Public Health Management in Saudi Arabia - Term Paper Example

INTRODUCTION “Health is wealth”. This is one of the oldest and most common saying which emphasize the value of good health. The irony of this is that despite ones adeptness in the health topic, there is absolutely no guarantee of perfect health in a lifetime. The responsibility of looking after ones health is shared by the person himself, his family, and local community. The emergences of issues pertinent to health services make health the concern, not only by a nation, but on a global scale. The statement delivered on the topic “Who cares wins – Leadership and the business of caring” (Wells 2006) focus on identifying the nurses as leaders in the health care industry. Accordingly, it indicated that it is “a study commissioned by The Burdett Trust for Nursing about the business of aspects of patient care and the implications for nurse leaders and their boards”. The objectives of this paper are briefly enumerated as follows; 1. to identify pertinent issues relating to Public Health Management (PHM) in Saudi Arabia; 2. to examine the implications of differing theoretical discourses for leadership and practice; 3. to link these theoretical discourses in real life situations on health care. KEY ISSUES IN PUBLIC HEALTH MANAGEMENT A. Definition of Terms The value of health can never be oversimplified. An individual’s personal health contain assessment and evaluation of several facets of ones well being. The study of public health is a collective concern of health issues pertaining to a community level. As defined, (Acheson 1988), “public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts”. Since the emphasis no is overseeing health concerns of an organized group, there is a person or group of people appointed or assigned to ensure that health issues are appropriately addressed. In Saudi Arabia, the sole responsibility of managing the country’s health service lies solely on the government. An article retrieved from IHR (2004) revealed that “the government of Saudi Arabia continues to provide massive support to existing as well as new projects in order to see that health services are accessible to all people at all levels of care - primary, secondary, and tertiary.” In specific health institutions, healthcare starts with the nurses. Nurses, in turn, are managed by nurse managers. A complete hierarchy of personnel is plotted in any institution to show its organizational chart (Unit managers, Department managers, Vice President for Nursing, President and CEO, Board of Directors). Public health management is defined by Alderslade and Hunter (1994) as “the optional use of the resources of society and its health services towards the improvement of the health experience of the population”. In other several studies (Alderslade et.al 1990- 1999), public health management was identified to include knowledge and skills to manage actions for health improvement and includes not merely scientific and technical practice but also the ability to build coalitions and partnerships for health. According to World Health Organization (2001), public health management “is directed towards managing systems based on health outcomes both at the level of population-based health programmes and at the level of patient care. Above all PHM is about leadership and managing change”. B. Current Health Management in Saudi Arabia A discourse on the healthcare system in Saudi Arabia retrieved from Sustainable Development (1997) revealed that “the Ministry of Health (MOH) of the Kingdom of Saudi Arabia, which takes charge of health care and hospitals, has made progress in most health and environmental areas. It can be classified as a national health care system in which the government provides health care services through a number of government agencies.” With this data, it is clear that leadership in healthcare system in Saudi Arabia is assumed by the government through MOH. Finances and provision of care on a “referral basis” are functions undertaken by the government. As discussed by Perrin (1999) “a referral system is a continuum of health care, moving from the initial contact (i.e. the health centres) to completion of treatment (in the hospital) and referral back to the initial contact. At present, MOH is working to improve the referral system to minimize duplication of services and inefficient use of resources. MOH should be strongly committed to the referral system and should reflect this commitment in its policy-making. Community education should be provided to minimize self-referrals. Continuing medical education program should be provided for hospital specialists and health centre physicians.” The private sector is seen as possessing a growing and increasing participative role in health care services through its health facilities including hospitals, dispensaries, laboratories, pharmacies, and physiotherapy units. It is interesting to note here that for private sector expatriates, it is the sponsors or employers who are responsible for paying for an extensive medical package for their health services. SITUATIONAL EXPERIENCE IN PUBLIC HEALTH MANAGEMENT A. Underlying Problem Saudi Arabia’s health services of individuals, family and community are covered by Article 31 of the Basic Governance System and approved by a royal decree. According to the report of WHO (2007), there is an alarming increase in cases of diabetes, hypertension, and cancer. Another relevant information revealed that the largest cause of death in adult male population aged 16 – 26 years is deaths from road traffic accidents. With these data at hand, the prominent issue affecting health service in the country is the problem of stability in healthcare personnel who