Today’s interconnected world has transformed trade, economy, education, immigration, and our world view. The concept of care too has witnessed transitions and kept pace with the changing times. One of these changes has been the surge in more and more people choosing to leave the comfort of their homes and seeking high-quality and increasingly affordable treatment on foreign shores.

According to estimates by the World Health Organization, between 12–14 million people go abroad to receive medical care each year. Recent reports highlighted that with a collective market share of 45.2 per cent, Thailand and Mexico dominated the medical tourism market in 2017, followed by India with a market share of 15.4 per cent.

This tremendous growth has been witnessed thanks to the amount of money saved by having treatments conducted abroad over the last decade. In fact, medical treatment combined with a luxury vacation has become the latest trend. 

Dynamics such as rising aging population worldwide, availability of affordable world-class medical facilities in emerging economies, and high medical insurance costs in developed regions are boosting the demand for medical tourism globally. 

International accreditation is another key factor enhancing international medical tourism. Currently, over 600 health facilities in the world are accredited by the U.S. Joint Commission International (JCI), which is growing by 20 per cent each year. 

Sun, Sand and Scalpels

Trends in the medical tourism industry have seen healthcare costs running rampant in many Western nations, and this is leaving people to increasingly go to developing countries such as Thailand, India, Singapore, or Costa Rica to seek treatment. 

Many medical tourists are people aged between 45-70 and are from places where healthcare costs have exploded in recent years. This includes people from Europe, Australia, Canada, New Zealand, and the U.S. One of the major factors for why people are heading East for treatments is also due to the long waiting time in these countries. 

Keeping this in mind, entrepreneurs and investors in the healthcare, tourism, and hospitality markets are today finding significant market opportunity and economic development potential in the medical tourism industry. Innovation within strategic partnerships and collaborations have further reduced costs and captured market share. 

The emergence of international communication companies, which act as intermediaries between patients and hospital networks, is making it easier for patients to access information and prices. Furthermore, the high cost of treatment in developed countries is compelling patients to travel to countries with affordable healthcare practices. 

A recent report underlined that The Global Medical Tourism Market is expected to reach $160.8 billion by the end of 2025 and is expected to exhibit a Compound Annual Growth Rate (CAGR) of 14.9 per cent between 2017 and 2025. The growing geriatric population coupled with improving the accessibility of high-quality and low-cost medical services/ procedures are likely to augment the market during the forecast period. 

The Asia Pacific continues to account for the largest share of around 40 per cent of the global market, whereas, North America was estimated to register the fastest CAGR over the forecast period. Asian countries provide high standards of hospitality and care. Plus, they are always updating to the latest technology and it’s a lot cheaper in Asia than other regions.

Thailand is projected to remain at the forefront of the market during the forecast period. This can be attributed to the availability of popular treatments such as cosmetic surgery and dental treatment. 

India is currently one of the most renowned medical tourism destinations for specialist cardiac surgeries, while Singapore is well-known for expertise in complicated surgical procedures. Malaysia offers some of the world’s best medical infrastructure and treatments by highly skilled medical professionals. 

Plus, the medical tourism market is witnessing constant growth due to rising advertising and marketing of medical facilities coupled with increasing government investments in healthcare infrastructure. For example, Apollo Hospital, headquartered in Chennai, India, is located in 60 sites across the country and has its own health insurance scheme. 

The private sector has been instrumental in creating the concept of “health cities” in places such as Chennai, Bangkok, Kuala Lumpur, and Sao Paolo, and this is gaining traction around the globe. Hospitals in these cities offer many services under one roof and provide a hospitable atmosphere to attract patients from various Western countries. 

Specialised Surgeries

Cardiovascular disease is one of the leading causes of death and reportedly causes 17.3 million deaths per year, and the cases are likely to grow beyond 23.6 million by 2030. This trend is projected to drive the medical tourism market during the forecast period. 

Also, growing demand for specialised surgeries such as breast augmentation, dermabrasion, and rhinoplasty and better pricing of such cosmetic surgeries will further fuel the growth of the medical tourism market during the forecast period. 

One of the latest developments seen in medical tourists is being called the “baby boom” of medical tourism. This includes hopeful parents who are travelling abroad to get IVF treatments and commercial surrogacy in places like Russia or Ukraine. 

There has also been the rise in what is being called the “China effect”. The Chinese are already the single-largest group of prospective parents travelling abroad that use IVF services to have more children. As China recently relaxed its single-child policy, we can expect this trend to continue to grow into the future. 

Many travellers also opt for LASIK eye surgeries or dental procedures that are not covered under many Western country insurance plans and are exceptionally expensive. By travelling for treatment, patients would generally pay about 30 per cent of what they would in the Western world. 

Weight loss surgery also draws many medical tourists as nearly 1/3 of all Americans are now reportedly said to be obese, and only about 10 per cent of their insurance plans cover weight loss surgeries such as lap bands or bariatric surgeries. 

Furthermore, some people travel to other countries to receive post-natal care or receive hearing aids or cochlear implants, at a much more affordable cost to them. Medical devices are often cheaper in other countries and this can help the person save a lot of money even after paying for travel expenses. 

Emerging Destinations 

While Thailand, India, and Malaysia have already become key regions for medical tourists, countries such as UAE, Greece, and Taiwan are becoming new players in the global medical tourism industry. These countries have shown promising growth over the past years in part due to their breath-taking landscapes that patients look forward to during their visit. 

The UAE is working aggressively to build expertise in the medical field and emerge as one of the hotspots for medical tourism in the region. To support this initiative, in April 2016, Dubai launched the world’s first comprehensive electronic medical tourism portal, Dubai Health Experience (dxh.ae), offering access to a comprehensive menu of health and related services including wellness, cosmetic and dental, ‘packages’, plus ophthalmology, orthopaedics, physiotherapy and other specialised medical tests. 

Plus, the UAE has entered into a number of prestigious partnerships to bring in advanced healthcare technologies, practices and standards from the West, and is firmly on its way to becoming the medical tourism hub in the region. 

Among the most sought-after institutions by patients flying into the UAE for medical procedures is RAK Hospital, an 80-bed hospital in Ras Al Khaimah. The hospital is accredited by Joint Commission International and Swiss Leading Hospitals and is managed by Sonnenhof Swiss Health Ltd, a Switzerland-based healthcare company. 

It specialises in respiratory medicine, anaesthesiology and intensive care unit, cardiac surgery, internal medicine, podiatry, spine and orthopaedic surgery, pain management clinic, endocrinology, paediatrics and neonatology, urology, surgery, etc. It is well supported by a distinguished team of doctors from different countries. The hospital also recently added a world-class ophthalmology wing and runs a dedicated Diabetes clinic. 

RAK Hospital is setting an example for institutes in the region as an epitome of excellence in strengthening UAE’s position as a medical hub. Its rising number of patients from abroad is a testimony of the popularity for its procedures and warm hospitality.

Nearly 100 million patients have crossed international borders for medical care since the beginning of this century, and even greater numbers have travelled within their own country for unavailable treatments closer to home. In 2019, more than 20 million patients will continue this practice. These international patients pursue medical care ranging from basic health or dental check-ups to complex, life-saving procedures. While the fundamental drivers—access to quality care and affordability—will remain in place this year, six key trends point to sustained growth in clinical quality and patient experience.

