Saudi Arabia PHC System - Essay Example

Critical review of the performance of a primary health care service in a Saudi Arabia against the key functions of primary health care. Introduction Saudi Arabia, as signatory to the 1978 Alma Ata declaration of Health For All by the year 2000 of the WHO, had identified the development primary health care as the important strategy for the purpose, with the result the country now has 1787 primary health care centres each serving an average population of 8727 people as in 2005 (MOH, 2002). Quality of health care has been defined as a combination of access to health care and effectiveness of health care. While access refers to health structures and processes available, effectiveness refers to clinical care and interpersonal care that deliver the desired results (Campbell, Roland, Buetow, 2000). PHC system Though health for all by 2000 could not be achieved, the PHC system has contributed significantly towards improvement of health conditions for those who are economically deprived. Being the flagship of the country’s health care system, all the PHCs are closely linked to the respective general hospitals which are linked to the tertiary care services through referral and feedback system. PHCs are also expected implement various facets of health care at the primary level and they carry out population and family census in the respective areas, maintain health files of the patients, conduct surveys at schools and routine home visits besides maintaining “health friends committees’ Their services are thus comprehensive in that they are promotional, preventive, curative and rehabilitative. They are owned by the Ministry of Health and wherever necessary PHC health care delivery is done through private dispensaries also. (Heath Systems Profile-Saudi Arabia) Present status of PHC system in Saudi Arabia As per the WHO report, the country has three types of PHCs catering to populations of 500, 5,000 and 25,000. Some, which are in cities, are liable to be overloaded to serve 100,000 people. And that additionally 900 PHCs are required to deliver an equitable health care service especially in remote areas. (WHO Report). Focus on Maternal Health Care Donabedian (1966), an authority on health care evaluation has suggested three levels of evaluation of a health service in terms of structure, process and outcome. While structure relates manpower, facilities and equipment, process involves assessment of the manner in which resources are used. Resources refer to health workers, procedures and techniques used to achieve the objectives. Outcome refers to evaluation of patient satisfaction, recovery rates and morbidity and mortality rates. Donabedian has opined that it would be ideal to adopt more than one of the three levels for evaluation to avoid misleading results. A study by Mansour (1996), cautions that people of Saudi Arabia are very polite and would not complain of poor services probably because they feel that the expatriate health workers would be harmed if complaints are made. The same study says that people of Saudi Arabia are generally content with low standards of care. Access to prenatal health care The study by Al-Ahamadi and Rolland (2005), which analysed 128 studies and selected 31 out of them, found access to prenatal health care was 67-95% which is considered good. (Al-Ahamadi and Rolland, 2005). There has been a steady decline in maternal mortality from 18 per 100,000 births in 1993 to 14 in 2003. 91 % of the births have been attended by skilled professionals, 86 % of whom were from public facilities. 86 % of pregnant mothers were fully immunised with tetanus toxoid. 90% of pregnant mothers received at least one antenatal check by a skilled profession. 21 % used contraceptives out of which 69% used pills and 24 % IUDs. Fertility rates fell from 6.5% in 1993 to 4.3 in 2003. Mean marriage age for females was 21.7 while for males it was 25.6 (WHO Report). However one report says that female mortality rates was 12 per 100,000 in 2000 (Health System Profile, 2006). A comparative figure of maternal mortality of 500,000 globally every year is noteworthy here. In Indonesia alone the rate is 20,000 every year (Healthcare Industry Today, 2010). Patient satisfaction Dissatisfaction rate was very high in respect of waiting time, waiting areas and physical environment of the buildings estimated as 74.9%, 58.1% and 63.8. % respectively. Although for most of the patients averaging more than 60%, PHCs were their best choice, 40 % of the patients surveyed expressed dissatisfaction with respect to opening hours, lack of access to specialist clinics and delays in getting