Reinventing Healthcare In The MENA Region How to ensure affordability and access to higher quality healthcare to people across the MENA region.

Access, quality, and cost– the three words the MENA region's healthcare policy makers often find too difficult to contemplate. Regional governments have been aiming to solve a not even seemingly simple equation for ensuring affordability and access to higher quality healthcare to all. There have been many attempts to work out the value of, let's say, X, when Y represents the currently lagging healthcare system characterized by different levels of state financial assistance and personal income, varying stages of rural and urban developments, and the shortage of quality healthcare practitioners- just a few of the issues that are pertinent to the region.

Increased healthcare spending has been laid on the table quite often- from US$30.4 billion in 2003, government spending in healthcare across the region is expected to reach $144 billion by 2020, according to Al Masah Capital. Yet, the problem still appears insurmountable. Instead of this less efficient expenditure, solving this equation might today be about rearranging the terms inside of it, or, to put it simply, allowing and encouraging new faster, better, cheaper models of delivering healthcare- a whole new X, if you will.

Due to the so-called "connected care" revolution spreading around the world over the last few years, technological advances have been shifting our focus from traditional asset-heavy hospital- related developments to pioneering medtech devices; to new sector niches, such as digital health, including its subcategories mobile health, wearable devices, telehealth and telemedicine, and personalized medicine; or more recently, to increased chatter about augmented reality and robotics applications in medicine. But for all of that to actually materialize, legal and regulatory constraints are the first to be cited as one of the key hurdles in fully implementing these innovations across the MENA region.

A case in point: telehealth. Often used interchangeably with the narrower term "telemedicine," telehealth is, according to the World Health Organization, a description of the remote diagnosis and treatment of patients by means of ICT technology. Now, while the region does boast of great infrastructure in this area, telehealth, however, has not yet found a broader enabling environment.

Although Saudi Arabia and the UAE did make it a central part of their healthcare policies, in the UAE, for example, Health Authority - Abu Dhabi (HAAD), Dubai Health Authority (DHA) and Dubai Healthcare City Authority (DHCCA) have made incomplete attempts to regulate telehealth practice in their jurisdictions- information security and medical liability are reportedly among the few issues that still need to be defined with more clarity and consistency.

"Unfortunately, there is no regulatory framework for telehealth," says Jalil Allabadi, founder of Altibbi, a Jordan-based digital health provider. "The only part of the Arab world that has a law regulating telehealth is in Abu Dhabi, and it is completely inadequate in its restrictiveness, not making it easy for any company to access the market. In other places, such as Dubai, the regulations are in the making and we only hope they don't follow Abu Dhabi's example, but be more flexible, for restrictiveness kills innovation and hinders new ideas."

The idea for Altibbi, which was launched in Amman in 2011, evolved from Allabadi's intention to make an extensive Arabic-language medical dictionary written by his father, general surgeon Dr. Abdul Aziz Allabadi, available online for all Arabic speakers around the world. The company today provides 1.5 million pages of comprehensive medical content in Arabic, in addition to a database of 12,000 registered doctors available for online consultations 24/7.

Altibbi's 28-strong team covers 10 Arab countries from their offices in Amman, Dubai and Gaza, with a plan to open an office in Cairo and Riyadh in the near future. "In the rest of the Arab world, we operate in a grey area yet, but we are confident that with our policies and procedures, which follow the example of American laws, we are well placed to adhere to any forwardlooking regulations," Allabadi adds. "We operate in a very critical industry touching human lives directly, yet in the US and the UK, there have been examples of laws that encourage new models of delivering healthcare to more people and this is what we would need our governments to focus on."

Despite operating in an ambiguous and restrictive regulatory framework across the region, Altibbi now boasts 350,000 unique visitors per day, of which 50,000 are subscribers to their premium service "Call A Doctor," which allows patients to make an unlimited number of calls to doctors per month, with the doctors' average response rate being 40 seconds. This growth has been fueled by the capital injections from the founder's family and friends and three external funding rounds, as well as advertising revenue. As with many other entrepreneurs trying to solve problems in their own local communities, raising funds has been one of Allabadi's biggest challenges.

