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Al-Thowini, Kasem (2009) Toward the indigenization of the nursing workforce in Saudi Arabia comaparative study of three gulf states Saudi Arabia, bahrain and Oman. PhD thesis, London School of Hy- giene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.00682428
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Toward the indigenization of the nursing workforce in Saudi
Arabia
Comparative study of three Gulf states: Saudi Arabia,
Bahrain and Oman
Thesis submitted by
Kasem AI-Thowini
BSc, MSc
F or the degree of
DOCTOR OF PHILOSOPHY
In the
Faculty of Health Services Research Unit
University of London
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
University of London
2009
Abstract
For the last three decades, the Gulf Cooperation Council (GCC) states, comprising
Bahrain, Kuwait, Sultanate of Oman, Qatar, Saudi Arabia and the United Arab
Emirates (UAE) have relied heavily on doctors, nurses and allied health professionals
recruited from other countries. Globally, there is a persistent shortage of doctors and
nurses and the GCC countries are no longer able to meet their human resource
requirements through international recruitment. They have thus pursued policies that
aim to increase the supply of qualified indigenous health-care professionals -
indigenization.
This study aims to understand and examine why and how an indigenization policy has
been formulated and implemented in a purposively selected sample of three Gulf
States. Saudi Arabia, Bahrain and Oman have many commonalities and the structures
of their health-care services, labour force and indigenization policies confront similar
broad issues and challenges. However, they were selected to represent different social,
cultural and policy environments in the region and different levels of success in
creating an indigenous nursing workforce.
This study employs a qualitative research approach to generate an in-depth
understanding of the factors that facilitate or inhibit the implementation of
indigenization policies in nursing. This includes semi-structured interviews with 78
stakeholders comprising current and former policy-makers, human resource
managers, religious leaders and nursing officials living and working in one of the
three Gulf States. Document analysis provided the historical and technical
background for understanding the mechanism of the indigenization policy process and
practices. Findings reveal that cultural, economic and political issues play important
roles, as do society's views on education, the role of women and the image of nursing.
The recommendations to address these issues, particularly in respect of increasing
women's participation in the workforce, may contribute to the development of nursing
in the Gulf.
2
Abstract
Index of contents
Dedication
Acknowledgments
Index of contents
Chapter 1. Gulf states: introduction and historical background
l.1 Introduction
l.2 Transformation of the Gulf
1.2.1 Background
1.2.2 Demographic characteristics
1.2.3 Transformation of Gulf society
l.3 The Gulf Cooperation Council (GeC)
1.4 Summary
l.5 Religion
l.5.1 Islam
l.5.2 Impact on health workers
l.6 Bahrain
l.6.1 Geography
l.6.2 Demographic and social characteristics
1.6.3 Health service and the Ministry of Health
1.6.4 Education
l.7 Oman
l.7.1 Geography
l.7.2 Demographic and social characteristics
l.7.3 Health service and the Ministry of Health
l.7.4 Education
l.8 Kingdom of Saudi Arabia
l.8.1 Geography
l.8.2 Demographic and social characteristics
1.8.3 Health service and the Ministry of Health
1.8.4 Education
3
2
3
8
9
10
10
11
11
12
14
17
18
18
18
19
20
20
21
23
24
25
25
26
27
28
29
29
30
32
34
1.9 Chapter summary
Chapter 2. Literature review
2.1
2.2
2.3
2.3.1
2.3.2
2.4
2.4.1
2.4.2
2.4.3
2.4.4
2.4.5
2.4.6
2.5
2.5.1
2.6
2.6.1
2.6.2
2.6.3
2.7
2.7.1
2.8
2.8.1
2.8.2
2.8.3
2.8.4
2.9
2.9.1
2.9.2
2.9.3
2.9.4
Introduction
Limitations
Nursing shortages
Factors contributing to global shortage of nurses
Consequences of nurse migration
Nursing shortages in the Gulf
Background
Recruitment and retention of indigenous nurses
Recruitment of foreign nurses
Factors influencing nurse shortages in the Gulf
Importance of an indigenous nursing workforce
Summary
Human resources for health in the Gulf
Shortage of indigenous human resources In the
heal th servi ce
Women's participation in the Gulf workforce
Women's participation in the three Gulf states
Why is Saudi Arabia different?
Summary
Human resources in the Gulf
Characteristics of human resources in the Gulf
Labour markets in the three Gulf states
Labour market in Saudi Arabia
Labour market in Oman
Labour market in Bahrain
Foreign labour in the Gulf
Policy-making in the Gulf
Background
Public policy-making process in the three Gulf states
Indigenization as a public policy
Bahrainizati on
4
35
37
37
38
39
40
41
42
42
44
45
46
48
48
49
50
52
54
54
56
57
57
59
60
63
65
67
70
70
71
73
76
2.9.5
2.9.6
2.9.7
2.9.8
2.10
Omanization
Saudization
Indigenization and the role of education and training
Indigenization policies and culture in the Gulf
Chapter summary
Chapter 3. Research process and methodology
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.7.1
3.8.
3.8.1
3.8.2
3.8.3
3.8.4
3.9
3.9.1
3.9.2
3.10
3.10.1
3.10.2
3.10.3
3.10.4
3.11
3.12
3.13
Introduction
The researcher and the research
Practical difficulties and implications of lack of data Evolution of research questions
Framework for understanding indigenization policies Research approach
Research design
Case studies
Data collection process
Selection of case studies
Selection of participants
Sampling strategies
Access to research setting
Data collection methods
Interviews
Documentary analysis
Data analysis of interviews and documents
What is stakeholder analysis?
Cross-national comparison
Open coding
Theoretical coding
Ethical considerations
Strategies for enhancing rigour of the research
Chapter summary
5
77
78
84
86
88
91
91
92
95
96
97
98
101
101
103
104
105
107
110
III
112
116
117
120
123
124
125
125
126
129
Chapter 4. Indigenization - regional policy, multiple voices 131
4.1 Introduction 131
4.2 Policy development and structure 132
4.2.1 One concept, different perspectives 132
4.2.2 Changing concept of indigenization policies 134
4.3 Bahrainization and Omanization 138
4.4 Implementation of the indigenization policy 140
4.4.1 Implementation in the public sector 140
4.4.2 Implementation in the private sector 146
4.4.3 Incentives and penalties for implementing 152 indigenization policies
4.5 Indigenization in the health service 154
4.5.1 Global competition 155
4.5.2 Strategy for development of indigenous health-care 155 workers
4.6 Indigenization in nursing: where is the indigenous 160 nurse?
4.6.1 Indigenization strategies in nursing 162
4.6.2 Nursing education 164
4.7 Recruitment and retention 169
4.7.1 Factors inhibiting recruitment and retention 171
4.8 Implementation of indigenization policy in 173 nursing: what and where are the problems?
4.8.1 Contextual factors 174
4.8.2 Organizational factors 191
4.8.3 Situational factors 194
4.9 Chapter summary 198
Chapter 5. Image of nursing in the Gulf: "What is an indigenous 200 woman like you doing working as a nurse"? 5.1 Introduction 201
5.2 Economic issues 203
5.3 Social attitudes 208
5.3.1 Role of the family 214
5.3.2 Knowledge 218
5.4 Religion 219
5.5 Gender relations in the Gulf 223
5.6 Media influence 227
6
5.7 Role models 228
5.8 Chapter summary 230
Chapter 6. Discussion and conclusion: fate of the indigenous nursing 233 workforce in the Gulf 6.1 Introduction 233
6.2 Empirical research literature 234
6.3 Key findings 236
6.3.1 Image of nursing is key to improving indigenization 236 of the nursing workforce
6.3.2 Human resource practices inhibit career progression 239 for indigenous nurses
6.3.3 Local cultures and religions: impact on 240 indigenization of nursing
6.3.4 Indigenous female nurses and multidimensional 241 di scriminati on
6.4 Is there a GCC policy process? 243
6.5 Implementation of indigenization policies: 243 challenges and constraints
6.5.1 Slow policy response 244
6.5.2 Recruitment and retention strategies 244
6.5.3 Indigenous workers lack skills and experience: myth 245 or fact?
6.6 Gulf education and training systems cannot meet 246 the needs of the labour market
6.7 International recruitment can be beneficial 247
6.8 Availability, accessibility and transparency of 247 data in human resources for health
6.9 Conclusion and recommendations 248
6.10 Future research 254
Appendices 256
References 272
7
Dedication
This dissertation is dedicated to my grandfather Abdullah, my father Mohammed and
my mother Latifa who have shared with me their knowledge and experience and
encouraged me to be always a student of knowledgeable and experienced people.
I also dedicate this dissertation to all the health-care professionals, especially those in
the nursing profession in all three Gulf countries, who desired to provide meaningful
information to help me complete this research.
8
Acknowledgements
I want to express my heartfelt thanks to all the participants - the indigenous nurses
and students~ national and local stakeholders~ and those who assisted in organizing
access to the research sites and willingly shared their thoughts, opinions and
experiences. This research would not have been possible without them. I also want to
express my great and deepest appreciation to my supervisors Anne-Marie Rafferty,
Jill Maben and Elizabeth West for their support and encouragement.
I must express my special appreciation and gratitude to my day-to-day supervisor Jill
Maben who also played the role of mentor, providing counsel and guidance
throughout this research. She believed in and helped me, especially in those times
when I really needed a friend and a supporter. I was so lucky to have someone like Jill
as a friend and supervisor.
In addition, I want to thank my supervisory committee members, especially Professor
Charles Tripp from the School of Oriental and Mrican Studies. He was always very
helpful and his input is very much appreciated. I also want to thank all the people and
friends who supported me throughout this research especially Gill Walt, John Cairns,
Karen Clark, Avril McAllister and all those who work in the health service and policy
research units and computer department. My appreciation also goes to Professor Pam
Smith (University of Surrey) and Dr. John Carrier (LSE) for their contribution and
recommendations as examiners. Finally, I want to express my indebtedness to my
wife Zubaida and my children Mohammed, Sara, Abdullah, Khalid and my newly
born son Talal for their continuous support, encouragement and patience. Without
them this research would not have been possible.
9
Chapter 1
Gulf states: introduction and historical background
1.1 I ntrod uction
The major focus of this research is shortages in :~.t Sc~:: "A.;-c'::'lan ~_:-~~~~; '.\ J~' ~ _H _-:
Bahrain and Oman \"ere selected as comparati\t: COL:-.::1e" t-l"_:'~'l" ::;c", ~ . .:.'c
introduced successful indigenization policies to meet ~uC:', sho;-::.~(":, C ,-'~~t-'.:~" ",':" ~ ,-
the roles and functions ()f indigcnization policies in the three (1-.:: <":~eS c'" . ..::" C' ~i't'
re<;carcher to analyse the contrasting experiences and asse ...... the:r \ ,!~"\ In:.: ':11;"J,,:> ,\!l
the nursing workforce Furthermore, comparative studle" "If a li,nlil:.!:t\ \.' :iJlU~1? J'c'
required for systematic examination ()f attitudes t(' cia ... s, gender anJ rt"'~'\.'T1 '.\:hn
the local populations and their impact on attitudes to nur"lng The (\.I!11i'3rJ::\t' ,:"'~\
indicates that there is no single blueprint for the applicillon ~)f ,;" indi~t'(1I/.!:Il)n
policy; each country must adapt polic\ t() local situati\'!1" Dt+,\;l" I o\.".j!l',j \",:i 1:1 :tll'
Gulf region and the broader international literature \\ ill help ",i",: -\rabl.! II.! Jl'\ l'i l ,!, an improved recruitment practice aimed at indigenous I'l'(li,!e
The Gulf region is \\here 1\\0 continents (\sia. Africa) and ihrl'e l'uIIUIO ( \:.Ib
African, Asian) meet and blend It traces its origins to the anl:lenl (Ultllll' I': I>:::rwn ,j
major trading link betw(,(,11 Mesopotamia l and \rabia ('eli, d (unfeJl'ratlc,n l'! ':cltl"
in the southern Arabian Peninsula \\ hich Conned a l1et\\ urI-. "\ 1 Lick r, ',dl" bel \\ ecr
India and,\fliL'a (Cordesman. Jl)l) .... ) (Jl·\l~l.\phicalh. the Per'lan (l)r \:ctbLifll ("t
liL's bel\\L'L'11 the-\rabian Peninsula and S~)lIth-\\e"l \,,13 It I" (~)nneC:l''': :r :' l"
.. \rabian Sea by the Strait of Honnuz !l)[ s('\ eral millennia. the (fl,';" dnJ the Red 'ta
the 1\ kditeITal1l':1I1,
Located In the sOllth-\\estem f"l't-ion (1f \"ia Jlh,] (l1\ t'n!1~ abl'lul ~ m k~" ~.'-' -he
.. \rabian PeninsliLl consisb lIt" Saudi .\l,lha, Ku\\ait. B,:;'~;l!n, (.)~ .. "'e I \f . e
1 \It.'Sl'l'I. I LlI111.l is the ,1Il'.l bc[\\een thl' rh.:ri, J"ci IlWhrJ;l" ~\C'.:!'" end (,(the -\r.d~l,lnl;lllf
L'
,.
'-
26 May 1981, the collective aim is to promote coordination between member states in
all fields in order to achieve unity (Christie, 1987). The three Gulf states which are the
focus of this study are Saudi Arabia, Bahrain and Oman.
This chapter seeks to provide relevant comparative analysis of the three Gulf states
and the context for comparative analysis of their human resources for health, with
particular regard to nursing. Compiling profiles of these three states poses
methodological problems as most Gulf states have relatively little information
available on their development. In the absence of uniform data sources on most
aspects of life (and human resources in particular) quantitative data on social,
economic and health services are derived from a number of different sources,
including the World Health Organization (WHO), the GeC and the World Bank.
The first section of this chapter examines the transformation of the Gulf region, its
historical background, demographic features and the transformation of society. In
addition, there is discussion of the pre- and post-oil eras - the importance of the
discovery of oil and the major changes that ensued. The second section discusses the
origin and formation of the GeC, its objectives and challenges. The third section
examines religion and the role and impact of Islam in the Gulf health service. The
fourth section examines the three Gulf states by focusing on key issues such as their
social, political and economic characteristics, elucidating the main similarities and
differences and examining public services and health in particular.
1.2 Transformation of the Gulf
1.2.1 Background
Most of the people who live in the Middle East and North Africa are Arabs, but they
have only recently controlled the region. Ottoman Turks controlled most of the
territory until World War I; the colonial era began when the British, French and
Italians succeeded them. Arab unity has been a dream for Arab nationalists for
decades. It is difficult to determine the particular historical period that marked the rise
of Arab nationalism, but Alnasrawi (1991) believes that awareness of a national
identity among some Arab groups began to emerge during the eighteenth century and
through the Ottoman occupation. Recent developments have made this more unlikely,
11
with increases in the Arab world ' s external dependen ce, internal fragmentation and
disputes (Hudson, 1999) . Arab intellectuals like Edw ard Said see the failure to
mobilize and integrate human and material resources as proof of the pow erlessness
which is the fundamental problem facing Arab countries today (Hudson , 1999) . Said
(1996) argues that the inability to deal with and solve the Arab-Israeli conflict is the
most fundamental problem facing Arab politics .
Despite the manifest failure to unify the Arab nations (more than twenty sovereign
countries) there have been repeated sub-regional efforts to achieve a measure of
integration or at least coordination (Hudson, 1999). The GeC is such an ex ample and
is discussed in section 1.3 .
Map 1 Gee states
Aral7 "an Peninsula
Yemen I -
1.2.2 Demographic characteristics
The population of the GeC states has grown more than tenfold during the last fi ve
decades (4 million in 1950; 40 million in 2006) . This is one of the highest population
growth rates in the world (United Nations, 2006). Demographic growth in the region
ranges from 3.32% in Oman to 1.51 % in Bahrain . Total fertility rates remain hi gh :
from 2.63 children born per woman in Bahrain to 4.05 and 5.84 in Saudi Arabia and
Oman , respectively (Table 1; Appendix 1). Further demographi c and popul atio n data
are presented in the relevant sections for each state. B y 2004 life expectanc in th e
12
GCC states had increased by almost 10 years to 72 years for males and 75 for females
and about one third to one half of the population was under the age of 15
(International Monetary Fund, 2003). Also, more than 12 million foreigners lived in
the GCC states - a significant proportion of the region's population. In the UAE,
indigenous people comprised 63.50/0 of the population in 1965 and less than 200/0 in
2004 (Table 2) (GCC, 2006; Ministry of Planning, 1997; United Nations, 2006).
Table 1 Demographic factors in Bahrain, Oman & Saudi Arabia (2005)
Annual Total Population
Birth rate growth rate fertility size
Country rate
(000) Birthsll 000 % Children
population born/woman
Bahrain 1038 18.1 1.51 2.4
Oman 3 100 36.73 3.32 4.5
Saudi Arabia 26417 24.5 2.28 3.17
Source: Central Intelligence Agency (CIA), 2006a
Table 2 Indigenous people and foreign workers in GeC states, 2004
Foreign Total Country Nationals 0/0 0/0
workers 2004
Bahrain 438209 62.0 268951 38.0 707 160
Oman 2325 812 80.1 577293 19.9 2903105
Saudi 16529 72.9 6 144236 27.1 22673 538
Arabia
Qatar 223209 30.0 520820 70.0 744029
Kuwait 943000 35.6 1 707000 64.4 2650000
UAB 722000 19.0 3278000 81.0 4000000
GCC 21 184 323 62.9 12486349 37.1 33 677832
Sources: GIrgIS, Untted NatIons, 2006
13
1.2.3 Transformation of Gulf society
The discovery of oil has transformed Gulf society, new social groups have appeared
and old ones have changed or disappeared - the Bedouin population has fallen
dramatically in the last twenty years. However, this does not mean that traditional
conservative values have been abandoned. Vassiliev (1998) argues that the powerful
scale of economic modernization and the penetration of Western ideas and values has
produced both partial erosion and, paradoxically, partial strengthening of tribal
traditions. The Gulf middle class has grown in both numbers and wealth as a result of
state financial aid for home and business loans (Vassiliev, 1998).
The GeC countries occupy about 90% of the Arabian Peninsula. About 1 % is
cultivated and the rest is mainly desert, although some areas are suitable for animal
husbandry. Lackner (1978) described the interior of the Arabian Peninsula where
Bedouins and peasant farmers in the oases persisted from pre-Islamic times into the
20th century. However, he argues that this was not a unified society as the tribal
structure and (later) Islam divided the oasis, desert and urban communities. Isolation
from each other and the modes of production quashed the possibility of a unified
social, economic and political structure (Lackner, 1978).
Prior to the discovery of oil, the Gulf states had few raw materials or economic
resources except the income generated from various locus-specific sources scattered
around the region. For example, Saudi Arabia's main source of income stemmed from
trading with and servicing Muslim pilgrims but this was not sufficient to provide even
the most basic necessities of life. Other Gulf states combined various land and sea
activities. Pre-oil Oman's two main economic enterprises were fishing and
agriculture. For centuries, Oman was known for its exports of agricultural products
such as dates, dried limes and frankincense.
The discovery of potentially vast reserves of oil in the 1920s and 1930s began a
transformation which was eventually to produce the modem Gulf states. In 1932, an
American geologist in Saudi Arabia found indications of oil (Vassiliev, 1998). In
1933, the Saudi Finance Minister signed an agreement with the American company
Standard Oil of California (SoCal) to begin explorations in the eastern part of the
country. This did not bring immediate wealth for Gulf state rulers but its discovery
14
made the internal politics of the Gulf important and of interest to the rest of the world,
particularly Western countries. The oil extraction industry and the huge wealth
generated from oil exports were controlled by a few people and increased pressure on
traditional social structures. Thus, social revolution accompanied the discovery and
exportation of oil and brought ideas, values and influences totally unknown in the
previous history of the region (Vassiliev, 1998).
From 1945, and with increasing speed, most Gulf states transformed from a collection
of small towns reliant on fishing, herding, oasis farming and trade to the world's
leading oil producers and exporters with high per capita incomes, a wide range of
welfare services and the beginnings of a modem petrochemical industry (Owen &
Pamuk, 1998). The oil and gas sectors grew to dominate the Gulf states' economies.
For example, many public works in Saudi Arabia in the 1950s and 1960s were carried
out by the Arabian American Oil Company (ARAMCO). AI-Rasheed (2007)
described how ARAMCO's involvement in building the infrastructure to facilitate oil
production and shipment extended beyond the construction of roads, pipelines, ports
and airports to the provision of schools, hospitals and a quasi-state administration. She
argued that ARAMCO filled the gap left by underdeveloped or non-existent public
services, education, water supplies and health facilities (AI-Rasheed, 2007).
Extensive political and economIC changes in the Gulf in the early 1970s were
followed by rapid changes in social conditions (especially in health and education)
over two distinct phases in the post-oil era. The first (1973-1984) followed the first
energy crisis; the second (1985-1997) followed the erosion of oil prices. Both are
discussed in more detail below.
The first energy crisis began when oil producers in the Organization of the Petroleum
Exporting Countries (OPEC)2 stopped exports to Western nations during the 1973 war
between Egypt, Syria, Jordon and Israel. During this embargo, the price of oil rose
more than 4000/0, from US$ 2.59 per barrel in 1973 to US$ 11.65 in 1974 (Shwadran,
1977). When oil exports resumed the Gulf states obtained huge increases in revenues
2 An oil cartel created in 1960. Consists of Iran, Kuwait. Saudi Arabia, Venezuela, Qatar, Indonesia. Libya, UAE, Algeria, Nigeria, Ecuador and Gabon
15
that continued into the early 1980s. These funded ambitious investment programmes
to build up physical and social infrastructures. Initially, the emphasis was on
construction and industrial development but rapidly increasing population and per
capita income levels spurred the development of domestic household services
(International Monetary Fund, 1997).
Social and economic changes followed this economic development. Largely rural or
nomadic tribal societies became highly urbanized with huge changes in lifestyle
(Kapiszewski, 2000). Gulf governments have changed from poor simple entities
sufficient for governing mainly desert lands into rich regimes that face the complex
challenges posed by international power politics and their people's newfound
appreciation of the possibilities of modem life.
During 1974 and 1975, some economists predicted that the unprecedented transfer of
wealth to oil exporting countries would make many of them rich beyond belief
(Askari et aI., 1997). Most of these predictions assumed that oil prices would not
decline and government policies would effectively use and transform this wealth into
productive projects or domestic assets. However, the majority of OPEC countries
experienced severe financial difficulties following the collapse of oil prices in the mid
1980s. Economic conditions weakened and GeC governments could no longer afford
lavish expenditure upon social services such as education, health and subsidies.
Yamani (1998) argues that welfare and development had been central tenets of the
ruling ideology and had protected the indigenous populations from the social and
political problems endemic in other Arab and Middle Eastern countries. Gulf
governments have tried to adjust to decreasing oil prices as they realize the danger of
relying on an economy based on a single source commodity.
Oil and related materials (e.g. petrochemical products) now account for major budget
revenues in most Gulf states. Saudi Arabia, the richest country in the Middle East, has
the largest reserves of oil and is the world's largest producer and exporter. The oil
sector in Saudi Arabia usually accounts for roughly 700/0-800/0 of budget revenues,
40% of GDP and 90% of export earnings (Central Intelligence Agency, 2002). Oman
and Bahrain are the only two GeC states in which oil reserves are small and
16
diminishing (Riphenburg, 1998). Oman was late to enjoy the benefits of oil wealth as
it began oil production in 1967.
1.3 The GCC
Following many failed attempts at Arab unity, some analysts argue that a form of
regional integration and cooperation might prove a tangible goal. The GeC is one of
several sub-regional efforts to achieve a measure of integration, or at least
coordination (Hudson, 1999). One of the least-studied regional organizations among
scholars of international politics (Legrenzi, 2002), the GeC was established officially
at a summit of Gulf State leaders in Abu Dhabi in May 1981. The six rulers
proclaimed a new era of cooperation which had been thought impossible in such a
tension-prone region (Abdulla, 1999).
The GeC comprises six Gulf states - Saudi Arabia, Kuwait, Bahrain, Qatar, the UAE
and Oman. All are geographically close and share a common religion (Islam),
language (Arabic), heritage and tribal background. Together, they control 450/0 of the
world's proven oil reserves (Fasano & Iqbal, 2003). They also have common systems
of government - all are either monarchies or ruled by a single family, centred on one
tribe (Gause, 1994). Their economies share many characteristics - oil contributes
about one third of their total gross domestic products (GDPs) and three quarters of
their annual government revenues and exports. Their predominantly subsidized
societies are thus highly dependent on oil. This form of government has created a
relaxed way of life peculiar to the area (Al-Naqeep, 1990) which gives the region its
own distinct identity.
Many political analysts predicted failure in the early years but the GeC has survived,
despite continuing doubts, and found a receptive audience within and beyond the Gulf
region (Nakhleh, 1986). Although relatively new, it is proving to be one of the few
(perhaps the only) cases in the Arab world where genuine cooperation is not only
working but also increasing, albeit intermittently (Christie, 1987). Some argue that the
GeC represents possibly the most effective model of integration in the Arab world
(Legrenzi, 2002).
17
It is important to note that the typically recalcitrant conservative Gulf states took less
than three months to agree unanimously on the broad ideas and goals of the GeC,
approve its final charter, sign many complex documents on policies and structures and
hastily announce its formal birth (Christie, 1987). Some argue that such extraordinary
and uncharacteristic speed only confirms the widely held belief that the GeC was
more of a hasty reaction than a calculated initiative (Al-Alkim, 1994). However, the
main objective of this regional organization is to effect coordination, integration and
interconnection between members in all fields in order to achieve future unity
(Abdulla, 1999). Economically, the GeC has created its own customs controls and
imposed common external tariffs.
1.4 Summary
This section has covered the history and transformation of the Gulf region, focusing
on its strategic location and describing the historical background, demographic
characteristics and development of society. It has also reviewed the economic and
social situation of the Gulf region before the discovery and exploitation of oil. In the
pre-oil era, extreme poverty and a lack of adequate health and education services were
common features. Changes and developments have taken place in the post-oil era,
especially extensive economic development and developments in public services
resulting from the huge oil revenues which have contributed to the development of the
region's societies. This section has also highlighted the main reasons and factors
behind the creation of the GeC, reviewed and discussed the council's objectives and
the growing debates over its achievements.
1.5 Religion
1.5.1 Islam
Islam is a major determinant of the socio-cultural and political profile of the Arab
world and the Gulf. It is a comprehensive system that regulates the spiritual as well as
civic aspects of individual and communal life in accordance with human nature
(Hasna, 2003). Islam is derived from the Arabic word for peace and means
submission to the Will of God; a Muslim is one who submits to the Will of God.
18
Muslims do not believe that God assumed human form although they believe in the
divine revelations of many prophets including Abraham, Moses, Jesus and
Mohammad. Islam and Arab culture have played a major role in shaping the future of
the Arab world and many other regions (Cordesman, 1997).
Most religious historians consider that Islam dates from 622 AD, as Mohammad lived
from about 570 to 632 AD. The last of a succession of prophets, Mohammad founded
Islam in Mecca, Saudi Arabia, following the angel Gabriel's recital of the first
revelation. These revelations form what is now known as the Quran. Mohammad died
after uniting the Arab tribes who had been tom by revenge, rivalry and internal fights.
He produced a nation that extended from the Atlantic Ocean in the west to the borders
of China in the east.
1.5.2 Impact on health workers
The sociological literature on the women's movement in Gulf countries is very
limited. The traditional view that religion is all-pervasive has played an important part
in forming feminist identities in the region. The teachings of the Quran state that both
sexes are equal under the eyes of God and therefore both should be treated with
justice and respect. However, traditional conservative Islam sees women as the
weaker, irrational and irresponsible sex that needs to be subject to the control and
protection of men. Some argue that Islam tries to minimize temptation, which may
lead to sexual interaction, by taking an unequivocally negative attitude towards the
interaction of the sexes (Mernissi, 1987).
Western culture tends to associate nursing with characteristics such as virtue and
purity. Women comprise the majority of the nursing workforce in the three Gulf states
but are challenged by the taint of immorality associated with gender interaction in the
workplace (EI-Sanabary, 1994). This is less true in Bahrain - although a Muslim
country, it is more open to other cultures than any other society in the Gulf. This
distinction is clear in the status of women in general and nurses in particular. In
Bahrain, women can vote, drive, work in most fields of employment and dress as they
like. These are precluded by religion in both Saudi Arabia and Oman.
19
Sometimes, local cultures are confused \\ith religion or the two are spo~.en of as ODe
and the same. Religion can also become conflated with cultural attitudes ar:2 it is :-':::-t:
for research to attempt to disentangle the two. Qualitatiye Srudlt:S :l1::-:Ji~~~:
considerable variation in individuals' views on the compatibility of a nursing C .. Ft:e:-
and their religious beliefs (Darr et aI., 2008). Different Gulf statt:s ha\t: ditTerent
interpretations of whether it is permissible to nurse members of the opposite --e\
Some see no conflict between Islam and nursing. citing examples from Islamic hiswr:-
where Muslim female nurses cared for injured soldiers on the battlefield (RassooL
2000). However, as indicated in this research, some conservatiYe indi\·iduals feel that
providing nursing care to adult members of the opposite sex is unacceptable within an
Islamic framework.
Issues with the style of nursing uniform (e.g. a fitted tunic) deter some parents and
students, especially in Saudi Arabia. In addition, Saudi Arabia does not sanction co-
education and so women do not meet male students during their initial nursing
education. Quranic teaching supports the active search for knowledge for b,)th se,es
but the question is how best to do this within the cultural interpretation of the
religious doctrine. Comparative studies of a qualitative nature that include young
people and their parents in the three Gulf states are crucial, as is the need for similar
studies that examine more systematically the impact of class, gender and religion
upon attitudes towards the nursing profession. The Gulf states face the challenge of
increasing the proportion of indigenous nurses who are able to deli\er high-qualit\
care, be aware of local cultures and speak the same language as their patients
The next section reviews the development of the three Gulf states that are the mai n
subject of this study - Bahrain, Oman and Saudi Arabia. Thi s includes the hi storical
background and social, political and economic characteristics
1.6 Bahrain
1.6.1 Geography
The Kinadom of Bahrain is a borderless nation comprising a group of ~6 island-- in o
the centre of the Persian!.~rabian Gulf 20 miles otT the eastern induqrial r l \ '\ inee of
::0
Saudi Arabia. The three main islands are Bahrain ocati
Sitra and Muharraq. Joined by causewa s~ the com se ~'UL
land area (Ministry of Informatio~ 2()(x) . Bahrai is
populated of the Middle East countries with 890/0 of the po
areas (United Nations Development Programme, 199 ).
Map 2 Bahrain
o 5 10 km • t t
o 5 "0 rnI
, SalmAn
Gull of
88htain
Source: Ministry of Information, 2000
1.6.2 Demographic and social characteristics
Bahrain (two seas) refers to the islands ' two sources of water - freshwater prin and
salty seas (Ministry of Information, 2000) . It has been populated by human 10
prehistoric times and has been proposed as the site of th e bibli cal Garden 0 Ed [ s
strategic location in the Persian Gulf has brought rul e and infl uen es
Assyrians, Babylonians, Greeks, Persians and, finally Arab 1:i 0 '
Information, 2000). Under the Arabs, Bahrain was one of the firs e
mainland Arabia to accept Islam, around 640 AD . Between the
centuries, Persian influences made Bahrain a staunchly Shii e M
During this time it appears to have been well-g vem ed and
important port on the trade routes between Ira an l a o
, 1
cosmopolitan ethnic structure of Arabs, Indians and Persians (Yarwood, 1988). The
population was estimated to be 688 345 in July 2005 (Central Intelligence Agency,
2006a). This is overwhelmingly Shiite (70%) and Sunni (30%) but there are also
small indigenous Jewish and Christian minorities. Most Bahrainis are of Arab origin
although some trace their roots to Persia.
Bahrain became a protectorate of Great Britain in 1861. After World War II,
increasing anti-British feeling spread throughout the Arab world and led to riots in
Bahrain. In the 1960s, Britain requested that the United Nations General Secretary put
Bahrain's future to international arbitration (Fuccaro, 2000). The majority of the
population voted for independence. Bahrain remained a protectorate until 1968. The
British withdrew in 1971 leaving an independent emirate under the rule of a sheik. In
February 2002, the Emir proclaimed himself king.