are servicing the people. Expatriates or foreigners form majority of the health force in Saudi Arabia. Statistics reveal that 61% of the health force is foreigners. Specifically, four-fifths of doctors and nurses and half of technicians are non-Saudis. This cause instability in providing health services due to several factors: (a) foreign personnel have other priorities, like thinking of their families in their native land; (b) foreign personnel lack the innate knowledge of customs, traditions and sentiments of the people; (c) communication barriers affect the effective implementation of health service; (d) patient – healthcare professional relationships are strained due to cultural differences; and (e) high turn-over of rate in health force due to migration of foreign personnel. B. Analysis There are several questions in relation to the issue of employing foreign health personnel. Among which are as follows: 1. Why do we need healthcare professionals from abroad? 2. Do we have enough educational institutions which are capable of developing good and qualified healthcare professionals who would cater to the health care needs of our people? 3. Do our health institutions give ample and appropriate incentives to motivate and entice our healthcare workforce or graduates to work in the country? 4. Do we have the capability and the resources to provide developmental programs for training and upgrading the level of education and expertise of our health force? 5. Do we have the facilities to monitor the leadership and management skills of our health providers to ensure public health safety and delivery of patient care? C. Proposed Health Reforms The government, as the lead and managing body in health care has continuously monitored the status of the healthcare industry. It has identified the need to improve its performance by suggesting reforms which have been recently enacted into new laws. In a related discourse, Berhie (1991) has identified that “the modern Saudi Health System has had four phases of planning with shifts, changes in priorities, overtime organizational arrangements. The proliferation of government health delivery system in both the public and private sectors within a short period of time has brought into focus several health planning issues--co-ordination, health information systems, the need for establishing a national health planning body, the need for developing and establishing an accreditation agency such as The Joint Commission of Accreditation of American Hospitals (JCAH), an acute shortage of trained manpower, reconsideration of option in financing health care, and reorganization of the Ministry of Health.” From among the most important reforms to improve the healthcare system and address the underlying problem, the following are summarized: 1. Health manpower. As identified earlier, majority of the health personnel in Saudi Arabia are foreigners, specifically of South Asian origin. There were several studies which reveal that these personnel receive salaries lower than the average salaries received by their national counterparts. To answer the questions in the analysis of the current manpower situation, the following responses are deduced: a. There is a steady growth in health services in recent years which raises the demand for labor in the health sector; b. Demand for health care services increases as a result of steady population growth and the increasing awareness of the population to avail of health services to prevent and cure diseases; c. The demand for labor can not be met by Saudi nationals due to the relatively small number of Saudi graduates from the medical educational training institution. To address this problem, itemized strategies being implemented by the Labor Force Council in Saudi Arabia for the development of labor force in the health sector contain short and long term goals to be achieved through the following policies (Nationalization of the Labor Force): 1. Encourage the private sector to invest in the establishment of medical schools and health colleges; 2. Increase capacity level in established health colleges and institutes; 3. Increase opportunities for scholarships in health specialties; 4. Encourage hospitals to establish their own training centers; 5. Establish more teaching/training hospitals; 6. Use non-conventional educational systems. 7. Enlarge the base of medical postgraduate studies; and 8. Strengthen the role of the Saudi council for Health Specialties These strategies actually have one major focus – continuous education and training. As suggested in the previous section, public health management needs training in every level of job responsibility. A newly graduate licensed nurse has several training courses to take to develop her skills in patient care. After six months of job immersion, she should attend another series of training courses in “on-the-job” services (assistance in operating or surgical procedures, emergency procedures, cardiovascular care, and pediatric care, among others). As the nurse progress in her expertise, her leadership and management skills are developed. She can become head nurse in their nursing unit, a clinical instructor to newly hired nurses, a nurse manager, and subsequently, a unit or department manager of the hospital where she is currently employed. 