Non-communicable disease and sustainability
Innovation in addressing NCDs: A case study from Abu Dhabi OLIVER HARRISON DIRECTOR OF PUBLIC HEALTH AND HEALTH POLICY AT THE HEALTH AUTHORITY OF ABU DHABI, UNITED ARAB EMIRATES
The global burden of non-communicable diseases (NCDs) is rising worldwide. Yet these diseases are preventable; the key risk factors and effective interventions have been known for decades. The challenge now is how to achieve the right suite of interventions tailored to the individuals and how to effectively prevent these diseases. Abu Dhabi, one of the seven emirates of the United Arab Emirates, has taken significant steps to implement an evidence-based strategy through population screening followed by targeted interventions, tracking near-term performance indicators and link actions today with longer-term outcomes, using innovative eHealth and mHealth approaches. Here we present their programme, “Weqaya” (Arabic for “prevention” or “protection”). Through its innovative work, Abu Dhabi is fast becoming an “NCD laboratory” generating insights for all countries (including low- and middle-income countries). Weqaya is based on building the NCD community and learning from what works in practice through an open-source platform.
Q. How did you start addressing the burden of NCDs in Abu Dhabi?
standard, the Framingham Risk Score. The results have
OH. Since the 1990s, the WHO had consistently reported the
confirming international data related to the world’s second
suggested a very high burden of cardiovascular risk factors,
UAE as having the world’s second highest prevalence of diabetes,
highest rate of diabetes (around 18%) and that in a very young
with about 20% of the adult population (based on population
population. The data have also showed high rates of obesity
sampling). In 2006, the Abu Dhabi government initiated a major
(35%), dyslipidaemia (44%) and hypertension (23%). Worse
health system reform primarily targeted at improving access and
still, the results also indicated a rapidly worsening situation, as
outcomes for residents. One of the key pillars of this strategy was
the population aged, without urgent effective intervention. As
building public health capacity, particularly in non-communicable
expected, the Weqaya screening alone has provided
diseases (NCDs). At the time, the Emirate had no real experience
significant impetus across government for affirmative action.
in collecting data, planning and monitoring, the core skills for
However, screening was just the beginning of the Weqaya
effective, scalable chronic disease management.
response.
Indeed, we
found there were very few suitable programmes for tackling
intervention programme at population scale, with a special focus
Q. On the basis of these screening results, what has been changed in the health system and policy?
on diabetes and cardiovascular diseases. We came up with a
OH. Abu Dhabi has been rapidly reforming its health system. It
NCDs. Thus, taking advice from local and international experts, we began implementing a novel evidence-based screening and
scalable and flexible strategic plan called “Weqaya” (Arabic for
was one of the first in the Gulf region to move away from the
“prevention” or “protection”); Weqaya has three simple and
traditional Ministry of Health model, creating in 2007 separate
adaptable modules: Screen, Plan and Act. Given the scale of the
functions within distinct government organisations: the Health
challenge, it was decided to focus initially on cardiovascular
Authority of Abu Dhabi (HAAD) as Regulator, SEHA as
disease (CVD), with a view to increasing Weqaya to other NCDs in
government operator, and Daman as government health insurer.
due course.
Since then, HAAD has been a pure regulator, setting policies and
From 2008 to 2010, the Weqaya screening enrolled nearly the
entire
Emirati
adults
(94%)
to
determine
standards and regulating against these through licensing and
their
inspection. Since 2006, HAAD has also built an internal Public
cardiovascular risk profile based on an evidence-based
Health Department, responsible for compiling data on disease
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From 2008 to 2010, the Weqaya screening enrolled nearly the entire Emirati adults (94%) to determine their cardiovascular risk profile based on an evidence-based standard, the Framingham Risk Score
burden, prioritising areas for action, and initiating and continuously
“Trust”). Although citizens were able to opt-out and obtain their
monitoring targeted and effective programmes.
Thiqa card without Weqaya screening, this proved to be an
On the basis of the Weqaya screening data, a population
effective way of setting the population default and driving uptake.
health census, we have been able to identify individuals, groups and population segments for effective and cost
Q. How is your baseline used?
effective action including the health sector, and the key “driver”
OH.