Today Bahrain is a constitutional monarchy headed by King Hamad bin Isa al-
Khalifa. His uncle is the head of government, the Prime Minister, who presides over a
IS-member cabinet. Bahrain has a bicameral legislature - the lower house (Chamber
of Deputies) is elected by universal suffrage; the upper house (Majilis al-
shuralConsultative Council) is appointed by the King (Central Intelligence Agency,
2006a). Bahrain has a long established and clearly defined commercial legal
framework, with somewhat looser civil and social legislation. A complex system of
courts, based on a synthesis of Sunni and Shiite sharia, tribal law and British-based
civil codes and regulations was set up in the early 20th century (United Nations
Development Programme, 1997). These codes continue to be updated, particularly
those regarding commercial legislation.
Women were granted the right to vote and stood in national elections for the first time
in 2002. However, Shiite and Sunni Islamist males dominated the election,
collectively winning a majority of seats. In response to the failure of the women
candidates, the King appointed six women to the Shura Council. This also includes
representatives of the Kingdom's indigenous Jewish and Christian communities
(Central Intelligence Agency, 2006a). In 2006, Bahrain took an unprecedented step
when the King appointed the first female judge in the Gulf region, highlighting the
progress of the women's movement and the rapid development of women's status in
Bahrain.
Bahrain is expected to be the first Gulf country to run dry of oil (International
Monetary Fund, 2003). This has proved to be an advantage as, without the resources
for a boom, Bahrain has moved slowly but firmly into the technological age. Since
1967 a policy of economic diversification and liberalization has been adopted and
vigorously pursued. State investment in large projects has been combined with the
promotion of an enabling environment for both large and small private sector
companies (United Nations Development Programme, 1997).
In Bahrain, oil production and processing account for about 600/0 of government
revenues and 30% of GDP. Economic conditions have fluctuated with the changing
fortunes of oil since 1985, such as during and following the Gulf crisis of 1990-1991
(International Monetary Fund, 2003). In the process of supporting economic growth,
the Bahraini government has been successful in providing a modem infrastructure - a
complex and well-developed transportation and communication system with regular
traffic to a variety of destinations. In 1998 Bahrain had the highest per-capita GNP;
percentage of population with access to safe drinking water; and number of adequate
sanitation facilities, compared to Saudi Arabia and Oman.
1.6.3 Health service and the Ministry of Health
Bahrain has the oldest health service in the Gulf. The first hospital (Victoria Hospital)
was built in 1900 and The American Mission Hospital (for male patients only) in
1902. In 1925 the Department of Health Services began as a clinic in a small shop in
which a government-employed Indian doctor treated injured pearl divers (Al-
Buraikhi, 1991). Following independence, the Department of Health of Bahrain was
renamed the Ministry of Health.
Bahrain has universal health care, is considered one of the most developed Arab states
and the 41 st most developed state in the world (United Nations Development
Programme, 2000). Child-mortality and life-expectancy levels compare well with
those of mature developed nations. Statistics reveal a more than 600/0 reduction in the
infant mortality rate (IMR) between 1978 and 1998. In 2006, infant mortality was 9
per 1000 live births (Appendix 1), the lowest mortality rate among the three Gulf
states in this study. Health-care expenditure has continued to rise and accounts for
8.3% of GNP.
The health service faces a number of challenges including the increasing number of
elderly people. Currently about 2.2% of the population, this figure is expected to triple
in the next decade and extra resources will be required (Bahrain Brief, 2000).
Bahrain's health service has progressed considerably since independence in 1971 and
its health indicators are the best among the three Gulf states (see Table 3).
Table 3 Health service indicators: Saudi Arabia, Bahrain & Oman (1970 & 2006)
Category Saudi Arabia Bahrain Oman
Years 1970 2006 1970 2006 1970 2006
Hospitals 74 338 6 9 1 50
Hospital beds 9039 28522 929 1680 12 4455
Physicians 1 172 34261 92 1 980 13 4290
Nurses 3261 74 114 428 4410 425* 9516
Primary health-care 591 1 804 19 24 19 128 centres
* Estimate Sources: Data based on statistics from Ministries of Health in Saudi Arabia, Oman, Bahrain
1.6.4 Education
As in other Gulf states, the only form of education in Bahrain at the beginning of the
20th century was traditional (Quran) schools aimed at teaching young people religious
duties and the reading of the Quran. However, following political and social changes,
the first modem public school for boys was established in Muharraq in 1919. The
Education Committee opened the second public school for boys in Manama in 1926.
Two years later, the first public school for girls was opened in Muharraq (Ministry of
Education, 2001). With a high level of government support, the Gulf Technical
College (now Gulf Polytechnic) opened as the first institution of higher education in
1968.
Bahrain has been at the forefront of reducing gender distinction in educatio n. The
Ministry of Education acts on the constitutional policy of equal opportuni ty in
education by extending educational opportunities to all Bahrainis in order to achie e
justice and equality (Ministry of Education, 2001) . The educational system comprises
nine years of basic education (primary and intermediate) and three years of secondary
education (Ministry of Education, 2001) . Bahrain has one of the highest literacy rates
in the Arab world and the highest female literacy rate in the Gulf.
1.7 Oman
1. 7.1 Geography
The Sultanate of Oman is an independent country in the south-eastern corner of the
Arabian Peninsula. An area of almost 309 000 km 2
borders the UAE to the north-
west, Saudi Arabia to the west, Yemen to the south-west and the Arabian Sea to the
east.
SAUDI ARABIA
Map 3 Oman
IRA oJ
$tJ , at" • Mina
Fahl ;'~ [.II -],
'I brT. S ' .:I~~
• Nlz "8
Duqm,
C EC .. ,:::.:! IT I t :) E~ 1:" ( 11
- Ray sC
Source : Ministry of Information, 2004
2 ~
1.7.2 Demographic and social characteristics
Oman's history goes back to the very dawn of civilization. The coastal area fronting
the Gulf of Oman is believed to have been known as Megan by the Sumerians who
imported its copper from as early as 3000 BC (Ministry of Information, 2004). Arab
history in the country began in the second century BC when tribal groups migrated
from what is now Yemen. Oman was a British protectorate between 1891 and 1971
(Ministry of Information, 2004).
The Omani population was estimated at a little over 3 million in 2005 (Central
Intelligence Agency, 2006a). Oman's long history of maritime trade, tribal migrations
and contacts with the outside world has produced a heterogeneous population.
Numerous ethnic and religious minorities include some who trace their origins to Iran,
Pakistan, East Africa and India. Some are a legacy of the country's slave trade with its
East African colonies; Omani of Indian descent result from historical trade ties
between Oman and the Indian subcontinent (Al-Yousef, 1995).
Oman has always been unique within the GeC states (Al-Yousef, 1995). It is a large
country with a diverse economy, settled agriculture, fisheries and a long maritime
commercial tradition (Allen & Rigsbee, 2000). Situated outside the Persian Gulf, the
Strait of Hormuz sits within its territorial waters. This narrow waterway passes
between the Gulf of Oman in the south-east and the Persian Gulf in the south-west.
Some 20% of global oil supply passes through it, making it one of the world's
strategically most important chokepoints (Al Yousef, 1995).
The Sultanate of Oman has neither political parties nor legislature. In 1991, Sultan
Qaboos bin Said established the Consultative Council (Majilis al-shura) in an effort
to systematize and broaden public participation by providing a conduit of information
between the people and government ministries. The selection process is unlike those
in other Gulf states. Each provincial governor convokes the government-denoted
notables (usually 100-200 people) in their area to recommend three potential council
members. The Sultan selects one of these to be the member for that province. Former
senior government officials comprise the largest group in the council but tribal leaders
and businessmen are also heavily represented. As the government designates notables
the representative nature of the electorate can be called into question. Nevertheless, it
26
is at least a means of bringing some of the citizenry into the process of nominating its
representatives (Gause, 1994).
The council is empowered to revIew drafts of economic and social legislation
prepared by service ministries, and provide recommendations to the Sultan. It also has
the right to question service ministers (heads of ministries delivering public services
e.g. housing, health, transport) who are also required to submit annual reports. This
council has no authority on matters of foreign affairs, defence, security and finance.
Like Bahrain, Oman is one of the less rich states in the Gulf. Before the first exports
of oil in 1967 it was a classically underdeveloped country depending on a traditional
(largely agricultural) economy using old technology with low levels of productivity.
As in all Gulf states, oil has been the basis of the Omani economy throughout the
reign of the present ruler, contributing more than 80% of total revenue and 95% of
foreign currency. This has enabled the government to pursue its programmes for
economic diversification and social change (Riphenburg, 1998). Like other Gulf
states, Oman is seeking to develop new sources of income to augment and reduce
dependency on oil revenues and increase national investments in promising non-oil
sectors, particularly manufacturing, mining, agriculture and fisheries (Riphenburg,
1998).
1. 7.3 Health service and the Ministry of Health
Oman's performance in the health sector has been remarkable since 1970, when there
were only twelve hospital beds (see Table 3 above). Annual growth rates for the
period from 1971 to 1990 averaged 16% for hospital beds, 17.6% for doctors, 22.3%
for nurses and 22.3% for inpatients (AI-Yousef, 1995). This enormous progress is
demonstrated by the increase in life expectancy - from 57 years for both sexes in
1980 to 71 years for men and 75 for women in 2005. The estimated infant mortality
rate dropped from 64 per 1000 live births in 1980 to 19.5 in 2005 (AI Riyami et aI.,
2004; AI Yousef, 1995; Central Intelligence Agency, 2006a). By the same year, the
crude death rate had declined to 3.5 per 1000 population and the total fertility rate
remained the highest among the GeC states at 4.5 births per woman (Appendix 1). In
2000, a WHO survey of 191 countries measured life expectancy against the amount of
resources spent per head of population between 1993 and 1997. Oman came first,
27
ahead of several European countries such as Italy (third), France (fourth) and Spain
(sixth). The survey results reflect Oman's effective and competent use of the financial
resources available for health services.
The Ministry of Health is the main health-care provider in Oman. Allen and Rigsbee
(2000) argue that the ministry's success in building a network of hospitals and clinics
and training qualified medical personnel in such a short time could be attributed to the
substantial base upon which they built. In 2005, the health service (Ministry of
Health) comprised 48 hospitals, 128 primary health-care facilities, 3455 hospital beds,
2981 doctors, 7909 nurses and 5634 allied health personnel. Other governmental
agencies (e.g. Armed Forces, Oman Police, Qaboos University) have their own
hospitals.
1.7.4 Education
The UN 1994 International Conference on Population and Development found that
education, particularly of women, is the single most important component in which a
nation can invest to improve the welfare of its people. The conference stressed the
importance of the links between education, women's empowerment and demographic
indicators (United Nations, 1994). The Omani government also considers education to
be a prime tool for developing the country's human resources. A universal education
policy for both boys and girls was introduced in 1970. Until then, there were three
primary schools (attended by approximately 900 boys personally selected by the late
Sultan) and three private girls' schools - two for Indians and one for the children of
American missionary staff (Riphenburg, 1998).
Between 1996 and 2000, 226 new schools were built and 11 new private schools were
opened. The total number of students is now 528 357, nearly half of whom are female.
Girls also comprise over 400/0 of the students in private education. Adult education
operates in parallel with the regular education system, allowing those who have been
unable to complete their education to obtain a qualification. In 2003, 80% of the
32345 teachers were Omanis (Ministry of Education, 2004). Higher education is
provided by a university, specialized institutes, technical vocational colleges and six
teacher-training colI eges.
28
1.8 Kingdom of Saudi Arabia
Saudi Arabia is unique. It does not fit any preconceived model of development as
some of its characteristics far override any of the features it shares with other
developing countries. Like many developing countries its borders have only recently
been defined but, unlike others, it was never fully colonized. The main difference
between Saudi Arabia and most other developing countries is its extreme wealth. Oil
revenues are huge and therefore the country is not dependent on external economic
aid. However, it does remain dependent on the West (particularly the USA) for its
continuing existence as a monarchy.
Saudi Arabia is an Arab-Islamic country that contains the two leading holy Mosques
of Islam. Social and economic development has taken place according to Islamic
religious beliefs and its legal system (sharia) has been developed from the Quran and
the prophetic traditions interpreted by the Prophet Mohammad (World Health
Organization, 1998b).
1.8.1 Geography
Saudi Arabia occupies about 80% of the Arabian Peninsular, in an important strategic
location between Africa and Asia. The Kingdom is bordered by Jordan, Iraq and
Kuwait in the north; the Persian Gulf, Bahrain, Qatar and the UAE to the east; Oman
and Yemen to the south; and the Red Sea to the west. The country is largely a land of
deserts and no rivers with a harsh hot climate. Divided into thirteen regions, the most
important are:
1. Riyadh - capital city
2. Eastern region - location of most oil fields
3. Mecca province -location of the holy mosque
4. Medina -location of the second most holy mosque
5. Qaseem region - central; mainly agricultural
29
Map 4 Kingdom of Saudi Arabia
YE EN
o '00200 m I o 100 200 m
IRAN
Arabian Sea
Source : Ministry of Culture, 2002
1.8.2 Demographic and social characteristics
Saudi Arabia was established in 1932 by the father of the present King Abdullah bin
Abdul Aziz Al Saud . King Abdul Aziz Al Saud ' s final conquests in the period after
World War II united diverse tribes and territories that had been fragmented for a lon g
period (Al-Rasheed, 2002) . Today most of the Saudi population (80%) lives in the
urban areas where most development projects and jobs are concentrated . This is a
change from the traditional Saudi way of life in which most of the population li ved in
the desert or in agricultural villages. As outlined above, the discovery of oil and the
large revenues from its export have dramatically transformed Saudi Arabian society .
In 2005 , Saudi Arabia's population was estimated to be about 27 million, inclu din g
more than 7 million resident foreigners . The population annual growth rate was
estimated to be 2 .31% and the total fertility rate was 4.05 (Table 1) (Central
Intelligence Agency, 2006b). Saudi Arabia is known as the birthplace of Islam and the
religion is evident in all aspects of life . The country has a highl y conservative cultural
environment and adheres to a strict interpretation of Islamic law (sharia) .
30
Saudi Arabia has developed into an urbanized and modernized country over the past
50 years. The centralization of government has undercut tribal autonomy and
undermined the social and economic benefits of its leaders but the system remains
strong and deep-rooted. More than 50 tribes maintain a fragile unity but most political
influence in the country rests with a few who derive their importance from a
combination of factors such as size; military power; geographical location; character
and orientation of their leaders; and religious outlook (EI-Mallakh & EI-Malkh,
1982). Tribal leaders (sheikhs) govern and acquire influence through their ability to
mediate disputes and persuade their followers towards a given course of action. In the
early years of the 20 th
century, some tribes proved politically decisive in the ongoing
acceptance of the royal family's (Al Saud) rule.
The Kingdom of Saudi Arabia occupIes an influential position because of its
geographical location; role in influencing Arab affairs; leadership in the creation of
the GeC; and special position in the Islamic world. It is a traditional and inegalitarian
system that preserves inequalities and concentrates wealth and power in the hands of
the few. Few such systems remain in the modern world (Walt, 1994).
The country's name is derived from that of its royal family. The house of AI Saud
consists of several thousand princes and princesses, all interrelated. Yamani (1998)
estimated that there are more than 8000 AI-Saud princes, making them the largest
royal or ruling family in the world. Adopted in 1992, the Saudi constitution declared
that Saudi Arabia is a monarchy ruled by the sons and grandsons of King Abdul-Aziz,
the founder of the kingdom, and the Quran is the constitution of the country. Saudi
Arabia has no separation of religion and state, no political parties and no national
elections. The King is Prime Minister and head of the armed forces. The ulema
(religious scholars), tribal leaders, wealthy merchants and educated technocrats
constitute the four major groups that have varying influence on, and access to, the
royal family.
In 1993, the King established the Consultative Council (Majlis al-Shura) to revievv
government policy and make recommendations for his final decision. Its 150
members are appointed by the King and are male. Saudi Arabia is under severe
pressure, internally and externally, to create a constitutional monarchy and reform its
31
political system. Women in Saudi Arabia cannot vote or participate in higher ~~o>::.::s
but, in February 2009, King Abdullah appointed the first woman as head of ...:: :-l' S
education (Aleqtisadiya, 2009). This position has always belonged to :~~e nl('st
conservative males in the country and therefore this appointment is considered to be a
milestone for women in Saudi Arabia.
Saudi Arabia has changed from a poor, isolated and mainly desert land into a rich
country in less than six decades. The sharp rise in oil revenues following the 1 ,) -;_~
Arab oil embargo made Saudi Arabia one of the fastest growing economies in th~
world. Though constrained by falling oil prices in the mid 1980s, since 2004 the Saudi
economy has seen a remarkable rise in its revenues due to sharp increases in the price
of oil. In 2004, Saudi Arabia earned about US$ 116 billion in net oil export re\enues.
35% more than 2003 levels. Net oil export revenues in 2005 and 2006 \\ere forecast
to increase to US$ 150 billion and US$ 154 billion, respectively (Energy Information
Administration, 2006). Oil accounts for approximately 90% of the country's ex ports
and nearly 75% of government revenues.
Since the early 1970s, eight Saudi Development Plans (SDPs) have been adopted,
aimed at achieving the country's economic development goals (AI-Farsi, 1996) Each
five-year plan has considered most aspects of the Kingdom's economy concerning
infrastructures and commercial and agricultural needs. The Saudi econom \' is based
on the free market philosophy and, despite its dependence on oil, the public sector is
the largest employer and government expenditure is substantial.
1.8.3 Health service and the Ministry of Health
Before the introduction of modern medicine, Saudis depended upon traditional
practitioners and religious healers. Organized preventive health sef\ices began in the
early 1950s when the Ministry of Health, ARAMCO and WHO launched a successful
campaign against malaria in the Eastern Province. This programme \\as extended to
other provinces in the country (AI-Yousuf et aL 2002) In terms of disease and
preventive health, Saudi Arabia is included in the \YHO Eastern \ 1editerranean
Region and is considered to be a low-to-middle economically developed countf\
(Littlewood & Yousuf, 2000).
Between 1970 and 1980 health services became predominantly curative as most
health personnel had been trained in patient-oriented, hospital-based medical
institutes. Health care was delivered through a network of hospitals and clinics;
preventive care was delivered by health offices and, to some extent, maternal and
child health-care centres. The Kingdom provides free health services to all although
foreigners are required to obtain health insurance and are generally treated in private
health-care facilities. Health care is the responsibility of the health ministry but a
number of other government health providers make considerable contributions to the
health service. In 2003, they were responsible for 17% of all government hospitals
and 25% of total beds (Ministry of Health, 2005).
As the main provider of health care, the Ministry of Health supplies comprehensive
care for citizens via a range of preventive and curative health services, including
health education programmes. In 1957, Saudi Arabia's health staff consisted of 62
doctors, 7 surgeons, 231 nurses, 71 technicians, 9 dentists and 64 midwives and
nursing assistants (Lipsky, 1959). By the end of 2005, the ministry employed more
than 100 000 doctors, nurses and allied medical staff. Primary health-care centres
throughout the country provide a patient's first point of contact. They form a network
closely linked to the general hospitals which, in tum, are linked to tertiary-care
services by a referral and feedback system. These centres implement the various
components of primary health care.
Currently, the principal health issues in Saudi Arabia are communicable diseases such
as schistosomiasis and malaria; conditions resulting from the abundant mental and
environmental stresses of modem societies; and injuries sustained from ever-
increasing automobile accidents (Al-Mazrou, Al-Shehri & Rao, 1990). Injuries from
road traffic accidents increased sharply from 504 in 1994 to 28 372 in 2002,4161 of
which were fatal (World Health Organization, 2005). Despite the emergence of these
diseases and injuries, rapid socio-economic development in recent decades has had a
visible impact on the health status of the population, changing mortality patterns and
improving the quality of life (W orId Health Organization, 2005).
The government funds approximately 87% of total health expenditure. The Ministry
of Health's allocation increased from 6.1% of the national budget in 2000 to 7.6% in
2005 (Ministry of Health, 2006). Other health service finance is derived from private
33
sources (e.g. personal out-of-pocket payments) and health Insurance premIUms
(mainly from large private companies).
1.8.4 Education
When Saudi Arabia became a nation, education was largely limited to a few religious
schools and has never separated from its religious roots. The Saudi education system
conforms to Islamic law and the traditional gender separation of male and female
students. Education is free, but not compulsory.
The Ministry of Education was created in 1953 and the first university opened in
1957. Girls' education started in 1960 despite violent opposition from the ulama in
some parts of the country. Nevertheless, education in Saudi Arabia has developed
remarkably since the 1970s. The urbanization and economic growth produced by oil
wealth contributed towards a marked reduction in illiteracy rates - from 85% in 1970
to 38% in 1990 (Mohammed, 2003). In general education there was a total of 3.8
million students and 286 000 teachers in more than 22 000 schools in 1995. By 1999,
there were about 4.4 million students and 357000 teachers in more than 26000
schools (Ministry of Planning, 2005). In 2004, there were 107 000 male and 159 000
female high-school graduates. In higher education, the total number of male and
female students enrolling at universities increased from 165 000 in 1995 to more than
263 000 in 1999, a 12.4% average annual growth rate. This rapid development in
modem education necessitated the employment of foreign teachers, especially in high
schools and universities. Elementary and intermediate education is largely managed
and taught by Saudis.
Since the 11 September 2001 attack on the USA, the Saudi education system has been
under scrutiny and criticized by various countries and organizations. The USA,
particularly, believes that the system has educated some of those now waging war
against them. Some minority groups in the country, especially the Shiites, also want
the government to reform its education system and to eliminate some false claims
against them in some textbooks used in Saudi schools. The Saudi Government has
responded to allegations that it teaches intolerance and promotes Wahhabism by
embarking on a campaign of educational reforms - changing the content of most
religious texts by replacing or omitting controversial and intolerant passages. The
Saudi government has requested American help to reform its education Sy stem and
monitor the contents and standards of its textbooks.
1.9 Chapter summary
In summary, this chapter has described the transformation of the Gulf region from :~~e
pre-oil era to the present day. The demographic characteristics of the Gulf rer~ eet the
highest population growth rates in the world since the 19~Os and their impacts on
development. The chapter has examined the role of oil - the two phases of the POS1-(1J!
era and the emergence of an oil economy in all Gulf states. Huge revenues have
impacted on Gulf society by bringing new ideas and \'alues and rapid changes in
social conditions, especially in health and education.
The chapter has examined the origin and objectives of the GCC and the di tTerent
viewpoints surrounding its creation. The GCC states depend mainly on oil for their
survival. Their development depends almost entirely on oil prices which are subject to
variation and make it difficult to plan long term. The process of economic
diversification has been accelerated in an attempt to reduce dependence on oil and
place greater reliance on other resources.
The context and emergence of the three Gulf states have been described and discussed
in Sections 1.6 to 1.8 inclusive. Descriptions and analysis of each state's demographic
and social characteristics, political context, economic development and de\elopment
of urban infrastructure were provided. These were followed by explanations of ho\\
relatively recently established states have embarked on such de\elopments
(particularly of health and education) and made great progress. Howe\er, health
services in these countries have faced the difficult task of ensuring that there are
sufficient and competent human resources to provide a senice to rapidly gro\\ ing
populations. Education has also witnessed remarkable development since the 19711S
The number of schools, colleges and students has grown substantially (especially for
female education) and increased investment in education has produced marked
declines in illiteracy rates.
Religion is a major component and detenninant of the sl)cio-cultur,d and !~olitical
profile of the Gulf Islam pla!'s a major role in fomling individual I\.kntit\ in gCflcr,11
and feminist identities in particular. Islamic scholars continue to debate women's role
in public life in the Gulf with major implications for the development of a nursing
workforce staffed mainly by women.
The Gulf states must confront and overcome a number of issues if they are to sustain
present and future development. One important question is - will they be able to
reform their economic, education and labour markets to meet current and future
challenges? It is apparent from the evidence discussed in this chapter that the GCC
has been a vehicle for coordination (and some integration) of similar political, social,
security, economic and labour concerns.
The next chapter reviews and examines various literature related to the development
of human resource and labour force characteristics, especially in the health service. In
addition, it examines and reviews the development of the nursing profession, the
shortage of indigenous nurses and its impact on the health service of the three Gulf
states. Finally, I examine and explore policy-making processes and indigenization
policies.
36
Chapter 2
Literature review
2.1 Introduction
As the effects of globalization are felt more widely, the survival of the economic and
social infrastructures of the GeC states depends on a highly skilled workforce. This
literature review consists of four main sections. The first elucidates nursing shortages
and the challenges that nations face in meeting the growing demand for qualified
nurses. The section highlights and reviews relevant literature related to nursing
shortages in general and in the GeC states and Saudi Arabia in particular. It
highlights and reviews literature related to the recruitment of indigenous and foreign
nurses and factors that influence the shortage of nurses in the Gulf.
The second section reviews the literature on human resources in the health service in
general and Saudi Arabia, Bahrain and Oman in particular. It examines the role of
women and the social and cultural variables related to them in the Gulf. The third
section examines and reviews the literature on the development and characteristics of
human resources and labour market policy in the three Gulf states~ and the role and
size of foreign labour in the Gulf and its effect on the development and employment
of indigenous people. The fourth and final section examines and reviews the literature
on policy and the policy-making environment in the Gulf~ implementation
mechanisms of the indigenization policies in the three states~ and the roles of culture,
education and training in an indigenous workforce.
It is important to note four limitations in the literature on the indigenous nursing
shortage in the Gulf states. First, few studies focus on this shortage. Second, most
published works are basic and exploratory in nature and lack explication or rigour.
Third, those that do exist do not adequately explain or clearly articulate the theoretical
foundations of the indigenous nursing shortage in the Gulf. Fourth, the literature does
not cover the consequences for the delivery of health care and the health system.
37
This literature review was not undertaken to generate or confirm hypotheses but rather
to uncover and review works relevant to nursing shortages in general, and in the Gulf
in particular. To this end, I have researched the period 1975 to 2007 in:
•
•
•
•
•
•
2.2
databases
published literature in Arabic and English
grey literature in Arabic and English
literature from the Arab and Gulf states and their sources
national and international organizations' sources
various web sites and search engines, e.g. Google, Science Direct,
International Council of Nursing and Saudi Medical Journal (see
Appendix 2).
Limitations
It is worthwhile noting other practical limitations to studying and analysing the Gulfs
health-care and nursing workforces. These include a lack of standardized data and
comparable databases and the quality and availability of basic data. For example,
there are no comprehensive systematic national databases relevant to the nursing
labour market. Also, employment statistics are not sufficient to provide a satisfactory
description of nurses. Some countries do not have detailed statistical databases on
their workforce and those data that are available are usually incomplete and often
contradictory or inaccurate. Despite progress in recent years, there have been few
efforts to use this information to improve the knowledge and management of health
services. These limitations affect the measurement and analysis of nursing supply and
demand across these three countries. Moreover, such limitations are not confined to
developing countries. For example, data collected in individual states in the USA, UK
and Europe also often have limited compatibility and comparability (Buchan, 1999).
In addition, the quality of the literature is inconsistent and there has been little
research and analysis of nursing supply and demand in the international labour market
(Baumann 2004). In the Gulf states, there are few review articles or data on human
resources including nursing shortages, recruitment and retention (Kapiszewski, 2000).
Data are fragmented, inconsistent, incomplete and difficult to compare. ~10dels of
38
health-care delivery and nursing roles differ between the Gulf states and so it is
difficult to interpret comparative statistics about nurses in a meaningful way, eyen
where data exist. To the best of my knowledge, no study has focused specifically on
the Gulfs indigenous nursing shortage and its consequences for the health service.
The next section highlights and reviews relevant literature on nursing shortages in
general and the development of nursing in the Gulf~ the chronic shortage of
indigenous nurses; and factors that influence the shortage of nurses in the three Gulf
states.
2.3 Nursing shortages
Both developed and developing countries face the major challenge of shortages in the
health workforce, particularly nurses. There is consensus among stakeholders that the
well-documented current and projected shortage of nurses exerts significant
constraints upon health-care delivery in most nations (O'Neil, 2003). Nursing
shortages relate not only to numbers but also to deficits in overall knowledge and
skills in the workforce (Buchan & Edwards, 2000). Demand is soaring to
unprecedented levels while a variety of factors limit the number of available nurses.
For example, the UK has relied increasingly on international recruitment in recent
years and annual admissions of foreign nurses have increased fivefold since the mid
1990s (Buchan, 2003). In 2001, 13% of nurses in the UK and 47% in London were
born overseas (Larsen et aI., 2005). In recent years, foreign nurses and midwives have
been recruited largely from the Philippines, India, South Mrica and Australia
(Nursing & Midwifery Council, 2004). As in other developed countries, the current
acute demand for trained nurses is expected to be exacerbated by the increasing
demand for health care (Royal College of Nursing, 2002).
Similarly, nursing recruitment needs in the USA between 2002 and 2012 have been
quantified to be in excess of 1 million nurses, including 623 000 to fill newly created
jobs (Royal College of Nursing, 2004). The nursing shortage in some Latin American
and Caribbean countries also threatens health care there. For example, Haiti has only
1.1 nurses for every 10000 people, compared with 97.2 per 10000 people in the USA
(pan American Health Organization, 2005). The shortage is most severe in the poorest
countries, especially in sub-Saharan Mrica (World Health Organization, 2006). For
39
example, in 2003 Malawi filled only 28% of nursing positions; South Africa had
32000 vacant nursing posts; and a Zambian hospital had only one third of the 1500
nurses required to function well (World Health Organization, 2006).
It is particularly worrying that developed and developing countries are competing for
a limited supply of health-care workers. Most developing countries face constraints
(particularly financial) in developing their human resources. Gulf states have almost
all the necessary resources but have not been able to take advantage of them. Over
the past thirty years, they have not yielded the expected results in term of preparing
and producing a well-qualified and skilled indigenous labour force.
2.3.1 Factors contributing to global shortage of nurses
Although little is known about their net effect on the demand for nurses (Simoens et
aI., 2005), the factors that contribute to shortages are well-documented. Increased
demand has resulted from:
• advances in technology
• shifts from acute to primary care
• ageing populations.
Simultaneously, the supply of nurses has decreased through:
• reductions in student numbers
• wider career choices for women
• profession's poor image (International Council of Nurses, 2001).
Changes in the world economy and world order since the beginning of the 1990s have
resulted in an increasingly global labour market (Agiomirgianakis & Zervoyianni,
2001). The international migration of nurses has increased in scale and scope but is
not a new phenomenon (Larsen et aI., 2005). Kingma (2006) and Bach (2003) argue
that this has produced a highly competitive market in nurse recruitment, generating
unregulated and sometimes unethical international recruitment practices. However,
there has been increasing attention on the development of ethical guidelines for the
recruitment of nurses in recent years (Ogilvie et aI., 2007).
40
Norway introduced an annual restriction on the number of foreign nurses that may be
recruited; an approach that has been adopted by others (World Health Organization,
2003). It is unlikely that the Gulf states would consider such an approach as foreign
nurses are desperately needed to staff their health services. The global nursing crisis
means that both developed and developing countries are seeking to solve domestic
shortages in an increasingly competitive labour market. This leads to "fishing in the
same pool" (Royal College of Nursing, 2002b) as health-care employers poach
international nurse recruits. For example, the Gulf states recruit health professionals
throughout the world, including Europe.
2.3.2 Consequences of nurse migration
A number of health and human rights organizations have focused on the controversial
brain drain of health professionals from poor developing countries. The migration of
doctors has received most attention; the movements of nurses and other health
workers have been addressed only recently (Narasimhan et al., 2004; World Health
Organization, 2006). A shortage of nurses does not only damage an organization's
capacity to meet patient needs and provide quality care. Some health-care scholars
have raised important questions about the impact of nurse turnover on the well-being
of nurses and system costs (Hayes et aI., 2006). The American Medical Association
published a study about the impact of patient overloading. This found that the risk of
patient death increased by 7% if a nurse's patient load increased from four to five
during a single shift. Also, the risk of death increases proportionally to additional
patient load (pan American Health Organization, 2005).
Aiken et al. (2001) report that emotional exhaustion and problems of work design
were common reasons for nurses leaving the profession in England, Scotland,
Germany, Canada and the USA. Laschinger et al. (1999) argue that empowered
nurses are more likely to initiate and sustain independent behaviours to achieve
intended objectives in the face of difficulty. Moss (1995) links nurses' perceptions of
themselves to quality of care and argues that dissatisfied and frustrated nurses can
give only routine care.
