In review: the healthcare framework in United Arab Emirates

All questions

Overview

The United Arab Emirates (UAE) is a confederation of seven emirates. The most well-known are Dubai and Abu Dhabi. The other emirates are Sharjah, Ajman, Fujairah, Umm al-Qaiwain and Ras al-Khaimah, often collectively referred to as the 'Northern Emirates'.

At the federal level, the UAE operates within a constitutional framework, which makes provision for the health and welfare of the population in that 'the community shall provide all the citizens with medical care and means of prevention and treatment from diseases and epidemics and shall promote the establishment of public and private hospitals, clinics, and treatment houses'.²

The Federal Ministry of Health and Prevention (MOHAP) oversees the implementation of federal government policy in relation to the provision of comprehensive healthcare for all UAE citizens and residents, and works in collaboration with all health authorities to ensure that all public and private hospitals are accredited according to clear national and international quality standards of medical services and staff.

The emirates of Abu Dhabi, Dubai and Sharjah have established their own health authorities, the Department of Health (DOH), the Dubai Health Authority (DHA) and the Sharjah Health Authority respectively, and have the most developed rules and regulations among the seven emirates with respect to healthcare matters. The emirates of Dubai and Sharjah have also made provision for healthcare investment by establishing healthcare sector free zones, such as the Dubai Healthcare City (DHCC) and the Sharjah Healthcare City. The remaining Northern Emirates rely on the MOHAP to act as their regulator to oversee delivery of healthcare services.

The UAE has always looked to other jurisdictions for inspiration in creating a legal framework for the healthcare sector. The priorities are to ensure adherence with international best practice and to support delivery of high-quality medical care to the population. The drive to achieve continuing improvements in healthcare services throughout the UAE is intended to reduce the need for people to travel abroad for specialised treatment, encourage medical tourism, and is a key driver in widening the scope of services provided and building a healthcare sector that is supported by private sector and insurance investment.

In 2020 and 2021 the healthcare sector was hit very hard by the arrival of the covid-19 pandemic. The health regulators issued numerous instructions to public and private sector operators on the handling of the situation, and as we now emerge into the post-covid-19 environment we examine how some of those measures have accelerated the transformation of the health sector into the digital era. Collectively, the measures adopted by the UAE government have allowed the country to top the global covid resilience rankings throughout 2021, and it is currently in the top five countries on the rankings as of May 2022.³ A number of these measures are discussed in this chapter, but this is not an exhaustive account of the collective effort to fight covid-19.

The healthcare economy

i General

The status of the healthcare economy in the UAE is inextricably linked to the general economy and the government's policy of diversification away from the oil and gas sector. The indications for the general economy predicted by the IMF in May 2022 are that the UAE will grow 4.3 per cent in 2022.⁴

The Abu Dhabi Economic Vision 2030 and the UAE Vision 2071 includes the objective of making the UAE a world-class healthcare system. Currently ranked 42 in the Healthcare Quality Index, a range of measures are currently under discussion to achieve this objective, and improve basic health outcomes, health infrastructure and preventative care, and physical and mental health satisfaction.⁵

ii The role of health insurance

The Insurance Authority established under Federal Law No. 6 of 2007 (as amended) introduced mandatory health insurance across the UAE.⁶ The UAE national Emirati population (and those of similar status) are covered by a government-insured scheme named 'Thiqa', which is administered by the UAE national insurance company, Daman, and provides for a comprehensive range of health insurance cover.

Abu Dhabi was the first emirate to fully implement mandatory health insurance for the expatriate population by Law No. 23 of 2005,⁷ which provides a basic level of cover for all employees and their families. A similar scheme was also implemented in Dubai pursuant to Law No. 11 of 2013,⁸ implemented from February 2014 over three phases according to employer workforce size, with the final phase completed in June 2016. Mandatory health insurance for expatriates has yet to reach every emirate in the UAE.

