Dr. Ashraf Ismail from Joint Commission International (JCI). He highlighted this issue and the impact it has on the quality of care at a systemic level. Although the country has some of the best facilities in the world, they require highly educated and coordinated health professionals to execute healthcare that is safe and effective. He stressed that safety is a culture that needs to be nurtured over time. This is difficult when the average physician and nurse stays in country for about 2 years before moving to higher-paying positions in other countries. In fact, many recruited healthcare workers view the UAE as a stepping stone to moving to countries in Europe or the US. This is a huge issue. Hospitals are constantly in the process of onboarding and training professionals and in most cases, the concept of “teaming” approaches to healthcare are lost entirely.

Another impact of this transient healthcare environment is that the general patient population (including Emirati) doubts the quality of care, despite the impressive infrastructure. Taken to the extreme, many patients travel internationally for healthcare services, especially larger procedures. Typically Expats return to their home countries (e.g. UK, India, Germany) for treatment. The Emirati are known for medical tourism outside the region as all of their health services are 100% covered if in a private facility (regardless of country). This is challenging on a number of levels because the lack of faith in the system creates a Catch 22 of lacking investment in the system.

It is also worth pointing out that the UAE is unlike many healthcare systems where the providers are consistent and the insurers change every few years. Instead it is quite the opposite, the insurers are primarily constant and the health providers are changing and varied.

Prevention Needs Recognition

For the majority of privately-covered patients (e.g. Expats) primary care is not covered or recognized as a needed investment. The purpose of health coverage is treatment and the majority of patients often wait until they are sick to seek treatment as a result. For diabetes specifically, early detection is varied among the community. The general awareness among nationals is very high for diabetes but few seek treatment early in the progression of their condition. Additionally, many expats from India, Pakistan and Western countries bring their propensity for the disease into the system as well.

I met with Zulekha Hospital in Dubai who is working to engage the community in awareness and education efforts for a variety of conditions it sees as high priorities in their patients. For example, their “healthy kidney” campaign has involved posters and providing free water bottles to all incoming patients to drive awareness. They expressed diabetes as an important area and gave suggestions on ways to reach patients in a community setting – mostly through the malls or festivals in country.

Cultural Perceptions and Care

For regional and national patients, a number of cultural perceptions significantly affect how healthcare is perceived. Patients’ conditions as well as motivation to seek help and treatment can be significantly affected. Mubadala is Abu Dhabi’s investment arm (you may have seen some ads for them during the World Cup?) and their lead for the healthcare sector expressed his experience with patient perceptions. The majority of patients with an Islamic background, for example, seemed to have a cultural acceptance of many diseases or conditions as if sent from God. With a belief that many events in life are fate-driven, it’s even more challenging to motivate patients to make changes in their lifestyle and health habits. I spoke with an internal medicine specialist and diabetes nurse at the International Modern Hospital that treats the largest number of Emirati patients outside in the private system. They stressed that it is difficult to get patients in the door and “even the concept of taking a pill” is a huge challenge for some. In an effort to reach patients more effectively, they tested some homecare concepts that failed completely, as many patients cancelled appointments last minute or were not home when the physician team was scheduled to arrive.

Additionally, the Dubai Health Authority spoke a lot about options for people to practice healthy habits such as exercise. Public spaces for walking, running, and playing are very important and already prioritized within the government / MOH efforts. However, over and over again I heard many challenges with respect to the weather (humidity and temperature) of the region. When I was in Dubai it was almost 50^oC and humid which can be almost dangerous conditions for any exercise. So how do you deal with this? They are piloting concepts that open health clubs for nationals to have exercise facilities that are included in their health coverage so this maybe an interesting (and replicable) solution if it works!

As I’ve mentioned before, having healthy options is a significant component of empowering patients to change their lifestyles. However, the culture must support the decision process that chooses these options over the status quo of inactivity (watching TV, sitting at the computer) and poor food choices (as it was described to me, “Krispy Kream is making a killing” in the UAE).

Opportunities for Diabetes Solutions

There is a lot to be hopeful for with respect to diabetes care in the UAE. It is already recognized as a national priority and once a strategy is in place, the funding and willpower is there to make it happen. I spoke with Dr. Ali Shakar, the previous Director General of the Ministry of Health for the UAE who spent a lot of time discussing past efforts and opportunities for the country (and what Project HOPE can do to help). He was interested in collaborating to develop a larger GCC effort that focused on patient empowerment and prevention efforts through Project HOPE’s “5 Steps to Self Care” and “Healthy Lifestyles” educational programs: one targeting the affected patient population and the other elementary students that represent the “future of the nation.”

Mubadala also emphasized their impressive investments in diabetes care to date – as well as plans to expand. Their work in the Diabetes Institute in the Empirical College, led by Dr. Maha Barakat, had been recognized internationally for its vision and success with execution. The center has driven so much volume that they are opening another facility in Al Ain, where 35% of their patients are commuting from for care. The facility provides all diabetes care and specialists in house (including lab and pharmacy services) with a range of specialty care including podiatrist, cardiologist, and weight management services.

I was also able to visit the Joslin Diabetes Center in Dubai which is a branch of a US-based chain that delivers top of the line care. I met with two diabetes educators there and the founder of the center who described the learning s they’ve had in the past 13 months since its opening. In the first year the facility was reserved exclusively for nationals and demonstrated the ability to reduce patients A1c levels in 3 months through treatment, lifestyle change, and close monitoring. The diabetes nurse walked me through their educational and treatment model.

She mentioned that they provide each patient a glucometer and strips for free and electronically “download” all glucose readings from the meters with each visit. This was fascinating to me as I’m not sure it’s a standard practice in the US. What happened was that patients actually started testing their glucose regularly and noticing changes based on their diet and medication (this also means patients can’t fake their glucose readings which can be a common issue otherwise).

They also highlighted a few challenges in the first year of care for the community. One, there are huge challenges finding nurses that have the technical skills and LANGUAGE skills to work with patients. This is not something that had occurred to me before. Because many healthcare workers are imported, many are not as proficient (or at all proficient) in Arabic. Could you imagine trying to talk about your emotional challenges with diabetes with someone who doesn’t even speak your language?

They also expressed some challenges with the “fate-centric” culture but that after time they were fairly compliant with care. Finally, I was shocked to discover that all of the model foods for carbohydrate counting and food-portion education were Western foods (e.g. green beans, rolls of bread). There was no hummus, falafel, pita, or anything that resembled what the majority of the patients consumed on a daily basis. This is a HUGE area for improvement – it’s not enough just to translate materials but the content of the education needs to be adapted to the culture itself. If patients don’t know that falafel has tons of carbs they are going to worsen the progression of their disease.

The UAE was by far one of my most productive visits with the majority of the interviews initiated from previous interviewees that supported the cause with the belief that Project HOPE can help. Influential interviews with Dr. Ashraf Ismail, Dr. Ali Shakar, Mubadala, and the health authorities of Dubai and Abu Dhabi provided a diverse perspective of the in-country priorities from a variety of stakeholders. The UAE’s unique location in the Middle East also makes them a strategic target for regionally-collaborated efforts that include the larger GCC region with similar patient needs. Additionally, the availability for national funding for pilots that could be successful in the region considering the national GDP per capita is larger in the UAE than the US (and almost double the US’ in Qatar).

I look forward to seeing what comes of Project HOPE’s work in this region as they focus on primarily government partnerships to facilitate program development and implementation, leveraging their expertise and experience with global diabetes efforts to date.