With a rapidly growing population that is accustomed to receiving high-quality care, Saudi Arabia’s health sector offers some of the most promising opportunities in the region for private providers. The government has scaled back health spending in a bid to boost efficiency and widen the scope for private participation, and the Vision 2030 economic development blueprint has singled out greater utilisation of primary health care centres (PHCs) as a key target.
Primacy Of Primary Care
Primary health care was highlighted in a recent EY report as a segment that is ripe for development across the GCC. Health care systems in the region are facing tighter budgets as a result of lower oil prices, and this has accelerated initiatives aimed at shifting towards a preventive health care model, as a way of reducing costs and pressures on hospitals and specialised health centres.
In addition to improving the accessibility and quality of primary care, the authorities will likely need to engage in public awareness campaigns to reduce the tendency to view tertiary care centres as primary points of contact, and highlight the benefits and services available at PHCs. In the long run this will help ensure more efficient use of the Kingdom’s facilities, streamlining services, optimising utility, and cutting down on waste and wait times, while at the same time reducing pressure on tertiary centres.
Capacity
The number of PHCs run by the Ministry of Health (MoH) in 2014 was 2281, up from 2094 in 2010, with Riyadh home to 18% of the total. The number of health care workers – including physicians, dentists, nurses, pharmacists and allied health personnel – working in these centres was 37,456, up 9.4% from 34,241 in 2010. This translates into an average of three physicians and dentists, 5.9 nurses, 0.11 pharmacists and 3.2 allied health personnel per 10,000 people. There were also 129 private clinics in operation in 2014, with the majority of them located in the provinces of Riyadh (39%) and Jeddah (46%).
Underutilisation
While the low level of private sector activity outside large population centres is mainly due to a lack of financial incentives, another factor is the underutilisation of clinics and PHCs, which stems from a widely held view among the population that hospitals guarantee better care. Changing this perception will be key if the primary care segment is to achieve its potential. “Primary and preventative care can be improved, the latter through enhancing awareness,” Taha Abdulrahman Bakhsh, chairman of Dr Bakhsh Hospital Group, told OBG. “Hospitals are reaching a lack of capacity, especially in the Western Region, where there is a shortage of beds.”
Public Image
One of the incentives for enhancing the Kingdom’s primary care network is the opportunity it affords to reduce pressure on tertiary care facilities. However, the underutilisation of the PHCs currently available is a chief obstacle in this regard.
Although the network of PHCs has been steadily expanding, organisational difficulties remain. “The number of PHCs is sufficient,” Dr Sultan Al Sedairy, executive director of the research centre at King Faisal Specialist Hospital and Research Centre, told OBG. “However, they sometimes lack efficiency due to factors that can include a lack of expertise, a lack of clear process for patients and low demand stemming from social attitudes towards primary care facilities.”
Utilisation rates are a persistent challenge, with patients tending to bypass PHCs and go straight to hospitals and specialised clinics as their first point of contact. This leads to unnecessary pressure on infrastructure and staffing capabilities at tertiary centres. “People want to come to a specialist hospital because they think they will get better care,” Al Sedairy said. “In the more common cases like belly aches and influenza, however, they would be better off going to their local PHC and then being referred. Public education campaigns need to be carried out so that people are made aware of the services available at PHCs.”
“It’s a historical problem,” Dr Mushabbab Al Asiri, executive medical affairs director at King Fahad Medical City, told OBG. “When health facilities started being built in the Kingdom they were big hospitals. We don’t have the history of small general practitioner (GP) clinics, so hospitals came to be seen as the primary and sole givers of care in the Kingdom.”
Supply Side
In response to this, many major hospitals have established in-house primary care facilities, where patients can be reviewed before being referred to a specialist. King Faisal Specialist Hospital and Research Centre in Riyadh offers a full range of primary care services, while the King Fahad National Guard Hospital in Riyadh offers these services to their employees and guards. The Kingdom Hospital in Riyadh is also now exploring this option.
“We’re thinking of getting GPs, family medicine doctors and geriatric medicine doctors who would be the first contact for patient care and who would identify the health care needs of patients before referring them to specialists or consultants,” Farah Halwani, director of operations and business development at Kingdom Hospital, told OBG. “With the short supply of specialists and consultants, a referral system would ensure a better utilisation of the skills, knowledge and time of the consultant physicians.”
In addition to launching education campaigns that divert patients towards PHCs, enhancing the centres themselves will be important. The cultural and linguistic links that underscore Saudis’ preference for local staff means patients tend to go to where the Saudi staff are based. However, local staff are often reluctant to work in PHCs, where the limited scope for career advancement and the lack of specialised treatment technologies often serve as disincentives.
In 2015 the Journal of Family and Community health care workers in Jeddah were leading to a high turnover of staff and a shortage of resources. The difficulties outlined included the lack of electronic medical record systems, internet and computer access at some centres. Shortages of laboratory services, reagents, x-ray equipment and ultrasound equipment in some MoH centres were also reported. Amenities were an issue in several centres, with some MoH family physicians listing the lack of a cafeteria and poor building maintenance as concerns.
Addressing these issues will be crucial in shifting the attitudes of physicians as well as patients towards a more benevolent view of primary health care, according to Al Sedairy. “A beautification process must take place in primary health facilities so patients feel comfortable in the waiting areas and confident making appointments,” he told OBG.
Trends
The current challenges are by no means insurmountable and, more than anything, present significant opportunities for the development of the primary care segment in the Kingdom. The consensus among industry players that a more integrated primary segment is crucial to streamlining the sector and reducing pressures on tertiary care providers, coupled with ambitions in Vision 2030 to significantly boost utilisation rates, indicates that primary care development and uptake will be the focus of renewed government efforts. Indeed, such a move appears to be in line with the current shift towards greater uptake of preventive care, as the authorities try to meet the challenges associated with rising rates of chronic and lifestyle-related diseases.
The Kingdom has the highest incidence of diabetes in the region, with almost 20% of its population affected, followed by Kuwait (18%) and Bahrain (18%), Qatar (16%), the UAE (11%) and Oman (8%). In a move to tackle these trends, the GCC announced plans in early 2016 to impose new taxes on tobacco products, energy drinks and soft drinks, which will see respective price hikes of 100%, 100% and 50% when the new taxes are introduced in 2017. The ongoing development of primary care services in the coming years will complement these legislative efforts.
Integrated Technology
According to an EY report, integrated technology-enabled PHCs are “the need of the hour”. The report outlines the areas where the private sector can play a role in meeting this demand. These include the development of PHCs equipped with advanced diagnostic capabilities for health screening; improvement of the referral system, ensuring smoother links between primary care providers and specialist or tertiary care providers, or other resources such as pharmacies; enabling of remote monitoring; greater focus on providing multidisciplinary teams at the primary care level through the introduction of nurse practitioners, referrals to specialists through telehealth programmes and disease management clinics; and adoption of innovative care initiatives, including telehealth, that can deliver round-the-clock monitoring and accurate e-health solutions to reduce the prospective burden of care.
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