Healthcare in Saudi Arabia Project

Healthcare in Saudi Arabia

Project Title: Development of Health Management Systems in Saudi Arabia

Geopolitical Overview

Within the global healthcare model there are various expressions of appropriateness of care. In the Kingdom of Saudi Arabia, for instance, healthcare has always been the purview of the government, funded at the behest of the ruling family, designed for a predominately young or middle aged population, and certainly not designed for the increasing urbanization and economic improvements that oil and natural gas have brought to the region. In addition, changing demographics in the Kingdom make it necessary to rethink the model of healthcare.

A geopolitical and cultural background of the country and comparison with the region is first provided to engage the reader in the synergism between these issues and healthcare management in the region. The focus is then turned to a newer model of contemporary health care - effective communication and the use of modern technological tools. Effective software and multi-platform communications by healthcare professionals takes the concern and worry out of many health care issues, and makes better control and dissipation of information possible. For this reason, we have decided to purchase and implement a multidisciplinary software program, specifically designed for the healthcare model, called Interactive Healthcare Solutions (IHC). IHC is a powerful tool that has modules available that incorporates every aspect of the healthcare model: Human Resources, Marketing, Finance, Records, Scheduling, Purchasing, Benefit Solutions, Interdepartmental Communications, and high-level reporting capabilities. The development and implementation strategies of the program are articulated, and individual departmental issues are assessed for synergistic development.

Chapter 1.0 -- Overview and Background

1.1 -- Geopolitical Overview

The Kingdom of Saudi Arabia, occupying most of the Arabian Peninsula, is located in the southwestern corner of Asia. More than half of its total area is desert terrain. The capital of Saudi is Riyadh, which is located in the central region of the country. Saudi Arabia's official language is Arabic, although English is also spoken in the Kingdom, most commonly in the business community. The official religion of Saudi is Islam. Two of the holiest Islamic cities, Makkah and Medina, are located within its borders. Makkah is the birthplace of the Prophet Muhammad, and is the focal point of the Islamic Pilgrimage. Medinah is where the Prophet Muhammad lived. The Kingdom's Judicial System stems from traditional Islamic Law and the Holy Qur'an (Library of Congress, 2007).

There are approximately 21 million people in the Kingdom. Although most are Saudi Nationals, many outsiders from the U.S. And surrounding Arabic nations come to Saudi Arabia for various employment opportunities. In fact, a large percentage of Saudi nationals do not work because of the lucrative returns from oil revenues. For those less fortunate, the Saudi work week is from Saturday through Wednesday with the weekend being Thursday and Friday because the Muslim holy day of the week is Friday. Businesses are usually closed during the heat of the day, for prayer and resting. Business hours are generally 8:00am-noon and 4:00pm-6:00pm ("Saudi Arabia," BBC, 2009).

The Kingdom of Saudi Arabia a monarchy headed by King Fahd Bin Adbul Aziz. The government is made up of the King, the Crown Prince, and the King's Council of Ministers. The Kingdom is divided into thirteen regions. Each is headed by an Emir (governor) who is appointed by the King. Emirs generally handle local affairs. The modern kingdom of Saudi Arabia was founded on September 23, 1932 by King Abdul Aziz Al-Saud. Shortly thereafter, oil was discovered and to this day, remains the basis of its economic development. Saudi Arabia accounts for more than a quarter of the world's total oil revenues. Saudi's largest non-petroleum sector is agriculture. It provides around ten percent of the country's revenue. Crops consist of wheat, rice, corn, and dates. Gains are also being made in poultry, dairy and livestock (sheep and camels) (Ibid).

1.2 the Arab World - Prior to discussing the healthcare situation in the country, it is advisable to understand the perspective of Saudi Arabia within the Gulf Region as a whole. In order to better understand the situation in Saudi Arabia, it is valuable to look at the environment in the Gulf States in general. Like many of the Central and Latin American countries, political upheavals, military conflicts, sanctions and embargoes have impacted many of the Arabian economies of the region causing declines in productivity and disrupting markets. This is not necessarily the case in Saudi Arabia because it has maintained close ties with the United States and has generally remained outside the military conflicts that have plagued the region. Problems associated with recovering from the ravages of war including substantial debt does not impact Saudi Arabia directly but it does indirectly influence the country's prospects for economic growth because of reduced ability to trade with its neighbors. Regardless of a particular nation's economic status, Gulf countries exhibit a substantial lag behind other regions in terms of participatory governance, something that is a significant issue for Saudi Arabia because the views and behavior of the Saudi royal family differ significantly from its overall populace that has come to resent its position, viewing it as abandoning traditional Arab and Muslim views and "selling out" to the United States. The wave of democracy that transformed governance in most of Latin America and East Asia in the 1980s and Eastern Europe and much of Central Asia in the late 1980s and early 1990s has barely reached the Arab States. Constitutions, legal codes and government pronouncements signify a de jure acceptance of democracy and human rights but in many cases this represents something that is "on the books" but is really not implemented and in some cases deliberately disregarded. Most Gulf countries are characterized by a powerful executive branch that exerts significant control over the other branches in government, reducing or eliminating the efficacy of a system of checks and balances ("Saudi Arabia," Population, 2009; Noland, 2007).

In many ways, the Gulf countries are a mass of contradictions. For example, Gulf countries have exhibited the fastest improvements in female education of any region including literacy rates that have expanded three-fold since 1970, female primary and secondary rates that have more than doubled during that time. In contrast, greater educational opportunities have not significantly impacted social attitudes and norms that stress the roles of wife and mother, with a maternal mortality rate double that of Latin America and the Caribbean and four times East Asia, while more than half of Arab women remain illiterate. Women also experience unequal citizenship and legal entitlements in terms of voting rights and legal codes, something that is contrary to the teachings of Islam, illustrating only one of the ways that Gulf societies have created social norms that do not necessarily mesh with the principles of the most prevalent religion that is also cited in the development of terrorism and the prevalence of terrorist groups in the region. The Human Development Report indicates that one of the greatest barriers to real development in the region is relative to education "bridled minds, shackled potential." About 65 million adult Arabs remain illiterate; two thirds of which are women, although illiteracy rates are much higher in the poorer countries. Ten million of the children between six and fifteen do not attend school and if current trends persist, considering current population growth, that number will increase to forty million by 2015. Gulf countries' access to and use of cutting edge technology is also considerably limited with only .6% of populations using the Internet and a personal computer penetration rate of 1.2% ("Human Development Report," 2008).