1. Raising the clinical trust bar: A critical mass of international accreditation helps bring universal standards to clinical process and patient safety, offering improved choice to cross-border patients and building increased trust throughout the global healthcare community. The U.S.-based Joint Commission International (JCI) has now accredited more than 1,000 hospitals, up from 87 just 10 years ago, an eye-popping 500 per cent growth. More than one-third are in the Middle East, with UAE topping the list at 188 accredited facilities. China, where rapid healthcare infrastructure development is finally beginning to resolve decades of insufficient patient access, now boasts more than 100 JCI-accredited facilities, and health officials expect that number to double by 2025. 

Other international accreditors report brisk business as well, including Temos (Germany), which has awarded nearly 70 hospitals and clinics to date. MTQUA (Thailand), specialising in medical travel certifications, has awarded some 60 facilities since its inception in 2014. Expect to see new and established accreditors—such as AAAHC and AAAASF—ride the quality train.

2. The rise of the OMA: The success of online travel agencies (OTA’s), such as Expedia, Booking.com, TripAdvisor, and Ctrip has paved the way for the parallel healthcare vertical, online medical agencies (OMA’s). These third parties facilitate unassisted bookings, enhance the international patient experience with concierge services, and follow a commission-based revenue model.

Leading the field is Bangkok-based Medical Departures and its sister company Dental Departures, having logged more than 100,000 bookings and over 42,000 verified patient reviews. CEO Paul McTaggart reports that unassisted bookings have risen by +125 per cent over the past five years, even for complex treatments, an indication of growing patient comfort with the model. Other online healthcare players on the radar: Quonomedical (Germany), GetDoc (Malaysia), and Practo (India). To date, large U.S.-based OMA’s such as ZocDoc (U.S.), HealthGrades (U.S.), and RealSelf (U.S.) have not yet spread their wings into the global healthcare arena. Expect their entry soon.

3. Health insurers not coming to the rescue: I am surprised by the number of healthcare leaders who continue to believe that the insurance industry will eventually embrace medical tourism. In truth, all the large U.S.-based carriers—Cigna, Aetna, Generale, and Allianz—have long since abandoned this perfectly reasonable, workable model, where a high-deductible policy offers travel coverage and other incentives to create a win-win for both patients and health plans. The reason why this is hiding in plain sight: member hospitals and clinics are relentlessly squeezed for greater discounts on negotiated rates, and have no appetite for the further humiliation of seeing their patients (and margins) exported to far-flung lands. 

Even without the participation of big health plans, the marriage of consumers to carriers is inevitable. In the U.S., third-parties such as IndusHealth have made real progress targeting mid-sized self-insured employers. Outside the U.S., Berlin-based Medigo is giving third-party administration a try, focusing initially on the EU market. 

4. But hark! Medical tourism is seeing healthy growth: Despite a lack of institutional and corporate support, international healthcare travel is set to grow at 15-20 per cent in 2019. Fuelled by greater access to quality care (see “accreditation” above), consumers in overpriced healthcare economies (such as the U.S., Canada the UK and most of the EU) are aggressively seeking affordable options, while those in rising economies (such as China and Vietnam), are travelling for the best available care without regard to price. International hospitals and clinics, hungry for attractive margins and heightened prestige, are competing aggressively for global patients. 

Expect to see even greater growth in regional patient flows, including North America to Mexico and Costa Rica; Australia and New Zealand to Southeast Asia; and EU countries to Eastern Europe.

5. More growth from China: As China struggles to improve healthcare access and resolve issues of extreme air, water and food toxicity, affluent Chinese are seeking cross-border care in record numbers. Medical centres in the U.S., Singapore, Malaysia, and Thailand are seeing a significant rise in the volume of Chinese patients seeking treatment for complex conditions, especially cancer and respiratory diseases. Middle Eastern destinations such as the UAE are also vying for Chinese patients. In September 2018, Dubai Healthcare City announced a tie-up with a third-party agent to promote its services in Macao. 

Ed McCarthy, VP for the Center for International Medicine at the U.S.-based City of Hope National Medical Center, reports growing numbers of adult and paediatric Chinese patients seeking treatment for lung and blood cancers (lymphoma, leukemia) as well as cancers of the gastrointestinal tract, breast, prostate, and brain. Southeast Asia’s leading international hospital, Bumrungrad International reports a similar increase in Chinese patients seeking treatment for high-acuity orthopaedic, brain and spine, cancer, liver, and kidney procedures. 

In addition to the demand for disease-specific medical care, some 40 million Chinese women are struggling to conceive a child since China’s one-child policy was lifted in 2016. While fertility clinics are opening throughout China at a rapid rate, the perception of poor clinical quality and patient services will keep concerned couples travelling for at least the next decade in search of the best outcome and a happy, healthy newborn. 

6. It’s either mental or dental: It’s unavoidable—our bodies generally outlive our teeth. Most of us will eventually require major restorative dentistry, particularly as affluent populations live well into their 80’s and beyond. Even as dental health is increasingly and inextricably linked to general health and well-being, complex dental procedures remain overwhelmingly elective (and expensive) for most patients. This lack of coverage ensures market growth, with dental tourism expected to increase at a 30 per cent clip, the highest rate within the medical tourism sector.

7. Millennials on the march: Unlike their moms and dads, young women and men in affluent economies have developed a distrust of doctors, insurers, hospitals, and big pharma. Who can blame them? In parallel, millennials are more open-minded about travel and way more savvy in using technology to research medical options. Expect to see a larger slice of the medical tourism pie composed of ageing millennials seeking better and less expensive alternatives to the status quo. 

Value-oriented millennials are fuelling a rise in “incidental” medical travel, integrating non-invasive procedures into existing travel plans saving hundreds, sometimes thousands on anything from a dental filling to a CT scan or dermal fillers. Popular destinations such as Thailand, Indonesia, Costa Rica, and Mexico will see more spent on health and wellness activities and less on the stereotypical Margaritaville holiday. 

8. Telemedicine: Good news and bad for medical travel: From second opinions to patient monitoring, telehealth’s ongoing contributions are well-documented. Less discussed are the benefits to medical travel providers and patients, where remote physician-to-physician consultation enables in-country diagnosis and treatment planning. This remote partnership builds in-country medical capacity and helps patients that do need to travel for a procedure better prepare for treatment and access greater support upon their return home. 

In Coimbatore, India, Sri Ramakrishna Hospital (SRH) has recently implemented a tele-diagnostics and tele-radiology programme, using technology from Tata’s new Gloheal division. Patients and doctors from participating providers in various countries can request diagnoses and second opinions online reducing the costs of travel and logistics. Healthcare professionals are trained on-site or remotely through a partnership with GE Healthcare Asia. 

Other regional start-ups in this arena include AlemHealth (Singapore), Cura Healthcare (Saudi Arabia), and eTobb (Lebanon).

An informal survey recently put the healthcare industry at the top of the key industrial sectors earmarked for growth in the GCC in 2018. Along with the education and F&B sectors, the healthcare industry is set to grow by leaps and bounds primarily because it is not affected by fluctuating oil prices.

Over the last decade, the healthcare industry has emerged as one of the most critical sectors for pursuing economic diversification in the GCC. Governments have started looking at private sector involvement as an alternative to sustain healthcare funding since oil prices started dipping. Public-private partnerships are being promoted, mandatory insurance coverage rolled out and private players being encouraged to set up facilities. The sector is also undergoing a structural shift as a younger, more health-conscious population is seeking preventive care rather than curative care.

Medical tourism is known to be growing across global markets, with estimated annual revenues of US$50 to US$65 billion and an annual yearly growth of approximately 15 to 20 per cent. Many countries in Asia like India, Singapore, Thailand, South Korea and China are investing millions of dollars to support the increase in demand for access to quality care across borders. 

