Healthcare System in the United

¶ … healthcare system in the United Arab Emirates (UAE) has developed alongside the economy in general, as one of the most important indicators of modernization and development in that nation (Shihab, 2001; and Al Sadik, 2001). Both the economic development and the attendant development of healthcare have occurred rapidly, fueled by the exploitation of oil reserves. This has generally led to improvements in the nation's collective standard of living. However, these developments have not always been without complications. For example, because the nation has been able to skip many traditional stages of economic and industrial development and implement a fully modernized industrial-technological society in matter of a generation, it has often had to deal with difficulties associated with having the trappings of modern economic development but still having a significant part of the population that operates from traditional beliefs. When modernity and tradition clash, the ready acceptance of some technological advancements and healthful innovations has met with resistance. In order to address such resistance, research is required to determine how products and services can be made more acceptable to the various publics which consume them.

This study considered the linkage between two prominent theoretical models for academic development of marketing systems -- diffusion of innovation and communities of practice -- to the extent that these two models provide a tool for usage in analyzing and further developing the system of healthcare provision in the UAE. Through an analysis of the theoretical underpinnings of these two models and an application of the theories to the practices involved in current administration of the healthcare system in the UAE, the study develops an integrated marketing program for improving and extending healthcare to all persons in the UAE.

Research Background

Kronfell (1999), among others, argues that many of the tools for a successful healthcare system are in place in the UAE already, but that "macroeconomic" factors such as lack of professionalism and financing are at play which hamper the acceptance of the programmed options by the public. While focusing on the improvement of structural problems may improve public acceptance of the healthcare system, it is believed here that the key factors driving the reluctance to adopt new healthcare programs among the UAE public are attitudinal and practical. The research begins, therefore, from a point which holds that basic economic and cultural attitudes have a great impact on the public's acceptance of healthcare programming. Several studies were identified which supported this contention. For example Khayata (2003) found that among infertile women seeking healthcare in the UAE, their sociocultural attitudes were among the most important determinants of the degree to which they participated in treatment programs. Wuyi et al. (2004) conducted a "comprehensive assessment" of the environmental and health-related conditions in China -- another rapidly developing economy -- and found that socio-economic considerations among the public were the dominant factor in explaining the degree to which people trusted and participated in that healthcare system.

It is expected that such will also be the case in the UAE generally, and that in order to address people's reluctance to enter the healthcare system, research is first needed that can identify the healthcare system's current capacity and status related to fulfilling the health needs of the population, as well as the current perceptions of the healthcare system among both those groups who administer it and those who benefit from it. Through linking the conceptual models for diffusion of innovation and communities of practice, the research addresses both the practical and the economic implications of the healthcare system, and suggests how marketing can be used to improve each.

The Research Problem

The research problem consists of an application of two academic models for analysis to the problem of increasing acceptance of the healthcare system among the population in the UAE. Through identifying the concepts of "diffusion of innovation" and "communities of practice" generally and applying them to the situation in the UAE specifically, the research facilitates the development of a marketing model which can succeed in overcoming the gap between the reality of the UAE's healthcare system capacities and the public's distrust of the system. The primary research problem will be, therefore, how to define the UAE's healthcare capacity and marketing responsiveness in ways that show it to be ready to meet the public's demands, and also how to link practitioners and consumers in such a way that their various needs and interests are served through a more efficient and effective program development.

Methods and Assumptions

The research methods to be applied in the study consist of analysis of a variety of data sources which define the UAE healthcare system, as well as a theoretical discussion of the two marketing models. Through statistical and conceptual analysis of the UAE's system, utilizing sources that address the healthcare's demographic, professional, economic, and cultural factors, the study will present information which supports the contention that the UAE's system in its current status is increasingly capable of meeting public needs, but that the trust levels between the various interests groups involved in the system must be brought together through effective marketing in order for the system to reach its full potential impact. A variety of data sources are used, including government data banks, survey analysis, marketing and business reports, and the like.

