Health care system in Saudi Arabia: an overview M. Almalki,1,2 G. Fitzgerald 2 and M. Clark 2

Health care system in Saudi Arabia: an overview M. Almalki,1,2 G. Fitzgerald 2 and M. Clark 2

ABSTRACT The government of Saudi Arabia has given high priority to the development of health care services at all levels: primary, secondary and tertiary. As a consequence, the health of the Saudi population has greatly improved in recent decades. However, a number of issues pose challenges to the health care system, such a shortage of Saudi health professionals, the health ministry’s multiple roles, limited financial resources, changing patterns of disease, high demand resulting from free services, an absence of a national crisis management policy, poor accessibility to some health care facilities, lack of a national health information system, and the underutilization of the potential of electronic health strategies. This paper reviews the historical development and current structure of the health care system in Saudi Arabia with particular emphasis on the public health sector and the opportunities and challenges confronting the Saudi health care system.

1College of Health Sciences, University of Jazan, Jazan, Saudi Arabia (Correspondence to M. Almalki: mohammed.almalki@gmail.com). 2Faculty of Health, School of Public Health, Queensland University of Technology, Brisbane, Australia.

Received: 28/12/08; accepted: 05/01/10

نظام الرعاية الصحية يف اململكة العربية السعودية: استعراض حممد املالكي، جريي فيتز جريالد، ميشيل كالرك

والثانوية، األولية، الرعاية: مستويات مجيع عىل الصحية الرعاية خدمات لتنمية اهتاممها ُجلَّ السعودية العربية اململكة حكومة أْوَلت اخلالصة: نت بدرجة كبرية صحة السعوديني يف العقود األخرية. إال أن هناك عددًا من املشاكل التي تضع حتديات أمام نظام الرعاية والثالثية. ونتيجًة لذلك حتسَّ الصحية، مثل نقص العاملني الصحيني السعوديني، واألدوار املتعددة لوزارة الصحة، واملوارد املالية املحدودة، والتغري يف أنامط األمراض، والطلب املرتفع الناتج عن اخلدمات املجانية، وعدم وجود سياسة وطنية إلدارة األزمات، وضعف القدرة عىل الوصول إىل بعض مرافق الرعاية الصحية، وعدم وجود نظام للمعلومات الصحية الوطنية، وضعف االستفادة من إمكانيات اسرتاتيجيات الصحة اإللكرتونية. وتستعرض هذه الورقة التطور التارخيي والبنية احلالية لنظام الرعاية الصحية يف اململكة العربية السعودية مع الرتكيز عىل قطاع الصحة العمومية، والفرص والتحديات التي تواجه

نظام الرعاية الصحية السعودي.

Aperçu du système de santé en Arabie saoudite

RÉSUMÉ Le gouvernement d’Arabie saoudite a accordé une priorité élevée au développement des services de soins de santé à tous les niveaux : primaire, secondaire et tertiaire. En conséquence, la santé de la population saoudienne s’est grandement améliorée au cours des dernières décennies. Toutefois, le système de santé est confronté à de multiples défis tels que la pénurie de professionnels de santé saoudiens, les rôles multiples du ministère de la Santé, des ressources financières limitées, l’évolution des tableaux de morbidité, la forte demande générée par la gratuité des services, l’absence de politique nationale de gestion des crises, l’accès médiocre à certains établissements de soins, l’absence de système national d’information sanitaire et la sous-utilisation du potentiel des stratégies de cybersanté. Le présent article passe en revue l’histoire du système de santé saoudien et sa structure actuelle et met l’accent sur le secteur de la santé publique, les opportunités qui s’offrent à ce système et les obstacles auxquels il est confronté.