the required care (Ali and Mahamoud,1993). Since most of the health professionals came from other countries not conversant with local Arabic language, 40 % of the patients surveyed informed language barrier preventing effective access to health care treatment (Al-Faris, Khoja, Falouda et al, 1996). Effectiveness Programmes in maternal health care were found to be effective (Beledo, 1995, p 32 & Al-Teheawy and Foda, 1992 76). Almost 85 % of the patients visiting the PHCs left with a prescription (average 1.44 drugs each). Besides, the prescriptions did not contain important information regarding dosage, strength and duration of treatment. (Al-Ahamadi and Rolland, 2005). Doctor-patient interactions referred to as interpersonal aspect, was also far from satisfactory. Only five minutes of interaction was observed which is considered as very short by international standards primarily because of the need for interpreters in the clinics as most of the health care professionals did not speak Arabic. Patients expressed dissatisfaction in respect of poor communication and exchange of information between patients and health care providers such as physicians, nurses, and pharmacists (Al-Faris, Al-Dayel and Ashton, 1994). 80% of the doctors did not speak Arabic coming from outside the region and the resultant information exchange was bound to be distorted by language barriers, cultural differences and differences in habits and traditions. Further health providers indicated that patient insisted on receiving medication or being referred to a hospital which resulted in interference in their preparedness to give high quality interpersonal care aggravated by lack of education in the community and compliance (Al-Khaldi et al, 2002). Attitude of professionals in providing maternal care in PHC A 1991 study had found that 66% of the medical and para medical staff was non-Arabic speaking and most of those who spoke Arabic were non-Saudis. This has an important bearing on communication with patients specifically in maternal care. However since many of the professional had put in more than two years of service, they were familiar with maternal care aspects in the PHCs. The previous work experience before coming to Saudi Arabia could also have influenced their views. They recommended antenatal clinics in the PHCs in order to ensure care on continuous basis under the care of particular staff. They also preferred to conduct low risk pregnancies at the PHCs for the sake of convenience to the patients. (Nasser et al, 1991). Barriers to quality of primary care that apply maternal health as well. Six barriers namely the factors of management, organisational, implementation of evidence based medicine, professional development, problems at the interface with secondary care and organizational culture were identified affecting the quality of primary care (Al-Ahamadi and Rolland, 2005). Management Factors Two studies have indicated satisfactory levels of management practices in the PHCs at the middle level regional managerial personnel and district technical supervisors. The technical supervisors who report to middle level regional managers are expected to oversee the functioning of primary health centres and their role is decisive in ensuring implementation and maintenance of the quality assurance in the care given by the PHCs. 65 % of them had no managerial training and 85 % had no post-graduate qualification. (Jarallah and Khoja, 1998). The middle level regional managers whom the technical supervisors report to, expressed difficulties due to lack of independent decision making, poor information, blurred lines of accountability and absence of supervision by qualified personnel. They also reported high staff turnover, no sense of career development, no uniformity in staff knowledge and skills. Besides, they cited operational difficulties to enable community participation, stressful working conditions, and poor coordination between health sub-sectors (Khoja and Kabbash, 1997). Organisational factors Recently the primary care centres have been better staffed and 90 of the centres maintained records, disease registers and follows up systems. (Khoja and Al-Ansary, 1998, p 64 & Al-Khaldi and Al-Shariff, 2002). The study of Al-Khaldi and Al-Shariff (2002). found that essential drugs were available in the range of 10-86%. There were shortages of health care educators since only 8% the centres had health educators. There was also no coordination between the PHCs and other agencies particularly with municipalities in respect of environmental heath issues including sanitation of water and food sources and waste disposal all of which