"First of all, health tech is new everywhere, so there are not many past experiences to learn from which increases the risk for health tech startups," he says. "Secondly, not many investors understand this field unlike e-commerce, for example, where VCs understand the drivers for success. Thirdly, it is again the regulatory environment, which is not yet clear, and increases the risk for anyone who wants to invest in this industry. On the other hand, one should not ignore the opportunities for health tech in our region, which is in dire need for better quality and better delivery of healthcare."

But one country in the region is trying to turn this situation around- and that is the UAE, with the 46-year-old nation attempting to leapfrog much more mature healthcare systems. The country's singular focus on marching forward has included the 2014 launch of the UAE National Agenda outlining, among other targets, a specific blueprint to provide world-class healthcare by 2021 to coincide with the UAE's 50th National Day; last year's fast-paced implementation of the Dubai 10X initiative, urging the Government of Dubai to embrace disruptive innovation for the city to become 10 years ahead of all other cities; as well as this year's announcement of the UAE Centennial 2071 plan, aimed at sustaining the country's development into its 100th anniversary.

Alongside all of that, the country's drive towards innovation has gained immense momentum with last year's establishment of the Dubai Future Accelerators (DFA) program, a government-supported accelerator that pairs public and private entities with entrepreneurs in order to jointly build, test, and deploy futuristic innovations. Its first cycle saw the participation of 30 companies trying to solve global challenges set by seven government entities, which resulted in the signing of 19 memorandums of understanding (MoUs). The second cohort resulted in 28 MoUs being signed between some of the 12 public and private entities and 35 companies participating. The DHA has taken part in the DFA program from the outset.

Since enrolling in the accelerator's first cohort, Sam Amory, founder of Alpha Systems Group, a Dubai-based startup specializing in telehealth solutions, has worked with the DHA to develop an autonomous digital mobile booth which replicates a medical doctor's clinic, allowing physicians to perform live consultations. Despite working on a governmentbacked idea, Amory also cites inadequate regulations as the main impediment. "First and foremost, it's the law, that's the main issue," he says. "In general, there is no law around telemedicine yet, it is still being developed. Today, traditional medicine states that you must see a doctor first and have a face-to-face consultation where a physician must be able to touch you.

The law today still states that your first consultation, not every consultation but the first one, must be with a doctor. Our booth has been designed in a way that there is the same length between you and the video screen as you have from a doctor sitting in front of you. We have made so much accuracy around it that it feels like you are sitting right next to the doctor. That law is what we are trying to change today." Amory's aim of creating a concept of a digitally connected health city in the UAE by establishing a broad network of those consult stations to satisfy the healthcare needs of the country's population is not far-fetched.

At the time of the interview, Alpha Systems Group's smart mobile booths were stationed in a number of government entities. "They just need to add the next phase [in the law]," he adds. "The way to do that is to have a project, and we are that project. We are crossing a new boundary and saying that this is actually a physical general practitioner's practice in a box because everything inside this clinic is the same as you would regularly have. Everything is so similar, but it's digital. So, we will help facilitate the alterations of the law. We are going to be that proof of concept for them to say, "This is why this works, and why we should do it.'"

The consulting stations can be installed at multiple different locations, allowing all stakeholders involved to benefit from the shift to digital. "The public sector absolutely loves it, because they have 85% of people going into Accident and Emergency, and leaving the same day, which means that it is unnecessary for them to go to there in the first place," Amory says. "That's a massive waste, and it's taking away from the doctors who should be allowed to spend more time doing the things that they should focus on. The private sector loves it because if they have one hospital and ten of those consult stations, all of a sudden, they actually have 10 hospitals. So, they are reaching their breadth- anybody walking into that station becomes their patient. The insurance companies like it even more because they are saying, "I am getting charged AED1,000 every time someone goes to Accident and Emergency, if I could reduce those by 50%, I would be saving so much money.' Lastly, a lot of patients don't want to go to hospital because they are afraid of catching something even worse. They want to go downstairs in their building, see the doctor, print out the prescription, go to the pharmacy, and it's done."

