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PATIENTS FROM THE UNITED ARAB EMIRATES SEEKING
HEALTHCARE SERVICES OVERSEAS DURING 2009 – 2016:
CHARACTERISTICS, MOTIVATIONAL FACTORS AND PREFERENCES
by
Wafa Alnakhi, MSc
A dissertation submitted to Johns Hopkins University in conformity with the requirement for the
Each year the Dubai Health Authority pays an average total expenditure of $771 million
dollars to cover on average 15002 UAE nationals seeking healthcare services overseas. There is
not enough evidence base, however, to guide patients in their decision making for choosing
treatment destinations (V. A. Crooks et al., 2013; Turner, 2011).
Purpose
The objectives of this study are to: 1. Examine the factors associated with treatment
destinations and total number of trips among patients treated overseas from the United Arab
Emirates sponsored by the DHA during 2009-2016. 2. Explore patients’ characteristics and the
motivational factors for choosing treatment destinations among the patients treated overseas from
the UAE during 2009 – 2012. 3 Explore associations between patient characteristics and
preferences for healthcare services if the treatment is made available in the UAE for the most
common conditions among patients treated overseas from the UAE during 2009 - 2012.
Methods
Secondary analysis from DHA: 1- UAE national patients who sought medical treatment
abroad sponsored by DHA during 2009 – 2016. 2- Knowledge Attitudes and Perceptions Survey
from Dubai Health Authority related to medical treatment overseas among residents of Dubai
with at least one family member who had experienced healthcare overseas during 2009-2012.
1 Average total expenditure for overseas treated patients during 2004 - 2016 2 Average number of overseas treated patients during 2004 - 2016
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Results
Choosing the treatment was associated with age, travel season, and medical specialty. The
total number of trips was associated with age, travel season, number of years being in the data set
and the medical specialty for which the patient sought treatment. The treatment destination was
associated with patient medical conditions and financial factors. Patient preferences were
associated with medical condition, age, financial factors, and family member responses if the
family member was answering on behalf of the patient.
Conclusions
This study contributes to the current knowledge related to medical travel. Findings may
help inform upstream policies aimed at regulating overseas treatment strategies at the Dubai Health
Authority.
Dissertation Readers:
Laura Morlock, PhD
Darrell J. Gaskin, PhD
Jodi Beth Segal, MD
Kevin Frick, PhD
Altijani H. Hussin. MA
iv
Acknowledgement
I want to thank, Dr. Wasif Alam and Dr. Eldaw Suliman, my workplace supervisors for
pushing me to apply to JHSPH; especially, Dr. Eldaw, who also guided me along the way to specify
my research questions to serve the government’s need. I like to acknowledge my workplace, Dubai
Health Authority and all its departments who provided me with the data for my first manuscript;
and Dubai Statistic Center for providing me with the Knowledge, Attitudes and Perceptions Survey
data for my second and third manuscripts. My sincere appreciation to all the faculty at JHSPH; I
applied many of the knowledge and skills that I have learned from their courses to this research
and I have become good friends with many of them. I also would like to thank all of the staff at
JHSPH; from the security guards who protected us on the streets of Baltimore to all administrative
assistants at the school who made our life so much easier as international students.
I am both professionally and personally indebted to all my friends, colleagues and
companions who sported me along the way. Special thanks to the following people who helped
me with data management and organizing my thoughts when writing my manuscripts: Knar
Sagherian, Youssef Farag, Omamah Alfarisi, and Nabil Natafgi. I am especially grateful for my
incredible family and friends in UAE, who have supported me and prayed for me to finish this
journey successfully and return home safely.
I want to acknowledge and send my sincere gratitude to my committee members. Dr. Jodi
Segal and Dr. Darrell Gaskin, whose courses provided me with a wealth of knowledge that I was
able to directly apply to my research. Dr. Kevin Frick, who always challenged me with questions,
and his door was always open to give me feedback to help me think like an economist and a
researcher. I am also lucky to have a great colleague from Dubai Health Authority be relocated
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here in the USA to be part of my committee, Mr. Altijani who has been very supportive and
encouraging.
I owe my success of finishing this work successfully to two women. My mother, who didn’t
get the chance to go to school and be educated. She can’t read and write, but always encouraged
me to be the best version of myself and to always continue learning to be the best I can be. My
advisor, Dr. Laura Morlock, who embraced me in her program and gave me all the support I needed
to accomplish this work. She believed in me and the idea that I can make a difference and bring
change to my country. At last, I am thankful to all the people in my life, who helped me finish this
journey successfully.
vi
Contents Abstract ........................................................................................................................................................ ii
Acknowledgement ...................................................................................................................................... iv
Problem Statement ................................................................................................................................... 2
Definition of Medical Travel ................................................................................................................... 4
Research on Medical Travel .................................................................................................................... 6
Curriculum Vitae .................................................................................................................................... 261
1
CHAPTER ONE: INTRODUCTION
2
Introduction
Background
The United Arab Emirates (UAE) is a country that is located in the Middle East, bordered
by the Kingdom of Saudi Arabia and Oman. The UAE is a federation of seven emirates and Abu-
Dhabi is the capital with a population of 9.1 million (Agency, 2018). There are three main entities
that oversee healthcare in the UAE. The Department of Health Abu Dhabi is the government health
authority that oversees the healthcare delivery system in the Emirate of Abu-Dhabi only (Abu-
Dhabi, 2018). The Dubai Health Authority (DHA) is the government health authority that oversees
the healthcare delivery system in the Emirate of Dubai only (Authority, 2018). The Ministry of
Health (MOH) is the federal health authority that oversees the healthcare delivery system in the
northern Emirates (Prevention, 2018). By government law, all UAE nationals are provided
healthcare at no charge to them in the government sector whether it is in HAAD, or DHA or MOH
and regardless of where they reside. In addition to providing healthcare services in the Emirate of
Dubai, other main responsibilities of the DHA are to serve as a licenser and a regulator of the
medical professionals and facilities, and to ensure the alignment of the private healthcare sector
with the policies and strategies for healthcare in the Emirate.
Problem Statement
Although the government in the UAE provides “free” healthcare services to UAE nationals
in order for them to access primary and tertiary healthcare facilities as per the government law,
there are a number of patients who travel seeking healthcare outside the UAE under different
sponsorships (Dubai Health Authority Annual Statistic Books, 2016). Despite that the DHA states
they are providing good healthcare services, the UAE nationals are still seeking healthcare services
overseas. The total number of UAE nationals seeking healthcare overseas is not accurately
3
calculated since there are many entities in the UAE that fund UAE nationals for their treatment
overseas in addition to the government health authorities. The number of medical travelers is
scattered among those entities; in addition, there are patients who pay out of their pockets.
Currently, there is no Emirate level or federal registry or a surveillance system that captures the
number of medical travelers from either the Emirate of Dubai or in the UAE. (Aw, 2010; Blair &
Sharif, 2012; Mokdad et al., 2014; Rahim et al., 2014)
Although there are some statistics that are published on the DHA website for the patients
who travelled through the support of the DHA, the data are incomplete regarding the numbers of
UAE nationals who travel overseas and their associated expenditures. The average total
expenditures per year for overseas treated patients in the Emirate of Dubai according to the DHA
from the year 2004 to the year 2016 was approximately 283.5 million UAE dirham, which is
approximately $77 million US dollars per year3. According to the DHA Annual Statistics Books,
the most common destinations that patients traveled to are the UK, Germany, USA, India, and
Thailand. The specialties that traveling patients sought overseas included the following: General
Medical, Surgery, Obstetrics and Gynecology, Fertility, Urology, Nephrology, Neurology, Neuro-
surgery, Orthopedics, Cardiology, Ophthalmology, Pediatrics and Pediatric Surgery, Neonatology,
Ear, Nose and Throat, Oncology, Dermatology, Gastroenterology, Dental and Dental Oral Surgery,
Hanefeld, & Smith, 2014). A qualitative study was conducted to look at the motivational factors
at different times before, during and after patient travel for healthcare. In this study, the
motivational factors for patients seeking healthcare abroad were based on the timeline, themes and
sub themes. Patient experience was dissected into three chronological stages of the overseas travel
experience. “Pre-travel” is the stage in which patients are conceptualizing their experience by
describing important events and thoughts that lead to travel internationally for healthcare. “Travel”
is the stage which focuses on patients obtaining the healthcare needed in the destination country.
“Post-travel” is the stage which highlights the follow up care of the patient after returning to the
home country. The time lines were further dissected into themes including motivation and research
in the pre-travel period, obtaining care during the travel period, and follow up, advice and future
healthcare needed in the post-travel period. The authors of this paper further categorized the
motivations with subthemes of perceived healthcare need, finance, dissatisfaction, and recreational
travel. Moreover, obtaining care was further described with the sub themes of logistics,
technology, concerns, reassurance, and communication (Eissler & Casken, 2013).
