Non-communicable disease and sustainability

Health G20 65

Q. How did you start addressing the burdenof NCDs in Abu Dhabi?OH. Since the 1990s, the WHO had consistently reported the

UAE as having the world’s second highest prevalence of diabetes,

with about 20% of the adult population (based on population

sampling). In 2006, the Abu Dhabi government initiated a major

health system reform primarily targeted at improving access and

outcomes for residents. One of the key pillars of this strategy was

building public health capacity, particularly in non-communicable

diseases (NCDs). At the time, the Emirate had no real experience

in collecting data, planning and monitoring, the core skills for

effective, scalable chronic disease management. Indeed, we

found there were very few suitable programmes for tackling

NCDs. Thus, taking advice from local and international experts,

we began implementing a novel evidence-based screening and

intervention programme at population scale, with a special focus

on diabetes and cardiovascular diseases. We came up with a

scalable and flexible strategic plan called “Weqaya” (Arabic for

“prevention” or “protection”); Weqaya has three simple and

adaptable modules: Screen, Plan and Act. Given the scale of the

challenge, it was decided to focus initially on cardiovascular

disease (CVD), with a view to increasing Weqaya to other NCDs in

due course.

From 2008 to 2010, the Weqaya screening enrolled nearly

the entire Emirati adults (94%) to determine their

cardiovascular risk profile based on an evidence-based

standard, the Framingham Risk Score. The results have

suggested a very high burden of cardiovascular risk factors,

confirming international data related to the world’s second

highest rate of diabetes (around 18%) and that in a very young

population. The data have also showed high rates of obesity

(35%), dyslipidaemia (44%) and hypertension (23%). Worse

still, the results also indicated a rapidly worsening situation, as

the population aged, without urgent effective intervention. As

expected, the Weqaya screening alone has provided

significant impetus across government for affirmative action.

However, screening was just the beginning of the Weqaya

response.

Q. On the basis of these screening results,what has been changed in the healthsystem and policy?OH. Abu Dhabi has been rapidly reforming its health system. It

was one of the first in the Gulf region to move away from the

traditional Ministry of Health model, creating in 2007 separate

functions within distinct government organisations: the Health

Authority of Abu Dhabi (HAAD) as Regulator, SEHA as

government operator, and Daman as government health insurer.

Since then, HAAD has been a pure regulator, setting policies and

standards and regulating against these through licensing and

inspection. Since 2006, HAAD has also built an internal Public

Health Department, responsible for compiling data on disease

Innovation in addressing NCDs:A case study from Abu Dhabi

OLIVER HARRISON DIRECTOR OF PUBLIC HEALTH AND HEALTH POLICY AT THE HEALTH AUTHORITYOFABU DHABI, UNITEDARAB EMIRATES

The global burden of non-communicable diseases (NCDs) is rising worldwide.Yet these diseases are preventable; the key risk factors and effectiveinterventions have been known for decades. The challenge now is how toachieve the right suite of interventions tailored to the individuals and how toeffectively prevent these diseases.Abu Dhabi, one of the seven emirates of the United Arab Emirates, has taken

significant steps to implement an evidence-based strategy through populationscreening followed by targeted interventions, tracking near-term performanceindicators and link actions today with longer-term outcomes, using innovativeeHealth and mHealth approaches. Here we present their programme,“Weqaya” (Arabic for “prevention” or “protection”).Through its innovative work,Abu Dhabi is fast becoming an “NCD laboratory”

generating insights for all countries (including low- and middle-incomecountries).Weqaya is based on building the NCD community and learning fromwhat works in practice through an open-source platform.

Non-communicable disease and sustainability

66 Health G20

burden, prioritising areas for action, and initiating and continuously

monitoring targeted and effective programmes.

On the basis of the Weqaya screening data, a population

health census, we have been able to identify individuals,

groups and population segments for effective and cost

effective action including the health sector, and the key “driver”

sectors that profoundly influence health-related behaviours,

particularly in the domains of nutrition, physical activity, and

tobacco, through a whole-of-society approach. Under

Weqaya we are now working towards sectoral Action Plans

and clear targets across food quality and labelling, urban

planning, tobacco-free environments, education, labour, and

media. We recognise the clear evidence that these sectors are

able to drive effective, low-cost solutions provided

government takes joined-up action. For this reason, the

second Weqaya module (Plan) and the third module (Act),

include not only health sector, such as care protocols, and

structured disease management, but also non-health sectors,

especially nutrition, exercise, and tobacco control. The

effectiveness of Weqaya relies on coordinated healthcare and

societal responses.

