Assessing Health Care Delivery in Saudi Arabia
1990; King Faisal Specialist Hospital and Research Centre; Volume: 10; Issue: 1 Linguagem: Inglês
10.5144/0256-4947.1990.63
ISSN0975-4466
Autores Tópico(s)Socioeconomic Development in MENA
ResumoSpecial CommunicationAssessing Health Care Delivery in Saudi Arabia Abdul-Rahman F. Al-SwailemPhD Abdul-Rahman F. Al-Swailem Address correspondence and reprint requests to Dr. Al-Swailem: Dean, Faculty of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia. From the Faculty of Applied Medical Sciences, King Saud University, Riyadh Search for more papers by this author Published Online:1 Jan 1990https://doi.org/10.5144/0256-4947.1990.63SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractThis paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influences in medical care, the availability of female Saudi and of expatriate physicians, and the special needs imposed by the annual pilgrimage, all of which influence health care delivery in Saudi Arabia. The bias and limitations which arise from the unqualified application of the physician-population ratio in determining the quality of health care in Saudi Arabia are also described. Recommendations are made for improving this overall ratio as well as better meeting the specific medical needs of the people through expansion of primary health care services.IntroductionThe physician's traditional role has been to care for and when possible cure the sick, to stem the progression of disease, to minimize damage, to relieve pain and suffering, and to comfort at all times. These are major aspects for which physicians are trained. There is, however, another increasingly important role for physicians, that of the educator who can facilitate the early recognition and prevention of disease by promoting health-fostering attitudes.As the practice of medicine has become increasingly complex and effective, physicians no longer single-handedly do everything required to treat their patients, much less take on all aspects of comprehensive care. They rely on a variety of trained personnel–nurses, laboratory technicians, radiographers, physiotherapists, pharmacists, and so forth.This means that in determining the needs for the efficient delivery of health care, two questions must be answered. First, how many of each category of health care personnel does a country need, in the short and long term? And second, what proportions will best meet the social mix and achieve the greatest economic efficiency? The answers depend on a steady flow of information about, and adequate appraisal of, health conditions in the country, the nature and magnitude of illness and their determinants, and the extent to which health requirements are part of overall socioeconomic development.One way to assess health care delivery is through ratios. In Saudi Arabia for the year 1407H (1987G), the physician-population ratio was 1:582; the nurse-population ratio, 1:276; the bed-population ratio, 3.3:1,000; and the primary health care center-population ratio, 1:7774. These are important statistics and indicate that Saudi Arabia has made great strides in the development of its health care delivery system.A physician-population ratio, which is a popular tool for assessing the quality of health care, is not by itself an accurate indicator of the health status of a country's population, although it may roughly reflect the level of development. Underdeveloped nations can have a ratio as low as 1:12,346 (Sri Lanka, 1983), while developed nations can have a ratio of 1:500 (U.S.A., 1982), but the ratios do not always correlate directly with development1 (Table 1).Table 1. Physician-population ratios for other countries.Table 1. Physician-population ratios for other countries.Other factors that influence the health status of a population include the quality of housing, personal hygiene, diet, sanitation, and level of education. A major drawback of the physician-population ratio is that a higher ratio is taken to mean better health care, which is not necessarily so. The quality and experience of practitioners also must be taken into consideration, remembering that good health care is that which is readily accessible at a low cost.Ratios can provide useful information when used in the correct context. The aim of this paper, therefore, is to discuss some of the limitations of the physician-population ratio, and to examine variables relevant to the health care delivery system, with special emphasis on Saudi Arabia.VARIABLES INFLUENCING QUALITY OF HEALTH CAREDemographyAlthough cities generally have higher physician-population ratios, they do not necessarily have more general practitioners per capita,2 and it is the general practitioner who provides primary health care. Many physicians in urban areas are specialists whose expertise is not really relevant to the general population, but their numbers augment the physician-population ratio.In a country like Saudi Arabia, where primary health care is a high priority, the concentration of physicians in urban areas is for this reason misleading in assessing the availability of general health care. In this context, only