8
Several studies have been conducted to try to understand people’s perceptions about
choosing destinations. Some studies were from the tourism perspective only, others were from the
medical tourism perspective, and some studies were specifically about patients seeking healthcare
abroad. Some research studies focused on the factors influencing choosing the destinations of
treatment and other research studies focused on factors influencing choosing the healthcare
facilities. A cross-sectional survey was conducted in Korea by interviewing people face-to-face at
Jeju International airport. The survey questions were presented in the native language of the study
participants including Chinese, Japanese and Koreans visiting Jeju Island in order to study the
motivational factors and cultural differences among the three ethnicity groups when selecting a
destination for medical tourism. By using the respondents’ socio-demographic characteristics and
a set of question items to understand people’s perceptions about medical tourism, the study
concluded that there were differences in the motivational factors among the three ethnicity groups
Pre Travel
Travel
Post travel
Motivation
Research
Obtaining Care
Follow up
Advice
Future
healthcare
Perceived
healthcare need
Finance
Dissatisfaction
Recreational
Travel
Logistics
Technology
Concerns
Reassurance
Communications
Timeline Themes Subthemes
Figure a. Thematic Analysis for Travelling Seeking Healthcare
9
related to the selection of a destination, including perceptions of inconveniences and preferences
for products. The differences were found to be statistically significant by using ANOVA and factor
analysis for statistical analysis of the survey questions (Yu, 2012).
Another study was conducted in Isfahan, Iran through a questionnaire to examine the
factors influencing destination choice among non-Iranian infertile couples who were referred to
the Isfahan, Iran Fertility and Infertility Center. The authors used frequencies and chi-square tests
for statistical analysis since the questions were asked in the form of a Likert scale. The authors
concluded that there are many factors that can influence destination choice for the treatment
country. The study concluded that factors such as cost, distance from home to the country of
treatment, lack of expertise in the home country, tourist attractions, legal and moral restrictions,
and respect for the patient’s ethical and religious beliefs systems are all statistically significant
factors that influence destination choice (Moghimehfar, 2011).
In the Netherlands, a study was conducted to assess the influence of previous patients’
experience and the availability of web-based hospital performance indicators on the decision-
making process of surgical clinic outpatients when choosing hospitals for surgical treatment. The
study was conducted through an internet-based questionnaire and used adaptive choice based
conjoint analysis. The study concluded that respondents valued patient experience as importantly
as hospital based information. Respondents mostly relied on information related to physicians’
expertise, waiting time and physician communication when choosing a healthcare facility (I. B.
De Groot, Otten, W., Dijs-Elsinga, J., Smeets, H.J., Kievit, J. and Marang-van de Mheen, P.J.,
2012; I. B. De Groot, Otten, W., Smeets, H.J. and Marang-van de Mheen, P.J., 2011)
Another study was conducted in the Netherlands, to examine patients’ hospital choice when
price was not a consideration to patients as they were covered by health insurance. A utility
10
maximization model and conditional logistic regression were used to examine the relationships
between patient characteristics and hospital attributes on the choice of a facility for non-emergency
hip replacement surgery. Travel time, the hospital quality rating publicly available, and waiting
time were all factors that had a significant impact on hospital choice. Researchers considered
creating interaction variables considering travel time, hospital attributes, patients’ heterogeneity
and examined patient preferences and changes overtime. The results show that patients were
sensitive to travel time to hospitals and publicly available hospitals’ rating and waiting time.
(Beukers, Kemp, & Varkevisser, 2014).
Studies have also examined the factors influencing the destination of choice among tourists
in general. A study was conducted for example to compare the different motivational factors of
British and German people visiting Spain and Turkey for tourism only and not seeking healthcare.
The objective of the research was to determine if motivational differences existed between tourists
from the same country visiting two different geographic destinations and also among tourists from
two different countries visiting the same destination by analyzing survey data using a series of
cross tabulations, content analysis for the qualitative data, factor analysis and two tailed t-tests.
The authors concluded that there are different motivational factors between British and German
people when visiting the two destinations Spain and Turkey. The authors classified the
motivational factors using the categories of culture, fantasy, relaxation and physical reasons
(Kozak, 2002).
From the studies conducted above and from the literature review, it can be concluded that
there are many frameworks, models and theories that can be used to explain the phenomena of
seeking healthcare abroad, including the decision making involved and the choice of country of
destination. The “Health Seeking Behaviors Framework,” for example, is a framework that was
11
used in health and social science research (Eissler & Casken, 2013). The framework utilizes
individual views of health and healthcare as well as other characteristics in explaining responses
to illness, wellness and health promotion. The “Maslow Hierarchy Theory” was also used in
some literature to explain a systemic approach to motivation structure. The individual needs are in
a hierarchal order of increasing motivational importance, with people differing on the needs that
are motivating their behavior (Jang, 2002). The “Smith & Forgione Model” consists of two
stages; stage-1 includes the factors of choosing a destination and stage-2 includes the factors in
choosing the healthcare facility (Heung, 2010).
Choosing a country of treatment is a complex process, and each framework, model and
theory related to this field has its own pros and cons. However, the “Push and Pull Motivational
Factors Framework” seems to be the most applicable theory for analyzing the three aims of this
thesis. The “Push and Pull Factors” can be viewed as a big umbrella that almost covers all of the
factors related to a patient’s home country and the treatment destination. In addition, the push and
pull factors theory covers the themes and the variables included in this cross-sectional study.
Conceptual Framework
As noted previously, seeking healthcare abroad has been growing which has drawn
researchers’ interests to understand the motivational factors involved. The motivation to travel in
general has been investigated by researchers in the fields of sociology, anthropology and
psychology. There are many studies which have been conducted to understand motivational factors
for tourism. A review of tourists’ motivations indicated that they can be analyzed in terms of “Pull
and Push Factors,” a finding that has been accepted by many scientists (Heung, 2010; Jang, 2002;
Mohammad, 2010). At the same time, there have been limited empirical studies conducted to
understand medical tourism and overseas treatment motivational factors. Therefore, the same
12
concept of “Pull and Push Factors” will be applied for overseas treatment in this analysis.
Understanding the motivational factors influencing patients treated overseas are important for the
health planner, policy makers and governments in order to focus their work to improve the factors
that pushed the patient away from his or her home country. Moreover, such an understanding can
help in using the best practices from the country of destination and applying them in the home
country of the patients to improve the healthcare services provided.
The push factors are defined as the factors that pushed the patients to choose overseas
treatment destinations instead of having their treatment in the home country. The pull factors are
defined as the factors that attracted patients to the country of destination as they are perceived by
the patient.(V. A. Crooks, et al, 2010; Hsu, 2009; Jang, 2002; Kozak, 2002; Moghimehfar, 2011;
Mohammad, 2010). The push factors can include: health services related issues, financial related
issues and patients’ characteristics, and complexity level of the health condition. On the other hand,
the pull factors can include health services related to the country of destination, advertisements
and information, county of destination reputation, and the patient’s previous experience. Knowing
the source of information and who the patient consulted to learn about the country of treatment,
credentials of the physician, and characteristics of the facility are all very important. Based on the
source of information, the patient will choose the country of destination. Some research studies
have indicated that the source of information is a proxy for the type of society. Patients who use
recommendations from family, friends, relatives, or neighbors reflect that the patient comes from
“a collective society concept.” Whereas patients who rely on the internet are more likely to be part
of an individualistic society. (Yu, 2012)
13
Figure b. Motivational Factors Framework to Choose Destination Country:
14
Dissertation Organization
This dissertation is organized as three empirical manuscripts with tables and figures
incorporated at the end of each chapter. Chapter one presents the introduction. Chapter two
presents the first manuscript which includes analysis of the first aim. The aim is divided into two
parts: 1a. Examining the factors associated with treatment destinations among patients treated
overseas from the United Arab Emirates sponsored by the DHA during 2009-2016. 2b.
Determining the factors associated with the total number of trips among the patients treated
overseas from the United Arab Emirates sponsored by the Dubai Health Authority during 2009-
2016. Chapter three presents the second manuscript with the analysis of the second aim of this
thesis. The aim is exploring patients’ characteristics and the motivational factors for choosing
treatment destinations among the patients treated overseas from the UAE during 2009 – 2012.
Chapter four presents the third manuscript of this thesis with the analysis of the third aim of this
thesis. The aim is exploring associations between patient characteristics and their preferences for
healthcare services if the treatment is made available in the UAE for the cases of Bone and Joint
Diseases, Cancer, Neurological Diseases, Eye Diseases and General Surgery among patients
treated overseas from the UAE during 2009 - 2012. Healthcare services options include: 1a.
Willingness to be diagnosed and treated by a known physician in the UAE. 1b. Willingness to wait
to be diagnosed and treated by a known physician in the UAE. 2a. Willingness to be diagnosed
and treated by a visiting physician to the UAE. 2b. Willingness to wait to be diagnosed and treated
by a visiting physician to the UAE. Chapter five reviews and discusses the findings and their
implications for policy and future research. Also included are references, appendices and a copy
of the knowledge, attitude and perception survey that was used for this thesis.
15
CHAPTER TWO: MANUSCRIPT ONE
Factors Associated with Treatment Destinations and Numbers of Trips among Patients
Treated Overseas from the United Arab Emirates Who Were Sponsored by the Dubai Health
Authority during 2009-2016
16
Introduction
The demand for global healthcare services is experiencing tremendous growth (Burkett,
2007; Chanda, 2002; Eissler & Casken, 2013; Forgione & Smith, 2007; Henson, 2015; P. C. a. F.