The study is conducted with a few basic research assumptions in place:

1. The goal of the healthcare system generally is to improve the healthful conditions of the citizenry.

2. Consumer demands and public perception have a critical impact not only on what the healthcare system offers, but also on how the healthcare system is able to offer what it offers.

3. Both the diffusion of innovation model and the communities of practice model can apply across cultural boundaries and industrial sectors to the degree that they provide useful explanatory power for understanding the UAE healthcare system.

Limitations of the study

The research presented is exploratory in nature. It applies two relatively new academic concepts (diffusion of innovation and communities of practice) to a relatively new economic focus (healthcare) in a newly-developing nation (the UAE). Therefore the study will present research which outlines the general problem and provides a structure for development of solutions. However, because of the many rapidly-changing variables involved in the administration of the UAE's healthcare system, the implications of this study must be weighed primarily against their short-term impact. Such a time-bound exploratory research stance has been used effectively by Masood et al. (2008) in a study designed to determine the best way to measure quality of healthcare in the UAE. The researchers in that study developed a number of different research models and applied them to the measurement of public perceptions to determine which one had the best fit, thereby providing the fullest explanatory power.

In light of the stated limitations, it seems significant here that this study is even concerned with the marketing of healthcare in the UAE in the first place. Only a brief generation ago, it would have made very little sense to conduct such a study, since the development of the healthcare system would have been only minor, thereby making such an analysis seem trivial. Today, however, the healthcare system in the UAE seems to have reached a moment when its institutional, structural, and economic foundations are in place for a rapid expansion. Marketing provides one tool to address this. This research, while ultimately limited in scope studies this crucial marketing application.

Review of the Related Literature

In order to outline the theoretical models for understanding and marketing the UAE's healthcare system, a review of the related literature was first conducted. This review was focused around three main objectives:

1. Definition of the UAE's healthcare system in its present state.

2. Definition of the diffusion of innovation theory and application to the UAE case.

3. Definition of the communities of practice model and application to the UAE case.

The relevant findings from the related literature for each of these areas are discussed below.

UAE's Current Healthcare System

Much progress has been made in the last several decades to develop the nation's healthcare system so that the healthful conditions of the population have been able to rise with the general standard of living. For example, Shihab points out that, between 1975 and 1997, the mortality rate in the UAE dropped from 7.3 per 1000 persons to 2.1 persons, while life expectancy rose from 65 years to 74.8 years. Similarly, during the same timeframe, the nation underwent a period of healthcare facility construction (including hospitals and clinics at the local levels), as well as increased professionalization through sophisticated training and technology programs designed to improve basic healthcare delivery. Shihab claims that 99% of all UAE residents now have access to health services, and that new government policies over the last twenty years have stressed beneficial programs such as preventative healthcare, perinatal healthcare, and the like. These advances have resulted in the UAE ranking above the United States in the WHO's ranking of world healthcare systems (World Health Organization, 2000). However, despite the development of these exemplary healthcare capacities, the UAE's system continued to suffer during this timeframe from a perception among the population that it lacked quality (Kronfel, 1999).

It cannot be discounted that the public may perceive the UAE's healthcare system as lacking in quality because the system does in fact have many developmental issues left to resolve. For example, a study by Margolis (2002) found that as healthcare rapidly expanded in the 1990s, statistically significant numbers of incidents of inappropriate medicine prescription also increased. This finding gave some validity to the concern about quality. However, the majority of the studies reviewed indicated that the UAE's healthcare system was comparable to the healthcare systems in most other developed and developing nations. For example, Margolis et al. (2003) conducted a survey analysis of elderly in the U.S. And the UAE and found that the system of elderly care in the UAE compares favorably with that found in the U.S., both in terms of care rendered and patient satisfaction. Similarly, Rizk et al. (2001) found that the delivery of care and consumer satisfaction regarding health programming around child birth was equal in the UAE to that found elsewhere. Therefore, the disconnect between systemic realities and public perceptions in the UAE's healthcare system seems to be related primarily to a perceptual gap held by the consuming public rather than any long-lasting or intractable problem with the delivery of care itself.