Abu Dhabi is already gearing up for the race. The Department of Culture and Tourism – Abu Dhabi (DCT) recently signed a memorandum of understanding with the Medical Tourism Association (MTA), a non-profit organisation that aids healthcare providers and governments in creating successful medical tourist programmes. Both entities will partner to promote Abu Dhabi as a medical tourist destination in markets such as Russia, China and the GCC, with focus on specialty areas like cardiology, oncology and executive screenings. The aim is to become the region’s leading medical tourist destination.

The 10-year agreement includes the opening of the MTA’s first office in Abu Dhabi, as well as the hosting of the World Medical Tourism and Global Healthcare Congress in Abu Dhabi next year, with hundreds of experts and organisations from more than 100 countries expected to take part.

The emirate had earlier kicked off a major drive to attract more medical tourists this year with a partnership between the Department of Health and the Department of Culture and Tourism. A worldwide marketing campaign is being planned to establish the city as a centre for medical tourism.

The campaign will highlight specific areas of medical excellence like open-heart surgery and cancer treatment, which are not common in the region. The emirate also plans to add a ‘tourism touch’, with packages that offer discounts on attractions for families accompanying the patients.

Dubai too is upping the stakes. The medical tourism industry generated more than AED1.4 billion for Dubai in 2016. The city received 326,649 medical tourists, an increase of 9.5 per cent over the previous year. The most popular areas of treatment for medical tourists last year were orthopaedics, dermatology and ophthalmology. 

At 37 per cent, Asian medical tourists were the largest segment of visitors. Arab and GCC countries were the second largest market, accounting for 31 per cent of tourists, and visitors from Europe accounted for 15 per cent of the total. 

The reason why medical tourism is increasing rapidly is the rising healthcare costs in western countries and the lack of insurance coverage for certain procedures. People are willing to travel to other countries to seek medical, dental, and surgical care that is not available, or they cannot afford at home.

Ageing Population

By 2030, older persons are projected to account for one in six people globally. The ageing population is estimated to grow by 56 per cent from 901 million to 1.4 billion, which is clearly a growing market. By 2050, the number of people over the age of 80 would reach 434 million, having more than tripled in number since 2015. With these figures, there is obviously an enormous potential market for medical tourism. 

Global healthcare spending is projected to increase at an annual rate of 4.1 per cent in 2017-2021, up from just 1.3 per cent in 2012- 2016. Ageing and increasing populations, developing market expansion, advances in medical treatments, and rising labour costs are expected to drive spending growth. 

Life expectancy is estimated to increase by more than a full year between 2016 and 2021 — from 73 to 74.1 years — bringing the number of people aged over 65 to more than 656 million, or 11.5 per cent of the total population. Much of the gain in life expectancy globally is due to falling infant mortality rates. 

According to a 2015 Deloitte report, healthcare spending growth in North America is projected to rise by an average of 4.6 per cent annually up to 2019, largely driven by expanded insurance coverage in the U.S. under the Affordable Care Act. Canada is projected to see even faster spending growth during the same period — 4.8 per cent annually — reflecting its older population. 

The same is true across the world. Take Germany as an example. The gradual ageing of its population — more than 20 per cent is aged 65 or older (behind only Italy and Japan among OECD countries) — is expected to increase demand for treatment of conditions related to old age and for elderly care. 

Along with improvement in medical environments and hygiene, Japan has become a country with one of the longest lifespans. However, the rapid improvement in the mortality rate has combined with the decline in birthrate to cause a major skew in the composition of the population, resulting in Japan having the largest population ratio of persons aged 65 years or older in the world. Furthermore, Japan is expected to become the most rapidly ageing society in history, with the population aged 65 years or older in the Tokyo metropolitan area increasing by 27 per cent in only 10 years from 2010. 

However, the healthcare infrastructure in developed countries is not growing in line with the ageing population and this will increase the demand for travel for care. The resulting stress on the social health delivery systems in regions like EU and countries like the U.S., Canada, Japan, UK, China and South Korea will be advantageous for medical tourism hubs like the UAE. Patients with higher disposable income would be able and willing to travel cross border for care. 

Gearing Up 

The time is ripe for UAE to take the lead in health tourism too. But for this it will have to beef up the existing infrastructure. However, the UAE has a strong health regulation framework, which has helped ensure quality healthcare, a catalyst for medical tourism. Investment in the medical sector from both the government as well as the private sector is also supporting related economic growth, with the UAE accounting for 26 per cent of total GCC government health care spend in 2016, according to an Alpen Capital report. 

Medical tourism is expected to contribute US$708 million to the GDP by 2020, with 13 per cent predicted year-on-year revenue growth, according to the Dubai Health Authority (DHA), which is in the process of adding 40 primary healthcare centres and three new hospitals under its 12-year master plan.

Pharmaceuticals and medical equipment are also two of the priority sub-sectors listed under the 2030 Dubai Industrial Strategy, which aims to promote the emirate as a global platform for knowledge-based, sustainable and innovation-focused businesses. 

The UAE Ministry of Health plans to have 34 indigenous pharmaceutical manufacturing factories by 2020. The market value of UAE’s pharmaceutical industry is projected to go up from AED9.5 billion at present to AED25 billion by 2025. 

Innovative Marketing

In April 2016, the Health Tourism Council launched the world’s first medical tourism portal, Dubai Health Experience (dxh.ae), offering access to a comprehensive menu of health and related services including wellness, cosmetic and dental packages, plus ophthalmology, orthopaedics, physiotherapy and other specialised medical tests. 

Forty-five healthcare providers are listed in the portal, which can also be downloaded as an Android app. Over 400 different healthcare packages are on offer. Discounted airfares, visa services and hotel partner recommendations are also a part of the package. 

Challenges and Opportunities

International tourism is at an all-time high, with as many as 1.32 billion tourists recorded to have travelled internationally in 2017. These tourists either go on holiday, or for reasons such as relocation and new jobs. This demonstrates a huge opportunity that global health insurance companies can tap in to. 

Having said that, the low levels of awareness about the benefits of global health insurance in several emerging markets, which also significantly feed into the medical tourism segment, continues to be a challenge. There needs to be concerted effort to realign the perception of affordability over need-based health services, which can only happen with a consistent and focused effort to educate and inform. 

Government’s Role

Throughout Europe, Middle East and Asia, the volume of international patients has been growing in the past 15 years, with developing countries gaining a larger market share. Healthcare spending is on the rise across the globe, and governments are increasingly realising the importance of investing in healthcare to drive patients to their country. In the UAE, more and more private players are being encouraged to enter the healthcare sector. These investments are necessary to make the country more attractive for medical tourists. Clearly, countries that focus on building the right quality of care at the right cost and supporting infrastructure will win in this space. 

Advantage Middle East

One of the most crucial factors that makes the Middle East an ideal medical tourism hub is its strategic location. The UAE, for example, is only an eight-hour flight away from two-thirds of the world’s population. That is part of the reason why the country, and particularly its commercial hub, Dubai, is on track to becoming a global medical tourism destination. 

The need to build world-class healthcare is one of the pillars of the National Agenda, and the UAE government is driving massive efforts to ensure seamless collaboration to build an effective healthcare system. This opens a valuable opportunity for global service providers to exchange expertise and capabilities. From improving healthcare experiences, to raising awareness on effective health coverage and health management, they must seek to address some critical gaps in the region’s healthcare sector. 