Smith, D.A., 2007). Each year the Dubai Health Authority (DHA), pays an average total
expenditure of 77 million dollars to cover an average of 1500 UAE national patients seeking
healthcare overseas (Dubai Health Authority Annual Statistic Books)4. The DHA is the
governmental entity that oversees healthcare facilities in the Emirate of Dubai in the United Arab
Emirates. In addition to providing healthcare services in the Emirate of Dubai, the DHA serves as
a licenser and a regulator of private medical professionals and facilities in the Emirate. Although
the government in the UAE provides free healthcare services to UAE nationals as per the
government law, there are a number of patients who travel seeking healthcare outside the UAE
under the sponsorship of the government. The total number of UAE nationals seeking healthcare
abroad, however, is not accurately calculated since there are many governmental authorities in the
UAE that sponsor the UAE nationals for their treatment.
Patients travelling abroad for healthcare seek an array of treatments ranging from
preventive to complex, and from low-middle income countries to high income countries. Obtaining
healthcare abroad might be associated with some risks and complications compared to obtaining
healthcare domestically (McCallum, 2007). Given the high cost of these medical services and
potential for patient risks, it is important to explore and analyze the treatment destinations and the
total number of trips for the medical specialties that patients sought abroad (I.G. Cohen, 2012; I.
Glenn Cohen, 2014; V. A. Crooks et al., 2013; Turner, 2011). This analysis will provide baseline
4 Average total expenditure and number of patients treated overseas during 2004 – 2016 based on Dubai Health
Authority Annual Reports
17
information for the government to improve polices and strategies related to seeking healthcare
abroad. Moreover, people tend to refer to all patients seeking healthcare abroad as medical tourists
which is not necessarily accurate. Medical travel is defined in this study as the movement of those
patients to the treatment destinations who were under the sponsorship of the government during
the period of 2009 – 2016. Included is travel only for the purpose of legal diagnosis and treatment,
regardless of the level of complexity. Not included is the shipment of laboratory samples or clinical
results for diagnosis and clinical consultations as a second opinion.
Methods
Aim-1a. Examine the factors associated with treatment destinations among patients treated
overseas from the United Arab Emirates who were sponsored by the DHA during 2009-2016.
Research Question-1a. Are there associations among patient characteristics or medical
conditions and treatment destinations for patients from the United Arab Emirates treated overseas
and sponsored by the Dubai Health Authority during 2009 – 2016?
Null hypothesis-1a. There are no associations among patients’ characteristics or medical
conditions and treatment destination for patients treated overseas from the United Arab Emirates
sponsored by the Dubai health Authority during 2009 – 2016 (Allua & Thompson, 2009).
Aim-1b. Determine the factors associated with the total number of trips among the patients
treated overseas from the United Arab Emirates who were sponsored by the Dubai Health
Authority during 2009-2016.
Research Question-1b. Are there associations between patients’ characteristics or medical
conditions and the total number of trips among patients treated overseas from the United Arab
Emirates sponsored by the Dubai Health Authority during 2009-2016?
18
Null hypothesis-1b. There are no associations among patients’ characteristics or medical
conditions and the total number of trips among patients treated overseas from the United Arab
Emirates who were sponsored by the Dubai health Authority during 2009-2016.
Data Source, Study Design, Variables and Measures
Secondary data analysis was performed using administrative data obtained from the DHA
which includes a large number of UAE nationals who sought medical treatment abroad during the
period 2009-2016 under the sponsorship of the DHA. The data contained the following variables:
birth date, gender, departure date, medical specialty sought abroad, and treatment destinations.
Birth date was converted to age as a categorical variable 0-4 yrs., 5-12 yrs., 13-18 yrs., 19-39 yrs.,
40-54 yrs., 55-69yrs., 70+ yrs. with the youngest age category treated as the reference group. For
gender, female was used as the reference group5. Departure date was used to create two categorical
variables and two continuous variables: 1) a total trips variable which is a discrete count with a
minimum of 1 trip to a maximum of 20 trips and defined as the total count of trips taken by the
patients to the treatment destinations; 2) a travel season variable which is a categorical variable
representing the four seasons of the year fall, spring and winter with summer being the reference;
3) a year variable, defined as the calendar year of the patient’s departure date; and 4) a variable
defined as number of years in the data set which was operationalized as “2017 – the calendar year
of the patient’s departure date for the patient’s first trip recorded in the data set.”
The medical specialty variable is a categorical variable with 103 administratively defined
medical specialties that was converted to 42 categorical variables by using the definitions of the
American Board of Medical Specialties to improve the standardization and increase the precision
5 Based on the pattern of the medical condition and age
19
of the measures. Medical specialty is defined as the area of specialty patients sought medical
treatment for at the treatment destination. Internal Medicine Oncology was used as the reference
group6. Patients who had more than one medical specialty reported in their record for a given trip
(3.2%), were removed from the analysis. Treatment destination consists of categorical variables
with 24 destinations and defined as the countries patients traveled to for medical
diagnosis/treatment. The Federal Republic of Germany was used as a reference group7. The study
protocol was submitted to the Johns Hopkins School of Public Health Institutional Review Board
where it was defined as not human subjects’ research (IRB No: 00007896).
Statistical Analysis
The statistical analyses were conducted by using Stata 13 (Stata Corporation, College
Station TX). Quality assurance and quality control of the dataset were performed by running a
wide range of summary statistics to detect missingness of key variables, and inconsistencies in the
data. Means, standard deviations (SD), and student t-tests were used for continuous variables
(Thompson, 2009). Frequency distributions, percentages, and chi-square tests were used for binary
and categorical variables (Curtis & Youngquist, 2013; Thompson & Panacek, 2008). Several
regression analysis models were constructed for this study. The first analysis was conducted
through a modified Poisson, to assess the associations between treatment destination as a binary
outcome and independent variables such as age, gender, travel season and medical specialty. Two
steps of regression analysis were built. The first regression analysis was a bivariate regression
where the outcome of interest was regressed on each independent variable separately. The second
6 Another categorical variables were created for medical specialties based on top 5, top 10 and top 15 medical
specialties were less frequent medical specialties were collapsed into others. Orthopedic Surgery was used as a
reference group. The variable with top 15 medical specialties was used for the regression model. 7 Another binary variable was created for treatment destination. Other destinations was used as the reference group.
The variable was used for the regression model.
20
regression analysis was an adjusted model, where each independent variable was adjusted for the
other independent variables (age group, gender, travel season, and top 15 medical specialties). The
modified Poisson model was used since the incidence of having the outcome of traveling to the
Federal Republic of Germany compared to other destinations was more than 10% (Zou, 2004).
The Akaike information criterion (AIC) test was performed to choose the simplest model with the
best fit; the model with the top 15 medical specialties variable had the lowest AIC (10397.44)
indicating the best fit. The second analysis consisted of a Negative Binomial model which was
used to identify factors associated with the total number of trips as an outcome as a discrete count.
Two regression analysis were built. The first regression analysis was a bivariate regression where
the outcome of interest was regressed on each independent variable separately. The second
regression analysis was an adjusted model, where each independent variable was adjusted for the
other independent variables (age group, gender, travel season, years in the data set, and top 15
medical specialties). Since the travel season and years in the data set variables were extracted from
the same data field (the departure date), the variance inflation factor (VIF) was performed to test
for collinearity; the mean VIF was (1.65) indicating there was no collinearity in the model. The
variance of the outcome was larger than the mean and the likelihood-ratio test of alpha = 0.000
indicated the appropriate selection of the model (Thorpe Jr, Gamaldo, Salas, Gamaldo, &
Not Specified Cases 1.04 (0.91,1.20) 0.555 1.10 (0.95,1.26) 0.198
Un specified Internal
Medicine
1.06 (0.92,1.22) 0.443 1.09 (0.95,1.25) 0.227
Other medical Specialties 1.10 (1.03,1.18) 0.007 1.05 (0.978,1.13) 0.196
*Adjusted for age group, gender, travel season, years, and medical specialty by using Negative Binomial as a model for analysis **Significance level p<0.05
42
CHAPTER THREE: MANUSCRIPT TWO
Patient Characteristics and the Motivational Factors for Choosing Treatment Destinations among
Patients Treated Overseas from the UAE during 2009 – 2012
43
Introduction
By government law, all UAE nationals are provided healthcare services. Therefore all UAE
nationals, whether or not they reside in Dubai, have free access to Dubai Health Authority primary
and tertiary healthcare facilities. Although the public healthcare sector strives to provide good
healthcare services to its people, there are still a number of people who travel overseas to seek
healthcare. However, the numbers of patients treated overseas are not accurately calculated, and
the reasons that “push” patients from the UAE and that “pull” them towards the treatment
destinations are unknown to the government (Crompton, 1979; Hsu, 2009; Jang, 2002;
Mohammad, 2010; Turnbull & Uysal, 1995; Uysal & Jurowski, 1994). Since the government is
also funding the UAE nationals for their treatment abroad, the government has started to seriously
investigate the reasons why UAE nationals are travelling overseas seeking healthcare instead of
utilizing healthcare services in the Emirate of Dubai and other Emirates in the UAE (Helble, 2011;
Mansfeld, 1992).
