An exclusive health policy education: Original insights from KSA.

Objectives: Health policy education is increasingly understood to be an important aspect in preparing future health professionals to become active policy leaders. However, current research on health policy education is limited and has been performed predominantly in Western contexts. The aim of this study was to explore and analyze the state of health policy education in KSA.
Methods: A qualitative document analysis was performed on the course materials of health policy courses offered in Saudi universities. The inductive and interpretive analysis revealed four themes that were finalized after iterative engagement with data and interpretation. The study's credibility was enhanced through negative case analysis and rival explanations.
Results: The results indicated that health policy education was delivered exclusively to specific programs. Whereas health policy courses had specific objectives, the programs' specialization or the Saudi context influenced the foci of these courses. The varying foci in health policy courses were accompanied by content reflecting the policy process and a discussion of various health policy domains.
Conclusion: The results underscore the importance of building momentum in health policy education and the crucial roles of academic, health and policy leaders. The holistic approach of this study comprehensively indicates the national status of health policy education and situates the ongoing conversation regarding health policy education in a global context.

Introduction

The past two decades have seen substantial international impetus in the field of health policy and analysis. Health policy usually involves several definitions, thus convoluting public health policy, healthcare policy, population health and health equity. However, health policy is increasingly understood to encompass decision-making processes, policy processes and the influences of policy issues. Generally, as a field, health policy connects appropriate knowledge to applications within healthcare settings. Accordingly, an understanding of health policy is important for the existing and future health workforce; as this importance continues to increase, so does the need for incorporating health policy knowledge into healthcare programs. Consequently, investing in health policy education is crucial to place healthcare professionals within the policy sphere. Healthcare leaders have advocated for having healthcare professionals assume leadership roles in developing the health policies that shape their practices.

Despite growing interest in examining health policy education, the literature on teaching health policy is quite scarce, with a few exceptions documenting that health policy courses are being taught as part of fellowship, residency, training and academic programs across several specialties, with an extensive focus on medicine and nursing professions.,7, 8, 9 Courses incorporating health policy into teaching are taught at both the undergraduate and graduate levels,,,10, 11, 12, 13, 14, 15, 16; some courses target healthcare professionals, managers and policymakers. These courses are offered by universities or research institutes, and vary in duration from several weeks or months to several years.,,

Such courses cover fundamental topics including healthcare systems and reforms, the politics of healthcare and health finance. Other peripheral topics include global health, quality improvement, health insurance, population health policy, policy processes, and ethics and law.,,,, Additional courses follow methodological approaches to teaching health policy, by focusing on quantitative or qualitative research methods., Studies have indicated that some topics are more important than others; for example, 70% of the 93 surveyed deans of US medical schools have reported that quality improvement is the most important topic in health policy courses. Moreover, surveyed and interviewed health policy leaders and practitioners in the United States have identified health policy finance, politics, analysis and research as the main knowledge areas needing to be taught.

To guide health policy teaching, researchers have developed frameworks for teaching health policy, mainly for specific target audiences, such as medical students and physician assistant students. As a preliminary contribution, given the need to adopt a unified health policy curriculum in medical schools across the United States, Patel and colleagues have proposed a framework for teaching health policy including four domains: systems and principles; quality and safety; value and equity; and politics and law. Similarly, Deon Kidd and colleagues have proposed a framework for health policy curricula for physician assistant students, which includes four components: foundations of population health; clinical preventive services and health promotion; clinical practice and population health; and health systems and health policy.

Increased awareness of the deficiencies in health policy education has improved the understanding of several barriers challenging health policy teaching. These barriers include inflexible curricula, time constraints, and poor administrative and financial support for health policy courses., Further barriers include students’ lack of perceived value to practice and lack of interest in health policy, as well as the faculty's insufficient interest, experience and capacity.,,, These barriers have led students to report limited or lacking instruction in health policy, thus hindering their involvement in the field.21, 22, 23 However, students have found that health policy courses, when offered, increase their intent to be involved in health policy, seek opportunities in the field and even transfer acquired knowledge to their peers.,

