Healthcare System in Saudi Arabia

EMHJ Vol.17 No.10 2011 EasternMediterraneanHealthJournalLaRevuedeSantdelaMditerraneorientale

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Review

Health care system in Saudi Arabia: an overviewM. 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 ministrys 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: [email protected]).2Faculty of Health, School of Public Health, Queensland University of Technology, Brisbane, Australia.

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

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Aperu du systme de sant en Arabie saoudite

RSUM Le gouvernement dArabie saoudite a accord une priorit leve au dveloppement des services de soins de sant tous les niveaux : primaire, secondaire et tertiaire. En consquence, la sant de la population saoudienne sest grandement amliore au cours des dernires dcennies. Toutefois, le systme de sant est confront de multiples dfis tels que la pnurie de professionnels de sant saoudiens, les rles multiples du ministre de la Sant, des ressources financires limites, lvolution des tableaux de morbidit, la forte demande gnre par la gratuit des services, labsence de politique nationale de gestion des crises, laccs mdiocre certains tablissements de soins, labsence de systme national dinformation sanitaire et la sous-utilisation du potentiel des stratgies de cybersant. Le prsent article passe en revue lhistoire du systme de sant saoudien et sa structure actuelle et met laccent sur le secteur de la sant publique, les opportunits qui soffrent ce systme et les obstacles auxquels il est confront.

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Introduction

Health care services in SaudiArabiahavebeengivenahighpriorityby thegovernment.During thepast fewdec-ades, health andhealth serviceshaveimprovedgreatly in termsofquantityandquality.Gallagherhas stated that:Although many nations have seensizablegrowth in theirhealthcaresys-tems,probablynoothernation(otherthanSaudiArabia]of largegeographicexpanseandpopulationhas,incompa-rabletime,achievedsomuchonabroadnationalscale,witharelativelyhighlevelofcaremadeavailabletovirtuallyallseg-mentsofthepopulation(p.182).[1]

AccordingtotheWorldHealthOr-ganization(WHO)[2],theSaudihealthcare system is ranked26thamong190of theworldshealth systems. It comesbeforemanyother internationalhealthcare systems such asCanada (ranked30),Australia(32),NewZealand(41),andothersystemsintheregionsuchastheUnitedArabEmirates(27),Qatar(44) andKuwait (45).Despite theseachievements,theSaudihealthcaresys-temfacesmanychallengeswhichrequirenewstrategiesandpoliciesbytheSaudiMinistryofHealth(MOH)aswell aseffectivecooperationwithothersectors.

This review outlines the historicaldevelopmentandcurrentstructureoftheSaudihealthcaresystem.Aparticularem-phasishasbeengiventothepublichealthsector that is operated by theMOH,includingthekeyopportunitiesandchal-lenges it faces. In addition, this reviewhighlightsdemographicchangesandtheeconomiccontextofSaudiArabiainrela-tiontotheSaudihealthcaresystem.

Demographic and economic patterns of Saudi Arabia

Thelastofficialcensus in2010placedthepopulationofSaudiArabiaat27.1million, comparedwith 22.6million

in 2004 [3].The annual populationgrowthratefor2004to2010was3.2%perannum[3],andthetotalfertilityratewas3.04 [4].Saudi citizens comprisearound68.9%of the totalpopulation;50.2%aremalesand49.8%females[3];67.1%of thepopulationareunder theageof 30 years and about 37.2% areunder15years;thepopulationovertheageof60yearsisestimatedat5.2%[5].According toUnitedNationprojec-tions,itisestimatedthatthepopulationofSaudiArabiawill reach39.8millionby2025and54.7millionby2050[6].This is anaturaloutcomeof thehighbirth rate(23.7per1000population),increased life expectancy (72.5 yearsformen,74.7yearsforwomen)[4]anddecliningmortality rateamong infantsandchildren[1].Theunder5yearsofagemortalityratefell250per1000livebirths in1960[7] to20.0per1000 in2009 [4].Apart from advancementsinhealthcareandsocialservices, theseimproved statistics canmostlybe at-tributed to thecompulsorychildhoodvaccinationprogramme implementedbythegovernmentsince1980[7].Thisunprecedented growth will increasethedemand for essential services andfacilities includinghealth care,whileat the same time creating economicopportunities.