Weqaya screening results provide a baseline for each
sectors that profoundly influence health-related behaviours,
individual, and for groups (for example, families, local
particularly in the domains of nutrition, physical activity, and
communities, employees), and for the whole population. This
Under
powerful health census creates a solid platform for assessing the
Weqaya we are now working towards sectoral Action Plans
tobacco, through a whole-of-society approach.
challenges, targeting resources, and measuring performance
and clear targets across food quality and labelling, urban
against baseline.
planning, tobacco-free environments, education, labour, and
We recognise the importance of affirmative action and have
media. We recognise the clear evidence that these sectors are
driven this in three waves. Firstly, we have delivered securely
able to drive effective, low-cost solutions provided
personal health reports with their Weqaya risk scores to
For this reason, the
around 120,000 citizens, often provoking family discussions
second Weqaya module (Plan) and the third module (Act),
about the risks and collective actions. Secondly, since we also
government takes joined-up action.
include not only health sector, such as care protocols, and
collected mobile phone number and e-mail addresses we
structured disease management, but also non-health sectors,
have been able to activate a web-based data system. Thirdly,
The
we are now building a secure cloud computing architecture to
effectiveness of Weqaya relies on coordinated healthcare and
enable confidential health data to become ubiquitous (much in
especially nutrition, exercise, and tobacco control. societal responses.
the way Visa or Mastercard enable financial data ubiquity). The aim is to unlock the creativity of a range of innovators with
Q. How did you succeed in screening 94% of the adult Emirati population?
a view to improving Abu Dhabi health, whilst maintaining the highest levels of confidentiality.
OH. Weqaya used a simple formula of encourage, enable and the line” promotion campaign, featuring carefully selected high-
Q. What are the limitations of Weqaya to date?
profile, influential individuals. Participation was enabled through a
OH. Weqaya is a population-based clinical programme, so it was
simple screening design (10 minutes only) and access, with 25
necessary to make design choices through that lens. Diabetes
dedicated clinics established, open in evenings and weekends,
screening with HbA1c alone cannot distinguish between Type 1
bookable through a call centre or walk-in. Finally, we were able to
and Type 2 disease, although linking to HAAD clinical encounter
link Weqaya screening with the issuance and renewal of a free and
data means we can now discriminate. We could not rigorously
comprehensive health insurance card (called Thiqa, Arabic for
enforce fasting which may have influenced the results for high
enforce. As a first step, screening was encouraged with an “above
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Non-communicable disease and sustainability
cholesterol. We used a single elevated clinical blood pressure
the delivery of quality care by clinical providers, that is, compliance
reading to define hypertension, possibly leading to overestimated
with Abu Dhabi's evidence-based healthcare pathways, and the
hypertension rates, although we note that the hypertension rate
upload of accurate clinical data to HAAD’s central population-wide
was considerably lower in our population (23%) compared with an
database.
In addition to “Pay for Quality” we have created another
age-standardised US population.
As a starting point we have calculated cardiovascular risk
novel incentive programme called “Pay for Health” for
using models from the US-based Framingham Heart Study.
structured Disease Management Programmes (DMPs) under
These models are currently among the best available in the
Weqaya. Under “Pay for Health”, DMPs are paid up to
evidence-base, although we know that both genetics and
US$1,500 per patient per year for improving measurable
environmental exposures are very different in the Abu Dhabi
“health” over the initial individual baseline. For the purposes of
population. Over the coming 3-5 years, Weqaya will generate
Weqaya, “health” is defined with clear evidence-based criteria
all the data required to generate Abu Dhabi’s own risk scores.
(starting with the Framingham Risk Score). With commercials
We expect that this process will reveal new risk factors,
tuned to ensure “Pay for Health” delivers return on investment
opening new targets for health interventions and research.
to government, this is effectively a structured mechanism for government to transfer financial risks associated with NCDs.