have a bearing on maternal health (Al-Khaldi et al 2002, Al-Shammari et al, 1995, Al-Khashman, 2001, Kalantan et al 1999, Khoja and Kabbash, 1997, Khoja and Al-Ansary, 1998). Inadequate implementation of EBM For evidence based medicine (EBM), there are national guidelines for some common conditions but the clinical decisions were not adequately evidence based. This has resulted in wide disparity in practice, insufficient diagnosis, and inadequate management of several medical conditions. The reasons for this state of affairs are poor circulation of the guidelines, lack of awareness of the guidelines among physicians have limited access to the internet for accessing journals, reviews and databases (Al-Ansary and Khoja,2002). Interface with secondary care The referral system was implemented in the country during1986 for improvement of coordination between PHCs and hospitals. Since introduction, it has resulted in the reduction of hospital outpatient visits by 40 %.It was due to low referral of patients for diagnostic purpose and specialised care and poor exchange of information between the primary and secondary care institutions. Referral letters were found to have been written casually without important information mostly in illegibly hand written forms. Further, hospitals sent feedback only in 22 to 39 % of the referrals and even those lacked information regarding advice given, diagnosis made and investigation findings (Khoja, Al-Shehri and Khawaja, 1997 & Khattab et al, 1999). Organisational culture The PHC staff considered service in the primary care inferior to other specialties and they felt like being underestimated as physicians and by the community. They were also not happy with the management practices, incentives and medical facilities available to them. Primary care physicians were stressed over job demands on family life, professional isolation, work environment, patient complaints, lack of appreciation from them, patient pressure, patient load and for the those who were expatriates, they were stressed over their income levels, contract conditions, and cultural differences. Professionally they lacked awareness on the high prevalence of chronic diseases and cost of care (Al-Shari et al, 1998). Professional development strategies Professional development strategies were noticeable by their absence. Only one third of the physicians had post graduate qualifications and their post graduation was not in primary care. It is attributed to the fact that they (57 % of them) never had educational leave and 50 % of them only had access to medical periodicals. Work load and lack of time were also the reasons for professional development (Jarallah, Khoja and Mirdad, 1998, and Al-Shammari and Khoja, 1994). Conclusion and Recommendations Primary care in Saudi Arabia is a bold initiative credited with considerable achievement especially with regards to integration maternal and child health which had been separate prior to coming of PHC system. Maternal mortality rate of 12 or 14 per 100,000 is not high compared to other Arab countries. In order to improve the standard maternal health care, following recommendations are made. 1) The evidence based medicine practice should be intensified since it is fool proof method of improving patient care (Al-Ansary and Khoja, 2002). 2) HIV/aids status in the country is conspicuous by its absence in the WHO reports though there are reports of about 1500 cases of aids appearing in the local health news. And the cases are attributed to foreign nationals in the country. Saudi Arabia has the policy of deporting such foreign nationals once they are found to be infected. However there is no guarantee that local citizens do not carry HIV/aids since infection is possible through unsafe practices in the hospitals and dispensaries. The country should therefore be in high prepared to prevent HIV infections. Women are more at risk and hence it will have a serious bearing on maternal health if timely action is not taken at least now. 3) The country should aim at expansion of primary health care services that would automatically offer Maternal care including post natal care as the PHC staffs are pivotally placed to be in regular contact with the local community. 4) Cooperative Health Insurance which is in the cards as part of the country’s health care reforms may be expedited. 5) Privatization and corporatisation of health care especially in cities will go a long way in reducing health care budget burden to the exchequer by making available paid health care to those who can afford and free health care to those who receive inadequate services duet to budget constraints. 