The sand-colored, Arabesque complex in the middle of suburban Abu Dhabi known as Sheikh Khalifa Medical City opened a decade ago, aiming to provide native Emiratis a level of health care they otherwise traveled to Europe or the U.S. to receive. But since 2007, the building sports the sign of its new management, renowned medical provider The Cleveland Clinic, brought to the United Arab Emirates (UAE) with similar hopes of improving the country’s quality of health care.

Once, the UAE and its oil-rich neighbors in the Gulf offered free public health insurance for citizens, but the economic and staffing burden of generous public medical care has proven unsustainable. As a result, many Gulf countries are moving to the private health care model, and Abu Dhabi is viewed as a leader in health care reform in the region, pushing the envelope in aggressive, strategic steps.

"Abu Dhabi is taking the lead in being equipped," says Laura Morlock, professor of health policy at Johns Hopkins School of Public Health. "The government is optimizing health care spending by using very good cost-effective analysis." And as GE Healthcare’s CEO John Dineen told, "Most health care systems can’t afford to throw money at problems anymore."

Another factor pushing the transition to private care is the rapid rise of diabetes, cardiovascular diseases and cancer in the region, which is putting heavy demands on staff, equipment and medicines available in hospitals and clinics. The World Health Organization ranks the UAE as having the second highest prevalence of diabetes in the world, noting that five of the top ten worst countries are in the Gulf region. In Abu Dhabi, more than half the population over the age of 50 has diabetes, according to the Health Authority of Abu Dhabi (HAAD).

In 2009, more than 25% of deaths were attributed to cardiovascular diseases, even with a young population whose median age is 19 years old. Around 14% of deaths in 2008 were from cancer, with the late detection of breast cancer being one of the major issues. "These alarming rates of diseases led our government… to enhance and help our systems," says Dr. Jamal Al Kaabi, director of customer services and corporate communications at the Health Authority of Abu Dhabi.

Blame Junk Food, Lack Of Exercise?

Abu Dhabi’s population of around 2.2 million people has an interesting profile, with profound effects on the health care system. The expatriate population accounts for as much as 80% of the residents, the majority of whom work in the construction industry. That group is comprised of mostly young Asian men between the ages of 20 and 40 years old. Of the Emirati nationals, two-thirds are under the age of 30 years old. Though the Emirati population is very young, it is starting to exhibit ‘old’ population diseases like diabetes and cancer, says Ali Hashemi, a health care management principal at Booz and Company. "What have become materially important are the numerous lifestyle, genetic, and nutritional factors that are causing this trend," Hashemi says.

Why are these chronic, non-communicable diseases so prevalent in Abu Dhabi? "That is the big question," says Dr. Oliver Harrison, director of public health and policy at HAAD. "It’s clear that the causes of non-communicable diseases, including cardiovascular disease are complex," Harrison notes. "We are exploring the interplay of three branches–genetics, environment and behavior." Abu Dhabi, he adds, has "experienced a unique historical change in the economic and socio-cultural environment. The rapid rise in wealth has resulted in rapid changes in behavior."

"It used to take two days to earn enough to buy a pound of rice but now there is a much greater wealth, so greater access to calories and a more sedentary lifestyle, resulting in a profound lack of physical activity," notes Dr. Omar Shafey, senior officer of medical research at HAAD. "Modernization and wealth have changed people’s behavior," adds Dr. Ali Abdulkareem Alobaidli, chief clinical officer at Abu Dhabi Health Services Company (SEHA). "We do sports less and eat more junk food." Al Kaabi concurs but suggests consideration of other factors. "There’s been a rise in better detection with an increase in screenings," he says.

Alobaidli hosts an Arabic television show, helping to educate the public about lifestyle and behavior changes that affect one’s health. He and 17 other Abu Dhabi health officials recently obtained a Master’s of Public Health from Johns Hopkins Bloomberg School of Public Health, and most are now going on to study for their doctorates.

