Enablers and challenges in implementing value-based healthcare in Dubai - Framework analysis

Enablers and challenges in implementing value-based healthcare in Dubai - Framework analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enablers and challenges in implementing value-based healthcare in Dubai - Framework analysis Yamen Elgeneadi, Sara Al Dallal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7606906/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite global investments in healthcare, access to and quality of care remain inadequate, particularly in the Middle East, where value-based healthcare (VBHC) is still an emerging concept. This study investigates the enablers and barriers to VBHC implementation in Dubai, a city with a rapidly evolving healthcare landscape. However, there is no formal policy framework supporting the emerging and strategic initiatives of the Dubai health sector to incentivise quality of care as a success factor in healthcare. Purpose The study seeks to pinpoint factors that impact the implementation of VBHC, address the challenges that hinder its full potential, and suggest a roadmap for shaping future policies. Methods A qualitative methodology utilised semi-structured interviews with 17 key stakeholders, including regulators, payers, providers, administrators and consultants in the healthcare sector in Dubai. These interviews took place between June 2024 and October 2024, and the collected data was analysed thematically using NVivo software with deductive and inductive coding to identify enabler and challenge themes. The connections between the two lists were mapped using a theory of change model to design the most possible action plan to obtain optimal short-term outcome and long-term impact of VBHC. The results are aligned to be validated against literature recommendations specially the Porter's VBHC implementation agenda. Results The results reveal that the six key enablers of VBHC in Dubai include strong stakeholder engagement and awareness, robust data and technology infrastructure, and a clear regulatory framework. Conversely, seven challenges, such as poor data quality, resistance to change, and cultural barriers, were identified as critical obstacles. The discussion of the data raised a model to facilitate VBHC implementation, which focuses on improving data accuracy, fostering collaboration among stakeholders, and ensuring that reimbursement models align with desired patient outcomes. Conclusions The study provides insights for policymakers, healthcare leaders and providers in Dubai. It also highlights the critical steps needed to transition towards a healthcare system that reimburses for quality, prioritises value over volume, enhances patient outcomes, and reduces healthcare costs. While many gaps still need to be filled, a proposed policy framework and theory of change were illustrated as pathways to further improvement. Challenges and enablers Dubai Gulf region Health policy Middle East region Qualitative analysis Policy frameworks Value-based healthcare Thematic analysis Theory of change Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Health equity, as defined by Braveman and Gruskin [ 1 ], is achieved when no individual is deprived of the opportunity to optimise their health due to their membership of a group that has been historically marginalised or disadvantaged economically or socially. The concept of healthcare equity is centred around the extent to which different population groups are able to attain comparable health outcomes and experience equitable responsiveness within a healthcare system. For international comparisons, the analysis often focuses on two key dimensions: substantive equity, which pertains to differences in health outcomes and quality of care provided, and procedural equity, which concerns the fairness of processes and access within a healthcare system [ 2 ]. This involves evaluating disparities across population groups and assessing systemic equity from multiple perspectives. Despite the enormous global investment in healthcare, there are still significant empirical gaps in these two types of equities [ 3 ]. Additionally, although societies remain inadequately prepared to confront the emerging health challenges posed by climate change and biological threats, clinical practice and research have yet to fully embrace the principle of substantive equity; that is, prioritising outcomes that genuinely matter to individuals, rather than those that are merely measurable or financially incentivised [ 4 ]. Value-based healthcare (VBHC) was defined by Michael Porter in 2010 as a framework for restructuring healthcare systems with the overarching goal of value for patients, with value defined as health outcomes per unit cost [ 5 ]. VBHC recognises the importance of value for the patient as the only shared goal in healthcare, delivering the care that matters and is sustainable, not what is pushed by an industry driven by high throughput and profit. Given the ongoing debates surrounding the ability of various universal health coverage models to effectively address procedural equity—particularly in terms of access—there is an increasing global and regional (Middle East) emphasis on enhancing value in healthcare, defined by the quality of care and services provided to patients. A value-oriented goal has been integrated into the Triple Aim framework, emphasising improving quality of care, enhancing population health, and reducing costs [ 6 ]. This objective shifts the focus from volume-based care towards delivery of VBHC that promotes patient centricity by integrating a broad range of stakeholders, which introduces significant complexities. The value represents a marked shift from payment systems and culture that primarily incentivise service volume provided to systems that reward quality, patient satisfaction, and outcomes, which are intended to explicitly improve patient health [ 7 ]. The literature suggests that patient-centred outcomes are usually built to support the use of an Integrated Practice Unit (IPU) as the most significant patient-centred VBHC tool [ 8 , 9 ]. Alongside the care delivery value chain, the adoption of time-driven activity-based costing and bundled payment models, as proposed by Porter and Teisberg [ 10 ], adds complexity to implementation of a comprehensive VBHC model. Despite this, VBHC is not yet universally practised. VBHC interventions are designed to assess clinical outcomes, patient outcomes and patient experience throughout each phase of the care continuum. These interventions generally conclude that improved health outcomes are closely associated with the costs incurred in delivering such care. Health authorities in the Middle East region, particularly in Dubai, have shown increasing interest in testing, piloting and implementing components of the VBHC framework [ 11 ]. This study explores the gap between research translation and policy development that is inherent in the adoption of VBHC (especially with the Porter’s agenda model of implementation) through a regional analysis focusing on Dubai [ 12 , 13 ]. The Middle East healthcare landscape presents distinguished and circumstantial factors that significantly influence the implementation of value-based care models. Closely we can interpret the model implementation in the Kingdom in Saudi Arabia (KSA) and in Abu Dhabi as the capital of the United Arab Emirates (UAE) as emerging and continuously growing models striving for balancing the quality outcomes and the volume of provided clinical services [ 14 , 15 ]. with Dubai emerging as a regional leader in healthcare innovation and progressive regulatory development. The Dubai Health Authority (DHA), formally established under the provisions of Law No. (14) of 2021 amending Law No. (6) of 2018, functions as the primary public entity responsible for comprehensive health governance and strategic oversight throughout the emirate [ 16 ]. This legislative framework strategically positions the DHA not merely as a traditional regulatory body but as a comprehensive system steward with extensive responsibilities for coordinating healthcare delivery across public and private sectors, licensing healthcare providers, and safeguarding service quality and safety standards. The regulatory environment established in Dubai reflects the emirate's strategic ambition to develop a healthcare system that is simultaneously high-performing and adaptive, capable of effectively meeting the healthcare needs of its rapidly growing and increasingly diverse population while maintaining both financial sustainability and operational efficiency. The DHA's comprehensive mandate extends beyond conventional regulatory functions to encompass health expenditure oversight, health data system management, and the active promotion of evidence-based healthcare practices aligned with internationally recognised best practices, thereby creating a conducive regulatory environment for systematic value-based care implementation. According to the Health Accounts System of Dubai (HASD) published by the DHA in 2023 [ 17 ], Total health spending in 2023 was 6 billion USD (5.2% of GDP), with an increase of 3.45% from the spending in 2022, which was 5.8 billion USD. Dubai Government has financed 39% of total healthcare expenditure which equals 2.3 billion USD, whereas 61% was private expenditure. Dubai's healthcare financing system has also evolved in the past decade, achieving such milestones as the establishment of universal health coverage, the transition to DRG reimbursement, the creation of special funds for high-cost oncology services for low-income groups, and the implementation of a unified drug formulary for insured members under the Essential Benefit Plan for low-income groups [ 18 – 21 ]. Current healthcare initiatives implemented in Dubai demonstrate substantial progress towards value-based care principles, particularly through the strategic implementation of the EJADAH 1 and NABIDH platforms, although notable policy gaps persist in achieving comprehensive VBHC adoption across the healthcare system [ 8 , 22 ]. EJADAH, established as a collaborative clinical guidance initiative by the DHA, aims to systematically unify clinical practice guidelines (CPGs), key performance indicators (KPIs), and clinical reporting [ 23 ]. Methods Dubai has implemented several healthcare policies and directives in the last seven years targeting the registration of healthcare facilities, health professionals, and experience of consumers, thus promoting tourism and boosting medical skills and expertise to keep service at the forefront. Currently, the EJADAH project is the most recent VBHC initiative in Dubai, as the DHA has not yet developed a policy for that directive. This study aims to examine enablers that shall support the achievement of the policy goals and identify possible challenges that might hamper the initiative's success as perceived by healthcare regulators, professionals and consumers. The primary objective of this qualitative study is to answer the following questions: (1) what are the enablers of VBHC implementation in Dubai, and which is the most essential? (2) what are the challenges and barriers to implementing VBHC in Dubai, and which is the most critical? Moreover, from the shortlisted enablers and challenges, (3) what could be the final VBHC implementation framework? The policy framework has been presented using the application of a theory of change (ToC) model in four distinct domains: inputs, activities, outputs and intended effects. Investigating the factors influencing outcomes and costs might not always lead to clear-cut data or quantifiable elements; instead, such an examination might require a flexible approach [ 24 ]. In particular, healthcare delivery and value are highly dependent on context and are influenced by culture, socioeconomic elements, and regulatory influences. Accordingly, a qualitative research method was chosen to analyse the data collected from semi-structured interviews. Study design The qualitative study is divided into two main consequent activities. Firstly, data was collected over three months from semi-structured interviews with several different stakeholders working in Dubai. The interviews were face-to-face sessions in which participants answered around 34 questions. The questionnaire was structured to gather data on the participants' backgrounds and involvement in the healthcare industry and VBHC. The structure of the interview questions adopted the VBHC agenda introduced by Michael Porter [ 25 ] (Fig. 1 ). Categories included integrated care model, costing, standardised practice, measuring outcomes, and patient-centredness, with multiple questions in each. Secondly, the collected Data were run through a thematic analysis to filter themes relevant to VBHC agenda elements. The thematic analysis utilised the NVivo-14 Pro software application. This approach aided the analysis by grouping wording and topics discussed into distinct themes to establish the route and challenges of adopting VBHC policy in Dubai. Data collection The study aimed to gain an in-depth, context-specific understanding of the views, experiences, and processes of leading healthcare professionals in Dubai’s public and private sectors, in collaboration with the DHA. Given the high contextual dependency and the potential ambiguity of health policy terminology, a semi-structured interview approach was adopted to facilitate clearer communication and easy interpretation for participants who may not routinely engage with such specialised language. Thus, the questionnaire started