Q. How is the health system financed? What is the cost of the Weqaya programme?
Driven by their clear incentives, DMPs have two roles: encouraging the compliance of their customers with clinical
OH. Abu Dhabi has mandatory insurance for all citizens and
care, and helping drive behaviour change to address risk
residents. From 2007, it became mandatory for employers to
factors such as obesity, lack of exercise, and tobacco
provide private health insurance for their expatriate workers; the
consumption. Under Weqaya, DMPs have access to a unique
citizens’ programme is called Thiqa (Arabic for “trust”) and was
secure cloud computing data architecture, which ensures
established in 2008. The health insurance system helps develop a
health data can be packaged and delivered where it counts.
competition among healthcare providers (such as Johns Hopkins,
This technology can support simple channels, such as text
Cleveland Clinic, and Imperial College London). In Abu Dhabi,
messages, call centres and face-to-face meetings.
clinical service providers are reimbursed at defined tariffs for
quickly we believe we shall see innovation in both content and
clinical activity. Data transparency and clear quality indicators
channel; this is a fertile ground for academic and industry
drive free patient choice and thus clinical provider revenues. In
R&D. This strategy will start working across the entire
addition, under a system called “Pay for Quality” providers receive
population, early 2012.
additional bonus payments for adherence to evidence based
Very
At individual level, through our Weqaya programme related to non-health sector, DMPs are able to deploy individual
clinical care pathways.
The first round of Weqaya screening cost around US$30 per
incentives (for example, loyalty points) to encourage healthy
person (including a reasonable profit margin to encourage
behaviours. Using smart mobile technologies for decision
facilities to help drive uptake).
Overall, over three years
support, and a range of 3G related applications, DMPs can
Weqaya has cost about US$10 million (that is, around US$57
effectively intervene at individual level, while creating the
per Emirati adult). The long-term sustainability of the
enabling environment to make healthier choices.
programme has been built-in right from the beginning, with
By influencing the demand side, we aim to shift
screening and clinical interventions funded through the health
consumption towards healthier choices; in parallel we have
insurance scheme, and rigorous calculation of the cost-benefit
partnered with a range of producers and service providers
of both specific components and the programme overall. We
who have shown an interest in making their products healthy,
are particularly excited about “Pay for Health”, a new initiative
or at least less harmful (supply-side impact).
for disease management programmes; this too, has been developed specifically with a view to sustainability. By design, through improving health, and flattening the growth of
Q. How do you manage to create this enabling environment?
healthcare costs, spending on “Pay for Health” actually saves
OH. We have taken a three-stranded approach. Firstly, we have
the government money right away.
created a scalable platform based on novel technologies developed on an open-source platform.
Secondly, we have
Q. Do you consider the provision of incentives as a key driver?
aligned incentives around a clear definition of health. Thirdly, we
OH. Yes, we believe incentives are critical at different levels, health
entire community, rather than changing one person by one
providers as well as individual levels. “Pay for Quality” incentivises
person. For example, if you are the only person that wants to quit
recognise that it can be easier to change a whole group, even an
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Non-communicable disease and sustainability
In addition to “Pay for Quality” we have created another novel incentive programme called “Pay for Health” for structured Disease Management Programmes (DMPs) under Weqaya
smoking and around you friends and family are still smoking
Soon, we plan to expand Weqaya to address NCDs beyond
quitting can be really difficult. However, if everyone quits, it is very
CVD; the approach can be adapted for all diseases where
hard not to quit smoking. In recognising this strength of
screening is beneficial to disease outcomes. This applies of
community action, and cross-sectoral alignment, Weqaya is
course to the diseases that together account for 60% of global
increasingly ubiquitous – a signpost for healthy choices in
mortality such as CVD, cancer, and chronic respiratory
restaurants, schools, shops, parks, on mobile phone applications.
disease, and to other diseases, such as HIV and depression.
We believe that a whole range of stakeholders can also
prioritise actions (for example, no smoking policies or
Q. Emerging countries as well as developing countries are also facing the rising burden of NCDs. What lessons does Abu Dhabi can share with these countries?
encouraging sports), benchmark their position in the market,
OH. Our data suggests that in high burden populations (such as
contribute to driving behaviour change. Employers can play a major role for better health or the worse; providing secure, anonymised Weqaya data for their employees helps employers
and track their performance over time. Social networks can
Abu Dhabi and other Gulf States), population screening followed
play a critical role to create new ways of thinking about health
by targeted interventions in well-stratified groups could yield good
and wellness as a brand related to positive behaviour
results both, in terms of rapid effectiveness and medium- and
changes; our cloud computing and mobile platform enables
long-term cost-effectiveness. Weqaya is based on a shared health
sharing data with the social network to drive action by the
database, linked through cloud computing to mhealth and ehealth
whole groups, for example sharing selected data (say, body
technologies. The architecture means Weqaya is rapidly scalable
mass index, food and exercise) with a spouse can help drive
at a low marginal cost.
