Health care services in saudi arabia: past, present and future.

Health services in Saudi Arabia have developed enormously over the last two decades, as evidenced by the availability of health facilities throughout all parts of the vast Kingdom. The Saudi Ministry of Health (MOH) provides over 60% of these services while the rest are shared among other government agencies and the private sector. A series of development plans in Saudi Arabia have established the infra-structure for the expansion of curative services all over the country. Rapid development in medical education and the training of future Saudi health manpower have also taken place. Future challenges facing the Saudi health system are to be addressed in order to achieve the ambitious goals set by the most recent health development plan. These include the optimum utilization of current health resources with competent health managerial skills, the search for alternative means of financing these services, the maintenance of a balance between curative and preventive services, the expansion of training Saudi health manpower to meet the increasing demand, and the implementation of a comprehensive primary health care program.

THE PAST

The history of health care services in Saudi Arabia dates back to 1949, when a small number of medical staff (111 doctors) and fewer than 100 hospital beds were documented.1 Since then, the Kingdom has made huge advances in the organization of its health care system. Major developments have brought health services to every corner of the vast kingdom. Compared to 1949, the number of doctors and nurses has multiplied 25 times and 20 times (1172 to 30281 and 3261 to 64790 in 1998) respectively, in more than 300 hospitals and 1700 primary health care centers around the country. Government spending on health rose sharply as the budget of the Ministry of Health (MOH) increased sixty fold to 12044 million SR (3.2 billion US$) in 1998, about 6.2% of the national budget.23

This remarkable development in the health care system has been accompanied by an improvement in the quality of health services, especially in curative medicine. Hos-pi-tals have become fully equipped and are able to perform a variety of advanced procedures in cardiovascular and cancer surgery, as well as all types of transplant operations.

Preventive services started in early 1950s when the ARAMCO oil company, in collaboration with the WHO, helped the MOH to control malaria in the eastern re-gion of the kingdom.4 Programs to control bilharziasis, leshmianisis, trachoma, tuber-cu-losis and other endemic diseases followed suit in the various regions of the country on both vertical and horizontal levels.5–7 The country also adopted the new concept of Primary Health Care (PHC) developed in 1978 and in 198389 began to promote it as the basis of its health delivery system. This strategic step has been most fruitful with the immunization of over 90% of the children in Saudi Arabia against infectious childhood diseases in the EPI system.10

Medical education has also developed considerably with over 340 doctors and 89 dentists graduating from five medical colleges and two dental schools in 1998.3 Another four government colleges in Madi-nah, Qassim, Gizan and Hassa are to be opened in due course and ambitious plans for private medical colleges are under dis-cus-sion. Local literature on health in Saudi Arabia has also developed. A large number of health research projects have been con-ducted in various fields of medicine and allied sciences over the last fifteen years and the results published in more than 10 Saudi medical journals.

THE CURRENT SITUATION

The MOH provides around 60% of the health services, free of charge, through 13 health directorates. Twenty per cent of the health service is delivered free through other government agencies3 and the remaining 20% is provided by the non-government sector, which is growing rapidly (Table 1).

Table 1

Distribution of health services in Saudi Arabia by type of providers (1998)

In 1998, the total budget of the MOH reached over 12000 million SR, with an average expenditure of 400 SR (108 US$) per capita per year. In other government agencies the expenditure also increased (200 US$ per capita). The relatively high health expenditure in this country compared to that of many developing countries has made the extensive coverage with curative services in Saudi Arabia possible. Nevertheless, this progress has not been equally commensurate with other important issues, such as: (1) The development of the health information system for the purpose of effective planning, monitoring and systematic evaluation; (2) The training of personnel in various medical fields and health administration; and (3) The enhancement of preventive services.