Despite modest levels of inflation and budget deficits, growth continues to stagnate in many Gulf countries, a situation that is significantly tied to the price of oil the quality of public institutions is low and critical macro variables such as employment, savings, productivity and non-oil exports is still under performing. Unemployment is a significant issue that impacts human development as well as overall economic progress. Trade performance remains sluggish as the region continues to be relatively closed with high tariffs and non-tariffs that impede trade. Exports from the region (over 70% of which are oil and oil-related products) grew only 1.5% annually, far below the six percent global rate. Manufacturing exports remain stagnant and private-capital flows lag behind other regions although Gulf governments are taking steps to improve the situation through policy initiatives that promote trade expansion as an engine of economic and technological development. Governments have made strides in establishing greater infrastructure and promoting dynamic private-sector development is a critical priority of economic governance among Gulf States (Henry, 2001). Many governments have also taken considerable steps in liberalizing the private sector but much remains to be done. Sound macroeconomic policies need to be maintained; adequate economic space needs to be provided for private initiative; central banks, banking systems in general, and financial services need to be strengthened; bureaucracy needs to be streamlined and red tape minimized. In addition, greater regional economic cooperation is critical to economic growth. The capacity of the state has fallen short of the requirements for rapid growth and the demands of human development although government spending as a percentage of gross domestic product is higher than in other developing regions. Lack of accountability, transparency and integrity, ineffectiveness, inefficiency and unresponsiveness to human development remain problematic (UNDP).

Poverty remains endemic in most Gulf States with health care and opportunities for quality education poor or unavailable, degraded habitats including urban pollution and poor soil conditions from inappropriate farming practices. Social safety nets are also entirely inadequate and all form part of the nexus of poverty that is widely prevalent in Gulf countries. While economic growth is not a sufficient condition for eliminating income poverty, it is certainly necessary in the overall scheme of things. Knowledge remains a cornerstone of development and knowledge absorption involves providing the capacity to use knowledge through education. One significant question remains relative to human development issues in Gulf States because the region has significantly outperformed all developmental regions with the exception of Latin America and the Caribbean. Taken as a group, Gulf countries spend a higher percentage of Gross Domestic Product on education that any other developing region, which is important because global estimates indicate that a one percentage point increase in the share of the labor force with secondary education translates to a six to fifteen percentage point increase in the share of income received by the poorest 40%. Knowledge acquisition entails not only building on a country's own knowledge base but generating new knowledge through research and development, but also promoting openness that includes the free flow of information and ideas, establishing constructive engagement in world markets, and attracting foreign investment. The commitment to openness is particularly important because the majority of Gulf countries lag behind other regions in terms of technological development. One issue that is relevant for the region is "brain drain" because many of the university-educated Arabs find little opportunities in their home countries and often remain abroad after completing their education rather than bringing that knowledge home (Ayubi, 1996).

Culture and values are critical in terms of development and this is where the Gulf States face significant challenges because of how globalization is viewed by many Arabs as a threat to their way of life. Those activities that will promote economic development are not necessarily considered desirable and significantly hamper the efforts of Gulf governments in providing greater advantages for their populations. Political participation in Gulf countries remains weak, primarily because of a lack of representative democracy and restriction on liberties. The weakening position of the state relative to citizens illustrates the philosophical differences between the royal families and average citizens. The position of the state as patron is diminishing while the power position of citizens is increasing as states depend on them for tax revenues, private sector investment and other necessities. The middle class, however, is experiencing greater power as a new range of resources have put them in a better position to contest policies and bargain with the state. Saudi Arabia is better suited to international trade because of its ties with the United States but it remains unclear whether the majority of its citizens benefit from this relationship. One significant issue is job creation that has not matched workforce growth. Special employment generating projects, programs and funds have a place in Gulf countries but broad-based growth is the major determinant of job creation and remains unable to meet demand (Metz, 1993; Oxford Business Group, 2007, 2008).

1.3 Saudi Arabia in comparison - Saudi Arabia is considered to be "medium" in terms of the Human Development Index although it is sixth in line behind Kuwait, Bahrain, Qatar, UAE, and Libya. SA's current population growth is more than 3%, which compounds problems like unemployment and job creation. Saudi Arabia has a significant urban population, more than 80%, which both provides opportunities in terms of economic growth as well as the problems experienced by countries from an historical standpoint in terms of industrialization and the dependency on government and the economy rather than the land for support. Conversely, education is high in Saudi Arabia, as there are 1915 active research scientists as compared with Kuwait at 884. Telecommunications are fairly good in Saudi Arabia as compared to other Gulf States but PC penetration remains insignificant. Saudi Arabia has ratified four of the principal international human rights treaties but has failed to ratify the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights. Life expectancy in SA for males is 68.4 and females 71.4, falling mid-range as compared to other Gulf nations with a total population of slightly over twenty million. The country's infant mortality rate is 18.3 per thousand, on the lower end of the spectrum as compared to its neighbors and the percent of children fully immunized at one year is 92%, one of the highest in the region. Total health expenditure, as a percentage of GDP is 3.5%, fairly average, while the responsiveness in terms of health as ranked among Arab countries is seventh. Energy production in SA remains high, 19.64 with consumption at 4.34. The number of adult illiterates is 2.7 million, with two thirds of that number being women. Saudi Arabia moved from 61% of the population in primary school in 1980 to 78% in 1995, a figure that has likely continued to increase. Secondary education rose from 29 to 58% during the same period while tertiary education rose from 7.1 to 15.3%. The unemployment rate remains relatively high at 15%, political participation nonexistent, while there are 125 civil societies as of 1992. Saudi Arabia's openness in terms of the economy is 77% and the country's inflation was reduced from 7% in 1960-1984 to 1% from 1985-1998 (Ibid; Bradley, 2006).

