1. Perspective Ramez Shehadi
Ali Hashemi
Walid Tohme
Jad Bitar
Getting a Handle on
Chronic Disease
Health Management
Services in the GCC
Region

2. Contact Information
Beirut
Ramez Shehadi
Partner
+961-1-985-655
ramez.shehadi@booz.com
Walid Tohme
Principal
+961-1-985-655
walid.tohme@booz.com
Jad Bitar
Senior Associate
+961-1-985-655
jad.bitar@booz.com
Dubai
Ali Hashemi
Principal
+971-4-390-0260
ali.hashemi@booz.com
Booz & Company

3. EXECUTIVE The growing prevalence of chronic diseases in Gulf
Cooperation Council (GCC)1 nations has socioeconomic
SUMMARY
implications that are quickly adding up. Chronic diseases
generate higher healthcare costs, which are borne by govern-
ments, insurers, and patients. They also lower productivity
among workers, clog healthcare service channels, and bring
about declines in a population’s health status. As GCC nations
continue to invest in their healthcare systems, the region’s
leaders should take their cue from certain developed nations in
adopting health management services (HMS) to help address
the specter of a chronic disease epidemic.
HMS programs address critical gaps practices—including effective use of
in the care of chronically ill patients incentives, physician involvement, and
by helping them understand the personalization—can help HMS pro-
implications of their disease and grams achieve their goals. But before
underlying lifestyle factors, amend GCC governments and healthcare
their harmful behavior, adhere to organizations can implement HMS
treatment regimens, and navigate the programs, they will need to answer
healthcare system. HMS programs strategic questions about the segments
have been proven to be successful at of society that should be targeted, the
improving individuals’ health and programs that will be most relevant,
generating significant savings for the incentives that would encourage
healthcare payors when all stakehold- involvement, the funding mechanism
ers—patients, physicians, hospitals, that will support HMS, the objec-
insurers, and government—buy into tives of the program, and the roles of
their development. A number of best public and private entities.
Booz & Company 1

4. KEY HIGHLIGHTS
• HMS programs are a key tool in
the effort to halt the rise of chronic
diseases in GCC countries and
keep healthcare costs in check.
• Numerous studies have
demonstrated the benefits of
HMS on individuals’ health
and on overall healthcare cost
management.
• HMS programs blend wellness
services that provide healthy
individuals with information and
encouragement to better manage
their health risks with disease
management that increases
chronically ill patients’ compliance
THE RUNAWAY hidden costs on society, such as lower
worker productivity. Recent research
with prescribed treatments. COSTS OF shows that on-the-job productivity
• Effective HMS programs are CHRONIC losses account for up to 60 percent2 of
the total healthcare costs associated
characterized by three common
themes: incentives to ensure
DISEASES with chronic diseases.
patient participation, strategies to
To counter these trends, care provid-
involve physicians as key program
ers in North America are increasingly
facilitators, and communications
turning to health management services
and incentives that are tailored to
(HMS). These services primarily work
individual preferences. Around the world, unhealthy lifestyles
in two ways: They help mitigate the
and aging populations are leading to a
spread of chronic diseases by estab-
higher prevalence of chronic disease,
lishing wellness programs and other
thus driving up healthcare costs and
preventive strategies, and they reduce
keeping economies from perform-
the costs of treating chronic diseases
ing at their true potential. Chronic
once they are diagnosed through
diseases strain healthcare providers
ongoing monitoring and frequent
and the overall healthcare system
interaction with patients.
with patients’ frequent and costly
trips to the emergency room (ER)
HMS will be a critical element of
and longer average stays. Long and
GCC countries’ overall healthcare
resource-intensive treatment periods
strategies in the future, as chronic
make patients with chronic disease
diseases exact a toll in terms of costs,
heavy users of healthcare services,
strain on providers, and healthcare
leading them to consume a dispropor-
status: In the coming years, chronic
tionate amount of the total available
diseases are expected to account for
services. This has a severe impact on
a significant portion of healthcare
the distribution of those services and
expenses. As governments, healthcare
clogs providers’ ER and other delivery
organizations, and private insurers in
channels.
the region look to develop a compre-
hensive health management strategy
Chronic diseases not only negatively
that addresses this mounting problem,
affect a population’s general health
HMS programs are a key tool.
status, but they also levy serious
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5. A PRESSING The rapid economic expansion of the
GCC region has brought its member
an increasing prevalence of chronic
diseases among their citizenry.