2. Sectoral Coordination. The article on Organization of the Saudi Health System (2002) revealed that there is a need to formulate a long-term overall management perspective to coordinate and integrate the provision of healthcare services by various agencies to ensure the optimal utilization of available resources as well as maintain a level of high performance through quality and efficiency. This need for coordination and integration efforts are pertinent due to the number of health care centers totaling 1,925 and broad base general and specialist hospitals numbering 220 hospitals in the Kingdom. (Health Indicators 2006) 3. Financing Health Care. Increasing demand in health care makes it inevitable for the government to sustain the present level of funds and opted to look for additional sources of finances to augment the current level and enable the Kingdom to upgrade its facilities and answer the needs of the public. D. Healthcare Leadership Experience One of the top hospitals in Saudi Arabia identified the high turn-over of nurses as their basic problem. Although the country produces numerous nursing graduates with good educational background and experience, the healthcare industry is unable to retain the nurses due to low salary and minimal monetary benefits. Further, the nurses feel that they are overwhelmed with work due to the bulk of reports and paper works they have to complete during their duty, in addition to patient care. Every nursing unit in the hospital is headed by a nurse manager who is assigned as the chief head nurse on duty. Her job responsibilities entail patient care as the primary task and managerial functions such as planning, directing, staffing and control. These multi-task functions coupled with low pay contributed to low morale and low productivity. These nurses opted to gain the minimum experience required to enable them to leave the country and work abroad. The leadership function assigned to nurse managers conflict with their functions as providers of patient care. They are expected to deliver timely reports on a daily, weekly and monthly basis. They monitor staffing requirements. They prepare the time sheets for payroll purposes. And most importantly, they are expected to know all the nursing intervention requirements for all the patients are their nursing units. There is this question on prioritization of function. As nurses, of course, they should prioritize patient care. But as managers, the function of attending to the human resource needs of the unit suffers. Reports are not completed on their specified time schedules. Upkeep of facilities in patients’ rooms and hospital areas are not regularly attended to. Equipments that need repair and reorder are forgotten. Staff vacation leaves are not properly plotted and thereby not taken as scheduled. Performance evaluation and appraisals are not conducted regularly for monitoring purposes. All of these functions are important managerial functions which would create an improvement in productivity and morale of a hospital unit. All of these should be attended to ensure customer satisfaction and efficient delivery of health service. What were the alternative courses of action open to management to solve this problem? The officers and top management of this hospital were aware that there were several options open to them, among which are: 1. Separate the patient care and managerial function from the nurse managers. 2. Hire administrative managers to take care of the managerial functions. The officers and members of the board of directors of the hospital deemed it appropriate to hire unit managers with masteral degree holders in business, to head the different nursing units. These unit managers have the sole responsibilities of ensuring compliance to reportorial requirements, human resources issues, facilities and equipment, budgeting, and other aspects of the units’ operations – except patient care. This solution was first met with complaints especially from the nurse managers who perceived the new position as a threat to their existence. They feared that they would eventually lose their “managerial” position and revert to a “staff” position since they would be relieved of the managerial functions and concentrate on patient care. However, top management assured them that this strategic move would enable them to focus on their primary concern as nurses and at the same time, take additional training courses to improve their nursing skills. Management developed another career path open to them which would eventually make them capable of becoming department managers and maybe, eventually, vice presidents for nursing. This move paved the way to increase morale and productivity in the units, and increased patients’ satisfaction with regard to the delivery of efficient and effective healthcare. CONCLUSION Public health management is appropriately described by WHO (2001) as about “leadership and managing change”. It is about taking the helm and steering it into action. The underlying issue that besieges PHM centers on the “attention devoted to analyzing problems rather than to action addressing them”. Problems are properly and accurately identified Leaders are assigned and employed to do their tasks. Systems are installed to implement the necessary changes. But there still exists a gap between knowing and implementing the solution. As timely recommended by O’Neil (2008), the leaders should create and head the teams to solve the problems. It should be a direct application experience. Leaders should not be wary or afraid to get their hands dirty for the sake of saving lives. By being part of the action team, only then can these leaders be assured that the solutions carefully drawn and crafted are efficiently and effectively implemented. Butts (2006) identified that the Quad Council of Public Health Nursing Organization (1999) emphasized that one of the tenets of public health nursing practice “includes an obligation to actively reach out to all who might benefit from an intervention or service”. Reaching out means outstretching ones arms to give assistance “to all” – not just the rich, not just the terminally ill, not just