Q. How did you succeed in screening 94% ofthe adult Emirati population?OH. Weqaya used a simple formula of encourage, enable and

enforce. As a first step, screening was encouraged with an “above

the line” promotion campaign, featuring carefully selected high-

profile, influential individuals. Participation was enabled through a

simple screening design (10 minutes only) and access, with 25

dedicated clinics established, open in evenings and weekends,

bookable through a call centre or walk-in. Finally, we were able to

link Weqaya screening with the issuance and renewal of a free and

comprehensive health insurance card (called Thiqa, Arabic for

From 2008 to 2010, the Weqaya screening enrolled nearly the entire Emiratiadults (94%) to determine their cardiovascular risk profile based on an

evidence-based standard, the Framingham Risk Score

“Trust”). Although citizens were able to opt-out and obtain their

Thiqa card without Weqaya screening, this proved to be an

effective way of setting the population default and driving uptake.

Q. How is your baseline used?OH. Weqaya screening results provide a baseline for each

individual, and for groups (for example, families, local

communities, employees), and for the whole population. This

powerful health census creates a solid platform for assessing the

challenges, targeting resources, and measuring performance

against baseline.

We recognise the importance of affirmative action and have

driven this in three waves. Firstly, we have delivered securely

personal health reports with their Weqaya risk scores to

around 120,000 citizens, often provoking family discussions

about the risks and collective actions. Secondly, since we also

collected mobile phone number and e-mail addresses we

have been able to activate a web-based data system. Thirdly,

we are now building a secure cloud computing architecture to

enable confidential health data to become ubiquitous (much in

the way Visa or Mastercard enable financial data ubiquity).

The aim is to unlock the creativity of a range of innovators with

a view to improving Abu Dhabi health, whilst maintaining the

highest levels of confidentiality.

Q. What are the limitations of Weqaya todate?OH. Weqaya is a population-based clinical programme, so it was

necessary to make design choices through that lens. Diabetes

screening with HbA1c alone cannot distinguish between Type 1

and Type 2 disease, although linking to HAAD clinical encounter

data means we can now discriminate. We could not rigorously

enforce fasting which may have influenced the results for high

Non-communicable disease and sustainability

Health G20 67

cholesterol. We used a single elevated clinical blood pressure

reading to define hypertension, possibly leading to overestimated

hypertension rates, although we note that the hypertension rate

was considerably lower in our population (23%) compared with an

age-standardised US population.

As a starting point we have calculated cardiovascular risk

using models from the US-based Framingham Heart Study.

These models are currently among the best available in the

evidence-base, although we know that both genetics and

environmental exposures are very different in the Abu Dhabi

population. Over the coming 3-5 years, Weqaya will generate

all the data required to generate Abu Dhabi’s own risk scores.

We expect that this process will reveal new risk factors,

opening new targets for health interventions and research.

Q.How is the health system financed? Whatis the cost of the Weqaya programme?OH. Abu Dhabi has mandatory insurance for all citizens and

residents. From 2007, it became mandatory for employers to

provide private health insurance for their expatriate workers; the

citizens’ programme is called Thiqa (Arabic for “trust”) and was

established in 2008. The health insurance system helps develop a

competition among healthcare providers (such as Johns Hopkins,

Cleveland Clinic, and Imperial College London). In Abu Dhabi,

clinical service providers are reimbursed at defined tariffs for

clinical activity. Data transparency and clear quality indicators

drive free patient choice and thus clinical provider revenues. In

addition, under a system called “Pay for Quality” providers receive

additional bonus payments for adherence to evidence based

clinical care pathways.

The first round of Weqaya screening cost around US$30 per

person (including a reasonable profit margin to encourage

facilities to help drive uptake). Overall, over three years

Weqaya has cost about US$10 million (that is, around US$57

per Emirati adult). The long-term sustainability of the

programme has been built-in right from the beginning, with

screening and clinical interventions funded through the health

insurance scheme, and rigorous calculation of the cost-benefit

of both specific components and the programme overall. We

are particularly excited about “Pay for Health”, a new initiative

for disease management programmes; this too, has been

developed specifically with a view to sustainability. By design,

through improving health, and flattening the growth of

healthcare costs, spending on “Pay for Health” actually saves

the government money right away.