PROBLEM FOR nations the benefits of advanced
GCC NATIONS “developed” countries—higher stan-
dards of living, lower unemployment,
In the typical GCC country today,
chronic diseases are a leading cause
and increased purchasing power. of mortality; in 2007, the region was
But along with such advantages also home to four of the top five nations
come new and pressing challenges, in the world for diabetes cases among
particularly in the realm of health- adults (see Exhibit 1). Based on data
care. In recent years, GCC nations available from several GCC geog-
effectively combated typical “third raphies, chronic diseases currently
world” health challenges such as account for approximately 35 percent
tuberculosis and malaria. However, or more of the deaths in those
due to the rapid growth and develop- regions—fast approaching levels in
ment of the region and the resultant developed countries such as the U.S.,
change in lifestyles, GCC leaders where chronic diseases account for an
are now turning their attention to estimated 70 percent of mortalities.
Exhibit 1
Prevalence of Chronic Diseases in the GCC Region
LEADING CAUSES OF DEATH IN ABU DHABI
2007
23%
Accidents/Injury
32%
Cardiovascular
Cancer
Diabetes
18% Congenital
6% Other
7%
14%
PERCENTAGE OF ADULT POPULATION WITH DIABETES BY RANKING
2007
30.7%
19.5%
16.7%
15.2% 14.4%
13.1%
11.0%
7.8%
Nauru UAE Saudi Bahrain Kuwait Oman Egypt USA
Arabia
Source: HAAD statistics; World Health Organization
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6. Lifestyle factors in the GCC region Because many of these factors are not ditures than governments in other
have contributed mightily to this addressed before they mature into parts of the world. Public spending
scourge, setting the stage for the chronic diseases, GCC governments on healthcare averaged 74 percent
creation of a chronic disease epi- are being forced to dedicate more of in GCC countries in 2006, nearly 20
demic. Increasing affluence in GCC their budgets to treat a growing wave percentage points higher than the
countries has caused a once highly of patients. In the UAE, where one in global average of 57 percent4 (see
active population to become largely every five adults is afflicted with dia- Exhibit 2). But the issue also looms
sedentary, resulting in reduced levels betes, treatment of that illness alone large for the private insurance compa-
of physical activity, increased smoking takes up approximately 40 percent of nies that are entering GCC markets,
rates, and other unhealthy lifestyle the nation’s overall healthcare expen- which need to keep their costs down
changes. These changes are triggering ditures.3 The burden posed by chronic to remain competitive.
heightened obesity rates and inci- diseases weighs more heavily on GCC
dences of hypertension, key factors governments because they shoulder
that contribute to chronic disease. a greater share of healthcare expen-
Exhibit 2
GCC Governments Contribute Significantly More to Healthcare Costs Than the Global Average
SHARE OF PUBLIC EXPENDITURE IN HEALTHCARE
2006
90%
Public Expenditure as a % of Total Healthcare Expenditure
80%
GCC Average = 74%
70% Top 30 HDI* Average = 71%
60%
World Average* = 57%
50%
40%
30%
United Japan Sweden France Germany Canada Australia Switzerland Republic United China Oman Kuwait Saudi Qatar United Bahrain
Kingdom of Korea States of Arabia Arab
America Emirates
*HDI = Human Development Index; World Average is based on 177 countries; Top 30 excludes Hong Kong, for which figures were not available.