The limited documentation of health policy education has initiated calls to examine and understand what health policy courses are offered and how teaching is approached.,, A major issue regarding current knowledge of health policy education is the lack of variation in contexts of studies and professions. The extant literature has predominantly focused on Western contexts, mainly on single health professions, in one or few institutions, despite calls for international documentation of health policy education. Therefore, the present study explored the state of health policy education in KSA, by understanding what courses are offered and to whom, and what knowledge the courses provide. The study's aim was to expand the current knowledge regarding health policy education to include health programs other than medicine and nursing, and to situate the ongoing conversation regarding health policy education within a global context. The holistic approach used in this study provides a comprehensive national-level picture of the current status of health policy education and enriches the current literature, which lacks evidence for guiding the teaching of health policy.

Materials and Methods

Research design

Through an exploratory qualitative approach, the study used document analysis of health policy courses’ materials. Document analysis is a systematic process used to examine, interpret and evaluate different types of documents to gain better understating and generate knowledge. As a stand-alone method, document analysis allows researchers to acquire knowledge and extract meaning on the basis of data analysis and interpretation. Previous studies have analyzed program and course materials to examine various topics within health education.,

Data collection and analysis

Data collection started in May 2021 and lasted 3 months. A list of Saudi universities and colleges was generated by retrieving them from the Saudi Ministry of Education's official website. Each of the Saudi universities/colleges’ official websites was searched to generate a list of health policy courses offered as part of academic degree programs. The search was performed in two phases. First, for each university/college, the webpages of all health/medical colleges and their respective programs were reviewed in a search for health policy courses. The second phase expanded the search beyond health/medical colleges and searched course directories for any health policy courses at each university/college. The search terms included “health policy” and its synonyms, as well as a combination of the search terms; “policy,” “regulation” AND “health,” “medicine,” and “healthcare”. Among the 66 public and private universities and colleges in KSA, 42 had health/medical colleges.

The compiled list of health policy courses was used to develop profiles for each course, containing descriptive data on the universities and their programs, and course documents including course descriptions, course specifications and syllabi. These documents provided an overview of the courses’ learning outcomes, objectives, descriptions and content covered. In cases in which the webpages did not include course descriptions and specifications, the courses’ instructors or program coordinators were contacted by email and asked to provide course materials. If no response was received after two email attempts, the courses were excluded from further analysis (n = 5).

The constructivist paradigm informed the study by revealing the meanings of health policy education as constructed and shaped by the local context. Given the exploratory nature of the study, the analysis was approached inductively, and codes were derived from the data rather than conforming to predetermined codes. The analysis started with extraction of data from documents and document instances to capture content corresponding to the study's aim. Via open coding, a search was performed for references capturing the courses’ foci, content covered and approaches taken to delivering courses, to provide a comprehensive picture. Through thematic analysis, the coding identified themes within the analyzed documents and developed categories and links among them. Through close reading of all documents several times, scripts were coded reflecting the study's aim. Throughout the analysis, attention was paid to any differences in the characteristics of courses and programs, such as the type and level of programs. Initially, broad categories were developed, and then sub-categories were constructed. During the interpretive analysis, themes were gradually generated and refined as needed, while concepts relevant to each theme were identified. Through iterative engagement with the data and its interpretation, the themes were revised, grouped and organized to reflect the final relevant themes. The use of Nvivo 11 facilitated the data analysis process.

Negative case analysis and alternative explanations are two methods used to enhance the credibility of the study., By using the alternative explanations method, the author searched for different ways of structuring the data that would result in contrary interpretations. The lack of data supporting alternative explanations contributed to the credibility of the generated themes. Negative case analysis involves a deliberate search for cases that do not confirm the generated themes. By identifying and analyzing such cases, the author was able to identify alternative explanations, and increase the nuances and appropriate interpretation of the data.

Results

The document analysis revealed four interrelated themes reflecting health policy education in Saudi universities: (1) exclusive teaching of health policy, (2) specific objectives of health policy courses, (3) diverse course content regarding policy process and health policy domains and (4) health policy targets according to the Saudi context or program specialization.