Q. Do you consider the provision ofincentives as a key driver?OH. Yes, we believe incentives are critical at different levels, health

providers as well as individual levels. “Pay for Quality” incentivises

the delivery of quality care by clinical providers, that is, compliance

with Abu Dhabi's evidence-based healthcare pathways, and the

upload of accurate clinical data to HAAD’s central population-wide

database.

In addition to “Pay for Quality” we have created another

novel incentive programme called “Pay for Health” for

structured Disease Management Programmes (DMPs) under

Weqaya. Under “Pay for Health”, DMPs are paid up to

US$1,500 per patient per year for improving measurable

“health” over the initial individual baseline. For the purposes of

Weqaya, “health” is defined with clear evidence-based criteria

(starting with the Framingham Risk Score). With commercials

tuned to ensure “Pay for Health” delivers return on investment

to government, this is effectively a structured mechanism for

government to transfer financial risks associated with NCDs.

Driven by their clear incentives, DMPs have two roles:

encouraging the compliance of their customers with clinical

care, and helping drive behaviour change to address risk

factors such as obesity, lack of exercise, and tobacco

consumption. Under Weqaya, DMPs have access to a unique

secure cloud computing data architecture, which ensures

health data can be packaged and delivered where it counts.

This technology can support simple channels, such as text

messages, call centres and face-to-face meetings. Very

quickly we believe we shall see innovation in both content and

channel; this is a fertile ground for academic and industry

R&D. This strategy will start working across the entire

population, early 2012.

At individual level, through our Weqaya programme related

to non-health sector, DMPs are able to deploy individual

incentives (for example, loyalty points) to encourage healthy

behaviours. Using smart mobile technologies for decision

support, and a range of 3G related applications, DMPs can

effectively intervene at individual level, while creating the

enabling environment to make healthier choices.

By influencing the demand side, we aim to shift

consumption towards healthier choices; in parallel we have

partnered with a range of producers and service providers

who have shown an interest in making their products healthy,

or at least less harmful (supply-side impact).

Q. How do you manage to create thisenabling environment?OH. We have taken a three-stranded approach. Firstly, we have

created a scalable platform based on novel technologies

developed on an open-source platform. Secondly, we have

aligned incentives around a clear definition of health. Thirdly, we

recognise that it can be easier to change a whole group, even an

entire community, rather than changing one person by one

person. For example, if you are the only person that wants to quit

Non-communicable disease and sustainability

68 Health G20

smoking and around you friends and family are still smoking

quitting can be really difficult. However, if everyone quits, it is very

hard not to quit smoking. In recognising this strength of

community action, and cross-sectoral alignment, Weqaya is

increasingly ubiquitous – a signpost for healthy choices in

restaurants, schools, shops, parks, on mobile phone applications.

We believe that a whole range of stakeholders can also

contribute to driving behaviour change. Employers can play a

major role for better health or the worse; providing secure,

anonymised Weqaya data for their employees helps employers

prioritise actions (for example, no smoking policies or

encouraging sports), benchmark their position in the market,

and track their performance over time. Social networks can

play a critical role to create new ways of thinking about health

and wellness as a brand related to positive behaviour

changes; our cloud computing and mobile platform enables

sharing data with the social network to drive action by the

whole groups, for example sharing selected data (say, body

mass index, food and exercise) with a spouse can help drive

diet improvements for the whole family.

Q.What is your vision and the next steps ofyour strategic plan?OH. Our central aim is simply saving more than 3,000 Emirati lives

from cardiovascular death over the next 10 years against

predicted mortality rates, and many more expatriate lives as well.

To achieve this, we are driving the coordination of government,

private and civic sector activities with the ambitious target of

making Abu Dhabi one the most improved health environments in

the World by 2030. Through this coordinated effort we shall also

build a range of opportunities for education, research and

industry. International partners already play a key role here to help

tackle current health challenges, for example we have undertaken

carefully structured public-private partnerships with two

pharmaceutical companies (AstraZeneca and Eli Lilly), and with

the UAE telecommunications company, Etisalat. Through our

partnerships, we aim for Abu Dhabi based companies to play an

increasing role developing novel technologies, innovations and

research, particularly in eHealth and mHealth.

You can see that the simple primary goal of saving lives can

be channelled to create a cascade of benefits across society.

