Health care system in Saudi Arabia: an overview

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Review

M. Almalki, G. Fitzgerald and M. Clark

The ability to formulate and apply practical strategies to retain and attract more Saudis into the medical and health professions, particularly nursing, is a clear priority for effective reform of the Saudi health care system. Many efforts have been taken by the government to teach and train Saudis for health professional jobs. Since ‎1958‎, a number of medical, nursing and health schools have been opened around the nation to meet this goal [7]. Apart from private colleges and institutes, there are a total of 73 colleges for medicine, health and nursing as well as 4 health institutes in Saudi Arabia [4]. Efforts to establish such colleges are in accordance with training programmes that aim to substitute the largely expatriate workforce with qualified Saudi Arabian nationals in all sectors, including health [18,29]. The budget allocation for training and scholarships has increased and many MOH employees are offered a chance to pursue their studies abroad [18]. This strategy could improve the skills of current employees, raise the quality of health care and, it is hoped, decrease the rate of turnover among health professionals. However, these efforts may not be enough to solve the challenges. The proportion of Saudi Arabian health professionals in the MOH workforce is expected to decrease in the future as the expansion in health care facilities around the country has the effect of spreading a scare resource even more thinly [17,30].

More realistic plans and long-term strategies need to be consolidated by the MOH in cooperation with government and private sectors. A good example of such cooperation is the King Abdullah international scholarship programme which was established by the Ministry of Higher Education. In its stage 4, priority has been given to medical specialists including medicine, nursing, pharmacy and other health majors [31]. However, more medical colleges and training programmes need to be established around the country. New laws and regulations to develop and reorganize medical human resources by the MOH are urgently required.

Reorganization and restructuring of the MOH

The public health sector is overwhelmingly financed, operated, controlled, supervised and managed by the MOH [32]. This model of management may not able to meet the population’s health care needs into the future unless serious and well-planned steps are taken to separate these multiple roles. Possible solutions include giving more authority to the regional directorates, applying the cooperative health insurance scheme and encouraging the privatization of public hospitals.

Decentralization of health services and autonomy of hospitals

To meet increasing pressure on the MOH, more autonomy has been given to the regional directorates in terms of planning, recruitment of professional staff, formulating agreements with health services providers (operating companies) and some limited financial discretion. It has been suggested that the functioning of the regional directorates is adversely affected by the lack of individual budgets and spending authority [16]. Expenditure for the majority of their activities must be authorized by the MOH, thus affecting the autonomy of regional directorates and hampering effective decision-making.

In terms of hospital autonomy, the MOH has tried a number of strategies for improving the management of public hospitals during past decades, including direct operation by the MOH, cooperation with other governments such the Netherlands, Germany and Thailand, partial operation by health care companies, comprehensive operation by health care companies and the autonomous hospital system [33]. Considering the advantages and disadvantages of these approaches, the MOH has standardized an autonomous hospital system for 31 public hospitals in various regions [34]. The autonomous hospital system for public hospitals is expected to raise the efficiency of their performance in both medical and managerial functions, achieve financial and administrative flexibility through adopting a direct budget strategy, apply quality insurance programmes and simplify the contractual process with qualified health professionals [33]. In 2009, the MOH issued new regulations for self-operating public hospitals to ensure a high level of management practices and to improve the quality of services provided [35]. Giving more autonomy to hospitals will help the transition to full privatization of public hospitals in Saudi Arabia. It gives public hospitals more experience in the management of their budgets, health care quality and workforce.

Health insurance in Saudi Arabia

Funding health care services is a central challenge faced by the MOH [32]. Since the total expenditure on public health services comes from the government and the services are free-of-charge, this lead to considerable cost pressure on the government, particularly in view of the rapid growth in the population, the high price of new technology and the growing awareness about health and disease among the community [14]. To meet the growing population demands for health care and to ensure the quality of services provided, the Council for Cooperative Health Insurance was established by the government in 1999 [19]. The main role of this Council is to introduce, regulate and supervise a health insurance strategy for the Saudi health care market.