Lifestyle-related Diseases

One of the most significant drivers of growth in medical tourism, apart from an ageing and growing population, is the high incidence of non-communicable diseases. In fact, the high prevalence rates of lifestyle-related conditions such as obesity and diabetes in the GCC suggests that many future medical and wellness tourists may be from neighbouring countries. To meet this demand, we must also focus on developing healthcare experiences that are focused more on wellness, as opposed to a treatment-based approach. 

Role of Health Insurance

The healthcare ecosystem is made up of various stakeholders, from providers to regulators and insurance service providers. The development of a successful medical tourism hub is extremely dependent on each of these elements combining their strengths to offer a seamless, integrated healthcare experience. Access to global coverage and local expertise serves to support medical tourism in regional markets.

Wellness tourism has evolved to become tourism industry’s fastest growing sector, recording a 10 per cent growth this year to make it a larger than US$500 billion market and a rapidly advancing niche within the global tourism economy. This remarkable growth is marked by a profound shift in the way wellness services are being perceived and consumed. Previously seen as luxury or add-on services, they are now being woven into every aspect of daily lives, making them part of work, travel, leisure and healthcare. Capitalising on their increasing popularity, a greater percentage of enormous multi-trillion industries such as real estate, food and beverage and travel are incorporating wellness services into their businesses.

With the awareness on fitness and well-being becoming widespread than ever, different sectors are competing to develop innovative wellness services and packages to meet varied needs of health-conscious customers. Availability of in-room yoga mats and other advanced fitness facilities in hotels are examples of this growing trend. The demand for wellness services is expected to remain steady in light of the growing focus on stress management. 

The current global wellness trends, as identified by the 2018 Global Wellness Trends Report include transformative wellness travel; the wellness kitchen; an increased focus on health and lifestyle of parents during the six months before they conceive a baby; extreme challenges; treatments and experiences that aim to redefine human limits; efforts to sustain happiness; and the feminist wellness trend built around women empowerment. 

Real estate properties that offer recreational and wellness facilities are attracting and catering to the growing demand of discerning customers. Meanwhile, modern workplaces are also creating wellness initiatives to help employees better cope with stressful, hectic work environments and lifestyles that hamper their work and outputs. Companies are embracing the culture of encouraging employees to maintain physical and mental health and well-being. 

Boasting an array of world-class spas, wellness centres and health facilities, Dubai has undoubtedly become a unique travel destination for today’s health-conscious traveller. The incorporation of traditional healthcare practices such as Ayurveda, Homeopathy and Yoga that place greater emphasis on preventive health into service offerings has played a significant role in the growth in this niche sector. Several wellness centres across the city have loyal clientele that keep visiting every year. The Medical Tourism Index 2016 ranked Dubai number one in the Arab world and 16th globally, further boosting the emirate’s aspirations to attract half a million tourists a year by 2020. 

With a range of medical spas and treatment centres, Dubai’s appeal to a wider range of audience who are on the lookout for well-being-related treatments of international standards is steadily rising. In response to this, the emirate’s wellness services market remains poised to provide visitors with a uniquewellness experience of global standards, with the help of state-of-the-art technology and highly specialised and educated staff. The emirate’s capability in health and wellness is further being enhanced through the continuous development of a range of smart technologies such as Artificial Intelligence and other electronic platforms, making Dubai on par with global initiatives which promote digital transformation in tourism. 

The UAE wellness and spa travel market, comprising both inbound and domestic travellers, represents roughly 15 per cent of the total tourism market. Authentic Middle Eastern spas, wellness experiences and beauty traditions such as hammam, are gaining traction which only signifies the growing importance of this sector. 

Wellness tourists to the emirate are also increasingly pursuing various outdoor activities that add value to their travelling experiences and personal well-being. Customers spend on various relaxing and rejuvenating activities such as sauna therapies, yoga, massages and spas in addition to cosmetic procedures such as anti-ageing therapies. Travellers’ quest for options to maintain health and fitness while travelling or while on holidays is shaping the growth of wellness tourism market in the UAE. 

DHA’s Health Tourism Department’s partnership with Emirates Holidays, the tour-operating arm of Emirates Airline, to offer visitors customised health and wellness holidays in Dubai reflects its keenness to boost the market’s growth. The Health Tourism Department has accelerated its efforts to support Dubai in its journey to become the most-preferred global health tourism destination and a hub for premier accredited healthcare facilities, in addition to providing a memorable holiday experience to visitors. 

Dr. Layla Al Marzouqi, Director of Health Tourism Department at the Dubai Health Authority notes: “Dubai’s attractiveness as an ideal leisure and tourism destination has been extending its scope in recent years to include health and wellness as another reason to visit the emirate. The growing number of visitors experiencing the world-class health and wellness facilities in Dubai attests to the valuable services available in numerous packages the emirate has to offer and we are keen to continue developing this sector to provide excellence and happiness, a lifestyle that is deeply embedded in Dubai’s culture.” 

Vyara Tosheva, Manager of East Crescent Wellness and Spa at the Palm Jumeirah, says: “Our range of signature wellness treatments prioritise healing of mind over healing of body, ensuring long lasting results and wellness. Currently, around 10 per cent of the hotel’s guests approach us seeking our services and we are working towards increasing this to minimum 15 per cent next year. Our client base includes UAE residents, nationals and expatriates, with expatriates coming predominantly from Kuwait and Oman. Europeans who come seeking our treatments include mostly French nationals, followed by UK residents. Detox, energy healing, holistic weight loss and holistic anti-ageing are the most sought-after treatments.”

Al Jalila Foundation, a global philanthropic organisation founded by His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice-President and Prime Minister of the UAE and Ruler of Dubai in November 2012 to position the UAE at the forefront of medical innovation, encourages groundbreaking research through specialist knowledge, expertise and resources across a range of scientific disciplines to support regionally-relevant medical advancements.

With an estimated one in five people diagnosed with diabetes in the UAE, it is evident that there is a critical need to invest in relevant local research and drive awareness on the subject. To date, Al Jalila Foundation has awarded 15 grants dedicated to diabetes research in the UAE.

One recipient of the Jalila Foundation grant for diabetes research is Dima Abdelmannan, MD, Consultant Endocrinologist, DHA, Associate Clinical Dean, Dubai Medical College, whose topic for research is the development of a simple test for the assessment of future type 2 diabetes mellitus (DM) risk in subjects with normal glucose tolerance.

Type 2 diabetes has reached an epidemic proportion in Arab countries including the UAE, where approximately 20 per cent of the adult population has the disease. Prevention of the development of type 2 diabetes mellitus will have enormous impact, not only on public health, but also on healthcare expenditure. Moderate weight loss and pharmacotherapy can significantly prevent/delay diabetes onset in high-risk individuals, meaning that identification of subjects at high risk for future type 2 diabetes mellitus is essential for every diabetes prevention programme. 

Dr. Abdelmannan’s study will examine the ability of a single administration of dexamethasone in subjects with normal glucose tolerance to determine their future type 2 diabetes mellitus diabetes risk. This simple test will provide a useful tool to be utilised in clinical practice to identify subjects at increased risk for type 2 diabetes mellitus at the NGT stage.

 In an interview, Dr. Abdelmannan discusses her chosen topic of research, the current challenges to overcoming diabetes in the UAE, and speaks on the current gaps in research on diabetes in the UAE and the wider region. 

1. Briefly, can you describe your research, and why you chose this particular topic? How does this test differ from what’s already available? 

Our research study looks at the ability of a simple blood test to identify individuals at high future risk for type 2 DM early while they still have normal glucose tolerance test. The study is unique because unlike most studies, which address the disease or its complications, we are trying to look at very early prevention. Such a simple test will provide a very useful tool to be utilised in clinical practice to identify subjects at increased risk for Type 2 DM and allows much earlier intervention to prevent/delay the onset of T2DM. 