FUTURE CHALLENGES

These can be grouped into four interrelated domains:

1. Management and financing of health services

Government services are currently provided by more than 10 agencies, including the MOH. The management of these services is not uniform, and some managed by private contractors are still expensive. However, the diversity of administrative systems could be a source of enrichment, especially in health administration and the management of resources. Better coordination among these agencies would result in more judicious use of available resources and expertise, to the greatest advantage. Health services are largely publicly financed, and in spite of an increased budget allocation for these free services, the actual average expenditure per capita is expected to decrease. This is a result of a rapidly growing population and declining government revenues.11 Thus, other sources of financing are essential. The government, therefore, is proceeding with its plan for the implementation of the co-operative health insurance scheme, which is already being applied to non-Saudis. Further plans for privatization of health services and facilities are on the drawing board, but there are still many issues to be resolved. There is a definite need for competent health management and an innovative approach to health administration and financing.

2. Curative versus preventive services

An official report by the Ministry of Planning on the utilization of health services was conducted on the PHC center level in 1984.12 The report documented a heavy focus on providing curative services, with over 90% of its activities directed towards individual patient care. This trend was noted in further studies in several regions of the country.13 Health planners for the fifth national health plan (1990-1995), thus felt the need to emphasize preventive services in PHC centers and shift interest towards reducing endemic disease, combating community health problems, and raising the health level of the population through application of all curative, preventive and promotive elements in PHC. The impact of these measures was evident in the extensive coverage of the children's immunization program, a 29% reduction in hospital attendance, and a 42% increase in PHC visitors for all types of services during the five-year period (1989-1994).14

3. Training and development of Saudi manpower

Official estimates show that the percentages of Saudi doctors, nurses and paramedics were 18.7, 18, and 43% respectively, of the working force of the health services in 1998.3 In view of the rapid population growth in the country, these figures pose a challenge to the smooth running of the health system by Saudi manpower. It is calculated that there will be a total of 15226 Saudi doctors in the Saudi health force by the year 2020, representing only 32% of the total health manpower. This is a rather conservative estimate, based on the present number of Saudi doctors (5699 in 1998), together with the projected 500 graduates per year, allowing a 15% dropout rate for various reasons. Hence, the country's dependence on expatriates to fill physicians’ posts will continue for long time. Similar shortage is also envisaged among Saudi nurses15 and other health personnel, indicating an urgent need to accelerate the training of the Saudi work force in all health fields. With the escalation of training costs in the health field all over the world, the involvement of the private sector in training, in conjunction with the privatization of the country's health system, could be part of the solution. It should be noted that the development and training of health manpower in the country should concentrate not only on the number of health workers trained but also on the assurance of the quality and the performance of those trained. This, undoubtedly, will mean the adoption of better quality assurance pro-grams in all health facilities to maximize the utilization of Saudi manpower and develop medical curricula in medical institutes to meet the required training standards.

4. Health development plans of the country

The provision of free health care to the entire population is enshrined in the constitution of Saudi Arabia. Previous development plans had repeatedly emphasized the right of all Saudi citizens to a healthy life, and the need to develop and organize the health system to achieve this. The sixth development plan (1995-2000) of the country clearly details this and specifies the following points: (1) The development of health manpower in terms of both quantity and quality, (2) The assurance of both curative and preventive services to all Saudis, (3) The development of primary health care services as a solid basis of the health delivery system to the entire population, particularly to mothers and children, (4) The control of all endemic diseases and their possible eradication.

Detailed, measurable objectives noted in this plan were as follows: (1) Maintain the current hospital bed rate of 2.4 beds per 1000 population, (2) Minimize the current rates of childhood infections and diarrheal diseases through immunization programs and other preventive measures, (3) Lower the infection rate of malaria in endemic areas to 200/100,000 and eradicate it from non-endemic areas, (4) Increase antenatal coverage for 97% of all pregnant mothers and increase the tetanus immunization rate of these mothers to 85%, (5) Reduce the rate of preterm babies to less than 2% of all deliveries.

CONCLUSION

The development of health care services in Saudi Arabia has influenced life in the Kingdom and changed the health map of the country in a very positive way. Previous health plans established most of the infrastructure for the health services with remarkable results. However, for successful implementation of a good health care system to provide adequate, high quality ser-vice to all citizens, a balance between preventive and curative services will have to be established, managerial and administrative skills in health facilities have to be sharpened through application of quality programs, and the quality and quantity of the training of Saudi health manpower should be properly developed.