What becomes clear when one evaluates the various statistics available for Saudi Arabia is that its educational and other potential has not necessarily translated into an improved way of life for the majority of the country's citizens. This is in terms of potential vs. reality although the country is considered medium in terms of human development. The challenge for Saudi Arabia in the future is finding a way for greater political and economic participation among its citizens, something that is likely to be difficult considering the problems that exist relative to the adversity between the government and the people. The government should continue to promote education and focus on technology and greater openness in trade with other countries throughout the region ("Saudi Arabia," Al-Bab, 2009).

1.4 the Current Healthcare System in Saudi Arabia -- the current healthcare system in Saudi Arabia is nationalized care. The government provides heal services through state controlled agencies, from the national to the local level. However, in recent years there seems to be a growing role and larger participation from the private sector and foreign companies.

The Saudi Ministry of Health (MOH) is the primary governmental agency responsible for preventative, curative, and rehabilitative healthcare for the country. The Ministry currently provides primary health care (PHC) services through a large network (about 2,000) of care centers situated throughout the country, typically based on population and demographic analysis (Saudi Ministry of Health Review, 2007).

The MOH is also the central referral system that provides services focused on curative care through 220 hospitals and clinics ranging from primary general practitioners to advanced technological and laboratory services. Within the Kingdom, the MOH leads all management, planing, financing, and regulating of the entire health care sector, while also supervising and ensuring that appropriate levels of care are provided at various levels of society. In general, then, most scholars view the MOH as a National Health Service for the entire population (NHS).

Additional healthcare services are ancillary parts of the Saudi government: primary, secondary, and tertiary care for specific demographic and pscyhographic parts of the population; security, armed forces, border and port control, etc. These ancillary services are provided by the Ministry of Defense and Aviation (MODA), the Ministry of the Interior (MOI) and the Saudi Arabian National Guard (SANG). Other governmental and bureaucratic organizations that operate under the MOH, for healthcare related issues, are:

Ministry of Education -- Healthcare for students of all ages.

Ministry of Labor and Social Affairs -- Healthcare for special needs (mentally or physically handicapped), and orphans.

General Organization for Social Insurance/General Presidency of Youth Welfare -- Healthcare for certain populations in connection with sporting facilities and events.

Royal Commission for Jubail and Yanbu -- Healthcare for employees and residents for those two cities and their specific populations.

Saudi Arabian Airlines -- Healthcare for employees and their families.

Saudi Arabian Higher Education Program -- Healthcare, through medical colleges and hospitals, specialist curative services and educational training programs; health research in conjunction with other agencies.

Saudi Red Crescent Society -- Emergency services, accident rescue, transportation of patients to hospitals; and an important management of healthcare for pilgrims during Hajj and Umrah in Mecca and Medina (Oxford; "New Saudi," 2007; Mufti, 2000).

The Saudi government is the primary financier and management organization for specialized care in two major research hospitals: King Faisal Specialist Hospital and Research Center and King Khalid Eye Specialist Hospital. Both centers use advanced technologies and are referral care centers for advanced and specialized care. Both also conduct research on Saudi health issues, publish, act as the primary advanced care hub. Regionally, the Khalid Eye Hospital is one of the finest facilities in the Middle East, and one of the few in the region that stores imported corneas awaiting transplant (Mufti, Luna, 1998).

Statistically, the Kingdom of Saudi Arabia has:

88 hospitals, almost 9,000 beds, accounting for 20% of the patient care beds in the Kingdom.

625 dispensaries, almost 800 clinics, 50 medical laboratories, and 111 physiotherapy centers.

285 pharmaceutical stores and 3,225 pharmacies.

Since 1990, the Kingdom has increasingly increased funding for the localized manufacture of medical supplies, appliances, and pharmaceuticals. The 1990s also saw a 5% rise in total outpatient visits and a 11% rise in inpatient care; all due to the increased funding and awareness campaigns, as well as the modernization of the healthcare system (Long, 1998, 2005)..

1.5 Challenges and Issues within the Current Saudi Health Care System

While there are numerous challenges to the Saudi Healthcare system, it is important to compare their system of healthcare with the national health care systems in other Gulf and regional countries; particularly in the areas of demography, health status, delivery system characteristics and health expenditures.

Demographically, Saudi Arabia's population growth rate and total fertility rate are the highest in the Gulf and among the top three in the Middle East/North Africa region. However, broken down into specifics, we find that Saudi Arabia's share of population over 65 is below the regional average, which may provide some linkage to types of geriatric care, or specific health problems of the aged.

Table 1.5.1 -- Demographic Indicators for Saudi Arabia as of 2008

Demographic Modifier

Global

Saudi Arabia

Estimated Population

28,147,000

Crude Birth Rate/1000 Population

21

29

Births, annual

828,000

Death Rate/1,000 Annualized

8

3

Total Deaths

73,000

Rate of Natural Increase (birth rate less death rate as a %)

1.2

2.7

Population Change to 2050

>39%

>77%

Infant Mortality Rate/1,000 live births

49

16

Total Fertility Rate

2.6

4

Life Expectancy

68

76

Urban Population

49%

81%

Population Density/sq. km.

13

Urban Population Living in Slums

20%

Population Using Adequate Sanitation

57%

Population Using Adequate Drinking Water

72%

97%

Births attended by skilled medical personnel

61%

91%

Hospital Beds/1,000 People

Ranked 54th globally at 2.2

(Source: Population Reference Bureau, 2009).