by asking for a general introductive and descriptive data of the current or previous involvement in the implementation of VBHC, then addressed the understanding and the perception of Pay for Performance (PFP), whether in the private or governmental sector. The questionnaire then dealt with the tools for implementing VBHC with 11 questions on care costing models, the role of providers and technology and data analytics. A specific set of questions on the enablers and the barriers to successful implementation were used and, finally, for the prospects and expected impact of the VBHC implementation in Dubai (Appendix A). The data were collected from health professionals employed at public and private healthcare facilities within Dubai's geographical jurisdiction. After considering all the stakeholders involved in the implementation of VBHC policy, the following were deemed the most significant participants: regulators (represented by DHA workers and policymakers), payers (governmental and private health insurers, providers (physicians and hospital leaders), administrators (finance, supply chain and quality workers) and management consultants (who support all players in setting strategies and analysing the market). In this study, 17 participants were interviewed following the criterion that we would interview at least two in each category of market player in order to collect diversified data covering the entire healthcare landscape in Dubai. The VBHC program lead, the CEO of DHIC, and the CEO of the Dubai Health Regulations Sector were interviewed, representing the regulatory body. Five administrators, two private payers, one governmental payer, two physicians and four healthcare management consultants participated in the study (Appendix B). All interviewees had either worked in Dubai's healthcare system or are currently exposed to VBHC initiatives. Each potential participant received a cover letter and consent form explaining the study before the interview. All candidates were asked to give consent to their participation in this research work, with clarification that all contributions to the study would be completely anonymous (Appendix C). In this manner, a final background review of the consenting participants was conducted to ensure they could provide insight into the concept design, support, advantages, and challenges of implementing the VBHC. The interviews lasted between 30 minutes and 1 hour, allowing the smooth delivery of the 34 questions in an interactive discussion. All interview sessions were held outside working areas to ensure privacy. Data were collected on voice-recordings in addition to personal notes made by the researcher (who conducted all the interviews). The records were converted into text and tabulated according to participant background and question categories. Data analysis The study utilised a thematic analysis after a data analysis plan was developed with predetermined themes, informed by an initially drafted semi-structured questionnaire. This plan aimed to help organise the interview data. First, data was imported into NVivo software to streamline the "start-level" deductive codes. Second, the output of the software analysis underwent another level of inductive coding, flagged as a "modified level of code". Finally, reiteration of coding was done as often as necessary to validate the code structure and develop the final list of themes (Appendix D). NVivo created a manageable initial outcome through only primary analysis [ 26 ]. Then, a coding tree was manually revised and expanded following multiple rounds of analysis based on personal experience, constant comparison, and reflection on the documented notes and interview background; the data was labelled with instances of the deductive and inductive codes developed called an "integrated approach" by Bradley et al. [ 27 ]. Summative content analysis examined how often a specific theme occurred, capturing contextual influences and comparing participants' data across different themes. A meticulous and repeated examination was undertaken to detect specific patterns, repetitions, relationships and differences. An approach involving the factoring and classification of data followed by cross-referencing (who has which background?) was used, which helped to identify areas of consensus, convergence and divergence among participants [ 28 ]. Generated data that was not captured by existing themes led to modification of the list of themes, and the analysis continued iteratively. Samples of the participants quotes recoded during interviews were illustrated in Table 1. Once the themes had been confirmed, the transcripts underwent line-by-line coding. Upon close reading of the data, the initial broad codes were elaborated. This technique of inductive content analysis gave an in-depth understanding of the different data perspectives. Data saturation was achieved, and no new data emerged, reinforcing the study's reliability. Finally, the identified codes were analysed at three levels: the enablers, challenges and the proposed policy framework, which resulted from the ToC model. This aimed at moderating the enablers as inputs and refined by grouping all the challenges into activities to be implemented. Results The findings of the analysis were organised to answer the three main research questions and the sub-questions using the most repeated inductive and deductive themes. Enablers of implementing VBHC Participants provided 51 deductive codes for enablers that underwent many repetitions; the enabler elements were filtered for 15 inductive codes that implied six different enabler themes. Approximately 76% of the themes received for VBHC implementation enablers were divided equally into three primary categories: engagement and awareness, data and technology, and policy framework (Figs. 2 and 3 ). Engagement and awareness: With a total of 13 mentions, the theme of stakeholder engagement and awareness was deemed prominent. Leaders, healthcare professionals, payers and policymakers need a clear understanding of the principles of VBHC to promote successful collaboration during implementation. Administrators and regulators identified in equal measure (four times each) the necessity for comprehensive training programs and awareness campaigns to foster a culture that supports VBHC. The leadership's willingness to invest in the active engagement of clinical healthcare professionals in designing and deploying VBHC strategies is seen as a vital enabler. This scheme is considered by far the most significant enabler for accomplishing appropriate transformation, as solely highlighted in 7 out of 17 responses to question 24. Data and technology: The importance of robust data infrastructure and technological advancements was consistently highlighted across the interviews. Inductive and deductive codes revealed this theme 13 times, five of which were responses from payers and four were from healthcare administrators. Most responses under this category implied the need to invest in powerful interoperable technologies (health information systems and EMRs) to ensure appropriate system-driven data essential for adequate analytics and seamless clinical and financial data integration. Such systems should allow availability and security in the exchange of health information between payers and providers under governmental monitoring. Policy and framework: Similar to the two themes above, regulatory policy, a clear implementation framework and a road map were categorised from 13 responses, including five by administrators and four by regulators. However, a range of diversified inductive codes emerged from the data. These codes reflect not only the presence of a clear and comprehensive governmental policy, but also the influence of political will. Additionally, they highlight the flexibility granted to providers and payers in implementing these policies. The codes also indicate support for complementary initiatives from market players, such as the EJADAH program by the DHIC, and organizational learning efforts such as activity-based costing and the use of PROMs. A supportive policy environment, underpinned by regulatory frameworks, is crucial for advancing VBHC in Dubai. Participants acknowledged that a well-defined framework would facilitate coordination among various healthcare entities, aligning their efforts towards achieving VBHC goals. Twenty-four per cent of the enabler theme categories varied among the remaining three categories: (iv) benchmarked measuring system: A standardised and benchmarked measuring system was identified as a significant enabler. Healthcare outcomes and quality indicators should be regularly benchmarked against global standards to ensure continuous improvement. Several participants (especially administrators) called for international best practices to be adopted while tailoring them to the unique needs of Dubai's healthcare system. (v) Availability of adequate resources: The availability of both financial and human resources was noted as a fundamental enabler of VBHC. Administrators stressed the need for sufficient funding and skilled professionals to implement the changes necessary for transformation. Finally, (vi) The appropriateness of reimbursement for quality of care: participants across all roles agreed that linking reimbursement to quality outcomes rather than the volume would incentivise providers to concentrate on delivering high-quality care. The need for financial reforms prioritising outcome-based payments was seen as essential to encourage a VBHC approach. Challenges to implementing VBHC The participants provided 49 challenging elements (deductive codes), some reflecting repetitions. These elements were inductively filtered to give 17 codes that implied seven different challenge themes. The data quality theme was mentioned 20 times (41% of the listed challenges; Fig. 4 ) by payers (six times), consultants (five), regulators (four), providers (three), and administrators (twice), each emphasising the value of having evidence-based measures (Fig. 5 ). Numerous participants indicated concerns related to inaccurate data hindering the tracking of outcomes. How the data was collected impacted the quality of the data itself and plays a role in evaluating the overall worth of healthcare services. If the data is not sufficiently dependable for stakeholders to rely on, it becomes challenging for them to shift towards a VBHC model. Both payers and administrators highlighted the importance of enhancing accuracy and ease of access to data. Change management: Another significant barrier identified was the complexity of managing organisational change, which was reflected in 17% of the listed challenges. Most administrators struggle with transitioning from an FFS model to a VBHC approach due to the complexity of existing structures and a lack of change management support. Additionally, the broad diversity of involved stakeholders makes conducting a smooth transition challenging. Cultural barriers were identified as a considerable challenge, as mentioned eight times by consultants and administrators. Traditional practices and mindsets are deeply ingrained in many organisations, making shifting to a performance-based approach difficult. The need for clear leadership, strategic vision and staff engagement was stressed by consultants and regulators who highlighted the current focus on the short-term revenue streams rather than the long-term quality of care. Twenty-six per cent of the listed challenge themes mainly reflect (iv) inconsistent utilisation of resources; (v) the difficulty in optimising fully integrated HIS; (vi) the involvement of the patients and their families in a complex process such as this transition; finally, (vii) unification and standardisation of guidelines and provision of care. Most participants who cited the last four themes were regulators, followed by healthcare payers (Fig. 5 ). Also, when participants were asked to cite the most critical challenge theme, data quality, change management, culture and integration capabilities each received four votes. Discussion VBHC implementation framework and policy structure The findings suggest that the primary objective is to create an integrated framework that aligns both enablers and challenges, offering a structured roadmap for VBHC implementation and for guiding the development of a comprehensive and actionable policy. The ToC is a powerful tool for mapping out the necessary preconditions, interventions and outcomes for achieving long-term strategies. The ToC model helps define the pathways by which to achieve specific health outcomes by identifying relationships between the inputs, activities, outputs, outcomes and impacts. This framework's long-term goal will be to fully implement the VBHC system in Dubai, which relies on health outcomes, enhances patient satisfaction, reduces costs, and incentivises the delivery of care of the highest quality. To incorporate the significance of The inputs for this framework, they will be the list of enablers (themes) shortlisted through the thematic analysis when mapped to the list of challenges (Fig. 6 ). Therefore, the initiatives (the list of suggested activities) in this ToC model provide solutions designed to address and mitigate these barriers. To address the challenges and leverage the enablers with the suggested ToC model, key activities had to be defined. These were: (1) Enforcing the wide use of EJADAH clinical guidelines and mandating the submission of the list of CROMs and PROMs after standardising the care provision protocols and pathways. (2) If healthcare