41
2.4 Nursing shortages in the Gulf
2.4.1 Background
Nursing is a relatively new profession in the Gulf. Until the 1940s local practitioners,
healers and dayas (unqualified but traditionally trained midwives) specialized in a
variety of treatments (Zurayk et aI., 1997). Today, dayas still perform a significant
role in the provision of maternal and child health care in rural areas. Accounts of
nursing shortages in the literature are compelling but research on nursing shortages in
the Gulf is limited. One of the criteria for inclusion in this review requires published
studies in which the nursing shortage is identified as either the purpose of the study or
an incidental finding in studies involving indigenous nurses. However, this only
served to highlight the paucity of research and data available. In 2006, the
International Council of Nurses (lCN) stressed the importance of nurses in the
provision of safe and effective care and as a vital resource for meeting the health-
related targets of the United Nations Millennium Development Goals (MDGs).
Like many areas of the world, the Gulf region is challenged by a chronic shortage of
indigenous nurses. Ball (2004) presents several reasons for this. Extensive economic
development is recent and rapid and there has been a large lag between this rapid
economic and social expansion and the growth of an indigenous labour force to
sustain it. Also, a large infusion of capital resulted in the rapid growth of health
facilities in the Gulf states in tandem with a politically motivated desire to exclude
most indigenous people from the immorality of modem sector employment. Finally,
the acute shortage of nurses can also be attributed to little enthusiasm for vocational
training among young indigenous people. This combines with cultural and religious
barriers that restrict female access to education and employment, especially in
professions that require contact between men and women (Ball, 2004).
There is a low ratio of indigenous to foreign nurses as internationally qualified nurses
are the majority in most Gulf states. In 2005, the ratio ranged from 36.5% in Bahrain
to 91.75% in Qatar. Bahrain has the highest percentage of indigenous nurses among
all Gulf states - 63.5% of the total number of nurses (Ministry of Health, 2006b). This
might be attributable to the progress and speed of modernization in Bahrain and the
resulting positive impact on education and health. Oman had only 5 indigenous nurses
in 1972 but 590/0 of its 7909 nurses were indigenous in 2005 (Ministry of Health.
42
2006c). This remarkable change was achieved in a relati vel y short time th ro ugh a
commitment to the development of human resources over the past ten years . \YHO
has recognized these efforts to develop the nursing wo rkforce . It has \\'orked
successfully with Oman to develop and increase the number of indigenous nurses and
helped to establish regulations for nursing and midwifery practice to ensure that
competent nurses deliver safe care (World Health Organization, 2003) . Oman has
invested heavily in nursing education, training and educational facilities. For example.
enrolment in general nursing has grown almost sevenfold from 220 in 1990 to 1423 in
2000 . This achievement has not been limited to nursing, a total of 435 ph ys icians
graduated between 1993 and 2000 (Ministry of Health , 2004) .
Saudi Arabia has not been able to replicate Bahrain and Oman ' s success in
developing and investing in their human resources . It is facing chronic shortages of
indigenous health-care workers, especially nurses and doctors . The next section
examines nursing development and shortages in Saudi Arabia.
The nursing shortage does not appear to be a short-term problem and is projected to
worsen significantly over the next decade. The current nurse rate in the Ministry of
Health is 28.2 per 10 000 population, one of the lowest in the Gulf states (see Fig . 1
below). It is estimated that Saudi Arabia needs 70000 nurses to meet current nursing
requirements (Ministry of Health , 2006a) . One projection estimated a shortfall of
about 200 000 nurses by 2025 (AI-Watan, 2004) .
5
4
Density in 1 oo~s 2
1
o
Fig 1. Density of nurses in the Gulf
Saudi Oman Bahrain UAE Kuwait Qatar Arabia
Source : Based on data from World Health Organi za ti on. 2008
The statistical associations between human resources for health, intervention coverage
and health outcomes have recently attracted attention. It is well-known that the status
and levels of coverage are positively associated with health worker density (defined as
the number of nurses per 10 000 population). For example, there is a statistically
significant relationship between the aggregate density of health workers and coverage
by both measles immunization and skilled midwives (World Health Organization,
2006). Nursing density varies, for example Qatar has a rate of 54.8 per 10 OOO~ the
European average is 66.3 nurses per 10 000 population (World Health Organization,
2005).
2.4.2 Recruitment and retention of indigenous nurses
Rapid population growth and worldwide nursing shortages have increased the demand
for indigenous nurses in Saudi Arabia. The government has made numerous attempts
to encourage educated indigenous women (particularly) to consider nursing as a
career, but with only limited success. The reasons cited include salaries, shift
schedules and the Saudi perception of nurses (Al-Ahmadi, 2002). In 2002, only 90
nurses graduated from the colleges of health in the 3 largest universities in the
country. An additional 537 females graduated from 13 other health institutes but this
number includes students from specialties other than nursing (Ministry of Health,
2004b).
In 2004, approximately 78% of the nurses working in the country's health service
were foreigners (Abu-Zinadah, 2006). In 2005, Saudi nurses comprised only 400/0 of
total nurses employed by the Ministry of Health (Ministry of Health, 2006a). WHO
has projected that Saudi nurses will comprise only 44% of the nursing workforce by
2020 (see Table 4), double the 2004 rate. Presuming that 2000 nursing students will
graduate annually, it will take more than 3 decades to fill the national shortage.
44
Table 4 Health workforce planning in Saudi Arabia (2005--2020)
Categories 8th plan 9th plan lOth plan
(2005-2010) (2010-2015) (2015-2020)
Total % Saudi Total 0/0 Saudi Total % Saudi
Physicians 38 104 23% 42300 28% 46846 330/0
Nurses 76573 31% 86756 38% 96 131 44%
Pharmacists 10830 33% 12269 42% 13 315 49%
Allied 51 049 62% 57837 72% 64087 81%
medi cal staff
Total 176556 360/0 199 162 42% 220379 51%
Source: Adapted from W orId Health Organization, 2005
In 2006, the ICN stated that the present chronic shortage of indigenous nurses is a
logical result of inadequate planning for human resources in the past 30 years. It could
be said to indicate a lack of political will to address the problem and find suitable
interventions to limit the negative impact on health systems. National strategic plans
for human resource development are critical and essential to the realization of national
health goals and to improve the population's health (International Council of Nurses,
2006).
2.4.3 Recruitment of foreign nurses
Globalization and trade agreements between countries have led to greater
interdependency and increasing mobility of workers between nations. However, many
international nurses prefer to migrate to Europe, the USA or Canada. Foreign nurses
often see employment in the Gulf as a means to improve their practical and academic
nursing skills and provide the financial capacity to sit the various exams and/or pay
the recruitment fees necessary to obtain employment in North America or Europe.
Ball (2004) argued that many Filipino nurses see their employment in Saudi Arabia as
a transition or stepping stone to employment in other nations. Consequently, many are
willing to endure difficult, often abusive and difficult working conditions in order to
accumulate the necessary capital and experience (Ball, 2004).
45
Such attitudes make recruitment in the Gulf more challenging (Baumann, 2004).
Saudi Arabia has attracted many foreign nurses with incentives such as tax-free
salaries, free accommodation and generous travel packages. However, Saudi Arabia
and other Gulf states recruit their foreign nurses according to a racialized division of
labour. Nurses from America and European countries hold senior administrative and
supervisory positions; Filipinos and Egyptians hold middle status positions; and
nurses from the Indian subcontinent usually hold low ranking and janitorial positions
(Ball, 2004). In addition, they receive different rates of pay for the same work.
All these factors combine with heightened terrorist activity; the international nursing
shortage; aggressive competition for nurses; and Saudi restrictions on female
movement to present severe challenges to continuing international recruitment to
Saudi Arabia.
2.4.4 Factors influencing nurse shortages in the Gulf
As a profession, nursing lacks both appeal and prestige in the Gulf. Medicine and
nursing are similar in that their educational and training infrastructures cannot
produce enough graduates but the nursing profession has to confront additional
barriers. Nursing does not have the same status as medicine and is widely perceived
as "unclean".
In 2002-2003, a study to determine Saudi high school students' knowledge and
perception of the nursing profession indicated minimal interest in nursing compared
with medicine, computer science and teaching. It also showed that many were
deterred by long and antisocial working hours; lack of respect for the nursing
profession; and working with the opposite sex (Al-Omar, 2004). A survey of Saudi
university students and their parents showed reluctance to enrol in nursing schools
and poor knowledge and a negative image of nursing as a career. Interestingly,
identical reasons (e.g. community image of nursing, long working hours, mixing with
the opposite gender) were found in other Gulf states (Al-Omar, 2004). However, the
study used a small sample of three female and three male schools in one city and used
a questionnaire survey method. Such methods do not produce the rich inducti ve data
necessary to understand and analyse students' attitudes toward nursing. In addition,
the survey data usually contain much random variation as respondents give erratic
46
answers that reflect non-attitudes and produce a good deal of random noise at the
individual level (Welzel et aI., 2003).
A similar study in Qatar aimed to identify why female students were not interested in
nursing. The findings were similar to those in Saudi Arabia as the majority of students
cited society's negative image of nursing; mixing and working with males; and
working conditions such as night shifts and long hours (Okasha & Ziady, 2001).
However, this used methods similar to the Saudi study so the same shortcomings
apply.
Under-investment, a poor career structure and low wages are three other reasons why
large numbers of unemployed indigenous males and females spurn nursing. For
example, the Bahrain Nursing Society cites low pay as one of the main reasons why
Bahrain's nurses leave to work overseas (Gulf Daily News, 2007). The majority turn
to careers with more pay, more prestige and easier working conditions. Other
obstacles include the absence of national regulatory and nursing bodies to ensure
quality and the professional representation of nurses; and poor coordination between
nursing education institutions, stakeholders and various health service providers.
However, a quarter of a million young men and women enter the Gulf job market
each year so there are insufficient "clean" jobs to go around (Aspden, 2006). The
image of nursing is changing slowly in some Gulf states and more indigenous women
are entering the profession. A study of nursing's image in a number of Arab counties
(including Bahrain, Oman and Saudi Arabia) concluded that this has improved
significantly only in Bahrain (Shukri, 2005). This study used a standard short
questionnaire and included only policy-makers and nursing organizations such as
nursing schools. Its findings are likely to be questionable as nurses and respondents
from wider society were not included. Economic growth in the Gulf states entails an
increase in employment opportunities and competition which gradually eliminates
gender inequalities in education, finance, training and overall female discrimination
(Morrisson & Jutting, 2005).
47
2.4.5 Importance of an indigenous nursing workforce
An indigenous nurse enhances patient care, the health service and the economy as a
whole. A nurse who understands patients' language, culture and health needs can
contribute enormously to the improvement of patient care and reduce costs to the
health service (Hassan, 1971). Despite better training, a greater appreciation of patient
care and broadening roles the effectiveness of foreign nurses in the GCC states may
be hampered by a lack of cultural understanding and inadequate Arabic. Indigenous
nurses can help to limit the effect of these differences between foreign nurses and
their patients (Hamdi & AI-Haider, 1996).
Many problems and constraints limit indigenous women's participation in nursing but
nursing managers and women's leaders are demanding more government intervention
to effect change. However, others oppose government interventions and argue that
nursing is an unsuitable career for Saudi woman as it subjects them to humiliation and
degradation (Hamdi & AI-Haider, 1996). Conservative Muslim scholars argue that the
breakdown of Saudi family values is directly related to women's employment outside
the home, especially in occupations where men and women work together (El-
Sanabary, 2003). Such a negative view, especially when voiced by respected groups
in society, is another key reason for indigenous women's low participation in the
nursing workforce.
2.4.6 Summary
This section began by noting the lack of available data, especially in the literature
related to the Gulf region. There has been significant growth in nursing shortage
literature in the last few years, driven by nursing shortages in both developing and
developed countries and stimulated particularly by the need to meet the increased
demand for more nurses. Despite the lack of comprehensive data (especially in the
Gulf region) on the nature and extent of the nursing shortage, this is expected to
become more serious as ageing populations in developed countries and growing
populations in developing countries substantially increase the demand for nurses.
Retention of nurses is a significant problem for many countries. Numerous studies
have reported that decreased levels of job satisfaction eventually lead nurses to leave
the profession and pursue other occupations. Relatively low wages and few benefits
are two of several factors that contribute to difficulties in both recruiting and retaining
48
nurses. This section has also focused on the nursing shortage in the Gulf and its
consequences on the development of the nursing profession in the region, reviewing
literature on the shortage of indigenous nurses and the various factors that influence
this shortage in the three Gulf states. The main factors that influence the shortage of
nurses in Saudi Arabia have been discussed in detail: a shortage of nursing colleges;
nursing's negative image; low levels of interest among high school graduates; poor
working conditions; night shifts; mixing with the opposite sex; and finally, and more
importantly, restrictions on women's movement and religious and cultural factors.
This section concludes with the importance of the role that indigenous nurses can play
in the quality of patient care and the potential benefits to a health service that has a
majority of indigenous nurses in its workforce.
The next section reviews the literature related to the development of human resources
in the Gulf since the beginning of the 1970s. It traces the history of foreign workers
and highlights the factors behind the current composition of the Gulf labour market.
2.5 Human resources for health in the Gulf
The performance of a country's health sector is only as good as the performance of
those who provide the services - from admissions staff to the most specialized health
personnel (Adams & Dussault, 2003). This fact has been systematically neglected by
policy-makers and managers in most countries. Whether the explanation lies in their
complexity; multi sectoral nature; political content; or a lack of ready-made solutions,
health workforce issues have been overlooked by many individual countries and the
international community as a whole (Adams & Dussault, 2003). Advances in
technology and longer lifespan have created an increasing demand for health care and
spiralling costs (Buchan, 2002; World Health Organization, 1998a).
Rapid technological change and the increase in the specialization of labour have
increased the demand for human resources in health services all over the world
(W orld Health Organization, 2006). Therefore, the global phenomenon that is the lack
of human health resources, particularly nurses, affects both developed and developing
countries. A recent WHO report reveals an estimated worldwide shortage of almost
4.3 million doctors, nurses and support workers (World Health Organization, 2006).
49
In the Gulf states of Saudi Arabia, Oman and Bahrain the availability and skill levels
of indigenous human resources (especially in the health service) make it difficult to
sustain development. The shortage of doctors and nurses is chronic. Baumann et al.
(2001) argue that health-care labour markets are affected by the interaction of long-
term trends and labour market cycles. Also, they contend that the nature of health care
and the services needed depend on the profile of the population to be served. As in
many other parts of the world, demographic changes have affected the health-care
labour market in the Gulf - the patient population and their growing needs for
different types of care have, in turn, affected the numbers of health personnel in the
labour force (Baumann et aI., 2001). Demographic trends show that health services in
the Gulf face a huge future challenge in providing health care to their growing
populations. However, these trends also show that a young population can be an
advantage if these future human resources are developed into qualified and trained
personnel. Success in this could well meet future needs, especially for human
resources such as doctors and nurses.
2.5.1 Shortage of indigenous human resources in the health service
As outlined in Chapter 1, health services in the GCC states have witnessed remarkable
developments since the 1970s as a result of the huge revenues generated by sharp
increases in oil prices. However, the health service is a labour intensive and highly
technical sector that requires qualified and experienced personnel to function
effectively (y/ orld Health Organization, 2002).
The three Gulf states lack the skilled indigenous personnel required to run their health
services. For the last three decades they have relied heavily on doctors, nurses and
allied health professionals recruited from other countries, particularly the Philippines~
the Indian subcontinent and other Arab countries such as Egypt, Sudan and Lebanon. ,
More than twenty-five different nationalities may be found working in one hospital.
Saudi Arabia is most dependent on immigrant labour - at the end of 2005 over 81 % of
physicians, 60% of nurses and 21% of allied health personnel were foreign born (see
Table 5).
50
Table 5 Human resource trends in health ministries in three Gulf states, 2003-2005
Human resources Saudi Arabia Bahrain Oman 2003 2005 2003 2005 2003 2005
Total number of 15 973 20219 816 1 026 2635 2981 doctors Number of doctors 3040 3773 673 848 624 813 who are nationals % of doctors who are 19.1 % 18.70/0 82% 82.50/0 240/0 270/0 nationals Total number of 38019 42628 1 967 2398 7319 7909 nurses Number of nurses 12384 17068 1 222 1 518 3 616 4680 who are nationals % of nurses who are 32.60/0 40% 620/0 63.5%) 49% 590/0 nationals Total number of 22470 23 116 570 671 4781 5634 allied health personnel Number of allied health 13 928 16 136 534 588 3 661 3980 who are nationals % of allied health personnel 62% 69.80/0 93.6% 87.6% 76.5% 70.5% who are nationals Sources: SaudI ArabIa Mmistry of Health 2006a~ Bahrain Ministry of Health 2006b~ Oman Ministry of Health 2006c
In Oman, 73% of physicians, 41% of the nursing workforce and 29.50/0 of allied
health workers were recruited internationally. Bahrain has the lowest number of
foreign health workers - 17.5% of physicians, 36.5% of nurses and 12.4% of allied
health personnel (Table 5) - and therefore the largest numbers of indigenous health
workers in all three categories.
Indigenous nurse shortages in Saudi Arabia and Oman seem to be the result of a set of
economic, cultural and sociological factors. However, little is known about the causes
of the severe shortage of indigenous physicians. For example, a yearly average of 90
physicians graduated in Oman between 2001 and 2005 (Ministry of Health, 2006c).
This rate is not considered high enough to speed the Omanization process in this
category. Medicine has a high status and is one of the most respected careers in the
Gulf, therefore comparisons with other occupations (such as nursing) are not equally
valid (EI-Sanabary, 1993). In Saudi Arabia particularly, medicine has received more
attention and resources than nursing because the shortage of indigenous doctors is
more severe. However, indigenous women doctors in the Gulf share the same
51
constraints as indigenous nurses. In Saudi Arabia, for example, all women face the
limitations on driving, travelling alone and working alongside males.
Competitive salaries and high-tech facilities have ensured a good supply of immigrant
workers in the GeC states. However, the increasing international shortage of health-
care workers means that this can no longer be guaranteed. In future, GeC states will
be competing with countries such as the USA and the UK, both desperately short of
health-care workers (especially nurses). They also offer relatively good pay and
attractive working conditions (Buchan, 2002).
International recruitment can be a quick fix for workforce problems but it may be an
obstacle to solving other social problems that are endemic in the region, such as youth
unemployment and women's exclusion from public life. Millions of foreign workers
are employed in the Gulf states, including many women, but large numbers of
indigenous women are unemployed. The Gulf states spend billions of dollars on
women's education and health yet do not utilize this important human resource in
their workforces.
This thesis is concerned with the shortage of nurses in the Gulf and, because the
nursing profession is dominated overwhelmingly by women (Davies, 1995), it is
imperative to discuss the role and employment of women.
2.6 Women's participation in the Gulf workforce
Arab women have the lowest local labour market participation rate in the world
(International Labour Organization, 2000). Since 2001, women's persisting exclusion
from public life in the Gulf (and Saudi society in particular) has been the most hotly
debated topic in the development process, amongst Muslims and internationally
(Hamdan, 2005). The number of women in the labour force is rising modestly but
remains relatively low throughout the Gulf region. Figures indicate that indigenous
and foreign female workers constitute less than 20% of the total labour force in the
three states (Appendix 1).
The GeC states spend billions of dollars on women's welfare (including education
and health) and the educational profile of the female workforce is much higher than
52
that of male workers . In 1988 , the graduating cla ss from government sec ond ar\ '
schools in Bahrain was evenly balanced between male s and female s (Fig 2) Since
1993, Bahrain's female secondary school graduates have outnumbered male (U nited
Nations, 2002 ; Fig . 2) . Females now outnumber males in all but the earlie st staoes of ;:,
the educational system. The percentage of women students enrolled at the Uni ver sit y
of Bahrain, the Arabian Gulf University and the College of Health Sciences is
substantially higher than that of men (United Nations, 2003) . Figures indicate that
women are graduating at nearly twice the rate of men in some states (Girgis, 2002 ;
United Nations, 2003) .
Fig. 2 Graduates of Bahrain secondary schools, by gender, 2001
3000
2500
2000
1500
1000
500
o 1988 1993 1997 2001
Source : Ministry of Education , 2002
DMen
_ Women
These statistics could indicate that women in the Gulf are over-educated and
consequently under-employed. The Gulf states have signed the United Nations
convention that prohibits all forms of discrimination against women (United N ations,
2007) . By accepting the convention, Gulf states commit themselves to undertake a
series of measures to end discrimination against women in all forms. Ratification has
strengthened the position of women in society but signing is not enough to guarantee
the rights of women. There is still substantial discrimination in employment and
women are often passed over in favour of men who may be less qualified and le ss
skilled . Gulf governments need to operationalize the United Nations ' con venti on
through binding government legislation and regulations that support women ' s ri ght s.
53
2.6.1 Women's participation in the three Gulf states
Indigenous women participate in the labour force at strikingly different rates across
the Gee states. In Saudi Arabia, indigenous women constituted 7% of the total
workforce in 1990, but only 4% in 2003 (Hamdan, 2005). Official data put the figures
at 12.2% for 2003 and 15% for 2004 (Appendix 1) (Ministry of Economy and
Planning, 2005a). Even these higher figures are lower than those in Bahrain and
Oman. For example, the number of indigenous women working in Bahrain's public
service has risen continuously from 7.1% in 1991 to 40% in 2005. The variety of
occupations in which they participate is also increasing (International Labour
Organization, 2005).
Restrictions on women's participation in the labour force cannot simply be attributed
to traditional, social and cultural boundaries as they are very similar in these three
states. Maben et al (2010) suggest that historical, cultural and religious forces create
challenges to women's participation in the labour market in the Gulf states and
impede local health workforce recruitment. However, the histories of Oman and
Bahrain differ from Saudi Arabia in at least one important respect. As British
Protectorates these two states were effectively within the UK's sphere of influence
from the late eighteenth century until independence in 1971. This close contact may
have had the effect of modelling different roles for women.
Women's rights in Bahrain and Oman have certainly advanced in the last ten years.
For example, it has been reported that Bahrain's rapid modernization has eroded
patriarchal authority in society to some extent. As a result, women have made
significant progress in many fields, including the labour market (Seikaly, 1994).
Social and cultural restrictions on women's education, skills and mobility still exist
but Bahrain is more open than the rest of its Gee neighbours and much has been done
to change these social circumstances. However, the prevailing social view stigmatizes
women as emotional beings better suited to the home and family - and women have
(in general) failed to complain publicly (United Nations, 2003).
2.6.2 Why is Saudi Arabia different?
Gender inequality keeps women at a disadvantage throughout their lives and
negatively affects the development prospects of their societies (World Bank, 2005).
Women in Saudi Arabia are subject to considerable discrimination and some authors
54
have suggested that a narrow and restricted interpretation of Islamic teachings has
restricted gender equality (Hamdan, 2005). Religious lawyers (ulema) or clerics
determine laws and conduct in Saudi society and reinforce practices such as the
segregation of men and women, the ban on women driving and numerous other social
restrictions. In fact, Saudi Arabia's adherence to sex segregation outside the home is
practised to a degree unknown in most of the Arab and Muslim world. Doumato
(2000) attributed this to two main reasons. First, Saudi Arabia's social fabric was not
disturbed by a colonial experience so Western influence is very recent and has arrived
to some degree selectively, by the Saudis own choosing. Second, social conventions
and religious-based attitudes that support sex segregation, female domesticity and
dependence on men have been incorporated into public policy. In combination, these
factors might at least partly explain the persistent opposition to Saudi women working
outside the home.
Generally, Saudi families also oppose the idea of women working outside the home,
especially in occupations where men and women work together. These family and
religious values have profound implications for policy-makers and planners in Saudi
Arabia. Nevertheless, rising levels of education among women combined with local
and international pressure on Gulf governments (especially Saudi Arabia) have
contributed to positive changes in recent years. Ironically, the 11 September 2001
attack on the USA advanced the issue of women's rights throughout the Gulf (and
Saudi Arabia particularly). Women are now in the spotlight and generating heated
debate between those who support more rights and those who oppose them. Recently,
several Saudi women have reported that the government is improving opportunities
and equality for women but the culture and organizations they work for are slow to
change (Vidyasagar & Rea, 2004).
Some authors suggest that Arabic society looks down on working women and views
them as incapable of performing as well as men (Al-Nimr, 1996). Although most
Gee governments have adopted public sector labour policies, including equal pay for
equal work (Al-Nimr, 1996), women's participation in the workforce remains low in
all except Bahrain. The Saudi Government stressed its commitment to enabling Saudi
women to participate in the development of their country in the eighth SDP.
We intend to provide more emplo~ment opportunities to Saudis, and .i~ particular to women and to adopt appropriate policies that enhance women's partICipatIOn In the
55
labour market in the positions that best suit the skills of women and do not contradict with sharia (Islamic law) principles (Ministry of Economy and Planning. 2005b. Chapter 8:p 1 0). ' .
2.6.3 Summary
Sections 2.3 to 2.6 examined the general shortage of human resources in the Gulf and
the particular shortage of indigenous human resources in the health service.
Recruitment and retention of health workers in general and nurses in particular are
major concerns for developing and developed countries alike. Moreover, countries are
reporting that current nurse shortages can be attributed partly to patients' increasing
care needs.
The literature review examined the development of human resources in the Gulf since
the beginning of the 1970s. It traced the history of foreign workers in the Gulf and
highlighted the factors behind the present composition of the Gulf labour market. One
of the main features of this was the huge influx of foreign workers following the
discovery and exportation of oil. It also examined labour force characteristics and
reviews and various development plans in the three Gulf states of Saudi Arabia,
Bahrain and Oman. A discussion of the shortage of indigenous human resources in
general focused on the health service in particular. This emphasized that Gulf states
suffer from a chronic and severe shortage of health-care workers in general and nurses
in particular. It also emphasized the great concern over the shortage of skilled and
unskilled indigenous human resources in most Gulf states.
Despite numerous attempts to reduce dependency on foreign labour, most of the Gulf
governments have failed to alter the composition of their labour market in favour of
indigenous workers. The employment of women in the Gulf and Saudi Arabia has
been examined with a focus on the subordinate role of women in the labour market
and the obstacles and restrictions on indigenous female employment. Finally, this
section has examined some of the social and religious values that have profound
implications for women's participation in the labour force in general and nursing in
parti cuI ar.
The next section reviews the characteristics of human resources in the Gulf and the
labour markets in the three Gulf states.
56
2.7 Human resources in the Gulf
It is important to note that very little work has been undertaken on comparative
human resource management in developing countries in general and the Gulf states in
particular (Budhwar & Debrah, 2003). In addition, health workforce issues have
become more prominent in many countries in recent years (Adams & Dussault, 2003;
World Health Organization, 2006) but human resources for health in the Gulf is still
in its infancy. However, in order to understand the nature of human resource
management in any country, it is necessary to be aware of the various external
contexts that affect their management.
Human resource management is shaped by external factors such as political,
economic, social, and labour market considerations (Hendry & Pettigrew, 1990). It is
known to be context-specific - that is, the degree and direction of influence of both
culture-bound and culture-free factors vary from country to country (Budhwar &
Debrah, 2003). Five contextual factors shape human resource management and
practices in the Gulf states:
1. structure of the economy
2. political environment
3. structure of the labour market
4. national human resource development strategy
5. national culture.
The first two of these contextual factors were highlighted and explored in Chapter 1.
The work relevant to the remaining three - the structure of the labour market; national
human resource development strategy and national culture - is discussed below.
2.7.1 Characteristics of human resources in the Gulf
Human resource management in the Gulf has certain defining characteristics that
include a highly segmented labour market with a clear distinction between privileged
indigenous workers and foreign workers with insecure employment. The history of
foreign workers in the Gulf began with the region's oil industry in the 1930s but the
region only started to import large numbers of foreign workers following the sharp oil
price increases in the 1970s. The young and growing private sector also recruits large
57
numbers of foreign workers to meet the enormous demand created by government
expenditure. These factors have increased international recruitment markedly.
Historically, private sector firms traded ongoing investment and job creation for
indigenous people in return for state patronage and a relatively free hand in the
recruitment and employment of foreign workers (Grahl & Teague, 2000). This
produced drastic changes in the population and labour force structures. The
population in the Gee states has grown more than tenfold over a period of 50 years-
from 4 million in 1950 to 40 million in 2006 (Kapiszewski, 2006). The growth rate
averaged about 5% between 1970 and 1980 and 4.8% between 1980 and 1990. This
compared with 2.4% and 2% respectively in developing countries and made it one of
the highest rates of population growth in the world (Jaber, 2000). The demographic
growth rate has now declined but fertility rates remain high at an average of about
four children per woman in the three states. For example, the latest figures indicate
that the Saudi population grew more than threefold during the last three decades, from
7.3 million in 1975 to 27 million in 2005. Population growth in the Gulf is attributed
to rising improvement in living, health and social conditions during the last three
decades. WHO data show that the majority of the Gulfs indigenous population is
young - 40% of Saudis, 33.7% of Omani and 27.6% of Bahrainis are aged <15; 3.1 %,
3.20/0 and 2.5%, respectively, are aged 2:65 (World Health Organization, 2004).
The increase in the Gulf states' population has been caused by a combination of the
natural growth of the indigenous population and the extensive recruitment of foreign
workers. The latter represent the majority of the total labour force in most Gulf states.
In 1975, the proportion of foreign workers ranged from over 13% of the population in
Saudi Arabia and Oman to over 22% in Bahrain. Two decades later (in 1995) the
proportion of foreign workers ranged from over 27% in Oman to over 38% in
Bahrain. Saudi Arabia had more than 6 million foreign workers, nearly half of its total
indigenous population that year (Girgis, 2002) (see Table 6). In 2005, the proportion
of foreign workers had decreased in both Saudi Arabia and Oman and increased
slightly in Bahrain. The reduction is generally attributed to the high rate of indigenous
population growth between 1995 and 2005.
58
Table 6 I d' n Igenous and foreign workers in the three Gulf states (197 5-2005) Saudi Arabia Bahrain Oman
1975 (1000s)
Indigenous 6089.3 201.6 666.0
Foreign 937.0 60 100.0
Total workers 7026.3 261.6 766.0
% foreigners 13.30/0 22.9% 13.1%
1980
Indigenous 7306 233.3 805
Foreign 2382 103.4 179
Total workers 9688 336.7 1 193
% foreigners 24.6% 30.7% 18.2%
1985
Indigenous 8764.2 276.1 973
Foreign 3 878.0 158.6 220
Total workers 12 642.2 434.7 1 193
% foreigners 30.7% 36.5% 18.4%
1995
Indigenous 13 272 362.2 1 563
Foreign 6262 223.9 586
Total workers 19534 586.1 2 149
0/0 foreigners 32.1% 38.2% 27.3
2005
Indigenous 17029000 438209 2325 812
Foreign 6644236 268 951 577293
Total workers 23673 707 160 2903105
% foreigners 27.1 38.0 19.9
Sources: Girgis, United Nations, 2006
2.8 Labour markets in the three Gulf states
GCC states share distinguishing characteristics - significant proportions of foreign
workers in their labour forces and segmented labour markets. Indigenous workers
with better education and training work mainly in the public sector as it offers higher
59
salaries, more benefits and greater job security. The private sector is heavily
dependent on foreign workers, recruited on fixed contracts and sponsored by
indigenous firms. The labour market is so segmented that (in most GeC states) as
much as 90% of the indigenous labour force is employed in the public sector and
foreign workers comprise a comparably high ratio in the private sector (International
Monetary Fund, 2004).
Sassanpour et al. (2004) argue that the labour markets in the GeC states are
segmented between several dimensions: public and private sectors; indigenous and
foreigner; and skilled and unskilled labour. They further point out that the most
important factors in this are significant disparities in wage and non-wage benefits
between the public and private sectors (even for comparable skills) and between
indigenous and foreign workers employed in the same sector. Public sector pay and
benefits is more generous to both indigenous and foreign workers. There are also
marked dissimilarities in educational background, training and qualifications between
indigenous and foreign workers (Sassanpour et aI., 2004).
A lack of relevant data makes it difficult to compare public and private sector wages
and benefits in most GCC states. Nevertheless, it is widely recognized that public
sector workers receive a guaranteed annual salary. In addition, indigenous workers
enter employment at higher levels; receive higher wages for similar work; are entitled
to extra benefits (highly subsidized housing loans, transportation allowances and
incentives for continued training and education opportunities locally and overseas);
and are promoted faster than foreign workers. However, almost all GeC states are
replacing traditional guaranteed employment policies for indigenous people in the
public sector with a more selective recruitment policy to reduce overstaffing. Current
labour market strategy stresses the importance of the private sector as the principle
source of employment opportunities for indigenous workers in the future.