Source: WHO Statistical Information System, 2006 data
4 Booz & Company

7. ADDRESSING Needless to say, the rising socioeco-
nomic costs of chronic diseases have
Typically, chronically ill patients need
assistance in four major elements of
GAPS IN PATIENT caught the attention of GCC govern- their disease management: under-
CARE ments. Some have set up government
bodies and programs to develop
standing the implications of their dis-
ease, such as treatment options, risk
preventative healthcare strategies and factors, and potential complications;
address the low level of health aware- navigating the healthcare system
ness in the region. In many cases and communicating with the various
involving chronic diseases, consumers care providers, especially for patients
have little knowledge about preven- with multiple chronic diseases who
tion and management of their condi- must make multiple visits; gathering
tions. For instance, a study about information about the various actions
osteoporosis among educated women they need to undertake, including
in the UAE found that 44 percent self-care, dietary changes, and exer-
of women with at least a secondary cise; and complying with their care
school education had minimal or zero regimen, such as planning multiple
knowledge of the disease.5 provider visits and taking prescribed
medicines.6
To date, however, such government
programs have not been able to Currently, though, such needs are
fully address the escalating needs of filled only during formal physician
the GCC region’s large and grow- visits or informally by other sources
ing population of chronic disease such as family and friends. These
sufferers. Post-diagnosis, chronic interactions only partially address a
disease patients have a broad array of chronically ill patient’s continuous
clinical and non-clinical needs associ- need for care advice, monitoring, and
ated with managing their condition. compliance. As such, critical gaps in
Diabetics, for example, need to care provision exist before, between,
continually manage their disease, on and after provider visits, particularly
top of identifying and changing the when it comes to identifying high-risk
lifestyle factors that caused it. Their behavior, adhering to a treatment
responsibilities include measuring regimen, patient monitoring, and
blood glucose levels, taking insulin other elements of care coordination.
shots, and getting regular screenings
and tests.
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8. FACTS AND FIGURES
THE CASE FOR
• Obesity: GCC nations are home to some of the highest obesity rates in the
world. Thirty percent or more of the adult populations in Saudi Arabia, the
HMS
UAE, Kuwait, and Bahrain have a body mass index (BMI) of 30 or more,
the clinical definition of obese. In Abu Dhabi, the average BMI is 29 among
adults.i
• Smoking: GCC countries have a relatively moderate number of smokers—36 To close these gaps and improve
percent versus a global average of 33 percent. But on a per capita basis, the overall care of chronically
their annual intake of cigarettes is much higher, fueled by higher consumption ill patients, healthcare leaders in
among young males. For example, the average Kuwaiti smoker consumes some developed economies are
more than 2,500 cigarettes a year, compared with a worldwide average of employing HMS, which bundle a
900. prescribed set of healthcare services
into condition-specific programs
• Physical Inactivity: At least 40 percent of the GCC population fails to achieve
that are based on scientific evidence
the minimum daily recommendation of 30 minutes of moderate-intensity
and data analysis. The healthcare
physical activity. This rate is more than double the global estimate of 17
services address the patients’ needs
percent.ii
identified above: risk identification,
• Hypertension: Modernization has been directly linked to higher stress levels awareness and education, adherence
in GCC nations. Roughly 34 percentiii of the adult population in Abu Dhabi to treatment regimen, monitoring
has high blood pressure, compared with just 18 percent in the U.S. Statistics health indicators, and care
also reveal a high correlation between hypertension and the occurrence of coordination. The HMS program
diabetes. encourages individual members to
improve their health by creating
a support system that helps them
manage their condition, increasing
their awareness, providing critical
guidance, and employing incentives
to encourage healthy behavior. HMS
also strengthen relationships between
hospitals and their patients and
physicians, by creating a continuous,
longitudinal view of patient care that
competitors cannot match.