facilities are to implement an interoperable and integrated health information system that links clinical and financial data across the facility and exchanges data with the NABIDH system, the system should detect noncompliance with clinical practice guidelines. (3) Streamlining the long-term benefits for leaders by illustrating success stories and the cost of poor quality in a quantified manner. (4) Continuing professional development for healthcare providers, payers, and administrators should be provided. Continuing professional development programs shall familiarise healthcare professionals about VBHC implementation, complemented by patient education campaigns that emphasise quality outcomes over service volume. (5) All health facilities and payers should collaborate with policymakers to introduce legislation that mandates outcome-based reimbursement and incentivises quality. (6) Collaboration with international organisations to create tools for benchmarking healthcare outcomes, such as ICHOM, ACHS and VBHC Center Europe. (7) Allocation of the funds required for the full implementation that includes a pool for VBHC-specific training in costing, case management, auditing and analytics, which require appropriate distribution of resources, ensuring sufficient support is provided for VBHC programs. Few outcomes represent the immediate and intermediate changes expected because of the implementation of the activities. Immediate outcomes should include improved accuracy of data, availability of appropriate tools for measuring outcomes, increased awareness and understanding of VBHC among healthcare professionals and patients, and a successful adoption of outcome-based reimbursement models in pilot programs. The intermediate outcomes should include implementing interoperable data systems across all sectors, improved alignment of providers with patient-centredness, the appropriate benchmarking of outcome-measurement tools, and increased patient involvement in decisions about their care by collecting follow-up data on their PROMs. The expected impact is a healthcare system in Dubai that successfully operates the VBHC model, where quality of care is prioritised over volume. Also, suitable monetisation of care outcomes and reduction of health expenditure by focusing on efficiency and high-value care. The optimal purpose of creating such a ToC model is so that policymakers in Dubai can validate against current initiatives to identify and complete the missing segments necessary for developing a VBHC policy that all stakeholders should follow. Literature recommendations versus study findings By examining the suggested ToC model against Dubai's healthcare landscape, we can identify critical congruencies between the enablers and challenges revealed by the research and the broader literature on VBHC, including foundational works such as "Redefining Health Care" by Michael Porter and Elizabeth Teisberg [ 10 ]. The emphasis on data and technology as primary enablers in Dubai echoes a fundamental VBHC principle stressing the importance of collecting and analysing outcomes data to improve patient care [ 5 ]. Porter's VBHC agenda asserts that data transparency and the ability to measure outcomes are crucial for enabling continuous improvement in healthcare delivery. In Dubai, stakeholders highlighted the need for robust data infrastructure to support these efforts, mirroring the global understanding that high-quality, interoperable data systems are essential for tracking patient outcomes and benchmarking performance. Therefore, the alignment between Dubai's situation and the literature stresses the importance of investing in healthcare technology to support VBHC implementation [ 29 ]. According to Porter [ 5 ], active stakeholder participation ensures that all parties, including providers and patients, work towards shared value creation and outcome improvement goals. Dubai's stakeholders emphasise the need for comprehensive training programs and patient education initiatives, which correspond with international best practices that encourage a collaborative approach to healthcare, in which patient outcomes and satisfaction are prioritised [ 30 ]. Interviewees in Dubai emphasised the need for clear government policies and regulatory frameworks to drive VBHC implementation. This is consistent with the broader literature, which stresses that without supportive policies, healthcare systems struggle to transition away from FFS models [ 31 ]. The challenges identified in Dubai, such as change management and cultural barriers, reflect the obstacles commonly seen in the literature addressing transitions to VBHC. Porter and Lee [ 25 ] describe the difficulties in shifting entrenched organisational cultures from FFS (represented by the DRG) to PFP (represented by VBHC) models, particularly in regions with established traditional practices. Healthcare professionals in Dubai highlighted the need for leadership and change management strategies to support this transition. This aligns with the literature, which underscores solid leadership and a clear strategic vision to guide organisations through complex changes [ 32 ]. Additionally, overcoming cultural resistance requires fostering both understanding and accountability. This involves encouraging healthcare providers to prioritise outcome improvement; a challenge that is common across many global healthcare systems [ 33 ]. The literature also suggests that engagement is critical to overcoming resistance to change [ 34 ], which is particularly relevant given that cultural barriers were identified as a significant challenge in Dubai's healthcare landscape. The training sessions conducted by the EJADAH initiative team are suggested to involve a broader range of stakeholders to ensure that awareness and engagement reach all levels of the process, including the patient as an end-user of the service. Well-established population health programs can also tremendously increase the patient's awareness of the required value they should experience [ 35 ]. It is notable that such well-established programs cannot proceed without appropriate IPU and care delivery value chain for each included medical condition [ 36 ]). Additionally, such population health initiatives require reliable integrated digital systems that can be trusted for data exchange and accuracy and used as a reservoir of an extensive database for the double loop organisational learning process. As NABIDH represent the centre data exchange platform, the only remaining part is the appropriate communication of these data through interoperable information systems installed by providers and payers. The activities mentioned in the ToC emphasise the role of culture change for involved stakeholders, particularly hospital leaders. Many interview participants considered it the most challenging part of the successful transformation. Once service provision leaders' buy-in is proven to regulators, the DHA can achieve consensus on the VBHC implementation policy, which will require changing the payment model. As a fixed payment model per condition severity, DRG indirectly sustains low cost and inconsistent service consumables and quality of qualifications. Quality incentives can be applied only when all stakeholders agree on a quality outcome resulting from medical consumables, preventive measures, providers' skills and qualifications, and an integrated multidisciplinary care approach. However, the role of the hospitals is to provide transparent data on CROMs, PROMs and PREMs; NABIDH must become fully functional, as it will be the only governance-monitoring entity. Furthermore, alignment between the literature recommendations (particularly with the work of Porter and others in the field) and the suggested framework from this study, illustrated through the ToC model, provides the Dubai policymakers valuable insights into the benchmarked implementation model. Although the participants in this research highlight the need for clear policy and a roadmap, the study did not include this element in the list of enablers. The policy framework should be the ultimate result of listing an action plan to embrace the success factors and overcome the barriers. VBHC and its components, including service and patient priorities, match Dubai's current approach to enhancing healthcare delivery and patient-centricity. By addressing these challenges and leveraging the enablers, Dubai can create a healthcare system that aligns with international best practices. Conclusions This study sheds light on the intricate dynamics that healthcare systems in Dubai undergo while transitioning towards VBHC. From the perspective of a health administration researcher, the insights gained are both practical and transformative. As Dubai strives to deliver care that prioritises patient outcomes over sheer volume of service, this research clearly outlines the essential enablers and challenges that should be addressed to ensure the success of VBHC initiatives. The ability of Dubai’s health stakeholders to harness data and technology as enablers is fundamental. Accurate and integrated data systems are the backbone of measuring patient outcomes; yet, as this study shows, health facilities in Dubai struggle with inconsistencies in data quality and fragmented technologies. For health service providers, this highlights the urgency of utilising seamless, interoperable systems that track outcomes and support continuous improvement in care processes. Equally important is stakeholder engagement. The findings show that collaboration and awareness at all levels, from frontline staff to policymakers, particularly hospital leaders, is critical to fostering a VBHC culture. Leading awareness campaigns and integrating VBHC principles into daily operations will instil a shared vision of patient-centred care. However, the challenges are substantial. Cultural barriers and change management are significant hurdles, particularly within organisations entrenched in typical clinical care services. The resistance to shifting from fixed FFS (DRG) to PFP or VBHC models can be daunting. However, this study affirms that clear leadership and a well-structured change management approach can gradually dismantle these barriers. Those hospital leaders must champion this shift, fostering an environment of accountability and openness to innovation, where staff and patients are engaged in the journey towards higher-value care, moreover, dismantling revenue orientation as the only success model. The identified enablers and challenges have inspired the development of a ToC model for initiating the actions needed to implement VBHC policy in Dubai. The actions can be integrated to build for the actual VBHC policy framework, which is why the "clear policy" was removed from the list of enablers, although it was mentioned several times. The results of this study align with literature recommendations and can be considered a benchmark for Dubai. This research provides a roadmap for policymakers, hospital leaders and providers. It highlights how players in Dubai's healthcare landscape can overcome barriers and leverage enablers to achieve a healthcare system that delivers better outcomes, reduces costs, and enhances patient satisfaction. The study was aimed not just towards policy change but also at guiding transformation within the sector. Abbreviations ACHS Australian Council on Healthcare Standards CEO Chief Executive Officer CPG Clinical Practice Guidelines CROM Clinical Reported Outcome Measure DH Dubai Health (the governmental health provider authority in Dubai) DHA Dubai Health Authority (the main regulatory body in Dubai) DHIC Dubai Health Insurance Corporation DRG Diagnosis Related Group EBP Essential Benefit Plan EMR Electronic Medical Record EJADAH A program developed by DHIC to unify the CPG and CROMs for listed medical conditions. FFS Fee For Service GDP Gross Domestic Product KPI Key Performance Indicator HIS Health Information System HQ Headquarters ICHOM International Consortium for Health Outcomes Measurement IPU Integrated Practice Unit IT Information Technology MOHAP Ministry of Health and Prevention NABIDH Network and Analysis Backbone for Integrated Dubai Health NVivo A certified software widely used for thematic analysis by clarifying codes and words to themes PFP Pay for Performance PREM Patient-Reported Experience Measure PROM Patient-Reported Outcome Measure ToC Theory of Change UAE United Arab Emirates USD United States Dollar VBHC Value-Based Healthcare Declarations Ethics approval and consent to participate This study ethical review application was reviewed and approved by the Research Ethics Committee of the Department of Health Policy in the London School of Economics and Political Science under application reference number 377180. All individuals who participated in the study or provided information gave written informed consent prior to their participation. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are available in a cloud folder ("Generated and Analysed Dataset"), which can be accessed at: https://1drv.ms/f/c/c56ad0a183f2e202/EmwhdbKcaWBMpDFZW3IRwkgBOzX8JPIvfXDwO4_2aP0Gyw?e=xXmQxG The signed consents to participation are not available in this directory, but can be provided upon request. Competing interests The authors declare no competing interests. Funding The authors did not source any funding for this study from any organisation or educational institutions and received no financial support for the research, authorship, or publication of this article. Authors' contributions Y.E. contributed to the study by structuring the research design, communicating with participants, conducting interviews, collecting data, analysing the data, and preparing the initial draft. Y.E is also acting as corresponding author. S.A. contributed to the study by guiding the data analysis, framing the results, finalising the manuscript and conducting scientific and language reviews. All authors read and approved the final manuscript, and they are accountable for their contribution Acknowledgements The authors acknowledge the work of Mr Adrian Neal who has conducted final language check of the manuscript before submitting it for peer review. References Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254–8. https://doi.org/10.1136/jech.57.4.254 Aday LA, Begley CE, Lairson DR, Balkrishnan R. Evaluating the healthcare system: effectiveness, efficiency, and equity. 3rd ed. Chicago: Health Administration Press; 2004 Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev. 2006;63(2):135–57. https://doi.org/10.1177/1077558705285291 Conrad DA. Incentives for healthcare performance improvement. In Smith PC, Mossialos E, Papanicolas I, Leatherman ST, editors. Performance measurement for health system improvement: experiences, challenges and prospects. Cambridge (UK): Cambridge University Press; 2010. pp. 582–612. https://doi.org/10.1017/CBO9780511711800 Porter ME. What Is Value in Health Care? N Engl J Med. 2010;363(26):2477–81. https://doi.org/10.1056/NEJMp1011024 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–69. https://doi.org/10.1377/hlthaff.27.3.759 Marshall, M., and S. Harrison. “It’s about More than Money: Financial Incentives and Internal Motivation.” Quality & Safety in Health Care, vol. 14, no. 1, 2005, pp. 4–5, https://doi.org/10.1136/qshc.2004.013193 . Ramos P, Savage C, Thor J, Atun R, Carlsson K, Neto M, et al. It takes two to dance the VBHC tango: A multiple case study of the adoption of value-based strategies in Sweden and Brazil. Soc Sci Med. 2021;282:114145. https://doi.org/10.1016/j.socscimed.2021.114145 Gangannagaripalli J, Albagli A, Myers S, Whittaker S, Joseph A, Clarke A, et al. A standard set of value-based patient-centered outcomes and measures of overall health in adults. Patient. 2022;15(3):341–51. https://doi.org/10.1007/s40271-021-00554-8 Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press; 2006. Farghaly M, Alrustamani LA, Aladawy AIA, Suliman EAMA, Mukherjee B. HPR67 EJADAH: implementation of value-based healthcare in the Emirate of Dubai. Value in Health. 2023;26(6):S223. https://doi.org/10.1016/j.jval.2023.03.1214 Conrad DA. The theory of value-based payment incentives and their application to health care. Health Services Res. 2015;50(S2):2057–89. https://doi.org/10.1111/1475-6773.12408 Atun R, Knaul FM, Akachi Y, Frenk J. Innovative financing for health: what is truly innovative? The Lancet. 2012;380(9858):2044–9. https://doi.org/10.1016/S0140-6736(12)61460-3 Kingdom of Saudi Arabia Council of Health Insurance. Value based health care in Saudi health insurance market; white paper on value-based payment; 2022. https://chi.gov.sa/ResearchLibrary/VBHC%20White%20Paper%20Version%20Final.pdf . Accessed 14 Nov 2024. Abu Dhabi Department of Health. Pay for quality standard DoH/SD/HCQS/PQS/V1/2025; 2025. https://www.doh.gov.ae/-/media/382860B41BFB4499 BD0EBECE83E6BA7C.ashx. Accessed 14 Jun 2025. The Supreme Legislation Committee in the Emirate of Dubai, Government of Dubai Law No. (14) of 2021 amending law no. (6) of 2018 concerning the Dubai Health authority. 2021. https://dlp.dubai.gov.ae/Legislation%20Reference/2021/Law%20 No.%20(14)%20of%202021%20Amending%20Law%20No.%20(6)%20of%202018.pdf. Accessed 22 Nov 2024. Dubai Health Authority. Health accounts system of Dubai; 2023. https://dha.gov.ae/uploads/012025/Health%20Accounts%20System%20of%20Dubai_20232025150630.pdf . Accessed 17 Jan 2025. International Monetary Fund. United Arab Emirates GDP (%) & Inflation Rate. Country Data. 2023. https://www.imf.org/en/Countries/ARE . Accessed 17 Jan 2025. World Bank Group. Inflation, consumer prices (annual %)—United Arab Emirates, Saudi Arabia. International Financial Statistics and Data Files. https://data.worldbank.org/indicator/FP .CPI.TOTL.ZG?end=2022&locations=AE-SA&start=2000. Accessed 17 Jan 2025. Dubai Healthcare City Authority–Arab Health. Dubai’s healthcare ecosystem highlights. White Paper Media; 2024. https://dhcc.ae/Documents/arabhealth-2024/highlight-report-5-2-24.pdf . Accessed 17 Jan 2025. Government of Dubai Media Office. Dubai sees 11.5% year-on-year growth in number of health facilities in Q1 2023. News; 2023. https://www.mediaoffice.ae/en/news/2023/May/31-05/Dubai-sees-more-than-11-percent-year-on-year-growth-in-number-of-health-facilities-in-Q1-2023 . Accessed 17 Jan 2025. Dubai Health Authority. What is NABIDH? 2024. https://www.nabidh.ae/#/comm/about . Accessed 17 Jan 2025. Dubai Health Authority, Insurance System for Advancing Healthcare in Dubai (ISAHD), EJADAH KPIs & recommendations; 2025. https://www.isahd.ae/Home/EJADAHKPIs . Accessed 17 Jan 2025. Creswell JW. Qualitative inquiry and research design: choosing among five traditions. Sage Publications; 1998. Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review. 2013;91(10):50. Flick U, Metzler K, Scott W. The SAGE handbook of qualitative data analysis. Sage Publications; 2014. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res, 2007;42(4):1758–72. https://doi.org/10.1111/j.1475-6773.2006.00684.x Denzin, Norman K., and Yvonna S. Lincoln, editors. Handbook of Qualitative Research. Sage, 1994, Pg 391–402 Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, Sweeney J. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood). 2013;32(2):223–31. https://doi.org/10.1377/hlthaff.2012.1133 Gray M, Turabi AE. Optimising the value of interventions for populations. BMJ. 2012;345:e6192. https://doi.org/10.1136/bmj.e6192 Kaplan RS, Porter ME, Frigo ML. Managing healthcare costs and value. Strategic Finance. 2017;98(7): 24–33. Shortell SM, Poon BY, Ramsay PP, Rodriguez HP, Ivey SL, Huber T, et al. A multilevel analysis of patient engagement and patient-reported outcomes in primary care practices of accountable care organizations. J Gen Intern Med. 2017;32(6):640–7. Miller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5):1418–28. https://doi.org/10.1377/hlthaff.28.5.1418 Greasley K, Watson P, Patel S. (2009). The impact of organisational change on public sector employees implementing the UK Government’s "Back to work" programme. Employee Relations. 2009;31(4):382–97. https://doi.org/10.1108/01425450910965432 Papanicolas I. Cylus J. Comparison of healthcare systems performance. In Kuhlmann E, Blank RH, Bourgeault IL, Wendt C, editors. The Palgrave International Handbook of Healthcare Policy and Governance. London: Palgrave Macmillan; 2015: pp. 116–32. Teisberg E, Wallace S, O’Hara S. Defining and implementing value-based health care: a strategic framework. Acad Med. 2020;95(5):682–5. https://doi.org/10.1097/ACM.0000000000003122 Footnotes EJADAH is a program initiated by DHIC (Dubai Health Insurance Corporation, Dubai Health Authority) in 2021 to work on specific medical conditions to achieve stakeholder consensus on preventive care parameters and appropriate treatment protocols. Until end of 2024, the program has published 20 CPGs aiming to ensure the collaboration of providers, pharmaceuticals, and payers to unify standardised CPG and outcome measures. The program aims to work on specific medical conditions that achieve the consensus of all stakeholders on preventive parameters and appropriate management. As per these CPG, payers started to reject coverage if providers were proven to not adhere to them; and planned in the future that all healthcare facilities will have to provide annual outcome measures database to the initiative to help in the double-loop learning model which shall serve as the new gateway to population health modalities. Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.Quotesfromtheinterviews.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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1","display":"","copyAsset":false,"role":"figure","size":32312,"visible":true,"origin":"","legend":"\u003cp\u003eValue-based healthcare implementation workflow [25].\u003c/p\u003e","description":"","filename":"Figure1.Valuebasedhealthcareimplementationworkflow.png","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/5ae92f6d987ca2f611b828a0.png"},{"id":94883262,"identity":"e15923ee-9401-430b-9cf0-4e20a67d8a98","added_by":"auto","created_at":"2025-10-31 17:26:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65401,"visible":true,"origin":"","legend":"\u003cp\u003eInterview analysis—distribution of enabler themes\u003c/p\u003e","description":"","filename":"Figure2.Interviewanalysisdistributionofenablerthemes.png","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/3f133959b0b2ccd877a46dc9.png"},{"id":94883267,"identity":"e5070a28-1f49-480f-8694-f24edbd75b5d","added_by":"auto","created_at":"2025-10-31 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themes.\u003c/p\u003e","description":"","filename":"Figure4.Interviewanalysisdistributionofchallengethemes.png","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/602167c164643b4545010348.png"},{"id":94987083,"identity":"6887ca9f-96e3-4db9-a052-d6fe48c30267","added_by":"auto","created_at":"2025-11-03 07:01:13","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":34806,"visible":true,"origin":"","legend":"\u003cp\u003eInterview analysis—distribution of challenger themes by participant category.\u003c/p\u003e","description":"","filename":"Figure5.Interviewanalysisdistributionofchallengerthemesbyparticipantcategory.png","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/7dc4618671e3a9a79644ba7d.png"},{"id":94883266,"identity":"ff5a2ba7-831d-4ede-b5dd-f44dff794eef","added_by":"auto","created_at":"2025-10-31 17:26:57","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":374675,"visible":true,"origin":"","legend":"\u003cp\u003eSuggested policy implementation framework according to the theory of change model.\u003c/p\u003e","description":"","filename":"Figure6.Suggestedpolicyimplementationframeworkaccordingtothetheoryofchangemodel.png","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/da514f771dfe840f7c5d5140.png"},{"id":104401037,"identity":"a8a591d8-b4f2-463a-a6be-b3de3302a175","added_by":"auto","created_at":"2026-03-11 12:11:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1173017,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/12b4a4a6-6a0b-4689-91a2-299e394c06cd.pdf"},{"id":94883268,"identity":"1e94b890-04e3-4309-9f01-b9c708e0679c","added_by":"auto","created_at":"2025-10-31 17:26:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":89349,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.Quotesfromtheinterviews.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7606906/v1/9d322309b7b5d47940c2bae9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enablers and challenges in implementing value-based healthcare in Dubai - Framework analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth equity, as defined by Braveman and Gruskin [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], is achieved when no individual is deprived of the opportunity to optimise their health due to their membership of a group that has been historically marginalised or disadvantaged economically or socially. The concept of healthcare equity is centred around the extent to which different population groups are able to attain comparable health outcomes and experience equitable responsiveness within a healthcare system. For international comparisons, the analysis often focuses on two key dimensions: substantive equity, which pertains to differences in health outcomes and quality of care provided, and procedural equity, which concerns the fairness of processes and access within a healthcare system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This involves evaluating disparities across population groups and assessing systemic equity from multiple perspectives. Despite the enormous global investment in healthcare, there are still significant empirical gaps in these two types of equities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, although societies remain inadequately prepared to confront the emerging health challenges posed by climate change and biological threats, clinical practice and research have yet to fully embrace the principle of substantive equity; that is, prioritising outcomes that genuinely matter to individuals, rather than those that are merely measurable or financially incentivised [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eValue-based healthcare (VBHC) was defined by Michael Porter in 2010 as a framework for restructuring healthcare systems with the overarching goal of value for patients, with value defined as health outcomes per unit cost [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. VBHC recognises the importance of value for the patient as the only shared goal in healthcare, delivering the care that matters and is sustainable, not what is pushed by an industry driven by high throughput and profit. Given the ongoing debates surrounding the ability of various universal health coverage models to effectively address procedural equity\u0026mdash;particularly in terms of access\u0026mdash;there is an increasing global and regional (Middle East) emphasis on enhancing value in healthcare, defined by the quality of care and services provided to patients. A value-oriented goal has been integrated into the Triple Aim framework, emphasising