2.S.1 Labour market in Saudi Arabia
One of the most important issues in Saudi Arabia is the labour market policy and the
severe shortage of qualified Saudi nationals in key professional areas such as the oil
industry, high-tech sectors and the health service. Saudi Arabia has a high level of
state intervention and a labour market clearly segmented into indigenous and foreign
60
workers (Mellahi & Wood, 2002). The sharp rise in oil revenues in the 1970s
provided the government with the resources to devise a comprehensive development
programme to improve development-planning mechanisms and the country's
economic situation. The government drew up a series of five-year plans focused on
improving infrastructures, most importantly those pertinent to human resources. Eight
SDPs were devised between 1970 and 2005 (see Appendix 3).
The first SDP (1970-1975) focused on the infrastructures and basic services affecting
education, health, electricity and water and initiated massive infrastructure projects.
Shortages of indigenous skilled and unskilled workers necessitated the recruitment of
foreign labour. By the end of the plan, foreign workers represented 43% of the total
labour force and 13.3% of the total Saudi population (see Table 7). This marked the
beginning of a massive recruitment of foreign workers and increasing dependency on
them. The trend continued in the second SDP (1975-1980) which required even more
foreign workers to develop the infrastructure and work in the expanding oil and gas
industries. By the end of 1980, the number of foreign workers had almost doubled
(24.60/0 of total population).
The third SDP (1980-1985) sought to continue the expansIOn of the country's
infrastructure. It is important to note that there are no unified data on the number of
foreign workers in Saudi Arabia; official figures show that there were 4.87 million
foreign workers in 2006 (see Table 7). In May 2004 Saudi's Labour Minister
disclosed that there were 8.8 million foreign workers in the country (Asia News,
2004), a figure significantly higher than the government had previously reported. The
third SDP extended projects to other parts of the country and included the building of
industrial cities. The number of foreign workers continued to rise and reached 72% of
the total labour force and 30.7% of the total population by the end of the plan. Thus,
foreign workers played a major role in implementing the massive Saudi infrastructure
projects initiated during these three development plans.
The decade from 1985 to 1995 was a period of economic difficulty for Saudi Arabia -
economic growth began to slow and revenues to decline as oil prices fell sharply.
However, the problems associated with the legalization of foreign workers retl ect
wider regulatory weaknesses in the Saudi state. Many of these weaknesses stem from
inadequacies in Saudi public administration. Those related to the labour market were
61
exacerbated by considerable deficits and slow or even negative economic gro\\1h
during the 1990s. Many of the peculiarities of the Saudi case lie within the adopted
legal framework and whether or not laws are enforced effectively.
Table 7 Indigenous and foreign workers in Saudi Arabia
(% of total workforce)
Date Indigenous workers Foreign workers
1975 57% 43%
1985 28% 72%
1997 36% 64%
2003 40% 60%
2005 44% 56%
Source: Al-Dosary, 2006
The sixth SDP (1995-2000) aimed to tackle unemployment at an early stage by
developing Saudi human resources (Saudization). More resources were invested in
education and training with an emphasis on ensuring that curricula could meet the
needs of the labour market. However, the end of this plan was marked by an increase
in unemployment among Saudis. With unemployment rates reaching 8.34% (Ministry
of Planning, 2001), the seventh SDP (2000-2005) again stressed the importance of
developing human resources and urged both public and private sectors to accelerate
indigenization. The government also pledged to reduce the number of foreign workers
to 200/0 of the total population in ten years (Looney, 2004).
It is important to note that (since the fourth SDP) most SDPs have included the same
or similar objectives. All have stressed the importance of reducing dependency on
foreign workers and increasing the number of indigenous workers. However, these
ambitious objectives are proving difficult to achieve. Despite numerous attempts to
reduce the number of foreign workers and encourage Saudi nationals to undertake
productive work in all economic sectors the number of foreign workers has continued
to increase, particularly in the private sector. Table 8 shows the composition of the
labour force in the Saudi private sector.
62
Table 8 Labour force in Saudi private sector by sex and nationality (millions)
2004 2005
Number Distribution Number of Distribution Annual of workers % workers % growth
rate Total labour 6.6 100 7.6 100 15.4 force Male 6.47 98.1 7.44 97.9 15.1
Female 0.13 1.9 0.16 2.1 28.1
Saudis 0.48 7.2 0.62 11.6 28.4
Male 0.46 6.9 0.59 11.0 27.9
Female 0.02 0.03 0.03 0.6 37.7
Non- 5.91 89.6 6.71 88.4 13.7
Saudis
Male 5.21 88.2 5.83 86.9 13.7
Female 0.7 11.8 0.88 1.5 25.7
Source: SaudI ArabIan Monetary Agency, 2006
In 2000, the Human Resources Development Fund (HRDF) was established to train
the Saudi labour force in the skills required in the private sector and to develop a
database for matching and placing Saudi workers in that sector. This independent
agency generates most of its financial resources from government-collected fees and
penalties imposed for the recruitment of foreign workers in the private sector. The
HRDF and the private sector share the costs of training and wages during an
employee's first two years (Appendix f). One of its most important aims is to
establish programmes to replace foreign workers with Saudi nationals with minimal
disruption. It also undertakes research and consultations on training and related issues
and makes recommendations to both the government and the private sector (HRDF,
2003). Another important reform was the establishment of a ministry of labour in
2004 with responsibility for labour and Saudization issues. Also, existing labour
policy was reformed and a new labour law was introduced in 2004.
2.8.2 Labour market in Oman
Oman also devised a series of five-year plans. These focused on diversifying the
economy and improving the management of its human resources through vocational
63
and technical training programmes. From 1975 to 2005, six Omani five-year plans
(FYPs) were devised. The first (1976-1980) aimed at establishing essential
infrastructure such as government buildings, power stations and communication
centres. The second FYP (1981-1985) aimed to complete the infrastructure needed to
modernize the economy and raise living standards. The third FYP (1986-1991) was
intended to augment the achievements of previous plans but the decline of oil prices
in this period forced the government to reduce and cancel some development projects.
The fourth FYP (1991-1995) concentrated on broadening and diversifying the
economy and developing Oman's human resources.
By the end of 1995, Omani nationals represented 36% of the total labour force and
foreign workers represented more than 27% of the population (Table 6). The fifth
FYP (1996-2000) was regarded as the beginning of a new era of development
planning in Oman. It called for wider public and private sector participation in
improving the education, training and creation of job opportunities for Omanis. The
sixth FYP (2001-2005) aimed at enhancing the drive for Omanization and providing
incentives to encourage private sector participation. As in Saudi Arabia, all the FYPs
stressed the importance of reducing dependency on foreign labour and increasing the
indigenous population's participation in the labour force. The main objectives of
Oman's human resource policies in the FYPs are listed below.
• Improve health and education services for the population in order to upgrade
human resource quality and productivity.
• Improve employment opportunities for Omanis in order to avoid
unemployment and provide training and qualifications that conform to labour
markets needs.
• Replace foreign workers with highly qualified Omani workers. Furthermore,
increase the participation of Omanis in the labour market in general, with a
particular focus on increasing the participation of Om ani women.
• Increase the efficiency of the Omani labour market by reducing the
differentials in wages between the public and private sectors.
• Improve and encourage good work ethics in order to increase Omani human
resources productivity (Ministry of Information, 2006).
64
However, the use of foreign labour has continued to rise despite all the efforts and
measures proposed by the government. During the first four FYPs (1976-1995), the
proportion of indigenous workers in the labour market decreased from 65% to 360/0
and foreign worker participation increased from 35.4% to 64.8% (AI-Alawi & Shiban,
1999). Since 1995, the situation has changed little and foreign-worker participation
remains high. In the public sector, Omanization increased slightly from 68.5% to 74%
between 1995 and 2000. However, the total Omanization ratio in the country's labour
force remained unchanged during this period, at 34% (Ministry of Social Affairs and
Labour, 2001).
In 2001, Oman established the Ministry of Manpower to be responsible for labour
force issues in the country. In 2002, the government established the Self-Employment
and National Autonomous Development (Sanad) programme aimed at increasing the
participation of Omanis in the private sector by sharing the cost of their training and
their first year's wage. This human resource development fund also provided financial
and technical support to self-employment proj ects and the development of small
businesses and aimed to establish a human resource database for better and effective
planning of Oman's own human resources (Ministry of Manpower, 2003). A new
labour law was introduced in May 2003 (Fasano & Iqbal, 2003).
Unemployment in Oman is estimated to be approximately 15% and considered one of
the highest rates in the Gulf (Central Intelligence Agency, 2006a). In 2005, foreign
workers in Oman represented more than 65% of the total labour force and 19.9% of
the population (Kapiszewski, 2006). Similar to Saudi Arabia, Oman began reforming
its education, training and labour force policies. The aim was to improve vocational
and technical training programmes and to set a uniform minimum wage for Omanis.
2.S.3 Labour market in Bahrain
The Bahraini labour market is defined by three key characteristics:
1. high percentage of foreign workers
2. high percentage of public sector employment
3. strong segmentation between low-paid foreign workers in the private sector
and well-paid Bahraini workers in the public sector (United Nations, 2002).
65
These are similar characteristics to those in Saudi Arabia and Oman. Therefore, one
of the aims of Bahrain's strategy to meet labour market demands was to train and
develop human resources, especially within the private sector (Ministry of Labour,
2006). Like most other Gulf states, Bahrain has more than 91 % indigenous workers in
its public sector and employs approximately 5% of the Bahraini population. However,
40% of Bahrain's public workforce is female (Ministry of Labour, 2006). Bahrain is
considering measures (e.g. changing working hours, reducing wages) to make the
public sector less attractive to indigenous workers.
The situation is strikingly different in the private sector where foreign workers
comprised more than 57% of the total labour force in 2004 (International Labour
Organization, 2005). Since 1975, Bahrain's foreign workers have constituted a higher
percentage of the population than foreign workers in Saudi Arabia or Oman (see
Table 6). In 2004, more than 64 000 jobs were created in the Bahraini labour market
but 820/0 of these went to foreign workers. Similar to Saudi Arabia and Oman, 77% of
Bahrainis who registered at the Ministry of Labour seeking jobs were high school
graduates (Ministry of Labour, 2006).
Like those in Saudi Arabia and Oman, Bahrain's labour market is also segmented
along gender lines - women are concentrated in a narrow range of occupations. The
ILO (2005) reported that more than half of the Bahraini female labour force works in
the public sector, mainly health and education. Women face additional constraints in
labour market integration as indicated by their unemployment rates. These have been
consistently double those of men since the 1980s. Unemployment among Bahraini
nationals stood at 14% in 2004 (International Labour Organization, 2005). As in
Saudi Arabia and Oman, high educational attainment does not necessarily translate
into jobs. For example, female students represent about two-thirds of all enrolments at
high school and post-secondary level but the 2001 census showed that women's share
in the national workforce was only 25.78% (International Labour Organization,
2005). Therefore, high educational performance is not matched with job opportunities
for the female population.
As in Saudi Arabia and Oman, the quality of education and training in Bahrain does
not match labour market needs. According to the ILO (2005), graduates of all
66
education levels (including university) do not meet required standards. Bahrain
developed a new National Employment Strategy that provided fiscal subsidies for
training Bahrainis in the private sector and financial aid for the unemployed. It also
introduced measures to improve educational standards and vocational and technical
training programmes~ increased the employment quotas for Bahrainis in small and
medium enterprises~ and abolished free visas for foreign workers (Fasano & Iqbal,
2003).
2.8.4 Foreign labour in the Gulf
In 2005, the Gulf states were home to 12.5 million foreign workers (United Nations,
2006). Their presence has enabled rapid development but created various difficulties
in foreign affairs and brought about a number of negative cultural and socio-economic
consequences (Kapiszewski, 2006). For example, Amnesty International reported that
half of the 102 people executed in 2007 were foreigners, many of them Asian workers
(Amnesty International, 2007). The Saudi government claims that these foreign
workers committed major crimes against society.
Abdelkarim (1999) argues that huge imbalances between the indigenous population
and foreign workers occur because most Gulf states have not formulated clear
policies. They have failed to address issues such as population imbalances;
unemployment among the indigenous populations~ and the need to create job
opportunities for their increasing numbers of young graduates. Abdelkarim further
argues that politics and security factors (rather than economics) in some Gulf states
largely determine attitudes to the presence and employment of expatriates
(Abdelkarim, 1999). This means that some have developed a selective recruitment
policy for foreign workers and more foreign workers will be recruited from friendly
countries, regardless of their quality or local economic demand. For example, Saudi
Arabia expelled the majority of around 1.5 million Yemeni workers during the 1991
Gulf War because Yemen sided with Iraq against Saudi-allied Kuwait.
Prior to the oil price boom in the early 1970s, the majority of skilled and unskilled
foreign workers came from Arab countries, mainly Egypt, Yemen, Palestine and
Sudan (Mohammed, 2003). By the early 1980s, an increasing number of foreign
workers were being recruited from Asia - mainly Pakistan, India, the Philippines and
67
Thailand. Asian workers were preferred in both public and private sectors as they
were cheaper, easier to manage (more organized, disciplined) and posed no threats to
the fragile Gulf identity and security (Mohammed, 2003). lureidini argues that the
numbers of Arab workers were being reduced for both economic and political reasons
as they were more expensive and their political activities in the Gulf were considered
potentially threatening (Jureidini, 2001). Asian workers had all the advantages listed
above but did not require the same level of social services (e.g. health and education)
as, unlike the Arabs, they were not likely to settle and bring their families (McMurray,
1999).
Foreign workers are employed under a sponsorship system - an employer (the state, a
company or an individual) invites them to the Gulf and provides the working contract
that allows residency. This system has been criticized by various international human
rights organizations as foreign workers are totally at the mercy of employers who can
retain their passports, limit their freedom of movement and prevent them from
changing jobs (Aspden, 2006). Assuredly, some are mistreated (International
Federation of Human Rights, 2003). However, their home countries (especially in
Asia) have pursued active policies for overseas employment and encouraged
migration to Gulf states in order to alleviate domestic unemployment and generate
foreign currency (Jureidini, 2001). In 2006, the World Bank estimated that
remittances worldwide reached a new peak of US$ 268 billion (Chisti, 2007). India
accounts for close to 10% of this global phenomenon and receives 24% of its foreign
currency in remittances from Indian workers in the Gulf region (Chishti, 2007). For
example, 6 million Indian workers working in the Gulf sent home around US$ 6
billion in 2006. In Saudi Arabia, foreign workers remitted more than US$ 15 billion in
2007 (AI-Riyadh, 2008).
At the beginning of 2004 oil prices began to rise and provide huge revenues for the
GeC states. As in the 1970s, the huge increase in oil price necessitated the
recruitment of more foreign workers in order to provide necessary services for the
growing economies. Between 2004 and 2005 the number of workers in Saudi Arabia
increased by 1 million (6.6-7.6 million). Foreign workers constituted more than 80%
of this increase but only about 150/0 of foreign workers in the country are engaged in
skilled labour (in oil, health care, communications), the majority are employed in 10\\-
68
skilled industries (pakkiasamy, 2004). The indigenous labour force exceeded its 4.7%
target and increased by 5.1 % during the seventh SDP but the number of foreign
workers also increased by 2.4% (Ministry of Economy and Planning, 2005a). This
was a small reduction on numbers during the previous plan but foreign workers still
filled more than 53% of the 1.04 million new jobs created, mostly in the private
sector.
Many countries face the challenge of creating new job opportunities for their people.
Saudi Arabia has many job opportunities and often demand exceeds supply, especially
in the private sector. But foreign workers occupy most of these jobs and their
presence divides the country's labour market. One part is the public sector that
provides reasonable wages, adequate working conditions, employment stability and
clear work rules and regulations. This sector employed 142 341 Saudis in 1975 and
733 866 in 2006 (33% female), 91 % of all public service employees (Saudi Arabian
Monetary Agency, 2006). The other part comprises the free or private sector with
generally low wages~ poor benefits and working conditions~ and workers subject to
arbitrary rules and regulations. However, the exceptionally favourable situations
enjoyed for decades by the Gulf s indigenous populations have started to change.
Growing numbers are experiencing difficulties in finding suitable jobs (Kapiszewski,
2006).
There is a low level of female participation in the Saudi private sector (see Table 8).
This is mainly attributed to the various cultural and religious restrictions imposed on
women's freedom to move. In addition, many private sector organizations are
reluctant to employ women as this requires them to meet certain measures and
requirements imposed by (mainly) religious institutions. For example, women must be
employed in a designated area, separate from the men's working area, and contact
between the two sexes must be limited.
The numbers of foreign workers have continued to grow in some Gulf states,
primarily because of increasing demand from the private sector. The Gulf
governments have begun to make serious efforts to reform their labour force and
employment regulations to control the level of expatriate recruitment and increase the
recruitment of indigenous workers. Saudi Arabia has begun to implement policy
69
reforms to create employment opportunities for the rapidly increasing indigenous
labour force, while reducing dependency on oil.
The next and final section will describe the characteristics and elements of policy-
making in the Gulf states. This leads to a discussion of the indigenization policies
initiated to reduce dependency on foreign workers in general, foreign nurses in
particular, and increase indigenous people's participation in the workforce.
2.9 Policy-making in the Gulf
2.9.1 Background
There is a huge gap in Western knowledge about the policy environment in the Gulf.
One aim of this research is to fill some of this by exploring and examining the policy-
making process in the three Gulf states. First, it is necessary to understand the
environment in which policy is developed in order to understand the context of
indigenization policies in the Gulf. This includes the process of policy-making (how
issues join the policy agenda) and the actors' characteristics - position in power
structures, values and expectations (Walt & Gilson, 1994). Social policy initiatives
emerge because either a consensus of interest develops around a particular proposal
for reform, or because it is functionally necessary in societies reaching certain stages
in their growth (Hall et aI., 1975).
In addition, this section aims to identify the policy drivers of indigenization and
explore the implications of indigenization in the nursing workforce.
Defining policy is rather like the elephant - you know it when you see it but you
cannot easily define it (Cunningham & Sarayrah 1993, cited in Keeley & Scoones,
1999).
Public policy is concerned with how issues and problems come to be defined and
constructed and how they are placed on the policy agenda (parsons, 1995).
Heidenheimer et al. (1990) point out that public policy is the study of: "how, why and
to what effect governments pursue particular courses of action and inaction". Many
policy-writers have claimed that policy is a purposive course of action followed by an
actor or actors to deal with a specific problem and that it is different from decisions;
70
being more comprehensive and involving a series of more specific actions (\Valt,
1994). Walt claims that public policies are those policies generated and developed by
government agencies, or bodies, and officials and that therefore focus on purposi\'e
action by governments.
2.9.2 Public policy-making process in the three Gulf states
Government is depicted as a powerful force at each stage of policy-making, from the
first stage of initiation of proposals to their final implementation (Hall et al., 1975).
Bahrain and Oman have inherited characteristics of public policy-making from the
period of British control (until the 1970s). Saudi Arabia has a number of
characteristics which arose from Egyptian influence, especially at the beginning of the
establishment of the Kingdom. In addition, the sharp increase in oil prices in the
1970s impacted hugely on public policy-making in the Gulf states due to the sharp
increase in the number of public institutions established to provide the services
necessary for these growing economies.
Hall et al (1975) argue that government is the locus of power when it comes to the
planning of legislation. They further argue that the way in which government is
organized and structured partly determines the nature and outcome of policy (Hall et
aI., 1975). Thomas and Grindle (1994) argue that the general context of the policy-
making process in developing countries forms a backdrop for the conditions and
circumstances that place particular issues on the agenda for government decision-
making. They further argue that circumstances of crisis alter the dynamics of
decision-making by raising or lowering political stakes for policy elites~ altering the
identity and hierarchical level of decision-makers~ and influencing the timing of
reform. They found that decision-makers adopt different decision criteria as a result of
different agenda-setting processes. They conclude that political factors concerning
religious and ethnic support and opposition~ cultural and religious conflict's potential
to destabilize the political system~ and concerns about the political implications of
projected unemployment appear to have been of central importance in shaping the
decisions of policy elites (Thomas & Grindle, 1994). The assumption is that the Gulf
region has similar policy-making characteristics as it is part of the developing world.
71
It is important to recognIze that most of the Gulf governments are traditional
inegalitarian systems. They preserve inequalities and oligarchical structures and
concentrate power and wealth in the hands of a few (Walt, 1994). For example, the
King takes all important decisions in Saudi Arabia. Lindblom (1980) differentiates
between democratic and authoritarian systems when considering policy-making and
policy outputs. He argues that authoritarian systems do not pursue policies designed
to encourage and protect civil liberties (Lindblom, 1980). Hall et al (1975)
differentiate between two approaches to the policy-making process: (i) pluralist
model~ and (ii) class model. The pluralist approach accepts that there are defects in
democratic political systems but that these are largely inescapable and residual
blemishes in a basically sound and just system based upon dispersed power. Also,
inequalities in society are neither so great nor so cumulative that they result in
domination by a single elite. The class or elite approach stresses the belief that social,
political and economic power is distributed in a fundamentally unequal way within
societies and power is centralized in the hands of a small and cohesive sector as is the
case in the Gulf states.
Socio-economic factors (as well as beliefs, norms and values) are important
dimensions of policy-making and its outcomes (parsons, 1995). Walt and Gilson
(1994) explain that actors are influenced by the context within which they live and
work. They argue that context is affected by a number of factors such as instability in
a political regime~ war~ ideology; historical experience; and culture (Walt & Gilson,
1994). This is even more relevant in a region like the Gulf where changes have
occurred rapidly since the 11 September 2001 events and the war in Iraq. These rapid
political and economic changes are crucial to an understanding of policy-making and
the policy environment in the Gulf region.
In general, the Gulf states may be viewed as highly centralized states with high levels
of administrative power and control vested in central governments. Therefore, central
governments that are closely involved in most aspects of decision-making and
planning take the important decisions. Administrative systems in the Gulf states
consist of three levels:
1. Central government compnsmg the civil servIce, ministries and public
agencies such as utilities, transport and trade.
72
2. Regional councils, which include regional municipalities (for example, Saudi
Arabia has 13 regional councils).
3. Local municipalities.
2.9.3 Indigenization as a public policy
Public policies are those generated and developed by governmental agencies, bodies
or officials and therefore focused on purposive action or decision (Walt, 1994). To
understand a policy-making process in any setting requires understanding of the
political process too. The political environment and processes which lead to changes
in policies are often complicated and sometimes obscure (Hall et aI., 1975).
Indigenization policy-making is classically political: a competition among multiple
stakeholders and interest groups each with differing goals, resources, tactics,
information and power. Hall et al (1975) argue that different bodies and institutions
within a political system frequently compete, jostle for advantage and engage in
conflict to test their relative strengths. Further, like governments, interest groups
(what they call pressure groups) have to examine the demands they champion in terms
of the consequences for their own support and resources (Hall et aI., 1975). Of all
interest groups in the Gulf states, religious and business groups have perhaps the most
pervasive and powerful influence on governments.
The three Gulf states have similar indigenization policies and one common
denominator - a reflection of widely shared "public ideas" that indigenization is a
regional issue and must be tackled as such. Cobb and Elder (1983) argue that the
larger the audience for whom an issue has a wide appeal, the more likely that such an
issue would move from a matter of popular concern to become a matter of
government concern (Cobb & Elder, 1983). However, Hall et al (1975) argue that
governments have substantial access to the public through mass communication and
can use persuasion to gain support for their view of what is for the public good. The
vast majority of planning and development legislations rest within governments and
they determine the flow of legislation through parliaments (Hall et aI., 1975).
Nevertheless issue creation is a cultural and social process~ something must be
defined as a problem amenable to human solution before it can be considered a public
issue (Burstein, 1991).
73
Indigenization's policy elements link it closely to other public policies (e.g. economic
or labour) and thus it is influenced by, and influences, them. For example, sharia
(Islamic) law in Saudi Arabia affects a wide range of public policy areas both
theoretically and in practice. These include sectors that do not adhere to Islamic rules
such as the non-Islamic financial sector, women's right to work and family law. The
process in which public policy is decided through elections, debates and political
processes does not exist in most Gulf states. This is because sharia law exerts great
influence on much of everyday life and must be recognized and acknowledged in
matters of public policy. However, indigenization policies reflect the Gulf
governments' public commitment to increase job opportunities for the local
population and reduce the number of foreign workers and dependency on their
expertise.
The indigenization policies in the Gulf focus on the preparation and training of
indigenous people to produce qualified workforces that, it is hoped, will fill the
countries' labour market needs. A GeC report examined the link between higher
education output and the demand for graduates to service economic development in
the Gulf area. This warned of the mismatch between the outputs of the education
systems and human resource planning, identifying those educational institutions that
produce graduates who are not suitably qualified for the needs of the labour market. It
further reported that despite the availability of huge job opportunities (especially in
the private sector) foreign workers are still preferred - mainly because they are a lot
cheaper and easier to manage (Gulf Cooperation Council, 1996).
In a study of the Kuwaiti labour force, Al-Dwailah (1997) reports that Gulf education
systems tend to produce far more humanities students. She argues that unemployment
is increasing because the labour market needs science and technical graduates. In
addition, indigenous graduates shy away from manual jobs available in the private
sector. This supports the argument of those who criticized the Gulf states' education
systems for producing graduates that lack the skills and knowledge needed in the
labour market. Al-Qahtani (1998) supports Al-Dwailah's (1997) argument and
suggests that science and technical higher education institutions in the Gulf are more
adaptable and more relevant to the labour market needs than humanity and art
institutions. He further argues that one of the most important obstacles for indigenous
74
graduate employment in the private sector IS their weakness in English and
information technology. Al-Qahtani (1998) concludes that education systems in the
Gulf suffer from structural weakness in preparing and enhancing indigenous
graduates' skills that are essential in the private sector. However, few (if any)
comprehensive studies in the Gulf examine and analyse the harmonization of
education systems and labour market needs.
Mellahi (2000) argues that research into education and vocational training in the Gee
states has been largely neglected. Despite its importance there has been no
comprehensive study on these issues. Girgis (2002) points out that the level of
education in both the indigenous population and the national workforce increased
appreciably between 1965 and 2000. However, he argues that instead of fostering
economic growth through productivity improvements educational efforts in these
countries were dissipated by two major factors. Firstly, the choice of major studies
was distorted by government employment and promotion policies that deviated
sharply from the mix of skills and basic knowledge required by both public and
private sectors. Secondly, indigenous people were hired in the public sector in order
to distribute oil dividends. This produced overstaffing, underemployment and
underuse of this important resource.
Girgis (2002) further argues that an inadequate and unresponsive education system
combined with a lack of proper human resource planning to produce a massive inflow
of foreign workers to meet increasing demand (particularly in the private sector).
However, the private sector could not act as the swing employer by employing
indigenous people regardless of their qualifications, experience and cost. In addition,
he noted that indigenous workers were reluctant to join the private sector and
employers were reluctant to hire them because they received higher wages for fewer
skills than their foreign counterparts (Girgis, 2002).
Given public sector employment policies and government's pervasive economic role
it is not surprising that the public sector is the largest employer of indigenous people
in most Gulf states. Indigenous workers would not accept the low wages and benefits
that foreign workers receive in the private sector. For example, Mellahi and Wood
(2001) report that approximately 85% of the jobs in the private sector pay less than a
75
Saudi national would accept as a minimum wage. Saudi nationals would expect about
six times the salary that a skilled foreign worker would accept.
2.9.4 Bahrainization
As in other Gulf states, unemployment is consistently the major government problem
in Bahrain. Some analysts have linked high unemployment in the majority Shiite
population with the continuing influx of foreigners (often Sunnis) from other Arab
states (Melia, 2002). Rapid population growth, a young population and dependence on
foreign labour increases the pressure for job creation, training and education. The
Bahrain Centre for Studies and Research (BCSR) produced a report on behalf of the
Ministry of Labour. This showed that as many as 20 199 (14%) Bahraini nationals
were unemployed in 2004 and Bahraini nationals accounted for 43% of a total
workforce of 336400 (International Labour Organization, 2005). The study also
showed that unemployment is mostly confined to Bahrainis. The Ministry of Labour
claimed that the unemployment rate was only 4% in 2006 (Bahrain Tribune, 2006).
However, Bahrain and other Gulf states conceal their true unemployment rates for
various economic and political reasons.
More Bahrainis have found private sector jobs in recent years but studies show that
there are obstacles to Bahrainization. These include inadequate workplace skills
among Bahraini job seekers; their unwillingness to take up manual work; low wage
levels; poor working conditions; and reluctance to hire Bahrainis among some
employers (International Labour Organization, 2005). Recently Bahrain's Labour
Minister blamed low wages and hard working conditions for the low Bahrainization
levels in the private sector and cited reforms to education and training programmes
(Bahrain Tribune, 2007). Similar to Saudi Arabia and Oman, the government has set a
quota for most private sector businesses and stipulated that some professions are to be
occupied only by Bahrainis. It has also established the Supreme Council for
Employment and Human Resources with responsibility for setting the employment
and labour force strategy for the country. Its main aim is to invest in human resources
development through appropriate training programmes and tap the skills of
indigenous workers to take up jobs in the labour market and make a positive
contribution to the country's development.
76
- ~~ :.:..:-c.~-
and enable their participation in the Bd.r.:-ain:zc:J~:--.
\1arh:t RtL!ulatory AuthrJrit\ \'.a~ established to :--\:": ~t=' ~:r.::c:- C"~ ,~~C' ...... ;:, _ ~
programmt\ to upgrade labour market skills in Bchral~ i::--.": rc·r:·...;~~c ~:::~';.::..
wi th the pri vate \tct()r
Bahrain is the only (JCC state to ha\t permitted the e'Lb.lshment (I:':. :'.:je .. " ... "
the General Federation of Bahrain Trade! nions '-" ,n C anahs: ... L','f1SII}er :"1:-- J ';,'J ,'r
breakthrough in the Gulf (International Labour ()r"':d: Ization, :oo~)
2.9.5 Omanization
Optimum utilization of the indigerwlI<; \\()r~f(\fl..l· is lin~.ed :" the ~il'\l'I\Jf'mlT:,"
Oman's economy (Mini<;tn of Development. \l)l)()) In 19,: t!~t' ~O\erl1ll1l·::t 1".iI.:J
Ministerial Decree Number 127 (J,l to 111l!'(I .... l· an ()lllani/~ttlllll ,l~j\'!.! ,'I: JI Pl\.l:l·
<;ector establishments. This ranged from (,(J o o in tIll' tr~lfhl'(\r1 ~\l1J I..'Ofl1I1lUnll,..::I. 'I
<;lTt()IS to 15° 0 in the contracting sector. all to be achie\ eJ b\ thl' l'l1d ,': I', It,
(r-dinistry or Social Atrails, 1999) Howe\·er. i ndi genous \\ or ~l'r .... II 'Ill rr' 'l·J . \ \ ~ ~ I \, () ]!) 0 of the pri vate sector Iw the end of I l)l)()
<;\.'\.'tOl (-\I-:\Ia\\i & Shiban. 1lJ l)l)) -\I-Ra\cln (1 l)qS) Tl'PI'T1l'd rH;'~dtl\l' .!:i·:",,~I.'
t()\\<lld thl' indigenous labour force in the OnLll1i pri\ate St.',,:," (h',:"1 \\~" l'r, .. '1: ....
lTiti(i/l'd for their lad, of ~q)PIl)~)lIate skIlls and l'reati\it\ \'-R.:\.:" I' 991,. 1 "Jlo.'olC" \
that the plivate sector prefers tllreign workers bCl..'au,l' th'\' JI..'I..'crt Ic)\\ \\ J':.:e' dc ... ' '~
SUpnil)1 skills and ha\l' higher pll,dultl\lt\ alhi a \\lllil1~nl'" :,"\ a((,T' 'l'LP
l'lllployment conditil)l1s He further ,1lSlIl'S tlut llhil~l'lll)U' \\l)r\.-.cf' LiTe nlc-re \ a t:
and lal'k a pWPl'1 \\ork ethil..'