Exclusive teaching of health policy

The first theme provides an overview of the offered health policy courses and their targets. As shown in Table 1, health policy courses are offered in a variety of degree programs. A total of 18 health policy courses were offered in 17 different programs. These programs were offered in 10 of the 30 public universities, and in 2 of the 20 private colleges; no courses were offered by the 14 private universities. Most health policy courses (n = 11) were offered as part of bachelor's degree programs, whereas six courses were offered in graduate-level programs.

Table 1

Health policy courses offered at Saudi Universities.

Health Policy Course	Level Offered	Credit Hrs.	Pre-req.	Program	College	University
Healthcare Systems: Policies, Planning & Evaluation	Any level	3	No	PhD in Nursing	Nursing	King Saud University, Public
Health Policy Analysis	Any level	3	No	Master of Health Administration, Health Policies track	Business Administration
Healthcare Service & Policy∗	4	2	No	BSc in Public Health	Applied Medical Sciences	King Khalid University, Public
Healthcare Policy & Procedures	6	3	Yes	BSc Health Services Management	Public Health & Health Informatics	Hail University, Public
Public Health Legislation and Policies∗	5	2	Yes	BSc in Community Health, Public Health track	Applied Medical Sciences	AlBaha University, Public
Tobacco Use: Prevention, Cessation and Policy∗	6	2	Yes
Public Health Policies	4	3	Yes	BSc in Public Health	Applied Medical Sciences	King Faisal University, Public
Public Health Policies	8	2	No	BSc in Public Health	Public Health	Imam Abdulrahman Bin Faisal University, Public
Public Health Policies	2	2	No	Master of Public Health, Healthcare Management track
Health Policy & Regulation	2	2	No	MS in Healthcare Quality & Patient Safety
Public Health Policy Society	5	2	Yes	BSc in Public Health & Health Informatics	Applied Medical Sciences	Majmaah University, Public
Health Policy & Saudi Healthcare System	4	3	Yes	BSc in Public Health	Health Sciences	Saudi Electronic University, Public
Health Policy & Saudi Healthcare System	5	3	Yes	BSc Health Informatics
Healthcare Policy Analysis & Development	3	3	Yes	Master of Healthcare Administration
Health Policies	3	3	No	Associate Diploma in Public Health	Community College	University of Tabuk, Public
Health Insurance & Health Policy	Any level	3	Yes	Master of Public Health, Health Policy & Management or Mass Gatherings Health	Medicine	Alfaisal University, Private
Health Policy∗	8/9	3	No	BSc Healthcare Administration	NA	Batterjee Medical College, Private
Health Policy for Pharmacists∗	9	3	No	Bachelor of Clinical Pharmacy	Clinical Pharmacy	Al-Rayan Colleges, Private

∗Not included in further analysis.

Although all programs were offered in health colleges or departments, one course, Health Policy Analysis, was offered by the College of Business Administration in the Health Administration department. Health policy courses accounted for either two or three credit hours and were offered once during study programs, except for the BS in Health Community, Public Health program, in which enrolled students took two health policy courses: Public Health Legislation and Policies and Tobacco Use: Prevention, Cessation and Policy. All offered courses were required core courses except for the Healthcare Systems: Policies, Planning and Evaluation course, which was part of the PhD in Nursing program. For bachelor's degree programs, health policy courses were offered to students at level four (second year) or higher. Most courses did not require pre-requisites; however, some courses required taking introductory prerequisite courses such as introductory public health, healthcare systems and healthcare management courses. Eleven health policy courses required pre-requisites as part of the bachelor's degree programs, and two required pre-requisites as part of the master's degree programs.

Specific objectives of health policy courses

Most of the health policy courses took a specific and narrow focus in teaching health policy, as shown in Table 2. Indeed, the analyzed documents clearly indicated the courses’ foci, mainly according to the course descriptions. The courses’ foci were not absolute but instead reflected the large portion of course content (main objective). Importantly, although the focus was the main angle in teaching health policy, other content was covered within the courses. For example, a course with a policymaking focus also covered health policy domains; however, it focused on policymaking.

Table 2

Results of document analysis.