In 2009 the Dubai Health Authority took the first step to explore the reasons for overseas
treatment by creating a knowledge, attitudes and perceptions survey in collaboration with the
Dubai Statistics Center to explore people’s perceptions and attitudes related to their treatment
overseas experiences. This study will not only help in understanding the motivational factors and
patients’ preferences when travelling abroad for healthcare services, but also will advance the
government’s understanding about patients’ choices for one destination over another. Enhancing
this understanding is very important since the treatment destinations vary in the costs which the
government is bearing.
44
Methods
Study Aim: Explore patients’ characteristics and the motivational factors for choosing
treatment destinations among the patients treated overseas from the UAE during 2009 – 2012.
Research Question: Are there associations among patients’ characteristics or motivational
factors and the destination of choice for treatment among patients treated overseas in the UAE for
the period 2009 – 2012?
Null Hypothesis: There are no associations among patients’ characteristics or motivational
factors and destinations of choice for treatment among patients treated overseas from the UAE
during 2009 -2012.
Data Source and Study Design
A secondary data analysis was performed from a cross-sectional Knowledge, Attitudes and
Perceptions (KAP) survey related to medical treatment abroad among residents of Dubai that was
conducted in Dubai, United Arab Emirates between June 2012 and July 2012 (Kaliyaperumal,
2004). The survey was conducted among 361 families who were residents of Dubai with at least
one family member who had experienced seeking healthcare overseas. Using the WHO definition
of trading in health services we are referring to the movement of patients to the country providing
healthcare services for diagnosis and treatment, and not the shipment of laboratory samples or
clinical results for diagnosis and/or clinical consultation as second opinions (R. D. Smith, Chanda,
& Tangcharoensathien, 2009). Designing the survey and collecting the data was through a
collaborative effort between the Dubai Health Authority (DHA) and the Dubai Statistical Center
(DSC) with the DHA designing the survey and the DSC collecting the data.
45
The survey was conducted with nonprobability sampling (purposive sampling) as the
methodology of sample selection (Etikan, Musa, & Alkassim, 2016; Farrokhi, 2012). The study
participants were selected through two main approaches. In the first approach the sample was
drawn from the Dubai Health Authority (DHA) medical records; 1678 cases were drawn from the
Dubai Health Authority records who had traveled at the government expense during 2010 - 2012.
There were 452 cases who agreed to participate in the survey. In the second approach the sample
was drawn from the Dubai Statistical Center Household Survey that was conducted in 2009. People
were selected who had travelled during the same year at their own expense. There were 384 cases
selected and 119 cases agreed to participate in the survey.
1678
Cases were drawn from
DHA for patients who
travelled at DHA expense
384
Cases were drawn from
DSC for patients who travelled at their own
expense
452
Cases agreed to participate
in the survey
119
Cases agreed to participate
in the survey
571
Total number of participants
in the survey
Figure 1. Non Probability Purposive Sampling
46
Response Rates of the KAP Survey
Residents Number of families
with overseas treated
patient identified and
intended to survey
Didn’t answer the
phone
Rejected and didn’t
complete the survey
Completed the survey
UAE Nationals 468 (82%) 90 40 338 (72%)
Non-UAE Nationals 103 (18%) 41 39 23 (22%)
Total 571 (100%) 131 79 361 (63%)
The Knowledge, Attitudes and Perceptions (KAP) Survey
The KAP survey was conducted to explore views, perceptions and experiences mainly for
the UAE residents related to treatment abroad for the period 2009 – 2012 (Erler, 2008). The survey
asked the patients (or a family member) about the reasons why the patient travelled abroad in order
to understand the motivations behind seeking healthcare abroad instead of seeking healthcare
services in the UAE. Both UAE nationals and non-UAE nationals were interviewed who sought
healthcare abroad during 2009 – 2012. The data includes people who paid from their own pocket,
and people whose expenses were covered by the government. All the patients who traveled for
healthcare services went for legal healthcare services in both the home country (UAE) and the
destination country. The patients travelled for different levels of treatment, including life
threatening diseases, serious diseases and medically optional conditions (Guy et al., 2015; Henson,
2015). Some patients travelled to high income countries such as Germany, UK and the USA while
others travelled to low-middle income countries such as India and Thailand (I. Glenn Cohen,
2014). The mode of data collection was through in-person and phone interviews with times ranging
from 45 minutes to an hour interview. Patients who were less than 15 years old and patients who
were not available for the interview were replaced by a family member 15 years old or above that
escorted the patient during the treatment abroad and who was eligible to respond to the KAP
survey.
47
The total number of people completing the survey was 361 with a response rate of 63%.
Non-UAE nationals, however, had a low response rate of 22%, so a decision was made to omit
them from this analysis and focus only on the UAE nationals who had a response rate of 72%.
(Appendix Figure 1)
The survey included 9 sections. Section (1) included the basic information about the survey
and the mode of data collection. In cases where the patient who had been through the travel
experience was not available, a family member who either escorted the patient or a family member
who didn’t escort but had enough information about the patient experience, and who was aged 15
years old and above, was eligible to answer the survey. The other 8 sections were the following:
Section (2) included general socio-demographic information about the patient who travelled
abroad. Section (3) included health seeking behavior in the UAE, including patient health status
before travelling abroad for healthcare and questions about the healthcare provider in the UAE and
the degree of satisfaction about the healthcare services received in the UAE.
Section (4) included travel related information about the last trip by the patient, reasons for
travelling abroad, motivational factors and sources of information for choosing the country of
destination, as well as the country selected for their most recent healthcare service. In addition,
this section included what information patients required when choosing the healthcare provider
abroad. Section (5) included treatment related questions such as the type of service the patient had
received, whether the service received was inpatient or outpatient, information sought when
choosing the physician abroad, and inquiries about the physician abroad. Moreover the section
included the patient’s diagnosis abroad, the availability of treatment in the UAE and the financial
coverage of the patient’s overseas treatment. This section also asked about the main reason for
deciding to obtain healthcare outside the UAE. Section (6) included family related information
48
and travel preferences. Section (7) included financial questions related to the refund policy in case
the treatment was not received as planned. Section (8) included questions about the risks of travel
and treatment abroad. The questions in this section were related to unfavorable reactions and
complications during or after the treatment abroad, reporting in case of medical error, and patient
decisions about the treatment destination in case the travel visa was not issued or delayed. Section
(9) included the patient’s satisfaction about the overseas treatment experience and whether the
patient would recommend the overseas treatment experience to others, and what services the
patient wished could be provided in the UAE.
Since the objective of this paper is to explore patient characteristics and motivational
factors for choosing treatment destinations among those patients treated overseas from the UAE
during 2009-2012, only those survey sections and variables were selected that are relevant for the
research question as guided by the study framework and literature review. Variables were used for
descriptive analysis and the study’s regression analysis models. Questions in the survey that were
in the various sections had different instructions regarding answering formats such as: select one
answer only, circle all that apply, respond according to the Likert scale from1 to 5, and rank in
order of importance from least important to most important. Cases with missing responses were
not omitted but included as “unknown.” The study was approved by The Johns Hopkins School of
Public Health Institutional Review Board as non-human subjects research with IRB No: 00007896.
diseases, heart diseases, eye diseases, obstetrics and gynecology diseases, general surgery, kidney
diseases, gastrointestinal diseases, urinary tract system diseases, high blood pressure, skin or
venereal disease, stroke (brain hemorrhage or clot), mental illness, trauma, medical screening
before surgery, oral and dental diseases, lung and respiratory diseases, (ENT) diseases, diabetes,
and routine and medical checkup (Table 6A and Appendix Table 6). A categorical variable was
also created in which patients with only one diagnosed condition were assigned to the appropriate
diagnosis category, and respondents selecting more than one condition were assigned to a multi-
54
morbidity category. Undiagnosed patients and those with unknown medical conditions (missing
values and/or respondents didn’t circle any answer) were also assigned to separate categories. For
this variable used cancer was used as a reference group (Table 6B). Main condition and diagnosis
stratified by the outcome of going to the Federal Republic of Germany compared to other
destinations and this variable is used as a categorical (Table 6C). The number of comorbidities
patients were diagnosed with abroad was treated as a categorical variable. Patients diagnosed with
two medical conditions was used as a reference group (Table 6D).