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Introduction

Health  care  services  in  Saudi Arabia  have been given a high priority by  the  government. During  the past  few dec- ades,  health  and health  services have  improved greatly  in  terms of quantity  and quality. Gallagher has  stated  that:  “Although  many  nations  have  seen  sizable growth  in  their health care sys- tems, probably no other nation (other  than Saudi Arabia] of  large geographic  expanse and population has, in compa- rable time, achieved so much on a broad  national scale, with a relatively high level  of care made available to virtually all seg- ments of the population (p. 182).” [1]

According to the World Health Or- ganization (WHO) [2], the Saudi health  care  system  is  ranked 26th among 190  of  the world’s health  systems.  It  comes  before many other  international health  care  systems  such  as Canada  (ranked  30), Australia (32), New Zealand (41),  and other systems in the region such as  the United Arab Emirates (27), Qatar  (44)  and Kuwait  (45). Despite  these  achievements, the Saudi health care sys- tem faces many challenges which require  new strategies and policies by the Saudi  Ministry of Health (MOH) as well  as  effective cooperation with other sectors.

This  review  outlines  the  historical  development and current structure of the  Saudi health care system. A particular em- phasis has been given to the public health  sector  that  is  operated  by  the MOH,  including the key opportunities and chal- lenges  it  faces.  In  addition,  this  review  highlights demographic changes and the  economic context of Saudi Arabia in rela- tion to the Saudi health care system.

Demographic and economic patterns of Saudi Arabia

The last official census  in 2010 placed  the population of Saudi Arabia at 27.1  million,  compared with  22.6 million

in  2004  [3]. The  annual  population  growth rate for 2004 to 2010 was 3.2%  per annum [3], and the total fertility rate  was 3.04  [4]. Saudi  citizens  comprise  around 68.9% of  the  total population;  50.2% are males and 49.8% females [3];  67.1% of  the population are under  the  age of  30  years  and  about  37.2%  are  under 15 years; the population over the  age of 60 years is estimated at 5.2% [5].  According  to United Nation projec- tions, it is estimated that the population  of Saudi Arabia will  reach 39.8 million  by 2025 and 54.7 million by 2050 [6].  This  is  a natural outcome of  the high  birth  rate (23.7 per 1000 population),  increased  life  expectancy  (72.5  years  for men, 74.7 years for women) [4] and  declining mortality  rate among  infants  and children [1]. The under 5 years of  age mortality rate fell 250 per 1000 live  births  in 1960 [7]  to 20.0 per 1000  in  2009  [4]. Apart  from  advancements  in health care and social services,  these  improved  statistics  can mostly be  at- tributed  to  the compulsory childhood  vaccination programme  implemented  by the government since 1980 [7]. This  unprecedented  growth  will  increase  the demand  for  essential  services  and  facilities  including health  care, while  at  the  same  time  creating  economic  opportunities.

Saudi Arabia is one of the richest and  fastest growing countries in the Middle  East.  It  is  the world’s  largest producer  and exporter of oil, which constitutes the  major portion of the country’s revenues  [8,9]. In recent decades, however, Saudi  Arabia has diversified its economy, and  today produces and exports a variety of  industrial goods all over the world. The  sound economy and well-established  industry base affects the Saudi commu- nity by increasing their income, leading  to a per capita income of US$ 24 726 in  2008 [10] compared with US$ 22 935  in  2007,  US$  14 724  in  2006,  US$  13 639 in 2005 [11,12] and US$ 8140  in 2000 [13]. Based on 2010  informa- tion, Saudi Arabia  is  ranked at  a high  level in the Human Development Index

(0.75), which gives  the country a  rank  of  55 out of  194  countries  [10]. The  improvement  in  the national  income  is expected  to  impact positively on  its  various  services  including  the health  care services.

