Modern Literature of the United Arab Emirates
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Clearly child and maternal health services, youth services, health promotion and preventative services and occupational health services should be priorities [ 17 ]. A recurring theme from the studies that we reviewed is the need to improve health data collection and reporting [ 17 , 22 ]. For example, birth and death data are reported but not by nationality, making it difficult to determine what, if any, specific, targeted strategies are required.
In summary, the demographic transition in the UAE is one characterized by declining birth and death rates which with high net in-migration has resulted in significant population growth [ 28 ]. There has been a second health transition in the UAE in recent decades, an epidemiological transition, characterized by a decline in communicable diseases and a rise in non-communicable or chronic diseases, such as heart disease, diabetes and cancer [ 28 ]. This is described in the following section.
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Eight studies discussed UAE mortality, morbidity and risk factors. As mentioned earlier, the UAE Government has set itself a number of challenging targets through its Vision strategy [ 5 ]. Of particular relevance are the targets to reduce the number of deaths per , population from cardiovascular disease from to Since its independence in , the UAE has made significant progress with increased life expectancy and lower maternal and infant mortality rates [ 29 ]. However, despite these achievements, the UAE faces a number of challenges including rising rates of non-communicable diseases such as diabetes, cardiovascular diseases and cancer [ 26 ].
The UAE has made progress with the control and prevention of communicable diseases, through a strong focus on immunization, surveillance, mandatory reporting and effective treatment [ 26 ]. The mandatory screening of all expatriate workers linked to the visa application and renewal process has also had an effect [ 30 ]. The leading causes of premature deaths in the UAE are road injury, cardiovascular disease and respiratory illnesses [ 17 ].
In the studies that we reviewed, authors identified the determinants of this health loss as unhealthy lifestyles physical inactivity, high caloric intake and a lack of health system focus on prevention, chronic disease management, early stage interventions and inadequate treatment options for NCDs and their complications.
As solutions, these authors proposed further research, the establishment of reliable surveillance and monitoring programs and improved training and education for healthcare professionals [ 26 , 31 , 33 ]. One such intervention is the Abu Dhabi Weqaya program that aims to screen adults for cardiovascular disease risk factors followed by targeted follow up, treatment and secondary prevention [ 34 ].
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Weqaya has confirmed a high prevalence of cardiovascular disease risk factors amongst the adult population. Following the successful implementation of screening in a small, high-risk population using newly agreed UAE screening guidelines other researchers have recommended a national diabetes screening program [ 35 ]. In the review we found a number of studies that reviewed the direct and indirect economic burden of selected diseases, including asthma and diabetes [ 33 , 36 ].
The authors of these papers that reviewed the economic costs of high burden diseases typically recommended improvements in management including nationwide early screening and rapid implementation of best-practice clinical guidelines as a means to improve outcomes while controlling costs. Seven studies discussed healthcare financing.
In Abu Dhabi, mandatory health insurance for all nationals and expatriates has been the major driver of its healthcare reform since [ 38 ]. In there were Even though there has been a steady rise in the number of claims Fig. However, other researchers have concluded that increasing claims and costs signal the need for further changes to ensure long-term financial sustainability [ 38 ]. The WHO and other sources estimate that the UAE government spent almost a quarter of its total healthcare expenditure in to send its citizens abroad for medical care [ 16 , 32 ].
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While in , Health Authority Abu Dhabi sponsored over patients [ 14 ]. At the same time, the UAE is working to attract medical tourists to its healthcare facilities, in particular its highly specialized hospitals. In the UAE the level of out-of-pocket OOP healthcare expenses is relatively low in comparison to other countries in the region and the rest of the world.
In the UAE, data on health care spending is not yet available in a standardized format. Denials, co-payments and sole payments are not included. Also cost estimates typically exclude capital expenditure, funding provided through other government institutions such as the Ministry of Defense and ADNOC and cash payments. The total number of hospital beds has more than doubled and there has almost been a five-fold increase in the number of nurses and physicians [ 15 ]. A number of case studies have reviewed the current demand and supply and made recommendations for future configuration and capacity.
Few of these studies reported that additional increases in hospital beds and staff numbers were justified [ 17 , 37 , 44 ]. However, Health Authority Abu Dhabi estimated that a further physicians and 13, nurses would be required for Abu Dhabi alone to meet the projected demand [ 14 ]. Despite these reported shortfalls in capacity and resources, the authors were unable to find any studies that analyzed the potential effects of the reported lack of manpower and hospital beds. On the contrary, a number of studies, as well as a report from the Abu Dhabi regulatory authority described potential oversupply in certain areas [ 14 , 17 ].
Only three of the studies focused on the impact of health system reforms.
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In Abu Dhabi, a study into perceptions and attitudes towards medical research amongst focus group participants noted that the UAE has one of the best healthcare systems in the region [ 47 ]. In our review we found few studies that reported quality and outcomes of care. However, in one study in Dubai that reviewed the quality of care for diabetic patients, using a standardized assessment, the researchers found a number of differences when compared to the US benchmark and recommended a nationwide benchmarking program [ 50 ]. Another study found that while a private hospital maintained its performance following JCI accreditation, accreditation did not contribute to an overall, sustained improvement [ 51 ].
Finally, in our review, we found that studies that examined patient satisfaction generally reported consistently high levels compared to other countries [ 8 , 17 ]. This review has highlighted the ambition and commitment of the UAE to build a world class health system and has catalogued the major reforms that have been implemented in the past decade to achieve this.
The paucity and limited scope of the studies means that it is not possible to conclude whether the reforms are working although patient satisfaction with services appears high and there are some isolated examples of quality improvement.