2. What, according to you, are the current challenges to overcoming diabetes in the UAE? 

Some of the major challenges in overcoming diabetes in the UAE are that despite all the ongoing efforts to increase awareness about the disease, there is a huge gap in education. Education about pre-diabetes and how to prevent/slow its progression, education about lifestyle interventions, and education about adherence to adopting healthy lifestyle habits and to medications when they commence, are severely lacking across the society. 

3. What do you think are traits of the disease which are specific to the UAE? 

The traits specific to the UAE (and the Gulf region) are both lifestyle challenges as well as genetic predisposition. 

4. What needs to be done on a societal level to overcome the prevalence of diabetes? 

Adopting a healthy lifestyle goes a long way to improving the instances of diabetes but spreading this message is also integral to improving statistics. Lifestyle education that combines both the adoption of healthy eating habits and exercise can be considered a powerful tool in combating the high rates of diabetes prevalent in our society. Implementing more diabetic education programmes and efforts to increase awareness about early identification of the disease, its risk factors and complication, are required to overcome the increasing epidemic of diabetes in the UAE and beyond. 

I think there should also be more collaboration between entities such as hospitals, universities and researchers, health authorities, schools, etc., to shape the best way forward. 

5. What are the current gaps in research on diabetes in the UAE and wider region? 

Some of the gaps, I believe, lie in the lack of consolidation of the efforts that are put in this field. There are many attempts that are taking place at different levels — awareness, diagnosis, treatment; however, at the same time, we see too much fragmentation.

Globally, diabetes is on the increase. The World Health Organization’s ‘Global Report on Diabetes’ published in 2016, estimates that 422 million adults were living with diabetes in 2014, compared to 108 million in 1980. The global prevalence (age-standardised) of diabetes has nearly doubled since 1980, rising from 4.7 to 8.5 per cent in the adult population. This dramatic rise reflects an increase in associated risk factors such as being obese or overweight.

Over the past decade, diabetes prevalence has risen a lot faster in low and middle-income countries than in high-income countries.  

In the Middle East and North Africa region (MENA) region, diabetes is a huge problem and one that is growing rapidly. There are approximately 38.7 million adults aged 20-79 years living with diabetes in 2017. Over two-thirds (67.3 per cent) of adults with diabetes live in urban areas.  

According to International Diabetes Federation (IDF), six out of the top 10 countries for highest prevalence of diabetes are in the MENA region — Kuwait (23.1 per cent), Lebanon (19.8 per cent), Saudi Arabia (23.9 per cent), Bahrain (21.9 per cent) and UAE (19 per cent). 

Diabetes is a growing and insatiable condition throughout the world, but the greatest and the fastest rise in the number of people with diabetes is in the MENA region, China and India. The disease affects all ages from the very young to the very old and has the greatest impact on health of all conditions, including cancer, as it contributes to blindness, heart attacks and kidney failure. 

Diabetes is a chronic disease that occurs either when the pancreas don’t produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body’s systems, especially the nerves and blood vessels. 

The disease can lead to complications in many parts of the body and can increase the overall risk of premature death. Possible complications include blindness, kidney failure, heart attacks, stroke and lower limb amputation. In pregnant women, poorly controlled diabetes increases the risk of foetal death and other complications. 

As Founder of The London Diabetes Centre, I work with a large team of experienced diabetologists specialising in different types of diabetes in children and in adults and using the latest technology with pumps and sensors. We are assisted by an obesity service, which can achieve sustained weight loss, and also have sleep apnoea and fatty liver experts, endocrinologists, ophthalmologists, nephrologists and cardiologists — so that every single aspect of the ramifications of this complex disease can be recognised and treated. We use advanced techniques and modern drug combinations to achieve the best in preventing heart, eye and kidney damage in our patients and have successfully done so for many years.

Globally, I also advise industry and colleagues on best standards of care and conduct lectures on new treatments in diabetes. As an early adopter of new solutions that improve diabetes care, I place the needs of the patient first to get the right solution for the right patient. It is so important that generalised population solutions are not thrust upon patients who may not be able to understand or manage their therapies. 

However, the best diabetes care requires regular attendance and support from diabetes educators, monitoring of many disease areas, and considerable expertise and experience. This is going to be increasingly difficult to achieve or afford with the worldwide increase in diabetes numbers. 

A report published in The Lancet ‘Diabetes & Endocrinology’ supports this claim. It states that the cost of diabetes worldwide was US$1.31 trillion, or 1.8 per cent of the global gross domestic product (GDP), in 2015. The study of the global economic burden of diabetes showed that two thirds of these total costs were direct medical costs (US$857 billion) and one third were indirect costs, such as lost productivity. Extensive treatments for diabetes and complications from the disease account for a lot of these costs, making it one of the most expensive diseases to treat in many parts of the world. 

In 2014, 8.5 per cent of adults aged 18 years and older had been diagnosed with diabetes. In 2015, diabetes was the direct cause of 1.6 million deaths and in 2012, high blood glucose was the cause of another 2.2 million deaths. 

It can thus be seen that diabetes is not only a global health problem because of its effect on mortality, morbidity and quality of life, but it is also a major problem for national economies. Out of all conditions, diabetes now creates the largest costs for any healthcare system. 

So, What is the Solution? 

I believe that diabetes is currently going through a technological revolution with venture funding in 2017 reaching US$6 billion and investment in high tech companies working in this space now showing a compound annual growth rate of over US$7 billion.

The driver for change is the improvement in acceptable glucose sensing and the smartphone which, when used together, have been shown to make substantial and significant improvements to diabetes long-term management. Soon we will be able to add continuous ongoing ECG and pO2 measurements to an array of physiological sensors monitoring health. 

Wireless technology has led to improvements in the ability to educate and to support people living with this long-term condition. I have witnessed enormous changes and improvements in diabetes care in the 40 years I have practised as a clinical diabetologist in London, but I have never previously experienced the extent and speed of change as seen in the last three years. 

With the forthcoming introduction of smart medicine and wearables (e.g. smart insulin pens and medication tracking devices), the scene is set for substantial changes in which diabetes care is offered, giving patients many more options to successfully live and manage their condition.

I believe that there is a substantial and increasing gap between the expertise available in specialist clinics such as The London Diabetes Centre in London, where many patients are seen every year — and the huge numbers of people who need education, technology and resources with which to treat their diabetes. 

The key requirement for successful care in diabetes is to help a patient understand that their knowledge and behaviour are integral to any successful strategy.

Traditional models of healthcare need to change and we now use the smartphone and social networks to harness these models of affecting a change in a person’s approach to chronic disease. This is where Artificial Intelligence will play a part. Already at The London Diabetes Centre, we download glucose test information on all our patients and use email and video to effectively support what we were never able to deliver in the past. 

Artificial Intelligence (AI) is a branch of computer science that is increasingly able to contribute to improving care in diabetes because of its ability to handle large amounts of complex data generated by the increased use of glucose sensors and insulin pumps. 

AI employs learning techniques that permit computers to learn automatically without human intervention or assistance. Clearly, the health outcome will depend considerably on the quality of the data being processed and its verification in real life application. 

Currently, there is an active interest in blood glucose control strategies, blood glucose prediction, insulin bolus calculators and lifestyle and daily support algorithms. Some of the most interesting are those that analyse and capture glucose–insulin dynamics. 