Brief overview of health services development

Health  services  in Saudi Arabia have  increased  and  improved  significantly  during  recent decades  [14]. The first  public  health department was  estab- lished in Mecca in 1925 based on a royal  decree  from King Abdulaziz [15]. This  department was  responsible  for  spon- soring and monitoring  free health care  for the population and pilgrims through  establishing a number of hospitals and  dispensaries. While it was an important  first  step  in providing curative health  services,  the national  income was not  sufficient  to  achieve major  advances  in health  care,  the majority of people  continued  to  depend  on  traditional  medicine and the incidence of epidemic  diseases  remained  high  among  the  population and pilgrims [15]. The next  crucial advance was  the establishment  of  the MOH  in 1950 under  another  royal decree  [15]. Twenty years  later,  the  5-year  development  plans  were  introduced by  the government  to  im- prove all  sectors of  the nation,  includ- ing  the Saudi health care  system [16].  Since  then,  substantial  improvements  in health  care have been  achieved  in  Saudi Arabia.

Current structure of health services

Currently  the MOH is  the major gov- ernment provider and financer of health  care  services  in  Saudi Arabia, with  a  total  of  244 hospitals  (33 277 beds)  and 2037 primary health care (PHC)

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centres  [4]. These  services  comprise  60% of the total health services in Saudi  Arabia [4]. The other government bod- ies  include  referral hospitals (e.g. King  Faisal Specialist Hospital and Research  Centre),  security  forces medical  serv- ices, army  forces medical  services, Na- tional Guard health affairs, Ministry of  Higher Education hospitals  (teaching  hospitals), ARAMCO hospitals, Royal  Commission  for  Jubail  and  Yanbu  health  services,  school health units of  the Ministry of Education and the Red  Crescent Society. With the exception of  referral hospitals, Red Crescent Society  and the teaching hospitals, each of these  agencies provides services  to a defined  population, usually employees and their  dependants. Additionally,  all  of  them  provide health  services  to all  residents  during  crises  and  emergencies  [16].

Jointly,  the government bodies oper- ate 39 hospitals with a  capacity of 10  822 beds  [4]. The private  sector  also  contributes  to  the  delivery  of  health  care  services,  especially  in  cities  and  large towns, with a total of 125 hospitals  (11 833 beds) and 2218 dispensaries  and clinics (Figure 1) [4].

The  advancement  in  health  serv- ices,  combined with other  factors  such  as improved and more accessible public  education,  increased health  awareness  among  the  community  and better  life  conditions, have contributed  to  the sig- nificant  improvements  in health  indica- tors mentioned earlier. It has been noted,  however, that despite the multiplicity of  health service providers there is no coor- dination or clear communication chan- nels  among  them,  resulting  in  a waste  of  resources  and duplication of  effort

[17]. For  example,  there  are  consider- able opportunities  to  take advantage of  equipment,  laboratories,  training  aids  and well-trained personnel  from differ- ent  countries. However,  as  a  result  of  poor coordination,  the benefit of  these  opportunities is limited within each sec- tor.  In order  to overcome  this  and  to  provide the population with up-to-date,  equitable,  affordable,  organized  and  comprehensive health care,  a  royal de- cree in 2002 led to the establishment of  the Council of Health Services, headed  by  the Minster of Health and  including  representatives of other government and  private  health  sectors  [18]. Although  the aim of the Council was to develop a  policy  for coordination and  integration  among all health care services authorities  in Saudi Arabia [19], significant progress  has yet to be achieved in this area [20].

Figure 1 Current structure of the health care sectors in Saudi Arabia (MOH = Ministry of Health) . Source of data: [4]

Employees &

their families

+

Emergencies

Armed forces medical services

Health services in the R oyal

Commission for Jubail & Yanbua

Red Crescent

Security forces medical services

National guard health affairs

% of hospital services provide by various health care sectors in

Saudi Arabia

59.5%

21.2%

19.3%

MOH Other Govt. Private

Emergencies

Referral hospitals

Teaching hospitals

School health units

ARAMCO health services

Saudi health care system

Govt. sector (free) Private sector (fee)

MOH (public)

Other agencies

All levels of health care

All levels of health care

All levels of health care

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Public health care system (Ministry of Health)