As the government reduces financial commitment to publicly funded services, which are largely accessed only by the Emirati population, the role of health insurance is critical to the ability of the remaining expatriate population to afford and access private medical services and medicines.

iii Funding and payment for specific services

Health insurance does not cover all healthcare needs. While the Thiqa cover for the Emirati population is reasonably comprehensive, recent cutbacks in spending have meant that access to certain Thiqa services has been withdrawn, and similarly, the expatriate population who benefit only from a basic level of cover must pay themselves for many services that are excluded from most policies. The extensive list of uninsured services means that expatriate patients themselves must pay, and in some cases, access services abroad, where they can be significantly cheaper.

Primary/family medicine, hospitals and social care

i Primary/family medicine

UAE patients can directly access medical specialist consultants without first transitioning through a primary care service. Direct access to specialist services is responsible for pushing up the costs of healthcare for both the government and insurers, with patients 'shopping' for services and seeking advice from a number of specialists for the same complaint.

Direct access is now being curtailed, with primary care becoming an increasing focus for healthcare regulators, with a view to improving the coordination of treatment throughout a continuum of care. The goal is the delivery of healthcare throughout the entire life cycle, in a process extending from the initial visit to a primary care physician, through the referral process, to the completion of treatment. Initiatives such as these should produce developments in the use of the expertise of primary care professionals through care pathways, and coordinated care between primary, secondary and tertiary healthcare services.

The DOH identified the need for primary care gateways as part of the emirate's master plan for delivery of healthcare services, and recently issued a standard for primary healthcare services in 2016.⁹ Similarly, the DHA has approved licences for 20 healthcare centres and clinics around the emirate providing primary healthcare services.

Insurers are increasingly taking the lead on adjusting health insurance policy terms and conditions to require patients to access primary care services and to have appropriate referrals from primary gateway providers before approving fees.

In terms of future developments, as the UAE rolls out licensing for telehealth services,¹⁰ we also expect the ability of patients to access teleconsultation pathways.¹¹

ii HospitalsPublic sector

The main public sector institutions that oversee delivery of healthcare services and quality are the DHA and the Dubai Academic Health Corporation (DAHC), the Abu Dhabi Health Services Company (SEHA) and the MOHAP. Within the scope of secondary care services provided by public hospitals are trauma facilities, obstetrics and gynaecology, orthopaedic, surgical services and the treatment of lifestyle diseases. The policy aim is to overlay these with more specialised services.

The DAHC establishing law positions the DAHC as the provider of a fully integrated academic health system for the emirate of Dubai with financial and administrative independence. The DAHC mission will strengthen Dubai as a global leader in medical education, research and scientific innovation as part of the broader strategy to strengthen the knowledge economy in Dubai. Further, the DAHC seeks to enhance the capabilities of Dubai's healthcare sector to prevent and treat diseases and epidemics. The new corporation also aims to develop educational and professional programmes for healthcare personnel and promote strategic public–private partnerships to meet its objectives. The DAHC is now tasked with managing and operating the following healthcare facilities:

1. all DHA hospitals, primary healthcare centres, specialised care centres, medical fitness centres and public health centres;
2. the Mohammed Bin Rashid University of Medicine and Health Sciences;
3. Dubai Dental Hospital;
4. the Al Jalila Foundation;
5. the Al Jalila Children's Specialty Hospital; and
6. any other entities mandated to be a part of the DAHC as per the legislation issued by the ruler of Dubai.

SEHA is an independent public joint-stock company that owns and operates all public hospitals and clinics across Abu Dhabi, consisting of 12 hospitals, 46 primary healthcare clinics and 10 disease prevention and screening centres, along with mobile clinics, a school clinic, blood banks, dental centres and a vaccination centre.¹² The central management of the SEHA hospitals now lies with Pure Health, a subsidiary company of the Abu Dhabi Developmental Holding Company as part of a consolidation of several companies to create the largest healthcare provider in the UAE. As part of the agreement, SEHA and the National Health Insurance Company (Daman) have merged into Pure Health.

Mubadala Healthcare, a division of the Abu Dhabi government investment vehicle Mubadala Development Company, has also played a prominent role in the provision of public healthcare services, also catering for privately insured or high net worth self-paying patients. Projects include the Cleveland Clinic-Abu Dhabi, Healthpoint Hospital, the Imperial College London Diabetes Centre, the Abu Dhabi Telemedicine Centre and the National Reference Laboratory. Recently, Mubadala health has also acquired the Amana home healthcare group, and UEMS Medical Services group (a group of companies that operates a women and children's hospital, and various IVF treatment centres).