Figure 1.5.1 -- Saudi Arabia Population Prospects based in United Nations data:

Figure 1.5.2 Distribution of Saudi Population as of 2007

Health Indicators for Saudi Arabia (Littlewood, 2000; Oxford, 2007; Saudi Ministry, 2006).

The Saudi Infant Mortality Rate (IMR) is the lowest in the Middle East/North Africa region, but slightly above the global trend line.

Compared to other Gulf countries, the Saudi maternal mortality ration is one of the lowest.

Saudi Arabia's adult mortality rate is below the MENA regional average, but still one of the highest in the Gulf.

Saudi Arabia's life expectancy statistics are above the regional average, and compared to the global population of countries with a similar economic average, median in range.

Saudi Arabia's malnutrition indicators are among the poorest in the Gulf: 14% of Children under 5 years of age are underweight; 20% growth stunted, and 11% acutely malnourished.

However, because of the increased economic influx, 25-30% of Saudi women are obese, and 15-20% of men.

Delivery System Capacity -- Saudi Arabia's physician-to-population ratio is well ahead of the MENA regional average, but remains in the median for the Gulf Sates. However, this ratio is higher globally than countries with similar economic indicators. The bed-to-population ratio is above the regional average, and again, median for the Gulf States; but lower than global countries with comparable economic statistics.

Health Expenditures

The Saudi GDP is above the regional average and the Gulf average.

Saudi Arabia's public share of total health spending is above the regional average, and medially comparable to the Gulf; but well above global countries with similar economic factors.

Figure 1.5.3 -- Saudi Spending on Healthcare

Saudi Arabia's per capital total health spending ratio is above the regional average, below the Gulf average, and slightly below similar global countries.

As a share of the GDP, Saudi Arabia's total health spending is median to the regional average and slightly above the Gulf average; but a bit lower than global countries with comparable economic indicators ("Healthcare in," 2004; "Healthcare System," n.d.).

Figure 1.5.4 -- Private Expenditure on Healthcare as Percentage of Total Expenditure on Health

In general, when looking at Saudi Arabia in the global context, the KSA is about average for healthcare issues. There are some clear inconsistencies, though -- the total health to GDP ratio is below the global comparable average, but public health to GDP ratio higher. Likewise, per capita total health expenditure is below the global similar average, while per capita public health spending is above -- and, the public share of total health spending is well above the regional average and global comparative averages (ASD Reports -- Saudi Arabia, 2009).

Figure 1.5.5 -- Gulf States Comparison on Mortality Rates

These averages, however, are part of the driving force for healthcare modification and change, and the KSA has committed to increase spending more than 400% by 2020, the length of time necessary primarily due to the challenges of logistics in a country of its size ("GCC to expand," 2009). Further scholarly research has shown, though, that one of the largest problems for the KSA is the variations in care; and while these exist in numerous other countries, including the developed world, Saudi Arabia is facing continual challenges due to growing demand on health services, rising costs, and increased public pressure demanding better services (Al-Ahmadi and Roland, 2005). The data, when taken as a whole and combined with the historical and sociological factors concludes that there remains a substantial variation in the quality of Saudi healthcare. In order to improve quality, there is a clear need to improve the health management system and organization of primary care services, while increasing professional development strategies and ongoing training and educational programs (Khoja, 1998; Al-Ansary, 2002; Battista, 2008).

Figure 1.5.6 Gulf States Mortality Causation Comparison

Chapter 2.0 -- Health Management Systems in Saudi Arabia

2.1 Health Management Systems -- a Background

A health management system (HMS) is a process, proposed by Nicholas Humphrey, which models the process of healthcare into a cost-benefit analysis and combines the rubric with physiology and health. The importance of this synergistic approach allows physiology and health to combine in a manner, particularly in developing countries, that allows a greater and more appropriate penetration of benefit ratios to a larger percentage of the population (Humphrey, 2002). Taking this model, and combining it with the intersection of information system, computer science, and the process of health care, and we have Health Management Information Systems (HMIS) or Health/Medical informatics. Specifically, this combination deals with the appropriate resources, devices, and methods that a healthcare system requires to optimize the acquisition, storage, retrieval and use of information within a given healthcare system. These informatics include not only technological tools, but also clinical guidelines, formal medical terminologies, information and communication systems, and are usually applied to nursing, clinical care, dentistry, ophthalmology, public health, bio-medical research, and general medical and surgical care (Saudi Association for Health Informatics (SAHI), 2009; Littlewood, 2000).

While this aggressive approach has been utilized in Europe, Australia, Japan, and the United States since the 1980s, the introduction of such a system into Saudi Arabia has been relatively recent.

2.2 Hospitals in Saudi Arabia -- Examples

While this aggressive approach has been utilized in Europe, Australia, Japan, and the United States since the 1980s, the introduction of such a system into Saudi Arabia has been relatively recent, and still in the evolutionary stages. Systems are in place in some of the major hospitals in the region, for instance the King Faisal Specialist Hospital and Research Centre in Jeddah.

The KFSH is an 894-bed multi-facility, multi-entity care hospital which provides specialized medical services, research and education programs. It also serves as the hub for the publication of the Annals of Saudi Medicine, and has strong ties to European and American medical organizations. Within this hospital are the National Centre for Children's Cancer Research, the Heart Institute, and the country's premier Oncology Centre. The importance of this institution in the general paradigm of infometrics is its leadership in the uses of Information Technology to focus on patient care and experience. The hospital has been on the cutting edge of the use of new HMIS implementing a three-phase program in 2007. Phase 1 included Patient Management, Scheduling Radiology, Pathology and Laboratory Medicine. Phase 2, in progress now, includes Surgery scheduling, Pharmacy integration and Emergency Medicine. Phase 3 will change the way staff and management use information for decision-making; and will include re-admission rates, infection rates, benchmarks, clinical and management data, and a Human Resources Management system that will streamline patient information from inception to outpatient and follow-up materials ("ITA," in King Faisal, 2009).