Farther afield, Morocco-based Zineb Drissi Kaitouni, co-founder of DabaDoc, a doctor-to-patient online platform, also had to build rapport with concerned stakeholders, but to reach a different target- to encourage a sustainable behavioral change in the market. Since its inception in 2014, the homegrown telehealth startup has enabled more than 3.5 million patients to connect with more than 4,000 doctors in 90 different specialties across 40 cities in three markets: Morocco, Tunisia, and Algeria.

"Our biggest challenge was to change mindsets because we came with a new technology that required them to change old habits," Kaitouni says. "Doctors were used to receiving phone calls from patients and having their assistants scribble the patient's name on notepads, and so on, and then we had to explain to them how technology was going to change all of that and actually help them better manage their appointments. Also, we had to educate both doctors and patients to respect the time of the appointments.

Getting to the doctor's office sometimes means that you have to wait for an hour or two, depending on the number of patients and the doctor you are visiting. With our online booking system, however, each doctor can set up their own agenda. It helps them reduce the no-show, or the patients being late through all the reminders that we send to them. So, it included explaining to both doctors and patients that they had to be punctual. Also, the tool enables patients to book appointments 24/7 versus calling during the office hours only, allowing them to see the availability of doctors in real time and in all transparency. So, we transformed the way people book appointments and streamlined the patient-doctor relationship."

For some entrepreneurs, however, a lack of more intimate knowledge of an emerging market proved too big an obstacle or required them to adopt new approaches. Two examples come from the UAE. Part of the DFA's agenda is to look outward for big tech ideas. The concept includes sponsoring air tickets, accommodation, and office space for the selected international teams to enable them to work on their projects in Dubai. Yet, Stephane Richard and Blaise Barrelet of Cure Match, a San Diego-based digital health company that helps oncologists to select appropriate therapies, who took part in the accelerator's first cohort, didn't find the local conditions ripe for their business ideas to spring into life.

"We started talking to people in the medical sector to see whether they were routinely using these kind of information, and it seemed it was something very novel for them," Barrelet recalls. "They were kind of familiar with it but not necessarily incorporating it in their standards of care. That was making it difficult for us to analyze the data because there was no data. If we were to do it again, or set up a collaboration in the UAE, the important part would be to find partners on the ground that would be able to help us, meaning that previously we were limited to only collaborate with the DHA, whereas there were some private clinics which might be more advanced in their use of genomics. Had we been helped to cooperate with them, we would have started working with a private clinic and then extended our experience to the public sector. We ended up not being able to set up this relationship. It was a fantastic experience to go to Dubai, but it basically helped us focus on our priorities."

Nathan Ramasarma, co-founder and CEO of ArcSecond, took a different approach. ArcSecond, his San Diego-based digital healthcare startup piloting the use of wireless, wearable motion sensors in physical therapy and rehabilitation participated in the DFA's second cohort and became one the three startups awarded an MoU by the DHA at the end of the program. The most important decision that I made was that since we knew our backyard, the US, very well, we should see what would happen if we went to a completely new place, what the reception of our technology would be from both the government side and the private sector side," Ramasarma says. "We went with a completely open mind and absolutely no expectations, but I did my homework by speaking with several startups from the first cohort and I got an idea on what they did and didn't learn. More importantly, my approach was that when given an opportunity, I was to make the best use of it, as opposed to taking something back from it, I would give it all that I had. Also, I thought this would be a good opportunity for the team to work in a place they hadn't been to before."

And the challenges were instant, says Ramasarma. "Dubai is a completely different market when it comes to how customers perceive new technologies," he explains. "We had to learn firsthand how to communicate the value of the technology really clearly. The US is a market that understands technology, but when we started working with the DHA and several of their hospitals, we had to communicate the value of our technology in terms of the language that they understood, which means focusing on their pain points first. Also, we had to work with the government, which works in its own way, but we were open about it, we often worked with them in their own settings to understand their pain points. We understood that in the region personal face time is very important, so we started doing that. In the US or in Europe, emails and phone calls are fine, but in the Middle East you have to establish that personal relationship. Since I grew up in India, I was exposed to that early on, but the rest of the team didn't understand that. For me, letting them be exposed to that was very important because we live in a global market today and we cannot just say that our solution doesn't work somewhere else. If it's valuable, it has to work everywhere. So, the value of the product has to be communicated in person in the Middle East for people to understand it. Thus, it was more of a learning experience than a challenge."

