Healthcare Management Systems Development in Saudi Arabia

Geopolitical and Cultural Overview of Saudi Arabia

Within the global healthcare model there are various expressions of what constitutes appropriate 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, and designed for a predominantly young or middle-aged population. It was certainly not designed to accommodate the increasing urbanization and economic improvements that oil and natural gas revenues have brought to the region. In addition, changing demographics in the Kingdom make it necessary to rethink the model of healthcare delivery entirely.

This paper first provides a geopolitical and cultural background of Saudi Arabia and compares it with the broader Gulf region, in order to engage the reader with the synergism between these issues and healthcare management. The focus then turns to a newer model of contemporary healthcare centered on effective communication and the use of modern technological tools. Effective software and multi-platform communications by healthcare professionals can remove much of the concern and confusion surrounding health care issues, and make better control and dissemination of information possible. For this reason, the paper proposes the purchase and implementation of a multidisciplinary software program specifically designed for the healthcare model, called Interactive Healthcare Solutions (IHC). IHC is a powerful tool with modules that incorporate 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.

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, Riyadh, is located in the central region of the country. Saudi Arabia's official language is Arabic, although English is also widely spoken, most commonly in the business community. The official religion of Saudi Arabia 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, while Medina is where the Prophet Muhammad lived and was buried. 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 foreigners from the United States and surrounding Arab 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 who do work, the Saudi work week runs from Saturday through Wednesday, with the weekend falling on Thursday and Friday, since Friday is the Muslim holy day. Businesses are typically closed during the heat of the day for prayer and rest. General business hours are 8:00 a.m. to noon and 4:00 p.m. to 6:00 p.m. ("Saudi Arabia," BBC, 2009).

The Kingdom of Saudi Arabia is a monarchy headed by the king. The government is composed of the king, the crown prince, and the Council of Ministers. The Kingdom is divided into thirteen regions, each headed by an emir (governor) 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 Saudi economic development. Saudi Arabia accounts for more than a quarter of the world's total oil revenues. The largest non-petroleum sector is agriculture, which provides around ten percent of the country's revenue. Major crops consist of wheat, rice, corn, and dates, with gains also being made in poultry, dairy, and livestock (sheep and camels) (Ibid).

The Arab World and Gulf Region Context

Prior to discussing the healthcare situation in the country, it is advisable to understand Saudi Arabia's position within the Gulf region as a whole. Like many Central and Latin American countries, political upheavals, military conflicts, sanctions, and embargoes have impacted many Arabian economies, causing declines in productivity and disrupting markets. This is not necessarily the case in Saudi Arabia, which 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 — do not impact Saudi Arabia directly, but they do indirectly influence the country's prospects for economic growth through a 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. This is a significant issue for Saudi Arabia because the views and behavior of the Saudi royal family differ significantly from those of the overall populace, which has come to resent what it perceives as the abandonment of traditional Arab and Muslim values in favor of closer alignment with the United States. The wave of democracy that transformed governance in much of Latin America and East Asia in the 1980s and Eastern Europe and Central Asia in the late 1980s and early 1990s has barely reached the Arab states. Constitutions, legal codes, and government pronouncements may signify a formal acceptance of democracy and human rights, but in many cases these commitments are not implemented and are sometimes deliberately disregarded. Most Gulf countries are characterized by a powerful executive branch that exerts significant control over other branches of government, reducing or eliminating the efficacy of checks and balances ("Saudi Arabia," Population, 2009; Noland, 2007).

In many ways, the Gulf countries are a mass of contradictions. Gulf countries have exhibited the fastest improvements in female education of any region, including literacy rates that expanded three-fold since 1970 and female primary and secondary enrollment rates that more than doubled during that time. In contrast, greater educational opportunities have not significantly altered social attitudes and norms that stress the roles of wife and mother. The maternal mortality rate is double that of Latin America and the Caribbean and four times that of 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 — a situation contrary to the teachings of Islam, illustrating one of the ways that Gulf societies have created social norms that do not necessarily mesh with the principles of the predominant religion. The Human Development Report identifies one of the greatest barriers to real development in the region as "bridled minds, shackled potential." About 65 million adult Arabs remain illiterate, two-thirds of them women, although illiteracy rates are much higher in the poorer countries. Ten million children between ages six and fifteen do not attend school, and if current trends persist, that number is projected to rise to forty million by 2015. Access to and use of cutting-edge technology is also considerably limited, with only 0.6% of the population using the internet and a personal computer penetration rate of just 1.2% ("Human Development Report," 2008).