SaudiArabiaisoneoftherichestandfastestgrowingcountriesintheMiddleEast. It is theworlds largestproducerandexporterofoil,whichconstitutesthemajorportionofthecountrysrevenues[8,9].Inrecentdecades,however,SaudiArabiahasdiversifieditseconomy,andtodayproducesandexportsavarietyofindustrialgoodsallovertheworld.Thesoundeconomyandwell-establishedindustrybaseaffectstheSaudicommu-nitybyincreasingtheirincome,leadingtoapercapitaincomeofUS$24726in2008[10]comparedwithUS$22935in 2007, US$ 14724 in 2006, US$13639in2005[11,12]andUS$8140in2000[13].Basedon2010 informa-tion,SaudiArabia is rankedat ahighlevelintheHumanDevelopmentIndex

(0.75),whichgives thecountrya rankof 55outof 194 countries [10].Theimprovement in thenational incomeisexpected to impactpositivelyon itsvarious services including thehealthcareservices.

Brief overview of health services development

Health services inSaudiArabiahaveincreased and improved significantlyduring recentdecades [14].Thefirstpublic healthdepartmentwas estab-lishedinMeccain1925basedonaroyaldecree fromKingAbdulaziz[15].Thisdepartmentwas responsible for spon-soringandmonitoring freehealthcareforthepopulationandpilgrimsthroughestablishinganumberofhospitalsanddispensaries.Whileitwasanimportantfirst step inprovidingcurativehealthservices, thenational incomewasnotsufficient to achievemajor advancesinhealth care, themajorityofpeoplecontinued to depend on traditionalmedicineandtheincidenceofepidemicdiseases remained high among thepopulationandpilgrims[15].Thenextcrucialadvancewas theestablishmentof theMOH in1950under anotherroyaldecree [15].Twentyyears later,the 5-year development plans wereintroducedby thegovernment to im-proveall sectorsof thenation, includ-ing theSaudihealthcare system[16].Since then, substantial improvementsinhealth carehavebeen achieved inSaudiArabia.

Current structure of health services

Currently theMOHis themajorgov-ernmentproviderandfinancerofhealthcare services in SaudiArabia,with atotal of 244hospitals (33277beds)and2037primaryhealthcare(PHC)


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centres [4].These services comprise60%ofthetotalhealthservicesinSaudiArabia[4].Theothergovernmentbod-ies include referralhospitals(e.g.KingFaisalSpecialistHospitalandResearchCentre), security forcesmedical serv-ices,army forcesmedical services,Na-tionalGuardhealthaffairs,MinistryofHigherEducationhospitals (teachinghospitals),ARAMCOhospitals,RoyalCommission for Jubail and Yanbuhealth services, schoolhealthunitsoftheMinistryofEducationandtheRedCrescentSociety.Withtheexceptionofreferralhospitals,RedCrescentSocietyandtheteachinghospitals,eachoftheseagenciesprovidesservices toadefinedpopulation,usuallyemployeesandtheirdependants.Additionally, all of themprovidehealth services toall residentsduring crises and emergencies [16].

Jointly, thegovernmentbodiesoper-ate39hospitalswitha capacityof10822beds [4].Theprivate sector alsocontributes to the delivery of healthcare services, especially in cities andlargetowns,withatotalof125hospitals(11833beds)and2218dispensariesandclinics(Figure1)[4].

The advancement in health serv-ices, combinedwithother factors suchasimprovedandmoreaccessiblepubliceducation, increasedhealth awarenessamong the community andbetter lifeconditions,havecontributed to thesig-nificant improvements inhealth indica-torsmentionedearlier.Ithasbeennoted,however,thatdespitethemultiplicityofhealthserviceprovidersthereisnocoor-dinationorclearcommunicationchan-nels among them, resulting in awasteof resources andduplicationof effort

[17].For example, there are consider-ableopportunities to takeadvantageofequipment, laboratories, training aidsandwell-trainedpersonnel fromdiffer-ent countries.However, as a result ofpoorcoordination, thebenefitof theseopportunitiesislimitedwithineachsec-tor. Inorder toovercome this and toprovidethepopulationwithup-to-date,equitable, affordable, organized andcomprehensivehealthcare, a royalde-creein2002ledtotheestablishmentoftheCouncilofHealthServices,headedby theMinsterofHealthand includingrepresentativesofothergovernmentandprivate health sectors [18].AlthoughtheaimoftheCouncilwastodevelopapolicy forcoordinationand integrationamongallhealthcareservicesauthoritiesinSaudiArabia[19],significantprogresshasyettobeachievedinthisarea[20].