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The UAE health system is not a single system, rather there are several systems and of these the three main systems are operated by the health authorities of Abu Dhabi and Dubai and the Ministry of Health MOH. The main element of the reforms have been a move to mandatory private health insurance for all citizens and expatriates, the development of the private sector to deliver services and the separation of planning and regulatory responsibilities from provider functions. These reforms have moved at different speeds, being most complete in Abu Dhabi, in the development phase in Dubai and just commencing in the MOH.
This patchy implementation has highlighted variations in access, affordability and quality across the Emirates. Amongst researchers and commentators opinion is divided on whether the reforms have been successful. Few, if any, studies have prospectively set out to define and measure outcomes and while some researchers have expressed optimism others have been more critical. The relevance of the reforms for public health and their impact on the determinants of chronic diseases have been questioned with some researchers citing market failure and oversupply.
The UAE has a rapidly growing population with a unique age and sex distribution. There is an unusually high proportion of young people and expatriates of working age, small numbers of older persons and rapid year on year growth due to high net in-migration.
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It might be expected that the unique characteristics of the population would be a major factor to be considered when planning and implementing health services but there is little published research to support this. While child and maternal health services are well developed, there is little published evidence of needs analysis in the areas of youth services, health promotion, preventative services and occupational health services. Also health data is not collected and reported in a way that allows the health needs of these population sub-groups to be defined.
The UAE has passed through the epidemiological transition with impressive reductions in health loss from infections and neonatal and nutritional disorders but an increasing burden of non-communicable disease NCD notably cardiovascular disease CVD , diabetes and road injury. The lifestyle risk factors for these diseases obesity, low physical activity are at high levels. From our review there is evidence of high level commitment to addressing these issues. The Abu Dhabi Weqaya program set out to identify and manage individual CVD risk factors but after the initial report describing the program and presenting baseline data there have been no updates on outcomes, effectiveness or recommendations to extend the program to the whole UAE adult population.
There is good evidence for the considerable cost burden that NCDs place on health budgets and bench-marking has shown that the situation in the UAE is comparable to that in other high income countries. However there is also evidence that in the management of NCDs international best practice is not always followed. Total expenditure on health has increased both in absolute terms and as a percentage of national income.
As in all health systems these increases can be explained on the basis of population growth, aging of the population, advances in technology and price inflation. In the UAE, the increases may also be justified if there was previously unmet need that is now being met. However in our review we found researchers who suspected over-use, waste and fraud and who questioned whether the increases in activity and cost were sustainable or whether further reforms were required.
In the review, a recurring theme was the need to economize on drug costs by encouraging greater use of generic products. In our review we were surprised that, given the excellence of the UAE health system, substantial numbers of patients are funded to have medical treatment abroad at substantial cost.
This is all the more noteworthy because the UAE health system is highly successful at attracting incoming medical tourists. In the review we found discussion of the percentage of total health expenditure that is contributed by out-of-pocket OOP expenses, a widely used metric to indicate financial security. In the UAE, the OOP percentage is comparable to that seen in other countries with well-developed progressive health systems. This might appear surprising given the high levels of disposable income enjoyed by many UAE citizens and expatriates.
However, once again our review highlighted the need to improve the quality of data collection and reporting and to make allowance for the fact that the UAE population is very heterogeneous. In this review, we found that a normative approach was typically adopted to plan and predict future capacity both for hospital bed numbers and numbers of doctors, nurses and other healthcare staff.
The norms or benchmarks that are used are those from North America and Europe. It is not clear if there is shortage or oversupply or what, if any, are the consequences of this. What is clear from published evidence is the high staff turnover and poor retention rates.
From our review, it is not possible to say if the UAE health systems reforms are working. Some researchers have concluded that it is too early to expect to see any effect but mostly the research in this area has not focused specifically on this question. We found isolated reports of initiatives that have improved quality. UAE national policy is that all hospitals should be JCI accredited and good progress is being made towards this target. Again, there are a few reports of the beneficial effects of accreditation but this is an area that is poorly researched. We found isolated examples of where services or programs had been audited against international best practice benchmarks with mixed findings.
Where researchers commented on patient satisfaction with services this was usually high. Despite the increased focus on healthcare reforms in many countries, it remains a concept lacking a clear definition [ 9 ]. With respect to the impact of reforms, several authors have cautioned against simplistic, cause-and-effect logic because of the complexities involved in overseeing and providing healthcare with multiple, demanding stakeholders, competing political priorities and high expectations [ 53 , 54 ].
However, despite this caution, over the last three decades, global institutions such as the World Health Organization and the World Bank have stimulated national government to reform their health systems, with notable results [ 55 ].. For example, governments of developing countries, such as Brazil, Russia, India, China and South Africa have committed themselves to radical reform programs with the goal of achieving universal health coverage and China in particular has made significant progress in ensuring that its population has access to healthcare [ 56 , 57 ].
Similarly, the Affordable Care Act in the US has resulted in an impressive decrease in the percentage of uninsured adults [ 58 ].. Specifically to the Middle East and North Africa region, researchers have commented on the increased focus on building or reforming health insurance systems as a popular method of reform [ 59 ].
This is the most complete summary, to date, of the evidence available on the progress and outcomes of health systems reform in the United Arab Emirates. Our study is not without limitations. We found a limited number of studies that addressed UAE health system reform and of those that did most lacked robust methodology and failed to focus on the outcomes of reform. Although our search strategy was broad and included both published and unpublished sources to minimize publication bias it is possible that papers meeting our inclusion criteria were missed and therefore, not included in the review.
Nevertheless, the review provides a stock-take or baseline from which future researchers can plan and develop their research questions.