The MOHAP manages public healthcare services in the Northern Emirates, overseeing 16 hospitals and over 60 clinics. While historically servicing the Emirati population, the MOHAP will soon extend services to all residents, such as through Ras al-Khaimah's flagship Sheikh Khalifa Specialist Hospital under the management of Seoul National University Hospital, and which now offers specialist cancer services.

Private sector

The expansion of the private sector is advanced and expected to play a significant role in the provision of healthcare in the future, with recent amendments to Federal Law No. 4 of 2015 (on Private Health Facilities), and Law No. 22 of 2015 Regulating Partnership between the Public Sector and the Private Sector in the Emirate of Dubai. For further details pertaining to private-sector hospitals, see Section IV.¹³

iii Social care

The Ministry of Community Development was created to oversee social care in the UAE,¹⁴ and largely focuses on development projects for Emirati families and persons with special needs. Since social care laws were first introduced in the 1970s, the concept of social care has remained immature. There has been very little focus on geriatric or dementia care services, resulting in an underdeveloped network supporting the transition of elderly or vulnerable patients from hospital care to home care with appropriate social care support. This burden was typically left to families to bear, but they will now benefit from additional support being made available through new initiatives by this Ministry and through the establishment of a Community Development Authority in Dubai and a Department of Community Development in Abu Dhabi. There are now a number of initiatives in place that support transition to home care, such as a collaboration in Abu Dhabi to transition patients from Cleveland Clinic Abu Dhabi to Amana Home Care services.

The licensing of healthcare providers and professionals

i RegulatorsMinistry of Health and Prevention

The MOHAP is the federal authority focused on creating a unified set of healthcare policies across the emirates. The MOHAP also plays the role of the primary health regulator for the Northern Emirates. In general, the MOHAP's activities include licensing and monitoring healthcare providers and healthcare professionals, administering disease prevention and awareness training programmes and regulating the registration and control of pharmaceuticals and medical devices.

Dubai Health Authority

The DHA was established pursuant to Dubai Law No. 13 of 2007. The responsibilities of the DHA were significantly changed in 2021 to that of unified health regulator for the emirate of Dubai, including in the free zones such as the DHCC. Specifically, the law provides that the DHA is replacing the Dubai Healthcare City Authority.

Department of Health (Abu Dhabi)

The DOH was established pursuant to Abu Dhabi Law No. 10 of 2018 (on Establishing the Department of Health – Abu Dhabi). The DOH owns and operates public healthcare services and is the primary regulator for the private sector, granting facility licences, regulating health insurance providers and healthcare professionals.

Sharjah Health Authority

The Sharjah Health Authority was established by Sharjah Emiri Decree No. 12 of 2010 (amended by Emiri Decree No. 33 of 2016) and regulates Sharjah's healthcare system.

ii Institutional healthcare providers

In this section, we focus on the licensing and approval regime for private healthcare facilities. All private healthcare facilities must operate under a licence granted either by their governing regulator, typically the DHA through the Healthcare Corporation, the DOH, or by the MOHAP (as delegated to the local emirate municipality) in the case of the Northern Emirates. Federal Law No. 4 of 2015 (on Private Health Facilities) (as amended) regulates the licensing of private healthcare facilities. The procedure for obtaining a licence entails making an online application to the regulator providing basic information to obtain an initial approval. Previously, it was required that the facility licence had to be issued in the name of a UAE national person rather than a corporate entity. This requirement has been relaxed, and now the facility licence can be owned by a 100 per cent foreign entity depending on the authority's approval,¹⁵ and in the case of a facility that comprises both local and foreign ownership. The application process then dives into further detail, with the applicant having to follow and conform to hospital or clinic planning, design and commissioning requirements applicable to the emirate and ensure that the facility is constructed to approved local standards.

The applicant must choose from a range of permitted activities, such as hospital, clinic, dental clinic and rehabilitation clinic. The activity categories can vary slightly in each emirate. The application will be subject to stringent scrutiny with a number of physical inspections of the facility while under development (or refurbishment) before the grant of the final licence. Time frames can vary significantly depending on the complexity of the project. The process of appealing against the refusal to grant a licensing application entails issuing an appeal in writing to the Minister of Health or the head of the health authority within 30 days of the date of notification of the denial decision. A further grievance may be appealed to a competent court.

