Impact of population variables on health services demand and provision in the United Arab Emirates.

Yeboah, David Achanfuo

INTRODUCTION

THE POPULATION OF ANY COUNTRY is the ultimate beneficiary of any policies, services and programs made for that area or country, including policies and programs in health care and health services provision. The health and medical centers, hospitals, clinics and allied health services in the United Arab Emirates (UAE) are made for the use of the residents of that country, albeit some non-residents can come in from outside to access those programs. The links between population and health have been discussed empirically and theoretically in the existing research literature (see for example, Weeks 1986; Yeboah 1998 & 2005). As evidenced from the literature and demonstrated later in this study, population variables such as size, composition, spatial distribution and dynamics impact the level, nature, types and variety of health services demand, and subsequent service provision. In addition, a leading determinant of health is the social environment (Syme 1992, Yen and Syme 1999), and population is an integral part, and a major player in the social environment.

A knowledge and understanding of these demographic variables are therefore essential for health services development and delivery, as it also allows for planning and targeted service provision. This is particularly so for population based and place based health planning (Yeboah 2005), community health programs (Dzewaltowski et al. 2002 and 2004) as well as targeted health education and health promotion (see for example, Green 1999). Not much exists on the inter-relationships between population and health in the United Arab Emirates (UAE). The purpose of this article is, therefore, to use data from the UAE to investigate and illustrate the theoretical and empirical links between population and health in the UAE, with a view to improving health service development and delivery.

SOURCES OF DATA AND METHODOLOGY

Data for this study have come from the Ministry of Health and the Department of Statistics, Ministry of Economy and Planning in the UAE. The two agencies have a variety of information on the demography and health of the UAE, including historical information on the population changes as well as increasing health services provision. The methodology includes an analysis of the demographic and health data to identify and discuss changes in the size, composition, distribution by Emirates and dynamics of the UAE population and their impact on demand and provision of health services. The methodology also includes the use of the above information to demonstrate the links between population variables and the demand for and provision of health services.

IMPACT OF POPULATION ON HEALTH

Yeboah (2005) presents a framework for place based health planning, which identifies and discusses the essential elements of population and health inter-relationships (figure 1). According to the figure, demographic variables impact on health directly and indirectly in conjunction with social disadvantage and community services. Demographic variables such as population size, population composition and population distribution (spatial or geographical) affect needs assessment, needs prioritization, as well as program development and delivery.

[FIGURE 1 OMITTED]

In general, the size, composition and distribution of population determine or rather influence the provision of health services (figures 1 & 2). Changes in any of the said demographic variables (called population dynamics) have the potential to impact on demand for and provision of health services. There is a positive relationship between population size and health services provision, the higher the population size, the greater the potential demand and the higher the level of health services provision. Population composition works on the basis that the potential demand is shared among the various segments of the population and, in particular the age distribution of the population.

[FIGURE 2 OMITTED]

The impact of the spatial distribution of the population is similar to population size in the sense that the geographical units with the largest concentration of population within countries tend to have the greatest demand and consequently the greatest provision of services. After all, health services and programs are viable when they are supported by the population for whom those services and programs are made. Within countries, the notion that regions or geographical areas with more population concentration tend to have more demand and service provision is natural and logical, and is supported by data from the UAE (as discussed later).

In terms of population composition, the distribution of the population by age, gender and ethnicity is very important. Mortality varies by age, gender and ethnicity among other characteristics (Weeks 1986, and Yeboah 1998). In countries like the UAE where there is a large population of various ethnic groups, ethnicity becomes increasingly important, as various ethnic groups exhibit diverse perceptions, norms, values, attitudes and practices towards health. Indeed, the importance of various attributes of ethnicity, such as culture, language, and religion, on health care has been noted by many researchers (see for example, Rosling 1999, and Yeboah 2005).

With regards to the age composition, the population may be divided into categories such as "Young (varies by country but generally 0-14 years), Adult and Old" with each broad group having a specific demand for health care (figure 3). For example, the Young population requires pediatric care, while the Old or elderly population requires geriatric care and related health services (see also Weeks 1986).

[FIGURE 3 OMITTED]

UAE Population

At the time the United Arab Emirates was established in 1970, there was a population of just 248,000 and health services provision was minimal, the direct result of small demand and a lack of oil money at the time. The population of the UAE has increased steadily since then to an estimated 4.04 million in 2003 (Table 1).

The population of the UAE has been growing rapidly with implications for the size and composition of the population. High growth rates of 7.6% were recorded for both 2002 and 2003. As population grows rapidly, its composition and distribution are also affected. Persistent high fertility resulted in a continuous young population for the UAE. Table 2 shows the age and gender composition of the UAE population in 2000. More than a quarter (26.2%) of the population is aged less than 15 years, but the largest single proportion is the working age group, 15-44 years, which accounted for 62.5% of the population.

Overall, gender imbalance exists in the UAE population, with males accounting for 67.3% of the population compared to 32.7% for females. This is due to the large proportion of expatriate workers in the UAE, most of whom, especially those on low wages, leave their wives in their home country.

