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GREENER JOURNAL OF MEDICAL SCIENCES

 

 ISSN: 2276-7797            ICV: 5.98

 

Submitted: 19/01/2016                               Accepted: 25/01/2016                         Published:30/03/2016 

 

 

Research Article (DOI: http://doi.org/10.15580/GJMS.2016.1.011916016)

 

Managing Sustainable Health Care Delivery in the UAE

 

David Achanfuo Yeboah

 

Professor of Epidemiology, Abu Dhabi University.

 

Email: David.Yeboah @adu .ac.ae

 

ABSTRACT

 

This study examines sustainability in health care delivery in the UAE and the most effective approach to achieving this so called sustainability in health care. The study analyzes both quantitative and qualitative data to postulate that the notion that sustainability in health care delivery is based only on finance is a myth. The study argues that attaining sustainability in health care delivery is determined by numerous diverse but interrelated factors in the Emirati society. These factors transcend social (including demographic and educational factors), cultural, economic and political factors. The study contends that the existing socio-cultural, economic and political institutions in the UAE have the potential to support the achievement of sustainable health care delivery and management in the UAE. It is the  conclusion of  the study that sustainability in health care is achievable in the UAE but that the planning, provision and management of health care delivery are of utmost importance.

 

Keywords: health care, health care sustainability, UAE.

 

 

INTRODUCTION

 

Health is everybody’s business. One of the greatest challenges that humankind continues to encounter throughout history (from generation to generation) is healthcare and, in particular, achieving optimum health outcomes for all population subgroups in individual countries. Indeed, the importance of health care cannot be overemphasized. Good health is everybody’s expectation as everybody is potentially at risk of getting sick or developing ill-health at any time. Besides, there are interrelationships between health and other social, economic and environmental factors. The Greek Philosopher Socrates stated over 2000 years ago that clear links existed between environmental conditions and the occurrence of disease. Today, there are a number of biological, environmental, social, cultural, economic and political factors which determine health.

The challenge remains as to how best to develop and deliver health care to ensure the achievement of optimum health outcomes including improving health status into the future and having a viable health care delivery system. The United Arab Emirates (UAE) Government and other governments around the world have tried to achieve these outcomes through the use of various strategies covering policies, legislation, programs and services. In addition, the provision of funding using various funding models has played a key strategic role in these developments (Yeboah, 2007). A key objective is to develop, deliver and manage what has been called sustainable health care in the country. However, the question still remains as to how to develop, deliver and manage sustainable health care in the UAE.

The purpose of the present study is to identify and propose potential means of addressing the question of achieving sustainability in health care in the country. The article undertakes theoretical and empirical analysis leading to the establishment of propositions to achieve sustainable health care and its management in the UAE. The study begins with an attempt to define clearly what is meant by sustainable health care, especially within the context of the social, economic and political structures of the UAE, and concludes with strategies to manage sustainable health care.

 

 

LITERATURE REVIEW

 

Not much exists on ethics and health care in particular and population and health generally, in the published research literature on the UAE. Raven (2002) discussed the intersection of healthcare organizational ethics, pointing out that healthcare providers are business organizations with ethical issues. Gulf News (2011c) discussed ethical issues surrounding Doctors being remunerated by commission instead of salary, while Gulf News (2011b )  reported warnings from health professionals regarding the sale of prescription medication over the counter.

National Newspaper (2011:1) pointed out the growing problems with waiting lists for various health procedures in the UAE while Yeboah (2007) examined population growth and the demand and provision of health services in the UAE up to 2006. He found that population growth was accompanied by new medical centers and increased number of public and private health services.