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

Employees &

their families

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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



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Public health care system (Ministry of Health)

InaccordancewiththeSaudiconstitu-tion, thegovernmentprovidesall citi-zensandexpatriatesworkingwithinthepublic sectorwith full and freeaccesstoallpublichealthcareservices[7,21].GovernmentexpenditureontheMOHincreased from2.8% in1970 [18] to6% in2005and6.2% in2009(Table1) [4].According toWHOthe totalexpenditure on public health during2009was5%ofgrossdomesticprod-uct [22].TheMOHis responsible formanaging, planning and formulatinghealthpolicies and supervisinghealthprogrammes, as well as monitoringhealthservicesintheprivatesector[23].It isalsoresponsible foradvisingothergovernment agencies and theprivatesectoronways toachieve thegovern-mentshealthobjectives[16].

TheMOH supervises 20 regionaldirectorates-generalofhealthaffairs invariouspartsof thecountry[18].Eachregionalhealthdirectoratehasanumberofhospitalsandhealthsectorsandeveryhealth sector supervises a number ofPHCcentres.The roleof these20di-rectorates includes implementing thepolicies,plansandprogrammesof theMOH;managingandsupportingMOHhealthservices;supervisingandorganiz-ingprivatesectorservices;coordinatingwithother government agencies; andcoordinatingwithotherrelevantbodies[23].Figure2 illustrates theorganiza-tional structureand the relationshipofdepartmentswithintheSaudihealthcaresystem from thecommunity toMOHlevel.Healthfriendsisaselectivecom-mitteeconsistingofusefulandinfluentialcommunitymembers, including repre-sentatives fromPHCcentres,whoareknowledgeable about common socialnormsandthepotentialofthecommu-nity.TheessentialroleofthiscommitteeistoliaisebetweenPHCcentresandthecommunitiestheyserve[24,25].

Levels of health care servicesTheMOHprovideshealthservicesat3levels:primary, secondaryand tertiary[4].PHCcentres supplyprimarycareservices,bothpreventiveandcurative,referring cases that requiremore ad-vanced care to public hospitals (thesecondary level of care),while casesthatneedmorecomplex levelsofcarearetransferredtocentralorspecializedhospitals (the tertiary level of healthcare).

Transition to PHC servicesUntilthe1980s,inlinewiththeexpecta-tionsofpopulation,health services inSaudiArabiawere largelycurative,em-phasizingtheprovisionoftreatmentforexistinghealthproblems [18,23].Thecurative caremodel, however, canbecostly tohealthproviders,whenmanydiseasescanbepreventedorminimizedthroughdevelopingapreventivestrat-egy.AvarietyofpreventivemeasureswererunbytheMOHthroughformerhealth offices and to some extentthroughmaternalandchildhealthcarecentres.Anumberofdisease controlactivitieswere performedby verticalprogrammes,e.g.malaria, tuberculosisandleishmaniasiscontrol[18,23].

In accordancewith theAlma-Atadeclarationat theWHOGeneralAs-sembly in1978[26], theSaudiMOHdecided to activate and develop thepreventive health services by adopt-ing the PHC approach as one of itskeyhealthstrategies.Consequently, in1980,aministerialdecreewasissuedto

establishPHCcentres.Thefirststepwastoestablishsuitablepremises through-out the country.Existing facilities lo-cated inadjacentareaswere integratedintosingleunits.Theseincludedformerhealthoffices,maternalandchildhealthcentres and dispensaries.Thehealthposts in small and ruraldistrictswereupgradedtoPHCcentres[18,23].Thehealthcentresaimedto focusonthe8elementsofthePHCapproach:educat-ing thepopulationconcerningprevail-inghealthproblemsandthemethodsofpreventingandcontrollingthem;provi-sionof adequate supplyof safewaterandbasicsanitation;promotionoffoodsupplyandpropernutrition;provisionof comprehensivematernal andchildhealthcare; immunizationofchildrenagainstmajorcommunicablediseases;preventionandcontrolof locally en-demicdiseases;appropriate treatmentofcommondiseasesand injuries; andprovisionofessentialdrugs[24,25].