Despite modest levels of inflation and budget deficits, growth continues to stagnate in many Gulf countries. The quality of public institutions is low, and critical macroeconomic variables such as employment, savings, productivity, and non-oil exports continue to underperform. Unemployment is a significant issue that impacts human development and overall economic progress. Trade performance remains sluggish, as the region is relatively closed, with high tariff and non-tariff barriers 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 global rate of six percent. 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 (Henry, 2001).

Many governments have also taken considerable steps toward 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 and financial services need to be strengthened, bureaucracy needs to be streamlined, and red tape minimized. Greater regional economic cooperation is also critical. Lack of accountability, transparency, and integrity — along with ineffectiveness, inefficiency, and unresponsiveness to human development needs — remain problematic (UNDP).

Poverty remains endemic in most Gulf states, with healthcare and quality education either poor or unavailable. Degraded habitats, including urban pollution and poor soil conditions from inappropriate farming practices, compound these difficulties. Social safety nets are entirely inadequate and form part of the nexus of poverty that is widely prevalent in the region. Knowledge remains a cornerstone of development; one significant question concerns why, despite outperforming most developing regions in education spending as a share of GDP, Gulf countries have not translated that investment into improved human development outcomes. "Brain drain" is one relevant factor, as many university-educated Arabs find few opportunities in their home countries and remain abroad after completing their studies rather than bringing knowledge home (Ayubi, 1996).

Culture and values are critical in terms of development, and this is where Gulf states face significant challenges, because globalization is viewed by many Arabs as a threat to their way of life. Activities that would promote economic development are not necessarily considered desirable, and this significantly hampers the efforts of Gulf governments to provide greater advantages for their populations. Political participation remains weak, primarily because of a lack of representative democracy and restrictions on civil liberties. The middle class, however, is experiencing greater power as a new range of resources has put it in a better position to contest policies and bargain with the state. Saudi Arabia is better positioned for international trade because of its ties with the United States, but it remains unclear whether the majority of its citizens benefit from this relationship. Job creation has not matched workforce growth, and broad-based growth remains unable to meet demand (Metz, 1993; Oxford Business Group, 2007, 2008).

Saudi Arabia is considered "medium" in terms of the Human Development Index, ranking sixth behind Kuwait, Bahrain, Qatar, UAE, and Libya. Its current population growth rate exceeds 3%, which compounds problems such as unemployment and job creation. Saudi Arabia has a significant urban population — more than 80% — which creates both economic opportunities and the challenges historically associated with industrialization and government dependency. Education is relatively high: Saudi Arabia has 1,915 active research scientists, compared with Kuwait's 884. Telecommunications are fairly good compared to other Gulf states, but PC penetration remains low. Saudi Arabia has ratified four 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 Saudi Arabia is 68.4 years for males and 71.4 for females, placing the country mid-range compared to other Gulf nations. The infant mortality rate is 18.3 per thousand, on the lower end of the regional spectrum, and 92% of children are fully immunized by age one — one of the highest rates in the region. Total health expenditure as a percentage of GDP is 3.5%, fairly average. The number of adult illiterates is 2.7 million, with two-thirds being women. Saudi Arabia moved from 61% of the population in primary school in 1980 to 78% in 1995. 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%, and the country's inflation was reduced from 7% in the 1960–1984 period to 1% from 1985–1998 (Ibid; Bradley, 2006).

What becomes clear when one evaluates the 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 its citizens. The challenge for Saudi Arabia in the future is finding a way to achieve greater political and economic participation among its citizens — something that will be difficult given the tensions between the government and the people. The government should continue to promote education and focus on technology and greater openness in trade with countries throughout the region ("Saudi Arabia," Al-Bab, 2009).

The Current Saudi Healthcare System

The current healthcare system in Saudi Arabia is a nationalized model. The government provides health services through state-controlled agencies, from the national to the local level. However, in recent years there has been 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 preventive, curative, and rehabilitative healthcare for the country. The Ministry currently provides primary healthcare (PHC) services through a large network of approximately 2,000 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, providing curative care services through 220 hospitals and clinics ranging from primary general practitioners to advanced technological and laboratory services. Within the Kingdom, the MOH leads all management, planning, financing, and regulation of the entire healthcare sector, while also supervising and ensuring appropriate levels of care at various levels of society. Most scholars view the MOH as effectively functioning as a National Health Service for the entire population.