Analyzing public health issues and regulating health care policies is a relatively new for HAAD. Prior to the 2006 move to health insurance, the government entity actually focused on providing free health care for its residents. Now, HAAD is a pure regulator, having created health insurance and spun out its provider arm, thereby creating SEHA. HAAD now focuses on setting policies and standards, collecting a wide range of health statistics, and creating prevention programs for its citizens.

Verisk Health, an American company specializing in medical intelligence, helped HAAD develop models to predict mortality rates and disease progression models. Abu Dhabi had little historical data to analyze because healthcare claims and billing weren’t documented that rigidly when the government was subsidizing full medical care for citizens, according to Jordan Bazinsky, vice president of science and technology at Verisk Health.

Verisk used historical medical information from American commercial and Medicare databases to develop models for various age and gender demographics. Certain modifications were made for the genetic makeup and lifestyle factors, like obesity, smoking, and family history for Abu Dhabi residents. "The key contribution of Verisk was to help us better predict future outcomes based on current health patterns in our population," Harrison says.

Aiming To Reduce Disease

In 2008, virtually the entire Emirati population (around 95%) was screened for cardiovascular disease and its risk factors, including diabetes. Participation in this program, "Weqaya" (Arabic for "protection" or "prevention") or withholding consent after a clinician consultation, was a requirement for citizens to obtain their national insurance card for the first time. "Right now, we’ve been putting in Abu Dhabi data into the same algorithms developed in the U.S., for example through the Framingham Heart Study (a large-scale research project to understand causes of cardiovascular disease) and the Verisk analysis, to see what the future patterns will look like," Harrison explains.

Verisk Health’s clinical classification systems are used to create individual level summaries of illness burden and drug usage for Abu Dhabi residents. The algorithms have been built in the software and the company provides coding updates for HAAD annually.

After establishing a baseline, HAAD is able to predict what the health care needs and costs will be in the future for its population. "We recognize the twin importance of both patient privacy and ensuring that the ‘data goes to work’", Al Kaabi says. "We want to utilize the data we collect in the best way possible so we can prepare ourselves for addressing all health care challenges, whilst guaranteeing the confidentiality of all our health care customers. We aim to change the factors for these chronic diseases."

HAAD has also been very proactive in addressing health issues with the Weqaya Program. Based on the premise of screenings and developing preventative medicine, like smoking cessation incentives and diabetes lifestyle instruction, it’s "setting the health system on a good foundation," Harrison says. Currently, there are 200,000 adults in the Weqaya program with an average age of 30. The frightening statistic for Abu Dhabi’s public health is that 71% have at least one risk factor for cardiovascular disease today. Additionally, 18% have diabetes and 26% have pre-diabetes with a high risk of developing diabetes in the next five years.

By coordinating the health sector with individual lifestyle programs to address issues like physical activity, nutrition and tobacco use, the aim is to reduce the incidence of diseases that are seriously impacting the public health of Abu Dhabi. "Patients are screened iteratively to see who is benefitting and who is being left behind," Harrison says. "If a program doesn’t work, we cut it and move on. The idea is to run with the wins and cut our losses, steadily improving the effectiveness and cost-effectiveness of the program over time."

There are other monetary incentives for doctors and companies to comply with Abu Dhabi’s evidence-based health care policy. A doctor will get a small bonus if they do the proper diagnosis and exams, follow up with correct medicines, and discuss the appropriate health interventions with the patients, Shafey explains. The information is then funneled to HAAD, which is entered into a population database.

In addition, there is a pay-for-health incentive program for companies called Disease Management Providers (DMPs). "By the first quarter of 2012, DMP providers will begin working across the entire population," Harrison explains. "The way it works is the companies will be paid approximately US$1,500 per patient per year for improving health data over the initial baseline data of the patients.

"This is highly cost-effective," he continues. "DMPs can do case management with text messages, face-to-face meetings–whatever is allowed by our policies and standards. They can’t force people to exercise or make them eat the right food. That is the power of Weqaya. We are beginning with the best of the current evidence base and we shall improve over time through using our wealth of data."