general practitioners should be considered in a count of physicians in urban areas, because only this figure can accurately portray the adequacy of primary health care delivery.QualityRatios are used to determine whether there is a sufficient number of physicians and to provide a basis of comparison with data from other parts of the world. However, ratios and other such statistics cannot supply information about the quality of the physicians serving the population. For example, in Saudi Arabia, a large proportion of the medical manpower is made up of expatriates of various nationalities (Table 2). Not all are of the same quality and training, and whilst many are outstandingly well qualified, some are under-trained. A large proportion do not speak Arabic, making communication with patients difficult. Expatriate personnel are often transient and this affects the long-term development of a patient-physician relationship. All of these factors have an important bearing on the quality and continuity of care.Table 2. Physicians in Ministry of Health according to nationality, 1987 (1407H).Table 2. Physicians in Ministry of Health according to nationality, 1987 (1407H).To assess the quality of a practitioner's care, many factors must be considered. Number of years and quality of training, standing in class, CME credits earned, society affiliations, board certification and the granting board, number of procedures performed and outcome (in the case of surgeons)–these are just some of the factors that must be considered when examining the ability of the practitioner and the quality of care, and statistics such as ratios cannot reflect this.To evaluate other aspects of the delivery system, even more factors must be considered. These include the number of hospitals and beds in each, the extent of the population served and the geographic area covered, emergency services, availability of supplies, and numbers of other paramedical personnel, just to mention a few.Financial InfluencesThe governmental sector of health care in Saudi Arabia provides mostly free service. The private sector performs an important function that is payable. The method of payment for medical care has a powerful influence in what individuals and professionals do, and is an important consideration in an assessment of health care.There are two basic types of payment: payment which encourages service to the individual (direct or item of service payment) and payment which encourages services to groups as a whole.Individual Service: Payment which encourages service to the individual includes payment made by the patient directly to the practitioner on a fee-for-service basis, or fee-for-service paid by a state or private insurance scheme.The advantages to payment for individual services include (1) encouragement of personalized service; (2) high job satisfaction among practitioners, because they get paid according to the amount and quality of their work; and (3) availability of patient criticism and feedback, and therefore a direct say in the kind of care received.The disadvantages to direct payment approach include the following. (1) It does not cultivate good health education and discourages preventive medicine. (2) Patients are left to “shop around” for medical care, often with little guidance or knowledge concerning the type of care they should be seeking. (3) Specialists under this scheme are inclined to congregate in urban areas, where the numbers of patients and income are greater, and there are also few controls in determining their numbers and location, to the detriment of the rural population. (4) Because the service is open ended, overservicing of the patient's needs can occur.Payment Based on Service to a Group: Payment which encourages service to a group as a whole is of three types: sessional, capitation, and full-time salary. There are four advantages to this approach: (1) it fosters a community health team approach; (2) it encourages preventive medicine and good health education; (3) because of this preventive approach, patients can be cared for within their community and the number and extent of hospitalizations are decreased; and (4) salaries can be adjusted to attract physicians to outlying areas, thus controlling the distribution of practitioners.Disadvantages of this system include the discouragement of personalized service, lack of financial incentives based on quality and amount of service, and the possibility that patients may be underserviced.It is also important to define the numbers of physicians in the government and private sectors (Table 3). The importance of the private health sector in providing health care in Saudi Arabia can be estimated by the magnitude of its bed capacity: in 1987G (1407H) it supplied 13.5% of the total hospital beds.Table 3. Health services supplied by different sectors in Saudi Arabia 1407H (1987G).Table 3. Health services supplied by different sectors in Saudi Arabia 1407H (1987G).Medical Assistants and Other Medical PersonnelPhysician-population ratios do not take into account other personnel such as pharmacists, nurses, laboratory assistants and so on (Table 4). Medical