The implementation of a cooperative health insurance scheme was planned over 3 stages. In the first stage, the cooperative health insurance was applied for non-Saudis and Saudis in the private sector, in which their employers have to pay for health cover costs. In the second stage, the cooperative health insurance is to be applied for Saudis and non-Saudis working in the government sector. The government will pay the cooperative health insurance costs for this category of employee. In the final stage, the cooperative health insurance will be applied to other groups, such as pilgrims [36]. Only the first stage has been implemented to date, with the cooperative health insurance being implemented gradually in a 3-phase programme to employees of the private sector and their dependants [14,37]. The first phase covered companies with 500 or more employees, while the second phase applied to employers with more than 100 workers. The third phase included employees of all companies in Saudi Arabia as well as domestic workers [14,37]. The government is now working systematically to apply the remaining 2 stages—for employees in the government sector and for pilgrims—before they privatize the state-owned health care facilities [14]. No information is available yet regarding the cooperative health insurance scheme for the population of Saudi Arabia other than employees and expatriates.

While the market for cooperative health insurance in Saudi Arabia started with only 1 company in 2004, it currently involves about 25 companies. The introduction of the scheme is intended to decrease the financial burden on Saudi Arabia due to the costs associated with providing health services free-of-charge. It will also give people more opportunity to choose the health services they require [14]. The real challenge for policy-makers in Saudi Arabia is to introduce a comprehensive, fair, and affordable service for the whole population. Clearly lessons can be learned from the experiences of other countries, including the advantages and disadvantages of different schemes.

Privatization of public hospitals

Privatization of public hospitals has been seen by policy-makers and researchers as the best way to reform the Saudi health care system [38,39]. Steps to implement a privatization strategy have been initiated and related regulation has been passed by the government. As a result, a number of public hospitals are likely to be sold or rented to private firms over the next few years [14]. Privatization of hospitals is expected to bring a number of advantages to the government and to the nation. It is hoped that privatization will assist in speeding up decision-making, reducing the government’s annual expenditure on health care, producing new financial sources for the MOH and improving health care services [38].

On the other hand, privatization may affect the current integrated system between hospitals and PHC facilities [14]. As hospitals become privatized, they will focus on attracting patients, even those who may not require hospital-level care. Moreover, people with health cover may prefer to access big hospitals directly instead of via PHC centres or community hospitals. Additionally, private hospitals will have incentives to shift non-refundable costs back to the public PHC [14]. Such practices will place financial burdens on the government.

A further drawback of privatization is that the traditional state/public hospitals will not be able to absorb enough of the health care market compared with private companies, unless they upgrade at all levels (e.g. management, infrastructure and workforce) before starting to privatize [14]. In the move to privatization, private companies are likely to focus their activities within cities and larger communities, leaving people in rural areas at a disadvantage. The government should set regulations that protect the rights of rural communities and provide them with fair and equitable health care services.

Finally, if the government does not apply adequate control over the health care market, expenditure on health care may increase dramatically as a result of higher pricing and profit-seeking behaviour [14].

Accessibility to health services

Optimizing the accessibility of health care services requires equity in the distribution of health care facilities throughout the nation and equity of access to health professionals, including transport to services and providers. Accessibility is also affected by the level of cooperation between related sectors [23,39]. The current MOH statistics indicate that there is a maldistribution of health care services and health professionals across geographical areas [4]. People experience long waiting lists for many health care services and facilities [14]. Additionally, there is a dearth of services for disadvantaged groups such as the elderly, adolescents and people with special needs such as disability, particularly in rural areas [39]. Finally, many people do not have the ability to access health care facilities, particularly those living in border and remote areas.

In order to improve accessibility to health care services in all parts of the country, a holistic strategy for the redistribution of health care services, involving PHC centres, general hospitals, central and specialist hospitals as well as the health professionals, should be adopted by the MOH. The MOH should also liaise with other sectors such transport, water and power companies and social security services in order to develop services in deprived areas and to care for people with the greatest needs.