\1-.-\1.1\\ 1 al1d ~hihan ( I')I.)I.J) al~lll' that 11.'\\ ~'r,)\.ith.:::\·ll~ J'h.1 a reL....:· ,,,~ ~ ~
manual jl'b~ ~1I1.' t\\l' l)f the main Ch,H.h'tl'TlStl(S 1filllhtins ()'''Lt''l :'~. ~:e c
from hiring indiSI.'lll.)ll~ \\I.'[kl'[~ They ~'I.)lnt l"Ut the \\h11' sar b('~\\((~ ",- the l'dll(.ltll)11 sYstem .1111.1 Llt'I.'lll market need,. (\.)rh:lu\.~'n~ That ~;...~ 3· I
--,
... ..
flexibility of foreign workers hinders the employment of indigenous workers (Al-
Alawi & Shiban, 1999). However, Girgis (2002) points out that the Omani private
sector employed 50923 more Omanis in the period between 1996 and 2000 (only
10846 between 1991 and 1995). This indicates a strong reversal of past trends. A
1999 study by the Oman Chamber of Commerce and Industry indicated that the
private sector was too small to absorb the increasing number of graduates and the
government would need to introduce more incentives to encourage the creation of
more job opportunities for Omanis. It also confirmed previous findings that the
education system is incapable of meeting labour market needs and Omanis prefer to
work for the public sector (Oman Chamber of Commerce, 1999).
2.9.6 Saudization
During the three decades between 1975 and 2005, human resources were defined as a
major challenge in Saudi Arabia, which has been described as "capital-rich, labour-
poor" (Alsaeeri, 1993; Al-Shuaibi, 1991). In 1985, the Saudi government initiated a
Saudization policy to tackle the severe shortage of indigenous human resources,
reduce dependency on foreign workers and alleviate rising unemployment. The
government estimated this to be 12.02% in 2006 (Ministry of Economy and Planning,
2007a). However, some human resource analysts argue that the Saudization policy
was born in oil exploration and production agreements with American oil companies.
These included a clause requiring Saudis to be employed wherever possible (Madhi &
Barrientos, 2003).
The fourth SDP (1985-1990) led to the emergence of an indigenization policy aimed
at reducing the country's dependency on foreign workers. All subsequent SDPs have
emphasized the importance of this policy, encouraging both public and private sectors
to provide more opportunities for Saudi participation in the workforce and introducing
various laws and regulations to restrict the employment of foreign workers (Ministry
of Economy and Planning, 2001). As in other Gulf states until the early 1990s, most
Saudis were guaranteed a job in the public sector. However, the inflated public sector
that resulted was populated by large numbers of indigenous employees without a real,
productive job. The number of government employees without a real job and the
number of graduates rose sharply between 1985 and 1995 (Abdelkarim, 1999). Since
then, this unsustainable policy of a guaranteed job for life has ceased.
78
Since its emergence, Saudization has seen intensi\'e debate about i ts dL~: nitk':~ i:~ ~
ultimate objectives, Some consider it to be a tool or means of replacin~ ~'oreigr,
workers and limiting their numbers. Others see it as a process of managin::: a trained
and qualified local workforce, not simply to replace foreign \\orkers but ra:ner :'or
systematic planning and management of an organization's human res,,'urce
requirement (Al-Harbi & AI-Dosary, 2001). Howlett calls it "a \\ay for emplo~ ers to
revitalize their business by placing Saudi nationals in positions \\ here they will clearly
add to company profits" (Howlett, 2002). Alzalabani asserts that foreign workers \\ ill
be replaced with Saudis so that they can take a more active role in the economic and
social development of their country (Alzalabani, 2003)
The fourth SDP defined Saudization as a long-term strategy approach that centres on
" ... the intensification of efforts to develop national manpower through a quantitative
expansion of education and training, especially in technical and \ocational areas"
(Ministry of Economy and Planning, 2000). Nevertheless, the majority of those who
have written or advocated Saudization agree on two important aspects - increasing the
participation of indigenous workers and limiting the number of foreign workers -\1-
Nimer (1993) defines the aim of Saudization as a "process of replacing non-Saudi
residents with Saudi citizens in particular areas, on the understanding that the latter
possess sufficient qualifications and abilities to perform these jobs"
The eighth SDP (2005-2010) clearly states the objectives of Saudization.
• To optimize use of the national labour force and encourage Saudi
nationals to engage in productive work in all economic sectors.
• To ensure harmony between the educational and training programme.;,
of Saudis and labour market requirements.
• To provide more employment opportunities to Saudi nationals in the
private sector.
• To rationalize the recruitment of foreign workers and limit it to actual requirements, to enforce decisions and regulations related II)
Saudization and to restrict employment in certain j ob categorie~ to
Saudi nationals
79
• To provide more employment opportunities for Saudi women by adopting appropriate policies that enhance women's participation in
the labour market in the positions that best suit their skills and do not
contradict sharia principles.
• To reduce the unemployment levels of Saudis and recommend
solutions that address unemployment.
• To encourage investment in productive and service activities that use
high technology (Ministry of Economy and Planning, 2005a).
While most of these objectives have been stressed and repeated in all SDPs, the
implementation mechanism(s) have not been clearly defined. Government agencies
and the private sector were left with a set of aims to accelerate Saudization without
proper guidelines on how to achieve these objectives.
Saudization has been the focus of Saudi policy-makers for various reasons: economic,
social and, more importantly, national security. The Saudi government has made
numerous attempts to alter the composition of the labour force through Saudization,
especially in the private sector. AI-Sudani and Abdulkhair (2001) argue that progress
is still slower than expected and the percentage of indigenous Saudi workers in the
private sector is less than 10%.
They attribute this to a number of factors:
• inadequate suppl y of and demand for indigenous workers;
• gap between the education, skills and wages of indigenous and foreign
workers;
• private sector preference for foreign workers rather than indigenous
workers who lack adequate skills and are more expensive.
Al-Sudani and Abdulkhair (2001) suggest that the Saudization policy should focus on
providing more training programmes and implementing existing labour and financial
regulations aimed at reducing the number of recruited foreign workers more
effectively. AI-Sultan (1998) argues that implementation of the Saudization policy
would replace the majority of foreign workers and alleviate the existing burden on
80
public services caused by foreign workers and their dependents. Al-Humaid (2003)
shares the view that large numbers of foreign workers have a negative impact on
public services, especially health and education. He argues that reducing the number
of foreign workers by implementing Saudization would give an accurate picture of
demographic realities in Saudi society and could lead to an improved distribution of
national resources and public services. The government often urges the private sector
to restrict new employment to Saudis and gradually replace existing foreign workers
to achieve an ideal indigenization of employment, with full optimal use of national
human resources (Manpower Council, 2002).
Looney (2004) examined the compatibility of a Saudization policy and the present
economic reform in Saudi Arabia, especially the implications of membership of the
World Trade Organization (WTO). Looney found that Saudization is considered to be
compatible with the economic reforms and does not conflict with economic diversity,
competitiveness, free trade and mobility in the labour force. In his recent study, Al-
Dosary (2004) points out that prolonged dependence on foreign workers has given
Saudis an ever-increasing contempt for both the government and the private sector.
He suggests a number of strategies that include: improving Saudis' competitiveness
and professional standards so that they can compete with foreign workers;
encouraging the commitment to employ, train and retain Saudis; and strengthening the
role of media campaigns to increase public awareness of the importance of
Saudization. In addition, he wishes to change public attitudes towards certain
professions. He concludes that these policy options may well lead to the
indigenization of the labour force by developing the skill of indigenous people and
implementing the labour force importation policies (Al-Dosary, 2004).
Madhi and Barrientos (2003) argue that employment and career opportunities are
clearly differentiated by nationality in the private sector, more than 80% of which
comprised foreign workers. They recognize their contribution to the rapid economic
development of the country and argue that the implementation of Saudization faces
important constraints. This is especially true in the private sector where productivity
and competitiveness are vital in the present global market. Foreign workers accept
lower wages and possess the necessary qualifications and experience that indigenous
workers lack. There is also the myth that indigenous workers lack a work ethic and
81
are unprepared for very demanding jobs. This is not limited to the Gulf states or
developing countries. However, the Saudization policy continues to face certain
constraints and challenges that include a continuous flow of foreign workers,
particularly the unskilled and low-paid. Also, private-sector employers show
continuing non-compliance with the resolutions and regulations of the Saudization
policy and its relevant implementation mechanisms (Ministry of Economy and
Planning, 2005b).
Foreign worker visas have been a source of easy money for some Saudis. Black
market visas are sold to foreign recruitment agencies and then resold, mostly to poor
foreign workers from countries such as India, Pakistan and Nepal. However, pressure
from various Saudi groups and the soaring increase in unemployment among young
Saudis has compelled the government to make drastic changes to employment
structures.
The government has indicated its commitment to enforce all Saudization legislation.
For example, it has pledged to enforce the most prominent Saudization resolution
(No. 50). Introduced in 1995, this requires private companies to employ Saudis and
increase their number by 5% annually (Ministry of Labour and Social Affairs, 1999).
In 2005, the Council of Ministers passed a decree to raise the private-sector
Saudization rate to 75%. This was widely welcomed by Saudis who believed that the
implementation of such a decision would significantly reduce unemployment in the
country. The measures were received with cautious resentment by the private sector.
It feared that they would compel the employment of untrained Saudis, which could
jeopardise the future of private businesses (Arab News, 2005). In addition, the
government has increased the cost of hiring foreign workers by introducing
compulsory health-care insurance and increasing the cost of issuing and renewing
work visas. Other measures include restrictions on transfers of sponsorship in order to
curtail foreign labour movement and foreign workers' families entering the country.
Also, a pool of professions (e.g. accounting, security, marketing) are to be filled only
by Saudis (Ministry of Labour, 2005a).
Despite these measures to increase the cost of foreign workers, Saudis are still more
expensive to employ. The private sector has voiced concerns over the implications of
82
Saudization (Mellahi, 2000) and has continued to raise concern s over measures such
as tightening the restrictions on importing foreign worker s. It ha s urged the
government to examine carefully this policy' s impact on the pri vate sect or. Som e
private sector owners are threatening to move their busine sses outside the country if
the government persists with these measures (Al-Watan , 2005) .
Some authors (Abdelkarim , 1999; Girgis, 2002 ; Jaber; 2000) have indicated that the
Saudi government has stopped its past open policy of hiring practicall y all in digenous
people who wish to work in the public sector. However, it now faces potential
negative consequences to national security from terrorism and increasing crime rates
among higher numbers of unemployed nationals . The official unemployment rate was
12% in 2006 (Ministry of Economy and Planning, 2007b) . It should be noted that the
official unemployment rate among Saudi women was 26 .270/0 in 2006 (Saudi Arab ian
Monetary Agency, 2007).
Fig. 3 Official unemployment rates in Saudi Arabia (2000-2006)
14.00
12.00
10.00
8.00 ...v,...,.:~-~I-----1
6.00
4.00
2.00
O. 00 jY.......L!:=:;:;;:::;::L..I~:::;::L~==;::L.J""==?-~=::::;:;;;l""I!=::::::::r
2000 2001 2002 2003 2004 2005 2006
Source : Ministry of Economy and Planning, 2007a
Since the late 1990s, many human resource and economic anal ysts have warned the
Saudi government about unemployment and its potentiall y dangerou s consequences
for the security and stability of the country (Financial Times, 2000) . Concentrati ng on
the social and security consequences of unemployment, Al-Thaqafi (2 002) argue s th at
dependence on foreign workers reduces job opportunities for Saudis and incre ases
unemployment rates, which can be positivel y correlated wi th cri me rate s. He poi Ilt s
out that unemployed Saudis committed more than 22 0/0 of th e cri me s in Saudi :-\rab i a
83
between 1988 and 1997. The Crime Prevention Research Centre in the Ministry of
Interior undertook a study of home burglaries in Saudi Arabia. This indicated that
750/0 of those who committed these crimes were either unemployed or single students
under the age of thirty, of whom the majority were Saudis (Al-Riyadh Newspaper,
2008). Reducing and controlling the inflow of foreign workers will create more jobs
for Saudis and reduce unemployment, especially among the young indigenous
population (Al-Thaqafi, 2002).
In the past, Saudization was never a priority because there was no immediate
necessity or urgency to implement it. The need for action became urgent only when
unemployment worsened, especially since the mid-1990s when the government
realized that the problem was no longer only economic. Unemployment in Saudi
Arabia, the largest GCC country, had increased to about 13% among all males in 2004
and was as high as 35% among those aged 20-24 according to some estimates (Shah,
2005). Such a problem in the largest exporter of oil in the world has started to threaten
the stability of the regime and now tops the government's agenda, perceived as an
increasingly serious problem with a multitude of social and security dimensions.
Since 2004, Saudi Arabia has attained high rates of economic growth. These far
exceed those achieved in the late 1990s - 2004 and 2005 may have been the best in
the Kingdom's recorded economic history. GDP growth is estimated at 6% and there
has been a significant expansion of foreign investment (Bank Audi Report, 2006). The
private sector employment ratio is approximately 84%, which would in theory enable
all Saudis to be employed (in the absence of foreign workers). Nevertheless,
generating employment for the fast growing Saudi labour force and reducing their
prevailing high level of unemployment remain as challenges for Saudi Arabia. This
reinforces the need to take immediate and difficult decisions to accelerate structural
reform in order to give renewed impulse to the expansion of non-oil economic
activity.
2.9.7 Indigenization and the role of education and training
Education and vocational training in the Gulf states has not provided indigenous
workers with the skills required in the public and private sectors. The vocational
training curriculum geared towards relieving unemployment has met neither employer
84
nor student needs, nor expectations of their place in the labour market (Wiseman &
Alromi, 2003). The GeC governments recognize the importance of skills and some
have supported initiatives to reform their education and training systems. For
example, Saudi Arabia recognized the importance of ensuring harmony between
educational and training programmes for the Saudi workforce and labour market
requirements (Ministry of Economy & Planning, 2004). Training and vocational
education is emerging as the cornerstone of the national human resource strategy in
Saudi Arabia, as in all other Gulf states. Since the late 1980s, human resource
development in general and vocational education in particular has assumed high
priority in Gulf development plans (Mellahi, 2000).
The fourth SDP indicated that structural changes, foreign investment and
diversification of the Saudi economy would increase the demand for professional and
skilled indigenous labour. It emphasized the necessity of orienting the complete
educational system more explicitly with the labour market in all relevant activities
(Ministry of Planning, 1985). Al-Dosary and Garba (1998) paint a bleak picture of
Saudi education and training systems. They argue that growing unemployment and
continued reliance on foreign workers indicates the ineffectiveness of education and
training systems that lead to the failure of the human resource management and
planning framework in the country.
The number of technical and vocational training institutes has increased since 2000
but education and training outcomes still do not align with labour market needs
(Calvert & Al-Shetaiwi, 2002; Madhi & Barrientos, 2003). The latter argue that high
school graduates prefer higher education over vocational and technical training. They
attribute this to prevailing attitudes among young Saudis and their families who
favour white-collar professions over manual and technical professions (Madhi &
Barrientos, 2003).
There has been extensive debate concerning education and training issues and their
relationship with the policy of Saudization. Some believe that inadequate and
ineffective education and training is responsible for unemployment in Saudi Arabia
However, despite the validity of some of the criticisms discussed above, most critics
have failed to demonstrate the link between education output and effective
85
Saudization . As previously described, 85 0/0 of forei gn wo rkers in the Gul f s pri \'ate
sector work in low-skill occupations and the maj ority have achieved high sc hool
standard or lower (see Fig. 4) .
Fig . 4 Educational levels of Saudi private sector workforce, 2005
6»
5')
4')
% 3,) 2')
VI
I)
L P ~ I S D B M P
CJ Ilitera:e a L i t~r3te o Primary' CI I nternedl3te • SeCJnd . ry
CI U p lJm a • "' cch elor [l 111 aster • f-Jh U
Source: Ministry of Economy and Plannin g, 20 06
The training of Omanis has received special attention and support . The Om ani
development plans have taken tangible steps to expand technical and vocati onal
training which has increased enrolment in these institutions . However, total enrolm ent
in higher education remains low and did not exceed 200/0 in 2000 (Mini stry of
Plan ning, 2002) .
WHO (2005) reports that the Gulf states ' skills crisis can be sol ved if the publi c and
private sectors invest more in adult skills training . Inadequate national competence ;
ineffectual plans for developing human resources in the health services; and poor
coordination between the health and education ministries and other stakeh old ers are
impeding progress.
2.9.8 Indigenization policies and culture in the Gulf
Societal culture refers to the main characteristics of a society th at are shared \'Ia
langu age, knowledge, skills, beliefs and customs . These combi ne to fom1 a society' s
86
way of life (Marcus & Ducklin, 1998) and help to explain much of the variance in
work ethics, values, attitudes and behaviour (Dastmalchian et aI., 2000; Hofstede,
1993). Gulf culture has its own traditions and values which are transmitted down the
generations. One of the Gee's key objectives is to reduce cultural diversity and foster
the homogeneity of the region's societal culture and all aspects of Gulf life. Gulf
culture is also a key factor in shaping (and continuing to shape) human resource
policies and practices in the region (Mellahi & Wood, 2001). For example, all the
SDPs have been designed to emphasize the importance of religious and cultural
values and reduce the influence of the different values and traditions of foreign
labour.
In October 1998, the General Secretary of the Gee stated: "The problem of expatriate
workers is starting to represent a danger for Gee states because they pose social and
political problems that could grow more complicated in the future" (Kapiszewski,
2000). Many in the Gulf share this view. AI-Farsi (1996) disagrees, arguing that the
presence of various cultural backgrounds, very different from the indigenous
population, has not affected the homogeneity of Saudi Arabian culture and its society
has been entirely unaffected. AI-Harbi (2003) argues that one of the most important
advantages of an indigenization policy is that it minimizes the influence of external
cultures brought in by foreign workers and maintains the purity of Gulf society and its
cultural values and traditions. However, some cross-cultural writers like Hofstede
(1993) consider that the commonality in religion and language accurately represents
the Gulf or the Arab national culture and assumes that the Gee states are culturally
identical.
The Gulf states do share more similarities than many other countries but the
differences between and within them should not be overlooked. For example,
indigenous people's low participation in the private sector is attributed partly to the
fact that most prefer office and managerial work which is in short supply. Indigenous
people in the Gulf shy away from manual work such as carpeting or plumbing and
leave it to foreign workers. Graham (1991) argues that this attitude is not a result of
the wealth and economic prosperity generated by oil revenues - manual work
provoked social stigma long before oil was discovered. Graham points out that the
Bedouin tribes shy away from what they consider shameful work and discourage their
87
people from accepting such jobs. Mellahi (2000) supports such views, arguing that
Gulf society holds a negative perception of skilled and manual work and associates it
with foreign workers. He agrees with Graham that families (especially Bedouin tribes)
take pride in working in mostly managerial and clerical jobs in the public sector and
not being involved in so-called "dirty work". It should be noted here that "dirty work"
includes nursing.
Recent research indicates that 25% of indigenous employees in the private sector in
Bahrain, Oman and Saudi Arabia failed to show up for work regularly and many
others left their jobs after six months (Khalaf, 2007). However, indigenous workers in
the Gulf are changing their attitudes towards jobs that traditionally have been looked
down on. For example, young Saudis are looking beyond white-collar jobs and no
longer focus mainly on clerical and managerial positions. This is encouraging to
governments and the private sector. Limited job opportunities in public organizations;
growing competition from foreign workers; high unemployment rates in most Gulf
states; and high demand in the private sector have persuaded many indigenous people
to consider manual work. For example, Saudis can now be seen working as waiters,
electricians and drivers. This could also have a positive impact on the nursing
profession in most of these countries and encourage more indigenous people to
consider a valuable career.
2.10 Chapter summary
Well-publicized intentions to reduce foreign labour forces and create more
opportunities for indigenous populations have not been realized. The numbers of
foreign workers have increased in all Gulf states, primarily because of increasing
demand, especially in the private sector. In response, the Gulf governments have
designed employment regulations and intervention policies specifically to control the
recruitment of foreign workers and increase the employment of indigenous people.
The first section in this chapter described the nursing shortages and the challenges of
meeting the growing demand for qualified nurses. It highlighted and reviewed
relevant literature related to nursing shortages in general and the Gee states and
Saudi Arabia in particular. It also highlighted and reviewed literature related to the
88
recruitment of indigenous and foreign nurses and factors that influence the shortage of
nurses in the Gulf.
The second section examined the literature related to human resources in the health
service in general and in the three states of Saudi Arabia, Bahrain and Oman in
particular. It examined the role of women and the social and cultural variables for
women in the Gulf. Apparently, women in Saudi Arabia face more constraints and
have more limited participation in the labour market than in any other Gulf state.
Cultural and family-level factors affect women's presence in the labour market and
their success in finding a job. Cultural proscriptions on female mobility are a
significant constraint on women's employment in Saudi Arabia and also are important
in explaining high unemployment rates among females.
The third section examined and reviewed literature related to human resources in the
Gulf and examined the development and characteristics of the human resources and
the labour market policy in the three states. It also examined the role and size of the
foreign labour force in the Gulf and its effect on the development and employment of
indigenous people. As increasing numbers of cheap foreign workers fulfilled the
demand for unskilled workers the particular jobs available became racial in nature.
Dirty, dangerous and difficult jobs have become associated with foreign Asian
workers because indigenous people have refused to undertake them, despite high
levels of unemployment. Although most scholars and labour specialists have cited
many of these points as the main reasons for the general shortage of indigenous labour
(in nursing particularly) they have seldom referred to the political dimension that most
Gulf states take into consideration with labour market issues. Labour market policies
are set in order to achieve a balance between indigenous people, foreign labour,
ethnicity and religion.
The fourth and final section examined and reviewed works related to policy and the
policy-making environment in the Gulf. It examined how social policy initiatives
emerge and the important role of government at each stage of policy-making. It
highlighted the main characteristics of the two (pluralist and elite) approaches to
policy-making and how they relate to policy-making in the Gulf. In addition, section
four examined how indigenization policy developed as a public policy in the three
89
states and how different agencies and bodies compete with each other for their own
interests. The section drew attention to how governments access and control the flow
of data and their techniques for gaining support from the public. The section
concluded by examining the implementation mechanisms of the indigenization
policies in the three states and the roles of culture, education and training in an
indigenous workforce. Research suggests that the indigenous nursing shortage in the
Gulf states is the result of a dynamic interplay between a number of complex factors
including personal beliefs and values; gender relations; negative images;
organizational structure; and religious and cultural constraints.
Scientific and rigorous research is needed to better understand the complexity of the
indigenous nursing shortage in the Gulf in general and Saudi Arabia in particular.
Therefore, the next chapter examines the methodology employed in this research.
Qualitative methods continue to offer a valuable means of understanding and learning
about nursing shortages and indigenization. Multiple methods of analysis are used to
understand and explain this complex phenomenon. However, qualitative methods are
especially appropriate for this research since its aim is to generate and provide an
explanatory account of the subject under investigation.
90
Chapter 3
Research process and methodology
3.1 Introduction
Previous chapters have examined the broad context of three Gulf states - Saudi
Arabia, Bahrain and Oman. In addition, they have reviewed the various literature
relating to the shortage of indigenous nurses in the public health services; the
development of an indigenization policy~ and the prevailing approach to
indigenization as a public policy. These policies are known as Saudization,
Bahrainization and Omanization, respectively.
My research aim IS to generate an in-depth understanding of the factors that
encourage or inhibit indigenous women from considering nursing as a worthy career
and the formulation and implementation of an indigenization policy in the nursing
workforce in Saudi Arabia. To this end, I have tried to gain an understanding of the
interests, strategies, perspectives and capacities of the various stakeholders in the
three states. This has involved an in-depth investigation into how these policies have
been formulated and implemented by stakeholders 3 and how they influence the
nursing workforce.
Consistent with this aim, the research has been guided by several research objectives.
• To examine and analyse the policy of indigenization in the public health
service and its impact on the nursing workforce in the three Gulf states, by:
a) examining and analysing indigenization strategies and implementation~
b) examining and analysing the principal differences and similarities in the
strategies adopted by the three states toward indigenization of their nursing
workforce.
• To explore the possible causes inhibiting or promoting the development of
nursing as a career amongst indigenous people in the Gulf.
• To contribute to the body of knowledge on this topic.
3 Stakeholders refers to those individuals and organizations who effect or are affected by a policy - for further explanation see the section on stakeholder analysis
91
These aims and objectives have emerged from my previous experience as a human
resource manager in one of the largest hospitals in Saudi Arabia and from extensive
review of related literature on human resources, specifically the indigenization policy
in the nursing workforce in Saudi Arabia. I believe that my own positionality is
important to this study as it has shaped the perspective of the researcher and of those
being studied and thus become part of the research process (Flick, 2006). The
researcher's reflections on his actions and observations in the field and his
impressions, frustrations and experiences became data in their own right and are
documented in this study. The next section provides more detail.
3.2 The researcher and the research
Even before my PhD candidacy I was interested in the discourse on human resources
in Saudi Arabia, having worked in the human resource department of the Medical
Service Department (MSD) of the Ministry of Defence and Aviation until 1997.
During this time I developed relationships with a number of policy-makers and human
resource managers, especially in the health service. At that time, I had not formed an
opinion on the validity of the Saudi government's stated intention to implement a
rigorous Saudization policy in the public and private sectors.
Like some of my colleagues, I was inclined to criticize rather than support
government policies. Nevertheless, I did not undertake this research in order to find
fault with, or dismiss as invalid, the government's understanding of what Saudization
might mean. I soon realized that much more in-depth study was required for me to
feel confident in my own knowledge. I began by collecting statements, documents and
reports from supporters of various government policies. My understanding grew over
time through reading, writing and interacting with those interested in the issue.
Myers has argued that:
The more infonnation we gather, the more we understand the organization as a whole and
its constituent parts. This henneneutic process continues until the apparent absurdities,
contradictions and oppositions in the organization no longer appear strange, but make
sense. (Myers, 1997)
92
It has been a major challenge to develop my own identity as a qualitative researcher. I
have had to overcome prejudice and a number of misunderstandings. Qualitative
studies require considerable skill on the part of the researcher. Some believe that they
are easy to conduct and require no skills or training but I have found that the opposite
is more likely to be true. However, my previous experience as a human resource
manager (e.g. problem solving, engaging with many different people) has helped me
to engage in qualitative research.
As a human resource manager, my responsibilities included designing and
implementing recruitment strategies and making sure that suitable and sufficient
health workers were recruited. Nurse recruitment was, and remains, one of the most
difficult tasks in the Saudi health service. It was difficult to recruit and retain suitable
candidates. Very few indigenous nurses are available so most are recruited from other
countries. Foreign health workers tend to work for short periods (around two years)
and my aim was to keep them for the longest possible time. During the few years I
worked there, only a few Saudi nurses were working in the hospital I worked in one
hospital for seven or more years and cannot recall employing a Saudi nurse - not one
applied.
This experience motivated me to examine the underlying issues of indigenization and
the lack of interest in nursing as a career, especially as the recruitment situation has
worsened with the global nursing shortage. I decided to look beyond the boundaries of
Saudi Arabia and explore the situation in Gulf countries that share similar
characteristics. I was not surprised to find similar problems in most Gulf states (with
some variations in employment-related characteristics) and was inspired to research
these crucial issues for the future benefit of the health service in Saudi Arabia. Few, if
any, studies have explored the issue of indigenization in nursing and the critical
shortage of indigenous nurses in the Gulf. In the absence of research into the
complexity of these issues, we can only guess at their nature and depth.
I was fortunate that the Saudi Arabian government granted me a PhD scholarship to
pursue my research aims. I became more immersed in the field as the research
progressed and the original research questions were broadened and re-evaluated Over
time I have realized that it is true that one of the most difficult tasks for researchers is
93
to turn the experiences of their research into respectable academic writing (Takacs,
2003).
As a male Saudi national, I was able to function as an insider when interviewing
Saudi respondents. The Saudis I interviewed probably knew something about me and
may have expected me to be somewhat more sympathetic and patriotic than a non-
Saudi. The clear aims of this study enabled me to understand and engage in debates
with informants and gain their trust and respect. I was able to develop a relationship
with informants and move from a stranger to a friend. Leininger (1991) holds that a
researcher is seen as a stranger (and is not necessarily given accurate information) but
becomes a friend when trust has grown. This enables the researcher to obtain reliable
data.
In Bahrain and Oman, I was considered an outsider when I interviewed Bahraini and
Om ani informants. These dual roles of outsider and insider carried certain advantages
and disadvantages. By crossing experientially and cognitively different standpoints
they offered what Bartunek and Lewis (1996) call a kind of marginal lens through
which to examine subject matter. I believed that it was important and necessary to
take account of the political environment and the different sub-systems including the
powerful interests groups such as religious and business elites when conducting
research in the Gulf region. Hall et al (1975) argue that the policy process is not
contained within, or limited to, a single centrally co-ordinated system. It embraces a
number of sub-systems that all acts with varying degrees of autonomy e.g. pressure
groups, political parties (if they exist) and other bodies (Hall et aI., 1975). This meant
learning to listen with an open mind and heart to all parties and respecting local
customs and understanding the gender relations in these states. When we constantly
engage to understand how our positionality impacts on our epistemology, we greet the
world with respect and interact with others to explore and cherish their differences
and understanding of the world (Takacs, 2003).
I felt that my gender affected my positionality, especially in a patriarchal, Islamic
culture. All the indigenous women I interviewed possessed an understanding of the
existing gender relationships and, as a result, we shared the gender-conscious rules of
society. In the Gulf s conservative society I had to negotiate access through a number
94
of gatekeepers such as semor managers and colleagues, especially for females.
Research interviewing was difficult, especially in Saudi Arabia where there are
restrictions on talking to women in public. Language and local dialect caused further
problems. Most interviewees spoke and understood English but some preferred, and
felt more comfortable, speaking Arabic in order to express their feelings clearly.
Interestingly, some used both languages.
My own overall reflections on this research highlighted the tensions, difficulties and
interesting challenges embedded in conducting research in a context like the Gulf.
Only limited data were available and there was an almost complete absence of any
other research on nursing and indigenization in the Gulf.
3.3 Practical difficulties and implications of the lack of data
As a researcher, I was challenged by the practical difficulties of conducting fieldwork
- not just gaining access to field sites. In general, it was difficult to find and access
any reliable data and written documents related to human resources in any of the three
states. For example, it was very difficult to obtain basic data from government
agencies in Saudi Arabia, either because such information did not exist or because it
was classified as confidential. This supported Hall et ai's (1975}_assertion that
governments enjoy advantages over other groups because they possess much
information unavailable to others. Information on workforce trends, unemployment
and other employment-related characteristics is not collected routinely in most Gulf
states. In addition, little is known about certain categories of health workers like
nurses. Government officials hesitate to make available written reports or statistics
other than those already in the public domain.
Labour surveys and other reports related to labour forces offer the best comparability.
Therefore, the researcher had no alternative but to rely on data provided by regional
and international organizations (e.g. United Nations, Gee, WHO, ILO, World Bank,
ICN and BBC) and independent local reports produced by financial institutions such
as banks or recruitment agencies. The latter produce predictable data and analyses that
may not always be based on reliable evidence, a common problem in developing
countries. This lack of data in many developing countries reduces the comparability
95
of data sources and raises problems with consistent definitions of health v%rkers
(pittman et aI., 2007). On occasions, the lack of reliable, up-to-date data restricted and
hampered research to assess the effects of policy implementation and workforce
trends.
The search for data that proved not to exist was a disappointing and time-consuming
process that prolonged the process and outcome of this research. It may also have
limited the interpretation and comparability of some data related to Saudi Arabia. The
limited availability of published data has caused greater reliance on the data from
primary interviews with participants. However, rigorous data collection methods and
techniques were applied to minimize the effects of such limitations, especially during
the interview phase. The researcher used the interview sessions with stakeholders
(especially those in senior positions as policy- and decision-makers) as opportunities
to gain more information and data by persuasion, stressing the importance of such a
study and offering assurances of anonymity and confidentiality.
Bahrainis, and to some extent Omanis, were more transparent and less secretive about
data and relevant reports. The majority of data sought were obtained with reasonable
effort. However, failure to remedy the shortage of available data and their reliability is
likely to result in the Gulf falling further behind the rest of the world in both the
provision of valuable and important research and the ability to design public policy
based on reliable evidence.
3.4 Evolution of research questions
As stated, my research aim is to generate an in-depth understanding of the factors that
facilitate or inhibit the implementation of indigenization policies in these three
countries. One of the most important steps in this study was the definition of the
research questions. Rein (1970) argues that social policy studies need good questions
rather than good tools. Higgins (1981) argues that a researcher who can decide upon a
series of good questions will avoid superfluous description and acquire deeper
understanding more quickly._The research questions for this research evolved over a
long period and were refined in response to reading the available literature in the
field.