Additional healthcare services are provided as ancillary parts of the Saudi government, covering primary, secondary, and tertiary care for specific demographic groups: security and armed forces, border and port control personnel, and others. 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 organizations operating under the MOH for healthcare-related purposes include:

Ministry of Education — Healthcare for students of all ages.
Ministry of Labor and Social Affairs — Healthcare for people with special needs (mentally or physically disabled) and for 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 in those two cities.
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, and health research in conjunction with other agencies.
Saudi Red Crescent Society — Emergency services, accident rescue, transportation of patients to hospitals, and 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 managing 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 serve as referral care centers for advanced and specialized care. Both also conduct research on Saudi health issues and publish their findings. Regionally, the King 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 and Luna, 1998).

Statistically, the Kingdom of Saudi Arabia has 88 hospitals with almost 9,000 beds, accounting for 20% of patient care beds in the Kingdom; 625 dispensaries, almost 800 clinics, 50 medical laboratories, and 111 physiotherapy centers; and 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 an 11% rise in inpatient care, due to increased funding and awareness campaigns, as well as the modernization of the healthcare system (Long, 1998, 2005).

Challenges and Issues Within the Current Saudi Healthcare System

While there are numerous challenges to the Saudi healthcare system, it is important to compare Saudi Arabia with 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, Saudi Arabia's share of population over 65 is below the regional average, which may be linked to specific patterns of geriatric care or particular health problems of the aged.

Key demographic indicators as of 2008 include: an estimated population of 28,147,000; a crude birth rate of 29 per 1,000 population (global average: 21); a death rate of 3 per 1,000 (global: 8); a rate of natural increase of 2.7% (global: 1.2%); a projected population change to 2050 exceeding 77% (global: over 39%); an infant mortality rate of 16 per 1,000 live births (global: 49); a total fertility rate of 4 (global: 2.6); life expectancy of 76 years (global: 68); an urban population of 81% (global: 49%); 97% of the population using adequate drinking water (global: 72%); and 91% of births attended by skilled medical personnel (global: 61%). Hospital beds are ranked 54th globally at 2.2 per 1,000 people (Population Reference Bureau, 2009).

Key health indicators include the following (Littlewood, 2000; Oxford, 2007; Saudi Ministry, 2006):

The Saudi infant mortality rate (IMR) is the lowest in the Middle East/North Africa region, though slightly above the global trend line. Compared to other Gulf countries, Saudi Arabia's maternal mortality ratio 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. Life expectancy statistics are above the regional average and median in range compared to the global population of countries with a similar economic profile. Malnutrition indicators are among the poorest in the Gulf: 14% of children under five years of age are underweight, 20% are growth-stunted, and 11% are acutely malnourished. However, because of increased economic affluence, 25–30% of Saudi women are obese and 15–20% of men.

Regarding 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 states, and is higher globally than countries with similar economic indicators. The bed-to-population ratio is above the regional average and also median for the Gulf states, but lower than global countries with comparable economic statistics.

Regarding health expenditures, Saudi Arabia's GDP is above the regional and Gulf averages. The public share of total health spending is above the regional average and comparable to the Gulf median, but well above global countries with similar economic factors. Per capita total health spending is above the regional average, below the Gulf average, and slightly below that of similar global countries. As a share of GDP, 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.).

In general, when placing Saudi Arabia in a global context, the Kingdom is about average for healthcare outcomes. There are some clear inconsistencies: the total health-to-GDP ratio is below the globally comparable average, but the public health-to-GDP ratio is higher. Similarly, per capita total health expenditure is below the global similar average, while per capita public health spending is above it (ASD Reports — Saudi Arabia, 2009).

These averages are part of the driving force for healthcare modification and change. The Kingdom has committed to increase healthcare spending by more than 400% by 2020, with the extended timeline primarily due to the logistical challenges in a country of its size ("GCC to expand," 2009). Scholarly research has shown that one of the largest problems for the Kingdom is the variation in care quality. While this issue exists in numerous other countries, including developed nations, Saudi Arabia faces continual challenges due to growing demand on health services, rising costs, and increased public pressure for better services (Al-Ahmadi and Roland, 2005). The data, taken as a whole and combined with historical and sociological factors, indicates that substantial variation in the quality of Saudi healthcare remains. 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).