Variables Related to the Most Recent Overseas Trip. The following travel related variables
were included: Time in months from the last trip to the interview, type of healthcare service(s)
received abroad, treatment availability in the UAE, source of financial coverage for treatment,
refund policy for healthcare service(s) received abroad, satisfaction with the healthcare services
received overseas, whether would recommend overseas experience to others, services would like
to be available in the UAE, unfavorable reactions/complications/outcomes during and after the
treatment abroad, knowledge of where to report medical errors, preferred choice of what to do if
there was a delay in issuing the visa. (Table 7 and Appendix Table 7)
Time in months since the last trip abroad was treated as a continuous variable. Type of
healthcare service(s) received was used as a categorical variable and included the categories of
inpatient, outpatient, and unknown. Inpatient services was used as a reference group. Treatment
availability in the UAE was used as a categorical variable with the categories of treatment
available, treatment not available, and unknown to respondent. Treatment available was used as a
reference group. Financial coverage for treatment was used as a binary variable with the categories
of government coverage and coverage from a nongovernment source (including self).The
government coverage was used as the reference group. Refund policy was used as a binary variable
55
with the categories of whether the respondent did or did not know about the provider’s refund
policy. Knowing about the refund policy used as a reference group. Responses regarding
satisfaction with the healthcare services received overseas were used to create three variables. The
respondent’s satisfaction level with 5 categories was used for the descriptive table (very
dissatisfied, dissatisfied, neither, satisfied, and very satisfied). Very dissatisfied was used as a
reference group). Satisfaction level with 3 categories was used for the regression model
(dissatisfied, neither, satisfied). Dissatisfied was used as a reference group. Recommending
overseas treatment to others was used as a binary variable with the categories of would or would
not recommend the experience to others. Would recommend the experience to others was used as
a reference group. In addition, a third variable for satisfaction was also created as a satisfaction
score about each destination traveled by residents of Dubai. It is a comparison with the satisfaction
level of the healthcare services provided overseas; among the top 5 destinations traveled by
residents of Dubai on their most recent trip during 2009 - 2012 (Table 9).
Aspects of Services Respondent Would Like Available in the UAE. Service aspects that
the respondent wished were available in the UAE was used as a binary variable (selected as a
response/not selected) with the following categories: reasonable waiting time, good healthcare
provider communication, hospitality of facility, education and reading material regarding patient’s
condition, and convenient atmosphere. (Appendix Table 7) Unfavorable
reactions/complications/outcomes during and after treatment was used as a yes/no binary variable.
No was used as a reference group. Knowledge of where to report a medical error was also used as
a yes/no binary variable. Respondents reporting yes were used as a reference group. Where to
report in case of medical error was used as a binary variable (selected as a response/not selected)
with the following categories: UAE embassy, treatment and overseas patient affairs office, police,
56
hospital administration/complaint center. Preferred choice of what to do if there was a delay in
issuing the travel visa was used as categorical variable with the categories of waiting further until
the visa was received, looking for another destination abroad, or searching for health providers in
the UAE with waiting until the visa was received used as a reference group.
Travel Preferences and Role of Family. Patient travel preferences and family related
variables included whether the patient preferred to be escorted, travel arrangement preferences,
and family roles in the overseas travel. Preferences for a travel escort was used as a binary variable
with the categories of preferred travelling alone or travelling with someone. Travelling alone was
used as a reference. The respondent’s travel arrangement preference was also used as a binary
variable that included the categories of preferred to arrange the trip on own, or have the trip
arranged by a travel agency. Prefer to arrange trip by the patient used as a reference group.
Responses regarding family roles in the overseas treatment experience were used to construct
binary variables (selected/not selected) for the following: shared bad experiences, provided help
and support, helped seek options in the UAE/other countries, provided financial help, and were
worried about the experience.
Statistical Analysis
Statistical analyses were conducted by using Stata 13 (Stata Corporation, College Station
TX). Quality assurance and quality control of the dataset were performed by running summary
statistics for missingness and inconsistencies in the dataset. Means, standard deviations (SDs), and
student t-tests were used for continuous variables. Frequency distributions, percentages and chi-
square tests were used for binary and categorical variables. The modified Poisson regression was
used since the incidence of having the outcome of traveling to the Federal Republic of Germany
vs other destinations was more than 10% (Zou, 2004). The Akaike information criterion (AIC) test
57
was performed to choose the best fitted model; the model with all significant variables as the
independent variables had the lowest AIC (525.4077) indicating the best model to be selected.
The outcome was defined as the country destination that residents of Dubai travelled to
during the most recent trip before the KAP survey interview. A binary outcome was created to
examine the associations between independent variables and travelling to the Federal Republic of
Germany compared to other country destinations. The independent variables selected for the
models were statistically significant in cross-tabulations, and bivariate analysis based on the push-
pull factor framework relevant for our outcome of interest and research question.
Two steps of regression analyses were built. The first regression analysis was a bivariate
regression where the dependent variable was regressed on each significant independent variable
separately from the cross tabulation. The second regression analysis was the modified Poisson
model. This was the adjusted model, where each independent variable was adjusted for all other
independent variables. Variables used in the final model were the significant variables in the
bivariate analyses and relevant to our framework. Two types of variables were not included in the
final model: variables that were significant in the cross tabulation and in the bivariate analysis but
not directly relevant to our framework (e.g. Unfavorable reactions/complications/outcomes during
and after treatment, High blood pressure diagnosed overseas) and variables that were significant
in the cross tabulation and the bivariate analysis but not significant in the final model (e.g. income
level, type of healthcare services, and financial help under family response towards overseas
treatment).The backward selection method was used to remove variables not statistically
significant from the model. To ensure that there is no collinearity among the variables in the final
model, the variance inflation factor (VIF) was performed. The mean VIF was (1.05) indicating
there is no collinearity in the model. P<0.05 indicated statistical significance.
58
Results
There were 336 UAE national families who sought overseas treatment during 2009 – 2012
and were interviewed regarding their most recent trip to explore their knowledge, attitudes and
perceptions. Only (n=125; 37%) from those who experienced medical treatment overseas as
patients answered the survey; whereas the majority of survey respondents were eligible family
members who escorted patients during the overseas treatment experience or family members who
didn’t escort the patient but did have enough information about the patient experience to serve as
survey respondents. The patients treated overseas travelled to 17 destinations. The top destinations
for treatment overseas among residents of Dubai based on the frequencies were: Federal Republic
of Germany (n=152; 45%), followed by the Kingdom of Thailand (n=64; 19%), and United
Kingdom (n=37; 11%). Other less frequent destinations are shown in Table 1.
Half of the patients were male and half female. The patients’ mean age was 40.09 ±22.66;
a higher proportion were married (n=177, 66%), not working (n=178, 66%), with up to a high
school education (n=132, 49%), and lower household income (n=203, 60%). The data on travel
destinations were dichotomized in terms of travelling to the Federal Republic of Germany and to
all other destinations. Patients who travelled to Germany were more likely than those travelling to
other destinations to have mid-level or higher household incomes (P=0.045) shown in Table 2.
Before seeking medical treatment overseas (n=277; 82%) patients were diagnosed
regarding their medical conditions and (n=285; 85%) did consult their healthcare providers before
travelling overseas. There were (n=215; 64%) patients who sought medical treatment overseas and
who received healthcare services in the government/public sector for their healthcare conditions
59
before obtaining medical treatment overseas.11 Overall, patients who traveled overseas either to
the Federal Republic of Germany or other destinations had a mean satisfaction rating of 1.88±1.34
which indicates they were neither satisfied nor dissatisfied with the healthcare services they
received in the UAE as shown in Table 3.
The most frequent medical conditions for which people traveled overseas were cancer,
bone and joint diseases, and heart diseases shown in Table 4A. Looking at patients’ medical
conditions (with multiple choices permitted), those who traveled to other destinations were more
likely to have diagnosed eye diseases (p=0.001) while patients who traveled to Germany were
more likely to have diagnosed stroke (brain hemorrhage or clot) (p=0.03) as shown in Table-4A.
When accounting for comorbidities as a separate category; (n=47; 14%) patients were diagnosed
with more than one condition as shown in Table 4B. Cancer, bone and joint diseases and heart
diseases remained the most frequent diagnoses for patients with only one condition. When
comparing patients by the outcome of going to the Federal Republic of Germany or other
destinations there were significant differences, with those going to the Federal Republic of
Germany less likely to have diagnosed eye diseases and obstetrics and gynecology; and more
likely to have urinary system diseases, and stroke. In addition, patients are more likely to have
undiagnosed medical conditions when travelling to the Federal Republic of Germany, compared
to those who traveled to other destinations (p=0.027) as shown in Table 4C.
As noted, 47 patients who travelled abroad had been diagnosed with multiple medical
conditions. These comorbidities included two medical conditions, three medical conditions, four
medical conditions and up to 5 medical conditions as shown in Table 4D. The most frequent
11 These public providers include: Dubai Health Authority inpatient/outpatient services, Abu Dhabi Health Services
Hospitals and PHCs (SEHA), and Ministry of health inpatient/outpatient services
60
comorbidities patients travelled overseas for were heart diseases with diabetes as a comorbidity
with two medical conditions, and heart diseases with diabetes with high blood pressure as a
comorbidity with three medical conditions. More details about baseline comorbidities (diagnoses
prior to travel) examined by the outcome of going to the Federal Republic of Germany versus other
destinations can be found in Appendix Tables 4E to 4N.
Almost all of the patients (n=332; 99%) who travelled overseas went for treatment
purposes only. Overall, those patients who travelled overseas to the Federal Republic of Germany
or to other destinations had no differences regarding their motivational factors, including: having
a previous experience in the destination country, vacation aspects, believing the country has a
friendly environment, and following someone’s advice. Of these factors, following someone’s
advice was the most important, with almost two-thirds of the patients citing this factor as important
or very important. Patients who travelled to the Federal Republic of Germany were less likely
than those travelling to other destinations to cite the cost of travel as an important factor in their
decision-making (p=0.002) as shown in Table 5.