Focusingon aPHC strategy andapplying a logical referral systemhashelped to reduce thenumberofvisitstooutpatientclinics [23].About82%ofclientvisitstoMOHfacilitiesduring2009weretoPHCcentrescomprisingmorethan54millionPHCclients[4].Thecreationof individual and familyhealthrecordsinsideeachPHCcentrehas reducedduplicationof consulta-tions.Theuseoftheessentialdrugslistanddocumentationofprescriptions inpatienthealthfileshasnotonlyreducedthecostsofmedications,butalso im-provedprescribingpractices.

Table 1 Budget appropriations for the Ministry of Health (MOH) in Saudi Arabia in relation to the government budget, 200509

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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Inrecentyears, theMOHhascon-tinued todevelop thenumberofPHCcentres(Figure3)andhasinitiatedfur-therprojectsaimedatdevelopinghealthcare ingeneralandPHCs inparticular.Forexample, theprojectof theCusto-dianoftheTwoHolyMosquesaimstoestablish2000advancedPHCcentres,andtodeveloptheexistingonesintermsofbuildings,workforceandservices.

Health services in the pilgrimage (hajj) seasonSaudiArabiahasauniquepositionintheIslamicworld,asitembracesthe2holi-estcitiesof Islam,MeccaandMedina.About2millionpilgrims fromallovertheworld perform thehajj annually.Duringthe2009season,therewere2.3millionpilgrims,69.8%ofwhomcamefromforeigncountries[4].Hostingsuchaneventannually isamajorchallengethat requiresaplannedandorganizedeffort acrossnumerous agencies anddepartmentstoensureadequateessen-tialservices,suchashousing,transport,safetyandhealthcare[21].

Healthcareservicesinthehajjseasonprovidepreventiveandcurativecareforallpilgrims,irrespectiveoftheirnation-ality.Preventive care includeshealtheducation programmes, vaccinationandchemoprophylaxis forallpilgrimsviaquarantine servicesat airportsandlandports.Theprovisionofemergencyandcurativeservicestakesplacethroughanetworkofhealthcarefacilities.Forex-ample,in2009,therewere21hospitals,ofwhich7wereseasonal,withatotalof

3408bedsand176bedsforemergencyadmissions.Therewerealso157PHCcentres,ofwhich119wereseasonal.Onaverage,eachPHCcentretreated4734pilgrims.Thetotalworkforce recruitedtowork in these facilitiesduring2009was17886;an increaseof5%on thepreviousyear.Ofthese,69%werephysi-cians,nursesandalliedhealthpersonnel[4].Onaverage,eachphysiciantreatedabout612pilgrims,while eachnursetreatedabout372.

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

No

. of

PH

C c

en

tre

s

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

of Health in Saudi Arabia, 200409. Source: [4]

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Every year, the Saudi health careagencies,particularlytheMOH,seektoimprove thehealthcare services topil-grims[21].Nevertheless,thefactthatalltheservicesareprovided freeofchargeforallpilgrims is creatingconsiderablepressureonthehealthcarebudgetanditmaybenecessarytoseekwaystoprovidebetterservicesata lowercost.Onesug-gestionistointroduceaseasonalhealthinsuranceforallinternationalpilgrims.

Challenges for health care reform

WhilemanystepshavebeenundertakenbytheMOHtoreformtheSaudihealthcare system, a number of challengesremain.Theserelatetothehealthwork-force,financingandexpenditure,chang-ingpatternsofdiseases, accessibility tohealth care services, introducing thecooperativehealth insurance scheme,privatizationofpublichospitals,utiliza-tionofelectronichealth(e-health)strat-egiesandthedevelopmentofanationalsystemforhealthinformation.