The spatial distribution of population by Emirate is shown in table 3. Abu Dhabi recorded the highest population from 1975 to 2003, followed by Dubai, Sharjah, Ras Al Khaimah and Ajman. Umm Al Quwain recorded the lowest populations for those years. A common feature is that population increased steadily in all the seven Emirates.

IMPACT OF POPULATION ON HEALTH SERVICES IN THE UAE

These relationships between population variables and the demand for and provision of health services discussed earlier are also true for the UAE. The UAE has made tremendous gains in health care development (Rosling1999), and this has partly been due to increasing demand for health care. Developments in the UAE during the last 40 years have made the country comparable to Western Europe and the United States in health and economy, while it preserved its cultural values (Rosling 1999, 11).

Since the UAE federation was formed in 1970, and it goes without saying that the increasing population has resulted in increasing demand and subsequent provision of services (table 4). The number of government hospitals increased from 7 in 1970 to 20 in 1980, 29 in 1990, 35 in 2000 to 38 in 2003, an increase of almost 450%. There has been an increase in the number of private hospitals in recent times, from 24 in 2000 to 30 in 2003, and increase of 25% in a few years, while the number of nurses increased by 1,368%, from a mere 1000 nurses in 1970 to 14,680 nurses in 2003 (Table 4).

Similarly, the number of health centers increased from a mere 21 in 1970 to 1,421 in 2003. So also did the number of physicians which increased (with rising population size) from 200 in 1970 to 1000 in 1980 to 5,222 and 6,946 in 1990 and 2000 respectively. Needless to mention that the number of nurses also increased by 1,368% from 1,000 in 1970 to 14,680 in 2003.

The impact of population size on health services provision is also evident from attendants of primary health care centers in the UAE. Table 5 shows that attendants of primary health care centers increased from 3,765,171 in 1992 to 4,519,385 in 2000, an increase of 20% during the 8 year period.

The increase in service provision resulting from increasing population size is even seen in allied health services. As population growth occurred, the number of laboratory tests undertaken in the UAE increased from 2,760,414 in 1979 to 11,787,937 in 1999, an increase of over 327% during that 20 year period. Sight should also not be lost of the fact that blood bank units increased from 9,005 in 1984 to 29,690 in 2000. Thus, the links between population size and health services provision is clear in the UAE, with population size exhibiting a positive statistical association with health services provision. That is, the higher the population size, the greater the demand and the greater the health services provision, with increasing population being met with increasing services provision.

POPULATION DISTRIBUTION AND HEALTH SERVICES PROVISION

The provision of health services is related to the spatial distribution of the population by Emirates. The UAE has seven Emirates with varying population concentrations, namely Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al Quwain, Ras Al Khaimah and Fujairah. Abu Dhabi is the largest Emirate with an area of about 67,340 square kilometers, followed by Dubai. Population is unevenly distributed over these Emirates with Abu Dhabi and Dubai having the largest population concentrations. Table 6 shows that the largest Emirate, Abu Dhabi, also has the largest number of primary health care centers and medical manpower in primary health care (Physicians and Nurses).

POPULATION COMPOSITION AND HEALTH SERVICES

The impact of population composition is more evident from the School Health Program. Total fertility rates have remained high in the UAE, albeit it is declining (5.4 in 1995-99 to 2.9 in 2003). The end product of persistent high fertility over a number of decades has been a young population with a strong growth in school age population. The health sector has responded to this population growth through the establishment of the School Health Program in 1960 and subsequent development of the program during the last four decades.

Evidence from Table 7 indicates a tremendous increase in the number of school health projects, as well as the manpower involved in the School Health Program. The number of schools participating in the School Health Program increased from 129 in 1970 to 615 in 1996, an increase of almost 377%, while the number of students cared for increased by almost 638% during the same period. There were vast increases in medical manpower in the School Health Program, with the number of doctors increasing by 2,075%, and the number of dentists and nurses rising by 1,000% and 1,117% respectively. This has contributed to improvements in the health of the children of the UAE as it does elsewhere (see Bellamy 1999):

As explained earlier, a key feature of the population of the UAE is the low proportion of elderly population, due to the large proportion of expatriate workers. This low proportion translates into low demand for geriatric services and, hence, lower geriatric health services provision. The growing number of foreigners buying properties and retiring in Dubai may change this proportion in the future; albeit the number involved is very minute at this stage (see also Yeboah 1998 & 2005).

CONCLUSION

An attempt has been made in this article to investigate the impact of population variables, such as size, composition, distribution and dynamics, on the demand for and provision of health services. The available evidence, as demonstrated in this study, points to clear positive links between the demographic variables and the provision of health services in the UAE. Rising population has resulted in increasing demand for and provision of various health services, including primary health care, allied medical services, school health programs as well as health/medical manpower. The UAE has a very high per capita GDP and this has enabled the country to respond well to the increasing demand for health care following tremendous increases in population. Today, improvements in access to curative and preventative health services together with an advanced referral system has resulted in a high health status for residents of the UAE (Rosling 1999).