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9. As an example, diabetics enrolled in Coaching and intervention-related such savings are often difficult to
an HMS program designed to help services are at the core of HMS quantify, numerous studies have
manage their condition can expect the programs and they are typically demonstrated the benefits of HMS
following services: conducted by a call center staffed on individuals’ health, as well as on
by nurses. The call centers contact overall healthcare costs. For instance,
• Comprehensive diabetes plan patients to provide them with vari- a study published in Health Affairs
including diet, medication, exercise, ous services based on the program in 2004 showed an 8.1 percent drop
and screening in which the patient is enrolled in hospitalization costs of diabetes
(e.g., information on care regimen, patients after they were enrolled in
• Diabetes articles and the latest reminders for screening, coordinat- an HMS program to help manage
research on diabetes ing physician visits). Through these their treatment.7 A separate finding
coaching and intervention services, published in 2005 in the European
• Coordination with provider HMS provide consumers with the Journal of Public Health found that
information and guidance required HMS smoking cessation programs
• Remote consultation and setting of while coordinating care in order to resulted in a 15 percent to 35 percent
appointments help consumers manage their health quit rate, saving employers (here
and directly address the gaps in care collectively referred to as payors) an
• Diabetic community tools provision. average of US$11,880 per smoker
over their lifetimes.8
• Glycemic index counter and low By supporting individuals in main-
glycemic food guide taining their health and helping
chronic patients with their condi-
• Medication and screening test tions, HMS programs have a direct
alerts impact on healthcare costs. Although
By supporting individuals in
maintaining their health and helping
chronic patients with their conditions,
HMS programs have a direct impact
on healthcare costs.
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10. Such success stories have led health HEALTH MANAGEMENT GOES ONLINE
insurance companies and payors to
HMS providers are increasingly leveraging technology to conduct data analytics,
increasingly adopt these services as
integrate remote monitoring devices, and leverage alternative access channels.
a way of controlling their soaring
Still, it wasn’t until recently that HMS began migrating to Internet-based
healthcare costs. The HMS industry
platforms. Traditionally, health management programs were delivered solely
has been growing significantly in
through a nurse or a coach—an expensive medium for parlaying services. In the
early adopter markets such as the
interest of reducing costs, providers have begun effectively incorporating Web-
U.S., where it has enjoyed a com-
based programs in conjunction with coaches and nurse-staffed call centers.
pound annual growth rate of more
Another advantage to online HMS is it provides more leeway to personalize
than 25 percent over the past decade
program elements, which evidence shows increases patients’ participation in
and now enjoys a penetration rate
and compliance with HMS programs.
of 5 percent to 10 percent of total
insured lives.9 In recent years, pilot Citing these advantages, leading HMS providers are making acquisitions
HMS programs have begun to crop and other key investments to incorporate Internet-based models as a key
up in Latin America, Europe, and vehicle for delivering HMS programs. In fact, certain leading-edge providers
Asia. Payors especially have found have introduced programs that are delivered exclusively over the Internet.
these programs to be beneficial, due Leading HMS companies, including Healthways Inc. and Matria Healthcare,
to their positive impact on employee have made notable forays into online program delivery. Healthways has made
productivity and satisfaction. significant, targeted investments in this area, mainly focused on building an
Additionally, HMS programs are one internal technology team that could help it deliver an online platform for its
of the few options available to payors programs, while Matria, now part of Alere Medical, acquired online HMS provider
that believe that prevention needs to WinningHabits.com. Conversely, leading healthcare portals such as WebMD and
be a key element of their healthcare Revolution Health have purchased companies to add HMS programs to their
cost containment strategy. A recent already popular Web services.
evolution in the HMS delivery model
has been the integration of Internet-
based platforms, while face-to-face
coaching continues to be used to
deliver interventions (see “Health
Management Goes Online”).
HMS programs are one of the few
options available to payors that
believe that prevention needs to be a
key element of their cost-containment
strategy.
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11. KEY screenings and immunizations (e.g.,
flu shots), and share information to
Both types of HMS program are
typically designed around four major
COMPONENTS OF foster self-care practices. Follow-up components:
HMS PROGRAMS support is provided by on-site,
telephone-based, or online coaching • Adoption focuses on understand-
assistance through condition-specific ing members’ or employees’ needs,
programs such as weight manage- evaluating patients’ risk profiles
ment, smoking cessation, and stress through health-risk appraisals,
management. selecting the appropriate program
HMS programs are broadly classified and pricing strategy, and encourag-
as either wellness programs or disease Disease-management programs offer a ing adoption through marketing
management programs. Whereas prospective, disease-specific approach efforts and enrollment incentives.