A real-time recurrent learning algorithm that models the blood glucose kinetics of people with Type 1 diabetes would have the ability to predict blood glucose levels and could help abolish two of the most costly and dangerous emergencies — coma that results from too low a blood glucose or that results from too high a blood glucose. 

Already we have a small community using open access closed loop pumps, which keep glucose levels within the desirable range and avoid undesirable lows and highs. Along with this are implantable sensors that are going to make these technological wearables more acceptable to patients, and alerts for patients, their doctors and their reimbursement agencies that will help identify inefficiencies so that resources and efforts can be selectively directed for best outcomes. Likely areas for early success will be diagnosing diabetes with wearable sensors and analysing patient phenotypes so that behaviour and outcomes can be predicted. Progress does not occur without its own barriers and these include usability, patient acceptability, real clinical outcome benefit, safety and data privacy 

Artificial Intelligence is going to play a greater role in medicine and governments and health agencies will increasingly look to using health data to better allocate resources and to alert and educate users on how they can help themselves.

International health concierge services are delivering rapid access to the best healthcare in the UK for private patients from around the world and the Middle East.

A “private health tourist” is someone who is prepared to travel beyond the borders of their native country, often with their families and loved ones, in search of the finest medical and healthcare expertise.

The UK continues to attract a large number of overseas patients especially from the Middle East and this is set to rise as we invest more in technology, communication and transport, not to mention healthcare concierge. Increasingly more people are willing to travel from the MENA (Middle East and North Africa) region to be treated by the best doctors and consultants in their fields.

Quality, access and convenience has meant that opportunities, including appointments and same-day diagnosis, rapid response multi-disciplinary review teams (MDT), second opinions and emerging treatments are becoming more and more sought after.

Why is this and what singles out the UK as a centre of excellence in the healthcare market?   

One reason is the UK boasts a unique blend of internationally acclaimed institutions such as The London Bridge Hospital, BUPA Cromwell, Great Ormond Street, Moorfields, and The Portland all within easy reach of each other. The country also features the Queen Elizabeth Hospital Birmingham, Centre for Defence Healthcare Engagement, through to the Centre for Endocrinology, Diabetes and Metabolism. 

Combine this with enough world-class consultants to populate a town and you have some of the single biggest concentrations of medical practitioners and facilities in the world. This means everything is on your doorstep and there has never been more choice between consultants, hospitals and clinics covering the full range of healthcare services and medical treatments. 

In my role as CEO of the Health Concierge Company Lexihealth, I would like to think we have helped to play a part in this. 

Health concierge is a relatively new concept in the UK and for “health tourists” concierge support is a critical addition for navigating the myriad of medical choice on offer and to access the best possible healthcare. With choice comes complexity. So how do you know which specialist is best for you? How can you be certain the hospital or clinic being offered has the highest reputation, or respects your personal or cultural needs? Where do you start? How do you know you are finding your way to the best possible care for you with absolute transparency on pricing? 

Less seasoned travellers may target the nearest, often cheapest services: however, those in the know tend to follow a strict list of key requirements. 

Dedicated health concierge manages the often-complex healthcare journey, from appointment negotiation to all the administration associated with one’s treatment.

It is about empowering patients by providing unparalleled access to the world of healthcare, ensuring complete transparency, convenience and choice at all times during their journey and removing all of the stress associated with the complexity of navigating the healthcare system. It offers a personalised and co-ordinated quality care with a discreet, bespoke, handheld concierge service throughout. A single point of contact with dedicated patient liaison managers is assigned to each case to organise appointments, screenings and treatments at times and in locations to suit the patient. Health Concierge is about enabling a patient’s best outcome approach by providing transparency, complete independence, trust and quality care. We want to ensure the patient gets from A to B as efficiently as possible having seen the right specialists first time around and with the highest patient satisfaction as the outcome.

I believe the UK leads the way with exceptional clinical governance and the highest medical standards for the benefit of private patients. I am also a firm believer in absolute transparency on treatment costs for healthcare with UK pricing structure meeting the needs for everybody irrespective of domicile or status. For example, at Lexihealth, we are guided by an independent Medical Advisory Committee (MAC) drawn from the world’s leading physicians and these clinicians personally assess and approve each consultant and specialist service before a single patient is referred. 

Another important aspect is offering family-centred holistic care for families and loved ones accompanying the patient. It can be a stressful time and to make the patient journey as easy as possible, the health concierge service can provide day-to-day assistance with any number of lifestyle requests such as renting accommodation, schooling, travel arrangements, booking hotels and restaurants, to organising translators, chauffeurs, city guides and itineraries. No request is ever too small. 

Our world is changing at an astonishing rate and healthcare is no different. 

Good healthcare and well-being are the most important matters for each of us and the world is learning more about the extraordinary variety of specialities, treatments and facilities that are available to us in healthcare. Advances in medical research and embracing the power of data science and personalised medicine, has meant that healthcare is getting closer to obtaining a much clearer picture of a person’s future risk disease profile and to tailor preventative treatments to their individual needs. 

The UK is a leader in quality evidence-based clinical practice which encompasses the breadth of tertiary level global experience and I have noticed an increase in screening packages among busy individuals who want to maintain their health to the highest standards. The approach is very much now about preventative medicine and one can look at the age profile, demographics, genetics and any family history and then design a screening package that can be undertaken in just 48 hours. 

Ultimately, it is about the quality of care and health concierge is about bringing all of these world-class doctors and facilities together to represent the patient in the centre of it all.  

One of the new projects Lexihealth is involved in is a new international patient offering, which will be launched at Arab Health 2019 by Birmingham’s Edgbaston Medical Quarter. The new medical concierge package supports patients who choose to be treated in Edgbaston — guiding them through every aspect of their treatment such as choosing the right consultant to finding the best place to stay. 

Edgbaston Medical Quarter offers some of the best places to be treated, particularly in oncology, trauma, diabetes and fertility and has become an ideal place for international patients to seek treatment. 

Located in the heart of the UK, Birmingham is ethnically diverse with 5.6m population within wider Birmingham. Birmingham International Airport has direct routes to Dubai and other Middle East cities and is only a 10-minute train ride to the centre of the city. Birmingham is also a centre of excellence for healthcare and life sciences, and The Queen Elizabeth Hospital Birmingham is a state-of-the-art facility that recently featured in a BBC series focused on its surgical excellence. Its new private wing is due to open this year. 

Within walking distance of many of the medical and healthcare providers, accommodation options range from four-star luxury hotels and high-end boutique hotels to more informal arrangements. For longer stays, there are family group sumptuous hotel suites and apartments to choose from. 

Edgbaston Medical Quarter offers a wide range of accommodation options, that can be selected to suit the individual patient needs, along with leisure activities. Close to the hotels are world-class art galleries, Edgbaston Cricket Stadium and Birmingham Botanical Gardens. There are 571 parks in the city and it also boasts some of the other finest shopping and entertainment in the UK including the Bull Ring shopping centre featuring a Selfridges department store, theatres, sports arenas, cinemas and more. It is also home to six Michelin starred restaurants and is a one-hour commute to Bicester Village, which specialises in luxury shopping. 

Patients choose Edgbaston because of its healthcare excellence, ease of access, value and the fact Edgbaston Medical Quarter’s medical facilities sit alongside thriving leisure and lifestyle communities. Friends and family can enjoy award-winning places to eat and a host of arts, leisure and sports facilities. It also is a culturally diverse and welcoming city, with beautiful green open spaces, which are the perfect place to relax and recover.