The UAE healthcare system, then, seems to suffer from a lack of trust in the system by those who must participate in order to achieve full mass health coverage. Even with significant economic and development advances, not only are the general masses not quickly moving to adopt the healthcare system's offerings, many even have actively negative reactions to the UAE's healthcare system ("70% of UAE residents would opt for medical tourism," 2009). There are a number of possible reasons for this gap. First, part of the concern may be due to the traditional beliefs of the Arab public generally (Heard-Bey, 2001). Because the UAE was, until recently, a tribal society -- and because the nation skipped through many of the stages of economic development, thereby failing to experience the ameliorating factors of long-phase development on traditional ways of life -- the traditional beliefs and practices remained intact among many demographics. For example, Foster et al., (2009) studied usage patterns of a health-related website among the Arab population and found that -- at least on the subjects of birth control and contraception -- the Arab population desired different types of information from such websites than English populations desired. Similarly, Ypinazar and Margolis (2006) found that Arab elderly healthcare patients operate from traditional cultural perceptions regarding the state of their health rather than from mindsets driven entirely by scientific need and reality. This suggested that the cultural attitudes of the Arab population may impact significantly upon the acceptance of programming in the healthcare system, as participants operate from traditional mindsets even in the face of modern institutional and technological structures.

Second, this may also suggest that there is a perception gap between practitioners and consumers, as those who administer the healthcare system may have different attitudes about what the public wants from healthcare than the mass population does. While Moore (2009) argues that such a perception gap between healthcare workers and consumers exists even in the most mature economies, it is possible that such a gap is exacerbated by the possibility of traditional beliefs impacting negatively upon the public's trust in the healthcare system.

In any event, perception remains high among those responsible for marketing the healthcare system in the UAE that the public still does not trust the healthcare system (Kronfel, 1999). Critical attention is therefore required in order to develop integrated strategies that speak to the needs and interests of the consuming public, and do so in ways that appeal to the public and entice them into the healthcare system (Al-Hosani, 2000). One of the more important needs of the moment is to establish a strong bond between the providers in the system and the consuming public regarding perception of the healthcare system, through the effective use of marketing to develop economic and healthcare messages that drive the country's expanding healthcare system. Significantly, the key questions become then what can the system offer, and what do the various publics involved in the system desire and intend? Ultimately these questions seemed to revolve around very basic questions of supply and demand: What can the healthcare system supply, and what does the consuming public demand? The role of marketing in defining these concepts and bringing demand and supply in closer alignment was thereby established.

In order to address these questions, the researcher turned next to the application of two models designed to provide analytical strength for understanding the institutional and cultural capacities of a product/service such as healthcare as well as the public's ultimate acceptance of marketing related to such a product/service.. Through review of the related literature on the concept of diffusion of innovation, the study defined what characterizes a product or service that is set for rapid launch and acceptance into an economic environment. The five stages of product/service adoption and acceptance, as identified by Rogers (2003) were analyzed in order to determine which stage seemed most appropriate for describing the current situation in the UAE. Then, through analysis of the communities of practice model, the research addressed the variety of ways that involved publics and interested parties can be brought into alignment through effective marketing campaigns designed to link consumer demands and supplier intentions.

Diffusion of Innovation

The diffusion of innovations theory addresses the capacity, the motivations, and the rate at which acceptance of new ideas, products, services, or technologies is evident in a culture. "Getting a new idea adopted, even when it has its obvious advantages, is difficult," Rogers writes (p. 1). His argument is designed to address a key need for marketers, which is the "common problem" of how to "speed up" the rate of acceptance for a given product or service. Rogers develops a theoretical argument and a variety of practical tools for understanding and bringing about this critical adoption attitude.