Okaida (2003) examined mental health in the Arab world while Zufur (2003) focused on women empowerment in the Arab world. Bener et al. (1993). (1993) investigated variables affecting health in the UAE, focusing on primary health care. They examined the 1986-1991 health strategy and concluded that health care had improved in the UAE. In addition, Matthew (2001) studied obesity in the UAE, indicating that there was a need to target obesity in the UAE. He concluded that obesity has a far greater impact in the UAE than acknowledged. UAE Ministry of Health (2001) presented professional code of conduct for health professionals, defining clearly what ethical practices were expected from medical practitioners and other health professionals. Ethical issues in health care have not received any attention in the published research literature on the UAE.

More recently, Yeboah (2014) investigated the over the counter sale of prescription-only medicines in Abu Dhabi and found an endemic practice of selling and buying medicines over the counter without prescription as required by law.

 

The present study

 

As stated in the introduction, this study focuses on sustainable health care and its management in the UAE. The initial question to be addressed is what is sustainable health care? The emerging approach to health care provision, usually referred to as sustainable health care, has been defined in a number of ways. The Oxford English dictionary defines sustainable as “capable of being upheld, maintainable”. According to Pencheon (2014), sustainable health care is environmentally sustainable, financially sustainable and makes far smarter use of virtually unlimited social and human capital.

Writing on sustainable health care, Richetta (2013) stated that sustainable health care is the adoption of people centric innovative strategies that safeguard health of individuals and society by providing prevention and care adapted to evolving care needs today and tomorrow.

A more persuading set of defining statements was presented by Prada (2012) as follows: It is a system that:

 

     Is designed to meet the health and health care needs of individuals and the population (from  health promotion and disease prevention to restoring health and supporting end of life);

     Leads to optimal health and health care outcomes;

     Responds and adapts to cultural, social and economic conditions and demands; and

     Does not compromise the outcomes and ability of future generations to meet their own health .and health care needs.

 

The present study defines sustainable health care as an evidence based, responsive, adaptable, maintainable and scientific approach which addresses the health needs of current and future generations and which strives to achieve optimal health outcomes now and tomorrow. To attain the tenets of this definition, sustainable health care must consider the existing environmental, social, cultural, political and economic factors (including existing institutions) as well as work in partnership with health service providers and identifiable key stakeholders. In addition, it is worthy to mention that the definition presupposes the need for a critical epi-statistical analysis of health data, especially disease data. Sustainable health care must exhibit a high degree of flexibility to allow relevant and key changes in the community to be incorporated. Indeed, there is research evidence indicating that community factors are essential in the development and delivery of health care (Yeboah, 2005; Whitelaw et al., 2006).

 

Developing sustainable health care

 

The challenge is how to develop and deliver sustainable health care. A number of diverse but interrelated factors have the potential to influence sustainable health care in any community such as the UAE. These include effective planning, smart use of resources, and existing socio-cultural, politico-economic and environmental factors in the community (figure 1). As evidenced in the published research literature an appropriate framework must include all the salient elements of sustainable health (White, 2013). As shown in fig 1, all the key elements of sustainability in health care are included in the proposed framework.

 

 

 

Resources

 

The successful achievement of sustainable health care depends on a number of human, financial and related resources which work individually and severally to achieve that outcome. The notion that funding is “sine qua non” for health is increasingly becoming a myth. There is no two ways about the need for adequate funding, but the provision of sustainable health care does not depend on just funding. Health care provision requires funding and most countries strive to fund health within the framework of their so called limited resources and competing sources for existing funds. The amount of money allocated for health care is usually analyzed as a proportion of Gross Domestic Product (GDP) or as a proportion of Total Government Expenditure (TGE).

Accordingly, to the WHO (2015), 15.6% of Total Government Expenditure was spent on health worldwide in 2013. Table 1 shows general government expenditure on health as a percentage of total government expenditure by WHO Region. It is evident that most Regions recorded an increase in government expenditure on health as a percentage of total government expenditure during 2000 and 2009, albeit the increases were very small. Most Regions recorded less than 1 percentage point increase during the 10 year period. Only the Region of the Americas and Western Pacific Region increased their expenditure on health by more than 1 percentage point. In terms of % change from 2000 to 2009, no WHO Region recorded a decline in General Government Expenditure on health as a percentage of Total Government Expenditure during the 2000-2009 period. On the contrary, all the Regions  increased their General Expenditure as a percentage of Total Government Expenditure, with the Region of the Americas recording the highest increase of 16.6% while the Eastern Mediterranean Region recorded the lowest increase of 2.9% (Table1).