the latter deals with patients already to coordinating the care of high-
afflicted with chronic diseases, the cost and high-risk populations with • Program delivery centers on core
former aims to reduce risk fac- chronic conditions, including dia- intervention elements that are
tors that cause the onset of chronic betes, asthma, and congestive heart designed to help the consumer
diseases in the first place through the failure. They typically involve a coor- manage his or her condition and
pursuit of mental and physical well- dinated set of healthcare interven- reduce risk factors through a per-
being. tions and communications designed sonalized delivery strategy.
to support the patient–physician
Typical wellness programs provide relationship by ensuring the patient’s • Monitoring sets clear performance
healthy individuals with information, compliance with the prescribed metrics, measures against them,
support, guidance, and encourage- care plan. These programs focus and verifies desired outcomes.
ment to better manage their lifestyle- on keeping conditions from being
related health risks. First, health-risk exacerbated, through co-morbidities • Improvement involves modifying
assessments help assign consumers to or other complications, by using the program elements to enhance
various risk groups. Then providers evidence-based practice guidelines the effectiveness of the program.
institute preventive measures such as and strategies to empower patients.
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12. PUTTING HMS To be sure, health management is
not an exact science, given that the
awareness of health issues in GCC
countries, there is greater reliance
INTO PRACTICE success of these programs depends on physicians by patients, making
to a large extent on their ability to physician involvement all the more
change behavior. The HMS industry critical. HMS programs in the region
is constantly innovating to develop will need to engage relevant physi-
new techniques to improve programs’ cian groups to obtain their buy-in
ability to ensure compliance, reduce and ensure their participation and
risk factors, and carry out preventive involvement.
screenings and thus deliver on their
promised benefits. There are three key Personalization: Tailoring com-
ingredients in successfully deployed munications and incentives to the
HMS programs, all of which can be individual’s tastes and preferences is
leveraged in GCC markets: a new and evolving trend credited
with increasing patient compliance
Incentives: Well-designed HMS with HMS programs. Participants
programs provide consumers with a receive personalized letters, educa-
variety of incentives to ensure partici- tional brochures, and booklets to
pation, such as reduced premiums, increase awareness. Incentives and
cash incentives, and redeemable other aspects of the plan’s design are
reward points akin to points given customized to adjust to the individual
by various reward programs. HMS participant’s ability to change. HMS
programs are also using negative providers are building large databases
incentives such as higher premiums of consumer information to document
or co-pays for non-participants. the success of interventions, incen-
Increasingly, programs are adopt- tives, and communications, and to
ing a combination of both—negative leverage these large data warehouses
incentives to ensure enrollment and to personalize their interactions with
positive incentives to effect behavioral other members.
change.
The ways in which these building
Physician Involvement: Coordinating blocks are used will be determined
program interventions and other by healthcare payors’ overall HMS
elements with the patient’s physi- strategy, which will require analysis,
cian is another critical facilitator in judgment, detailed design, and pilot-
assuring program efficacy. In a case ing of alternative concepts, as well
where drug adherence is identified as allocation of significant resources
as a problem, for instance, involving for implementation. Payors will also
the physician isn’t just about relat- likely require the involvement of lead-
ing critical information; it creates an ing disease management and wellness
opportunity for the physician to inter- companies from mature HMS mar-
vene and reinforce the importance of kets—primarily the U.S.—to ensure
sticking to the drug regimen. Given that the plan imperatives highlighted
the low level of health literacy and above are incorporated.
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13. CONCLUSION To help jump-start the process and
lay a sound foundation for successful
• What would be the financial and
health status objectives of HMS
implementation, GCC governments programs? Should GCC govern-
and healthcare organizations must ments support these programs if
assess their current overall healthcare the financial return on investment
strategy to address a number of stra- is not clear but there is a positive
tegic questions: impact on the health status of the
population? What will be the role
• How should HMS programs be of healthcare providers and health
integrated into their current health- insurance companies?
care strategic framework?
• Through which entity will the
• Which segments of the population programs be offered? Will it be a
will be targeted? How will the pro- public–private partnership between
gram design be modified to address a GCC government and an interna-
the cultural characteristics of the tional disease management/wellness
population? company, or will it be an entirely
private undertaking?
• Which HMS programs would
be most relevant for GCC • What policy initiatives will be
populations? required to support HMS rollout?