In accordance with the Saudi constitu- tion,  the government provides all  citi- zens and expatriates working within the  public  sector with  full  and  free access  to all public health care services [7,21].  Government expenditure on the MOH  increased  from 2.8%  in 1970  [18]  to  6%  in 2005 and 6.2%  in 2009 (Table  1)  [4]. According  to WHO the  total  expenditure  on  public  health  during  2009 was 5% of gross domestic prod- uct  [22]. The MOH is  responsible  for  managing,  planning  and  formulating  health policies  and  supervising health  programmes,  as  well  as  monitoring  health services in the private sector [23].  It  is also responsible  for advising other  government  agencies  and  the private  sector on ways  to achieve  the govern- ment’s health objectives [16].

The MOH  supervises  20  regional  directorates-general of health affairs  in  various parts of  the country [18]. Each  regional health directorate has a number  of hospitals and health sectors and every  health  sector  supervises  a  number  of  PHC centres. The  role of  these 20 di- rectorates  includes  implementing  the  policies, plans and programmes of  the  MOH; managing and supporting MOH  health services; supervising and organiz- ing private sector services; coordinating  with other  government  agencies;  and  coordinating with other relevant bodies  [23]. Figure 2  illustrates  the organiza- tional  structure and  the  relationship of  departments within the Saudi health care  system  from  the community  to MOH  level. “Health friends” is a selective com- mittee consisting of useful and influential  community members,  including  repre- sentatives  from PHC centres, who are  knowledgeable  about  common  social  norms and the potential of the commu- nity. The essential role of this committee  is to liaise between PHC centres and the  communities they serve [24,25].

Levels of health care services The MOH provides health services at 3  levels: primary,  secondary and  tertiary  [4]. PHC centres  supply primary care  services, both preventive and curative,  referring  cases  that  require more  ad- vanced  care  to  public  hospitals  (the  secondary  level  of  care), while  cases  that need more complex  levels of care  are transferred to central or specialized  hospitals  (the  tertiary  level  of  health  care).

Transition to PHC services Until the 1980s, in line with the expecta- tions of population, health  services  in  Saudi Arabia were  largely curative, em- phasizing the provision of treatment for  existing health problems  [18,23]. The  curative  care model,  however,  can be  costly  to health providers, when many  diseases can be prevented or minimized  through developing a preventive strat- egy. A variety of preventive measures  were run by the MOH through former  health  offices  and  to  some  extent  through maternal and child health care  centres. A number of disease  control  activities were  performed by  vertical  programmes, e.g. malaria,  tuberculosis  and leishmaniasis control [18,23].

In  accordance with  the Alma-Ata  declaration at  the WHO General As- sembly  in 1978 [26],  the Saudi MOH  decided  to  activate  and  develop  the  preventive  health  services  by  adopt- ing  the  PHC  approach  as  one  of  its  key health strategies. Consequently,  in  1980, a ministerial decree was issued to

establish PHC centres. The first step was  to establish suitable premises  through- out  the  country. Existing  facilities  lo- cated  in adjacent areas were  integrated  into single units. These included former  health offices, maternal and child health  centres  and  dispensaries. The health  posts  in  small  and  rural districts were  upgraded to PHC centres [18,23]. The  health centres aimed to  focus on the 8  elements of the PHC approach: educat- ing  the population concerning prevail- ing health problems and the methods of  preventing and controlling them; provi- sion of  adequate  supply of  safe water  and basic sanitation; promotion of food  supply and proper nutrition; provision  of  comprehensive maternal  and child  health care;  immunization of children  against major communicable diseases;  prevention and control of  locally  en- demic diseases; appropriate  treatment  of common diseases and  injuries;  and  provision of essential drugs [24,25].

Focusing on  a PHC  strategy  and  applying  a  logical  referral  system has  helped  to  reduce  the number of visits  to outpatient clinics  [23]. About 82%  of client visits to MOH facilities during  2009 were to PHC centres comprising  more than 54 million PHC clients [4].  The creation of  individual  and  family  health records inside each PHC centre  has  reduced duplication of  consulta- tions. The use of the essential drugs list  and documentation of prescriptions  in  patient health files has not only reduced  the costs of medications, but also  im- proved prescribing practices.

