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Learn More. Many countries now struggle to provide cost-effective, quality healthcare services to their citizens.
Saudi Arabia has experienced high costs along with concerns about quality of care in its public facilities. To address these issues the country is currently restructuring their healthcare system to privatize public hospitals and introduce insurance coverage for both foreign workers and citizens. The situation also demonstrates a unique case in the Middle East for greater reliance of the private sector to address rapidly escalating healthcare costs and deteriorating quality. The complexity of changing a healthcare system is discussed with the many challenges associated with the change.
Many countries across the world are struggling to improve healthcare quality, contain or control costs, and provide access to healthcare for their citizens. Much has been written about United States and European struggles to balance quality, cost, and access to healthcare. The situation in the Kingdom of Saudi Arabia is less well known, but is distinctly unique, with fascinating reforms taking place that will radically change the way healthcare is provided.
The country has offered comprehensive, universal access for many decades, and now, as a result of spiraling costs and perceptions of low quality, is radically reforming the healthcare market by introducing private health insurance, feefor-service medicine in governmental hospitals, and the privatization of hospitals. With its land area of a 2 square kilometers, the Kingdom of Saudi Arabia is the largest country in the Middle East, consisting of mostly desert and huge subterranean reserves of oil.
The Saudi economy continues to be highly dependent upon oil demand and pricing. Saudi Arabia has the largest reserves of petroleum in the world, and is the largest exporter. The population of Saudi Arabia has expanded rapidly in the past few decades from approximately 7.
Healthcare in Saudi Arabia currently is provided free of charge to all Saudi citizens and expatriates working in the public sector, primarily through the Ministry of Health and augmented by other governmental health facilities. The government requires that expatriates working in the private sectors have some level of healthcare coverage paid by their employers.
What has been distinctive has been the low level of private insurance involved in the provision of healthcare. Almost all of the private expenditures have been out-of-pocket payments for services in private hospitals and clinics. Governmental funding is allocated through annual budgets to individual ministries and programs. Royal decrees may be issued for allocations of additional funding for special health programs and projects. There currently exist very few specialized institutes dealing with medical research.
Research focuses primarily in four areas: cancer, genetics, cardiovascular diseases, environmental health and infectious diseases. Another unique aspect of healthcare in Saudi Arabia is that every year the country serves more than 5 million pilgrims and visitors to the Holy Mosque in Makkah.
The government provides free health services to pilgrims through the Ministry of Health MOH facilities. In , in the month of Ramadan, nearly 3. According to the Saudi authorities, more than cases of pilgrims were treated in the MOH facilities that year. MOH assigned 22 hospitals and primary care centers to serve pilgrims during the Hajj pilgrimage activities with more than 9 personnel, including physicians, nurses and allied health personnel, engaged to work in these health centers.
Health services in Saudi Arabia are provided through three main sectors: the MOH network of hospitals and primary healthcare centers that are distributed throughout the country, other governmental institutions, and the private sector.
The country is divided into 13 regions and 20 health directorates. Each directorate enjoys relative autonomy in managing their health affairs, subject to the reasonably loose policy guidelines set by the MOH. Regions are provided lump-sum budgets, which they then distribute to their hospitals. The MOH focuses intensely on prevention and primary care and sponsors over health centers across Saudi Arabia. Citizens can generally only access the primary care centers in their residency areas.
Other governmental sector healthcare providers, funded outside the budget of the MOH, include facilities that are highly respected, and generally, considered better quality. The second largest healthcare provider, other than the MOH, is the Medical Services Department of the Ministry of Defense and Aviation, which has over hospital beds and employs over physicians. Overall, KAMC has hospital beds, physicians, and nurses. The Security Forces Hospital is a bed tertiary care referral facility that is internationally accredited.
They also sponsor 73 primary healthcare centers. It is an bed tertiary care hospital providing highly specialized treatment to the people of the kingdom. It serves Saudi citizens for tertiary care services and the extended royal family and dignitaries for all levels of care. The private healthcare sector has grown rapidly since the advent of interest free loans from the government to construct private facilities. The private sector grew rapidly over the past several years and expanded its services, especially in large cities.