There are no exceptions to the requirement to obtain a facility licence. The licence must then be renewed periodically; the renewal period can vary and can be from one to five years. A breach of the licence conditions empowers the regulator to take disciplinary action, which usually takes the form of additional conditions being placed on a licence or suspension or revocation of the licence.

A penalty may also be applied against a general manager of a private facility, with potential sanctions including imprisonment for a period of no less than six months and a fine of no less than 100,000 dirhams.

iii Healthcare professionals

No person may practise as a healthcare professional in the UAE without first being licensed by the applicable health authority. A healthcare professional's licence is directly linked to a healthcare facility. All practising health professionals must have a designated facility sponsor whose name appears on their health professional licence. Thus, healthcare professionals who are not affiliated with a facility may apply for licensure at the relevant authority and receive a letter of eligibility while seeking employment, but may not practise the profession until a final licence is issued in connection with an employing healthcare facility.

If an individual is discovered to be practising as a health professional without the appropriate licence from the appropriate authority, civil and criminal penalties may be issued to the individual and the facility where the individual is carrying out the activities.

In the emirate of Dubai, the DHA have purview to regulate healthcare professionals in the emirate. The DHA is the sole authority authorised to issue a licence to practise medicine and other healthcare professionals operating in Dubai. The DHA has the charge to supervise, regulate and discipline healthcare professionals operating in its jurisdiction. Overseas visiting healthcare professionals are also required to obtain a DHA licence to practise their profession in the emirate of Dubai.

The DOH regulates healthcare professionals practising in the emirate of Abu Dhabi and maintains a similar online portal and applications process to the DHA. The MOHAP regulates health professionals practising in the Northern Emirates and in certain facilities regulated by the MOHAP.

Unified qualification requirements

The framework for healthcare professional licensure has been brought under a unified process by virtue of the Healthcare Professionals Qualification Requirements 2014 (PQR), jointly issued by the MOHAP, the DHA and the DOH to standardise healthcare professional requirements across the emirates. While the PQR has been adopted across the authorities, each authority still maintains its individual regulatory purview to approve and issue licences in its particular emirate. Consequently, the PQR acts as a baseline for the authorities to assess the documents submitted by healthcare professionals within their geographical jurisdiction, but does not unify the licensing approvals. Thus, if a healthcare professional practising in Abu Dhabi with a DOH licence moves to Dubai, an application will need to be made to the DHA for transfer of the licence, or granting of a new licence, by the DHA.

With regard to foreign licences, healthcare professionals who successfully complete one of the international examinations listed in the PQR, or hold an active registration or licence to practise with certain regulatory bodies, will be exempt from the assessment required to obtain the professional licence. A valid certificate of current status confirming good standing registration of the applicant issued by the registration or licensing authority at the time of application will be required. The other requirements will also still apply, however, including credentialling, experience and primary source verification. If there is a gap of more than two years in a healthcare professional's practice, the assessment exemption policy will not apply.

Ownership of healthcare businesses

Cabinet Resolution No. 17 of 2023 sets out the executive regulations accompanying the main Federal Law No. 4 of 2015 concerning Private Health Facilities. The new Law no longer requires the ownership of a private health facility to only be under a UAE national. The restriction on foreign ownership is removed, provided the conditions set out in the new Article 6 of this law are satisfied.¹⁶

At present, the DHA and DOH have put a process in place enabling 100 per cent onshore ownership of healthcare facilities. Companies established in free zones are exempt from the local partner requirement if the relevant free zone has special provisions regulating the company, in which case, where the services are established in a healthcare free zone, this would permit 100 per cent foreign ownership.