Rogers' argument links the capacity of the product or service to fulfill the needs of a public, with the ready acceptance of such a product or service. He identifies four critical elements of a diffusion of innovation, including (1) the innovation itself, (2) the types of communication channels available for communicating information about the innovation, (3) the rate at which the innovation takes place, and (4) the social system which frames the innovation (p. 10). If the given innovation does not address the public's needs or does so in a way that cannot be communicated in an advantageous fashion through appropriate channels, then its rate of diffusion will likely be slow. However, if the innovation can be communicated to the proper social participants through acceptable channels, and the innovation can be shown to be relevant and acceptable to the public it is aimed at, the rate of diffusion will likely increase. An innovation which shows higher relevance, as determined by a better ability to satisfy the public, will have still higher acceptance, and the rate of diffusion can be rapid and complete. The capacity to satisfy the public must be in place in order for adoption to take place. Obviously, in the absence of a product, no adoption takes place. Similarly, otherwise fully acceptable products will not succeed if the public does not favor them.

Rogers argues that once the four elements of diffusion are in place, the process of diffusion takes place in a five stage development. The five steps include the following:

1. Knowledge, in which the participant is first made aware of the innovation.

2. Persuasion, in which the individual becomes actively involved with the innovation and seeks out additional information.

3. Decision, in which the participants weigh and pros and cons of adoption the innovation.

4. Implementation, in which the individual employs the innovation.

5. Confirmation, in which participant makes the final decision to use the product and begins to use to its potential. (pp. 162-172)

At any step in this process, the individual and collection of individuals can turn back from a full adoption or choose to adopt another innovation. Therefore some innovations get adopted quickly and permanently whereas others are only adopted temporarily or partially, or both.

Rogers argues that in those cases where the elements of diffusion are in place, and a product can be shown to be advantageous, acceptance can be rapid. He identifies a number of characteristics of innovations which determine their ready acceptance by their target publics. These include relative advantage over previous innovations, compatibility with needs and values, complexity for added utility, trialability so that it can be tested, and observability so that the participant can see the difference that the innovations makes. If each of these attributes are present in ways that satisfy the participants, rapid and wide-spread adoption can occur.

Rogers cites as an example the attempt by government workers in Peru to persuade mountain villagers to boil their drinking water in order to address recidivism rates of illness related to bacteria in the drinking water. Some consumers were receptive to the idea in whole, and adopted the suggested technique despite the fact that cultural attitudes toward warm drinking water were prohibitive. Some consumers applied the suggested techniques only on certain occasions or only in part, thereby defeating intended health benefits. Some rejected the suggestion outright, relying on their own cultural interpretations of what constitutes acceptable drinking water, despite evidence showing that boiled water had health benefits. Ultimately the suggested technique failed, according to Rogers, because the public was too involved in their traditional belief structure to see the health benefits of boiled water and make the required changes to their cultural practices. Therefore, a very simple technology was rejected not because it was not useful, and not because it was too difficult to apply, but because the consumer who ultimately had to adopt the change to receive the improved health benefit, didn't like the taste of warm water.

Rogers (1995) argues that often change agents forget that most participants in change evaluate new innovations almost entirely from the perspective of their past experience (p. 241). While Rogers' primary point here is that new innovations are evaluated according to how well they match up with the one currently in use, the point can also be taken as a caution for the case of healthcare's acceptance in the UAE. Because traditional beliefs have complicating and shifting impact on the decision-making process, they may work to slow down adoption decisions. Therefore, the marketer's job is to determine both the context of the decision that the participant has to make, and the impact of the adoption decision on the various culturally-determined viewpoints that the public is likely to have. In cases where the innovation is presented as a good in itself, as with the Peruvian boiled water case study, there is no guarantee that change will be adopted. The public has to see the usefulness of the change they are considering, feel it fitting with their other attitudes, actions, and beliefs, and move toward a decision in a timely fashion that allow critical mass to be reached and a given innovation to become the new convention.