The study concludes that population impacts on health services, and that the links between population and health services provision observed elsewhere are also discernible in the UAE. The study concludes further that it would appear imperative for health planners and service providers in the UAE and the wider Arabian Gulf, to take the population characteristics of their jurisdictions into consideration in the planning, development and delivery of health services and programs.

REFERENCES

Bellamy, C. The State of the World's children 1999. United Nations Children Emergency Fund, 1999.

Dzewaltowski, DA, Estabrooks, PA, and Johnson JA. Healthy Youth Places Promoting Nutrition and Physical Activity. Health Education Research, 17: 2002, pp. 541-51.

Dzewaltowski, DA, Estabrooks, PA, and Klesges, L, M. Behavior Change Research in Community Setting: How Generalized are the Results. Health Promotion International, 19: 2004, pp. 235-45.

Rosling, H. Health development in the UAE from a Global Perspective. Abu Dhabi, Emirates Center for Strategic and Scientific Studies, 1999.

Syme, S. Social Determinants of Disease. In Last JM and Wallace RB (Eds), Public Health and Preventative Medicine. Norwak, Connecticut, Appleton and Lange: 1992, pp.953-70.

Weeks, J, R. Population: An Introduction to Concepts and Issues. Belmont, Wadsworth Publishing Company, 1986.

UAE Ministry of Health Website (1): website, www.uae.gov.moh

UAE Ministry of Health Website (2): www..moh.gov.ae

UAE Ministry of Economy and Plannng Website: www.tedad.ae

Yeboah, D. A. Basic Demography. London, Minerva Press, 1998.

Yeboah, D. A. A Framework for Place Based Health Planning. Australian Health Review, Vol. 29, No. 1: 2005, pp. 30-36

Yen, J. H. and Syme S.): The social Environment and Health: A Discussion of the Epidemiological Research. Annual Review of Public Health, 20: 1999, pp.287-308.

David Achanfuo Yeboah teaches in the Heath Sciences Program, Zayed University, Abu Dhabi, United Arab Emirates.

Table 1. Population of the UAE 1970 to 2003

Year Population Growth Rate (%)

1970 248000 --
1975 557900 --
1980 1040000 --
1985 1300000 --
1990 1844000 --
1995 2411000 --
2000 3108000 5.8
2001 3488000 7.4
2002 3754000 7.6
2003 4041000 7.6

Source: UAE Ministry of Health website

Table 2. Population by age and gender, UAE, 2000

 Male Female Total
Age
Group Number % Number % Number %

0-4 140000 4.50 133000 4.28 273000 8.78
5-14 284000 9.14 256000 8.24 540000 17.37
15-44 1398000 44.98 544000 17.50 1942000 62.48
45-64 252000 8.11 68000 2.19 320000 10.30
65-79 15000 0.48 12000 0.38 27000 0.87
80+ 3000 0.10 3000 0.10 6000 0.19
Total 2092000 67.31 1016000 32.69 3108000 100.00

Source: Compiled from Ministry of Economy & Ministry of
Health Websites

Table 3. Population distribution by Emirate 1975-2003

 1975 1980 1985 1995 2003

Abu Dhabi 211812 451848 566036 942463 1591000
Dubai 183187 276301 370788 689420 1204000
Shar'ah 78790 159317 228317 402792 636000
Ajman 16690 36100 54546 121491 235000
Umm Al 6908 12426 19285 35361 62000
 Quwain
Ras Al 43845 73918 96578 143334 195000
 Khaimah
Fujairah 16655 32189 43753 76180 118000
Total 557887 1042099 1379303 2411041 4041000

Source: Ministry of Economy and Planning, 2005

Table 4. Population growth and health services provision, UAE,
1970-2003

 1970 1980 1990 2000 2003

Population 248,000 1,040,000 1,844,000 3,108,000 4,041,000
Hospitals 7 20 29 59 68
Beds 700 3,000 4,300 7,083 8,343
Out 21 65 90 1,159 1,421
Patients
Clinics
Physicians 200 1,000 1,500 5,222 6,946
Nurses 1,000 3,300 46,000 12,280 14,680

Sources: Ministry of Health databases, and Ministry of
Economy and Planning

Table 5. Attendants at Primary Health care Centers,
UAE, 1992-2000

Year Attendants

1992 3,765,171
1995 3,891,641
2000 4,519,385

Source: Ministry of Health

Table 6. Primary Health Care Services by Medical District, 2000

Districts Centers Physicians Nurses

Abu Dhabi 21 128 173
Western 8 15 22
Al Ain 20 93 164
Total Abu Dhabi 49 236 359
Dubai 9 33 42
Shar'ah 14 35 43
Ajman 6 25 30
Umm Al 5 11 12
 Quwain
Ras Al Khaimah 16 55 59
Fu'airah 7 7 14
Total - UAE 106 402 559

Source: Ministry of Health

Table 7. School Health Program Information, UAE, 1970-1996

 1970 1986 1996

Schools 129 -- 615
Students 40,000 -- 295,000
Doctors 4 83 87
Dentists 2 14 22
Nurses 3 319 365

Source: Ministry of Health