Population selected for analysis

The population of health system users of Dubai can be classified as follows:

  1. 1.

    UAE Nationals (Emiratis) in the Emirate of Dubai

  2. 2.

    Non-nationals (Expatriates) with employment visas from Dubai and residence inside Dubai

  3. 3.

    Non-nationals (Expatriates) with employment visas from Dubai and residence outside Dubai

  4. 4.

    Tourists who visit Dubai

The Dubai Statistics Centre considers only the first two groups as part of Dubai’s population. However, according to the law, government agencies and private employers in Dubai are mandated to offer healthcare coverage to all employees with Dubai employment visas regardless of their geographical residence. Thus, for the purposes of this study, the first three groups will be considered. We can further segregate the non-nationals based on their type of residence – households, collective housing and labor camps. Non-nationals residing in labor camps represent a less privileged social class than those living in households and those living in collective housing have intermediate social status. Health spending by tourists is not included in this study as the population of short-term tourists varies seasonally.

Data – Dubai household health survey (DHHS) 2014 and 2018

The Dubai Household Health Survey (DHHS) is the largest comprehensive household survey of healthcare and health issues carried out in the Emirate of Dubai. The survey provides a statistically accurate and representative outlook of key health and healthcare variables across the entire population of Dubai. It was first conducted in 2009, and repeated in 2014 and 2018.

The surveys of 2014 and 2018 were based on a multi-stage stratified cluster sample. The sampling was designed so that after weighting it would be representative of the four sub-populations: UAE citizens, Non-nationals living in households, Non-nationals living in collective housing, and Non-nationals living in labor camps. Surveyors personally visited these randomly selected households to obtain detailed information on issues ranging from household health expenditure, and access to health services to questions on exercise levels, dietary habits, lifestyle diseases, mental health, and a detailed module on the use of public and private health services in Dubai. The 2018 survey was designed by DHA and the logistics and field work was led by the Dubai Statistics Center (DSC), and had a response rate of 96%. The design and methodology of the survey were adopted from those used in the World Bank’s Living Standards Measurement Surveys (LSMS), the World Health Organization’s World Health Surveys (WHS) and the US Center for Disease Control’s National Health Interview and Examination Surveys (NHIES).

Importance weights were assigned by Dubai Statistics Center because UAE citizens were oversampled. After weighting, the sample was representative of a geographical population of 3.2 million Dubai residents as of 2018. The sample size for 2018 was a total of 9630 persons in 2200 housing units of whom 5665 were UAE citizens, 2342 were Non-Citizens in Households, 1335 were Non-Citizens in collective housing, and 288 were Non-Citizens in labor camps. The samples in 2014 and 2018 included a total of 3271 and 2200 separate household units respectively. The survey was sanctioned by the institutional review board of the Dubai Health Authority.

The surveyors each received extensive training in the collection of self-reported expenditure data and interviewed a person in the household who is 15 years and above and most knowledgeable about recent medical utilization. After collecting a household roster and basic demographics for each household member, the surveyor asked whether each household member had had any outpatient utilization in the last 30 days, made any discretionary purchases of medical supplies or over the counter medicines (mentioning blood pressure cuffs, blood sugar monitors, orthopedic supplies, medicines, etc.) in the last 30 days and whether each household member had had an overnight inpatient stay in the last 12 months. For households where more than one member had experienced outpatient utilization in the last 30 days, an individual member was selected at random and details of their medical events were collected to investigate the total of out of pocket spending for various categories of discretionary spending, outpatient spending and inpatient spending, after adjusting for the appropriate weights. All household members who had overnight inpatient stay in the last 12 months were asked to fill an inpatient module questionnaire.

Data – system of health accounts 2012–2017

The results from the published System of Health Accounts (SHA) from 2012 to 2017 were used for triangulation to ensure the OOP expenditure estimates from the survey data were accurately captured for the population defined [6].

Analysis

In our analysis of DHHS we calculated the probability that each of the 4 categories of household would have any discretionary, or any outpatient, or any inpatient out of pocket spending. For outpatient spending the household survey included the number of outpatient encounters experienced in a 30-day period and the number of hospital admissions experienced in a 12-month period. Then for each type of household the probability of any spending was multiplied by a weighted estimate of the annual average total out of pocket expenditure for households who incurred that type of event. Estimates were adjusted for the incidence of multiple outpatient visits in a month. Only 5 households reported greater than one hospitalization per month, so this adjustment had a negligible effect on estimates of hospitalization incidence and costs. Health care spending data can be dominated by outliers that could dramatically skew estimates of average expected spending in small samples. This was found to be true of the DHHS health spending data. Consequently, all calculations of average health spending excluded outliers above the 99th percentile to reduce the skewness of the data.

Estimates of outpatient and discretionary spending in the last 30 days were annualized to offer estimates of total annual out of pocket spending for each of the four types of households. Finally, total annual spending for each type of household in 2018 was multiplied by estimates of the proportion of these households in the population of Dubai in 2014 based on government data showing that at this time there were 8% UAE citizens, 42% UAE non-nationals living in households, 11% UAE non-nationals living in collective housing, and 39% living in labor camps.

The findings on out of pocket spending for both 2014 and 2018 were used to linearly interpolate to 2015, 2016 and 2017 by adjusting for population growth of the total population and assuming that the proportion of each type of household remained constant. Costs from different years were deflated from and inflated, using the consumer price index so that costs are expressed in real AED with a baseline of 2014.

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