First published in ITIJ 120, January 2011
Carved out of the Arabian Desert, Dubai has become a mecca of bustling commercialism. Forty years ago, it was a small trading and fishing community. Today, it is better known for the world’s tallest building, man-made palm tree-shaped islands, the six-star hotels of Jumeirah beach and unfettered luxury. Tatum Anderson reveals what the emirate offers to the millions of expatriate workers and holidaymakers in need of care in the country’s burgeoning healthcare system
The second largest of seven emirates formed in 1971, as part of the United Arab Emirates (UAE), Dubai lies in the eastern Arabian Peninsula, bordering the Gulf of Oman and the Persian Gulf. Like all the emirates, it is sandwiched between Oman and Saudi Arabia. The discovery of oil in the UAE has been behind its transformation to a modern state with high standards of living – according to the World Health Organization (WHO), 50 years ago it was an impoverished collection of small desert principalities and there was not a single public hospital.
The UAE’s newly found riches have attracted expatriate workers from all over the world. In 2010, its population is expected to rise to 7.56 million, from 5.63 million a year earlier says Dubai’s Health Authority. And of that figure, around 80 per cent are expatriates. Halfof the population of Dubai is South Asian, although there are many westerners too – over 120,000 British expats live in the region for instance.
The discovery of oil in the UAE has been behind its transformation to a modern state with high standards of living
The population of Dubai has followed a similar trajectory, increasing by 7.6 per cent from 2009 to 2010. Some estimates suggest Dubai swells by more than 10,000 new residents every month. It has mushroomed in recent years by diversifying away from a dependence on oil revenues (it has smaller oil reserves than other emirates) and towards commercial property and other business interests, including tourism. Visitors swarm towards its beach resorts, golf courses and luxury hotels and it can still charge some of the highest average room rates in the world, despite the global economic downturn. This is surprising given that Dubai was perhaps the highest profile casualty of the downturn in the Middle East. It sent global markets tumbling at the end of 2009 after one of its investment companies, Dubai World, applied for a six-month extension from creditors.
The downturn has claimed a few casualties in Dubai’s health sector too. The Mayo clinic, which opened its first clinic outside the US in the boom times of 2005 has closed, albeit temporarily. A few hospital building projects are being delayed too, say insiders, but things are picking up. Today, the standards of healthcare for both western expats and tourists rival those found in the developed world. Private facilities are generally comparable with those of the UK, for instance. In contrast, standards vary at public facilities and are generally not comparable to private hospitals.
There are plenty of modern basic public facilities available in the principal cities of the UAE, says the US State Department, but not much outside these areas. There are around 26 hospitals and 106 primary healthcare centres across the UAE.
The medical care of Dubai nationals, visitors and resident expatriates is managed by the Dubai Health Authority (DHA), one of six federated authorities overseen by the UAE’s Ministry of Health. Indeed, the DHA is responsible for the governance of all the government hospitals, smaller clinics and 20 primary health centres throughout the emirate. According to the DHA, there is one health centre or clinic for every 30,000 individuals and many run by an international staff that hails from India and Sudan to the countries of the Middle East. The best-known government hospitals include, but are not limited to, Rashid Hospital, Dubai Hospital, Al Wasl Hospital and Hatta Hospital. Al Wasl Hospital is considered the de facto facility for women across the northern Emirates. Rashid Hospital, meanwhile, has 582 beds and every year treats approximately 14,759 inpatients, 138,000 emergency patients and 121,692 outpatients.
The downturn has claimed a few casualties in Dubai’s health sector too. The Mayo clinic, which opened its first clinic outside the US in the boom times of 2005 has closed, albeit temporarily
Peter Hogg of Neuron, a Dubai-based healthcare administration company, says that although standards in public facilities are not comparable to private hospitals, things are getting better. “Improvements have been made and the trauma unit at Rashid Hospital is world-class. Al Wasl is possibly one of the best places to have a baby unless you are concerned about the comfort,” he says, adding, “I believe that they are quite capable of dealing with foreigners.” English is used widely, although speakers of other European languages a few and far between. Many public hospitals are not used to dealing with insurance procedures and international assistance companies, adds Hogg, while some others are not equipped to accept credit cards and work on a cash basis, for instance. “They won’t be good at producing paperwork or getting authorisations,” he warns. Healthcare is free for UAE Nationals and funded from the government’s coffers, despite there being no tax or social security payments.
You get what you pay for
For foreigners either visiting or working in Dubai, only emergency services are free and only then until a patient is stabilised. After that, facilities will expect cash or credit card payment for further treatments, hence why expatriates require some form of health coverage. The penalties for not being covered are high – for instance, people can be prevented from leaving the country until they have paid for whatever healthcare treatment they have received, and bills can be extremely expensive, say experts.
Foreigners without private health insurance coverage are advised by the DHA to apply for a health card. Valid for one year, the card entitles residents to low-cost medical treatment at public hospitals and clinics. Public hospitals supply application forms in Arabic, which can be submitted, along with the appropriate documents, at a local healthcare centre. The card costs around 300 United Arab Emirates Dirham (AED) (AED100 = US$27 or EU20) and must be accompanied by a medical examination that costs AED200.
All workers applying for a work or residency permit must undergo medical testing within the first three months of residence, conducted almost universally without counselling or consent. Those testing positive for a range of diseases may be deported. A US State Department Report on human rights in 2008 reckoned the UAE deported 1,518 non-citizen residents infected with HIV, hepatitis types B and C, and tuberculosis that year. In August 2010, the rules were relaxed slightly for expats coming to work in the emirate, as the DHA scrapped mandatory testing for hepatitis C, while hepatitis B tests will only be applied to a handful of professions.