 

 

 

Table 2 shows government health expenditure as a % of Total Government Expenditure in the UAE and the GCC compared with selected other countries. UAE (10.2%) and Bahrain (10.6%) recorded the highest general government expenditure on health as a % of total government expenditure in the GCC. Oman and Saudi Arabia recorded the lowest proportions of government expenditure on health. Elsewhere, Argentina recoded some of the highest general government expenditure on health as a % of total government expenditure (31%).

 

 

 

Within the realm of resources, another key indicator or factor for sustainable health care is the health workforce.  Table 3 shows the health workforce for various WHO Regions during the 2005-2010 period. With the exception of European Region and Region of the Americas, all other Regions recorded lower density per 10,000 population than the global averages.

 

 

 

Planning

 

According to the present study, planning is an integral component of the framework for sustainable health care. To achieve sustainable health care in the UAE, effective and efficient planning at national and regional (by Emirates) levels is essential. The study proposes the adoption of place based health planning in sustainable health care. Following Yeboah (2005), planning for sustainable health care must be holistic and comprehensive, taking into consideration existing local demographic, socio-cultural, politico-economic and environmental conditions (see also Whitelaw, 2006).

 

Community factors

 

A number of community factors are included in the framework for sustainable health care. They include population characteristics such as size, composition, distribution and dynamics, socio cultural factors (education, norms and values etc.), economic factors (including employment and unemployment, incomes etc.) as well as political factors. The proposed framework for sustainable health care works on the fundamental notion that the existing local conditions operate individually and severally to determine the potential for sustainable health care. The proposed framework postulates further that the existing socio-cultural politico-economic and related local institutions must support sustainable health care, otherwise it will be near impossible to achieve sustainable health care in any society.

 

Evidence based approach

 

The framework proposes the incorporation of epi-statistical evidence in the development and delivery of sustainable health care. Continuous needs assessment is a “sine qua non” for sustainable health care. Evidence from needs assessment including future projections together with data on patterns of disease and injury, funding and population dynamics would have to be included in any approach to achieve sustainable health care. On a related matter, It is the postulation of the framework that due consideration be given to regular data collection and analysis if sustainable health care is to be achieved. There is also evidence to suggest that data on settlement patterns, internal and external migration, and urbanization and population redistribution will impact on planning and, thus, sustainable health care (Yeboah,2005).

 

Stakeholders and partnerships

 

According to the proposed framework, sustainable care would benefit from the identification of key stakeholders in the community and the establishment and nurturing of ongoing partnerships with those stakeholders. Key stakeholders include patient and patients advocacy groups, service providers (public and private) funding agencies, health professional associations, community leaders, politicians etc. A salient feature of partnerships is consultation. Decisions must be made in consultation with key stakeholders who the framework suggests should be considered as partners and treated as such. The framework emphasizes the need for all parties to work together (Richetta, 2013).

 

Management

 

Management is an integral component of sustainable health care. The study concedes that, sustainable health care cannot be achieved without the effective and efficient management of the whole process. In addition, the framework postulates the need to manage relationships between the Ministry of Health and the Health Authorities as well as relationships with patients, stakeholders including service providers. Health management in the UAE involves two broad levels, namely federal and Emirate. The Ministry of Health is the national agency which makes decision for the country. However, national decisions are passed on to health authorities in each Emirate and these authorities have the responsibility to implement those decisions (Figure 2). Each Emirate has an Executive Council that is usually chaired by the Crown Prince and this Council makes and approves health and other decisions, proposals, projects etc.

