Introduction

The United Arab Emirates has seen private and public sector healthcare service growth. The private sector has a vital role to play in the development of the structure of the healthcare system in the country. In the post-pandemic recovery period, it is critical to develop business plans that will help the business to regain its position aligned with the long-term goals, as well as recover the emotional, technological, systemic, and financial damage during the COVID-19 pandemic. It is observed that increased healthcare demand in the UAE is causing pressure on organizations to maintain their operational activities to the desired level of customer satisfaction. The benefits of increased demand can be compromised in the presence of associated challenging factors. For example, the overworked staff, increase in declining insurance claims, increased pressure on the existing infrastructure, and higher cost of operations are causing frustration among healthcare organizations. The hospitals are also meeting the healthcare compliance requirements for an increased satisfaction of stakeholders in the presence of a high degree of competitiveness. One of the strategies of healthcare service providers to deal with these challenges is the outsourcing of some operations. The obvious reasons include meeting compliance requirements; addressing the competition; continuity of services; and reducing direct involvement in the support services. Despite the observable reasons, the hospitals in Dubai may have latent reasons to support outsourcing practices. 

For example: 

·       The outsourcing of health services is strategically aligned.

·       The bandwagon effect [1] can encourage hospitals to adopt outsourcing practices as a fashionable way of doing business. 

·       The marketing efforts of outsourcing firms are often successful, and they present convincing attractive reasons in front of hospital management to consider outsourcing as a viable option. 

·       The vested interests [2] of medical staff can influence the organizational decision-making to adopt outsourcing practices. 

·       The hindsight bias [3] can impact decision-making due to the successful experiences of senior leadership in previous jobs.

The outsourcing services provided by partner companies in the Dubai healthcare sector are covering operations related to HR processes, IT services, Equipment, Laboratory services, Pharmacy, Cleaning, Laundry, Finance/Accounting, HR processes, and Security. The outsourcing of operations allows maximum time and resources of hospitals to be engaged towards the core functions of health care. 

The key stakeholders of healthcare sectors are government, patients, healthcare sector staff, suppliers, and outsourcing firms. Healthcare service providers and governments are found to favor outsourcing as a strategic option. The outsourcing companies, as being the direct beneficiary support the outsourcing. But on the other hand, the three groups of stakeholders are found to have varying degrees of disagreement with the outsourcing options. They are current healthcare service staff, suppliers, and customers. Current staff are afraid of losing their job if their organization opt for outsourcing. The increased fear among permanent staff leads to the practices to protect their jobs. They are found creating justifications for their roles in the organization. This leads to many inefficiencies in the organization. Some of them also take an aggressive stance against outsourcing by raising voices and developing general opinions among staff. It is also observed that outsourcing staff has weak organizational commitment. They are more committed to their own companies instead of the hospitals. The lack of enough alignment between outsourcing firms' goals and hospitals' objectives is causing poor responses to the patients and affects the quality of healthcare services. From the suppliers’ point of view, the suppliers’ firms are considering outsourcing practices in their favor. Outsourcing firms have their own listed supplier firms. Many current suppliers attached to the hospitals in tier-1 and tier-2 categories have either lost their business or they have compromised to work with outsourcing firms at lower returns. The third stakeholder is the patient. Patients find some degree of disconnection with serving staff from outsourcing firms. The feelings of decrease in the personalized healthcare service cumulate the dissatisfaction score. The patient's interaction with their healthcare practitioner results in the patient's experience. It serves as their foundation for forming opinions about the healthcare organization. Every encounter, from making an online appointment to receiving post-operative care, has an impact on how patients feel about their whole experience. Patients are also found complaining about the higher treatment cost, and the insurance companies are also not approving the costly treatments. As a result, they prefer to travel back to their home countries for cheaper treatment, or to destinations where cheaper quality health service is available. Those who cannot travel, are found compromising on the health issues and delaying the treatment. This increases the risk of their life. In the case of the working class, this condition is affecting their performance and they are facing the risk of losing jobs. 

A large volume of literature is available on outsourcing in the healthcare sector. The available literature is not considered enough to understand the post-pandemic scenario of outsourcing in healthcare services, especially in the context of the UAE. The purpose of this study is to examine the case of outsourcing practices and to produce a valid justification for outsourcing in Dubai's healthcare sector. 