Health workforceTheSaudihealth care system is chal-lengedby the shortageof localhealth

careprofessionals, suchasphysicians,nurses andpharmacists.Themajorityofhealthpersonnelareexpatriatesandthisleadstoahighrateofturnoverandinstability in theworkforce [27].Ac-cording to theMOHthe totalhealthworkforceinSaudiArabia,includingallother sectors, is about248000;morethanhalfof them(125000)work intheMOH[4].Saudis constitute38%ofthistotalworkforce.Ofthese,23.1%arephysicians,while32.3%arenurses(Figure4).IntheMOH,Saudisconsti-tuteabout54%ofthehealthworkforce,(physicians22.6%andnurses50.3%).The ratesofphysicians andnurses inSaudiArabiaare16and36respectivelyper10000population, lower than inothercountriessuchasBahrain(30and58per10000),Kuwait(18and37per10000),Japan(12and95per10000),Canada (19 and 100 per 10000),France(37and81per10000)andtheUnitedStatesofAmerica(27and98per10000)[28].

The ability to formulate and ap-plypractical strategies to retain andattractmoreSaudis into themedicaland health professions, particularlynursing, isaclearpriority foreffectivereformoftheSaudihealthcaresystem.Manyeffortshavebeen takenby the

government to teach and trainSau-dis forhealthprofessional jobs.Since 1958 , anumberofmedical, nursingandhealthschoolshavebeenopenedaround thenation tomeet this goal[7].Apart fromprivate colleges andinstitutes, therearea totalof73col-legesformedicine,healthandnursingaswell as4health institutes inSaudiArabia [4].Efforts to establish suchcollegesare inaccordancewith train-ingprogrammesthataimtosubstitutethe largelyexpatriateworkforcewithqualifiedSaudiArabiannationals inall sectors, includinghealth [18,29].Thebudgetallocationfortrainingandscholarshipshas increasedandmanyMOHemployeesareofferedachancetopursue their studies abroad [18].Thisstrategycould improve theskillsofcurrentemployees,raisethequalityofhealthcareand,itishoped,decreasetherateofturnoveramonghealthpro-fessionals.However,theseeffortsmaynotbeenoughtosolvethechallenges.TheproportionofSaudiArabianhealthprofessionals in theMOHworkforceisexpectedtodecreaseinthefutureastheexpansion inhealthcare facilitiesaround thecountryhas theeffectofspreadingascareresourceevenmorethinly[17,30].

0

10

20

30

40

50

60

70

80

90

100

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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Morerealisticplansand long-termstrategiesneedtobeconsolidatedbytheMOHincooperationwithgovernmentandprivatesectors.Agoodexampleofsuchcooperation is theKingAbdullahinternational scholarshipprogrammewhichwas establishedby theMinis-try ofHigherEducation. In its stage4, priorityhasbeengiven tomedicalspecialists includingmedicine, nurs-ing,pharmacyandotherhealthmajors[31].However,moremedicalcollegesand trainingprogrammesneed tobeestablishedaround the country.Newlaws and regulations to develop andreorganizemedicalhumanresourcesbytheMOHareurgentlyrequired.

Reorganization and restructuring of the MOHThepublichealthsectorisoverwhelm-ingly financed, operated, controlled,supervisedandmanagedbytheMOH[32].Thismodelofmanagementmaynotabletomeetthepopulationshealthcareneeds into the futureunless seri-ousandwell-plannedstepsaretakentoseparate thesemultiple roles.Possiblesolutionsincludegivingmoreauthoritytotheregionaldirectorates,applyingthecooperativehealth insurance schemeand encouraging theprivatizationofpublichospitals.

Decentralization of health services and autonomy of hospitalsTomeet increasing pressure on theMOH,moreautonomyhasbeengivento theregionaldirectorates in termsofplanning, recruitmentofprofessionalstaff, formulating agreements withhealth services providers (operatingcompanies)andsomelimitedfinancialdiscretion.Ithasbeensuggestedthatthefunctioningoftheregionaldirectoratesisadverselyaffectedbythelackofindi-vidualbudgetsandspendingauthority[16].Expenditure for themajorityoftheir activitiesmustbe authorizedbytheMOH,thusaffectingtheautonomyofregionaldirectoratesandhamperingeffectivedecision-making.