Soon, we plan to expand Weqaya to address NCDs beyond

CVD; the approach can be adapted for all diseases where

screening is beneficial to disease outcomes. This applies of

course to the diseases that together account for 60% of global

mortality such as CVD, cancer, and chronic respiratory

disease, and to other diseases, such as HIV and depression.

Q. Emerging countries as well as developingcountries are also facing the rising burden ofNCDs. What lessons does Abu Dhabi canshare with these countries?OH. Our data suggests that in high burden populations (such as

Abu Dhabi and other Gulf States), population screening followed

by targeted interventions in well-stratified groups could yield good

results both, in terms of rapid effectiveness and medium- and

long-term cost-effectiveness. Weqaya is based on a shared health

database, linked through cloud computing to mhealth and ehealth

technologies. The architecture means Weqaya is rapidly scalable

at a low marginal cost.

Since Weqaya is modular (Screen, Plan and Act) it is

possible to adapt the specific approach depending on local

epidemiology and available resources. For example, we have

worked with a group from Cameroon to design Screening for

just one dollar, and Actions for US$10 a year (with SMS

behavioural advice, and just one or two low-cost generic

medications). Even in developing countries, mobile

penetration is very high, enabling the tracking of effectiveness

through linked mHealth technologies.

This cost effective approach is very promising worldwide to

move forward not only the fight against NCDs but also

communicable diseases and deliver results, including in the

poorest countries. There is an opportunity to convert this

approach into a Global Action Plan.

Q. What are you projects with the Gulfregion?OH. We view Weqaya as simply a clear and practical means to

implement non-communicable disease resolutions such as the

2008-13 WHO Action Plan, and the 2010 Dubai Declaration on

Diabetes and Chronic NCDs in the MENA Region.

We are beginning to talk to other countries in the Gulf

In addition to “Pay for Quality” we have created another novel incentiveprogramme called “Pay for Health” for structured Disease Management

Programmes (DMPs) under Weqaya

Key facts from Weqaya screening in Abu Dhabi

• 2/3 adults are overweight or obese

• 44% are either diabetic or pre-diabetic

• Almost 1/2 have abnormal cholesterol

• 71% have at least one risk factor for CVD and therefore

need to change their lifestyle to avoid heart attacks and

stroke

• Total societal cost to Abu Dhabi may be more than

AED300 billion over 10 years

• The potential cost savings from an effective Weqaya

Programme from diabetes alone are tremendous

Non-communicable disease and sustainability

Health G20 69

region. We are keen to develop a community of Weqaya

approaches, each with harmonised standards, but adapted to

local context. We propose that these Weqaya programmes

ideally be driven from a single database to enable countries to

learn from each other, using the same data, the same

protocol, all Internet based. This approach will facilitate

benchmarking and help overcome this issue of interoperability

of the telecom systems and many others current challenges.

Such a strategy is very exciting as it opens the potential for

multi-national impact, open-source learning and innovation.

Q. What would be your messages to theglobal leaders who are attending the majorG20 conference?OH. The burden of NCDs continues to worsen worldwide. The

major challenge is now how to achieve the right suite of

interventions tailored to the individual, and how to effectively

prevent these diseases. Weqaya can be adapted for a range of

populations; it has the potential to become a multinational Action

Plan, tailored for local context but harmonised to ensure

continuous learning.

Building on the momentum of the recent UN Summit on

NCDs, Europe could help take a lead in driving the fight

against NCDs worldwide, using its unique assets, experience

and resources. This major public health concern should be on

the top of the political agenda, it is not only a priority to

contribute to global health sustainability, but it is also an

economic asset with a potential high return on investments.

The UN Summit on NCDs stated that mitigating the cost of

NCDs, about US$47tn for over 20 years, should provide a

multi-trillion dollar growth opportunity. At a time of scarce

resources and financial crisis, hopefully, Global leaders of the

G20 may be sensitive to this consideration and will commit to

taking affirmative action. �

Interviewed by Therese Lethu

Dr Oliver Harrison is a UK trainedneuroscientist, physician and academic. Prior tojoining HAAD, Oliver spent five years withMcKinsey. He is a medical doctor withpostgraduate training in Psychiatry, a FoundationScholar in Medicine and Neuroscience at JesusCollege, Cambridge, an Honorary Lecturer atImperial College London.