improving quality of care, enhancing population health, and reducing costs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This objective shifts the focus from volume-based care towards delivery of VBHC that promotes patient centricity by integrating a broad range of stakeholders, which introduces significant complexities. The value represents a marked shift from payment systems and culture that primarily incentivise service volume provided to systems that reward quality, patient satisfaction, and outcomes, which are intended to explicitly improve patient health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The literature suggests that patient-centred outcomes are usually built to support the use of an Integrated Practice Unit (IPU) as the most significant patient-centred VBHC tool [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Alongside the care delivery value chain, the adoption of time-driven activity-based costing and bundled payment models, as proposed by Porter and Teisberg [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], adds complexity to implementation of a comprehensive VBHC model. Despite this, VBHC is not yet universally practised. VBHC interventions are designed to assess clinical outcomes, patient outcomes and patient experience throughout each phase of the care continuum. These interventions generally conclude that improved health outcomes are closely associated with the costs incurred in delivering such care. Health authorities in the Middle East region, particularly in Dubai, have shown increasing interest in testing, piloting and implementing components of the VBHC framework [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This study explores the gap between research translation and policy development that is inherent in the adoption of VBHC (especially with the Porter\u0026rsquo;s agenda model of implementation) through a regional analysis focusing on Dubai [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Middle East healthcare landscape presents distinguished and circumstantial factors that significantly influence the implementation of value-based care models. Closely we can interpret the model implementation in the Kingdom in Saudi Arabia (KSA) and in Abu Dhabi as the capital of the United Arab Emirates (UAE) as emerging and continuously growing models striving for balancing the quality outcomes and the volume of provided clinical services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. with Dubai emerging as a regional leader in healthcare innovation and progressive regulatory development. The Dubai Health Authority (DHA), formally established under the provisions of Law No. (14) of 2021 amending Law No. (6) of 2018, functions as the primary public entity responsible for comprehensive health governance and strategic oversight throughout the emirate [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This legislative framework strategically positions the DHA not merely as a traditional regulatory body but as a comprehensive system steward with extensive responsibilities for coordinating healthcare delivery across public and private sectors, licensing healthcare providers, and safeguarding service quality and safety standards. The regulatory environment established in Dubai reflects the emirate's strategic ambition to develop a healthcare system that is simultaneously high-performing and adaptive, capable of effectively meeting the healthcare needs of its rapidly growing and increasingly diverse population while maintaining both financial sustainability and operational efficiency. The DHA's comprehensive mandate extends beyond conventional regulatory functions to encompass health expenditure oversight, health data system management, and the active promotion of evidence-based healthcare practices aligned with internationally recognised best practices, thereby creating a conducive regulatory environment for systematic value-based care implementation.\u003c/p\u003e\u003cp\u003eAccording to the Health Accounts System of Dubai (HASD) published by the DHA in 2023 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], Total health spending in 2023 was 6\u0026nbsp;billion USD (5.2% of GDP), with an increase of 3.45% from the spending in 2022, which was 5.8\u0026nbsp;billion USD. Dubai Government has financed 39% of total healthcare expenditure which equals 2.3\u0026nbsp;billion USD, whereas 61% was private expenditure. Dubai's healthcare financing system has also evolved in the past decade, achieving such milestones as the establishment of universal health coverage, the transition to DRG reimbursement, the creation of special funds for high-cost oncology services for low-income groups, and the implementation of a unified drug formulary for insured members under the Essential Benefit Plan for low-income groups [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Current healthcare initiatives implemented in Dubai demonstrate substantial progress towards value-based care principles, particularly through the strategic implementation of the EJADAH\u003csup\u003e1\u003c/sup\u003e and NABIDH platforms, although notable policy gaps persist in achieving comprehensive VBHC adoption across the healthcare system [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. EJADAH, established as a collaborative clinical guidance initiative by the DHA, aims to systematically unify clinical practice guidelines (CPGs), key performance indicators (KPIs), and clinical reporting [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eDubai has implemented several healthcare policies and directives in the last seven years targeting the registration of healthcare facilities, health professionals, and experience of consumers, thus promoting tourism and boosting medical skills and expertise to keep service at the forefront. Currently, the EJADAH project is the most recent VBHC initiative in Dubai, as the DHA has not yet developed a policy for that directive. This study aims to examine enablers that shall support the achievement of the policy goals and identify possible challenges that might hamper the initiative's success as perceived by healthcare regulators, professionals and consumers. The primary objective of this qualitative study is to answer the following questions: (1) what are the enablers of VBHC implementation in Dubai, and which is the most essential? (2) what are the challenges and barriers to implementing VBHC in Dubai, and which is the most critical? Moreover, from the shortlisted enablers and challenges, (3) what could be the final VBHC implementation framework? The policy framework has been presented using the application of a theory of change (ToC) model in four distinct domains: inputs, activities, outputs and intended effects.\u003c/p\u003e\u003cp\u003eInvestigating the factors influencing outcomes and costs might not always lead to clear-cut data or quantifiable elements; instead, such an examination might require a flexible approach [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In particular, healthcare delivery and value are highly dependent on context and are influenced by culture, socioeconomic elements, and regulatory influences. Accordingly, a qualitative research method was chosen to analyse the data collected from semi-structured interviews.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThe qualitative study is divided into two main consequent activities. Firstly, data was collected over three months from semi-structured interviews with several different stakeholders working in Dubai. The interviews were face-to-face sessions in which participants answered around 34 questions. The questionnaire was structured to gather data on the participants' backgrounds and involvement in the healthcare industry and VBHC. The structure of the interview questions adopted the VBHC agenda introduced by Michael Porter [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Categories included integrated care model, costing, standardised practice, measuring outcomes, and patient-centredness, with multiple questions in each. Secondly, the collected Data were run through a thematic analysis to filter themes relevant to VBHC agenda elements. The thematic analysis utilised the NVivo-14 Pro software application. This approach aided the analysis by grouping wording and topics discussed into distinct themes to establish the route and challenges of adopting VBHC policy in Dubai.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe study aimed to gain an in-depth, context-specific understanding of the views, experiences, and processes of leading healthcare professionals in Dubai\u0026rsquo;s public and private sectors, in collaboration with the DHA. Given the high contextual dependency and the potential ambiguity of health policy terminology, a semi-structured interview approach was adopted to facilitate clearer communication and easy interpretation for participants who may not routinely engage with such specialised language. Thus, the questionnaire started by asking for a general introductive and descriptive data of the current or previous involvement in the implementation of VBHC, then addressed the understanding and the perception of Pay for Performance (PFP), whether in the private or governmental sector. The questionnaire then dealt with the tools for implementing VBHC with 11 questions on care costing models, the role of providers and technology and data analytics. A specific set of questions on the enablers and the barriers to successful implementation were used and, finally, for the prospects and expected impact of the VBHC implementation in Dubai (Appendix A).\u003c/p\u003e\u003cp\u003eThe data were collected from health professionals employed at public and private healthcare facilities within Dubai's geographical jurisdiction. After considering all the stakeholders involved in the implementation of VBHC policy, the following were deemed the most significant participants: regulators (represented by DHA workers and policymakers), payers (governmental and private health insurers, providers (physicians and hospital leaders), administrators (finance, supply chain and quality workers) and management consultants (who support all players in setting strategies and analysing the market). In this study, 17 participants were interviewed following the criterion that we would interview at least two in each category of market player in order to collect diversified data covering the entire healthcare landscape in Dubai. The VBHC program lead, the CEO of DHIC, and the CEO of the Dubai Health Regulations Sector were interviewed, representing the regulatory body. Five administrators, two private payers, one governmental payer, two physicians and four healthcare management consultants participated in the study (Appendix B). All interviewees had either worked in Dubai's healthcare system or are currently exposed to VBHC initiatives. Each potential participant received a cover letter and consent form explaining the study before the interview. All candidates were asked to give consent to their participation in this research work, with clarification that all contributions to the study would be completely anonymous (Appendix C). In this manner, a final background review of the consenting participants was conducted to ensure they could provide insight into the concept design, support, advantages, and challenges of implementing the VBHC. The interviews lasted between 30 minutes and 1 hour, allowing the smooth delivery of the 34 questions in an interactive discussion. All interview sessions were held outside working areas to ensure privacy. Data were collected on voice-recordings in addition to personal notes made by the researcher (who conducted all the interviews). The records were converted into text and tabulated according to participant background and question categories.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe study utilised a thematic analysis after a data analysis plan was developed with predetermined themes, informed by an initially drafted semi-structured questionnaire. This plan aimed to help organise the interview data. First, data was imported into NVivo software to streamline the \"start-level\" deductive codes. Second, the output of the software analysis underwent another level of inductive coding, flagged as a \"modified level of code\". Finally, reiteration of coding was done as often as necessary to validate the code structure and develop the final list of themes (Appendix D). NVivo created a manageable initial outcome through only primary analysis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Then, a coding tree was manually revised and expanded following multiple rounds of analysis based on personal experience, constant comparison, and reflection on the documented notes and interview background; the data was labelled with instances of the deductive and inductive codes developed called an \"integrated approach\" by Bradley et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSummative content analysis examined how often a specific theme occurred, capturing contextual influences and comparing participants' data across different themes. A meticulous and repeated examination was undertaken to detect specific patterns, repetitions, relationships and differences. An approach involving the factoring and classification of data followed by cross-referencing (who has which background?) was used, which helped to identify areas of consensus, convergence and divergence among participants [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Generated data that was not captured by existing themes led to modification of the list of themes, and the analysis continued iteratively. Samples of the participants quotes recoded during interviews were illustrated in Table\u0026nbsp;1. Once the themes had been confirmed, the transcripts underwent line-by-line coding. Upon close reading of the data, the initial broad codes were elaborated. This technique of inductive content analysis gave an in-depth understanding of the different data perspectives. Data saturation was achieved, and no new data emerged, reinforcing the study's reliability. Finally, the identified codes were analysed at three levels: the enablers, challenges and the proposed policy framework, which resulted from the ToC model. This aimed at moderating the enablers as inputs and refined by grouping all the challenges into activities to be implemented.