those who need emergency health service – but to all who might (or even those who might not) benefit from the health service. To go back to the statement delivered by Sir William Wells, there indeed is an extensive change occurring in health care. In the past century, there are vast advances in public health and in medical breakthroughs than in any point in time one can imagine. The sad part remains that indeed, “the ability to provide care and compassion to every user remains a legitimate public expectation”. Every individual expects to be given appropriate health care. But unfortunately, health care and the delivery of health service are not available to every one. The soaring costs of medical intervention, professional fees, medicines, laboratory tests, and other health requirements are neither readily accessible nor available to the public. Only the rich can afford to avail of health care. Although public health institutions provide free medical consultations, almost always, the poor cannot afford to buy the medicine prescribed. Most of the time, the medical facilities of public health institutions are not complete and therefore not available to the public. Therefore, the required medical and laboratory examinations of patients in public health need to be taken to private health institutions that require expensive cash outs before the tests could be administered. More of a nations’ budget should be allocated for health. In Saudi Arabia, the general expenditure on health as a percentage of general government expenditure as of 2003 is on 9.4%. (WHO 2006)The leaders recognize the need to address health issues but still, they allocate only a meager amount of the countries financial resources to answer these needs. In their financing reforms, the following proposals of the government were identified: (1) apply a cooperative health insurance system where the employer mandate is required to purchase cooperative health insurance to cover medical expenses; and (2) encourage private sector to undertake a greater role in financing and construction and management of health facilities. In addition, as pointed out by Roper (1988) “although there are large numbers of dedicated, hard-working, and able workers in the public health community, we are suffering from a grave shortage of leaders to deal with the magnitude of the threat to health that we now face, and to cultivate the real potential for substantial progress that exists for dealing with these threats. He identified that there are three impediments to leadership in public health: morale, skills and systems. Having identified the problems and solutions to leadership issues in public health, the only task left is for the governing body to implement these recommendations. There should be close coordination between the leaders of public health and leaders of health institutions or medical schools. As Roper suggested, “the academic institutions that are training future leaders for medical care and for public health must collaborate to produce both physicians who are equipped to deal with the health problems of populations and public health workers who understand the medical care system. Indeed, over the long term, we can aspire to having a "health system" that does not involve constant discussion of this matter of two separate and different worlds.” Leadership and management should be about being able to put analysis into action. With the majority of the reforms explicitly identified and most have been put into laws, the implementation phase should be closely monitored to ensure their success. Action, after all, is the most important saving factor needed for the country’s health care system. References Acheson, D (1988) Public Health in England. Cmnd 289. HMSO, London. Alderslade, R and Hunter DJ (1994) ‘Commissioning and public health’, Journal of Management and Medicine, 8 (6): 20-31. Berhie G(1991) Emerging issues in health planning in Saudi Arabia: the effects of organization and development on the health care system, Riyadh Butts, J and Rich, K (2006) Nursing Ethics: Across the Curriculum and into Practice, Jones and Bartlett Publishers, Sudbury, MA. Health Indicators (2006) Ministry of Health, Department of Statistics, Hunter, DJ (1997) ‘Managing the public health: incorporation or liberation?’ In: Scally, G (ed) Progress in Public Health, Financial Times Healthcare, London Hunter, DJ and Berman PC (1997) ‘Public health management: time for a new start?’ European Journal of Public Health, 7 (3): 345-9. Hunter, DJ (1999) Managing for Health: Implementing the new health agenda. Institute for Public Policy Research, London. International Hospitals Recruitment, Inc. (2004) Health Care in the Kingdom of Saudi Arabia, retried from O’Neil, M (2008) ‘Human resource leadership: the key to improved results in health’, Human Resource for Health, open access article Perrin J.E (1999) Unpublished report retrieved from Eastern Mediterranean Health Journal on Organization of the Saudi Health System, Roper, W (1988) “Why the Problem of Leadership in Public Health?” Institute of Medicine, Committee for the Study of the Future of Public Health. Sustainable Development (1997) Social Aspects of Sustainable Development in Saudi Arabia, retrieved from The Nationalization Of The Labor Force in Saudi Arabia:Logistical Consideration and Practical Strategies retrieved from The Work of WHO in the Eastern Mediterranean Region – Annual Report of the Regional Director, 2006, Cairo, EMRO. Wells, W (2006) “Who cares wins: leadership and the business of caring”, The Burdett Trust for Nursing, World Health Organization (2001) “Public Health Management”, University of Durham, World Health Organization (2007) Country Cooperation Strategy, Read More