Table 2.2.1 -- Three Phase HMIS System for King Faisal Hospital

Phase 1

Phase 2

Phase 3

Overview

Integrated Clinical Information

Provides real-time clinical information for all departments ensures appropriate patient check-in and follow through.

Laboratory Medicine

Any department may access laboratory data, tests, x-rays or other procedures. Archived electronically for future use.

Surgery

Scheduling, procedure documentation, biopsy report -- integration with laboratory medicine.

Pharmacy

Ensures appropriate dosage and non-reaction; historical data.

Emergency Medicine

Access so that if patient undergoes emergency procedures complete health history is available.

Human Resource Management

Global system to improve integration and training of staff; access to appropriate levels of information.

Data Tracking

Tracking of patient data, real-time and historical.

Statistics and Clinical Quality

Ability to combine multi-department and disciplinary reporting structure for additional patient and clinical analysis.

Complete Integrated Decision Making System

Complete availability of information cross-functionally, designed to aid in administrative and clinical decisions.

2.3 Future of Current System

The current system, while seemingly adequate in relation to the region and in comparison with numerous demographic and economic profiles globally, does not take into account the rapid growth of the Saudi population, nor the manner in which the increased birth and lowered mortality rate will change the make-up of the healthcare systems needs over the next few decades (Ba-Isa, 2005). The current system is bogged down based on three primary issues: managerial factors, organizational factors, and the organizational culture itself.

Managerial Factors -- Historically, the Saudi culture is heavily specialized and bureaucratic. Supervisors tend to report to mid-level managers, but much of the care is extremely compartmentalized, with almost 65% of the supervisors receiving no training, and almost 90% without post-graduate qualifications (Jarallah and Khoja, 1998). Most supervisors, while having a reasonable understanding of their exact jobs, lack the expertise and broad range training that helps put individual activities into the rubric of healthcare itself. Indeed, rather than looking at managing healthcare issues as a motivational tool, improving care, or educating the public, they see their duties as inspection of defects and the uncovering of mistakes (Khoja and Kabbash, 1997).

Organizational Factors -- Certainly the primary care services have vastly improved organizationally since the 1970s, with 90% now having written or computerized records. However, there remain inadequate information systems, a high staff turnover, physician overload, and a shortage of resources. Even essential drugs and laboratory items are unavailable 30-40% of the time. This, plus the amount of bureaucracy and the internalization and mistrust between departments, increases the number of obstacles within the system (Ibid; Kalantan, et.al. 1999).

The Saudi Organizational Culture -- the current system, again while evolving, tends to set up a non-teamwork, negatively competitive culture. Physicians are overworked, hospitals understaffed, and equipment and needed medicines not always readily available. Most healthcare workers indicate that under the current system they are too worries about keeping up with the patient load to even begin to analyze cost of care, patient complaints, and other customer service issues (Kalantan; Al-Ansary).

2.4 Issues and Challenges of Current System

Within the current system, both Saudi nationals and expats are eligible for a comprehensive package of public health products, preventive care, diagnostic and curative services and pharmaceuticals we very few exclusions and almost no cost sharing. Approximately 11% of the governmental budget is allocated for these services, typically from natural gas and oil revenues. Funds are transferred by the Ministry of Finance, but challenges arise due to an inflexible policy regarding line-item funding changes and the lack of a way to bank funds by fiscal year if not spent. Within this structure there are three primary issues affecting the future of the current system: the challenge of appropriate implementation; challenges with interfacing and referrals, and professional development strategies (Aldossary, 2008).

Professional Development Strategies -- Only about 1/3 of primary care physicians have post-graduate qualifications, and only half have access to professional journals. There is very little continuing or ongoing education and training at all levels, thus decreasing the ability to cross-train, promote from within, and create a system in which multiple layers of the organization share a buy-in to the system (Al-Shammari and Koja, 1994).

Implementation Strategies -- There are, of course, some national guidelines for common conditions; and written protocols for efficient modes of treatment when called to address certain conditions. However, there seems to be a lack of evidence-based medicine; resulting in numerous misdiagnoses, inappropriate clinical decisions, and some unsafe prescribing patterns. Because of the bureaucracy, there is inadequate distribution of guidelines, changes of practices, the ability to review other procedures, attend larger conferences, or even have access to a professional level database (Al-Ansary; Mansour; Kalantan).

Referrals and interface with secondary and tertiary care -- in 1986, a national referral system was established in Saudi Arabia to improve levels of communication and coordination between primary care centers, hospitals, clinics and doctor's offices. However, many of these referrals were unreadable, undocumented, and lacked follow through. In fact, hospitals sent feedback for less than 40% of patients, and what feedback arrived lacked details, pertinent findings, and some even diagnoses. Again, this is attributed to two major factors: overwork and a cultural mentality that avoids sharing responsibilities (Khoja, et.al., 1997).

Finally, the evolution of the Saudi system must, by its very nature, begin to include an increased number of qualified nurses, preferably at the R.N. level. It is impossible for physicians to act in their stead, continue to perform their own duties, and find the time to increase education and compliance. While there are certainly cultural issues regarding female nurses, it is possible for nurses to obey Saudi religious structure, while still offering appropriate levels of care. This is such a serious part of the future of Saudi healthcare that the World Health Organization and International Council of Nurses continue to lobby the Saudi government (Littlewood and Yousuf, 2000).

2.5 Stakeholder's Expectations

Within the healthcare system, the stakeholders are the human parts of the paradigm. Often, their individual goals and aspirations are disparate, based on their own priorities, personal agenda, concerns, and constraints. The successful implementation of any healthcare system, however, requires that the stakeholders approve of the process and will, in effect, help ensure its success. Figure 2.5.1 shows the interplay between a typical information system and a healthcare model, but it is important to note that the following types of individuals have vested interests within the project itself (Ollenschlager, et.al., 2004):

Government -- in Saudi Arabia, the government controls all; societal rules, funding, state-based religion, media, and access to healthcare. They are the primary stakeholder and utilize healthcare both for domestic and foreign policy concerns.