Table 1 Budget appropriations for the Ministry of Health (MOH) in Saudi Arabia in relation to the government budget, 2005–09

Year Government budget (SRa) MOH budget (SR) %b

2005 280 000 000 16 870 750 6.0

2006 335 000 000 19 683 700 5.9

2007 380 000 000 22 808 200 6.0

2008 450 000 000 25 220 200 5.6

2009 475 000 000 29 518 700 6.2

Source: [4]. aUS$ 1 = 3.75 SR; bAs a % of the total government budget. SR = Saudi riyals

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In recent years,  the MOH has con- tinued  to develop  the number of PHC  centres (Figure 3) and has initiated fur- ther projects aimed at developing health  care  in general and PHCs  in particular.  For example,  the project of  the Custo- dian of the Two Holy Mosques aims to  establish 2000 advanced PHC centres,  and to develop the existing ones in terms  of buildings, workforce and services.

Health services in the pilgrimage (hajj) season Saudi Arabia has a unique position in the  Islamic world, as it embraces the 2 holi- est cities of  Islam, Mecca and Medina.  About 2 million pilgrims  from all over  the world  perform  the hajj  annually.  During the 2009 season, there were 2.3  million pilgrims, 69.8% of whom came  from foreign countries [4]. Hosting such  an event annually  is a major challenge  that  requires a planned and organized  effort  across numerous  agencies  and  departments to ensure adequate essen- tial services, such as housing, transport,  safety and health care [21].

Health care services in the hajj season  provide preventive and curative care for  all pilgrims, irrespective of their nation- ality. Preventive  care  includes health  education  programmes,  vaccination  and chemoprophylaxis  for all pilgrims  via quarantine  services at  airports and  land ports. The provision of emergency  and curative services takes place through  a network of health care facilities. For ex- ample, in 2009, there were 21 hospitals,  of which 7 were seasonal, with a total of

3408 beds and 176 beds for emergency  admissions. There were also 157 PHC  centres, of which 119 were seasonal. On  average, each PHC centre treated 4734  pilgrims. The total workforce  recruited  to work  in  these  facilities during 2009  was 17 886; an  increase of 5% on  the  previous year. Of these, 69% were physi- cians, nurses and allied health personnel  [4]. On average, each physician treated  about 612 pilgrims, while  each nurse  treated about 372.

Figure 2 Organizational structure of the Ministry of Health (public) health care system in Saudi Arabia. Source: [23]

2037

192519251905

1848

1986

1750

1800

1850

1900

1950

2000

2050

2100

2004 2005 2006 2007 2008 2009

N o

. o f

P H

C c

en tr

es

Figure 3 Trends in the number of primary health care (PHC) centres in the Ministry

of Health in Saudi Arabia, 2004–09. Source: [4]

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Every  year,  the  Saudi  health  care  agencies, particularly the MOH, seek to  improve  the health care  services  to pil- grims [21]. Nevertheless, the fact that all  the services are provided  free of charge  for all pilgrims  is  creating considerable  pressure on the health care budget and it  may be necessary to seek ways to provide  better services at a  lower cost. One sug- gestion is to introduce a seasonal health  insurance for all international pilgrims.

Challenges for health care reform

While many steps have been undertaken  by the MOH to reform the Saudi health  care  system,  a  number  of  challenges  remain. These relate to the health work- force, financing and expenditure, chang- ing patterns of diseases,  accessibility  to  health  care  services,  introducing  the  cooperative health  insurance  scheme,  privatization of public hospitals, utiliza- tion of electronic health (e-health) strat- egies and the development of a national  system for health information.