The UAE Federal Law No. 4 of 2012 (regulating competition) regulates anticompetitive practices, prohibiting: restrictive agreements, dominant position (market share of the establishment exceeds 40 per cent of the total transactions in the relevant market), and economic concentrations (application for approval should be submitted to a committee prior to concluding the relevant contract and applies to share acquisitions, transfers of assets and liabilities and should be made where the market share of the parties exceeds 40 per cent of the total transactions undertaken in the relevant market).¹⁷

Marketing and promotion of services

All advertising must comply with the MOHAP Healthcare Advertising Regulation.¹⁸ The Healthcare Advertising Regulation contains a comprehensive list of matters that are relevant to healthcare advertising.

The MOHAP must formally approve all advertising content by way of an application and approval process, which leads to the MOHAP giving a reference number that must be cited on all advertising material.

The MOHAP will take into account prohibitions on advertisements in poor taste, misleading statements of a medical nature, misleading statements of a comparative nature and misleading statements of a general nature, as well as on sales incentives directed to certain persons. The prohibitions of advertisements that breach good taste are basically couched in terms of prejudice to public morals, and violation of the customs and traditions of UAE society or Islamic values.

Procurement of services and goods

The commissioning of healthcare services is government-led in terms of the policy position. The MOHAP, Dubai and Abu Dhabi health authorities dictate policy, identify what services are required and determine whether these should be provided by public or private sector investment. This process is governed by both federal and emirate level procurement laws that place restrictions upon the types of supplier that qualify to provide services to the public health system.

The DHA must hand over public hospital assets to the DAHC, which in turn must put in place a new procurement process. It is not yet clear how the procurement process will be managed between these two authorities during the handover process.

In Abu Dhabi, the DOH has updated its master capacity plan, analysing a vast amount of population, demographic and healthcare data across the emirate to identify gaps in the provision of services and to prioritise what services will be required in future years. The private sector is expected to take a leading role in developing new services or recommissioning existing provision, with international brands committing to significant investment in large healthcare infrastructure projects.

Reimbursement of services and goods

The principles for reimbursement for healthcare services and goods through universal and private insurance are outlined in Section II.ii.

In addition, the MOHAP, DOH and DHA control the prices at which certain medical products are supplied within the UAE. These controls are typically with regard to pharmaceutical products and medical devices, all of which must be registered with the MOHAP and the price approved according to the Pharmacy Law.¹⁹ There are some differences between public and private sector provision of products. The public sector is able to request additional discounts off the listed price of the product in order that such products are affordable particularly when ordered in large quantities. In the private sector, the MOHAP has introduced (through various circulars) restrictions on the level of discounting and offering of free-of-charge goods, samples and other incentives initiated by medical products suppliers through the supply chain.

Digital health developments

Federal Law No. 2 of 2019 (with implementing regulations), concerning the Use of Information and Communications Technology in Health Fields, regulates the use of information and communication technology in the areas of health in the country.²⁰ The Law aims to achieve (among other things) the following objectives:

1. require health authorities to set standards for the confidentiality and control of electronic patient records;
2. create a central health record storage system; and
3. restrict the transfer of patient health data outside the country without permission granted by the health authority, or in an exempt category.

The following laws also make provision for patient confidentiality, and remain in place alongside the new law.

Federal Law No. 5 of 2019 (concerning the Practice of Human Medicine Profession), which governs doctors licensed in the UAE, provides that in the absence of the patient's consent, no doctor has the right to divulge a private secret, either if the patient has directly confided it to them, or if they have come to know it by themselves in the course of their work.

The MOHAP Code of Conduct 1988 governing medical practitioners, pharmacists and other healthcare professionals licensed in the UAE requires complete confidentiality of patient information (including medical records and personal information related to the patient) and prohibits disclosure without the patient's prior informed consent.

The DOH Data Standard 2008 requires that healthcare providers in the emirate of Abu Dhabi develop and institute policies and procedures relating to confidential health information, which includes information that can be used to identify a patient. Policies developed pursuant to the Data Standard must ensure that only the minimum necessary personnel have access to confidential health information, and such information must be kept from unauthorised access.

The DHA introduced the Salama Electronic Medical Record System in 2017. This is a unified electronic medical record system currently connecting the government hospitals. In the long term, this scheme will be rolled out to all hospitals in the emirate of Dubai. The DOH has completed the implementation of a centralised electronic medical record central database, MALAFFI, mandating that all licensed health facilities in Abu Dhabi join the system and upload patient health information to the system.