In termsofhospitalautonomy, theMOHhas triedanumberof strategiesforimprovingthemanagementofpublichospitalsduringpastdecades,includingdirectoperationbytheMOH,coopera-tionwithothergovernments such theNetherlands,GermanyandThailand,partialoperationbyhealthcarecompa-nies,comprehensiveoperationbyhealthcare companies and the autonomoushospital system[33].Considering theadvantagesanddisadvantagesof theseapproaches, theMOHhas standard-izedanautonomoushospitalsystemfor31publichospitals in various regions[34].Theautonomoushospitalsystemforpublichospitals isexpectedtoraisetheefficiencyof theirperformance inbothmedicalandmanagerialfunctions,achieve financial and administrativeflexibility through adopting a directbudgetstrategy,applyqualityinsuranceprogrammes and simplify the con-tractualprocesswithqualifiedhealthprofessionals[33]. In2009, theMOHissuednewregulationsforself-operatingpublichospitalstoensureahighlevelofmanagementpracticesandto improvethequalityof servicesprovided [35].GivingmoreautonomytohospitalswillhelpthetransitiontofullprivatizationofpublichospitalsinSaudiArabia.Itgivespublichospitalsmoreexperienceinthemanagementof theirbudgets, healthcarequalityandworkforce.

Health insurance in Saudi ArabiaFundinghealthcareservicesisacentralchallengefacedbytheMOH[32].Sincethe total expenditureonpublichealthservices comes from thegovernmentandtheservicesare free-of-charge, thislead toconsiderablecostpressureonthegovernment,particularly inviewoftherapidgrowthinthepopulation,thehighpriceofnew technologyand thegrowing awareness abouthealth anddiseaseamongthecommunity[14].Tomeetthegrowingpopulationdemandsforhealthcareand toensure thequal-ity of services provided, theCouncil

forCooperativeHealth Insurancewasestablishedbythegovernmentin1999[19].Themain roleof thisCouncil isto introduce, regulateand superviseahealth insurancestrategy for theSaudihealthcaremarket.

The implementation of a coop-erative health insurance schemewasplannedover3stages.Inthefirststage,the cooperativehealth insurancewasappliedfornon-SaudisandSaudisintheprivatesector,inwhichtheiremployershavetopayforhealthcovercosts.Inthesecond stage, the cooperative healthinsuranceistobeappliedforSaudisandnon-Saudisworkinginthegovernmentsector.The governmentwill pay thecooperativehealth insurancecosts forthiscategoryofemployee. In thefinalstage, thecooperativehealth insurancewill be applied toother groups, suchas pilgrims [36].Only the first stagehas been implemented to date,withthecooperativehealth insurancebeingimplemented gradually in a 3-phaseprogrammetoemployeesoftheprivatesector and theirdependants [14,37].Thefirstphasecoveredcompanieswith500ormoreemployees,while thesec-ondphase applied to employerswithmorethan100workers.ThethirdphaseincludedemployeesofallcompaniesinSaudiArabiaaswellasdomesticwork-ers [14,37].The government is nowworkingsystematically toapply there-maining2stagesforemployeesinthegovernment sectorand forpilgrimsbefore theyprivatize the state-ownedhealthcare facilities[14].No informa-tionisavailableyetregardingthecoop-erativehealthinsuranceschemeforthepopulationofSaudiArabiaother thanemployeesandexpatriates.

While themarket for cooperativehealthinsuranceinSaudiArabiastartedwithonly1 company in2004, it cur-rently involves about 25 companies.The introductionof the scheme is in-tendedtodecreasethefinancialburdenonSaudiArabiadue to the costs as-sociatedwithprovidinghealthservicesfree-of-charge. Itwill alsogivepeople

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moreopportunitytochoosethehealthservicestheyrequire[14].Therealchal-lengeforpolicy-makersinSaudiArabiais to introduce a comprehensive, fair,and affordable service for thewholepopulation. Clearly lessons can belearned fromtheexperiencesofothercountries,includingtheadvantagesanddisadvantagesofdifferentschemes.

Privatization of public hospitalsPrivatizationofpublichospitalshasbeenseenbypolicy-makers and research-ersasthebestwaytoreformtheSaudihealth care system [38,39]. Steps toimplementaprivatizationstrategyhavebeen initiated and related regulationhasbeenpassedbythegovernment.Asa result, anumberofpublichospitalsarelikelytobesoldorrentedtoprivatefirmsoverthenextfewyears[14].Priva-tizationofhospitalsisexpectedtobringanumberofadvantagestothegovern-mentandtothenation.Itishopedthatprivatizationwill assist in speedingupdecision-making, reducing thegovern-ments annual expenditureonhealthcare,producingnewfinancial sourcesfor theMOH and improving healthcareservices[38].