6) Primary Health Care professionals should be treated on para with the professionals. speciality clinics and secondary care institutions in terms of pay and designations. 7) Last but not the least, the country should accelerate development and Saudization of health professionals and other health manpower to make visiting patients feel at home and to avoid possible complications due to poor communication or miscommunication and also to reduce economic burden of the interpreters who can be better utilised in other areas of the health system appropriate to their qualifications. This can be achieved in the long run by establishment more medical colleges and health institutes and creation of more health jobs in the health budget. References AL-Ahamadi Hanan and Roland Martin, 2005, Quality of primary health care in Saudi Arabia: a comprehensive review. Al-Ansari Lubna and Khoja A Tawfik, 2002, The Place of evidence based medicine among primary health care physicians in Riyadh region, Saudi Arabia, Family Practice, 19(5) Oxford University Press. Al-Faris EA, Al-Dayel, MA, Ashton C., 1994, The effect of patients’ attendance rate on consultation in a health centre in Saudi Arabia. Fam Pract; 11: 446–452. Al-Faris E, Khoja T, Falouda M et al., 1996, Patients’ satisfaction with accessibility and services offered in Riyadh health centres. SMJ; 17: 11–17. Al-Khaldi Y, Al-Sharif A., 2002, Availability of resources of diabetic care in primary healthcare settings in Aseer region, Saudi Arabia. SMJ; 23: 1409–1513. Al-Khaldi Y, Al-Sharif A, Al-Jammal M, Kisha A, 2002, Difficulties faced when conducting primary healthcare programs in rural areas. SMJ; 23: 384–387. Al-Khashman A., 2001, Screening for hypertension: assessing the knowledge, attitudes, and practice of primary health physicians in Riyadh, Saudi Arabia. SMJ; 22: 1096–1100. Ali M., Mahmoud M., 1993, A study of patient satisfaction with primary health care services in Saudi Arabia. J Community Med; 18: 49–54. Al-Shammari S, Khoja T., 1994, An assessment of the current status of continuing medical education among primary healthcare doctors: a case for the creation of a national CME body. SMJ; 15: 443–449. Al-Shammari S, Khoja T, Al-Subai A., 1995, Job satisfaction and occupational stress among primary care centre doctors. Int J Ment Health; 24: 85–95. Al-Shahri M, Elzubier A, Mandil A., 1998, Cost estimation and physicians’ awareness concerning hypertension management: Experience from primary care centres. SMJ; 19: 390–393. Baldo MH., 1995, Coverage and quality of natal and postnatal care: women’s perceptions, Saudi Arabia. J Trop Paediatr; 41 (suppl. 1): 30–37. Campbell SM, Roland MO, Buetow SA, 2000, Defining quality of care. Soc Sci Med 51: 1611–1626. Donabedian, A. 1966. Evaluating the quality of medical care. Millbank Memorial Q. 44, pp 166-203. Healthcare Industry Today, 2010, Maternal Health News, More attention needed on health, Healthcare Industry Today, Jan, available at < http://health.einnews.com/news/maternal-health > accessed 13 Jan 2010 Heath Systems Profile-Saudi Arabia, 2006, Regional Health Systems Observatory, World Health Organisation, available at accessed 26 December 2009. Jarallah J, Khoja T., 1998, Perception of supervisors of their role in primary healthcare programmes in Saudi Arabia. East Mediterr Health J; 4: 530–538. Jarallah J, Khoja T, Mirdad S., 1998, Continuing medical education and primary healthcare physicians in Saudi Arabia: perception of needs and problems faced. SMJ; 19: 720–727. Kalantan K, Al-Taweel A, Abdulghani H., 1999, Factors influencing job satisfaction among PHC physicians in Riyadh, Saudi Arabia. Ann Saudi Med; 19. Khattab M, Abolfotouh M, Al-Khaldi Y, Khan M., 1999, Studying the referral system in one family practice centre in Saudi Arabia. Ann Saudi Med ; 19. Khoja T, Al-Shehri A, Khawaja A., 1997, Patterns of referral from health centres to hospitals in Riyadh region. East Mediterr Health J; 3: 236–243. Khoja T, Kabbash I., 1997, Perception of mid-level health managers about primary healthcare implementation obstacles. Tanta Med J; 26: 841–861. Mansour Ahlam A, 1996, A study of health canters in Saudi Arabia, Int. J. Nurs. Stud 33(3) pp309-315. MOH, 2002, Ministry of Health, Health Statistical Year Book. Saudi Arabia World Health Statistics, 2008, available at < http://www.who.int/countries/sau/en/ > accessed on 25 December 2009. Nasser-Al, N.Abdulaziz, Sekait-Al, Mohammed A, et al, 1991, Journal of Community Health; Feb; 16, 1; ProQuest Health and Medical Complete pg. 1 WHO Report, Country Cooperation Strategy for WHO and Saudi Arabia 2006-2011, Available at accessed 25 December 2009. Read More