When asked about sources of information utilized, (n=181; 54%) patients reported using
a physician’s recommendation as a source of information when travelling overseas, followed by
word of mouth from family and friends (n=176; 52%). Moreover; (n=95; 28%) patients reported
they would look at the physician’s experience first when choosing a healthcare provider for
services abroad, followed by (n=80; 23%) who would look at the reputation of the medical
center/hospital. The majority of patients (n=256; 76%) inquired about the physician at the
treatment destination; in addition, (n=191; 56%) patients inquired about the physician’s training
and qualifications, followed by (n=128; 38%) who inquired about recovery time as an inpatient.
Patients who sought treatment in the Federal Republic of Germany were less likely to ask about
61
the costs of treatment and follow-up than patients who travelled to other destinations (p=0.01)
when inquiring about the physician overseas. When asked about their main reason for travelling
overseas, (n=29; 8%) patients stated that long waiting time for an appointment was the main reason
for deciding to obtain healthcare services overseas followed by (n=27; 8%) patients who stated
that privacy and confidently was another main reason to seek healthcare overseas shown in Table
5.
Cancer, bone and joint diseases and heart diseases remained the most frequent conditions
when patients were diagnosed abroad. Looking at patients medical conditions (with multiple
choices permitted), there were still differences between going to the Federal Republic of Germany
over other destinations. Patients travelling to Germany were less likely to be diagnosed with eye
diseases (p=0.04) and high blood pressure (p=0.01). On the other hand patients are more likely to
be diagnosed with stroke (brain hemorrhage or clot) (p=0.03) when travelling to other destinations,
as shown Table-6A. When accounting for comorbidities as a separate category, the number of
patients who were diagnosed with more than one condition increased to (n=92; 27%) compared to
the baseline number of 47 who had multiple diagnoses in the UAE. Cancer remained the most
frequent diagnosis for patients with only one condition (n=58; 17%) and heart diseases became the
second most frequent condition (n=28; 8%), with bone and joint diseases moving to the third most
frequent condition (n=25; 7%) compared to the baseline diagnoses in the UAE as shown in Table
6B). When comparing patients by the outcome of going to the Federal Republic of Germany over
other destinations there were significant differences between the medical conditions diagnosed and
treated in the Federal Republic of Germany compared to other destinations (p=0.032) as shown in
Table 6C.
62
As noted, while seeking medical treatment abroad, patients had a higher number of
diagnosed comorbidities compared with the baseline diagnosis in the UAE. Some patients were
diagnosed with two medical conditions, three medical conditions and up to 7 medical conditions
as shown in Table 6D. The most frequent comorbidity with two medical conditions was cancer
with bone and joint disease, whereas the most frequent comorbidity with three medical conditions
was cancer with high blood pressure and diabetes. More details about comorbidities diagnosed
abroad examined by the outcome of going to the Federal Republic of Germany versus other
destinations can be found in Appendix Tables 6E to 6S.
Table 7 examines factors related to the most recent trip abroad for seeking medical care.
The average number of months was 15.66±15.71 from the last trip for healthcare abroad to the
time of being interviewed for the KAP survey. Overall, (n=228; 67%) patients who received
medical services overseas had inpatient treatment (surgical or non-surgical), with patients traveling
to Germany more likely to receive inpatient services than those travelling to other destinations
(p=0.04). More than half (n=187; 55%) stated that their medical treatment was not available in the
UAE, with no significant differences by treatment destination. Overall, the majority (n=265; 78%)
indicated that their expenses of treatment were covered by the government, although those
travelling to Germany were significantly more likely to have government coverage than those
travelling to other destinations (p=<0.001).12 The majority (n=296; 88%) revealed that they didn’t
know about the refund policy the health care provider overseas. Overall, patients who received
overseas medical treatment had a higher mean satisfaction level (3.45±0.94) with the healthcare
received during the last healthcare trip abroad than with the healthcare services they had received
in the UAE. The great majority (n=302; 90%) would recommend their overseas healthcare trip
12 Government of Dubai, or Ministry of health, or Government of Abu-Dhabi
63
experience to someone else, with no differences by country of destination. When asked about the
aspects of services the survey respondents would like to have available in the UAE, the top 3 were:
good healthcare provider communication13 (82%), a convenient access and atmosphere14 (64%),
and a reasonable waiting time at the clinic15 (42%).
In addition, although most patients (n=274; 81%) who received medical treatment overseas
did not experience any unfavorable reactions/complication/outcomes during or after treatment
overseas,16 patients travelling to Germany were more likely to experience such events than patients
traveling to other destinations (p=0.002). The majority (n=286; 85%) of the respondents expressed
that they knew where to report in case of a medical error and (n=237; 70%) indicated they would
contact the UAE embassy at the destination country, with no significant differences by country of
destination. In addition, the majority (n=257; 76%)17 expressed that they would wait and still go
to the same destination if they faced a delay in the issuing of a visa of entry to their desired
destination as shown in Table 7. (Council of the European Union, 2015)
With regard to preferences for travelling overseas for treatment and the role of family
members, the great majority (n=326; 97%) of the respondents preferred travelling overseas
escorted by a family member, (n=241; 72%) preferred the trip to be arranged by a travel agency,
and (n=314; 93%) disclosed that their family’s response was to support and help in their decision
13 Treating doctor talked clearly to me about my condition, Treating doctor gave me different treatment options,
Treating doctor explained to me how I can cope; live normal life with my condition, Treating doctor explained what
might happen to me in the future, The medical staff was polite, and courteous, The medical staff was able to respond
to my inquiries efficiently and referred me to the right persons, The treating doctor was listening to me 14Easiness of booking for an appointment “convenient, didn't take long time”, Consultation and Diagnostic work-ups
and treatment were all in the same building, The hospital called to report my results instead of me going to them 15 Reasonable waiting time at the clinic before seeing the doctor 16 Fever/infection after the surgery, allergy from medication, wrong diagnosis, other surgical complications, other
medical complications, results not as explain by the doctor 17 The survey was before the agreement between the European Union and the United Arab Emirates in Brussels on
May 6th 2015 on the short-stay visa waiver were Ireland and the United Kingdom are not part of this agreement
64
about travelling overseas to receive medical treatment. However, financial help from family was
less likely for those travelling to Germany in comparison to those who travelled to other
destinations (p=0.02) as shown in Table 8. Although the top travel destination for treatment
overseas among residents of Dubai was the Federal Republic of Germany, the percentage satisfied
or very satisfied with their experience was 87%, which is lower than the other top destinations
which were: 95% for Thailand, 92% for the United Kingdom, 93% for India, and 92% for the
United States of America as shown in Table 9.
The motivational factors and association with country of destination when seeking healthcare
services overseas
The model examining motivational factors associated with choosing country of destination
when seeking healthcare services overseas. The model was adjusted for the covariates cost of
treatment, and treatment coverage with the medical conditions (eye disease and stroke), associated
with the outcome. Prevalence ratio is shown in Table 10. People diagnosed with eye diseases had
a 66% lower prevalence ratio of choosing the Federal Republic of Germany (PR 0.34, 95%CI:
0.13, 0.87, p=0.03) compared to people with other medical conditions. On the other hand, people
who were diagnosed with stroke (brain hemorrhage or clot) had a 90% higher prevalence ratio to
choose the Federal Republic of Germany compared to people with other medical conditions (PR
1.90, 95% CI: 1.45,2.51, p=<0.001).
People who had the cost of treatment as an important reason to choose the country of
destination for treatment had a 29% lower prevalence ratio of choosing the Federal Republic of
Germany compared to people who had the cost as not important at all (PR 0.71, 95% CI: 0.51,0.10,
p=0.05). People who were not sponsored by the government had a 67% lower prevalence ratio of
65
choosing the federal Republic of Germany compared to people who were sponsored by the
government.
Discussion
Nearly half of the patients from the United Arab Emirates who travelled overseas during
2009-2012 sought medical treatment in the Federal Republic of Germany as a first trip. The
prevalence of travelling to the Federal Republic of Germany was significantly associated with
lower concerns about financial costs and having government coverage for medical expenses in
comparison to travelling to other destinations. Patients who travelled to the Federal Republic of
Germany were more likely to be diagnosed with stroke (brain hemorrhage or clot) and less likely
to be diagnosed with eye diseases. Although receiving advice from someone was not statistically
significantly different between those choosing the Federal Republic of Germany over other
destinations, it had the highest frequency compared to other motivational factors such as having
been there before, vacation aspects, and a perceived friendly atmosphere. Moreover, physician
training, qualifications and experience followed by reputation of the medical center, were
important information that patients inquired about in general when seeking healthcare services
overseas.