On the other hand, privatizationmayaffectthecurrentintegratedsystembetweenhospitals andPHC facilities[14].Ashospitalsbecomeprivatized,theywill focuson attractingpatients,even thosewhomaynot requirehos-pital-levelcare.Moreover,peoplewithhealth covermayprefer to accessbighospitalsdirectly insteadof viaPHCcentresor communityhospitals.Ad-ditionally, private hospitalswill haveincentivestoshiftnon-refundablecostsback to the public PHC [14]. Suchpracticeswillplacefinancialburdensonthegovernment.

A furtherdrawbackofprivatizationis that the traditional state/publichos-pitalswillnotbeabletoabsorbenoughof the health caremarket comparedwith private companies, unless theyupgradeatall levels(e.g.management,

infrastructure andworkforce)beforestarting toprivatize [14]. In themovetoprivatization,privatecompaniesarelikely to focus their activities withincities and largercommunities, leavingpeople in ruralareasatadisadvantage.Thegovernmentshouldsetregulationsthatprotecttherightsofruralcommu-nities andprovide themwith fair andequitablehealthcareservices.

Finally,ifthegovernmentdoesnotap-plyadequatecontrolover thehealthcaremarket, expenditureonhealthcaremayincreasedramaticallyasa resultofhigherpricingandprofit-seekingbehaviour[14].

Accessibility to health servicesOptimizing theaccessibilityofhealthcare services requires equity in thedistribution of health care facilitiesthroughout thenation and equityofaccess tohealthprofessionals, includ-ingtransport toservicesandproviders.Accessibilityisalsoaffectedbythelevelofcooperationbetweenrelatedsectors[23,39].ThecurrentMOHstatisticsindicate that there isamaldistributionofhealthcareservicesandhealthprofes-sionals across geographical areas [4].Peopleexperiencelongwaitinglistsformanyhealthcareservicesand facilities[14].Additionally, there is adearthofservices fordisadvantagedgroupssuchas theelderly, adolescentsandpeoplewith special needs such as disability,particularly in ruralareas [39].Finally,manypeopledonothavetheabilitytoaccesshealthcare facilities,particularlythoselivinginborderandremoteareas.

Inorder to improveaccessibility tohealth care services in all partsof thecountry,aholisticstrategyfortheredistri-butionofhealthcareservices,involvingPHCcentres,generalhospitals,centraland specialisthospitals aswell as thehealthprofessionals,shouldbeadoptedby theMOH.TheMOHshouldalsoliaisewithothersectorssuchtransport,waterandpowercompaniesandsocialsecurity services in order to developservicesindeprivedareasandtocareforpeoplewiththegreatestneeds.

Patterns of diseasesThechange in disease patterns fromcommunicable tononcommunicablediseases in Saudi Arabia is anotherchallenge that needsmore attentionfrom theMOH[21].Therehasbeenanalarming increase in theprevalenceof chronicdiseases, such asdiabetes,hypertension, andheartdiseases, can-cer,geneticblooddisordersandchild-hoodobesity[28,40,41].Treatmentofchronicdiseasesiscostlyandmayevenbe ineffective [40]. For example, theannual cost for treatmentofdiabetesmellitus inSaudiArabiawasestimatedtobe7billionSaudi riyal (SR)(US$1.87billion) [42].Earlyprevention isthemost effectiveway to reduce theprevalenceofchronicdiseasesand thecosts anddifficulties associatedwithtreatment in the laterstagesofdisease.Anyprojectedreformsinthehealthcaresystemmust involveplans to addressthischangeinemphasize.