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe findings of the analysis were organised to answer the three main research questions and the sub-questions using the most repeated inductive and deductive themes.\u003c/p\u003e\n\u003ch3\u003eEnablers of implementing VBHC\u003c/h3\u003e\n\u003cp\u003eParticipants provided 51 deductive codes for enablers that underwent many repetitions; the enabler elements were filtered for 15 inductive codes that implied six different enabler themes. Approximately 76% of the themes received for VBHC implementation enablers were divided equally into three primary categories: engagement and awareness, data and technology, and policy framework (Figs.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n\u003cli\u003e\n\u003cp\u003eEngagement and awareness: With a total of 13 mentions, the theme of stakeholder engagement and awareness was deemed prominent. Leaders, healthcare professionals, payers and policymakers need a clear understanding of the principles of VBHC to promote successful collaboration during implementation. Administrators and regulators identified in equal measure (four times each) the necessity for comprehensive training programs and awareness campaigns to foster a culture that supports VBHC. The leadership's willingness to invest in the active engagement of clinical healthcare professionals in designing and deploying VBHC strategies is seen as a vital enabler. This scheme is considered by far the most significant enabler for accomplishing appropriate transformation, as solely highlighted in 7 out of 17 responses to question 24.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eData and technology: The importance of robust data infrastructure and technological advancements was consistently highlighted across the interviews. Inductive and deductive codes revealed this theme 13 times, five of which were responses from payers and four were from healthcare administrators. Most responses under this category implied the need to invest in powerful interoperable technologies (health information systems and EMRs) to ensure appropriate system-driven data essential for adequate analytics and seamless clinical and financial data integration. Such systems should allow availability and security in the exchange of health information between payers and providers under governmental monitoring.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePolicy and framework: Similar to the two themes above, regulatory policy, a clear implementation framework and a road map were categorised from 13 responses, including five by administrators and four by regulators. However, a range of diversified inductive codes emerged from the data. These codes reflect not only the presence of a clear and comprehensive governmental policy, but also the influence of political will. Additionally, they highlight the flexibility granted to providers and payers in implementing these policies. The codes also indicate support for complementary initiatives from market players, such as the EJADAH program by the DHIC, and organizational learning efforts such as activity-based costing and the use of PROMs. A supportive policy environment, underpinned by regulatory frameworks, is crucial for advancing VBHC in Dubai. Participants acknowledged that a well-defined framework would facilitate coordination among various healthcare entities, aligning their efforts towards achieving VBHC goals.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTwenty-four per cent of the enabler theme categories varied among the remaining three categories: (iv) benchmarked measuring system: A standardised and benchmarked measuring system was identified as a significant enabler. Healthcare outcomes and quality indicators should be regularly benchmarked against global standards to ensure continuous improvement. Several participants (especially administrators) called for international best practices to be adopted while tailoring them to the unique needs of Dubai's healthcare system. (v) Availability of adequate resources: The availability of both financial and human resources was noted as a fundamental enabler of VBHC. Administrators stressed the need for sufficient funding and skilled professionals to implement the changes necessary for transformation. Finally, (vi) The appropriateness of reimbursement for quality of care: participants across all roles agreed that linking reimbursement to quality outcomes rather than the volume would incentivise providers to concentrate on delivering high-quality care. The need for financial reforms prioritising outcome-based payments was seen as essential to encourage a VBHC approach.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eChallenges to implementing VBHC\u003c/h2\u003e\n\u003cp\u003eThe participants provided 49 challenging elements (deductive codes), some reflecting repetitions. These elements were inductively filtered to give 17 codes that implied seven different challenge themes.\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n\u003cli\u003e\n\u003cp\u003eThe data quality theme was mentioned 20 times (41% of the listed challenges; Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) by payers (six times), consultants (five), regulators (four), providers (three), and administrators (twice), each emphasising the value of having evidence-based measures (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). Numerous participants indicated concerns related to inaccurate data hindering the tracking of outcomes. How the data was collected impacted the quality of the data itself and plays a role in evaluating the overall worth of healthcare services. If the data is not sufficiently dependable for stakeholders to rely on, it becomes challenging for them to shift towards a VBHC model. Both payers and administrators highlighted the importance of enhancing accuracy and ease of access to data.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u0026nbsp;Change management: Another significant barrier identified was the complexity of managing organisational change, which was reflected in 17% of the listed challenges. Most administrators struggle with transitioning from an FFS model to a VBHC approach due to the complexity of existing structures and a lack of change management support. Additionally, the broad diversity of involved stakeholders makes conducting a smooth transition challenging.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCultural barriers were identified as a considerable challenge, as mentioned eight times by consultants and administrators. Traditional practices and mindsets are deeply ingrained in many organisations, making shifting to a performance-based approach difficult. The need for clear leadership, strategic vision and staff engagement was stressed by consultants and regulators who highlighted the current focus on the short-term revenue streams rather than the long-term quality of care.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTwenty-six per cent of the listed challenge themes mainly reflect (iv) inconsistent utilisation of resources; (v) the difficulty in optimising fully integrated HIS; (vi) the involvement of the patients and their families in a complex process such as this transition; finally, (vii) unification and standardisation of guidelines and provision of care. Most participants who cited the last four themes were regulators, followed by healthcare payers (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). Also, when participants were asked to cite the most critical challenge theme, data quality, change management, culture and integration capabilities each received four votes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eVBHC implementation framework and policy structure\u003c/h2\u003e\u003cp\u003eThe findings suggest that the primary objective is to create an integrated framework that aligns both enablers and challenges, offering a structured roadmap for VBHC implementation and for guiding the development of a comprehensive and actionable policy. The ToC is a powerful tool for mapping out the necessary preconditions, interventions and outcomes for achieving long-term strategies. The ToC model helps define the pathways by which to achieve specific health outcomes by identifying relationships between the inputs, activities, outputs, outcomes and impacts.\u003c/p\u003e\u003cp\u003eThis framework's long-term goal will be to fully implement the VBHC system in Dubai, which relies on health outcomes, enhances patient satisfaction, reduces costs, and incentivises the delivery of care of the highest quality. To incorporate the significance of The inputs for this framework, they will be the list of enablers (themes) shortlisted through the thematic analysis when mapped to the list of challenges (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Therefore, the initiatives (the list of suggested activities) in this ToC model provide solutions designed to address and mitigate these barriers.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTo address the challenges and leverage the enablers with the suggested ToC model, key activities had to be defined. These were: (1) Enforcing the wide use of EJADAH clinical guidelines and mandating the submission of the list of CROMs and PROMs after standardising the care provision protocols and pathways. (2) If healthcare facilities are to implement an interoperable and integrated health information system that links clinical and financial data across the facility and exchanges data with the NABIDH system, the system should detect noncompliance with clinical practice guidelines. (3) Streamlining the long-term benefits for leaders by illustrating success stories and the cost of poor quality in a quantified manner. (4) Continuing professional development for healthcare providers, payers, and administrators should be provided. Continuing professional development programs shall familiarise healthcare professionals about VBHC implementation, complemented by patient education campaigns that emphasise quality outcomes over service volume. (5) All health facilities and payers should collaborate with policymakers to introduce legislation that mandates outcome-based reimbursement and incentivises quality. (6) Collaboration with international organisations to create tools for benchmarking healthcare outcomes, such as ICHOM, ACHS and VBHC Center Europe. (7) Allocation of the funds required for the full implementation that includes a pool for VBHC-specific training in costing, case management, auditing and analytics, which require appropriate distribution of resources, ensuring sufficient support is provided for VBHC programs.\u003c/p\u003e\u003cp\u003eFew outcomes represent the immediate and intermediate changes expected because of the implementation of the activities. Immediate outcomes should include improved accuracy of data, availability of appropriate tools for measuring outcomes, increased awareness and understanding of VBHC among healthcare professionals and patients, and a successful adoption of outcome-based reimbursement models in pilot programs. The intermediate outcomes should include implementing interoperable data systems across all sectors, improved alignment of providers with patient-centredness, the appropriate benchmarking of outcome-measurement tools, and increased patient involvement in decisions about their care by collecting follow-up data on their PROMs. The expected impact is a healthcare system in Dubai that successfully operates the VBHC model, where quality of care is prioritised over volume. Also, suitable monetisation of care outcomes and reduction of health expenditure by focusing on efficiency and high-value care. The optimal purpose of creating such a ToC model is so that policymakers in Dubai can validate against current initiatives to identify and complete the missing segments necessary for developing a VBHC policy that all stakeholders should follow.