Many studies have stated that financial cost plays a vital role in influencing decisions
regarding seeking healthcare services overseas (Culley et al., 2011; Eissler & Casken, 2013; Gan
& Frederick, 2013; Guiry & Vequist, 2011; Guy et al., 2015; Horowitz & Rosensweig, 2007; Khan,
128. Is the treatment that you had abroad available in the UAE?
1. Yes Continue
2. No Move to question 130
3. Don't Know Move to question 130
129. What were your main reasons for deciding to obtain healthcare outside the UAE?
Do not read responses. Probe by asking “any other reasons” three times. Circle all responses
A) Can not afford the treatment in the UAE (limited insurance coverage or no coverage) B) Not eligible_ services provided only in the military hospital
C) Long waiting time to get an appointment D) Undesirable treatment outcome from previous personal experience
E) Undesirable treatment outcome from others' previous experience F) Privacy and confidentiality reasons
G) Negative attitude from health care providers
H) The post treatment rehab/care is not available in the UAE I) Expecting reverse treatment outcome that might result from treatment in the UAE
J) Other. (Specify)
130. Who paid for the cost of treatment abroad?
1) Governor's Diwan, Government of Dubai 2) Federal Ministry of Health
6) Others (Specify) 7) you own pocket or from your household budget
131. The next question asks about expenditure in your last overseas trip. I would like to ask you about
how much were spent on treatment, accommodation and travel expenses. We want you to remember all
the expenses related in AED.
a. Own Pocket/
Household
b. Government/
Diwan
c. Insurance
Treatment
Accommodation
Travel
236
FOR INTERVIEWER: IF THE ANSWER FOR QUESTION 129 IS (A) "CAN NOT
AFFORD THE TREATMENT"THEN ASK THE FOLLOWING SET OF QUESTIONS (132
TO 151) BASED ON THE DIAGNOSIS OF PATIENT (SEE ANSWERS OF QUESTION
126)
1. Cancer
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF CANCER FOR WHICH THE
RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for cancer treatment package in the UAE on
average (consultation, investigations, admission, medicines) is (8,500
) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
132 Suppose that the price of cancer
treatment increased to (15,000) AED.
Would you go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 134
Go to 134
133 Suppose that the price of cancer
treatment increased even further - to
(21,000) AED, would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
Go to 135
134 Suppose that the price increase was
less than the previous amount.
Suppose the price of cancer treatment
increased to (12,000) AED. Would you
go abroad for treatment?
Yes 1
No 2
Don't know 99
135 What would be the maximum price you
would be willing to pay for … cancer
treatment abroad?
Amount _________ continue
237
2. Neurologic Diseases and Neurosurgery
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH
THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for the treatment of Neurological Diseases and
Neurosurgery package in the UAE on average (consultation,
investigations, admission, medicines) is (16,000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
136 Suppose that the price for the
treatment of “Neuro” increased to
(25,000) AED. Would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
Go to 138
Go to 138
137 Suppose that the price for the
treatment of “Neuro” increased even
further - to (35,000) AED, would you
go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 139
138 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
“Neuro” increased to (20,000) AED.
Would you go abroad for treatment?
Yes 1
No 2
Don't know 99
139 What would be the maximum price you
would be willing to pay for the
treatment of “Neuro” abroad?
Amount _________ Continue
238
3. Pediatric Diseases:
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF HEART DISEASES FOR WHICH
THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for the treatment of Pediatric disease package in
the UAE on average (consultation, investigations, admission, medicines)
is (10,000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
140 Suppose that the price for the
treatment of Pediatric disease increased
to (19,000) AED. Would you go
abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 142
Go to 142
141 Suppose that the price for the
treatment of Pediatric diseases
increased even further - to (29,000)
AED, would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
Go to 143
142 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
Pediatric diseases increased to
(14,000) AED. Would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
143 What would be the maximum price you
would be willing to pay for the
treatment of Pediatric diseases abroad?
Amount _________ Continue
239
4. Bone and Joint Diseases
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH
THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for the treatment of Bone and Joint diseases
package in the UAE on average (consultation, investigations, admission,
medicines) is (9,000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
144 Suppose that the price for the
treatment of Bone and Joint diseases
increased to (13,000) AED. Would you
go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 146
Go to 146
145 Suppose that the price for the
treatment of Bone and Joint diseases
increased even further - to (17,000)
AED, would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
Go to 147
146 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
Bone and Joint diseases increased to
(11,000) AED. Would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
147 What would be the maximum price you
would be willing to pay for the
treatment of Bone and Joint diseases
abroad?
Amount _________ Continue
240
5. Hearth Diseases
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR
WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for pediatrics diseases treatment package in the
UAE on average (consultation, investigations, admission, medicines) is
(15,000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
148 Suppose that the price for the
treatment of Heart diseases increased
to (30,000) AED. Would you go
abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 150
Go to 150
149 Suppose that the price for the
treatment of heart diseases increased
even further - to (45,000) AED, would
you go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 151
150 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
Heart disease increased to (22,000)
AED. Would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
151 What would be the maximum price you
would be willing to pay for the
treatment of Heart disease abroad?
Amount _________ Continue
241
6. Eye Diseases
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR
WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for pediatrics diseases treatment package in the
UAE on average (consultation, investigations, admission, medicines) is
(8,000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
152 Suppose that the price for the
treatment of Eye diseases increased to
(11,000) AED. Would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
Go to 154
Go to 154
153 Suppose that the price for the
treatment of Eye diseases increased
even further - to (15,000) AED, would
you go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 155
154 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
Eye disease increased to (9,000) AED.
Would you go abroad for treatment?
Yes 1
No 2
Don't know 99
155 What would be the maximum price you
would be willing to pay for the
treatment of Eye disease abroad?
Amount _________ Continue
242
7. Obstetrics and Gynecology Diseases
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR
WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for pediatrics diseases treatment package in the
UAE on average (consultation, investigations, admission, medicines) is
(7,000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
156 Suppose that the price for the
treatment of OBGYN diseases increased
to (10,000) AED. Would you go
abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 158
Go to 158
157 Suppose that the price for the
treatment of OBGYN diseases increased
even further - to (13,000) AED, would
you go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 159
158 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
OBGYN diseases increased to (8,000)
AED. Would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
159 What would be the maximum price you
would be willing to pay for the
treatment of OBGYN diseases abroad?
Amount _________ Continue
243
8. General Surgery
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR
WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for pediatrics diseases treatment package in the
UAE on average (consultation, investigations, admission, medicines) is
(5000) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
160 Suppose that the price for the
treatment of General Surgery increased
to (7,000) AED. Would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
Go to 162
Go to 162
161 Suppose that the price for the
treatment of General Surgery increased
even further - to (9,000) AED, would
you go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 163
162 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
General Surgery increased to (6,000)
AED. Would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
163 What would be the maximum price you
would be willing to pay for the
treatment of General Surgery abroad?
Amount _________ Continue
244
9. KIDNEY TREATMENT PER SESSION
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR
WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for pediatrics diseases treatment package in the
UAE on average (consultation, investigations, admission, medicines) is
(550) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
164 Suppose that the price for the
treatment of Kidney per session
increased to (650) AED. Would you go
abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 166
Go to 166
165 Suppose that the price for the
treatment of kidney per session
increased even further - to (700) AED,
would you go abroad for treatment?
Yes 1
No 2
Don't know 99
Go to 167
166 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
Kidney per session increased to (600)
AED. Would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
167 What would be the maximum price you
would be willing to pay for the
treatment of Kidney diseases per
session abroad?
Amount _________ Continue
245
10. Gastro-intestinal Diseases
FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH
THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT
Q. QUESTION RESPONSE CODE SKIP
READ TO RESPONDENT:
If the current price for the treatment of Neurological Diseases and
Neurosurgery package in the UAE on average (consultation,
investigations, admission, medicines) is (2,500) AED.
READ TO RESPONDENT:
I would like to ask you some questions about your response to
potential changes in the price of this treatment fee. In answering these
questions, please bear in mind the following:
1. Price stated above are in the UAE (travel and accommodation abroad
is not included)
2. Cheaper alternative treatment is available in the UAE
168 Suppose that the price for the
treatment of GI increased to (4,500)
AED. Would you go abroad for
treatment?
Yes 1
No 2
Don't know 99
Go to 170
Go to 170
169 Suppose that the price for the
treatment of GI increased even further
- to (6,500) AED, would you go abroad
for treatment?
Yes 1
No 2
Don't know 99
Go to 171
170 Suppose that the price increase was
less than the previous amount.
Suppose the price for the treatment of
GI increased to (3,500) AED. Would
you go abroad for treatment?
Yes 1
No 2
Don't know 99
171 What would be the maximum price you
would be willing to pay for the
treatment of GI abroad?