International Agencies -- the United Nations and relevant agencies (WHO, etc.) are very interested in the manner in which healthcare reform evolves in all countries, but particularly those countries in which have the economic resources to distribute the care more equitably toward the population.

Funding Institutions -- for Saudi Arabia, funding is primarily done through the government. However, recent developments have increased the size of stakeholders to a few foreign, primarily European, investors with technological or other agendas.

Executive Management -- Since most report directly to the government, these individuals are interested in seamless integration and decision making information systems.

Employees -- One of the problems with current Saudi care is lack of training and expertise. New HMIS would allow greater cross-training, an ease of overtaxed employees, and access to greater real-time information.

Clinical and Administrative Department -- Decision-making models and projections are or primary concern; as is ease of installation and training.

External Consultants -- Depending on the module, external consultants may arrive from a variety of companies and locations; they are effective in "cheerleading" the project through local employee resistance, as well as negotiating strategy.

Vendors -- Have a vested interest in creating a seamless operational paradigm; ease of use and training, as well as ongoing support for upgrades and new technological formats (Winter, et.al., 2004).

Within Saudi Arabia, for instance, there is a distinct need for the government and upper echelons to appear modern and contemporary within the medical field -- this is part of their overall foreign policy, as well as crucial since there are so many foreign workers and personnel within the country.

Combined with this need to ensure that the world views the Saudis as modern and technologically advanced, global economic events, as well as issues with oil and gas consumption reflect directly upon healthcare policy, and the Saudi government's ability to spend and modernize (Dhillon and Hakimian, 2009).

Figure 2.5.1 -- Stakeholder Flowchart and Information Flow for Saudi Arabia

Chapter 3.0 -- the Future of Saudi Healthcare

3.1 Overview of a new system

Because of the challenges of both geography and demography, Saudi Arabia has conditions that make it ripe for a new healthcare model.

Numerous health experts have commented over the last 5-8 years that the growing affluence of Saudi Arabia and the region means that new healthcare systems will be required; and will need fiscal investment and expertise in order to prosper. At present, the Saudi government funds most of the demand for healthcare, but analysts believe they will not be able to continue this alone. Indeed, the Saudi MOH has recognized and identified healthcare as one of the key sectors in privatization programs ("Booz Allen Hamilton," 2007). To accomplish this, not only is a new system required, but a new model of allowing international participation in what has traditionally been a very tightly reined organization. The MOH has set three major goals to accomplish this:

Create a stronger institutional set-up and effective regulatory framework to promote private sector investment in healthcare and the production and distribution of pharmaceuticals and medical supplies,

Develop a business environment that will make Saudi Arabia a more attractive destination for private healthcare providers, and Attract investors and other partners to the Middle East's largest market for healthcare (Ibid; Saudi Ministry of Health)

In order to ensure that a new system is properly integrated within the current structure, as well as the proposed strategic care environment, the Saudi MOH signed a partnership agreement with numerous organizations. One particularly relevant example of this partnership is the Saudi agreement with GE Healthcare, a business subsidiary of General Electric. GE will provide solutions to the Saudis based on GE's expertise in diagnostic solutions, disease prevention, and treatment options.

This agreement is crucial in the establishment of a new healthcare information system, since in order to synergize a complete care package, most of the GE systems require a more advanced HIS platform. Through workshops, training, and consulting, GE will guide Saudi Arabia's implementation of a new system, and, as a result, rebuilt the healthcare model in the region (Al-Bawaba, 2007).

3.2 -- Overview of a new system model

After identifying some of the unique issues within the Saudi system, and some of the pertinent challenges, a new healthcare system should provide both internal and externally driven capabilities. In addition, because of the Saudi's regional importance, issues such as external marketing and advertising take on more importance than ever imagined.

At the heart of healthcare as an institution is, of course, the need to care for the sick and the injured. However, in the contemporary model of healthcare, effective communication and the use of modern technological tools is vital. Effective software and multi-platform communication by healthcare professionals takes the concern and worry out of the situation; offers a quicker resolution, makes better control of information possible, earns the trust of the public and individual families; and keeps the flow of information consistent and accurate, thus averting potential external problems. Technology has increased the ease and ability for adequate communication -- there are more translators, access to databases, sharing of information, speedier access to test results, etc. within the field, and certainly there is more information about healthcare available for the layperson. However, the manner in which modern medicine works -- the reality that the system itself works only as well as the understanding and ability of interdepartmental professionals to effectively utilize medical systems to improve both patient care and their own ability to perform their task. (Nemeth, 2008).

In order to both streamline many of the medical tasks and improve the general quality of healthcare in Saudi Arabia, a specific healthcare model, herein called Interactive Healthcare Solutions (IHC), is proposed as the working rubric for the country's new push towards reform. IHC is a powerful system that has modules available that incorporate every aspect of the healthcare model: Human Resources, Marketing, Finance, Records, Scheduling, Purchasing, Benefit Solutions, Interdepartmental Communications, and high-level reporting capabilities. Utilization of IHC will not only streamline our operation, but also allow managers from each specific business unit to more effectively manage their information flow; whether that be for supplies, interaction of data management with other units, reporting responsibilities, or even individual budgets. The ability of individual departments to produce reports that are easily exportable into hierarchical data base systems allows executive management to glean a more "real-time" vision of the organization, and to make better strategic and tactical decisions.