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLiterature recommendations versus study findings\u003c/h2\u003e\u003cp\u003eBy examining the suggested ToC model against Dubai's healthcare landscape, we can identify critical congruencies between the enablers and challenges revealed by the research and the broader literature on VBHC, including foundational works such as \"Redefining Health Care\" by Michael Porter and Elizabeth Teisberg [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The emphasis on data and technology as primary enablers in Dubai echoes a fundamental VBHC principle stressing the importance of collecting and analysing outcomes data to improve patient care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Porter's VBHC agenda asserts that data transparency and the ability to measure outcomes are crucial for enabling continuous improvement in healthcare delivery. In Dubai, stakeholders highlighted the need for robust data infrastructure to support these efforts, mirroring the global understanding that high-quality, interoperable data systems are essential for tracking patient outcomes and benchmarking performance. Therefore, the alignment between Dubai's situation and the literature stresses the importance of investing in healthcare technology to support VBHC implementation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. According to Porter [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], active stakeholder participation ensures that all parties, including providers and patients, work towards shared value creation and outcome improvement goals. Dubai's stakeholders emphasise the need for comprehensive training programs and patient education initiatives, which correspond with international best practices that encourage a collaborative approach to healthcare, in which patient outcomes and satisfaction are prioritised [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Interviewees in Dubai emphasised the need for clear government policies and regulatory frameworks to drive VBHC implementation. This is consistent with the broader literature, which stresses that without supportive policies, healthcare systems struggle to transition away from FFS models [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe challenges identified in Dubai, such as change management and cultural barriers, reflect the obstacles commonly seen in the literature addressing transitions to VBHC. Porter and Lee [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] describe the difficulties in shifting entrenched organisational cultures from FFS (represented by the DRG) to PFP (represented by VBHC) models, particularly in regions with established traditional practices. Healthcare professionals in Dubai highlighted the need for leadership and change management strategies to support this transition. This aligns with the literature, which underscores solid leadership and a clear strategic vision to guide organisations through complex changes [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Additionally, overcoming cultural resistance requires fostering both understanding and accountability. This involves encouraging healthcare providers to prioritise outcome improvement; a challenge that is common across many global healthcare systems [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The literature also suggests that engagement is critical to overcoming resistance to change [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], which is particularly relevant given that cultural barriers were identified as a significant challenge in Dubai's healthcare landscape.\u003c/p\u003e\u003cp\u003eThe training sessions conducted by the EJADAH initiative team are suggested to involve a broader range of stakeholders to ensure that awareness and engagement reach all levels of the process, including the patient as an end-user of the service. Well-established population health programs can also tremendously increase the patient's awareness of the required value they should experience [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. It is notable that such well-established programs cannot proceed without appropriate IPU and care delivery value chain for each included medical condition [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]). Additionally, such population health initiatives require reliable integrated digital systems that can be trusted for data exchange and accuracy and used as a reservoir of an extensive database for the double loop organisational learning process. As NABIDH represent the centre data exchange platform, the only remaining part is the appropriate communication of these data through interoperable information systems installed by providers and payers. The activities mentioned in the ToC emphasise the role of culture change for involved stakeholders, particularly hospital leaders. Many interview participants considered it the most challenging part of the successful transformation. Once service provision leaders' buy-in is proven to regulators, the DHA can achieve consensus on the VBHC implementation policy, which will require changing the payment model. As a fixed payment model per condition severity, DRG indirectly sustains low cost and inconsistent service consumables and quality of qualifications. Quality incentives can be applied only when all stakeholders agree on a quality outcome resulting from medical consumables, preventive measures, providers' skills and qualifications, and an integrated multidisciplinary care approach. However, the role of the hospitals is to provide transparent data on CROMs, PROMs and PREMs; NABIDH must become fully functional, as it will be the only governance-monitoring entity.\u003c/p\u003e\u003cp\u003eFurthermore, alignment between the literature recommendations (particularly with the work of Porter and others in the field) and the suggested framework from this study, illustrated through the ToC model, provides the Dubai policymakers valuable insights into the benchmarked implementation model. Although the participants in this research highlight the need for clear policy and a roadmap, the study did not include this element in the list of enablers. The policy framework should be the ultimate result of listing an action plan to embrace the success factors and overcome the barriers. VBHC and its components, including service and patient priorities, match Dubai's current approach to enhancing healthcare delivery and patient-centricity. By addressing these challenges and leveraging the enablers, Dubai can create a healthcare system that aligns with international best practices.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study sheds light on the intricate dynamics that healthcare systems in Dubai undergo while transitioning towards VBHC. From the perspective of a health administration researcher, the insights gained are both practical and transformative. As Dubai strives to deliver care that prioritises patient outcomes over sheer volume of service, this research clearly outlines the essential enablers and challenges that should be addressed to ensure the success of VBHC initiatives.\u003c/p\u003e\u003cp\u003eThe ability of Dubai\u0026rsquo;s health stakeholders to harness data and technology as enablers is fundamental. Accurate and integrated data systems are the backbone of measuring patient outcomes; yet, as this study shows, health facilities in Dubai struggle with inconsistencies in data quality and fragmented technologies. For health service providers, this highlights the urgency of utilising seamless, interoperable systems that track outcomes and support continuous improvement in care processes. Equally important is stakeholder engagement. The findings show that collaboration and awareness at all levels, from frontline staff to policymakers, particularly hospital leaders, is critical to fostering a VBHC culture. Leading awareness campaigns and integrating VBHC principles into daily operations will instil a shared vision of patient-centred care.\u003c/p\u003e\u003cp\u003eHowever, the challenges are substantial. Cultural barriers and change management are significant hurdles, particularly within organisations entrenched in typical clinical care services. The resistance to shifting from fixed FFS (DRG) to PFP or VBHC models can be daunting. However, this study affirms that clear leadership and a well-structured change management approach can gradually dismantle these barriers. Those hospital leaders must champion this shift, fostering an environment of accountability and openness to innovation, where staff and patients are engaged in the journey towards higher-value care, moreover, dismantling revenue orientation as the only success model.\u003c/p\u003e\u003cp\u003eThe identified enablers and challenges have inspired the development of a ToC model for initiating the actions needed to implement VBHC policy in Dubai. The actions can be integrated to build for the actual VBHC policy framework, which is why the \"clear policy\" was removed from the list of enablers, although it was mentioned several times. The results of this study align with literature recommendations and can be considered a benchmark for Dubai.\u003c/p\u003e\u003cp\u003eThis research provides a roadmap for policymakers, hospital leaders and providers. It highlights how players in Dubai's healthcare landscape can overcome barriers and leverage enablers to achieve a healthcare system that delivers better outcomes, reduces costs, and enhances patient satisfaction. The study was aimed not just towards policy change but also at guiding transformation within the sector.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eACHS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAustralian Council on Healthcare Standards\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCEO\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChief Executive Officer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCPG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eClinical Practice Guidelines\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCROM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eClinical Reported Outcome Measure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDubai Health (the governmental health provider authority in Dubai)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDHA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDubai Health Authority (the main regulatory body in Dubai)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDHIC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDubai Health Insurance Corporation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDRG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiagnosis Related Group\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eEBP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEssential Benefit Plan\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eEMR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eElectronic Medical Record\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eEJADAH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eA program developed by DHIC to unify the CPG and CROMs for listed medical conditions.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eFFS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFee For Service\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGDP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGross Domestic Product\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eKPI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKey Performance Indicator\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHIS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Information System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHQ\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHeadquarters\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eICHOM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Consortium for Health Outcomes Measurement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIPU\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntegrated Practice Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInformation Technology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMOHAP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMinistry of Health and Prevention\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNABIDH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNetwork and Analysis Backbone for Integrated Dubai Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNVivo\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eA certified software widely used for thematic analysis by clarifying codes and words to themes\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePFP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePay for Performance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePREM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient-Reported Experience Measure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePROM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient-Reported Outcome Measure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eToC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTheory of Change\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUAE\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Arab Emirates\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUSD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States Dollar\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eVBHC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eValue-Based Healthcare\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study ethical review application was reviewed and approved by the Research Ethics Committee of the Department of Health Policy in the London School of Economics and Political Science under application reference number 377180. All individuals who participated in the study or provided information gave written informed consent prior to their participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available in a cloud folder (\"Generated and Analysed Dataset\"), which can be accessed at: https://1drv.ms/f/c/c56ad0a183f2e202/EmwhdbKcaWBMpDFZW3IRwkgBOzX8JPIvfXDwO4_2aP0Gyw?e=xXmQxG\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe signed consents to participation are not available in this directory, but can be provided upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not source any funding for this study from any organisation or educational institutions and received no financial support for the research, authorship, or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.E. contributed to the study by structuring the research design, communicating with participants, conducting interviews, collecting data, analysing the data, and preparing the initial draft. Y.E is also acting as corresponding author. S.A. contributed to the study by guiding the data analysis, framing the results, finalising the manuscript and conducting scientific and language reviews. All authors read and approved the final manuscript, and they are accountable for their contribution\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors \u0026nbsp;acknowledge the work of \u003cem\u003eMr Adrian Neal\u003c/em\u003e who has conducted final language check of the manuscript before submitting it for peer review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBraveman P, Gruskin S. Defining equity in health. 