Health Policy Course	Course Focus	Course Content		Health Policy Target
		Policy Process	Domains	Saudi	Specialization
Healthcare Systems: Policies, Planning and Evaluation	Healthcare system	✓	✓		✓
Health Policy Analysis	Policy process	✓			✓
Health Care Policy and Procedures	Policy process	✓
Public Health Policies, King Faisal University	Ethics and law	✓	✓		✓
Public Health Policies,Imam Abdulrahman Bin Faisal University (BS)	Policy process & analysis	✓	✓	✓	✓
Public Health Policies,Imam Abdulrahman Bin Faisal University (MPH)	Policymaking		✓	✓	✓
Health Policy and Regulation	Policymaking	✓	✓	✓
Public Health Policy & Society	Healthcare system	✓			✓
Health Policy and Saudi Healthcare System, BSc Health Informatics	Policymaking	✓		✓
Health Policy and Saudi Healthcare System, BSc Public Health	Policymaking	✓		✓
Healthcare Policy Analysis & Development	Policy evaluation & analysis	✓	✓
Health Policies	Policymaking	✓	✓	✓
Health Insurance & Health Policy	Health insurance & policy analysis		✓		✓

As illustrated in Table 2, the courses’ specific foci reflected policy process, ethics and law, healthcare systems and health insurance. Most courses (n = 9) focused on the policy process; either overall or a specific phase, specifically, policymaking and policy evaluation. These courses were part of four bachelor's and master's programs, and one associate diploma program. Among these nine courses, five focused on policymaking, three focused on the entire policy process, and one focused on policy evaluation.

Policy analysis always emerged as a focus combined with other foci in three courses: Public Health Policies, Healthcare Policy Analysis & Development and Health Insurance & Health Policy. In addition to the focus on policy analysis, each of these courses had a focus on policy process, policy evaluation and health insurance, respectively. In contrast, two courses had a healthcare system focus and were part of the BSc in Public Health and Health Informatics, and PhD in Nursing degrees. Ethics and law, and health insurance were the foci of courses that were part of the BSc in Public Health and Master of Public Health degrees, respectively.

Diverse course content: policy process and health policy domains

According to the analysis, the content covered in health policy courses could be categorized into (1) policy process and (2) health policy domains. The first category included content reflecting various phases of the policy process, mainly policymaking, implementation and evaluation. Most courses (seven) included content in policymaking. Within policymaking, the emphasis was on policy actors including governmental and non-governmental entities; public and private sectors, such as accreditation agencies; and healthcare managers and their roles in policymaking. The courses used a narrow definition of policy actors including only formal actors, and overlooked informal policy actors and those influenced by polices. Second, only four courses covered content associated with policy implementation. Knowledge of policy implementation included discussion of implementation frameworks, and their applications and challenges. Finally, policy evaluation was part of four courses. These courses provided a methodological understanding of evaluation through quantitative and qualitative methods; measuring policy effectiveness, outcomes and impacts from various perspectives; and factors including social, economic, cultural and legal aspects.

The second category could be grouped into health policy domains. Eight of the courses covered health policy domains, specifically quality, cost, access and equity. These courses foregrounded the domains of health policy according to a discussion of their roles in and effects on health policies, and their relationship with healthcare systems. The quality domain included how health policies affect quality; the delivery of quality healthcare; the evaluation of policies’ effects on quality and patient safety; and the regulatory forces governing the delivery of quality healthcare, such as accreditation bodies. The cost domain involved discussion of the cost of healthcare services, financing healthcare systems, and mechanisms to control costs and ensure cost effectiveness. The access domain included issues limiting or preventing access to healthcare systems, and the roles of health insurance and access. Equity was covered through discussions of economic and social determinants, and the development of policies to improve equity in healthcare.

The results also revealed a distinction in terms of the content covered between undergraduate- and graduate-level courses. All undergraduate-level courses included content associated with the policy process, whereas most courses covering health policy domains were offered as part of graduate-level programs.

Health policy target: bounded by the Saudi context or program specialization

Data analysis revealed that two factors were the targets of the health policy courses: the Saudi context and program specialization. Six courses targeted the Saudi context, with a focus on policymaking. Delivered through the lens of the Saudi context, these courses included references to the Saudi healthcare systems or policies, and were accompanied by terms such as “in-depth,” “with a focus on,” and “emphasis on.” Indeed, the titles of two courses reflected their targets through the Saudi context: Health Policy and Saudi Healthcare System. The lens of the Saudi context in these courses reflected an in-depth exploration of the Saudi healthcare system (including an overview of the system, delivery of services, finances, and the roles of governmental and non-governmental entities in the system and its operation), as well as an analysis of Saudi health policies.