96
The following research questions guided this study.
1. What are the main causes inhibiting or promoting the development of nursing
as a career among indigenous women of the Gulf?
2. What are the main factors facilitating or inhibiting the formulation and
implementation of an indigenization policy in the nursing workforce in Saudi
Arabia?
These questions were framed to explore what the stakeholders involved in the study
understand by their respective indigenization policies in general and how they
interpret their relevance to nursing in particular. The second question was particularly
aimed at pinpointing potential explanations for Bahrain and Oman's greater success in
increasing their indigenous nursing workforces. This could indicate what lessons can
be learned from this success and their applicability to Saudi Arabia. A research
approach was required to accommodate the diverse and complex views and
perspectives of stakeholders' understanding.
3.5 Framework for understanding indigenization policies
The literature suggests that economic, social, cultural and human resource policies
and practices, factors and variables are important determinants of indigenization
policies and practices. Indigenization is presented as context-specific and it is argued
that there is a strong need for more cross-national indigenization studies, given the
growth of the national workforce; increased levels of competition; and the
globalization of recruitment of health personnel, especially nurses.
The literature on the Gulf states shows the absence of an integrated framework that
can help to highlight the different roles of context-specific facets of indigenization
practices. The framework used in this thesis delineates the main distinctive facets
associated with national factors, contingent variables and human resource strategies
that may be used to analyse cross-national comparative indigenization policies and
practices. This comparison of indigenization policies and practices at a national level
helps to answer some typical questions, such as: How are indigenization programmes
structured in each of the three Gulf states? What strategies are discussed? \\'hat is put
97
into practice? What are the similarities and differences? What influence is exerted bv
national factors such as religion, culture, government policy, education and training
systems? The degree and direction of these factors is context-specific and varies from
country to country.
Interestingly, most models of indigenization in the three Gulf states are recent, with
principles developed from a restricted sample of human experience. The framework
applied in this study utilizes a number of different approaches to understand the
policy environment. This thesis draws on the Walt and Gilson (1994) policy
framework to emphasize the context, actors and policy process of indigenization.
Within context, the thesis highlights economic, social (including religious) and
political factors. The main actors and their interests are identified by stakeholder
analysis. A number of different approaches to process are used - for example, a
grounded theory process of analysis which includes a number of distinct features
(such as the use of constant comparisons and a coding paradigm) to ensure conceptual
development and density.
Finally, the thesis utilizes approaches from the human resource literature to highlight
why a shortage of health workers occurs and the influence of human resource policies
and strategies on the indigenization policy. Each of the approaches and models
identified in the thesis is a piece of a larger phenomenon. The thesis framework ties
them together and presents the range of main national factors that create a metalogic
for indigenization policies and their various components. Knowledge of the complex
interactions and cause-and-effect relationships between these different sets of
metalogic factors, contingent variables and policy environments is essential to
understand the nature of indigenization policy in the three settings.
3.6 Research approach
This section examines the paradigm used in this research. Lincoln and Guba (1985)
define a paradigm as a world view or a general perspective of breaking down the
complexity of the real world. Qualitative inquiry has passed through a number of eras
in which certain sets of principles and beliefs guided inquiry in different ways The\"
specified a number of features of qualitative research, including the following
98
• Whenever possible, research should be carried out in the natural context
because individuals cannot be understood in isolation from their contexts· ,
relationships are complex rather than linear~ and contextual value structures
partly determine findings.
• Humans are the primary data-gathering instruments because it is impossible to
create a priori a non-human instrument able to adjust to various realities and
meamng.
• Tacit knowledge is legitimate because many nuances can be appreciated only
tacitly.
• Meanings and interpretations are corroborated with participants because it is
their constructions of reality that the investigator seeks to understand and
explore.
Qualitative methods facilitate the study of issues in depth and detail to produce data
that are freely defined by the subject rather than structured in advance by the
investigator (Patton, 2002). Therefore, the decision was made to use the qualitative
paradigm to achieve the aims and objectives of this research. Lincoln and Guba's
(1985) comprehensive and rich naturalistic inquiry book became the researcher's
main source for qualitative approaches and a constant companion throughout this
research.
The researcher chose interviews and documentary analysis as the most appropriate
methods for this research for the following reasons.
• It is well-known that the qualitative method is used usually when too little is
known about a phenomenon for standardized instruments to have been
developed or even be ready to be developed (Morse & Field, 1995~ Patton,
2002). This was the case in this research.
• Indigenization issues, shortages of indigenous nurses and indigenous people's
lack of interest in nursing as a profession clearly involve a number of factors
and stakeholders. Thus, the researcher needed to choose research methods
appropriate for uncovering and understanding the relationships between these
various factors and stakeholders.
99
• From the indigenous participants' point of view, qualitative methods are
particularly useful when describing issues such as a shortage of indigenous
nurses and indigenization policies. Human resources management is in its
infancy, especially on issues related to the nursing workforce in the Gulf. This
study aims to extend our understanding of human resources in general, and
nursing human resources in particular, in the three Gulf states. This goes
beyond the descriptive approach and uses an exploratory qualitative
methodological approach to examine indigenization of the nursing process in
the three countries.
By determining the focus for the inquiry and comparing the characteristics of both the
qualitative and quantitative paradigms with the goals of this research, the researcher
was able to identify the most appropriate method for understanding the study
phenomena within their context. Quantitative research seeks to count occurrences and
establish statistical links among variables or to test hypothetical generalizations. In
contrast, this study seeks to explore and understand the development and
implementation of the policy of indigenization and its impact on an indigenous
workforce in a specific setting. These aims cannot be achieved by means of statistical
procedures or other quantitative methods. This study is concerned with newly
developing phenomena which, as already stated, have not been fully explained by
previous knowledge and understanding. In addition, qualitative approaches were
considered more appropriate because of the sensitivity of the phenomena being
studied and the scarcity of reliable published records. The flexibility of a qualitative
approach allows appropriate pursuit of sensitive issues and reveals in-depth
information that standardized and closed-ended questions might fail to reveal
(padgett, 1998).
A cross-sectional survey was considered but dismissed because of the lack of data to
inform the survey questions. In addition, survey methods require the use of closed
questions using defined categories. These were not known to the researcher during the
data collection phase due to the lack of available evidence. A possible exception
might be the use of open questions in a questionnaire but this was not considered
appropriate as it might not produce the rich and valuable data required to understand
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and analyse the phenomena. The researcher believed that face-to-face interviews and
documentary analysis were the best methods to achieve the aims of this research.
3.7 Research design
Research design refers to the overall configuration of a piece of research to explain
what kind of evidence is gathered and from where; and how such evidence is
interpreted in order to provide robust answers to the basic research questions (Easter-
Smith et aI., 1991). Similarly, Yin (2003) defined research design as a way of
collecting and analysing empirical evidence. He suggested three criteria for
distinguishing between different research strategies: (i) the type of study questions:
(ii) the researcher's control over actual events; and (iii) the degree of focus on
contemporary, rather than historical, phenomena.
It is crucial to study the real-life context as the aim of this research is to understand
and examine why and how indigenization policy has been formulated and
implemented by stakeholders in the three Gulf states. A case study approach was
deemed the appropriate strategy. The justification for this is presented below.
3.7.1 Case studies
This qualitative research exammes stakeholders' perspectives of indigenization
policies in three Gulf states and reveals factors that impede or promote their success
in transforming nursing workforces. A case study strategy is useful and appropriate to
gain a rich understanding of such a complex issue within its context, particularly
when a holistic, in-depth investigation is needed. Hall et al (1975) report that the use
of case studies has proved an attractive and useful method of illustrating and
conveying the rich detail of various kinds of events. They argue that the case study
approach is as effective as other approaches in suggesting general propositions about
how policy develops. Also, that this approach is a valuable and useful means of
conveying the immensity of the task confronting those who embark upon the journey
from description stage to generalization stage. Case study overwhelmingly moves
towards a conclusion and suits the exploration of the meanings actors attach to their
behaviour in policy-making situations (Hall et aI., 1975).
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Chelimsky (1990) points out that case study is a method for learning about a complex
issue, based on a comprehensive understanding obtained by extensive description and
analysis of that issue taken as a whole in its context. Yin (1994) defines a case study
as "an empirical inquiry that investigates a contemporary phenomenon within its real-
life context, especially when the boundaries between phenomenon and context are not
clearly evident". He gives several reasons for selecting this tool: "Case studies are the
preferred strategy when how or why questions are being posed, when the investigator
has little control over events, and when the focus is on a contemporary phenomenon
within some real-life context" (Yin, 1994). However, Hall et al (1975) point out that
the status of case study remains dubious, illustrating two main types of criticism of
thi s approach:
(1) method has not been employed in a sufficiently scientific way to advance
theory; and
(2) method does not lend itself to generalization and cannot form the basis of a
theory.
Nevertheless, they conclude that the use of the case study method is justifiable and
profitable if there is a conceptual framework from which to depart; a reasonably
similar set of cases to provide good opportunity for careful comparison; and if policy-
making is considered over time rather than by isolated decisions (Hall et aI., 1975).
Taking all the advantages and disadvantages of the case study into consideration, this
approach is appropriate for this research which seeks to delineate how stakeholders
think about and interpret their country's indigenization policy. It captures the meaning
of stakeholders' personal descriptions of their experiences and perspectives of
indigenization policies and how they are implemented. Case study is also appropriate
because the researcher has no control over actual behavioural events. The
phenomenon is contemporary and the study questions fit the case study criteria. As a
national and social policy, indigenization operates multidimensionally and involves
many variables and factors over which the researcher has no control. Ghauri and
Gronhaug (2002) argue that case study is particularly useful when the variables and
concepts under study are difficult to quantify. In addition, the case study enables a
holistic view of the phenomena and the issue of context. Its unique strength is its
ability to deal with a full variety of evidence that includes documents, artefacts,
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interviews and observations. Here, the case study strategy was used to identify the
trends in indigenization policies in the three selected Gulf states and to establish the
degree of success in implementing these policies in the nursing workforce.
This study involved multiple cases selected carefully to enable comparison. Based on
the aims of this research, the single case strategy was not deemed appropriate to
address the study questions. This study does not represent the critical case that seeks
to test any hypothesis or theory. It does not represent an extreme or unique case but
rather homogeneous cases that seek to understand and compare issues related to
indigenization and nursing. Most importantly, multiple cases were necessary because
one main objective of this research was to examine and analyse the principal
differences and similarities in the strategies adopted to advance indigenization of
nursing workforces. A single case study approach could not achieve this - it has been
criticized for being weak in design as it does not allow meaningful comparisons
(Ghauri & Gronhaug, 2002).
Multiple case studies were accepted as appropriate and essential for this research
because indigenization of a nursing workforce involves a number of issues and
stakeholders. This requires examination and comparison between and within the three
cases. Multiple case strategies are more powerful and convincing as they provide
more insight into the indigenization policy in three nursing workforces than would be
possible in a single case strategy. Multiple case study research requires more
extensive resources and time but provides more compelling evidence and enhances
the overall impact of the study (Hakim, 2000).
3.8 Data collection process
Qualitative methods are being used increasingly in the public policy arena due to the
increasing need to understand complex behaviours, needs, systems and cultures
(Ritchie & Spencer, 1994). Jenkins-Smith (1990) suggests that the nature of the policy
problem is such that a variety of approaches are required to deal with the complexity
of the process. The questions and aims of the research are guided by the methods
used. In this study, qualitative methods were considered most appropriate to describe
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and explore the phenomena under study. Van Maanen (1983) defines qualitative
methods as:
an umbrella term covering any array of interpretive techniques which seek to describe,
decode, translate, and otherwise come to terms with the meaning, not the frequency, of
certain more or less naturally occurring phenomena in the social world.
As outlined above, natural settings obtained through semi-structured interviews and
documentary analysis were used as the direct sources of data in this study. Before
detailed explanation of the interviewing and documentary analysis stages it is
important to highlight the selection of participants and means of access to the
research's setting process and its sampling techniques.
3.S.1 Selection of case studies
The case studies selected for this study were the three Gulf states of Saudi Arabia,
Bahrain and Oman. These have many commonalities in their societal nonns and
economic bases but differ in their management practices, policy development
environment and implementation. Health-care servIces, labour forces and
indigenization policies confront similar broad issues and challenges throughout the
Gulf states. Saudi Arabia, Bahrain and Oman were selected to represent (to some
extent) the different social, cultural and policy environments in the region. They were
chosen for two main reasons: access and specific features pertinent to the research.
Bahrain and Oman were sampled because they had indigenization policies and
interesting issues associated with nursinglindigenization. Bahrain was chosen to
represent one of the smaller states in the Gulf in tenns of area, population and labour
force and for the size of its indigenous nursing workforce. It also has the highest
percentage of indigenous nurses among the Gulf states (63% of the workforce are
Bahrainis) and was therefore thought to be a useful case of indigenization best
practice that could offer relevant insights.
Oman is a medium-sized country with several important population and labour-force
features. There are sizeable numbers of foreign nationals among its population and it
has a thriving indigenous nursing workforce (49%), second only to Bahrain. Given
that Oman had only five indigenous nurses in 1975, this remarkable achievement
makes it an essential case study for any investigator studying indigenization in the
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nursing workforce in the Gulf. Oman is also unique among the Gulf Arab states for its
ethnic diversity - many different Islamic and ethnic groups play important roles in its
affairs.
Saudi Arabia is the largest state in the Gulf in terms of area, population, economy and
labour force. It was chosen for the diversity of its health-care labour force and its huge
reliance on foreign health workers, especially nurses. It was also one of the first Gulf
states to initiate an indigenization policy. The high percentage of foreign workers in
its health service enabled this study to emphasize the issues around indigenization
policies and thereby analyse and anticipate their likely impact on the indigenous Saudi
nursing workforce. In addition, it is the home country of the researcher and therefore
best known to him.
Finally, some of these states were interested in facilitating a study of indigenization in
the health service in order to improve current practice. This made access and the
progress of research more likely.
3.8.2 Selection of participants
Having prepared the interview instrument, the researcher had to decide who to
interview. This has been a major challenge, especially as the phenomena under
investigation were new and never before researched in the Gulf countries. A total of
78 stakeholders were included and took part in semi-structured interviews (see
stakeholder profiles Tables 9-13). The researcher sought to undertake individual
interviews with stakeholders who had experience in the nursing workforce, education
and/or training and those who had knowledge and experience of indigenization
policies and human resource management.
Four parallel approaches were used to select stakeholders for this study. Firstly, the
researcher's previous working experience in the Saudi health service enabled him to
take advantage of personal relationships and connections with various individuals.
Stakeholders who have worked in the Gulf states' health service for a number of years
were contacted personally, by telephone and bye-mail. Secondly, the researcher
contacted the Health Ministers' Council for the Gulf Cooperation Council (miC).
The HMC contacted a number of potential stakeholders in Bahrain and Oman,
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described the study and invited those interested to contact the researcher by telephone
or e-mail. Full information about the study was e-mailed to those who made contact
(26) and interviews were arranged. The third overall sampling strategy involved case
study visits to various health-care organizations, especially in the researcher's home
country of Saudi Arabia.
The researcher spent three weeks approaching potential interviewees in their offices
and workplaces to arrange flexible individual interviews (in order to avoid any effect
on their work) with various stakeholders. Some interviewees knew about the study;
others required explanations of the purpose and procedure. Convenient interview
times were arranged for those interested in taking part (17), the majority of whom
were from Saudi Arabia.
This section provides an overview of the participants in the three countries. Table 9
shows that stakeholders were drawn from a number of disciplines but a significant
number were nurses, nursing students or from a nursing background. Nearly 600/0
were males but this is attributed to the fact that the Saudi Arabian case study provided
more than half the stakeholders. In Saudi Arabia, males dominate most positions in
nursing - especially at senior levels. The majority of stakeholders were Gulf nationals
currently working in the three health services.
Table 9 Disciplines and backgrounds of stakeholders
Stakeholders Saudi Arabia Bahrain Oman Totals
Policy-makers 6 3 2 11
Human resource/indigenization managers
4 2 2 8
Hospital administrators 4 1 1 6
Nursing school 5 1 4 10 administrators Nurses 6 2 4 12
Nursing students 8 2 5 15
Religious leaders 3 1 1 5
WHO officer - - 1 1
Community/public 6 2 2 10
Total 42 14 22 78
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Table 10 Nationality of stakeholders Saudi Arabian 41 (53%)
Omani 23 (29%)
Bahraini 14 (18%)
Table 11 Age of stakeholders (years) 21-25 12 (15%) 26-35 14 (18%) 36-45 19 (24%) 46-55 25 (32%) 56-60 6 (8%) 61+ 2 (3%)
Table 12 Gender of stakeholders Male 46 (59%)
Female 32 (41%)
Table 13 Ethnicity of stakeholders Gulf nationals 73 (94%)
Foreign nationals 5 (6%)
3.8.3 Sampling strategies
There are many qualitative and quantitative sampling strategies. The most dominant
sampling strategy in quantitative research is probability sampling. This depends on
the selection of a random sample from the larger population and aims to generalize a
study's findings to the population (Hoepfl, 1997). By contrast, purposeful sampling is
the most dominant strategy in qualitative inquiry. This seeks information-rich cases
which can be studied in depth (Patlon, 2002). This research starts with a purposive
sampling technique and proceeds with another - snowballing. These sampling
techniques were used in the present study, not for statistical reasons but simply as a
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means of ensuring representation from the full spread of stakeholders in the three
states, with as little bias as possible.
This qualitative research stresses in-depth investigation of new, rarely researched
phenomena. Purposive sampling is used rather than random sampling because the
emphasis is on the quality of stakeholders rather than their numbers. This is to gain
the maximum knowledge about the subject of the inquiry. Patton (1990) identifies and
describes sixteen types of purposeful sampling including: deviant case~ typical case;
maximum variation~ snowball~ and purposive. Purposive or theoretical sampling
derives from the belief that the investigator's knowledge about the population and its
elements can be used to handpick participants in the sample (polit & Hungler, 1991).
The composition of a sample can be adjusted to meet a study's aims and coverage by
adopting and designing a range of different approaches to purposive sampling
(Ritchie & Lewis, 2004). Homogeneous samples were chosen in this study to give a
detailed picture of the indigenization policies in the nursing workforces in three Gulf
states which share similar subcultures and characteristics. This allows detailed
investigation of social processes in a specific context. The stakeholders were chosen
specifically to represent a range of views within the nursing industry; to represent the
whole Gulf region; to unpack and examine issues on the policies and practice of
indigenization~ and because they shared common experiences and knowledge of
indigenization policies and nursing issues in the Gulf. However, they also offered a
diversity of views in their understanding, interests and perspectives of indigenization
policy and nursing. This enabled the researcher to gain a more rounded and deeper
understanding of the multi-dimensional aspects of indigenization.
The purposive sampling criteria employed in this study included participants with
experience of indigenization policies; working in a nursing environment mainly
staffed by foreign workers; and working in a nursing environment containing
indigenous workers. Also, people living and working in one of the three Gulf states of
Oman, Bahrain and Saudi Arabia and those employed by public health organizations
such as hospitals, nursing schools and ministry of health agencies.
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In spite of the apparent flexibility in purposeful sampling, Patton (1990) advises
researchers to be aware of three types of sampling error that can arise in qualitatiye
research: (i) distortion caused by insufficient breadth in sampling; (ii) distortion
introduced by changes over time; and (iii) distortion caused by lack of depth in the
data collection process.
The researcher handpicked stakeholders that he considered possessed the necessary
knowledge and experience. In order to gain a true perspective of stakeholders'
responses to the indigenization policy, interviews were conducted with those with
experience of both an indigenization policy and working in a nursing environment
staffed mainly by foreign workers but containing a considerable indigenous element.
This was a relatively easy task in the researcher's home country (Saudi Arabia)
because of his previous knowledge of the health sector and strong networking. The
first interviews were held with existing contacts who met the specific criteria
(purposive sampling): thirteen Saudi officials: nine male and four female. I asked a
number of questions including the following:
l. What is the indigenization policy and what is this stakeholder's position on its
implications for the nursing workforce?
2. Who does this stakeholder believe the researcher should talk to concerning
indigenization and nursing and why?
The same steps were used in Bahrain and Oman but the researcher had to seek the
help of the HMC in Riyadh, Saudi Arabia, to find the appropriate stakeholders.
Snowballing is a well-known technique used in network studies, particularly in
situations where stakeholders are not easily identifiable (Goldenberg, 1992). It is a
simple process of expanding the number of contacts by asking an initial group of
stakeholders or participants to identify individuals they feel should be involved in the
research (Goldenberg, 1992; Wassennan & Faust, 1994). This technique was
extremely useful in helping to identify relevant individuals and organizations in the
three Gulf states. Initially, pertinent stakeholder groups were identified by reviewing
documents and conducting a series of brief and infonnal interviews to identify those
with interest in, and knowledge of, the indigenization policy. This was used to
establish a stakeholder database from e-mail and telephone lists and other databases.
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A checklist for identifying stakeholders was drawn up to ensure that all were listed
and that all potential supporters and opponents of indigenization policies had been
selected. The key to the success of this process is to be as exhaustive as possible so
respondents were asked to review this list to identify any potential stakeholders that
they felt had been omitted. The majority named one or more potential participants.
When the names of suggested new interviewees began to be repeated the researcher
considered that he had reached the exhaustive stage at which no new participants can
be suggested. The decision to stop sampling took consideration of the research goals
and the need to achieve depth through triangulation of other data sources. Guba
(1978) identifies strict guidelines to indicate when to stop the data collection process.
These include: (i) exhaustion of resources; (ii) emergence of regularities; and (iii)
overextension (researcher goes too far beyond the boundaries of the research goals).
3.8.4 Access to research setting
As a Gulf national the researcher required no special arrangements or visas to enter
any of the countries. However, officials from ministries of health and other
government agencies had to grant permission for visits to various organizations and
health-care facilities in all three Gulf states. The researcher encountered many
difficulties in gaining access to the required sites in most of these countries. Officials
and people in Bahrain were the most helpful individuals in the three states.
Lofland and Lofland (1984) believe that successful access to situations is more likely
if the researcher makes use of contacts who can help to remove barriers to access;
avoids wasting participants' time by undertaking advance research for information
that is already on public record; and treats participants with respect and courtesy_
However, it was problematic to access some locations, especially in Saudi Arabia
when women were present. Such situations required special arrangements in advance.
Sensitivity to local practice suggested that I approach the management of the
organization supervising a nursing college if I wished to make a visit.
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3.9 Data collection methods
3.9.1 Interviews
Interviews were considered to be the most appropriate method for this study. In the
absence of reliable data and information about indigenization, a guided conversation
method is the most appropriate technique for eliciting rich, detailed materials that can
be used in qualitative analysis (Lofland & Lofland, 1984). Qualitative interviews may
be used either as the main strategy for data collection or in conjunction with
observation, document analysis or other techniques (Hoepfl, 1997). Interviewing is
one of the most widely employed methods in qualitative research and an important
source of case study data (Fontana & Fry, 1994; Silverman, 1999; Yin, 1994).
I believed that face-to-face interviews would provide a richness of detail that would
help to clarify and elicit stakeholders' beliefs and experiences of the study
phenomena. Live interviews are particularly important and valuable as they supply
immediate feedback on the enquiry and suggestions for its future (McNiff, 1997). In
addition, stakeholders have greater freedom to talk about the issues that are relevant
and important to them. This study employed the interview method because of its
potential to provide in-depth penetration of the issues surrounding indigenization,
especially those related to the perceptions, meanings and definitions of stakeholders.
Interviewing enables the researcher to see the research topic from the perspective of
the stakeholders. The potential to understand how and why a stakeholder holds a
particular perspective enables the researcher to produce data of great depth.
Patton (1990) identified three types of qualitative interviews:
1. informal, conversational
2. semi-structured
3. standardized, open-ended.
Semi-structured interviews leave the researcher free to probe and explore within
predetermined inquiry areas (Hoepfl, 1997). They also provide interviewees with full
opportunity to express themselves freely and behave naturally. Semi-structured
interviews were employed to encourage participants to relate to the story, that is - the
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indigenization policy and the shortage of indigenous nurses. Data were sought to
illuminate dynamics in two key dimensions.
1. In-depth examination and understanding of stakeholders' experiences with,
and views on, indigenization policies and opportunities and barriers for
indigenous nurses.
2. Contextual understanding of indigenous nurses' situations 10 local
workplaces and how these might vary according to local policies and
practices in the three Gulf states.
These two dimensions were operationalized through individual semi-structured
interviews with stakeholders with different backgrounds and experiences in different
circumstances across the three countries. A participant interview letter in both English
and Arabic (see Appendices 4 and 5) was sent to potential participants. A series of
semi-structured interviews was conducted with 78 stakeholders (see Tables 9-13)
over an 8-month period from June 2005 to January 2006. Each interview lasted
between 60 and 90 minutes~ 19 were conducted in English and 59 in Arabic. The
majority of interviews were audio recorded but 8 interviewees (6 Saudi Arabian; 2
Omani) asked to be interviewed without a tape-recorder. The majority of infonnants
were interviewed in their own organization's offices. Those who did not belong to an
organization were interviewed in public places such as hotel lobbies and libraries.
Three were interviewed in their own homes.
Four group interviews were conducted. The first was held with a group of three
female nursing students in Saudi Arabia who preferred to be interviewed together in
the college dean's office. The second involved four Omani nursing education
personnel who preferred to be interviewed together because of time constraints. The
third and fourth group interviews involved three Saudi female nurses and three Omani
nurses, respectively. They also wished to be interviewed together. Most (especially
young) women preferred to be interviewed in groups because of the local culture,
shyness and religious requirements that a woman should not be alone with a strange
male. All these interviews used the same process and were arranged either by the
individual whom I had intended to interview or by their organization. Group
interviews have become popular in health research as they offset some of the
disadvantages of one-to-one interviews (Green & Thorogood, 2004).
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Semi-structured interviews allow the researcher to set the agenda and are also used as
a way of encouraging participants to relate to the story or phenomena of the study.
However, they are also time consuming, expensive and may miss important areas
(Silverman, 1999). Despite the possible limitations associated with the use of
interviews and the possible advantages of other approaches to data collection (such as
questioner or focus groups), this approach to data collection was found to be the most
effective means to gather and handle an adequate and appropriate range of data, given
the context of limited resources within which this study was carried out.
The researcher prepared a semi-structured interview process (see Appendix 6) that
incorporated an interview guide for use with stakeholders. In addition, the guidelines
in Arabic and English (see Appendices 7 and 8) included general questions for all
interviewees and specific questions designed for each case study. An interview guide
is a list of questions or general topics that the researcher wants to explore during each
interview (Hoepfl, 1997). The interview process is guided by this core of common
questions but allows some flexibility in the questions posed by the researcher. This
helps the researcher to draw out detailed data from stakeholders. Patton considers that
the interview guide strategy offers more structure than a completely unstructured,
informal conversational interview, but maintains a relatively high degree of flexibility
(patton, cited in Rubin & Babbie, 2001).
The interview guide presented two mam groups of questions. The first set was
designed to collect basic information about the stakeholders and their role in their
organizations. The second was designed to elicit responses regarding a number of
topics and sub-topics including: (i) human resources; (ii) the labour market; (iii)
indigenization policy; and (iv) women's role in public life. Interviews were
audiotaped and transcribed; field notes were typed into a word processing programme.
The first two interviews in each country were used as pilots to test for ambiguous or
missing questions that could be clarified or added for subsequent interviews.
In qualitative studies, the flow of information from participants sharpens the focus of
the research question and other related questions of a more general nature (Strauss &
Corbin, 1990). At the beginning of an interview, each stakeholder was asked several
general questions (Appendices 7 and 8). Spradley (1979) calls these "grand tour
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questions" as they ask stakeholders to give a verbal tour of something they know well.
They are important for putting the respondent at ease and provide an opportunity for
the researcher to show interest and build a rapport. At the conclusion of each
interview, respondents were thanked for their participation and asked if there was
anything that they wished to add or thought would be important for the researcher to
know. Some interviewees provided additional information in the form of reports or
referrals to related web sites or conference documents.
It should be noted here that the interview questions varied according to the
interviewee's role and responsibilities. Specific questions were designed to reflect
differences between stakeholders with different roles and responsibilities. In
summary, these interviews aimed to identify the issues regarding the shortage of
indigenous nurses and indigenization policies. The interview protocol provided a core
of common questions but allowed some flexibility to adapt to different interviewees.
It can be problematic to carry out research when the researcher is not sufficiently
familiar with the social mores or the language of his/her subjects (Hancock, 1999). As
a Gee national whose native language is Arabic, my familiarity with the region's culture and norms helped me to navigate my way through these interviews and deal
with some of the cultural challenges. Language is very important in qualitative
research. Interviews were conducted in two languages (Arabic and English) so
translation and clarification of questions was necessary to ensure validity and
accuracy. Mainly, Arabic was used to obtain the data.
Some interviewees preferred and felt more comfortable in their Arabic mother tongue
even though they could speak English. They felt that their own language enabled them
to give a more accurate picture of what they wanted to say, especially those in
important positions who felt that their words could reach a superior. Some
interviewees were uncomfortable about expressing their feelings despite assurances of
confidentiality. This may be due to the existing political culture and lack of
transparency that characterizes the political systems in the region, particularly Saudi
Arabia. Some respondents preferred to use English and others used English as their
first language with occasional Arabic phrases or words to explain some cultural or
social terms. Green and Thorogood (2004) suggest that: "Language functions largely
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as the method of providing access to 'facts', as a window on the world, through which
we can see the respondent's opinions, beliefs or behaviours". But they say that
language is more central in most qualitative work: "It is seen as the route to
understanding how the respondents see their world ... or as the route to understanding
the categories that shape the world."
All interviewers need at least to be aware of how interaction itself produces meaning.
This entails sensitivity to the social context of the interview as experienced by both
parties. It also assumes a cultural familiarity with the ways in which language is used
in practice: how phrases, words and opinions are used other than for their intrinsic
content. The researcher's bilingualism was very helpful for carrying out interviews
and translating the transcripts into English although it was very time-consuming to
translate and analyse the data at the same time. Yet translation is a vital part of the
data analysis process. The comprehensibility of the English versions of the interview
transcripts were checked with a native English speaker. No major problems were
encountered in the interviews in Oman and Bahrain where they speak Arabic using
similar dialogue or slang. The more social and cultural similarities there are between
interviewer and interviewee, the better they will understand each other (Green &
Thorogood, 2004).
Research in developing countries, such as those in the Gee, can face a number of
problems concerning local cultural norms. The researcher's previous employment as a
personnel manager with experience of many interviews with a range of people helped
tremendously. It is not easy to interview women in these Gulf states (especially Saudi
Arabia) and a number of steps are required to ensure good responses and cooperation.
Most interviews with Saudi women had to be conducted either with the door of the
room open or in the presence of a chaperone. For example, I had to interview three
Saudi nursing school students in the presence of the director of the nursing school, a
Jordanian woman. Two of these students wore a nilwb, a type of veil which covers the
whole head and face apart from the eyes. The third wore a scarf covering only her
head. In Oman, some interviewees felt able to voice certain views and opinions on
social and political issues that they might not have told to a fellow Omani. They felt
that an outsider was unlikely to discuss these issues with other Omanis. Generall y.
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people in the Gulf states are hesitant to talk openly about sensitive issues such as
politics and religion, fearing state reprisal.
As indicated earlier, all the Gulf states share common social and cultural
characteristics. However, Saudi Arabia was the most difficult country among the three
in this study in terms of access to research sites and to participants, especially women.
Prior approval was required for visiting and interviewing female students. For
example, in one college in Saudi Arabia the researcher had to pass through two
guarded gates before arriving at the main gate. A Saudi female chaperone
accompanied him inside the college and warned female students and staff to wear
their veils (in Saudi Arabia these cover both head and face) by saying loudly that a
male was on the premises. The researcher's cultural background and previous
working experience enabled him to negotiate and navigate such customs during the
fieldwork and interviews.
3.9.2 Documentary analysis
Analysis of documents was an invaluable source of information for this research.
Multiple data collection methods provided not only rich and valuable information
about the investigated phenomena but also enabled one source of information to be
tested against another. Different forms of evidence from different management levels
allowed scrutiny of alternative explanations (Mehmetoglu & Altinay, 2006).