Health A National Priority

For a developing nation with a recent influx of wealth, managing a healthier population becomes a priority in moving forward. Prior to the discovery of oil in 1962, there was hardly any health care system in place, especially in rural areas. The population of several thousand residents was dispersed over a barren desert landscape. When it was created, an expansive Federal Ministry of Health was put in place to provide health care and regulate the industry. By the mid-90s, the "quality was felt to not be improving, if not getting worse," Harrison says. "Capacity was an issue so we wanted to expand services in a comprehensive form," Kaabi adds.

As a result, the Health Authority was created, and by 2007, a federal decree mandated that HAAD create regulatory guidelines for the health care system, as well as manage the future of what health care should look like in Abu Dhabi.

"Not long ago, Abu Dhabi’s health sector looked like the rest of the Middle East with a single body, the General Authority for Health Services, acting much like the existing Ministries of Health (MoH) elsewhere," Hashemi says. "It covered everything from owning hospitals, to paying for the care, to regulating the market overall. In the years since, Abu Dhabi has been evolving very rapidly in the overall governance and structure of its healthcare system. It was the first to move away from the traditional ‘MoH model’ and split up its functions into separately governed organizations–the Health Authority of Abu Dhabi as the regulator, SEHA as the healthcare provider, and Daman as the insurer."

In 2006, HAAD launched a health insurance system for the first time. It was a basic state-subsidized product for the low-paid expatriate that cost employers around US$180 for local coverage. In 2007, it became mandatory for employers to provide private health insurance for their expatriate workers. In 2008, a regional government-funded health insurance product, Thiqa, was launched for Emirati nationals.

"Now there is broader coverage for broader segments of population, as well as improved access and more demands on the provider," Alobaidli says. "We can also do more customized disease management programs, such as Weqaya."

Along with these new health insurance systems, competition developed among health care providers and health insurance companies. "Abu Dhabi is a very interesting laboratory of managed health provider competition," says Morlock, at Johns Hopkins School of Public Health. "We’ve talked a lot about it in the U.S. but it is being very thoughtfully implemented."

As a result, international health care organizations, such as Johns Hopkins, the Cleveland Clinic, and Bumrungrad Hospital, have set up in the country as contracted managers of individual public sector hospitals in Abu Dhabi. The Cleveland Clinic is in fact building its own facility on one of Abu Dhabi’s new island districts.

However, traditional fee-for-service management contracts have been wrought with challenges, and players in the region are looking to evolve the model for how they engage with international partners. "Most governments in the Middle East do not need the money, but an equity involvement is one way to ensure that international partner’s interests will align with local stakeholders," Hashemi says. "Previously, some of the international health care management companies didn’t have much skin in the game beyond tangential brand exposure."

The new focus on health care reform has created some growing pains. HAAD predicts that up to 5,000 additional doctors and 6,500 nurses will be needed by 2019. Based on current turnover rates, approximately 1,600 doctors and 1,800 nurses need to be recruited every year to meet the UAE’s health care demands. HAAD examined various specialties and determined that pediatrics, orthopedics, ophthalmology and gynecology are areas experiencing dire shortages in expertise. "The magic phrase is, we need to sustain our health system. We need local physicians and health care professionals contributing with their knowledge and experience," Al Kaabi notes.

Health care reform in the UAE hasn’t generated the same debate as it has in the U.S. or Europe. Hashemi points out that due to the political and leadership structure in the Middle East, there has typically been a single strong leader or a small group of leaders who have "helped shape the agenda top-down. Reform can be accomplished much faster and without as much discord or political distraction to hinder evolution. The risk, or course, is losing the intellectual benefit that comes from the diversity of a healthy debate."

However, given the recent turbulence in the region, he notes that "governments are now more closely assessing the social impact of potential reform efforts, with particular sensitivity to short-term implications that may come with have high political cost. For this reason, we may see that on some levels there will be a slow-down in major transformative and structural changes in favor of incremental improvements in quality of and access to health-care provision that result in a visible benefit to society."

"Currently, Abu Dhabi is ahead of its peers in the region on the axis of structural reform," he adds. "It was the first to institute many reforms. They’ve come a long way, and have forged a solid example for other neighbors in the Gulf Cooperation Council."