Foreign workers, until recently, have not been allowed to use MOH facilities, except for emergencies. However, the private sector has also primarily served Saudi citizens.
The use of global budgets in Ministry of Health hospitals made the construction of private hospitals a positive event for the public hospitals, as patients obtaining care outside of MOH hospitals preserved more of their global budgeted funds.
Initially the private hospitals were small, generally physician-owned facilities funded primarily by out-of-pocket and expatriate payments. However, the move to provide insurance coverage has recently encouraged the entrance of multi-hospital systems into the market. During the early s, the country began to design its first structured health system based on a mixed private, public, and other governmental sector model. Saudi Arabia oriented its health-care system towards primary healthcare-based services encouraged by the MOH.
Patients requiring higher levels of care at MOH facilities must receive a referral from a primary care physician. In the past decade this role was strongly enforced, which improved appropriate utilization of services and subsequent cost reduction. The primary care program in Saudi Arabia has achieved considerable success since its establishment. This success is reflected in good access to and high rates of immunization, maternal health, and control of endemic diseases.
In public hospitals waiting times for non-emergency surgeries may be several months to a year. Overall, the public perceives that the quality of MOH services is much worse than those offered by private companies or other governmental healthcare providers. The Saudi MOH has served the traditional role of the chief governmental health coordinator. The MOH has a broad scope of regulatory powers. These include regulating health products and quality of services, and setting prices.
It also allocates global budgets for each hospital through each regional health directorate. However, one significant difference is the lack of comprehensive authority. Unlike many countries where the healthcare ministry exercises authority over all segments of their healthcare systems, the Saudi MOH lacks authority over two important public sector health systems. The university teaching hospitals and the military hospitals fall outside of their purview. Also, the MOH exerts only indirect control over the growing private sector.
University hospitals are directly under the Ministry of Higher Education and receive direct financial allocations from the Ministry of Finance. The military hospitals, the National Guard, Armed Forces, and Interior hospitals are directly governed and funded through their respective ministry budgets and can be seen as competitors for healthcare budget allocations to the MOH.
This allows for wide variation in funding levels and personnel policies. For example, the funds allocated per bed are significantly higher in the non-MOH hospitals and physicians who work for the National Guard Hospital may earn two to three times the amount that physicians working for the MOH make.
These facts create the perception that service quality, ease of access, and technology is much higher in non-MOH hospitals. The MOH does have the authority to set prices and establishes them according to tiered levels, which is mostly applicable for private services. Hospitals may receive one set of prices based on three different tiers, as determined by their service levels. This dictates the prices that they can be reimbursed for private services. The MOH also sets maximum charges for pharmaceutical drugs.
Because of the rapid industrialization of the country, the educational infrastructure has not existed in the past 40 years to produce an adequate number of physicians, nurses, and healthcare technicians. Even though the educational capacity has drastically increased, the vast majority of healthcare professionals in Saudi Arabia continue to be non-Saudis. Since foreign nationals tend to remain in the country only a short time, continuity is a problem. The average tenure among non-Saudi physicians and nurses is just 2.
These professionals also receive very generous premiums for vacation and holiday pay. To attract healthcare professionals, hospitals provide up to 58 days leave per year. Interestingly, Saudi physicians tend to work more often for the MOH and the other governmental hospitals. As competition for patients has begun to increase, the incentive for each sector of the healthcare system to obtain and operate the latest capital equipment has been amplified.
The acquisition of expensive equipment enhances the reputation of the individual facility. Under global budgets for operations and special allocations for equipment, with no cross-sharing of costs, individual facilities may augment their reputation by obtaining sophisticated equipment, but have little incentive to use it efficiently.
In fact, if the service is used less frequently the operating costs saved can be retained and used for other purposes. This is especially true in underfunded organizations, which most of the MOH hospitals could be considered.
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