 

 

 

DISCUSSION

 

As indicated in the framework, a number of factors work individually  and severally  to achieve sustainable health care. Resources are key or essential factors, especially in relation to funding and health workforce. As a rule, no country provides adequate funding for health and this is a direct result of limited availability of funds and competing sources for the national wealth. Table 1 shows government expenditure on health as a percentage of total government expenditure for WHO Regions. It is worthy to observe that, with the exception of the Region for the Americas, the general government expenditure on health as a percentage of total government expenditure was less than 10 for the other Regions. Clearly, government health expenditure is not adequate. Sustainable health care requires adequate health funding which must be maintained at a level to guarantee adequate health care for current and future populations.

Health funding as an element in sustainable health care transcends just the provision or supply of money. In addition to substantial lmonetary outlays, the concept of funding should include appropriate management of health funds, avoidance of waste, substantial and efficient public and private sector investments as well as innovative approaches to health funding. Indeed, affordable financial resources and investments and innovative funding models have been identified by Prada (2012) as one of the 6 key elements and principles of sustainable health care. This study argues that, without a prudent management of health funds and the adoption of innovative funding approaches, no amount of money would ensure the attainment of sustainability in healthcare.

One such innovation to health funding is the proposal for the UAE to adopt place based health funding model inherent in place based health planning (Yeboah, 2005). The demographic dynamics, availability, affordability, access and use of health services vary from society to society and from Emirate to Emirate in the UAE. This presupposes a need to include local conditions in the development and delivery of health care to achieve sustainability. This study advocates and supports place based health funding as an integral component of the place based health planning model. Besides, as noted by Pencheon (2015) a key challenge to embedding sustainability in health care is for health systems to strive to remain within tight financial environments. The onus is on health managers to strike the right balance and achieve sustainability.

Another key resource which is essential for sustainability in health is health workforce. No health system will be successful without well trained and skilled professional personnel. There is evidence in the research literature postulating that sustainable health care is dependent on thriving and sustainable workforce (see, for example, Prada 2012). In the UAE, Health care providers are striving to attract, recruit and maintain highly qualified and skilled health personnel from all corners of the globe.

It is worthy to note that the UAE workforce consists of professionals from various parts of the world, and this is true for Doctors of all disciplines and specializations, Nurses and pharmacists etc. While this has been the practice for a long while, the country would have to put due emphasis on the training of Emirati health professionals to ensure sustainability. In that direction, the leadership of the country has adopted an innovative approach by developing policies, programs and activities to achieve what is called the knowledged society. In addition, the Government has lent support to the establishment of numerous medical and health institutions in most Emirates. It is a primary objective to have a skilled health workforce in this country. That will surely contribute to the attainment of sustainability in healthcare.

The key challenge in terms of sustainability is the effective and progressive management of the health environment including resources and workforce to ensure low turnover and high levels of retention. Maintaining skilled workers for current and future populations is key to sustainable health care. Strategies to achieve this objective include better employment conditions for workers, continuous training and creating safe and healthy work environment. All these prevail in the UAE and the challenge is to maintain them into the future.

Planning is also required to manage expected and unexpected developments in the health sector today and tomorrow. The study proposes that health planning in the UAE should adopt place based health planning, instead of the population based models. The basic nature of UAE society, including relatively small  population size, highly  active population dynamics, responsibility for health care resting with individual health authorities in each Emirate together with the availability of health funds, enhance the potential for sustainability. The rapidly and continuously changing population in the country (with foreign workers arriving and departing daily) does not facilitate or rather support population based planning models. Place based health planning adopts a holistic approach to health care and involves local demographic, socio-economic and environmental conditions. As these conditions vary by Emirate, Planning managers should give due consideration to the prevailing conditions in their own Emirate including the resources available to them and develop their health plans accordingly. This is essential for sustainability in health care in the UAE. Besides, following Yeboah (2005), it is inherent in place based health planning to identify and prioritize local health needs, and to adequately articulate or translate those needs into policy and program development. That is a sure way of achieving sustainability in health care in the UAE.