• What incentives will be required to • How will GCC governments ensure
ensure significant program adop- that other healthcare stakeholders,
tion among targeted segments? primarily providers, support the
rollout of the HMS programs?
• How will health management ser-
vices be funded? How will the costs • What will be the role of e-health in
(and risks) be distributed among delivering HMS to the population?
the various stakeholders?
Booz & Company 11

14. • How will the execution of HMS productivity, and immense strain on ing significant investments in their
programs be managed across the healthcare system. healthcare systems. Indeed, rapid
various governmental authorities? implementation of such programs is
What are the critical factors for the Well-crafted HMS programs are a within grasp for smaller markets in
successful execution and rollout of valuable tool that can help GCC the region.
HMS programs? nations stem the rising tide of chronic
diseases by helping to identify As GCC nations prime for a robust
Chronic disease management is unhealthy and risky behaviors, raise economic recovery, their leaders will
an issue that GCC nations can ill awareness of underlying lifestyle fac- need to put a premium on “smart
afford to ignore. Countries that fail tors, improve adherence to treatment growth” strategies. When it comes
to address this pressing concern run regimens, and strengthen the bonds to managing the population’s most
a real risk of being engulfed in a between patients and physicians. serious and costly illnesses, there is
chronic disease epidemic, resulting Now is an opportune time for GCC no smarter healthcare strategy than
in reduced health status, crippling nations to adopt HMS programs as HMS.
healthcare costs, lower workforce most GCC nations are undertak-
12 Booz & Company

15. Endnotes
1
The Gulf Cooperation Council consists of Bahrain, Kuwait, 7
Victor G. Villagra and Tamim Ahmed, “Effectiveness of a Disease
Oman, Qatar, Saudi Arabia, and the United Arab Emirates. Management Program for Patients with Diabetes,” Health Affairs,
vol. 23, no. 4, 2004, 255–266.
2
WHO Mortality Fact Sheet for Saudi Arabia (2006) and Qatar
Ministry of Health statistics. 8
Susanne R. Rasmussen, Eva Prescott, Thorkild I. A. Sørensen,
and Jes Søgaard, “The Total Lifetime Health Cost Savings of
3
“Treatment of Diabetes a Big Drain on National Healthcare Bud-
Smoking Cessation to Society,” European Journal of Public
get,” Gulf News, November 11, 2007.
Health, vol. 15, no. 6, December 2005.
4
WHO Statistical Information System, 2006 data. 9
Booz & Company estimates.
5
Haider M. Al Attia, Amal A. Abu Merhi, and Maha M. Al Farhan, i
Health Authority–Abu Dhabi (HAAD) statistics.
“How Much Do the Arab Females Know about Osteoporosis? The
Scope and the Sources of Knowledge,” Clinical Rheumatology, World Health Organization and Oxford Health Alliance; the rates
ii
vol. 27, no. 9, September 2008, 1167–1170. for physical inactivity in UAE were for the top and bottom quintiles
of income class.
6
A presumably simple element of the compliance regimen,
adherence to prescribed drug regimen, suffers from a large iii
HAAD statistics.
noncompliance rate.
About the Authors
Ramez Shehadi is a partner Walid Tohme is a principal with
with Booz & Company in Booz & Company in Beirut and
Beirut. He leads the informa- a leader in the information tech-
tion technology practice in the nology practice with a focus on
Middle East. He specializes in healthcare. He specializes in
e-government, e-business, and the management and strategic
technology-enabled transfor- use of technology to enable the
mation, helping both private transformation of healthcare
corporations and govern- organizations, services, and
ment organizations leverage infrastructure.
technology, achieve operational
efficiencies, and improve Jad Bitar is a senior associate
governance. with Booz & Company in Beirut
and a leader in the informa-
Ali Hashemi is a principal with tion technology practice with
Booz & Company in Dubai a focus on healthcare. He
and a leader in the healthcare specializes in healthcare and
practice in the Middle East. business technology, par-
He specializes in business ticularly strategy, organization,
strategy for players throughout operations, and innovation.
the healthcare value chain, as
well as advising government
entities on defining their overall
healthcare agendas.
Booz & Company 13

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