Documentary analysis provided the historical and technical background for
understanding the mechanism of the indigenization policy process and practices.
Various government publications, reports, decrees, historical documents, policy
statements, conference materials and newspaper articles related to the indigenization
policies and nursing workforces in the three Gulf states were collected and analysed.
Public records or official statistics produced by international organizations (e.g.
WHO) and regional and national agencies (e.g. GeC) were rich sources of data for
exploring the history of nursing in the GeC countries and the concerns of the nursing
profession during the last 30 years or so. Special attention was paid to media and
Internet reports and articles as in the Gulf they often contain ad hoc statements from
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government officials who cite data that are not published. In addition, in a country
like Saudi Arabia where there was a scarcity of information regarding indigenization
and nursing, these materials were particular rich documents of social events and
labour-market issues. Bryman and Burgess (1993) argue that documents tell us about
the aspirations and intentions of the period to which they refer and describe places and
social relationships at a time when we may not have been born, or were simply not
present.
Several methodological issues were raised by the documentary analysis. First, the
research was limited by what is available and accessible in the three countries. In
most Gulf states, especially Saudi Arabia, not all organizations retain records or
would allow a researcher access to them. Second, data collected or generated for one
purpose can be difficult to use for another. Third, a researcher has no control over (or
often much knowledge of) how data were collected. Finally, documents can be read in
a number of ways and also can provide insight into the perspective of those who
produced them. Official reports, policy statements and other documents (e.g. grey
literature, unpublished reports) are sources of information that may enable the
researcher to explore the political processes and world views of those who produce
them (Green & Thorogood, 2004).
3.10 Data analysis of interviews and documents
This section describes the analysis and interpretation of the interview data and
documents in the study. It should be noted here that all participants were stakeholders
and policy stakeholder analysis was used to analyse the data from interviews and
documents.
Bogdan and Biklen (1998) define qualitative analysis as: "working with data,
organizing it, breaking it into manageable units, synthesizing it, searching for
patterns, discovering what is important and what is to be learned, and deciding what
you will tell others". It was daunting to organize data that included hundreds of pages
of interview transcripts, field notes and documents (see Appendix 9). Transcribing
and, in this case, translating was very time-consuming and exceeded time estimations
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- one hour of Arabic audiotape took about seven hours to transcribe. Basic Microsoft
Word software was used for storing transcribed audiotapes.
The analysis depended on locating the documents in the political process and
competing institutional discourses within which they were produced. This required
them to be read with prior knowledge of the topic; sensitivity to what had been
omitted; and the relationships between the subjects of the report, the writers and the
commissioners. However, the study is informed by policy analysis which is concerned
with both prescription and description. It utilizes a framework proposed by Walt and
Gilson (1994) who drew upon a number of theoretical disciplines. They suggest that
policy analysis should focus on four dimensions: (i) content; (ii) context; (iii) process;
and (iv) actors.
Content includes the substance of policy (such as the detail of the mechanisms of
coordination among actors) and describes that surrounding policy-making and
implementation. This study has two distinct contexts and their interface. The Gulf is:
(i) represented by the political, economic and social context in the three states; and (ii)
governed by the operation of the indigenization policy such as national and local
policies in each state. The study also considered the influence of situational factors
(e.g. transfer or death of actor who had acted as initiator or coordinator for
implementation of the policy); structural factors (e.g. establishment of a new ministry
of labour in Saudi Arabia; revision of labour laws in the three states); cultural factors
(e.g. views on working women; psychological dependency on foreign workers); and
external factors (e.g. 11 September 2001 attack on USA, Iraq war and their impact on
various social issues in the Gulf, especially those related to women).
Process is concerned with agenda setting and decision-making in relation to the
indigenization policies in the three states. This study focuses on the processes
involved in indigenization management and coordination among various actors.
Actors, the fourth dimension of the policy analysis, were of particular interest and
therefore this study began with a stakeholder analysis. This is explained and described
in the next section.
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Codes and categories were generated directly from the data and not selected prior to
data analysis. Often they were labelled with words found in the data. A stakeholder
analysis approach centres attention on the actors or stakeholders, the active
contributors to the policy environment. Semi-structured interviews were completed
with stakeholders representing various national organizations, institutions, ministries
and community members. The interviews were based on issues and themes derived
from the study aims. The following topics and issues were covered:
• understanding of the indigenization policy~
• indigenization as a priority and the stakeholder's interest in the indigenization
issue, especially in the health service~
• stakeholder's influence and importance in relation to the implementation of
indigenization policy~
• stakeholder's position and input on the indigenization policy and relation with
other stakeholders.
The matrix table used in the analysis of the indigenization policy in the three Gulf
countries is shown in Fig. 5.
Fig. 5 Matrix table for analysis of indigenization policy
Identify Identify stakeholder 1-+ interests
• + Identify first Expectations interviewees
.L T "
Snowballing Benefits
.- t Establish Resources database
~ • Final list of Conflicts stakeholders
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Influence/ ~ power
+ Importance
T
Authority
.- Knowledge
• Strategic resources
f+ Position
I
.Ir Supportive
T
Opposed
Neutral
Impact on interests
The stakeholder analysis and matrix used in the analysis are described and explained
in detail in the following section.
3.10.1 What is stakeholder analysis?
Stakeholders can be defined as those actors who affect and are affected by a process
through action or non-action (Freeman, 1984). Clarkson (1995) defines stakeholders
as: "Persons or groups who have, or claim, ownership rights or interests in a
corporation and its activities, past, present or future".
Stakeholders are any individuals or groups who are harmed or benefit by, and so have
a legitimate interest in, the issue concerned. Clarkson identifies two types of
stakeholders: (i) primary - those who are essential to the survival of the organization
(shareholders, workforce, customers, those with authority and power over the
organization)~ and (ii) secondary - those with whom the organization interacts but
who are not essential to its survival (competitors, suppliers) (Clarkson, 1995~
Freeman, 1984). Key stakeholders are those who can significantly influence, or are
important to, the success of the policy (Overseas Development Administration, 1995).
The stakeholder analysis approach has become an established framework in policy
analysis.
Reich (1994) claims that stakeholder approach aims to identify the main policy actors~
their understanding of the issue~ and their position, interests and influence on the
issue. Stakeholder analysis is an approach for gathering information about actors in
order to understand their position on certain policies or decisions. Freeman (1984)
originally investigated groups in terms of governments, political groups, shareholders,
activist groups, consumers and employees. Several authors have proposed a variety of
stakeholder types. For example, Henriques and Sadorsky (1999) introduce four
groups: regulatory, community, organizational and media. Sirgy (2002) categorizes
stakeholders into three groups: internal, external and distal. Lim et al. (2005) say that
stakeholders are likely to require different degrees and types of attention and interest
depending on their power, legitimacy and urgency and that the levels of these
attributes can vary from time to time. Varuasouszky and Brugha (2000) argue that
stakeholder analysis is a tool, or combination of tools, for generating knowledge about
actors, groups and organizations in order to understand their behaviour, intentions,
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interrelations and interests for assessing the influence and resources which they have,
and can bring to bear, on decision-making or implementation processes.
A number of steps are used in stakeholder analysis. Dick (1997) suggests four: (i)
identify the principle stakeholders; (ii) investigate their roles, interests, power and
capacity to participate; (iii) identify the extent of cooperation or conflict between
stakeholders; and (iv) interpret the findings of the analysis. Brugha and Varvasovszky
(2000) argue that the collection and analysis of data on actors makes it possible to
develop an understanding of - and possibly identify opportunities for influencing -
how decisions are taken in a particular context. Gergen (1968) recognizes the
importance of gathering infonnation on actors and of their role as potential leverage
points in the process of policy fonnulation.
Stakeholder theory addresses how the diverse and conflicting interests of stakeholders
can be reconciled. However, it fails to address how to resolve conflicting interests
within a category of stakeholders. Those within a stakeholder group may have
different interests or interests that are ill-defined or even ill-conceived (Donaldson &
Preston, 1995). The fonnulation, adoption and implementation of policy involve the
interaction of stakeholders as they negotiate, accept and reject decisions and
proposals. An indigenization policy discourse may involve many actors from various
sectors pursuing various programmes of action, with varying interests and goals.
Therefore, stakeholder analysis is a useful and effective approach for policy research.
The four steps of the framework are described and explained in detail below.
The first step was to identify stakeholders; therefore all potential stakeholders were
identified and listed (Table 9). This is a very important stage as it is critical to identify
relevant stakeholders, especially where (as in this study) there is little understanding
of the phenomena under investigation. The stakeholder literature provides few
methods of identification; nor is it helpful when dealing with the self-selected groups
that do not represent all those with interests in the issue. As explained earlier,
purposive sampling was used in conjunction with snowballing techniques.
The second step was identification of stakeholders' interests in the policy. It was
hoped that this would help to identify conflicts of interest. During interviews, each
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stakeholder was asked about his/her interests in relation to the policy. The matrix
table (Fig. 5) illustrates stakeholders' expectations and benefits, the resources that
affect the policy and the conflicts between them. For example, there were major
differences between the expectations and resources of the Ministry of Health in Saudi
Arabia and other government agencies who control and supervise their own nursing
schools. Donaldson and Preston (1995) argue that all stakeholders' interests have
intrinsic value and recognition of these ultimate values and obligations gives
stakeholder management its fundamental normative base. This stage was problematic
because it was difficult to define some of the stakeholders' interests in the policy and
thus establish any hidden interests. However, familiarity with the policy and the use
of certain questions (concerning stakeholders' expectations, benefits, resources and
interests that might conflict with the policy) helped to define these interests.
The third step was assessment of the influence and importance of stakeholders. The
Overseas Development Administration (ODA, 1995) holds that influence refers to
how powerful a stakeholder is and importance refers to those stakeholders whose
problems, needs and interests are the priority of an indigenization policy. There was
considerable discussion with a number of individuals who were familiar with various
stakeholders of "significant importance" or influence on the policy. For example, the
Ministry of Interior in Saudi Arabia exerts powerful influence (because of personal
connections and its minister's power over other stakeholders) over the implementation
of the Saudization policy. Also, it is highly significant that this ministry controls
strategic resources for the policy, e.g. visas for foreign workers. In their typology of
stakeholders, Mitchel et al. (1997) labelled those who have power and legitimacy as
dominant stakeholders. Power can be defined as: "the probability that one actor within
a social relationship will be in a position to carry out his own will despite resistance,
or the ability of some actor A, to get another actor B to do something that B would
otherwise not do" (Mitchel et aI., 1997).
The position of stakeholders was assessed in the fourth step. Are they supportive,
opposed, neutral or not interested in the policy and its outcomes? Brugha and
Varvasovszky (2000) suggest that an analysis of stakeholders' interests helps to
predict the positions that indigenization policy stakeholders have adopted. It is
important to know each stakeholder's level of support for a comprehensive
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indigenization policy as it defines the level of resources that he/she can bring and how
much importance and priority is given to the policy.
The ODA guideline is a useful tool but has some limitations. As the analysis deals
with a rapidly moving context, in which positions and power are subject to change, it
may have to be updated if results are not used at once. In addition, there is a risk of
overemphasizing actors' importance in the policy-making process (Varvasovszky,
1998).
The data were analysed inductively, a decision influenced by the grounded theory
process of analysis. This theory-building research methodology includes a number of
distinct features such as drawing constant comparisons and the use of a coding
paradigm to ensure conceptual development and density (Glaser & Strauss, 1967).
Within this study this element of constant comparisons was enhanced by the cross-
national comparison method, therefore it is important to highlight the importance of
comparative analysis in social policy. A description of the importance of comparative
analysis in this study will be highlighted in the next section.
3.10.2 Cross-national comparison
The comparative approach has long been central to the study of social policy and is an
important methodological tool for exploring key issues. Higgins (1981) argues that
without some degree of comparison it will be very difficult to know whether problems
of policy are peculiar to certain types of political and economic system or are inherent
in the policies themselves. She further argues that comparative methods in social
policy widen our understanding of the range of policy options. Higgins suggests that
lesson-learning is another advantage of comparative studies but warns of the inherent
dangers - a country could be lured into imitating the policies of another without
sufficient regard for differences in national context. Higgins uses the examples of the
UK and Germany to illustrate how different countries borrow ideas from each other.
Initially the UK developed sickness and unemployment benefits while Germany
concentrated upon pensions and sickness benefit. As both countries gained experience
their systems came to resemble each other very closely (Higgins, 1981).
The example given above indicates that it is not practical to analyse indigenization
policies in Bahrain, Oman and Saudi Arabia without some background knowledge
and assessment of their social, political and economic performance. This comparative
study of indigenization policies and practices at a national level shows that each
country is pursuing indigenization policy through varying approaches. These
differently affect the speed and outcome of the implementation process. The
comparative approach helped to answer some typical questions, e.g. How are
indigenization policies structured in each of the three Gulf states and what are the
similarities and differences between them? In addition, the comparative method
helped to investigate the degree of influence exerted (e.g. by differences in national
culture, national institutions, human resource strategies) on indigenization policies
and the possible reasons.
The original grounded theory was used in this research because it is so useful when
applied to documents. It is also devoted to the development of concepts, categories
and systems related to the research phenomenon. Glaser and Strauss (1967) originally
described two levels of coding: (i) substantive or open coding; and (ii) theoretical
coding. These are described and explained below.
3.10.3 Open coding
Each completed interview was transcribed into a Microsoft Word text format.
Interviews in Arabic were translated into English and the documents were edited by
adding headers to each interview. For example, an interview with the first stakeholder
from Saudi Arabia was entered as (Z) 01S followed by the interview date, location
and position. Open codes were applied by examining each interview text line by line
and identifying labels or codes from the stakeholders' words. The data were coded
manually twice. Each of these codes was compared with other codes within the same
country and then with other codes in other countries. Codes were assigned to
categories according to best fit, established by examining common concepts or
similarities between themes. The goal was to conceptualize and create categories.
Throughout this process, the data were subjected to various comparisons and
questioning.
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A pattern-coding system was used to categorize and correlate data across interviews.
This resulted in the emergence of a number of abstracted categories. For example,
several statements mentioned "people do not respect nursing as a career" and "as a
nurse many people think of me as a maid". These were categorized as - negative
image of nursing. This category was then compared with other categories across the
three states to discover links, what Van Maanen (1983) calls umbrella terms. Another
example generated from the data addresses the ill feeling caused by the lack of
support and the rejection experienced by female nursing school students. This
category (social influences) incorporates these specific concepts and their associated
properties and dimensions. Each category generated from the data through open
coding has been described with its properties and dimensions. Strauss and Corbin
(1998) describe properties as: "characteristics of a category, the delineation of which
defines and gives it meaning".
3.10.4 Theoretical coding
Theoretical coding was the final stage of data analysis, building upon the foundation
of the open coding phase. At this stage the "negative image of nursing" category (also
labelled by its inductive code of: "What's an indigenous woman like you doing
working as a nurse?") was selected. In the other data from Saudi Arabia, this
important finding was validated by comparison with other categories. No other
properties or dimensions emerged during the rest of the analysis. The reliability of the
data provided and the researcher's reliability in collecting and analysing these were
verified by a number of participants in the three countries (Lincoln & Guba, 1985).
The fieldwork memos written up throughout the data collection and analysis phases
were a very helpful tool, enabling the researcher to identify and remedy any gaps in
the approach. An example is given in Appendix 10.
3.11 Ethical considerations
Approval to conduct this research was obtained from the London School of Hygiene
and Tropical Medicine Ethics Committee. Ethical issues in this research were
addressed in keeping with the school's guidelines.
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Before the fieldwork research began, each stakeholder was given written assurances
in both English and Arabic concerning ethical considerations of infonned consent and
the right to anonymity and confidentiality (Appendices 11 and 12). Infonned consent
is a very important element of ethical consideration. In one case in Saudi Arabia the ,
director of a nursing college requested those female students who had agreed to
participate in the research to provide written consent. This was an extra measure to
protect herself, given the local culture that guides interactions between men and
women.
Each participant received a brief description of the research and an assurance of
confidentiality and their right to withdraw at any time without obligation. In the Gulf,
as elsewhere, these are crucial and essential considerations for the development of
trust and the proper conduct of research practice. The researcher was familiar with the
culture and norms and recognized that this type of research requires a high degree of
sensitivity to the feelings and position of stakeholders. It was important to gain trust
during and after the data collection phase. As some people might feel uncomfortable
with audiotaping, each participant was informed of its purpose and asked for
permission to tape their interview.
3.12 Strategies for enhancing rigour of the research
Early in the research process the researcher became aware of the importance of
providing checks and balances to conform to acceptable standards of scientific
inquiry. Padget (1998) and Denzin and Lincoln (1994) identify and elaborate on a
number of strategies for enhancing the rigour of research. These include:
1. prolonged engagem ent
2. triangulation
3. member checking
4. trustworthiness
5. credibility
6. transferability
7. dependability and conformability
8. negative case analysis
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Strategies 4-8 inclusive were employed in this research and are now described in
more detail.
Within a qualitative approach, trustworthiness refers to a conceptual soundness from
which the value of the research can be judged (Marshal & Rossman, 1995). Denzin
and Lincoln (1994) suggest that four important aspects should be considered to
establish the trustworthiness of findings: credibility, transferability, dependability and
conformability. Each of these important factors was addressed in this research.
In general, trustworthiness is bolstered by the amount of time the researcher can spend
in the field and on the data, the triangulation of that data and the subsequent biases
that the researcher brings to the study (Brown et aI., 2002). The researcher spent more
than five years collecting and analysing data and writing this research. Rigour was
assured by making sure that the categories fitted the data; no data were forced or
selected to fit preconceived or pre-existing categories; and no categories were
discarded. Therefore, the researcher feels that this research is the result of good
science and its findings are worthy of attention.
Credibility is produced primarily through prolonged engagement with stakeholders
and triangulation of the data (Lincoln & Guba, 1985) therefore emerging concepts,
categories and (later) findings were shared and checked with the stakeholders. Close
relationships and regular contact with the stakeholders were maintained throughout
the various phases of this research. Findings that emerged were e-mailed to the
stakeholders for confirmation that they matched their expectations. They did.
Guba and Lincoln (1981) describe member checks as a continuous process which
participants should not use to verify findings. Several methodologists have warned
that the tendency to define verification in terms of whether stakeholders or potential
users of the research judge the analysis to be correct may be considered a threat to
validity (Morse et al., 2002). This may be true but does not apply to this study which
is concerned with sensitive phenomena that have not been comprehensively
researched and because of the scarcity of reliable published literature.
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The credibility of this research also rests on the richness of the information gathered;
the ability to analyse data triangulated with a comprehensive review of the literature
on indigenization of the nursing workforce and related issues; and a documentary
review of legislation and policy documents in the three Gulf states.
Lincoln and Guba (1985) argue that the researcher's goal is not to provide an index of
transferability but rather an adequate database from which other researchers can draw
a transferability judgment. Therefore, the findings of this study about shortages of
indigenous nurses in the Gulf and indigenization policies may be transferable to other
health-service groups and other public and private services. This will depend on the
degree of similarity with the situation to which it is transferred. The researcher cannot
specify the transferability of these research findings but can provide sufficient
information and data for the reader to determine whether the findings may be
applicable elsewhere (Lincoln & Guba, 1985). In addition, this research presents a
body of literature and findings with detailed descriptions of the phenomena which
may have value for future studies by researchers.
Denzin and Lincoln (1994) describe dependability as the stability of the research
findings over time. Conformability is the internal coherence of the data in relation to
the findings, recommendations and interpretations. An audit trail can be used to
accomplish dependability and conformability simultaneously (Lincoln & Guba,
1985). For this study, a PhD colleague with demonstrable understanding of the
research process and analysis acted as auditor. He followed all the steps of this
research, starting with the transcriptions and ending with the findings, and was
satisfied with the analysis. This reinforces my belief that the research demonstrates a
sound and credible research process and findings.
Negative case analysis is an important concept in achieving credibility by examining
carefully those stakeholders who appear to be exceptions (Brown et aI., 2002; Lincoln
& Guba, 1985). In this research, negative case analysis involved re-examination of all
cases (after initial analysis) to discover whether the characteristics of the emergent
themes were applicable and fitted all cases. The analysis was considered complete
when the researcher had determined that there were no negative cases.
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3.13 Chapter summary
This chapter provided a detailed discussion of the research process, beginning with an
explanation of the background for the interest of such research and the topics that the
researcher was interested to unpack and investigate. It also highlighted the
positionality of the researcher~ his reflections on this research~ and the tensions,
difficulties and challenges of conducting such research in a context like the Gulf. The
practical difficulties and implications of the lack of reliable data on the phenomena
under investigation have also been identified and elaborated upon.
The researcher has highlighted the difficulties and challenges encountered during his
fieldwork, especially the difficulty in accessing data and information from various
government bodies. The chapter highlighted the importance of developing good
questions in order to acquire better and deeper understanding of phenomena. There is
a detailed explanation of the research approach, paradigm used and reasons for
choosing qualitative methods. A description and explanation of the research design
process is followed by an examination of the case study and comparison between the
case study employed in this study and other research approaches. The chapter also
highlighted the advantages and disadvantages of applying the case study approach in
policy-making studies and the main reasons for adopting it in this research.
The detailed steps used to select case studies, participants and the sampling strategies
employed in this research have been described. A multi-case study strategy was
selected to acquire an in-depth understanding of indigenization within its real-life
context and to support meaningful comparisons between the three cases of
indigenization in Bahrain, Oman and Saudi Arabia. The chapter also examined and
explained the two data collection processes - interviews and documentary analysis.
This included the interview structure guidelines and highlighted some of the
difficulties the researcher encountered during the interviewing stage. The research
analysis process included both interview and documentary analysis and highlighted
some of the methodological issues raised by analysing documents in the three Gulf
states.
129
The study was influenced by some elements of the grounded theory process of
analysis which include a number of distinct features such as the drawing of constant
comparisons and the use of a coding paradigm. The chapter highlighted the
importance of the comparative approach in the study of social policy in general and in
this research in particular. It examined the usefulness of using the approach to analyse
the variables related to the social, political, economic and labour market performance
in the three Gulf states. The chapter also described and explained in detail the
stakeholder analysis and the framework and matrix table used to analyse the
indigenization policy in the three Gulf states. The chapter concludes with an
explanation of the main strategies used to enhance the rigour of the study:
trustworthiness; credibility; transferability; dependability and conformability; and
negative case analysis. The following chapters present the research findings.
130
Chapter 4
Indigenization - regional policy, multiple voices
4.1 Introduction
Indigenization remains an ambiguous and sensitive topic in the Gulf. A lack of
detailed empirical research and reliable data on the labour market ensures that this
remains an under-researched and under-evaluated policy. In addition, indigenization
is a highly politicized and sensitive issue due to its association with virtually every
aspect of life. For example, in Saudi Arabia, criticism of this government policy can
be interpreted as a lack of commitment and therefore a lack of patriotism.
Queries about the policy aims, implementation process and employment practices had
to be considered with political and cultural sensitivity. Some participants used vague
concepts in order to conceal their real feelings or sensitive information. This made it a
lengthy and challenging process to examine the interview transcripts for patterns, key
words, key sentences or messages behind words and statements; and (finally) to
interpret the data and produce findings. However, the resulting data revealed
shortages of indigenous human resources in all three Gulf states' health services in
general and a chronic nursing shortage in particular, in both Saudi Arabia and Oman.
Direct quotations from the interviews have been used in the results chapters. Each
interviewee was assigned a pseudonym that is used to identify their quotations.
It is important to note that the economIC and social outlook of the GeC states,
including their ability to meet major challenges, will be shaped most directly by
factors that influence the demand for oil and related products. The GeC states must
address a challenging set of problems to maintain economic, social and political
stability in the region. Many indigenous and non-indigenous political, human
resources and economic researchers have identified the indigenous human resource
shortage in the Gulf as the greatest problem and one that exacerbates other troubled
areas (Abdullah, 1999).
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4.2 Policy development and structure
As outlined in Chapter 2, the rapidly growing populations in the GeC states are
producing demographic changes with important implications for the labour market.
Traditionally, the GeC's government sectors have absorbed large numbers of
indigenous workers who have benefited from guaranteed employment with the higher
wages and social benefits associated with government posts. However, this practice
has been limited by budget constraints resulting from declining oil prices in the 1980s
and 1990s. The GeC states have responded by initiating a policy to meet the dual
objectives of creating high levels of employment for their own people while reducing
their dependency on foreign workers - indigenization.
Agiomirgianakis and Zervoyianni (2001) define indigenous people as those who are
linked by ties of culture, shared genealogy and history, religion, race or national
origin. They point out that the operational definition of indigenization has varied
among countries, although all have attempted to increase the number of natives in
their workforce. The term is used in this study primarily to focus on activities or
programmes to replace foreign workers with natives of the Gulf states.
The indigenization policies in the three Gulf states require broad definition and a
dynamic perspective. Therefore, any analysis of them requires an understanding of the
livelihood priorities of the indigenous workers~ the relevant policy sectors~ and
whether these sectors have appropriate indigenization policies. Despite widespread
rhetoric and increasing support for indigenization in the three Gulf states, their policy
structures remain predominantly vertical and have not been operationalized
realistically. The majority of administrators (especially in Saudi Arabia) have found it
difficult to improve matters.
4.2.1 One concept, different perspectives
Indigenization in the three Gulf states has emerged from the pressure of growing
unemployment among indigenous populations and other conditions prevailing in local
labour markets, including the increasing presence of foreign labour and supply and
demand conditions. Although some evidence points to the crucial role of foreign
workers, there are limited data about the precise nature of the relationship between
132
foreign workers and high unemployment among indigenous people. A Gee official
commented:
We are certain that there is a strong relationship between the large presence of foreign
labour and unemployment among Gulf indigenous people. When you have more than
12 million foreign workers in the Gulf states, there must be negative consequences on
both the economy and the people. (Sami)
Others disagree with such an analysis and feel that foreign workers have been used to
justify and explain high unemployment rates. One head of an indigenization
department in Oman commented:
We always hear policy-makers blaming foreign workers for their problems. After all
these foreign workers came because we recruited them, they are not imposed on us or
invaders. I think such remarks and justifications epitomises the ostrich syndrome.
(Khaldoon)
Indigenization in the Gulf is often deemed to be a proper remedial measure for
addressing the acute shortage of an indigenous workforce in vital sectors like the
industrial and health-service sectors. Indigenization in the Gulf states is widely
considered a national public programme that requires a policy response. One Saudi
stakeholder indicated:
The concept of indigenization is the same in all Gulf states, although its
implementation differs from state to state. Indeed, policy-makers in the Gulf states
discussing indigenization policy will not always tackle the same issues. (Waleed)
My interviews with many stakeholders, especially in Saudi Arabia, seem to indicate
less than full understanding and limited knowledge of the indigenization policy and its
procedures.
There is a consistent failing on the part of large numbers of stakeholders in the
country [Saudi Arabia] who cannot identify or understand fully the indigenization
policy. If you ask people about it [indigenization policy] you \\'ill get different
responses. Why is that? Because there is no agreement on \\'hat indigenization means
and how it should be implemented. (Waleed)
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4.2.2 Changing concept of indigenization policies
Until the early 1980s, the Gulf states guaranteed ajob for every citizen graduate. This
ceased when the governments were unable to fund higher salaries. The number of
government employees without real, meaningful jobs and the number of graduates
have risen sharply in the last 20 years. Although part of the Gulf governments' policy
agendas, indigenization did not receive more substantial attention until the 1990s. It
has never become a priority. Complexities in coordination and conflicts about
responsibility have often led to ambiguities, fragmentation and neglect in government
policy. For example, the fourth SDP (1985-1990) witnessed the official emergence of
Saudization as a national policy aimed at reducing reliance on foreign workers by
investing in the development of Saudis to replace them.
The Fourth Development Plan was a turning point in labour force planning and
employment in Saudi Arabia because it strongly focused on reducing the dependency
on foreign workers and providing a practical dimension to the concept of Saudization.
(Ministry of Economy and Planning, 2004)
However, stakeholders have come to no agreement about the definition and aims of
Saudization. Some policy documents refer to it as a long-term human resources
development strategy aimed at developing national human resources through
education and training as originally introduced in the fourth SDP: "The issue of
Saudization centres on the intensification of efforts to develop national manpower
through a quantitative and qualitative expansion of education and training, especially
in technical and vocational areas" (Ministry of Economy and Planning, 2000).
Other stakeholders consider Saudization to be a programme to replace foreign
workers in order to solve the unemployment problem in the country. A government
guideline document defines it as:
. . . a restriction of employment to Saudis and gradual replacement of existing
expatriates with national labour according to a number of dimensions, reaching at the
end of the day an ideal localization of employment with full usage of national
manpower.(Manpower Council, 2002)
It is interesting that these two definitions are drawn from two different governmental
documents. The government (policy-makers) that initiated and produced this policy
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cannot agree on the definition and implementation of its own policy. So how can such
a policy be adopted and implemented by its stakeholders? This must cause them huge
confusion and foster a lack of commitment. A female Saudi administrator was very
critical of the Saudization policy:
There are few direct policy and actual legal policy statements on Saudization. What
may be termed 'policy statements' are letters and directions from various policy-
makers to indigenize by giving Saudi nationals preference over foreign workers.
There is a lack of procedures and guidelines regarding how to implement Saudization.
The Saudization policy is fragmented and there are many bits and pieces that need to
be tied together. (Ahlam)
Asked about this ambiguity In the Saudization policy objective, a semor policy
stakeholder replied:
No. No ambiguity at all. Both definitions you [the researcher] referred to are right.
First, we must upgrade their skills [the Saudis] by providing education and training
then finding suitable jobs for them. It is not true that creating jobs for Saudis
necessitates terminating expatriates. That is one way, but as our economy grows, new
jobs will be created. (Waleed)
While the Saudi administrator denied the ambiguity and confusion created by the lack
of clear objectives and structure of the indigenization policy, his counterpart in Oman
admitted that indigenization policy was not well-developed:
It is true that Omanization is a loose term. The only direction we have is to Omanize
[indigenize] full stop. But how, where, and do we have the necessary resources to do
so? Nobody gave us any answers. (Salmeen)
Salmeen was referring to a statement in a document from the Ministry of Manpower.
This stated that Omnization is:
To improve employment opportunities for Omanis to avoid unemployment and to
provide them with training and qualifications in order to conform to labour market
needs; and to replace foreign workers with highly qualified Omani workers.
Furthermore, to increase the participation of Omanis in the labour market in general
and with particular focus on increasing the participation of Omani women. (Ministry
of Manpower, 2003)
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The published indigenization policies are not accompanied by realistic assessments of
how they are to be implemented within existing structures and constraints. Many
administrators in all three states expressed concern about the lack of indications or
guidelines as to how indigenization policies were to be implemented. On many
occasions the researcher asked administrators for a copy of strategies and standards of
implementation but not one could be produced. One head of an indigenization
department in Oman commented:
We do not have detailed written strategies and guidelines to explain what we should
do and what are the main objectives of the policy [Omanizationl We find it difficult
to delegate responsibility to others to implement the policy. This impedes any
coherent coordination of the policy between administrators. (Khaldoon)
Another Saudi administrator in charge of Saudization pointed out:
Administrators in various ministries have no links with indigenization policy-making
because that's all done by others in the Ministries of Interior and Labour, and senior
managers in this ministry [Ministry of Health]. This makes it very difficult for us
because we see no links or coordination at the top level and many of us see no reason
why they should link on our level. (Zaher)
Such confusion about the aims of the policies has created internal wrangling about
where the responsibility for indigenization policies should lie and who should be
responsible for overall maintenance. A substantial advance towards a coordinated
indigenization policy could be achieved if any of these three Gulf states brought
various actors into closer working relations with clear guidelines.
Most of the Saudi government's resolutions and initiatives on Saudization relate to
quantitative aspects rather than qualitative dimensions. For example, the Council of
Ministers decree (No. 50) in 1995 summarized the action required to meet the national
objective of replacing foreign workers with Saudis, whenever possible. In addition,
this decree urged further controls on the availability of foreign workers and
introduced the first Saudization quota for private enterprises - requiring those with 20
workers or more to indigenize their workforce by at least 5% per annum (Shah, 2005).