Federal Decree-Law No. 45 of 2021 (the UAE Data Protection Law) covers the protection of all other categories of information that a healthcare operator may possess about its employees or patients.

Coronavirus

The UAE declared an emergency response to the covid-19 pandemic during the period between 1 April 2020 and 31 July 2021.²¹ The MOHAP published the National Guidelines for the management of covid-19 patients by health facilities, which also included specific instructions regarding covid-19 testing, taking central control of the type of testing that could be undertaken (based on World Health Organization guidelines). The local health authorities then issued local circulars and resolutions to put the National Guidelines into effect. In both Abu Dhabi and Dubai, samples could only be analysed by approved laboratories. Initially, these were government-owned laboratories, but to be able to cope with increased demand, some private-sector laboratories received approval to perform analysis. In Abu Dhabi, the DOH has mandated that healthcare facilities where covid-19 samples were collected should notify only confirmed covid-19 PCR results to the DOH's Abu Dhabi Public Health Centre using the infectious diseases notification system (IDN) immediately after receiving the result from the laboratory.²² Hospitals in the Northern Emirates report results to MOHAP directly. Federal Law No. 14 of 2014 on Communicable Disease Control was updated further by Federal MOHAP Resolution No. 223 of 2020 to include covid-19. Doctors, pharmacists, pharmacy technicians and medical practitioners are obligated to report any known or suspected cases of covid-19 within 24 hours. Breach of the law is punishable by imprisonment or a fine, or both.

Future outlook and new opportunities

The future outlook and opportunities listed in this chapter are subject to overcoming the immediate covid-19 pandemic crisis, which has inevitably impacted the priority of services but has also identified new opportunities for the health sector.

i Medical technology and innovation

In the enduring and post-covid-19 environment, the greatest opportunities will come from the medical technology, life sciences and biotechnology sectors, bringing a choice of vaccines, and a plethora of medical products and devices that will protect the population from the virus and similar attacks on population health. The MOHAP has put in place a less formal and faster route to medical device approvals and for clinical research. A covid-19 device or application can be assessed and approved very quickly. The MOHAP is engaging more actively with international companies and procuring goods and services more quickly while managing to have regard to local procurement laws (that have not yet been amended). Meanwhile, the MOHAP and health authorities have approved much wider use of telemedicine services, e-prescriptions and the delivery of medicines to patients in their homes.

ii Public–private partnerships

With Law No. 22 of 2015, the emirate of Dubai was the first to promulgate a law to govern public–private partnership (PPP) projects. This Law was aimed at a wide range of PPP projects, but its application has been slow because of the absence of detailed procedures; these procedures are expected to be issued by the government soon.

Notwithstanding the absence of regulatory guidance, the DHA has begun to discuss how to promote the introduction of more PPPs into the healthcare system. The DHA has created an investment strategy promoting Dubai as a viable and competitive hub for investment in healthcare that addresses the needs of the emirate, while providing future opportunities and the best service for investors to enable development of a sustainable public–private model in Dubai.²³

More recently, the emirate of Abu Dhabi²⁴ has followed suit with the issuance of Law No. 1 of 2019 regulating PPP projects to encourage the private sector to participate in development projects and to maximise investment in the various relevant fields in a way that helps economic and social development in the emirate of Abu Dhabi. This Law is still very newly enacted and has yet to be put into practice.

Following the impact of covid-19, it is expected that the UAE government will increase efforts to attract private sector investment through PPP legal frameworks but also in parallel with other regulatory changes to make inward investment more attractive. The government has made a number of announcements of incentives to be offered by way of low-cost finance, and either waiving or heavily discounting fees payable by corporate establishments.

Conclusions

The healthcare sector is expected to expand rapidly through a combination of public and private investment and a realignment of some of the larger groups. 2023 is already seeing significant restructuring, along with merger and acquisition activity. Opportunities within the wider healthcare sector, such as life sciences and medical technology, are expected to grow significantly. Regulators have adopted a series of long-term initiatives to create a healthcare sector that will be fit for purpose and guide the sustainable growth of this sector, supported by a legal framework created with reference to equivalent laws in other international jurisdictions and creating an environment where private and foreign investment can thrive.