              Closely related to planning are community factor which include demographic, socio-economic, political and environment conditions. The framework provides for consideration of factors such as income, employment and occupational classification and an index of siocio—economic disadvantage to be included in policy and program development. Wealth and other indicators of modernization and development are not evenly distributed across the 7 Emirates of the UAE. Abu Dhabi and Dubai are more developed and wealthier than the other Emirates. It is imperative to give due consideration to those factors because that would determine the availability of resources and service provision for current and future populations. Within each Emirate, analysis of the existing situation in each of the Emirates needs to be carefully and skillfully managed. There is merit in exercising caution when including current community conditions/factors in sustainable health care, as innovation, new health technology and potential wealth creation can affect the provision of health care in the future.

Another element in the framework for sustainable health care focuses on the identification of key stakeholders and the establishment of partnerships. This is at congruence with the tenets of place based health planning. In the UAE, major stakeholders include the Ministry of Health, Health Authority in each Emirate, public sector health providers, private sector health service providers, professional associations and various health advocacy groups. To maintain adequate health care for current and future generations of health care consumers, the key stakeholders must first be identified, followed by the establishment of partnerships and collaborations on all aspects of health care development and delivery. All parties must work together to achieve sustainability in health care (Richetta, 2013). No one group or agency can work individually to establish sustainable health care, and collaborations are essential amid competitive health environments. Health managers in all sectors must be committed to working together and sharing vision and ideas to achieve sustainability in health care in the UAE.

As noted earlier, the private sector is a key stakeholder and needed partner in the provision of health care in the UAE. Throughout the country, there are 1000s of private health care providers, some of which belong to international health care organizations and companies. To ensure sustainability in health care, these private providers must thrive. There is a need to expand the involvement of the private sector in the provision of sustainable health care in the country. For the private sector to thrive, they must provide affordable health care while making some level of profit at the same time. The country’s responsibility to health care affordability is demonstrated in the introduction of laws establishing compulsory health insurance. In Abu Dhabi, all residents are required to have a health insurance paid for by their sponsors including business entities. The Emirate of Dubai has also introduced laws on compulsory health insurance to be implemented over a period of time, and the other Emirates would be following. In addition, the country is enjoying a dramatic increase in the number of visitors who come in for medical tourism. The health sector recorded an increase of over 20% between 2014 and 2015 (Sankar, 2016), and this increasing trend is expected to continue in the future. Increasing levels of medical tourism will support the viability of both public and private health care providers, and contribute positively to the attainment of sustainable health care in the country.

In terms of the framework, the penultimate factor in sustainable health care is evidence based analysis which should manifest itself in all aspects of health care provision. The continuous collection and analysis of data on patients, financial, human and related resources, local socio-economic and environmental conditions, service provision and utilization together with demographic dynamics cannot be over emphasized. Needs assessment for current populations and estimates of potential future health needs based on scientific data collection and analysis are paramount to achieving sustainability in health care. A number of factors outside the health environment affect health care. Government social policies, education and employment all influence health outcomes, both current and future estimates of data on those factors should serve as catalysts for the achievement of sustainability in health care.

Data collection and analysis are particularly important in the UAE because of the wide disparities in the socio-economic status of the population both within and across Emirates. 80-90% of the UAE population have been born outside the country. Migrant workers come in with their own culture (norms, values and beliefs), educational levels and skills which influence their acceptance and use of health services. There is also wide variation in individual incomes which determine health care affordability. The situation is exacerbated by the fact that there is no universal health insurance in the UAE. With exception of the Emirate of Abu Dhabi which has a national insurance scheme and where it is compulsory for all residents to have health insurance cover, all the other Emirates have no universal  health insurance. Health cost is high in all countries and the UAE is no exception. One sure way of achieving sustainability in health care is to make health care affordable to the population at risk of using the health system. National Health Insurance Schemes, such as what is prevalent in Abu Dhabi Emirate, will contribute to reducing the cost of health care to patients and other users of the system, and enhance sustainability.