auxiliaries include nurse practitioners, physicians' assistants, pediatric assistants, family health workers, and midwives. In the U.S.A, medical auxiliaries perform a major role in the delivery of health care, and relieve physicians of many responsibilities that formerly fell to them. The use of medical auxiliaries as physician extenders improves the access of patients to health care. Thus, the meaning of physician-population ratios has changed as physicians have come to serve increasingly as leaders of teams of health care professionals, and such ratios must therefore be interpreted in the light of the extent and quality of such auxiliary services. Table 5 shows the number of physicians and nurses working in the Ministry of Health during the period 1978-1987.Table 4. Professional medical employees in Ministry of Health 1987 (1407H) according to nationality and sex.Table 4. Professional medical employees in Ministry of Health 1987 (1407H) according to nationality and sex.Table 5. Physicians and nurses in hospitals of the Ministry of Health, 1398–1407 A.H. (1978–1987G).*Table 5. Physicians and nurses in hospitals of the Ministry of Health, 1398–1407 A.H. (1978–1987G).*Medical SpecializationOverall physician-population ratios do not differentiate among the numbers of practitioners in various specialties, and cannot accurately show whether there is an over or undersupply. For example, in the U.S. it is generally acknowledged that there is an oversupply of surgeons, and if these doctors are counted into the physician-population ratios, the delivery of general health care looks better than it actually is.Health care planners must project demands based on accurate statistics to ensure correct numbers of physicians representing different specialties. Table 6 shows the total number of physicans working in the Saudi Ministry of Health categorized by specialty for the year 1407H (1987G). The total number of physicians in the Ministry of Health (11,326) yields a ratio of one physician to 582 people. However, a ratio roughly double (1:1013) results when only the 6513 general practitioners are considered.Table 6. Number of physicians working in the Ministry of Health by specialization (1987). *Table 6. Number of physicians working in the Ministry of Health by specialization (1987). *Women PhysiciansIn a country such as Saudi Arabia it is important to distinguish between the numbers of male and female health care workers, including physicians and paramedical personnel, because of the Muslim customs which dictate greater segregation of the sexes and make it preferable for female patients to be examined by female physicians. Table 4 shows the male and female distribution of Saudi and non-Saudi medical personnel in 1987.The PilgrimageDuring the annual Haj pilgrimage the health care services of Saudi Arabia are particularly strained. Between 1970 and 1982 the number of pilgrims doubled from one to two million, and the number from outside the country rose from 431,000 to 853,000. Thus, in considering the quality of health care delivery, one must note that the physician-population ratio is altered by the large influx of pilgrims.Any estimate of health manpower must consider the special problems posed by the annual pilgrimage, not only in terms of the number of people but also the special health problems associated with this group of people.Expatriate and Saudi PhysiciansDuring 1987, expatriate physicians constituted 90.5% of physicians in the Ministry of Health (see Table 2). With a trend toward reducing the number of expatriate personnel and replacing them with Saudi personnel, close consideration must be given as to how this process will affect the overall ratio and how to effect a smooth transition toward the development of a dominantly Saudi corps of health care personnel.The enrollment in Saudi medical schools increased from 276 in 1975 to 3,000 in 1985, but these numbers do not take into consideration the quality of the education, the postgraduate specialty areas pursued, the number of Saudis receiving medical education abroad, and other qualitative factors that numbers cannot describe.Primary Health Care ApproachUntil 1979, the emphasis of health services in the Kingdom of Saudi Arabia was primarily on cure and not prevention. Such care was provided by hospitals and dispensaries. Many dispensaries were not open full-time and over half were run by auxiliaries.3–6Since 1980, the Ministry of Health has gradually implemented the primary health care approach. The health offices and maternal child health centers were abolished and their functions incorporated into those of primary health care centers, which have increased yearly in number so that now such care extends throughout the Kingdom. As of 1987, 1438 primary health care centers were in operation. In addition, the Ministry of Health adopted the following strategies:Expanding and extending the delivery of comprehensive health services with optimum quality, to be accessible to all people, through primary, secondary, and tertiary levels.Strengthening the link between these three levels of health service.Newly trained primary care physicians can help