The research objective is to analyze the types, benefits, and challenges of outsourcing in Dubai's healthcare sector, to evaluate the justification of outsourcing practices in Dubai's healthcare service providers. 

The objective can be achieved by finding the answer to the following questions with reference to the Dubai healthcare service providers:

1.     What major types of outsourcing activities are in practice?

2.     Is the outsourcing strategically aligned?

3.     What are the benefits (impact) of outsourcing?

4.     What are the challenges in outsourcing?

5.     What are the concerns of the patients, suppliers, and staff?

6.     Can the stakeholders’ interests be aligned in favor of outsourcing?

The examination of types, benefits, and challenges of outsourcing in Dubai healthcare service providers will serve the objective of understanding the current outsourcing trends and finding the justification for outsourcing practices. 

The current study assumes that the post-pandemic healthcare environment is sliding away from the emergent to the perspective strategic profile. The service providers are able to anticipate healthcare requirements and can develop strategic plans with more confidence. Outsourcing as a strategic option can help in achieving the goals of reducing the cost of doing business; providing the latest treatment facilities; providing faster healthcare services to patients; facilitating treatment processes; and complying with healthcare service standards. The potential impact of outsourcing can be seen from different perspectives. Alignment between stakeholders of healthcare services can increase the effectiveness of outsourcing practices.

To keep up with the health needs of the increasing population, the UAE has continuously enhanced the efficiencies of private hospitals. Private hospitals have been largely dependent on their outsourcing process to enhance their quality and grow their revenue. As per [4] outsourcing by external companies to private hospitals has enabled enhancing the IT supports in the hospitals. The IT framework has enabled private hospitals to stay updated as well as to enhance their treatment facilities instantly. On the other hand, private hospitals have also outsourced services to external companies. They have provided external companies with safety and health regulations, nurses to check the health issues of their employees, and basic medicines to provide basic treatments to the workforce. Therefore, it can be observed that both internal and external outsourcing has been largely beneficial for private hospitals in the United Arab Emirates. 

Outsourcing has been successful in the areas of pharmacy, security, laboratory services, cleaning, laundry, It services, etc. [5] Application development, application maintenance, and infrastructure management are all examples of IT outsourcing [6]. To reduce maintenance costs, hospitals outsource application maintenance [7,8]. The size of outsourcing of medical professionals is high, according to a review of the literature. The most essential motivation for outsourcing is the excessively high costs of maintaining one's own workforce, which is a result of high staff costs that occur when creating collaboration under the terms of a contract of employment [9]. Outsourcing is a vital activity that hospitals should achieve [10]. According to [11], poor service quality, management systems, customer orientation, and data protection had a greater impact on supplier evaluation. 

Outsourcing has also enabled hospitals to reduce the pressure. It has been hard for private hospitals to accommodate an increasing number of affected patients. Hence, they have outsourced the necessary equipment and medications to the local medical bases to enable them to treat the affected. The services outsourced by private hospitals have enabled them to enhance their business reputations as well as profit percentages. It has also been observed that private hospitals have outsourced their services globally. The UAE has supported other Gulf nations to fight the pandemic by continuously outsourcing services through their private hospitals. Considering the growing importance of outsourcing, private healthcare’s have intended to outsource their resources and equipment from foreign nations. According to [12], the nations like the United States, the United Kingdom, France, and others have maintained effective healthcare systems. They have used advanced equipment to ensure proper treatments for their patients. Outsourcing from foreign markets has enabled private healthcare to enhance its overall treatment and cure facilities.

In another study by [13], hospitals in Turkey use outsourcing in a wide range of operations covering financial investments, consultation, research and development, ambulance and customer transportation, accounting, laundry, security, laboratory, imaging, food, medical devices, maintenance, cleaning, and information systems. The main objectives behind outsourcing were to achieve service efficiency, service quality, speed and flexibility in delivery, and risk management.

Hospitals in developing countries also rely on outsourcing. The proportion of health care services in these countries are provided by government hospitals. The gap in technology and skills is covered by adopting outsourcing options. Outsourcing is considered a strategic action to fill the gap between the desired level of services and current conditions on the ground, and major outsourcing in these countries is covering administrative processes [14].

For example, a study on eighty-three private (49) and public (29) hospitals in Jordan examines the nature of outsourcing practices [15]. The study shows that all these hospitals used at least 2 outsourced services. The main purpose of using outsourcing was waste management and workforce supply.