In addition, analysis of data on health care affordability will help determine levels of utilization now and in the future. That fact also supports the notion of placing emphasis on local conditions as postulated in place based health funding and place based health planning. Needless to stress the prevalence of variations in levels of development by Emirate, a fact which re-emphasizes the need to include local conditions in any attempt to achieve sustainable health care in the country.

              While all the factors hitherto discussed are essential, sustainable health care ultimately rests with effective and efficient management of the health care environment. Successful management of the health care environment is based on the organizational culture of health agencies and service providers (Piuye, 2004). There are many elements in the management of sustainable health care. They include leadership, chain of command or hierarchy, innovation and knowledge transfer, resources and relationships management. Strong and committed leadership is naturally required for any emerging development in the health environment but more so in sustainable health care. In the UAE, the Ministry of Health, Health Authority in each Emirate, and the Executive Council in each Emirate have a direct responsibility to provide leadership in any attempt to achieve sustainability in health care in the country.

In terms of hierarchy and chain of command, the Ministry of Health is at the top and responsible for setting national policies and directions and liaising with international and regional organizations. Next in the hierarchy are the Executives councils, followed by the Health Authorities (Fig. 2). National decisions and policies together with strategic directions are passed on from the Ministry to the Health Authority in each Emirate for implementation within their jurisdictions. The point must be made that the Health Authority in each Emirate is responsible for health within its Emirate, but the Executive Councils have final say on all health matters in the Emirate.

The Executive Council in Each Emirate approves the health budget and all health projects in the individual Emirate for example. A case in point is the approval of 17.5 billion AED for various sectors by the Abu Dhabi Executive Council for 2016. They included projects for the health sector as well as other sectors which impact on health (education, 1.8b AED), housing (5.9b AED) social facilities (644m AED) (Gulf News, 2016). In each Emirate, the Executive Councils also have the vision to set directions for health and other sectors which impact on health within the jurisdiction of their individual Emirate.

All these governance levels must demonstrate leadership and commitment to sustainability in health care to enhance the successful achievement of sustainability in health care in the UAE.

The point must further be made that sustainable health care transcends leadership, chain of command and commitment. The management of other elements in the framework for sustainable health care is crucial. Resources (human and financial), projects, equipment, innovation and knowledge transfer as well as a diverse range of relationships would have to be properly managed. The effective management of relationships with stakeholders and partnerships, government organizations, public and private health providers would enhance sustainability in health care in the UAE as it would elsewhere in the world. Thus, the need for all parties to collaborate and work together cannot be over emphasized (Richetta, 2013), and managers have the responsibility to promote collaborations.

 

 

CONCLUSION

 

This study has proposed a framework for sustainable health and attempted to explore how it could be achieved in the UAE through proper management of the health environment. It is the conclusion of this study that sustainability in health care can be achieved in the UAE albeit strong leadership and commitment in all levels will be needed. The study concludes further that numerous elements work individually and severally to enhance the successful achievement of sustainable health care in the UAE, including continuous collection and analysis of health data, funding and personnel, together with relationship management. The standpoint taken in this study is that sustainable health care can be achieved in the UAE, but only if all the parties involved work collaboratively and support the innovative approach and each other. Finally, it is the contention of this study that health funding is only one element in a series of elements which have the potential to enhance the achievement of sustainable health care, not the only one.

 

 

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Cite this Article: Yeboah DA (2016). Managing Sustainable Health Care Delivery in the UAE. Greener Journal of Medical Sciences, 6(1): 001-009, http://doi.org/10.15580/GJMS.2016.1.011916016