As the NHS continues with its 70th birthday celebrations, much of the commentary around the outlook for the UK healthcare sector is centred on the pressures of upholding consistent care quality standards while pushing for greater efficiencies. Economic factors, technological advances, and emerging public health issues have led to rapid changes in the way healthcare has been delivered in the UK throughout 2018 and continuing challenges such as an ageing population and the rising prevalence in chronic conditions are likely to compound this problem.

In response to these challenges, the healthcare sector in the UK is expected to shift its approach to care delivery by adopting more efficient and effective models of care provision such a personalised care, which will focus on delivering treatment based on the patient’s specific needs, preferences and physical condition.

A Focus on Digital Health Technology

Digital healthcare technologies will take centre stage in managing these efficiencies with Deloitte predicting that the UK will account for 7 per cent (£2.9 billion) of the £43 billion global digital health market by 2018.

According to Dr. Indra Joshi, clinical lead for NHS England’s digital experience programme, writing in a blog post published on the NHS England website, the most promising market for growth is mobile health with sales of apps and wearables predicted to increase by 35 per cent in the UK by 2018. 

“With the increasing value of these markets comes increased focus on the policy around health IT systems and interoperability. This is key to enabling safe and effective data exchange.” However, she warns that there is a lack of interoperability with digital health tools such as devices, wearables and integrated apps, which need to be addressed and that in order to address this nationally, “it is clear that a standard of what is ‘good’ needs to be developed and adopted.” 

Opportunities and Challenges 

In a report titled What will new technology mean for the NHS and its patients? Four Big Technological Trends, researchers from the Health Foundation, Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust joined forces for the first time, using combined expertise, to shed light on some of the big questions on the NHS. The report focused on four current trends — genomics and precision medicine, remote care, technology-supported self-management, and data and Artificial Intelligence (AI) – and the potential that they have to improve healthcare in the future if they continue to progress. 

The authors found that if the trends outlined in the report continue to progress, they have the potential to completely transform healthcare in terms of personalised treatments, improved access to specialist advice, tools and support for patients to become real experts in their health and care; and a data-driven system able to continuously learn and improve. However, it suggests that substantial barriers also exist, which slow the implementation of these new technologies including requiring large changes to both the workforce and workflows. 

“While there is no doubt technology offers sizable benefits to the NHS, the NHS needs to be aware of the challenges and opportunity costs that new advances present, as well as the policy questions that need answering in order to make the most of future potential,” the report concluded. 

Bridging the Skills Gap

According to Health Education England, the health service workforce in the UK, which already stands at 1.4 million, will need to increase by 190,000 by 2027 unless the rise in illness recedes. With the ageing and growing population creating a greater need for care, in order to prevent any more ‘brain drain’ the UK healthcare service is looking at new approaches to bridge the skills gap, attract new talent and retain existing staff. 

As a crucial part of delivering the next steps of the NHS Five Year Forward View, Health Education England is expanding current routes to the frontline and opening innovative new ones to attract the best people into the health service. According to the NHS Five Year Forward View, there is a need to continue to improve productivity and grow frontline workforce, especially in priority areas such as nursing, mental health, urgent and primary care. 

The document also described how “achieving this will require more training, more recruitment, better retention and greater return to practice after time out of the workforce. It will also require flexibility as roles and places of work evolve in line with changes to the practice of medicine and the shape of healthcare.” 

Taking to the Global Stage

According to Healthcare UK managing director Deborah Kobewka, who sat down with Arab Health Magazine during Arab Health 2018, the UK’s ability to stand out on the global stage in terms of its healthcare capabilities is down to the uniqueness having an excellent healthcare system — the NHS. 

“This system has been in development for 70 years, supported by a private sector that works closely with academia to develop cutting-edge technologies that are taking forward healthcare in the UK,” she explained. “Over the years, the NHS has amassed huge amounts of data and insights, which we have been able to leverage and, in combination with very innovative digital capabilities, provide real leading-edge insights into healthcare and use that to improve patient outcome and safety. We are very proud of what we have been able to develop in terms of the NHS.” 

Last year, at Arab Health, the focus for Healthcare UK was on prevention, quality and innovation, with exceptional applications in the field of digital healthcare. During the trade show, British healthcare technology company Babylon announced an agreement between themselves and THIQAH to provide AI health services to the citizens of the Kingdom of Saudi Arabia (KSA), in association with the KSA Ministry of Health. 

Indeed, there remains a significant opportunity for UK businesses and the NHS in healthcare exports across the globe. The NHS will be ready to target up to £7 billion of opportunities a year over the next decade with its world-leading healthcare expertise, thanks to a new government support service. 

The Healthcare UK Export Catalyst is set to help the NHS to access global healthcare export opportunities, with worldwide spend in the sector growing at 7 per cent a year. Healthcare UK has already supported NHS organisations to win export business of more than £100 million over the last two years. 

The catalyst sets out to boost this further and comes as the result of a pilot with NHS organisations to identify the services that would best suit them as they embark upon their export journey. The service will provide continued support, right through to finding opportunities and winning contracts. 

Sir Malcolm Grant, Chairman of NHS England, said in a press release: “In my view, Healthcare UK have done a great job already in raising the profile of UK healthcare services and systems overseas. Their new Export Catalyst service will further enhance the service available to NHS Trusts in developing their export capabilities, so they can reach a wide range of international markets. 

“In the next year, the mission will be closely focused on providing a showcase for great British healthcare services, building a strong brand across the globe and realising the amazing export potential of our world-class health system.”

Without doubt, the application of ionizing radiation and radioactive materials in diagnostic, interventional and therapeutic procedures in medicine is beneficial for hundreds of millions of people each year. Everyday applications of ionizing radiation for diagnosis and treatment help millions of patients all over the world.

A patient-centred culture is defined by caregivers that are engaged to deliver safe, reliable, high-quality care. Organisations that foster a culture committed to safety not only improve quality of care but also deliver better patient and caregiver experiences, and better outcomes.  

Safety has been always a top priority goal of successful healthcare systems. It was maintained by assessing the safety culture of the organisation through direct feedback from employees, nurses and physicians to understand the level of organisational focus on safety as well as develop targeted programmes to achieve this goal. 

The radiation safety culture in healthcare facilities is an integral component of safety culture programmes in medical settings. 

In order to build a radiation safety culture, the workplace behaviour has to be fully understood. This could be maintained by taking some actions to engage caregivers and patients in the Radiation Safety (RS) culture such as:  

• Mapping relevant stakeholders in RS culture in medicine and facilitate the cooperation between stakeholders  
• Proper education and training are essential to raise awareness of radiation risk and establish a positive attitude towards Radiation Safety  
• To accept and believe that radiation is associated with hazard and to handle radiation with cautiousness  
• Engagement of leaders and managers for a strong leadership support focusing on RS to provide commitment to the radiation safety programme  
• Caregivers responsibilities for safety has to be clearly defined within the whole organisation (top-down).  
• Integrate radiation safety into patient safety procedures/systems  
• Preventing accidental and unintended exposures, strengthening radiation safety culture and promoting reporting and learning systems  
• Proper risk communication with colleagues, patients and society  
• Foster a change in attitude towards RS by establishing training, continuous professional development, awareness sessions as well as education through the following activities: 1) discussions, 2) surveys, 3) organising and hosting stakeholder meetings and workshops, and 4) publishing position papers on key issues  
• Reducing unnecessary radiation exposures to patients and caregivers through justification of medical examinations and optimisation of protection
• Make the radiation safety culture a high priority when implemented through hospital management and Quality Assurance (QA) systems  
• Assessment of RS programme(s) by internal/external audits to evaluate attitude and level of implementation to identify areas of improvements
• Local system for reporting and follow-up events, with a no-blame policy. Implement corrective actions to prevent future occurrence of events  
• Developing an effective communication strategy and providing tools to support benefit-risk dialogue for healthcare providers, patients and caregivers  
• Engage the patients with the radiation safety and awareness education  Inform the patient about any mistakes or events associated with their procedures if any.  
• Promoting good practices by caregivers and recognising and awarding outstanding works.  
• Assign passionate radiation safety champions to assist and support the radiation safety culture  Improving patient safety and achieving consistent performance in patient safety requires adopting a culture and processes that support high reliability.  
• Assessing safety culture at the organisation and work unit-level supports awareness of patient safety issues  
• Evaluates the impact of patient safety interventions and performance over time
• Encourage accreditation and recertification programmes for health professionals  
• Allocate financial resources to sustain the RS culture in workplace. 