Promotion and prevention programmes for crisesDevelopment and implementationof practical plans and procedures tomeetnational crises inSaudiArabia,suchaswars,earthquakesandfiresandexplosionsatpetroleumfactories,areafurtherimportantneed.Roadtrafficac-cidents,forexample,killedmorethan39000andinjuredabout290000peoplebetween1995and2004[43].Accord-ingtoWHO,roadtrafficaccidentsarenowthehighestcauseofdeath, injuryanddisabilityinadultmalesaged16to36years inSaudiArabia [32].Caringforpeople affectedby roadaccidentsconsumes a significantproportionoftheMOHbudget;forexample,thecostof treating injuredpeopleduring2002wasestimated tobeSR652.5million(US$174million) [43].These fundscould be used to develop the healthsystemand improve services.Plans tomanage issuesof thiskindneed tobecomprehensive andwell-coordinatedamongtherelatedsectorsinordertobeachievable.


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References

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e-health and national health information systemsThere is increasingconcernabout theunderutilizationofelectronichealthsys-tems inSaudiArabia. Implementationofe-healthandelectronic informationsystemshasalreadystartedinanumberofhospitalsandorganizations suchastheKingFaisal specialisthospital andresearchcentre,nationalguardhealthaf-fairs,medicalservicesofthearmyforcesand university hospitals [44].Whileuptakeof e-health systems ismovingslowlyinMOHinstitutions,thereareanumberofinformationsystemsoperat-ing in the regionaldirectoratesand incentralhospitals.Unfortunately, theseinformationsystemsarenotconnectedtoeachotherortootherprivateorspe-cializedhealthorganizations[44].

Todevelope-healthservices in thepublic sector, abudgetofSR4billion(US$1.1billion)wasallocatedby theMOHtoruna4-yeardevelopmentpro-gramme(200811)[45].Additionally,aseriesofconferencesone-healthhavebeenheldbytheSaudiAssociationforHealth Information toemphasize theimportanceof e-health in enhancingthequalityofhealthcaredeliveryandtoexplorethenecessarystrategies,policies,applicationsandinfrastructure[46].

Morecoordinationamongdifferenthealthcareprovidersisneededinordertoenhancetheuseofe-healthstrategiesandtolaunchacomprehensivenationalsystem forhealth information.Ahigh

levelofcoordinationmustbeachievedwithotherrelatedsectorstoprovidetherequiredinfrastructuresuchas internetandphoneservices.

New strategy for health care servicesTomeet the challengesof theSaudihealth care system and to improvethequalityofhealthcare services, theMOHhas set a national strategy forhealthcare services.This strategywasapprovedby theCouncilofMinistersinApril2009.Itfocusesondiversifyingfunding sources;developing informa-tion systems; developing thehumanworkforce; activating the supervisionandmonitoringroleoftheMOHoverhealthservices;encouragingtheprivatesector to take itsposition inprovidinghealth services; improving thequalityofpreventive, curative and rehabilita-tive care; anddistributinghealthcareservicesequallytoallregions.

Thenationalstrategyforhealthcareservices is tobe implementedby theMOHincooperationwithotherhealthcareprovidersanditwillbesupervisedby theCouncilofHealthServices.A20-year timeframe for achieving theobjectivesofthisstrategyhasbeeniden-tified[39].

Conclusion

Asa resultof thecontinuedattentiontoand support from thegovernment,

Saudi health services have advancedgreatlyover recentyears inall levelsofhealthservices:primary,secondaryandtertiary. Asa consequence, thehealthof theSaudipopulationhas improvedmarkedly.TheMOHhas introducedmanyreforms to its services,with sub--stantialemphasisonPHC.

Despite these achievements,healthservices,and inparticularpublicsectorhealthservices,arestillfacingmanychal--lenges.These include:humanresourcedevelopment;separationoftheMOHsmultiple roles (financing, provision,controlandsupervisionofhealthcaredelivery);diversifyingfinancialsources;implementing the cooperativehealthinsurance,privatizationofpublichos-pitals,effectivemanagementof chronicdiseases;developmentofpracticalpoli-ciesfornational crises;establishmentofanefficientnationalhealthinformationsystemandtheintroductionofe-health.Inordertoaddressthesechallengesandcontinue to improve the statusof theSaudi health care system, theMOHandother relatedsectors shouldcoor-dinate their efforts to implement andensure the successof thenewhealthcarestrategy.

Acknowledgements

Thispaper ispartof thefirst authorsdoctoral research, supported by thegovernmentofSaudiArabia.

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Healthcare System in Saudi Arabia