The outsourcing partners will enable hospitals to adopt new technologies and carry out additional operations to enhance the capacity of hospitals to provide satisfying services to patients [16]. For example, IT support companies have enabled modern hospitals to enhance their treatment facilities by enabling doctors to stay updated with the changing natures of healthcare requirements [17].  Hospitals can avoid channelizing financial resources into new investments and instead use current resources for better service quality. The outsourcing companies on the other hand fill the gap by investing in technologies and skills to extend services to partner hospitals [4]. Outsourcing companies are specialists in this sense [18], and they will have the ability to offer the service much more efficiently and effectively at a lower cost. Hospitals are outsourcing multiple services, which take the form of a network of outsourcing companies attached to the hospital and increasing the overall service quality and capacity. According to [15], managers in the majority of the hospitals in Jordan encourage outsourcing in healthcare facilities as a means to achieve long-term goals.

Apart from all the benefits, outsourcing has also included some challenges. The hospital's management has no direct control over the staff from the outsourcing companies [19]. They can send feedback or report poor performance. The staff of an outsourcing company at any location is more attuned to the original employer. Similarly, it is observed that the companies involved in outsourcing have often faced problems in decision-making. According to [20], the original decision undertaken by the organization is influenced by external companies. In the case of the healthcare sector, it is observed that outsourcing has made the price determination process challenging. The healthcare sector has to rely upon the decisions of its external outsourcing companies to determine the price for their services. As discussed by [20] the issues in price determination often led to the increasing price of services and treatments in hospitals. Thus, patients are obtaining care at a higher cost. On the other hand, the management of healthcare does not have control over the employees of external companies. Due to a lack of management, external employees often disrupt the ethical consideration and compliance of healthcare to health and safety regulations. Political interference also affects the performance of healthcare services and reduces the benefits of outsourcing [15]. Other challenges of outsourcing include the breach of the private data of patients. That is because having no control, supervision, management, or power over the outsourced employees can put a threat to the data and information of the patients [21]. In addition, it is well known that the more people who have the authorization to access private patients, the more the risk and threat of a breach. Healthcare services through outsourcing companies are also affected due to miscommunication between hospital staff and partner companies. This results in delay and patient dissatisfaction. The use of outsourcing for reducing the workforce resulted negatively in Turkey [15]. This resulted in compromised confidentiality and privacy of confidential information about patients and other matters. 

The literature review guides the study for the following theoretical framework.

Figure 1. Theoretical Framework

Healthcare service providers consider outsourcing as a strategy to improve the standard of their services and to provide healthcare facilities at affordable prices. Despite the fact that it has been so many years since the outsourcing strategy was implemented in the healthcare industry, there is a requirement for a model that guides decision-makers in the healthcare sector to the key factor which acts as an enabler for achieving strategic goals. The model proposes the leadership role in the protection of the interests of all stakeholders while adopting an outsourcing strategy. The framework suggests that the success of outsourcing practices depends on the perceived impact on stakeholders. If hospitals are able to design an outsourcing strategy in a manner that can align and protect the stakeholders’ interests, the outsourcing practices will cause a positive impact on outsourcing. Outsourcing as a strategic attempt is required to address the challenges faced by healthcare service providers. The benefit of outsourcing must be reflected in the lower cost of service, improved patient satisfaction, better equipment, and service facilities. The key stakeholders are patients, suppliers, and hospital staff are satisfied if their concerns are addressed. The proposed model suggests the moderating role of the deliberate alignment process, which can create success in outsourcing strategy. The perception of stakeholders can be changed to favor outsourcing if the potential fear is controlled. 

 The following research hypotheses are framed.