Service providers, institutions clinicians, administrators, and policy makers must work together to improve the quality of healthcare through robust programmes of safety in general and radiation safety in particular.

The risk of transmission of pathogens and subsequent infection in healthcare facilities is substantial. Pathogens may be transmitted from other patients (cross infection), the hospital personnel, and/or the hospital environment leading to Health Acquired Infections (HAIs). The risk is variable and depends on a patient’s immune status, the local prevalence of various pathogens, and the infection control practices and antimicrobial stewardship utilised during hospitalisation. Apart from the well-established pathogens (bacteria/fungi/viruses) causing Ventilator Associated Pneumonia (VAP), Catheter related Blood stream Infections (CRBSI), Urinary Tract Infections and drug resistant Methicillin Resistant Staphylococcus aureus (MRSA), there exist some less established opportunistic pathogens.  

Opportunistic Infections

Opportunistic infections (OI) are caused by pathogens of low virulence, which are usually non-pathogenic in a healthy individual. These are bacterial/viral/fungal/parasitic infections contained by immunocompetent hosts which cause progressive disease in immunocompromised patients (Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS)) and are often characterised by latency and reactivation. 

The Immunocompromised Host 

An immunocompromised host is a person who does not have the ability to respond normally to an infection due to an impaired, weakened or defective immune system, predisposing him to infections, often life-threatening, which would not otherwise occur. This inability to fight infection can be caused by a number of disease conditions: HIV/AIDS, malnutrition, cancer therapy with Immunosuppressive drugs etc. 

Epidemiology 

According to World Health Organization (WHO), major OIs include: Acquired Immunodeficiency Syndrome (AIDS) caused by HIV, Tuberculosis (TB), Pneumocystis jiroveci pneumonia (PCP), herpes infections, Cytomegalovirus (CMV), candidiasis, cryptococcal meningitis and cerebral toxoplasmosis in different chronology depending on multiple factors. 

Immunocompromised patients are at high risk for opportunistic infections. Traditionally, there are infections that arise from endogenous reactivation of latent infections, and nosocomial transmission. Therefore, it is deemed likely that special infection control (IC) interventions are required to prevent transmission in healthcare settings. 

Reinfection with pathogenic organisms in new cases of immunocompromised population can occur possibly by means of airborne transmission and nosocomial spread especially with respect to tuberculosis. Most studies support the view that infectious complications in immunocompromised patients are exogenous in origin and more epidemiological studies are needed to define the risk of nosocomial spread and need for better infection control practices to prevent these infections. 

The fact that infectious complications in immunocompromised patients are often predictable and can be prevented, makes infection control practices a very important step in the improvement of the quality of care provided to the immunocompromised patients. In addition, by reducing infectious morbidity, infection control practices will contribute significantly to cost savings. 

Tuberculosis – (Pulmonary TB) 

TB is caused by Mycobacterium tuberculosis and is an airborne disease, transmitted from person to person through aerosols route. It is a highly communicable disease that can be spread while talking, sneezing, coughing and shaking hands. The UAE being a cosmopolitan country with a dynamic influx of people from more than 200 nationalities poses a major challenge to the control of tuberculosis. As per 2018 census, of the total 9.54 million UAE population, majority, 8.4 million (88.5 per cent) is constituted by a floating population of expatriates. Immigrants from India, Sri Lanka, Pakistan and Bangladesh are major contributors to this OI. Thankfully, the incidence has been reduced due to stringent visa control measures implemented by the Ministry of Health and Prevention in the UAE.

Although the prevalence of TB in UAE is fairly low, the rising incidence among expatriates poses a major challenge. An increasing number of cultures have confirmed TB and multi-drug-resistance tuberculosis (MDR-TB) among native and expatriate patients, necessitating improved vigilance in case detection, effective management and prevention of MDR and XDR-TB emergence in the country. 

HIV and TB Co-infection - A Major Infection Control Challenge 

HIV/TB co-infection is another major challenge especially in MDR-TB cases. Although HIV incidence is very low in UAE and restricted to expatriates and in transits from high prevalence African countries, treatment cost and medical management poses a challenge for the hospital in terms of infection control, patient isolation, clinical management and care. 

The incidence of other OIs like CMV, PCP and Herpes, fungal and parasitic infections are very low in the UAE and only rare cases have been reported. 

Transplant and Immunosuppressive Therapy

There is a growing number of immunocompromised patients because of the use of intensive therapeutic regimens in patients with cancer and organ transplantation, besides those with HIV infection. 

Post-surgery, an organ transplant patient is at his most vulnerable state. The immunosuppressive medications enable them to avoid rejection of the new organ, but at the price of a defenseless immune system. ICU patients, neonates, HIV-positive patients and the elderly - each of these groups are at a higher risk of infection than the average hospital occupant. It is the infection control staff’s duty to assess the risk factors, minimise as many as possible and annihilate infectious organisms that take advantage of the situation. 

Improvements in patient survival have been observed in all categories, but the risks of infection related to immunodeficiency continue to be substantial by either resident or environmental bacterial, fungal, viral, and protozoal parasites. Even low-virulence microbes (opportunistic pathogens) may invade, proliferate, and cause disease in the immunodeficient host. Furthermore, newer organisms previously considered as contaminants or harmless colonisers have now emerged as significant human pathogens in the immunocompromised host.

Handwashing, Self-hygiene and Standard Precautions

Hands are the most common vehicle for transmission of organisms. It is estimated that 30-40 per cent of hospital acquired infections are related to contamination of healthcare workers hands. Proper “hand hygiene” along with standard universal precautions likes gloves, gown, mask, shoe and head cover are the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. Limiting visitation by patient attendants, routine floor cleaning with disinfectants, cleanliness of the hospital staff and nurses is paramount in infection control.

Adenosine triphosphate (ATP) level and fluorescent markers have been used as surrogates of contamination to assist monitoring of cleaning especially in ICU’s for monitoring protective microbial contamination and reducing chances of OIs in immunocompromised patients, but their role in determining surface microbial contamination is controversial. On the other hand, infections like TB are airborne infections and can be only controlled using tight fitting doors and negative pressure isolation ventilations. Protection using N-95 respirator mask should be practiced before entering isolation room. 

There is an elemental role of the microbiology laboratory and Infection Control officer in the prevention and control of infections and for providing awareness and training. Direct observation and feedback of cleaning services including an education component ideally can result in change in behaviour and goes a long way in implementation of good infection control practices. 

Prevention of infection, prompt diagnosis and treatment remain the cornerstones of management of OIs. The importance of basic infection control measures cannot be over-emphasised. In addition, appropriate prophylactic agents, rapid diagnostic techniques and the early institution of appropriate therapy are essential for good infection control practices.