Patterns of diseases

The change in disease patterns from communicable to noncommunicable diseases in Saudi Arabia is another challenge that needs more attention from the MOH [21]. There has been an alarming increase in the prevalence of chronic diseases, such as diabetes, hypertension, and heart diseases, cancer, genetic blood disorders and childhood obesity [28,40,41]. Treatment of chronic diseases is costly and may even be ineffective [40]. For example, the annual cost for treatment of diabetes mellitus in Saudi Arabia was estimated to be 7 billion Saudi riyal (SR) (US$ 1.87 billion) [42]. Early prevention is the most effective way to reduce the prevalence of chronic diseases and the costs and difficulties associated with treatment in the later stages of disease. Any projected reforms in the health care system must involve plans to address this change in emphasize.

Promotion and prevention programmes for crises

Development and implementation of practical plans and procedures to meet national crises in Saudi Arabia, such as wars, earthquakes and fires and explosions at petroleum factories, are a further important need. Road traffic accidents, for example, killed more than 39 000 and injured about 290 000 people between 1995 and 2004 [43]. According to WHO, road traffic accidents are now the highest cause of death, injury and disability in adult males aged 16 to 36 years in Saudi Arabia [32]. Caring for people affected by road accidents consumes a significant proportion of the MOH budget; for example, the cost of treating injured people during 2002 was estimated to be SR 652.5 million (US$ 174 million) [43]. These funds could be used to develop the health system and improve services. Plans to manage issues of this kind need to be comprehensive and well-coordinated among the related sectors in order to be achievable.

e-health and national health information systems

There is increasing concern about the underutilization of electronic health systems in Saudi Arabia. Implementation of e-health and electronic information systems has already started in a number of hospitals and organizations such as the King Faisal specialist hospital and research centre, national guard health affairs, medical services of the army forces and university hospitals [44]. While uptake of e-health systems is moving slowly in MOH institutions, there are a number of information systems operating in the regional directorates and in central hospitals. Unfortunately, these information systems are not connected to each other or to other private or specialized health organizations [44].

To develop e-health services in the public sector, a budget of SR 4 billion (US$ 1.1 billion) was allocated by the MOH to run a 4-year development programme (2008–11) [45]. Additionally, a series of conferences on e-health have been held by the Saudi Association for Health Information to emphasize the importance of e-health in enhancing the quality of health care delivery and to explore the necessary strategies, policies, applications and infrastructure [46].

More coordination among different health care providers is needed in order to enhance the use of e-health strategies and to launch a comprehensive national system for health information. A high level of coordination must be achieved with other related sectors to provide the required infrastructure such as internet and phone services.

New strategy for health care services

To meet the challenges of the Saudi health care system and to improve the quality of health care services, the MOH has set a national strategy for health care services. This strategy was approved by the Council of Ministers in April 2009. It focuses on diversifying funding sources; developing information systems; developing the human workforce; activating the supervision and monitoring role of the MOH over health services; encouraging the private sector to take its position in providing health services; improving the quality of preventive, curative and rehabilitative care; and distributing health care services equally to all regions.

The national strategy for health care services is to be implemented by the MOH in cooperation with other health care providers and it will be supervised by the Council of Health Services. A 20-year timeframe for achieving the objectives of this strategy has been identified [39].

Conclusion

As a result of the continued attention to and support from the government, Saudi health services have advanced greatly over recent years in all levels of health services: primary, secondary and tertiary. As a consequence, the health of the Saudi population has improved markedly. The MOH has introduced many reforms to its services, with substantial emphasis on PHC.

Despite these achievements, health services, and in particular public sector health services, are still facing many challenges. These include: human resource development; separation of the MOH’s multiple roles (financing, provision, control and supervision of health care delivery); diversifying financial sources; implementing the cooperative health insurance, privatization of public hospitals, effective management of ‎chronic diseases; development of practical policies for national crises; establishment of an efficient national health information system and the introduction of e-health. In order to address these challenges and continue to improve the status of the Saudi health care system, the MOH and other related sectors should coordinate their efforts to implement and ensure the success of the new health care strategy.

Acknowledgements

This paper is part of the first author’s doctoral research, supported by the government of Saudi Arabia.

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