There is no law to compel employers to provide healthcare facilities. However, some provide on-site clinics, facilities at labourers’ accommodation or buy bulk services from private clinics. That said, Dubai has long been considering various plans to introduce a compulsory insurance scheme and what it eventually establishes will be similar to others that have recently been introduced to the Middle East. Saudi Arabia and Abu Dhabi have in recent years begun insurance schemes that compel employers to buy medical insurance for all employees and their families. Both expats and UAE residents, at least those who can afford it, are more likely to use private facilities. The UAE boasts 15 internationally accredited hospitals.
The private sector caters to several very different groups of expats, according to Neuron’s Hogg. “The private sector caters for all the different racial and socio-economic groups present in Dubai, from up-market clinics catering to westerners and others [in this income group] to much more basic low-cost providers that cater to labourers.” As a result, prices for care can vary widely. A consultation with a GP will range from US$15 to $140, while an angiogram and angioplasty might cost anything between $10,000 to $20,000. Dubai’s healthcare costs are much cheaper than western countries, but still around double that of Southeast Asia, according to Alpen Capital, a Dubai-based consultancy firm. A cardiac bypass costs around $130,000 in the US, compared with $44,000 in the UAE. The same surgery costs around $18,500 in Singapore and $11,000 in Thailand.
Choice of facilities
The private clinics in Dubai are adept at handling claims directly with third party administrators and insurers based in Dubai, and at filling in the forms needed for visitors. However, occasionally, smaller clinics run by individual doctors are not. “They are not so happy dealing directly with insurers, but even so they are well able to complete the forms needed to get the claim reimbursed back home,” says Neuron’s Hogg.
There is a good range of high-quality facilities available for expats or tourists who need hospital treatment. The American Hospital Dubai has been widely recommended. A 143-bed, acute care, general medical/surgical hospital, it trades on the fact that it can provide an American standard of healthcare and was the first in the Middle East to get accredited by the Joint Commission International (JCI) accreditation scheme. It has a 10-bed intensive care unit; a 10-bed cardiac intensive care unit, emergency services and a 13-bed paediatric suite, among a host of other services.
In addition to facilities such as the American Hospital Dubai, Dubai Healthcare City (DHCC) is an entire area dedicated to international healthcare and home to two hospitals, around 90 medical facilities and 1,700 healthcare professionals. Many major national and international brands operate here including Moorefield’s Eye Hospital and Harvard Medical School. University Hospital, the first in Dubai, is also under construction in the city. And City Hospital is one of the most highly recommended hospitals in DHCC. Owned by the Dubai-based Varkey Group, Medi-Clinic Corporation (South Africa) and GE Healthcare, the 210-bed City Hospital won JCI accreditation in June 2010. Its sister hospital is Welcare, which has traditionally ranked as one of the best in Dubai. The City Hospital, says Hogg, is now overtaking Welcare in reputation, and the quality bar is much higher here too. According to experts, higher qualifications are required for doctors practicing within DHCC than those outside. City, like most other private facilities, operates 24-hour services and is equipped to handle most emergencies.
There are plenty of modern basic public facilities available in the principal cities of the UAE, says the US State Department, but not much outside these areas
That said, in the event of a major accident patients are automatically taken to the public Rashid Hospital, which is considered better equipped for major traumas. In this case patients are normally collected by government ambulance. However, those who choose to go to a private hospital instead must pay a charge for the ambulance on the spot. Costs for international repatriation vary considerably, with a flight to the UK costing anything from around $30,000 to $70,000 depending on the company used. Hogg of Neuron says local air ambulance companies as such don’t exist, but some of the nearby executive carriers will convert their planes to carry people regionally. “This is not a well-developed area, but equally there doesn’t seem to be too much demand,” he adds.
However, there remain significant gaps in Dubai’s healthcare system. The UAE may be the world’s fourth-largest oil producer and the richest state per head of population, but it spends a fraction on healthcare for its citizens compared to other countries.
So, luxury private facilities aside, Dubai still lacks the expertise and specialist hospitals to deal many health challenges, according to local and international experts. Together with other emirates, it spends approximately AED7.5 billion ($2 billion) every year to send its own citizens abroad to receive treatment that is not available locally. In 2007, Dubai alone sent close to 1,000 patients overseas for medical care at a total cost of over AED176 million ($48 million). The majority of these patients were treated in Germany, the UK, US and India, and most consultations were in the fields of oncology, cardiology, paediatrics and orthopaedics.
There is also an acute shortage of human resources and the region relies to a large extent on expatriate staff. Some estimates put the proportion of expat nurses in UAE at a whopping 92 per cent, says Alpen Capital. And with two physicians per 1,000 population, Gulf States rank below the US and Europe, which have 2.6 and 3.2 doctors per 1,000 people respectively. Yet there is a growing need for healthcare facilities as the emirate ages and increasingly suffers from diseases of affluence (the UAE ranks second highest in the world for diabetes prevalence at 20 per cent and has a significant obesity problem). The health authorities in the UAE predict that demand for hospital beds will increase by 160 per cent by 2025, and of course, it will need a corresponding rise in staff. Health reforms are also afoot in more than one emirate: the DHA is restructuring, for example, and there are many grand hospital-building projects planned across the region (there are at least three maternity hospitals being built for instance). But how much a proliferation of hospital projects across the region will duplicate each other and cannibalise the already limited human resources should be a point of concern.