Since Weqaya is modular (Screen, Plan and Act) it is
diet improvements for the whole family.
possible to adapt the specific approach depending on local
Q. What is your vision and the next steps of your strategic plan?
epidemiology and available resources. For example, we have
OH. Our central aim is simply saving more than 3,000 Emirati lives
just one dollar, and Actions for US$10 a year
worked with a group from Cameroon to design Screening for (with SMS
from cardiovascular death over the next 10 years against
behavioural advice, and just one or two low-cost generic
predicted mortality rates, and many more expatriate lives as well.
medications).
Even
in
developing
countries,
mobile
To achieve this, we are driving the coordination of government,
penetration is very high, enabling the tracking of effectiveness
private and civic sector activities with the ambitious target of
through linked mHealth technologies.
making Abu Dhabi one the most improved health environments in
This cost effective approach is very promising worldwide to
the World by 2030. Through this coordinated effort we shall also
move forward not only the fight against NCDs but also
build a range of opportunities for education, research and
communicable diseases and deliver results, including in the
industry. International partners already play a key role here to help
poorest countries. There is an opportunity to convert this
tackle current health challenges, for example we have undertaken
approach into a Global Action Plan.
carefully structured public-private partnerships with two pharmaceutical companies (AstraZeneca and Eli Lilly), and with the UAE telecommunications company, Etisalat.
Through our
Q. What are you projects with the Gulf region?
partnerships, we aim for Abu Dhabi based companies to play an
OH. We view Weqaya as simply a clear and practical means to
increasing role developing novel technologies, innovations and
implement non-communicable disease resolutions such as the
research, particularly in eHealth and mHealth.
You can see that the simple primary goal of saving lives can be channelled to create a cascade of benefits across society.
68 Health G20
2008-13 WHO Action Plan, and the 2010 Dubai Declaration on Diabetes and Chronic NCDs in the MENA Region.
We are beginning to talk to other countries in the Gulf
Non-communicable disease and sustainability
Key facts from Weqaya screening in Abu Dhabi • 2/3 adults are overweight or obese • 44% are either diabetic or pre-diabetic • Almost 1/2 have abnormal cholesterol • 71% have at least one risk factor for CVD and therefore need to change their lifestyle to avoid heart attacks and stroke • Total societal cost to Abu Dhabi may be more than AED300 billion over 10 years
Dr Oliver Harrison is a UK trained neuroscientist, physician and academic. Prior to joining HAAD, Oliver spent five years with McKinsey. He is a medical doctor with postgraduate training in Psychiatry, a Foundation Scholar in Medicine and Neuroscience at Jesus College, Cambridge, an Honorary Lecturer at Imperial College London.
• The potential cost savings from an effective Weqaya Programme from diabetes alone are tremendous
region. We are keen to develop a community of Weqaya approaches, each with harmonised standards, but adapted to local context. We propose that these Weqaya programmes ideally be driven from a single database to enable countries to learn from each other, using the same data, the same protocol, all Internet based. This approach will facilitate benchmarking and help overcome this issue of interoperability of the telecom systems and many others current challenges. Such a strategy is very exciting as it opens the potential for multi-national impact, open-source learning and innovation.
Q. What would be your messages to the global leaders who are attending the major G20 conference? OH. The burden of NCDs continues to worsen worldwide. The major challenge is now how to achieve the right suite of interventions tailored to the individual, and how to effectively prevent these diseases. Weqaya can be adapted for a range of populations; it has the potential to become a multinational Action Plan, tailored for local context but harmonised to ensure continuous learning.
Building on the momentum of the recent UN Summit on NCDs, Europe could help take a lead in driving the fight against NCDs worldwide, using its unique assets, experience and resources. This major public health concern should be on the top of the political agenda, it is not only a priority to contribute to global health sustainability, but it is also an economic asset with a potential high return on investments. The UN Summit on NCDs stated that mitigating the cost of NCDs, about US$47tn for over 20 years, should provide a multi-trillion dollar growth opportunity. At a time of scarce resources and financial crisis, hopefully, Global leaders of the G20 may be sensitive to this consideration and will commit to taking affirmative action.
I
Interviewed by Therese Lethu
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