Modeling the new system can be expressed by a basic SWOT analysis of the new system, showing the integration and overall manner in which various models work interactively to refine results:

Table 3.2.1 IHC Modeling

Department

Strengths

Weaknesses

Opportunities

Threats

Communication

Easier interdepartmental communication, synergism

May rely too much on technology, not enough on people skills

Change the paradigm of the program; use communications as a tool for hospital growth

Resistance to change, new systems, more training, increased short-term costs

Finance

More information to make fiscal decisions, real-time data

Information overload

New reports, new models, new system approach

Quality of data dependent upon other departments

Human Resources

Moves from HR clerk to HR management with effects upon strategies for company

Changes paradigm, some employees may not be able to make the switch

Looking more at future development of the company, rather than filling positions; increased management of training and staff development opportunities

Again, quality of data, some resistance to change; management's by-in to new form and paradigm of HR

Department

Strengths

Weaknesses

Opportunities

Threats

Marketing

Tracking improved, demographic data and departmental integration

Reliance on systems rather than active marketing role

Energetic manner of change management, tout abilities of new system to improve care and overall global image

Competition from other foreign hospitals or organizations; some resistance from medical professionals, may lose some talent

Management

Information accessible, decision making using real-time information

New system, fear of paradigm change; lack of confidence in reporting structure; resistance to training

Change management could easily improve decision making and strategic planning almost immediately. Access to real-time data quite vital for growth.

Governmental bureaucracy may not be apt to fully utilize new system; major change for Saudi management.

Patient-Client

Easier scheduling and historical storage of records; more holistic approach

Fear of too much information held with hospital; new system may scare some patients; older demographics hesitant

Far easier check in, all records easier and accessible, more of a holistic approach to patient care

Patient will need to participate and take responsibility for their care

Records & Scheduling

Speed, efficiency and access to patient data

Input time and training of staff for new procedures

Streamlined system, more efficiency, use of staff for more productive issues

Resistance to new system; bugs in system; time and dollars to implement

3.3 Current tools and lack of integration

With very few exceptions, even with modernization, most Saudi healthcare facilities operate in an individualized vacuum. Each department is compartmentalized, sharing of information is sketchy, and if a patient changes facilities, records are often inaccessible. Fortunately, most of the Saudi population lives in urban areas, and the communication systems between these areas are quite good, but there is no real integration. Additionally, health management systems as a whole are relatively new to the area, and lack a cohesive trained population. Care in Saudi Arabia faces significant challenges that can be solved by establishing a comprehensive program that includes quality assessment, accountability, and improved information system management (Al-Ahmadi and Roland, 2005; Al-Rasheed, 2002).

3.4 the benefit of using the new proposed system

As we can see in Figure 3.3.1, the new system is completely integrated, and takes into account various synergies of interactions within individual hospitals as well as cross-functionally with other Saudi and regional medical care facilities. The increased synergism of the system will allow employees at all levels to more efficiently perform their duties; be part of both the strategic and tactical goals of the organization, and to more accurately fulfill the needs of the patient, the hospital, and their own ability to grow within the organization and achieve actualization. The organization will benefit through greater efficiencies, employee loyalty, fiscal savings, and real time reporting. The hospital will become more attractive for international fiscal involvement (Foundation, Sponsorship, etc.), United Nations grants, attracting seminars and new talent, and forming specialization clinics and interdepartmental expertise at a far greater speed and scale than prior, as well as international medical tourism (Al-Deeb, 2009; Alaiban, 2003).

Figure 3.3.1 -- Synergistic Model of Proposed Saudi Healthcare Model

3.5 -- System benefits by functional area

Much of the literature and current use of integrated healthcare management systems has centered in the developed world (Europe, Japan, the United States), and therefore many of the sources and modeling foci are more appropriate for larger, capitalistic-based healthcare systems. Normally, this would be inappropriate for Saudi Arabia, but in light of the new MOH operative, the use of these systems is not only appropriate, but from the Saudi point-of-view, quite necessary for successful implementation. Unique to the situation, though, will be the creation and paradigm changes necessary to grow certain departments in a way rarely seen within the Gulf States (e.g. Human Resources, Marketing, Advertising, etc.) (Zirinski, 2005).

Governmental Organizations -- Allows greater international investment into the Saudi healthcare system; but changes the mindset and mission. Rather than the Saudi MOH providing care to the large majority of citizens and workers, the new model allows for a profit-based system to evolve, while still improving the demographic challenges for the internal population. Because the Saudis do not have adequate human resources to staff a large healthcare system, the integration also allows for greater flexibility when hiring international personnel (Cockerman, 1997; SAMIRAD, 2009).

Allows Saudi Arabia to excel regionally and globally with a new "model" of healthcare.

Increased global attention from United Nations and other humanitarian organizations, superb public relation opportunities.

Increased international investment in an infrastructure that will ultimately benefit the majority of aging Saudis.

Access to improvements that would typically require a trip to Europe or the United States.

Modeling for the pan-Arab world and use of appropriate expertise regionally.

Executive Management, Strategic Planning -- Changes the overall mission and paradigm of the hospital to an active, rather than reactive, paradigm in health care. With real-time data, access to multi-dimensional platforms and interdepartmental information, the constancy of information will allow management to make more informed decisions at a more strategic level. The quality of the information will be less suspect because it is real-time and gleaned from actual data; and the reporting structures are customized and designed specifically for the goals of the hospital and specific managerial needs. Use of the new system will help with HR and Marketing recruitment, but also as a tool to bring in and retain additional talent and improve relations with Ministries (Samli).

Mini strategic management data base on every executive's desk

Monetary savings, informational strategies and what if scenarios easier

Communication with department heads more synergistic and easier

Interaction with external community and governmental agencies more streamlined

Increased fiscal management and quicker (and more accurate) billing will result in great financial stability (when foreign operation is in place)

Increased strengths will allow system to become more attractive to grants, improvements, international attention

Client Records/Scheduling -- for any modern healthcare facility to work effectively, patient information and scheduling must be organized, available to all relevant departments, and most important -- accessible to all medical personnel who need the information in order to provide quality and appropriate care. Technology and automatic will free the practitioner to spend time treating patients as opposed to managing records. Additionally, greater efficiencies in time and logistics abound with the use of a medical information system -- particularly relevant when sharing information cross-platform or with different hospitals, doctor's offices, clinics, etc. (Skurka, 2003)

More streamlined process -- from initial appointment, through treatment, follow-up

Records and data (including imaging) available to all healthcare professionals as needed and real-time

Ability to share appropriate information with specialists; require less retesting and duplication of effort

Clients able to schedule multiple appointments that do not conflict between departments

Greater access to appropriate communication and information

Interdepartmental Communications/Reporting Structure and Depth of Reporting -- a significant improvement in both employee moral and error management occurs when interdepartmental communications become easier for staff and managers. Key to this process is decision support, helping busy departments to interact more positively with others. Additionally, employees feel more empowered within their own job grouping (Drake, 2005).