Six courses targeted their respective programs’ specialization: BSc in Public Health, Master of Public Health or PhD in Nursing. Five courses reflected the public health specialization, whereas one course was part of the nursing specialization. In these courses, the program's specialization was the lens through which the courses were delivered. For example, the Health Insurance and Health Policy course, as part of the Master of Public Health program, targeted public health specialization. Therefore, the course content included discussions of health policy and health insurance, specifically their effects on public health, and approached policy analysis in relation to public health. Unlike courses targeting the Saudi context, reflecting a single focus (policymaking), courses targeting their respective programs’ specialization reflected a variety of foci including ethics and law, policy processes, healthcare systems and health insurance.

Although courses targeted specialization or the Saudi context, two courses reflected an interplay between both specialization (in public health) and the Saudi context. The Public Health Policies course, as part of the BS in Public Health and Master of Public Health programs offered by the same public health department, reflected a combination in which the content covered was delivered through the lens of Saudi public health.

Discussion

This study's purpose was to explore the state of health policy education in SA. Health policy education typically represented a single course in the programs’ curricula, thus reflecting limited health policy education. Although courses had specific objectives, the programs’ specialization or the Saudi context shaped the foci of these courses. The varying foci of health policy courses was accompanied by content reflecting the policy process and health policy domains.

In the context of similar studies in health policy education, the findings of this study affirm some prior results and contradict others. In agreement with the literature on the deficiency in health policy knowledge, the results of this study highlight the same deficiency, in which a limited number of courses are offered as part of specific programs. Saudi universities and colleges with more than 130 health programs offer only 18 courses. Similarly, the extant literature has documented a deficiency in health policy education and provided evidence of the efforts of various countries and institutions to address this deficiency. Such efforts have included delivering health policy knowledge as part of academic programs within universities or through specialized expert teaching provided or sponsored by professional societies.,,,,,,

In contrast to the literature, in which health policy courses have been reported to be delivered almost exclusively in medical and nursing schools,,7, 8, 9 a clear lack of such specialization was found in this study. Thus, the small portion of graduates of Saudi universities with foundations in health policy are graduates of public health, healthcare services and healthcare administration degree programs. This finding may be concerning, given that most leaders and policymakers within the Saudi healthcare system are indeed graduates of national universities. Consequently, Saudi universities are not necessary equipping or exposing future leaders to health policy, despite the importance of acquiring such knowledge for preparing future health leaders.,

The study's findings, in which health policy courses target undergraduates and graduates equally, are consistent with the consensus in the literature regarding the importance of integrating health policy courses into undergraduate programs.,, With few exceptions, the literature has concluded that health policy courses are usually not provided at bachelor's degree levels, and graduate programs have the largest share of health policy courses. Some authors have suggested that this aspect is problematic, given that not all bachelor's graduates continue their education, thus leaving a large percentage of graduates without knowledge or preparation in health policy.,

While acknowledging the importance of health policy education, expecting that one course, or even a degree, would yield graduates sufficiently well-prepared and well-rounded to participate in health policy professional opportunities would be unrealistic. Instead, the delivery of health policy courses, from a health policy education perspective, could be considered a foundation-builder. Introducing students to health policy can simulate their motivation, interests and thinking within the realm of health policy. Having such foundational knowledge early on would set the stage for students, so that they can complement their knowledge through advanced degrees and training to pursue further in their careers.

Given the study's findings, graduates of programs offering health policy courses acquire knowledge that is discernible from their program's specialization or the Saudi context. The predominance of public health specialization as a lens shaping health policy courses reflects the crucial roles of colleges of public health in health policy education. Hence, the absence of other specializations highlights the need for other specialties to participate in and contribute to health policy education. By contrast, targeting the Saudi context reinforces previous arguments for approaching health policy as “socially constructed” and context-bound., Indeed, understanding health policy in relation to local contexts is detrimental in policymaking and implementation and their role in influencing policy success.