meet the primary care needs of the population, especially in rural, bedouin, and inner-city areas. They can deliver high-quality care, substantially increase the productivity of the physician's practice, and enhance preventive services to patients. This is the most acceptable method of improving the physician-population ratio.Recommendations and ConclusionsIt is a cardinal principle that the manpower pattern in any health service must be governed by what countries can afford, rather than by what health authorities would like.What ratio of different grades of health personnel will best utilize the limited budget allocated for a given district? The answer should be reflected in the grades and numbers of personnel being trained.The aim is access to health care for all by the year 2000 through the further development of the primary health care system, which requires careful analysis of manpower needs. To ensure an adequate supply of appropriately trained primary care practitioners, there must be a substantial increase in the number of residents in primary care training programs. It is really the primary care physician who manages the great majority of health problems.There must also be greater use of the team approach, with good exposure to clinical experience. Instruction in epidemiology and the behavioral and social components of patient care is also necessary. Medical students who currently rotate predominantly among in-hospital services should also serve in a primary care setting. Interdisciplinary training should be promoted so that health professionals can serve in a collaborative delivery system.Medical schools should be affiliated with at least one primary care residency program. Extensive and imaginative initiatives are needed to orient medical education sufficiently toward primary care. Such initiatives will generate unavoidable inconveniences and costs for medical schools, but ultimately the benefits from the quality of primary care training will outweigh the cost of change.More accurate data and information about the use and accessibility of primary care services must be obtained to ensure effective health planning and policy making.An efficient nursing workforce is essential to guarantee equal access for all to quality health care at a reasonable cost. Table 5 shows the increase in nursing and physician personnel from 1398H to 1407H (1978-1987G). Although the statistics are encouraging, one must bear in mind that these numbers include a large proportion of expatriate personnel.In addition to decreasing the over-reliance on non-Saudi physicians, health authorities must also find suitable incentives for urging Saudi females to enter the nursing profession. The reasons for the evident deficiency of Saudi nurses must be investigated and solutions sought.There must be an active and continuous program to monitor the number of physicians in different specialties and the geographic distribution of all physicians, nurses, and auxilliaries.These measures will create a suitable physician-population ratio, with a cost-effective and efficient health service as the ultimate benefit.ARTICLE REFERENCES:1. Aswami VR. How many doctors. World Health; 1987. Google Scholar2. Newhouse JP, Williams AP, Bennett BW, Schwartz WB. "Does the geographical distribution of physicians reflect market failure" . The Bell Journal of Economics, 1982; 13: 500. Google Scholar3. Institute of Medicine. A manpower policy for primary health care. Washington, D. C.: National Academy of Sciences, 1978. Google Scholar4. Ministry of Planning, Kingdom of Saudi Arabia. Achievements of the development plan, 1983. Google Scholar5. Scheffler RM, Weisfeld N, Ruby G, Estes EH. "A manpower policy for primary health care" . N Engl J Med. 1978; 298: 1058–62. Google Scholar6. Sebai Z. "Health manpower: the problem facing Saudi Arabia" . Saudi Med J. 1982; 3 (4): 217–21. Google Scholar7. Ministry of Health, Kingdom of Saudi Arabia. Annual Statistical Report, Riyadh (1980, 1407H). Google Scholar8. Ministry of Finance and National Economy - Central Department of Statistics, Kingdom of Saudi Arabia. The Statistical Indicator, 12th Issue 1407 A. H, 1987 A. D. Google ScholarARTICLE REFERENCES:Al-Rabieah O.. "Coordination in health services between public and private sector" . Coordinating health care in Saudi Arabia. Riyadh, Saudi Arabia: Institution of Public Administration, 1984. Google ScholarSorkin AL. Health manpower: an economic perspective. Lexington, Massachusetts: D.C. Heath, 1977;107–24. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byGray A, Ezzat A and Volker S (2019) Developing Palliative Care Services for Terminally Ill Patients in Saudi Arabia, Annals of Saudi Medicine, 15:4, (370-377), Online publication date: 1-Jul-1995.Jackson C and Gary R (1991) Nursing: Attitudes, Perceptions and Strategies for Progress in Saudi Arabia, Annals of Saudi Medicine, 11:4, (452-458), Online publication date: 1-Jul-1991. Volume 10, Issue 1January 1990 Metrics History Accepted12 August 1989Published online1 January 1990 InformationCopyright © 1990, Annals of Saudi MedicinePDF download
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