The question of how to arrive at such a critical mass was found to be key. Rogers argues that there are a variety of different types of adopters, ranging from those who adopt early to those who adopt late. One suggestion may be, therefore, to attempt to identify the different adoption needs of these subjects and market the product to each group differently. Rogers also argues that organizations can be oriented towards accepting change with a cycle that includes agenda setting for the group, matching the change to the need, redefining the need and the change in new terms that speak to the innovation, clarifying the innovation and its new role, and routinizing the new process. This programmed technique for implementing change can be useful within certain communities of change, according to Rogers. One possibility that arise here lies in utilizing a push to change as described with each of the different types of adopters so that those who are eager to change are focused quickly on those aspects which are more likely to see lasting change, while later innovators are challenged with early information designed to persuade them to move through the adoption process at a faster rate.

Rogers' view of innovation holds much promise for application to the case of the UAE. Generally, the fact healthcare has an innovative system in place that affords many benefits which are superior to those of the traditional health system being replaced suggests that change acceptance should be possible. Specifically, Rogers provides tools for moving the participants through the recognition, consideration, and adoption of new innovations. One of the primary things that the marketer will have to do in order to achieve such an end is to appeal to the traditional values, practices, and beliefs of the public in ways that show the innovation to be compatible and advantageous, and that build a sense of urgency for the participants to move to adoption.

Communities of Practice

Wenger (1998) identifies communities of practice as those groups which share in some idea, interest, or profession. Such groups can occur naturally or they can be formulated specifically to achieve a goal such as, for example, realizing the spread of information. In those cases where they occur naturally, Wenger suggests that they generally derive from traditional or conventional ways of life. In cases where the groups are organized directly to achieve an end, they are often brought together with the purpose of solving a problem collectively. This suggests that such groups may be approached as a modeling concept for cultivating acceptance of healthcare programming -- provided that the right interest groups can be identified and adequate information groups can be developed to interact with reluctant adopters until questions are answered and fears are allayed.

There are a number of ways in which communities of practice may apply to the marketing of the heathcare system in the UAE to improve the institutional acceptance of the system bys it participants. First, Wenger argues that communities of practice are primarily useful for the development of institutionalized learning and for achieving practical ends. Through communities of learning, for example, craftsmen may come together to practice their craft, thereby acting as a virtual storehouse of information. Similarly, through organized communities of learning, groups come together to develop and deliver messages and thereby change public opinion. Both communities are defined by how well the domain for their activity is laid out, how clearly the community itself is defined, and how deeply shared the practices which lie at the heart of the group engagement are. In the case of late or reluctant adopters of technological innovations, it seems likely that the groups might be loosely knit but that the traditional beliefs and practices they hold might be very deeply felt. A group of healthcare providers organizing for a push towards winning adoption of new technology may be closely organized, however, but their core beliefs may be practical rather than ideological. Therefore, it seems likely that those organizations which have coordinated structural elements and deeply-held meaning elements will have a better chance of succeeding in group endeavors.

Second, in defining the ways groups organize, Wenger distinguishes between theories of social practice which are concerned with everyday elements of life, and theories of identity which include social and cultural interpretations of meaning. It seems clear from this view that the community of late adopters would likely come from the latter group, while healthcare promoters would be concerned with the practical. This division between practical and ideological concerns is relevant to the development of messaging for communities of practice, because, as Wenger argues, they "constitute forms of social and historical continuity and discontinuity" (p. 13). Wenger claims that learning is "caught in the middle" in such juxtaposition of convention and practice. In other words, learning occurs when groups challenge their members, and in such groups learning becomes the "vehicle for the evolution of practices and the inclusion of newcomers" as well as the "vehicle for the development and transformation of identities" (p. 13).