1. Outsourcing is adopted as a strategy to meet the long-term goals of the hospitals. 

1.1. Outsourcing in Dubai health care helps in reducing the cost of doing business.

1.2. Outsourcing in Dubai health care helps in providing quality modern health care services.

1.3. Outsourcing in Dubai health care helps in providing faster health care series to patients.

1.4. Outsourcing in Dubai health care helps in increased patient satisfaction.

1.5. Outsourcing in Dubai health care helps in attracting GCC patients.

2. Outsourcing arrangements are protecting the interests of stakeholders.

2.1 Patents' interests are addressed

2.2 Suppliers’ interests are addressed.

2.3 Healthcare staff interests are addressed.

3. Outsourcing practices are helping Dubai's healthcare sector to meet its strategic goals.

3.1. Outsourcing in Dubai health care helps in reducing the cost of doing business.

3.2. Outsourcing in Dubai health care helps in providing quality modern health care services.

3.3. Outsourcing in Dubai health care helps in providing faster health care series to patients.

3.4. Outsourcing in Dubai health care helps in increased patient satisfaction.

3.5. Outsourcing in Dubai health care helps in attracting GCC patients.

2. Materials and Methods

The data was collected through questionnaires and interviews. Three interviews were conducted to obtain a deeper insight into the outsourcing practices. One interview was conducted with senior leadership of the hospital, one with an official in the Ministry of Health, and one with a patient with longer treatment history. A descriptive research design is appropriate for producing the data evidence to examine the hypotheses in this study. The primary quantitative data was collected from employees and leadership of 32 private hospitals in Dubai through an online survey. The questionnaire was sent to doctors and nurses. Out of 255 responses, 252 responses were included in the analysis after removing three unengaged responses. The survey questions were measuring the degree of agreeableness on the 5-point Likert scale. The respondents were asked to provide information about age, and sex to understand the demographic distribution of the data. Other questions were taking opinions about the understanding of the purpose of outsourcing in their hospitals, criteria to select outsourcing partners, types of services outsourced, benefits of outsourcing to their organization, and key challenges in finalizing for the outsourcing company.

3. Results

The proportion of 52% of respondents was between the ages 25 to 30 years, followed by 37% between 35 to 40 years, and only 10% were above 45 years of age. The majority of participants who are chosen for the survey are young and the gender proportion is male (60%) and female (40%) respondents. Data shows that laundry services are the most popular (42%) outsourcing activity among hospitals, followed by IT services (31%), food (12%), laboratory tests (6%), transport (6%), and cleaning (3%). The survey data also confirms that there is no clear agreement among respondents about the outsourcing of HR services. About 44% respond supporting HR services being outsourced, whereas another 45% go against it and consider HR operations should remain in the direct control of hospitals. The common reasons, why hospitals outsource health services include reducing and decreasing cost (76%), enhancing the quality of services (57%), faster delivery of healthcare services (53%), increasing patient satisfaction (43%), and attracting GCC patients (40%).  The survey results show that the majority of respondents are clear about the challenges faced by healthcare service providers. About 42% of respondents understand that outsourcing limits direct managerial control over the services provided by the partner firms. There is a concern among respondents (23%) that outsourcing companies failed to meet contractual requirements. Some (30%) consider that outsourcing is a reason for the higher price of services, and it can be reduced if hospitals themselves provide these services.

4. Discussion

The current study has attempted to understand the nature, purpose, and impact of outsourcing practices by healthcare service providers in Dubai. The survey data analysis shows that outsourcing is essential for enhancing all-around operations and qualities in healthcare facilities. The survey has stated that outsourcing has enabled Dubai private hospitals to enhance their treatment facilities for patients. As supported by [20], the enhanced quality has enabled hospitals to cure critical diseases and carry out surgeries effectively. The outsourcing partner was chosen based on various criteria including the company’s experience and reputation in the market, cost-effectiveness, quality of service, company size, and scope of services. To develop an understanding between the partners, external companies need to have the right knowledge and experience in healthcare facilities. The major outsourcing was done in laundry, IT services, and food delivery. According to [22], the most important outsourcing services in private hospitals in Dubai are laundry and IT services. The laundry service is used for both patients and staff. It has also enabled hospitals to maintain safety and health regulations. On the other hand, IT services have been important for enhancing the efficiencies of healthcare professionals. The IT services have enabled doctors and nurses to stay updated with modern treatment techniques and medications. It has also enabled doctors to use advanced equipment in critical surgeries. Price negotiations and what services to be outsourced were considered two key challenges during the selection process. Hospitals have faced some difficulties in negotiating with their outsourcing partners. As per the majority’s view, private hospitals and external companies have often disagreed on price determination. Hospitals and outsourcing companies belong to different sectors; thus, it is not possible to expect the right price [23]. 

H1: Outsourcing is adopted as a strategy to meet the long-term goals of the hospitals. 