Stronger interdepartmental access to information

Departments see they are part of the flow of information and able to provide more appropriate data

Quicker and easier solutions by having information available

Breaks down "glass" ceilings and allows healthcare personnel to work better as a team

Real-time reporting easier, more efficient, quicker

Access to information more accurate

All departments have same information

Managers able to make informed tactical and strategic decisions

Executives have access to greater depth of data

Finance, a/R, a/P, Procurement -- Builds consensus, transforms operating model, allows greater decision making at the individual level, real time data allows for better decisions, integration of model allows financial decisions to be proactive instead of reactive; monetary savings occur through synergism of cash-flow management, and integrated spending policies. Additionally, will allow an easier transition to patient billing as international care model improves, opening up numerous opportunities for work with international aid organizations, other Arab countries (cross-country billing, etc.) (Corley, et.al., 2005).

Greater integration of financial systems

Cross departmental information easier

Saves dollars and resources in data entry and processing

Departments are able to assist in budget management

Overall fiscal health information available to CFO easier

Brings synergies together by combining departmental needs

Real-time reports show individual managers status of equipment needs

Monetary savings using bulk or negotiated purchasing techniques

Interface with finance allows greater control of cash flow

Fixed and variable budgetary issues for supplies easier to track

Inventory management module and interdepartmental responsibilities easier

Increases interdepartmental communication

Marketing/Business Development/Advertising -- Allows a new model for the Saudis -- marketing themselves as a destination spot for healthcare, regionally, and even internationally. Will drive more talent to the area, allow for greater penetration of staffing, and the needed improvements in nursing and secondary healthcare professionals. Marketing information systems provide information on past, present, and future projects, related events, and a more accurate picture of the client base, demographic and pscyhographic movement, and areas in which marketing, advertising, and business development can act more strategically. If certain product/service offerings are being outsourced, the system will allow marketing to gain appropriate statistics and details that might require both outside time and research instead of more appropriate, interdepartmental information (Samli, 1996).

Access to real-time data

Analysis of demographic data easier

Strategic marketing and development needs quickly defined

Direct measurement tools for advertising campaigns

Greater interdepartmental communication

Change of paradigm and reduce competition by touting benefits of new system

Reach out to become beta-test for international grants and programs

Move hospital to regional center of expertise for certain levels of expertise

Use as a recruitment tool for top medical talent

Use increased technology to drive seminars and national attention to center

Human Resources -- Over the past few decades, though, and with the advent of increasingly sophisticated technology, Human Resource management has changed from using people to employ people, develop people, and track the utilization and compensation of their services. Instead, a newer system has evolved using computers, database management, and data mining to provide more optimal ways in with the Human Resources department can move to more of a Personnel Department, playing a major role in staffing, training, and helping to manage people within the organization in order to strategically recruit, train, and retain the best people who will work towards the company's strategic goals. This new form of management is titled eHRM, or Electronic Human Resource Management. This will also allow the Saudis to improve their guest worker program that focuses on healthcare by providing greater opportunities for skilled workers (Boudreau, 2007; Cullen, 2001).

Easier and more efficient recruitment and hiring

Data mining to find more appropriate internal and external candidates

Allows HR to manage rather than just clerk

Allows HR regular and more efficient communication interdepartmentally

HR becomes less tactical and more strategic

HR becomes part of higher level executive planning

Easier to manage long and short-term benefit solutions

Greater employee loyalty by managing promotions and educational opportunities from within

Use as a recruitment tool for top talent; and keep human resources by managing change and educational improvement

Chapter 4. 0 Integration and Rollout

4.1 -- Rollout Plan (National)

With any new system-wide rollout, there are potential challenges and pitfalls. In the case of a new Saudi system, the recommendation is best understood as a tiered approach, moving from one hospital to the other based not necessarily on population, but on technical support, readiness for the program, and ability to support and prioritize. Prior to implementation, however, there are several tasks for the MOH:

Table 4.1.1

Task

Need

Implementation or Outside Influences

Actual Vendor

Bids and presentations from appropriate international vendors

Ability to establish Saudi needs, future growth, multilingual nature, appropriateness of training and timing; fiscal issues

Master Rollout Schedule

Based on vendor choice.

What equipment, wiring, changes are necessary to roll out new system.

Recruitment Needs

Hire international firm to recruit, interview and recommend talent at all levels

Establish short and medium term plan; decide, as well, how MOH wants Saudi nationals to interact within system

Ancillary Needs (Housing, etc.)

Involve other departments, construction needs, additional transportation issues, etc.

New apartment or housing complex; ensure enough resources for additional staffing; decide on international medical tourism and develop plan

Cultural Considerations

Impact of additional foreign nationals

Impact of foreign patients; pan-Arab or humanitarian issues, ROI

Strategic Alliances

Other companies, the United Nations, Humanitarian Organizations, investment and venture capital firms, etc.

Design for maximum cultural and fiscal ROI; anticipate Saudi cultural changes over next few decades.

Task

Need

Implementation or Outside Influences

Training and Educational Strategic Planning

Training personnel from vendors, ongoing staffing issues

What types of it and other personnel are necessary to complete model?

International Investment

Level and appropriateness

Overall goal; ROI, issues of dependency, etc.

Hospital Rollout

Strategic Planning

Tactical Planning and involved parties; set up separate management committee with impetus and authority to integrate various agencies at local and international levels.