Health workforce The Saudi health  care  system  is  chal- lenged by  the  shortage of  local health

care professionals,  such as physicians,  nurses  and pharmacists. The majority  of health personnel are expatriates and  this leads to a high rate of turnover and  instability  in  the workforce  [27]. Ac- cording  to  the MOH the  total health  workforce in Saudi Arabia, including all  other  sectors,  is  about 248 000; more  than half of  them (125 000) work  in  the MOH [4]. Saudis  constitute 38%  of this total workforce. Of these, 23.1%  are physicians, while 32.3% are nurses  (Figure 4). In the MOH, Saudis consti- tute about 54% of the health workforce,  (physicians 22.6% and nurses 50.3%).  The  rates of physicians  and nurses  in  Saudi Arabia are 16 and 36 respectively  per 10 000 population,  lower  than  in  other countries such as Bahrain (30 and  58 per 10 000), Kuwait (18 and 37 per  10 000), Japan (12 and 95 per 10 000),  Canada  (19  and  100  per  10 000),  France (37 and 81 per 10 000) and the  United States of America (27 and 98  per 10 000) [28].

The  ability  to  formulate  and  ap- ply 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 Sau- dis  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 col- leges for medicine, health and nursing  as well  as 4 health  institutes  in Saudi  Arabia  [4]. Efforts  to  establish  such  colleges are  in accordance with  train- ing 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 pro- fessionals. 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].

0

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20

30

40

50

60

70

80

90

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MOH Other govt. Private Total

% Physicians Nurses Allied health

Figure 4 Distribution of Saudi health personnel in the Ministry of Health (MOH), other government and private health care

sectors in Saudi Arabia, 2009. Source: [4]

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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 Minis- try  of Higher Education.  In  its  stage  4,  priority has been given  to medical  specialists  including medicine,  nurs- ing, 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 overwhelm- ingly  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  seri- ous 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 indi- vidual 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, coopera- tion with other governments  such  the  Netherlands, Germany and Thailand,  partial operation by health care compa- nies, comprehensive operation by health  care  companies  and  the  autonomous  hospital  system [33]. Considering  the  advantages and disadvantages of  these  approaches,  the MOH has  standard- ized 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  con- tractual 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 qual- ity  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  coop- erative  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 sec- ond phase  applied  to  employers with  more than 100 workers. The third phase  included employees of all companies in  Saudi Arabia as well as domestic work- ers  [14,37]. The  government  is  now  working systematically  to apply  the re- maining 2 stages—for employees in the  government  sector and  for pilgrims— before  they privatize  the  state-owned  health care  facilities [14]. No  informa- tion is available yet regarding the coop- erative 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  cur- rently  involves  about  25  companies.  The  introduction of  the  scheme  is  in- tended to decrease the financial burden  on Saudi Arabia due  to  the  costs  as- sociated with providing health services  free-of-charge.  It will  also give people

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more opportunity to choose the health  services they require [14]. The real chal- lenge 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  research- ers 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]. Priva- tization of hospitals is expected to bring  a number of advantages to the govern- ment and to the nation. It is hoped that  privatization will  assist  in  speeding up  decision-making,  reducing  the govern- ment’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 hos- pital-level care. Moreover, people with  health  cover may prefer  to  access big  hospitals directly  instead of  via PHC  centres or  community hospitals. Ad- ditionally,  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 hos- pitals 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 commu- nities  and provide  them with  fair  and  equitable health care services.

Finally, if the government does not ap- ply 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,  includ- ing 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 profes- sionals  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 redistri- bution 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,  can- cer, genetic blood disorders and child- hood 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 ac- cidents, for example, killed more than 39  000 and injured about 290 000 people  between 1995 and 2004 [43]. Accord- ing 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.

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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 sub– stantial emphasis on PHC.

Despite  these achievements, health  services, and  in particular public sector  health services, are still facing many chal– lenges. 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 hos- pitals, effective management of  chronic  diseases; development of practical poli- cies 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 coor- dinate  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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