The findings regarding the fairly specific focus in teaching health policy courses in Saudi universities are particularly important in investigating or developing best practices for teaching health policy. The results prompt an important question regarding whether a comprehensive or a focused approach to teaching is better. Although this question is important, the extent to which health policy courses should be exhaustive, broad or specific remains unclear, and such discussion has been neglected in the extant literature. Answers to this question would be essential for academia to respond to the needs for incorporating health policy courses into curricula, and developing courses and course content. Such responses are expected to be cautious and small in scale, e.g., by incorporating a single course, thus providing limited space to cover a wide range of health policy knowledge.

Considering the four domains and their respective components proposed by Patel and colleagues, this study underscores the variety of content that should be included in teaching health policy. Although Patel and colleagues have clearly identified these domains as part of national curricula for US medical schools, the findings of this study expand this knowledge to non-Western contexts. Although the content taught in health policy courses in KSA can mirror the framework of Patel et al., the four domains were rarely the focus of the courses. Instead, the policy process, particularly policymaking, was the focus of most the courses, an aspect not previously reported in the literature. Parallel to this focus was a lack of knowledge regarding theories of the policy process across courses, despite the critical role of such knowledge in influencing policy change. In line with this finding, the lack of policy process theories can undermine students’ understanding of health policy and their ability to navigate the complex health sector. In the 21st century, skills and competencies in health policy literacy are no longer preferable but instead are required to understand contexts, frameworks and operations within healthcare systems., However, teaching health policy in the sense of content covered and domains may not be the best way to emphasize the importance of policy process and its complexity. Thus, health policy education must be built around the policy process along with health policy domains, and must include a wider range of health programs and specializations. Students who will be future policymakers, implementers or evaluators must be equipped with knowledge and skills regarding the different phases of the policy process that they will need to use in real life.

The study examined health policy education in Saudi universities by analyzing course materials. However, one limitation of the study is that the review of health policy education through academic programs might have overlooked other types of health policy education offered through nonacademic entities. Additionally, given the specificity of the study to the Saudi higher education system and healthcare system, the study's findings should be generalized cautiously.

Conclusion

The study documented the state of health policy education in KSA. The findings reflect the exclusivity and specific objectives of health policy education, which varied according to courses’ foci and content. The study emphasizes the importance of building momentum in health policy education and the crucial roles of academic, health and policy leaders. The study's holistic approach provides a comprehensive view of the national status of health policy education and situates the ongoing conversation regarding health policy education in a global context.

Recommendations

The study's findings indicate the need for comparative studies to understand different approaches of health policy education and their effects, and to identify best practices in teaching health policy. Future studies will be necessary to examine health policy education in health specialties other than medicine and nursing. In addition, future research should investigate the role of health policy education in influencing policy leaders in the health sector.

The study's findings have several implications, such as shaping career trajectories and opportunities by understanding what health policy knowledge graduates acquire. Indeed, further collective understanding of the need for health policy education among leadership and academic communities is imperative to place health policy education on universities’ decision-making agendas. Accordingly, health policy leaders, academicians and professional bodies play major roles in building momentum in health policy education. These roles reflect a commitment to advocate for the need for health policy education to improve national and global healthcare systems. Thus, national-level intake in health policy education is necessary to introduce change within KSA at the Ministry of Education level.

Professional bodies have an important role by including health policy as part of their programs’ assessments, licensing and exams for healthcare practitioners. In other countries, several national professional bodies have updated their professional competencies or published new competencies reflecting various aspects of health policy.,,,, Thus, continual evaluation of current educational programs is necessary to deliver programs that equip graduates with the knowledge and skills allowing them to actively and effectively engage in health policy. The expansion and transformation of the healthcare system in KSA, and worldwide, provides opportunities for leadership positions that require health policy literacy. Such opportunities necessitate the expansion of health policy education across health specialties and among different educational levels.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The author has no conflict of interest to declare.

Ethical approval

The author confirms that this research was conducted in accordance with COPE rules and regulations. Given the nature of the research, IRB review was not required.