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Boston: Harvard Business School Press; 2006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFarghaly M, Alrustamani LA, Aladawy AIA, Suliman EAMA, Mukherjee B. HPR67 EJADAH: implementation of value-based healthcare in the Emirate of Dubai. Value in Health. 2023;26(6):S223. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jval.2023.03.1214\u003c/span\u003e\u003cspan address=\"10.1016/j.jval.2023.03.1214\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConrad DA. The theory of value-based payment incentives and their application to health care. Health Services Res. 2015;50(S2):2057\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1475-6773.12408\u003c/span\u003e\u003cspan address=\"10.1111/1475-6773.12408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtun R, Knaul FM, Akachi Y, Frenk J. Innovative financing for health: what is truly innovative? The Lancet. 2012;380(9858):2044\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(12)61460-3\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(12)61460-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKingdom of Saudi Arabia Council of Health Insurance. Value based health care in Saudi health insurance market; white paper on value-based payment; 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://chi.gov.sa/ResearchLibrary/VBHC%20White%20Paper%20Version%20Final.pdf\u003c/span\u003e\u003cspan address=\"https://chi.gov.sa/ResearchLibrary/VBHC%20White%20Paper%20Version%20Final.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 14 Nov 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbu Dhabi Department of Health. Pay for quality standard DoH/SD/HCQS/PQS/V1/2025; 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.doh.gov.ae/-/media/382860B41BFB4499\u003c/span\u003e\u003cspan address=\"https://www.doh.gov.ae/-/media/382860B41BFB4499\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eBD0EBECE83E6BA7C.ashx. Accessed 14 Jun 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Supreme Legislation Committee in the Emirate of Dubai, Government of Dubai Law No. (14) of 2021 amending law no. (6) of 2018 concerning the Dubai Health authority. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dlp.dubai.gov.ae/Legislation%20Reference/2021/Law%20\u003c/span\u003e\u003cspan address=\"https://dlp.dubai.gov.ae/Legislation%20Reference/2021/Law%20\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eNo.%20(14)%20of%202021%20Amending%20Law%20No.%20(6)%20of%202018.pdf. Accessed 22 Nov 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDubai Health Authority. Health accounts system of Dubai; 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dha.gov.ae/uploads/012025/Health%20Accounts%20System%20of%20Dubai_20232025150630.pdf\u003c/span\u003e\u003cspan address=\"https://dha.gov.ae/uploads/012025/Health%20Accounts%20System%20of%20Dubai_20232025150630.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Jan 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInternational Monetary Fund. United Arab Emirates GDP (%) \u0026amp; Inflation Rate. Country Data. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.imf.org/en/Countries/ARE\u003c/span\u003e\u003cspan address=\"https://www.imf.org/en/Countries/ARE\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Jan 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Bank Group. Inflation, consumer prices (annual %)\u0026mdash;United Arab Emirates, Saudi Arabia. International Financial Statistics and Data Files. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.worldbank.org/indicator/FP\u003c/span\u003e\u003cspan address=\"https://data.worldbank.org/indicator/FP\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.CPI.TOTL.ZG?end=2022\u0026amp;locations=AE-SA\u0026amp;start=2000. Accessed 17 Jan 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDubai Healthcare City Authority\u0026ndash;Arab Health. Dubai\u0026rsquo;s healthcare ecosystem highlights. White Paper Media; 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dhcc.ae/Documents/arabhealth-2024/highlight-report-5-2-24.pdf\u003c/span\u003e\u003cspan address=\"https://dhcc.ae/Documents/arabhealth-2024/highlight-report-5-2-24.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Jan 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGovernment of Dubai Media Office. Dubai sees 11.5% year-on-year growth in number of health facilities in Q1 2023. 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Accessed 17 Jan 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDubai Health Authority, Insurance System for Advancing Healthcare in Dubai (ISAHD), EJADAH KPIs \u0026amp; recommendations; 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.isahd.ae/Home/EJADAHKPIs\u003c/span\u003e\u003cspan address=\"https://www.isahd.ae/Home/EJADAHKPIs\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Jan 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW. Qualitative inquiry and research design: choosing among five traditions. Sage Publications; 1998.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePorter ME, Lee TH. The strategy that will fix health care. Harvard Business Review. 2013;91(10):50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlick U, Metzler K, Scott W. The SAGE handbook of qualitative data analysis. Sage Publications; 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res, 2007;42(4):1758\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1475-6773.2006.00684.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1475-6773.2006.00684.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDenzin, Norman K., and Yvonna S. Lincoln, editors. Handbook of Qualitative Research. Sage, 1994, Pg 391\u0026ndash;402\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, Sweeney J. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood). 2013;32(2):223\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1377/hlthaff.2012.1133\u003c/span\u003e\u003cspan address=\"10.1377/hlthaff.2012.1133\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGray M, Turabi AE. Optimising the value of interventions for populations. BMJ. 2012;345:e6192. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.e6192\u003c/span\u003e\u003cspan address=\"10.1136/bmj.e6192\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaplan RS, Porter ME, Frigo ML. Managing healthcare costs and value. Strategic Finance. 2017;98(7): 24\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShortell SM, Poon BY, Ramsay PP, Rodriguez HP, Ivey SL, Huber T, et al. A multilevel analysis of patient engagement and patient-reported outcomes in primary care practices of accountable care organizations. J Gen Intern Med. 2017;32(6):640\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5):1418\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1377/hlthaff.28.5.1418\u003c/span\u003e\u003cspan address=\"10.1377/hlthaff.28.5.1418\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreasley K, Watson P, Patel S. (2009). The impact of organisational change on public sector employees implementing the UK Government\u0026rsquo;s \"Back to work\" programme. Employee Relations. 2009;31(4):382\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/01425450910965432\u003c/span\u003e\u003cspan address=\"10.1108/01425450910965432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapanicolas I. Cylus J. Comparison of healthcare systems performance. In Kuhlmann E, Blank RH, Bourgeault IL, Wendt C, editors. The Palgrave International Handbook of Healthcare Policy and Governance. London: Palgrave Macmillan; 2015: pp. 116\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTeisberg E, Wallace S, O\u0026rsquo;Hara S. Defining and implementing value-based health care: a strategic framework. Acad Med. 2020;95(5):682\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ACM.0000000000003122\u003c/span\u003e\u003cspan address=\"10.1097/ACM.0000000000003122\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e EJADAH is a program initiated by DHIC (Dubai Health Insurance Corporation, Dubai Health Authority) in 2021 to work on specific medical conditions to achieve stakeholder consensus on preventive care parameters and appropriate treatment protocols. Until end of 2024, the program has published 20 CPGs aiming to ensure the collaboration of providers, pharmaceuticals, and payers to unify standardised CPG and outcome measures. The program aims to work on specific medical conditions that achieve the consensus of all stakeholders on preventive parameters and appropriate management. As per these CPG, payers started to reject coverage if providers were proven to not adhere to them; and planned in the future that all healthcare facilities will have to provide annual outcome measures database to the initiative to help in the double-loop learning model which shall serve as the new gateway to population health modalities.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Challenges and enablers, Dubai, Gulf region, Health policy, Middle East region, Qualitative analysis, Policy frameworks, Value-based healthcare, Thematic analysis, Theory of change","lastPublishedDoi":"10.21203/rs.3.rs-7606906/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7606906/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDespite global investments in healthcare, access to and quality of care remain inadequate, particularly in the Middle East, where value-based healthcare (VBHC) is still an emerging concept. This study investigates the enablers and barriers to VBHC implementation in Dubai, a city with a rapidly evolving healthcare landscape. However, there is no formal policy framework supporting the emerging and strategic initiatives of the Dubai health sector to incentivise quality of care as a success factor in healthcare.\u003c/p\u003e\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThe study seeks to pinpoint factors that impact the implementation of VBHC, address the challenges that hinder its full potential, and suggest a roadmap for shaping future policies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative methodology utilised semi-structured interviews with 17 key stakeholders, including regulators, payers, providers, administrators and consultants in the healthcare sector in Dubai. These interviews took place between June 2024 and October 2024, and the collected data was analysed thematically using NVivo software with deductive and inductive coding to identify enabler and challenge themes. The connections between the two lists were mapped using a theory of change model to design the most possible action plan to obtain optimal short-term outcome and long-term impact of VBHC. The results are aligned to be validated against literature recommendations specially the Porter's VBHC implementation agenda.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe results reveal that the six key enablers of VBHC in Dubai include strong stakeholder engagement and awareness, robust data and technology infrastructure, and a clear regulatory framework. Conversely, seven challenges, such as poor data quality, resistance to change, and cultural barriers, were identified as critical obstacles. The discussion of the data raised a model to facilitate VBHC implementation, which focuses on improving data accuracy, fostering collaboration among stakeholders, and ensuring that reimbursement models align with desired patient outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe study provides insights for policymakers, healthcare leaders and providers in Dubai. It also highlights the critical steps needed to transition towards a healthcare system that reimburses for quality, prioritises value over volume, enhances patient outcomes, and reduces healthcare costs. While many gaps still need to be filled, a proposed policy framework and theory of change were illustrated as pathways to further improvement.\u003c/p\u003e","manuscriptTitle":"Enablers and challenges in implementing value-based healthcare in Dubai - Framework analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 17:26:52","doi":"10.21203/rs.3.rs-7606906/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eab0c758-8b05-4418-b657-ef4b30298df4","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-03T17:24:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-31 17:26:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7606906","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7606906","identity":"rs-7606906","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}