Another inevitable part of the future of healthcare are AI and robotics. A recent report by PwC, What Doctor? Why AI And Robotics Will Define New Health, revealed that when questioned about receiving care from a nonhuman healthcare provider, the willingness of MENA consumers outpaced their Western counterparts. About 44% of respondents in the UAE and 45% in Saudi Arabia would undergo a major surgery performed by a robot, which is significantly higher than 27% in the UK. In the UAE, customized robotic solutions have been introduced in a number of sectors, from the country's first Robocop joining Dubai Police last May, to developing the world's first humanoid robot customs inspector, or exploring robotic applications in the education sector.

However, Hamish Clark, Partner at PwC's ME Health Industries, says that the capabilities and insights from AI and robotics still need to come more firmly into the region's healthcare regulatory system in order to allow it to be ahead of disruption- not behind it. "The existing legal framework tends to focus on what we call old health, which means that it is very focused on hospital-based systems," he says. "There could be more pace to this disruption in the UAE, because if you drive along Sheikh Zayed Road, you will see many advertisements for what I call old health. There are not many references to anything that does not include coming to hospitals. I think that the implementation challenge is a mindset one, because where there is a will, there is a way. There are many hospitals being built at the moment, but healthcare is a knowledge-based business. The implementation now is about getting clinicians and leaders to think in a very different way about it, and then the regulation will catch up."

With local entrepreneurs solving problems of their own, smaller communities across the MENA region, and with the increasing flows of know-how towards the region, particularly to the UAE, the big question now is whether the region will be just a transit point or it has the ability to influence and shape the future of the whole healthcare industry. "We think that the UAE could become a world class center of excellence for AI and robotics," says Clark.

"All the conditions are here, you have an innovative economy, forward-thinking leadership, a digitally-savvy population, as well as the opportunities such as Expo 2020 coming up, to make the UAE really leapfrog the West. More established health systems, like Germany or the UK, are not that willing to embrace these new technologies [AI and robotics], there is a far more vested interest in what I call the old health system of bricks and mortar hospitals. The health systems here are not as mature because they haven't been around for long as in other parts of the world, and they are more open-minded to having care through AI and robotics."

Hamish Clark, Partner at ME Health Industries, PwC
Source: PwC

Ramasarma believes that Dubai and the whole Middle East have a geographical advantage in exposing locally-based entrepreneurs to 1 billion people within just a four to six-hour reach. However, he says, the region's main strength is its talent pool. "I was introduced to excellent gaming companies based in Jordan, Lebanon and Syria," he explains. "All these countries have rich talent, but the problem is that they cannot enter the US or European market for political reasons. The GCC can solve that problem by becoming a hub where it can consolidate talent from parts of Asia, parts of Europe, parts of the Middle East, and become that hosting solution of technology." In addition, Ramasarma opines that the region should expand its currently limited knowledge base. "People come to the Middle East, do business, and then they disappear," he says. "I think that the Middle East should invest research money, not just commercial money, so that the technologies can stay in the region. For example, companies like us come to the Middle East, we see a huge market, we become successful, but what is the incentive for us to develop that technology further in that region? I would love to establish a research center in Dubai and get talent from Jordan or other countries, which, as a US company, I cannot do otherwise. So, the government and other entities in Dubai need to support a knowledge-based economy, not a commercial-based economy, which is happening today. If this is taken into account, the MENA region can become a larger knowledge hub or a technology player. The government is on the right path, but accelerators are just one part of it. There are many things that need to be done."

So, how long will it take? According to Amory, introducing change is more feasible in this region, especially in the UAE, than in other parts of the world. "There is a reason why I started here [UAE]," he says. "There is a very quick path to getting things done. If I was to do that in the UK, it might take me 10 years. Here you have enthusiastic people who love innovation, they want to be the first, they want to do things that nobody else has done before. They want to be ahead of the curve, they want to be riding the wave. Other places have the ambition, but they don't have that drive." This kind of thinking often does not come easily to regulators and decision-makers across the MENA region, but in the UAE, government officials obviously do not lack the spark that is often so prevalent in entrepreneurs. Therefore, the country seems set to change the region's healthcare equation- it seems to be only a matter of time.

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