The survey and interview results show that the majority of respondents are clear about the challenges faced by healthcare service providers. The highest score is observed for reducing healthcare service costs (76%). Other common issues identified are improvement in quality and speed of service, increased patient satisfaction, and attracting GCC patients to UAE. This indicates that outsourcing is justified as a strategic option to deal with these challenges. The analysis data confirms that the majority of respondents believe that outsourcing has helped in achieving cost efficiency and quality of health care services. HR services were also considered appropriate for outsourcing as it has a direct link to cost efficiency and quality of service. These results also confirm [15] findings that the majority of managers in Jordanian hospitals considered outsourcing in healthcare facilities as a means to achieve long-term goals. 

H2: Outsourcing arrangements are protecting the interests of stakeholders.

The analysis shows that the majority (54%) of respondents have no fear or bias towards outsourcing. Although 46% of respondents replied that they fear losing their jobs. In the interview with the supplier, it was observed that small-size supplier companies are afraid they will lose their business, whereas the large supplier companies do not consider it as a fear, as they are also qualified suppliers for the outsourcing companies in UAE. The interview with the patient provided evidence that in routine medical checkups, the patient has not observed any difference in the personalized service quality. The patient with long disease history and frequently treated has observed that the quality of the permanent staff was better than the staff from outsourced companies. The interview with a government official in health ministries confirmed that they are satisfied with the outsourcing operations in the hospital as it helps in increased quality and capacity, and to obtain competitive prices of health services. Moreover, the outsourcing firm with international experience contributes to the uplifting of service standards in the country.

H3: Outsourcing practices are helping Dubai's healthcare sector to meet its strategic goals.

The interview analysis with senior leadership in the hospital confirmed that outsourcing as a strategy helped in reducing the cost of doing business. The quality of services has increased and is provided with the use of the latest equipment, technology, and materials. The key benefit is the availability of improved services to the patients. It was highlighted that before outsourcing practices access to the latest technology and equipment was not very quick and it took a long time to seek approval for the change in machines, software, and processes. Leaders replied that they are observing improvement in customer satisfaction and demand for health care services by the GCC patients. In reply to the question about the appointment of outsourcing firms, the respondents mentioned that the role of leadership is very important for such decision-making. Companies are invited through a prequalification process, followed by extensive negotiations to reach a contract that can assure the protection of the interests of all stakeholders, especially the patients, staff, and small-size supplies of the hospitals. The criteria to select outsourcing partners were based on industry experience, cost-effectiveness, quality of service, company size, and market position. The experience of the partner company was considered an important element to offer outsourcing facilities. The major point on the negotiation agenda was the determination of the price offered by the outsourcing companies. It was pointed out that the determination of the scope of services was always a major challenge in finalizing the contract with outsourcing firms.

5. Conclusions

The study guides the research that outsourcing is important to improve the capabilities of healthcare facilities and to meet strategic goals. Outsourcing enables the healthcare service providers in Dubai to bring high-quality efficient service to an affordable range of patients in the UAE and GCC. The business arrangements with the outsourcing companies should be carefully finalized so that the interests of key stakeholders are addressed. The role of leadership is important in protecting the stakeholders’ interests. Hospital management can influence the three stages. First when pre-qualifications of outsourcing firms are undertaken, second when the contract is written, and third at the stage of final decision grating contract to the shortlisted firms. The stakeholder analysis process must be completed beforehand to understand the conditions that should be considered before taking an outsourcing firm on board. The following recommendations have been made to ensure the future development of the outsourcing process to complete the future operations of healthcare services in Dubai: 

·      Partnership development: It is important to have an effective relationship between the hospitals and outsourcing companies. The developed partnership will enable parties to get benefits for each other and carry out the process effectively.  

·      Cross-cultural management: Cross-cultural management is necessary to mitigate the cultural and ethical barriers between hospitals and outsourcing companies. Thus, they will be able to understand each other requirements.  

·      Decision-making: Both healthcare and outsourcing company needs to participate equally in the decision-making process. Proper negotiation is important to meet the requirements. 

·      Risk management: The hospitals need to have a risk management strategy in case their outsourcing partner poses threats to them. 

·      Stakeholders’ alignment: The hospitals should improve communication with patients, suppliers, and current staff for more informed decision-making.

Notes:

all authors declare that there are no conflicts of interest.

all authors declare that this research did not receive any funding for the research.