Amount _________ Continue
246
Section 6 Family Related
172. In your opinion, what are your preferences in, travelling abroad for treatment?
172.1 Preference for travel escort.
One answer only
1) Travelling alone
2) Travelling with someone
172.2 Arrangement Preferences
One answer only
1) Arrange the trip by self 2) Arrange the trip by agency (airfare, transport, accommodation, consultation)
172.3 Other Preferences
Circle all responses
a) Tourism aspect of the destination
b) Travelling to treatment destinations closer to UAE
c) Others. (Specify)
173. When you decided to travel, what was your family response? (Family in UAE or abroad)
Do not read responses. Probe by asking “any other reasons” three times. Circle all responses
A) They told stories of bad experiences in the desired destination
B) They helped in the arrangements of the trip C) They foresaw bad outcomes that are difficult to be managed abroad
D) They looked for different treatment options in the UAE/other countries E) They provided financial help
F) They expressed worry about lack of family support abroad
G) They suggested an escort H) They encouraged family support abroad
I) Others. (Specify)
Section 7 Economic Related
174. Do you know about the refund policy by the health care provider abroad?
1) Yes Continue
2) No Move to question 176
175. Do you know when you can get a refund?
Circle all responses
A) In case you changed your mind
B) Operation not done
247
C) You can’t get all the procedure needed
D) Exemption E) Emergency case
Section 8 Risk of Travel & Treatment
176. Unfavorable reactions/complication/outcomes during or after treatment abroad
176.1 Have you experienced any of the unfavorable reactions/complications/outcome, during or after
your treatment abroad,?
1) Yes
2) No
176.2 What unfavorable reactions/complication/outcomes during or after treatment abroad have you
experienced?
Do not read responses. Probe by asking “any other reasons” three times. Circle all responses
A) Fever/ infection after the surgery B) Allergy from medicine
C) Wrong diagnosis D) Other surgical complications
E) Other medical complications
F) Results not as explained by the doctor
177. In case of medical error, do you know whom to report to?
1) Yes Continue
2) No Move to question 179
178. If yes, whom would you report to?
Circle all the answers
A) UAE embassy
B) Treatment and Overseas Patient Affairs Office C) Police
D) Hospital administration/complaint center
E) Others, specify
179. Suppose that you faced a delay in issuing of Visa of entry to the desired destination, what would be
your next decision?
1) Wait further till you receive the visa
2) Look for another destination abroad 3) Search for health providers in the UAE
248
Section 9 Satisfaction about Overseas Treatment
180. Overall how satisfied were you with the last healthcare trip overseas?
1) Very satisfied 2) Satisfied
3) Neither satisfied nor dissatisfied 4) Dissatisfied
5) Very dissatisfied
181. Would you recommend your healthcare trip overseas experience to someone else?
1) Yes
2) No
182. What are the factors related to the medical services you find abroad that you wished are here in
hospitals and clinics in the UAE?
Do not read responses. Probe by asking “any other reasons” three times. Circle all responses
A) Reasonable waiting time at the clinic before seeing the doctor B) Easiness of booking for an appointment (convenient, didn't take long time)
C) Consultation and Diagnostic work-ups and treatment were all in the same building D) Treating doctor talked clearly to me about my condition
E) Treating doctor gave me different treatment options
F) Treating doctor explained to me how I can cope, live normal life with my condition G) Treating doctor explained what might happen to me in the future
H) The medical staff was polite, and courteous I) The hospital called to report my results instead of me going to them
J) The medical staff was able to respond to my inquiries efficiently and referred me to the right persons
K) The facility (hospital, clinic) was clean and welcoming
L) The treating doctor was listening to me M) Availability of reading material on my condition in Arabic and English
N) Treating doctor was paying full attention to me (not distracted by phone or writing) O) Others (Specify)
249
We would like to ask you about some scenarios related to your preference when
considering healthcare services in the UAE. We will use a scale from 1 to 5 to record your
preference, where 1 means (least preferred) and 5 means (most preferred)
SDA= Strongly Disagree, DA = Disagree, N = Neutral, A = Agree, SA= Strongly Disagree
183. Preference for Healthcare Services in the UAE and Waiting Time for Cancer
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
184. Preference for Healthcare Service in the UAE and Waiting Time for Neurologic Diseases and
Neurosurgery
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
185. Preference for Healthcare Services in the UAE and Waiting Time for Pediatric Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
250
186. Preference for Healthcare Services in the UAE and Waiting Time for Bone and Joint Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
187. Preference for Healthcare Services in the UAE and Waiting Time for Heart Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
188. Preference for Healthcare Services in the UAE and Waiting Time for Eye Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
189. Preference for Healthcare Services in the UAE and Waiting Time Obstetrics and Gynecology Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
251
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
190. Preference for Healthcare Service and Waiting Time for General Surgery
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
191. Preference for Healthcare Service and Waiting Time for Kidney Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
Known Physician
in the UAE
Visiting Physician
192. Preference for Healthcare Service and Waiting Time for Gastro-intestinal Diseases
Preferences Preference for diagnosis and treatment for the
case
Preference for the diagnoses for the waiting
time
Choices SDA DA N A SA 1
Week
2
Weeks
1
Month
3
Months
6
Months
252
Known Physician
in the UAE
Visiting Physician
193. Complete the price-quality table, what do you think of health services in terms of price (High,
medium, low) and quality (high, medium, low). Please tick a response.
(a). Thailand Price
High Medium Low
Quality
High
Medium
Low
(b). India Price
High Medium Low
Quality
High
Medium
Low
(c). Germany Price
High Medium Low
Quality
High
Medium
Low
(d). UK Price
High Medium Low
Quality
High
Medium
Low
253
(e). USA Price
High Medium Low
Quality
High
Medium
Low
194/195/196 Complete the Preference Table (rank your answers from 1 least preferable, to 5 most
preferable)
Preferred
Destination if I have
to pay for care
myself
Preferred
Destination if
insurance will cover
treatment costs but
not travel,
accommodation
Preferred
Destination if the
government will pay
for my care
a) USA 194 195 196
b) UK 194 195 196
c) Germany 194 195 196
d) France 194 195 196
e) Singapore 194 195 196
f) Malaysia 194 195 196
g) Thailand 194 195 196
h) India 194 195 196
i) Jordan 194 195 196
j) Egypt 194 195 196
k) Turkey 194 195 196
254
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Curriculum Vitae
Wafa Khamis Alnakhi
Address: Department of Health Policy and Management
624 N Broadway
Baltimore, MD 21205
+12029107527
Objectives:
As a quality oriented professional and passionate to be involved in challenging environment, I am seeking
an opportunity with a dynamic high growth organization/institution that welcomes innovative ideas, and
dedication, where I can practice and apply my skills in health policy, planning, research & strategy.
Education:
Johns Hopkins University, School of Public Health (2013- 2018)
Doctor of Public Health (DrPH) in Health Policy and Management Dept. Healthcare Management and Leadership
with research focus on “Patients from the United Arab Emirates Seeking Healthcare Services Overseas during 2009 –
2016: Characteristics Medical Conditions and Preferences"
Johns Hopkins University, Zanvyl Krieger School of Arts and Science-Advanced Academic
Program (2009 – 2011)
Master Degree in Biotechnology with Concentration in Enterprise
United Arab Emirates University, Faculty of Medicine & Health Sciences (2004 – 2005)
BSc. Degree in Medical Laboratory technology
Higher Colleges of Technology, Sharjah Women's College (2000 – 2004)
Higher Diploma in Medical Laboratory Technology
Work Experience:
JOHNS HOPKINS UNIVERSITY SCHOOL OF PUBLIC HEALTH
Teaching Assistant for the course: Fundamentals of Management for Health Care Organizations
[312.601.01] (2014 – 2016)
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DUBAI HEALTH AUTHORITY
HEALTH POLICY & STRATEGY SECTOR (HPSS)
Senior Policy and Strategy Analyst (2011-2013)
A team member in the strategy development and implementation of Dubai Health Authority Strategy
2011-2013 A coordinator with “Total Alliance Health Partners International” (TAHPI) in conducting “Dubai Clinical
Services Capacity Plan 2020” for Dubai Health Authority, to ensure the health services are well-positioned
to meet the demand for high-quality healthcare services for the citizens and residents of the Emirate of Dubai.
A DHA representative in the data collection from health service providers “Public Sector” in Dubai
A team member in the strategy development of “Overseas Treatment Survey” to explore knowledge, attitude
and perception related to medical treatment abroad among residents of Dubai
Project manager of “Dubai Medical Tourism” initiative to position Dubai as the leading medical tourism
hub of the world because of its well-developed infrastructure and the strategic geographical location between
Europe and South East Asia
Designing and creating departmental policies related to Health Policy and Strategy Sector
Collecting, analyzing and interpreting health quantitative information and data used for Stata Research
Assisting in producing high quality health reports and relevant documentation to be raised to the decision
makers
Undertaking research, analysis, benchmarking, and planning activities for the surveys, strategies and KPIs in
the Health Policy and Strategy Sector
DUBAI CORD BLOOD & RESEARCH CENTER (DCRC)
Medical Laboratory Scientist (2006 – 2009)
Laboratory Safety Identifying and handling specimens
Processing the umbilical cord blood, harvesting stem cells and cryo-save them for transplantation
Human Leukocyte Antigen test at Molecular Base
Performing quality control
Write & review SOPs relevant to DCRC
LATIFA HOSPITAL
Medical Laboratory Scientist (2005- 2006) Hematology, Blood Bank, Molecular Genetics (special and routine tests)
MINISTRY OF HEALTH TAWAM HOSPITAL & ALAIN HOSPITAL Medical Laboratory Scientist (October 2004)
• Training and observing in Biochemistry, Hematology, Histopathology