136
These initiatives and measures indicate that the Saudization policy was used as a
short-term tool to alleviate the unemployment problem in the country. Most
government documents measure progress by the numbers of Saudis who have been
employed and the foreign workers who have been replaced, without reference to the
broader economic and development considerations. A head of department in the Saudi
Ministry of Interior explained his understanding of the Saudization policy:
Saudization is a national demand because one of the most important objectives of this
policy is reducing the number of foreign workers. This will create more jobs for our
people and at the same time reduce the level of unemployment, especially among Saudi
youth. (Bandar)
These views focus on replacing foreign workers with indigenous workers and often
represent policy-makers' stand on Saudization. However, the country's long-term
development strategy spelled out in the eighth SDP (2005-2010) stresses the
importance of meeting the requirements of diversifying the economy by providing
qualified and skilled human resources:
... to develop human resources and continually ensure an increasing supply of
manpower; upgrading its efficiency sufficiently to meet the requirements of national
economy; and replacing non-Saudi manpower with qualified Saudis ... and therefore
diversifying the economic base and reducing dependence on the production and
exploration of crude oil as the main support of the national economy. (Ministry of
Economy and Planning, 2005b)
Although this clearly states that the ultimate aIm of Saudization is to reduce
dependency on foreign workers, it has been bound with certain guidelines and
conditions. The country's planners see the strategic objective as not a purely
replacement strategy but one that considers the requirements of national
diversification of the economy, requiring qualified Saudis who can perform at the
same (or higher) level as foreign workers. This strategic view and the mechanisms to
achieve such aims have been spelled out:
The ultimate source of a nation's wealth increasingly lies in its human resources and
the productive skills of its labour force ... recognizing this trend from the onset of
development planning, the Kingdom's successive plans have given greater attention
to human resources development through continuous support of primary,
intermediate, secondary and higher education, as well as of technical education,
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vocational training, and pre-service and in-service training. (Ministry of Economy
and Planning, 2006a)
The majority of stakeholders in Saudi Arabia expressed satisfaction with such
statements that broadly outline the main objectives of the country's human resource
policy and stress the importance of education and training. However, all stakeholders
expressed their dissatisfaction and disappointment with the way the policy has been
implemented on the ground. One senior Saudi administrator explained:
People lost trust in these documents and statements. They are there for public
consumption both internally and externally. Policy-makers wish to make people
believe that they are doing something about unemployment and Saudization. These
statements do not tackle cultural, political and economic issues affecting Saudization.
(Ahlam)
4.3 Bahrainization and Omanization
Since gaining independence from Britain in the 1970s, Bahrain and Oman have
developed two of the most progressive and advanced economies in the Gee states.
Both have sought to diversify their economies in order to reduce dependence on
declining oil reserves and encourage foreign investment. Bahrain and Oman are
responding to shortages of indigenous workers by pursuing strategies similar to those
in Saudi Arabia. The Bahrainization policy was established in 1988; Omanization
started in 1994. Like Saudization, these terms mean the creation of employment for
indigenous people by replacing foreign workers with nationals.
In 2001, Bahrain's Ministry of Labour and Social Affairs developed a strategy for
employing and integrating the national workforce. This laid the basis for a range of
policies aimed at expanding employment for Bahrainis, including reform of the labour
market. Bahrain and Oman aim to tackle joblessness among the indigenous
populations and reduce dependency on foreign workers. Their integrated and
comprehensive approaches comprise the following components.
1. Adoption of a comprehensive human resource development and
employment policy.
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2. Removal of distortions and segmentation III labour markets through
gradual but consistent structural reforms.
3. Investment in the quality of human capital by enhancing the productivity,
skills and employability of youth.
4. Evaluation and institutionalization of labour market interventions and
introduction of innovation-targeted programmes.
However, Bahrain differs from both Saudi Arabia and Oman in its human resource
vision and willingness to seek professional assistance. Bahrain has asked the
International Labour Organization (ILO) for help in developing a strategy to employ
and integrate its national workforce in the labour market. This would include the main
themes of creating more job opportunities for citizens; minimizing dependence on
foreign workers; and supplying the labour market with a well-trained national
workforce. One senior officer in the Bahraini Ministry of Labour pointed out:
We have a clear vision and strategy for Bahrainization and as I have told you before
we have asked for ILO assistance to help us achieve Bahrainization objectives. We
need to join efforts by everybody in the country in order to implement Bahrainization
policy. (Dawood)
However, it is obvious that combating unemployment is a dominant issue in both
Bahrain and Oman. The Bahraini government adopted a number of proposals to
Bahrainize jobs in order to solve this problem. For example, the National
Employment Project (NEP) aimed at:
Investing in human resources and developing them through appropriate training
programmes and tapping the skills of local professionals so as to be accommodated in
the labour market and have their positive contributions to the country's steady
development. (Ministry of Labour, 2006)
Bahrain and Oman both adopted vocational training projects to upgrade graduate
competencies and enable them to participate in the indigenization process. Bahrain
has established a Labour Market Regulatory Authority to set up strategic schemes and
programmes to upgrade the labour market in the country and reinforce cooperation
with the private sector. Its aim is: "To put up mechanisms capable of ensuring more
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stability m the labour environment and large-scale trammg and
rehabilitation programmes for job seekers" (Ministry of Labour, 2004).
However, there is growmg concern about unemployment among Bahrainis and
Omanis, despite the sustained and targeted investments that have maintained
economic growth and diversification and despite all measures and initiatives to limit
dependency on foreign workers and create job opportunities for nationals. An ILO
estimate predicted that nearly 100000 Bahrainis (approximately 1/5 of the total
population) would enter the labour market in the period 2003-2013 (International
Labour Organization, 2004).
A BCSR study showed that unemployment is confined mostly to Bahrainis
(International Labour Organization, 2005). Unemployment rates for Bahraini males
and females were 14% and 20.4%, respectively. Unemployment among Bahraini
youth was among the highest in the world at 40% (International Labour Organization,
2005). The proportion of foreign workers in the total workforce remained unchanged
between 1998 and 2004, at more than 57%. The ILO attributed this to inadequate
workplace skills among Bahraini job seekers~ their unwillingness to accept manual
work~ low wage levels~ poor working conditions~ and some employers' reluctance to
hire Bahrainis (International Labour Organization, 2005).
4.4 Implementation of the indigenization policy
4.4.1 Implementation in the public sector
Indigenization began in the public sector. In the GeC states the public sector has seen
continuing economic development since the 1970s, with significant expansion in the
number of agencies, services and budgets during the 1970s and 1980s (Abdelkarim,
1999). Since a policy of indigenization in the Gulf was announced, the idea of
employing indigenous workers in the public sector has gained considerable legitimacy
and support. The Gulf governments have become the main employers of indigenous
workers. For example, in 1977 the Saudi Civil Service Bureau that oversees
employment in the public sector passed a resolution requiring only Saudis to be
employed in that sector. The Saudi Civil Service Law explains the exception: " ... an
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exception may be allowed for non-Saudis to work temporarily in those positions that
require special qualifications not available in Saudi nationals" (Ministry of the Civil
Service, 1977).
This exception includes a large number of public institutions. The oil industry, health
service, communication and many other highly technical and scientific institutions
employ large numbers of foreign workers because of the shortage of qualified
indigenous workers. Therefore, the main targets of the Saudization policy have been
mostly clerical, managerial and low-skilled positions. Between 1975 and 2006, Saudi
public-sector employees increased more than fivefold (see Appendix 9) - from
142341 in 1975 to 733 866 in 2006. Of these, 243 757 (approximately 33%) were
female workers. Together they represented 91 % of all public service employees
(Saudi Arabian Monetary Agency, 2006). The number of Saudis increased by 2.9%
during 2005 but there was an insignificant reduction in foreign workers (less than 1%)
in the same period. This is in clear contrast to one of the most important manpower
developments goals highlighted in the last development plan:
... rationalizing the recruitment of labour from abroad and linking its employment and
use with the actual need, activating Saudization decisions, and restricting
employment in some occupations and economic activities to the national labour force.
(Ministry of Economy and Planning, 2005a)
Analysis of foreign workers in the public sector shows a steady increase in numbers
between 1975 and 1994, around 8.5% annually. In Saudi Arabia, the number of
foreign workers in the public sector began to fall by around 9% annually from 1994
until 2004 when numbers began to rise by around 2.4% (Tables 14 and 15). It is
interesting that the reductions in foreign workers started almost ten years after the
official introduction of the Saudization policy. This suggests that the Saudi public
sector is able to absorb only a small fraction of the growing number of Saudi job
seekers and may indicate that the private sector will be the only significant source of
new job creation.
In 2003, Manpower Council Resolution M48/2003 fixed a ceiling for foreign workers
and their dependents - not to exceed 20% of the total Saudi population by the end of
2013. In the same year, the Minister of the Interior (also Chairman of the Manpower
Council) pledged to establish a quota system for foreign workers in which no
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nationality may exceed 10% of the total population (Manpower Council, 2003). It is
difficult to imagine that the government can be serious about such a pledge when it
issued 600 000 foreign worker visas in 2003 and more than 750000 visas in 2004, an
increase of 25% (Abou-Alsamh, 2004). It is also difficult to imagine that such an
ambitious goal can be achieved when the number of foreign workers increased by
13.7% in 2005 (see Table 16), a trend that may well continue for the next few years.
Table 14 Saudi public service employees, 1975-1996
Number of employees
Year Indigenous Foreign Total
Male I Female Male I Female 1975 142341 42400 184741
1976 140807 47055 187862
1977 148062 50976 199038
1978 154789 57252 212041
1979 165056 64 182 229238
1980 183 501 69397 252898
1981 195604 72867 268471
1982 247978 86243 334221
1983 258 124 106 124 364248
1984 274459 121331 395 790
1985 299738 129281 429019
1986 316629 140494 457 123
1987 336456 144523 480979
1988 356307 147 552 503 859
1989 369093 150 116 519209
1990 386760 147938 534698
1991 396891 151 658 548 549
1992 420653 159612 580265
1993 444364 144934 589298
1994 460845 133 014 593 859
1995 480313 128698 609011
1996 506577 109714 616291
Source: Ministry of the Civil Service, 2002
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Table 15 Saudi public sector workforces by sex and nationality, 1997-2005
Saudis Non-Saudis Total
Saudis & Growth Growth
Year Male Female Total Male Female Total non- rate % rate %
Saudis
1997 379025 181 653 560678 10.68 51 827 44 151 95978 -12.52 656656
1998 383996 195419 579415 3.34 49736 39272 89008 -7.26 668423
1999 387779 203879 591 658 2.11 46956 35940 82896 -6.87 674554
2000 408640 204682 613 322 3.66 45776 35672 81448 -1.75 694770
2001 416803 214221 631024 2.89 45644 34 191 79835 -1.98 710 859
2002 438023 214912 652935 3.47 43400 31 653 75053 -5.99 727988
2003 452555 224965 677520 3.77 41698 27748 69446 -7.47 746966
2004 463487 231 007 694494 2.51 41 342 27429 68771 -0.97 763265
2005 472727 240 108 712835 2.64 41 436 29005 70441 2.43 783276
Source: Ministry of the Civil Service, 2006
Table 16 Saudi private sector workforces by sex and nationality, 2004-2005
2004 2005
Number Distribution Number of Distribution Annual
of workers (%) workers (%) growth
(mill.) (mill.) rate (%)
Total labour 6.6 100 7.6 100 15.4 force Male 6.47 98.1 7.44 97.9 15.1
Female 0.13 1.9 0.16 2.1 28.1
Saudis 0.48 7.2 0.62 11.6 28.4
Male 0.46 6.9 0.59 11.0 27.9
Female 0.02 0.03 0.03 0.6 37.7
Non-Saudis 5.91 89.6 6.71 88.4 13.7
Male 5.21 88.2 5.83 86.9 13.7
Female 0.7 11.8 0.88 1.5 25.7
Source: Saudi Arabian Monetary Agency, 2006
Since 2004, a sharp increase in oil prices has produced rapid growth in the Saudi
economy. This has driven the recruitment of more foreign workers to meet increasing
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C
n
demands, especially in the private sector. The Ministry of Economy and Planning
attributed the increased demand and continuing dependency on foreign workers to:
Inadequate numbers of Saudi graduates in scientific, technological and technical
fields in general, and in various medical specializations in particular; and the
difficulty for female graduates in taking up job opportunities in locations far from
their families and homes. (Ministry of Economy and Planning, 2005b)
This might also be attributable to the accompanying growth in government spending
and the creation of a huge number of projects in almost all sectors of the Saudi
economy. Data show that gross domestic product (GDP) grew by 23.7% during 2005;
the gross national product (GNP) grew by 6.6%. This was one of the highest growth
rates in the world (United States Department of State, 2006). Accordingly, this
increase in foreign workers is likely to continue as long as the Saudi economy
continues to grow at the present rate, as more skilled and qualified foreign workers
are required to sustain development. For example, the Saudi construction sector
demanded that the Saudi government issue at least 1.2 million foreign worker visas to
meet the requirements of contractors on government projects alone. The Chairman of
the National Committee for Contractors pointed out that:
... to implement these projects we need at least 1.2 million additional visas to recruit
engineers, skilled labour and ordinary workers. One thing everybody should know.
There will not be any employment [for Saudis] without implementing development
and service projects. (Arab News, 2007)
A Ministry of the Civil Service report issued in 2007 attributed the continuous
presence and recent increase in the number of foreign workers in the public sector to:
The absence of a comprehensive national Saudization policy in the country and the
lack of coordination between government agencies. It also contributed to the shortage
of qualified Saudis who could replace foreign workers. (Ministry of the Civil Service,
2007)
Saudi Arabia's labour force is characterized by a high percentage of public sector
employment and strong divisions between low-paid foreign workers in the private
sector and well-paid indigenous workers in the public sector. Bahrain and Oman are
similar, with the number of indigenous workers in their public sectors exceeding 91 %.
Therefore, the labour markets of the three Gulf states share many structural features,
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face similar constraints and are influenced broadly by the same set of trends.
Differences in the resources available and economic diversification are likely to
influence the speed and depth of the required policy efforts but there are enough
similarities to discuss a broad common indigenization policy in all sectors of the
economy.
As seen above, responses to the formulation and implementation of the indigenization
policies have been confined to the bureaucratic arena. Strong commitment and
leadership is necessary to ensure that these policies are implemented effectively.
However, the most likely future scenario is that Gulf governments, decision-makers
and human resource managers remain ambivalent. They will continue to rely on their
own initiatives and understanding of how a policy should be implemented. In
addition, indigenization might lose the direct attention and support of various non-
governmental groups and those who have advocated these policies over the past two
decades. Future training and monitoring evaluation efforts might also suffer as a result
of serious implementation deficiencies, already recognized by stakeholders. One
senior Saudi stakeholder explained:
We know what the government should do to improve implementation of the policy
but the problem is nobody is listening to us. On many occasions I myself have
recommended certain measures to be taken to improve the policy from my experience
working to implement the policy but no action has been taken. So what can I do? If I
continue banging on about the issue they will consider me as a trouble-maker and you
know what will happen to trouble-makers in our country. (Marzook)
There are fundamental deficiencies in the implementation of the indigenization
policy, especially in Saudi Arabia. The public sector has insufficient capacity to set
the overall direction; coordinate the strategy and work plans for the indigenization
policy; and periodically monitor and evaluate achievements. Reforms could consider
whether technical assistance from the ILO or other international organizations might
enable the Saudi government to build its managerial capacity for indigenization. Also,
stakeholders require more financial support to enable them to monitor and evaluate
indigenization policy services.
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4.4.2 Implementation in the private sector
The literature review described how GeC governments are keen for the private sector
to become the main employer of their growing labour forces. This requires more
detailed analysis of how indigenization is perceived and implemented in this sector. It
is also important to note that the private sector health service is one of the fastest
growing private sectors in all GeC states. All three Gulf states have youthful
populations that produce an increasing number of job seekers who expect their
governments to employ them. However, these governments have the finances and
structures to absorb only a small fraction.
In almost all Gulf states, traditional open employment in the public sector is gradually
being replaced by a more selective recruitment policy. This is intended to reduce
overstaffing which has emerged as a major problem in most public sector
organizations. Most GeC governments have formally announced that job
opportunities in the public sector are likely to remain limited and that job seekers
should consider the private sector. One Bahraini stakeholder commented on the
government's role in employing Bahrainis:
People have to realize that the golden years when the government guaranteed a job
for every citizen are over. We cannot employ all Bahrainis in the public sector. We
have more than we need, a lot more. Actually we need to reduce the size of our public
sector employees. It is neither economical nor logical to be the main employer in the
country. Private sector must take a responsibility in providing more jobs for our
people. (Dawood)
As outlined in Chapter 2, a large segment of the indigenous workforce continues to
prefer public sector employment because it offers higher wages, better merit
increases, job security and training. However, as the public sector has reached
saturation point the Gulf governments have turned their focus to the private sector.
They have concentrated on improving the organizational and administrative
environment of private sector establishments to make them more attractive to
indigenous job seekers. The Gulf governments have realized that a rapidly growing
private sector is essential for any progress in attacking their unemployment problems
and job creati on needs:
146
It is a strange phenomenon we have in the Gulf, here we have millions of foreign
workers who come to work and take advantage of our economic growth, and in the
same time we have our own people unemployed. I think the private sector is getting
greedy and taking advantage of the situation. What I mean is that we [the
government] help the private sector to thrive in order to employ our people but it is
not doing its job. (Dawood)
In recent years these governments have adopted a strategy of economic diversification
in non-oil industrial activities and have started to pay more attention to small and
medium-sized firms, which were often neglected in the past. In many countries, small
and medium-sized firms have played a crucial role in creating jobs and providing
economic stability (Looney, 2004). Although there have been several great successes
in creating large numbers of jobs for the indigenous population, generally the private
sector has shown reluctance to replace large number of foreign workers with
indigenous workers.
The private sector in the three Gulf states is underpinned by a historic compromise
which granted private firms access to state incentives and a free hand in sourcing and
utilizing foreign workers in return for investment. The private sector employs 95% of
the foreign workers in the three Gulf states, 85% of whom are unskilled (Al-Dosary,
2006). The private sector's lack of enthusiasm for indigenous workers and preference
for foreign workers is based on a number of factors. Extensive surveys carried out by
the Council of Saudi Chambers of Commerce and Industry documented the main
Issues.
• Foreign workers accept lower wages than indigenous workers.
• Foreign workers possess the necessary qualifications and experience to
perform their duties; these are lacking in indigenous workers.
• Flexibility of movement - foreign workers will go anywhere in the country
but indigenous workers prefer urban areas.
• Foreign workers are more stable; indigenous workers tend to move from
job to job.
• It is easy to terminate the employment of foreign workers and repatriate
them at any time.
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•
•
Foreign workers are eaSIer to manage, more disciplined and more
committed than indigenous workers.
Indigenous workers are unwilling to adjust to working conditions in the
private sector (working hours, shorter public holidays, six-day working
week vs. five in the public sector).
(Council of Saudi Chambers of Commerce and Industry, 2002)
Over the years, the private sector has used many myths to portray indigenous workers
as unstable, unqualified, unwilling or incapable of performing at the same level as
foreign workers. There is also the myth that indigenous workers lack a work ethic and
are unprepared for very demanding jobs. However, this is not limited to Gulf states or
developing countries. A government study in the UK showed that immigrant workers
have a better work ethic, are more reliable and work harder than British-born workers
(London Paper, 2007). The Gulf governments have rejected such myths as bias. The
private sector is simply justifying its reasons for not employing indigenous workers
and continuing to employ foreign workers. For example, one Saudi senior manager in
the Ministry of Labour commented:
The government has done a lot for the private sector. As you know we have no
taxation on Saudi businesses and have adopted a number of initiatives to help those
[businessmen] to gradually phase out foreign workers. But unfortunately many are
reluctant to employ Saudis and try to use a number of tactics to avoid Saudization.
Previous experiences have proved that Saudi workers have been successful in many
public and private organizations when they are given the opportunity to prove
themselves. Unfortunately what the private sector is spreading about Saudis I
consider a type of discrimination. (Waleed)
This strong verbal commitment to indigenization is not matched in practice. For
example, an analysis of figures issued by the Ministry of Labour in Saudi Arabia
showed that the number of private sector workers totalled 5.4 million at the end of
2005 (other independent figures estimate around 8 million), a 15.4% increase on
2004. Saudi workers comprised only 11.6% of the total labour force in the private
sector (Table 16). In Bahrain, foreign workers comprised more than 57% of the total
labour force in 2004 and the percentage increased in the following year (International
Labour Organization, 2005). This illustrates that governmental institutions and the
148
private sectors have diverging interests and different perceptions of indigenization.
The differences between the two parties are real.
It is interesting to note that the percentage of female workers in the private sector
increased faster than that of male workers. For example, female worker numbers in
Saudi Arabia increased by 37.7% to 0.03 million; male workers increased by 27.9%,
to 0.59 million. The private sector is employing more female workers in line with the
Gulf governments' drive to increase job opportunities for women while respecting
religious and cultural attitudes. As indicated earlier in this chapter, foreign worker
numbers in the three Gulf states have increased since 2004, suggesting that their
indigenization policies face similar challenges in both public and private sectors. It
also supports the contentions of some experts and critics that the indigenization
policies written into the various development plans of the three Gulf states are barely
being implemented (Cordesman, 2003).
Nevertheless, growmg awareness of the existence of an indigenous people
characterized by severe distress, chronic unemployment and hopelessness has
reinforced the conviction that Gulf governments cannot remain indifferent and
passive. The GeC Secretary General warned about the possible consequences: "The
Gee countries need to look at the massive presence of expatriates basically as a
national security issue and not merely as an economic matter" (Gulf News, 2005).
Other experts, like the president of the Arab American Institute, believe that foreign
workers are: " ... a time bomb waiting to explode and unleash riots in the Gulf states"
(Kapiszewski, 2006).
In Oman, business people have voiced their concerns over the mechanism adopted to
force Omanization on the private sector. An Omani businessman commented:
They [the government] always pressure us to employ Omani even if we do not need
them or they cannot undertake the duties and responsibilities of the vacant position. If
we say no, they accuse us of not been patriotic and preferring foreign workers
instead. It is a huge problem for many of us. (Alshabibah, 2004)
However, such strong criticisms of the way that the indigenization policy is being
implemented in the private sector are usually met by a government counter attack.
149
The private sector is accused of profiteering and not responding to major local
challenges, especially growing unemployment among the indigenous populations. For
example, the Saudi Minister of Labour and Social Mfairs warned the private sector of
more restrictions and measures to limit the recruitment of foreign workers:
Saudi Arabia is not a recruitment agency for foreign workers coming from all
directions. We have a responsibility toward our Saudi people to provide them with
decent jobs. This is their right. We will do all we can to limit the number of foreign
workers. (AI-Hayat, 2004)
Private-sector business people in the three Gulf states have argued that indigenization
policies have produced fake jobs to fulfil government quotas. They assert that
indigenous workers have been paid token sums to claim that they were working when
they were not. The Ministry of Labour and some influential Saudi businessmen have
clashed violently and there have been threats to move businesses outside the country
if the government continues this forced Saudization. The policy has been described as
a stumbling block to effective partnership with the government, demonstrating a lack
of understanding of private-sector concerns, methods and principles.
There is a perception that the government is trying to shift liability and responsibility
for the indigenization policy to the private sector. Forceful approaches to
Saudization, such as the quota system, have encountered strong opposition from local
businessmen who say it is potentially harmful and adversely affects productivity and
profitability (Kapiszewski, 2006). One Saudi newspaper described an episode of
Saudization in the private sector:
One fine morning it was decided that the entire fruit and vegetable trade should be
Saudized, and the next moment there were raids on fruit and vegetable stalls across
the country. If any expatriate was found staffing the shop, he was arrested and the
shop was closed down. This drastic measure led to complete confusion in the trade,
which subsequently reported huge financial losses. (Arab News, 2004)
There is growing pressure on the new leadership in Saudi Arabia to push for
Saudization although, as stated previously, this poses a challenge. The Minister of
Labour and Social Affairs (who has the full support of the leadership in his endeavour
for Saudization) said:
150
They [Saudi businessmen] are attacking me every day and accuse me of slowing
down their business by not granting them the [foreign worker] visas they demand; I
am not going to succumb to such criticisms. Saudization will continue whether they
agree with it or not and those who threatened to leave the country I tell them we have
not closed the airport. (Al-Watan, 2006)
In 2005, the Bahraini Parliament introduced restrictions to limit some jobs to
Bahrainis only. This is similar to what has been implemented in both Saudi Arabia
and Oman (Table 17). However, some stakeholders in the three Gulf states have
questioned the effectiveness of restricting some professions to indigenous workers
and warned of adverse consequences on the quality of services and indigenization
objectives. A senior official in the Ministry of Labour in Saudi Arabia commented:
While restricting some sectors of the economy to create additional jobs for Saudis,
people take this for granted. In some sectors, this has affected the quality of services.
It has also deprived some of these sectors of foreign experience. Some businesses
have complained that this measure has increased the price of their services and raised
their labour costs. (Waleed)
A Bahraini administrator agreed with such an assessment and explained:
Some business people have complained about this restriction because it has restricted
them from employing foreign workers who are more experienced and cheaper than
Bahrainis. It has also created a shortage of qualified personnel in some of these
designated sectors. (Dawood)
The Gee labour market will experience an enormous influx of young indigenous
workers in the next few years. These workers will need meaningful work and the
projected job opportunities may not be enough to accommodate them. In addition, the
Gee states employ large numbers of foreign workers at a fraction of the cost of
employing an indigenous person with the same qualifications, or training them to the
same level. Some private sector firms in the three Gulf states will not indigenize
voluntarily and mandatory quotas might be considered as a last resort to force
compliance with these policies. Already, these three states have introduced several
strategies that include incentives for firms that comply and cooperate and penalties for
those that do not.
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Table 17 Policy instruments to reduce supply of foreign workers and increase numbers of indigenous workers in the three Gulf states
Supply of foreign workers Demand for indigenous workers
Direct and indirect fees for foreign Establishment of vanous human workers and their sponsors (work permits, resource development funds to train health insurance) indigenous workers
Centralized visa service with strict New vocational training institutions regulations for international recruitment
Indigenization quotas for private firms Incentives for employing indigenous workers
Restricted employment of foreign workers Indigenization quotas in private firms in certain occupations
Creating more job opportumtles for indigenous population only
4.4.3 Incentives and penalties for implementing indigenization policies
Private firms in all three Gulf states may be asked to justify why foreign workers are
necessary and prove that their skills and experience are unavailable among indigenous
workers. The governments may force organizations to repatriate foreign workers and
stop the transfer of foreign worker sponsorship from one organization to another.
Moreover, private firms that tender for government contracts must meet the specified
indigenization quotas and use money that would have been spent recruiting foreign
labour on training programmes for nationals. The Oman Secretary General of the
Tendering Board stated that: "For a private sector organization to win a government
contract, it must meet Omanization quota requirements" (Al-Watan, 2004).
All three states have limited the number of foreign visas issued to private firms. This
is aimed at minimizing the sale of visas to foreign workers, especially in Asia where
many workers are desperate to enter Gulf states. Some private firms employ "ghost
workers" - recruiting more foreign workers than they need and hiring them out to
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other firms in order to collect a portion of the workers' wages. This practice is illegal
and considered un-Islamic but is widely practised in most Gulf states. However, the
measures introduced to limit and control such practices are usually open to abuse by
well-connected people. As one Saudi Ministry of Interior administrator explained:
The problem we are facing is when we introduce a policy like this [visa control] we
find it difficult to implement it on those who are well-connected to decision-makers.
In this case, these people get their own way by getting foreign worker visas that they
do not need and which they sell as a commodity and make money out of it. They are
creating a black market and depriving our people of job opportunities. (Bandar)
Not many private firms have fulfilled their requirements as it is proving difficult to
enforce these regulations. Also, some labour-exporting countries have expressed
concern over the effects of this recent acceleration of indigenization. For example,
India estimates that the present Saudization policy could affect 1 million Indian
workers working in Saudi Arabia, directly or indirectly (Arab News, 2007).
The Saudization policy in the early 1980s focused on top and middle management but
this approach affected not only productivity but also the overall performance of the
private sector. However, the government's aim of employing indigenous workers in
meaningful organizational roles was at least partly achieved. The airline, banking and
oil sectors have all achieved a 60%-90% indigenous workforce although the situation
for health professionals is not so positive (see Chapter 2). This shows the effect of
structured, rational decision-making. The banking sector achieved a 60% increase in
Saudization in less than five years but the policy has barely begun in other sectors.
This shows the selectivity within Saudization - it is dependent on the sector that the
government chooses and who supervises or controls that sector. It also means that the
government is concentrating on productive sectors rather than service and social
sectors like the health service. However, successful Saudization indicates that
indigenization aims can be attained by providing the right training and skills through
well-planned programmes.
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4.5 Indigenization in the health service
The health sector in the Gulf has witnessed major developments since the 1970s. The
region has some of the most modern health-care facilities with the most advanced
medical technologies in the world. However, Gulf health services face the difficult
task of providing sufficiently competent labour forces to meet the increasingly
complex health-care needs of rapidly growing populations. For the last three decades
(as outlined in Chapter 2), the GeC states have relied heavily on doctors, nurses and
allied health professionals recruited from other countries, particularly the Philippines;
the Indian subcontinent; and other Arab countries such as Egypt, Sudan and Lebanon.
For example, in Saudi Arabia, 80% of all physicians, 78% of nurses and 50% of allied
health personnel come from abroad (World Health Organization, 2005). Moreover, a
sizeable proportion of Saudis working in the health service are engaged III
administrative duties. A Ministry of Health official reported during his interview:
Many of our Saudi employees in almost all fields prefer to perfonn administrative
duties rather than their own specialties. This is a serious problem especially among
those we need most like doctors and nurses. It is a waste of resources. (Marzook)
The sustainability of a health-care system so dependent on foreign workers was called
into question when oil prices fell dramatically in the mid 1980s. This gave further
impetus to policies designed to increase the proportion of the workforce drawn from
the indigenous population, including doctors, nurses and allied health professionals.
Oil prices have soared and billions of dollars in revenues have enriched the GeC
states since 2004 but international and domestic events provide continuing support for
the policy of indigenization. Competitive salaries and high-tech facilities have always
ensured a good supply of foreign health personnel but this is no longer guaranteed as
international shortages increase. One Saudi senior Ministry of Health official
commented:
The golden days of the 80s and 90s are over. We used to hire any numbers we
required and choose from a pool of candidates who were competing to get a job in
Saudi Arabia, but not any more. We have now a difficult time to fill some positions
especially those in critical areas such as oncology, intensive care and cardiac where
there is a huge competition from other countries. (Aisha)
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4.5.1 Global competition
The GeC states now compete with countries such as the USA, UK and others who
have severe shortages of health-care workers. Although offering good pay and
attractive working conditions, some of their competitors may be more attractive
socially - particularly to female workers who are subject to various restrictions on
their movement in the Gulf states. The UK also allows nurses and doctors to be
accompanied by their families, something that is restricted or impossible in some
parts of the Gulf. A senior member of the Saudi Commission for Health Specialties
(SCHS) commented:
Experience taught us not to be entirely dependent on foreign workers. During the
second Gulf war when Iraq attacked Riyadh with Scud missiles many foreign workers
fled the country. It was very difficult in the health service. We had to close wards and
cut services. We were in a desperate situation; we had to offer very generous bonuses
and other incentives to persuade people to remain in the country. This experience has
made us realize that foreign workers are here temporarily and we need to depend on
ourselves. (Salem)
Although international recruitment can be a quick fix for workforce shortages, it may
also be an obstacle to solving some of the other social problems that are endemic in
the region, such as youth unemployment and the exclusion of women from public life.
Home-based solutions such as improving working conditions, improving staff
retention and attracting returnees through part-time career opportunities may be more
cost-effective than international recruitment (World Health Organization, 2003). The
Gee governments have generally supported the migration of foreign workers from
countries such as India, Pakistan, Bangladesh and the Philippines but are keen to
reduce the outflow of revenue through remittances sent home by foreign health-care
workers. They also want to ease the pressure on labour markets, reduce
unemployment and accelerate development (United Nations, 2006).
4.5.2 Strategy for development of indigenous health-care workers
To meet the challenge imposed by shortages, the GeC governments have adopted
strategies for the development of health-care workers in both public and private
sectors. This comprises short- and long-term goals, including those listed below.
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1. Setting specific priorities and mechanisms for indigenization in the health
service according to their importance and the possibility of filling them by
national manpower.
2. Rationalizing the recruitment of foreign workers and linking their
employment and use with actual need.
3. Achieving greater harmonization between educational and training
programmes and health service needs for a national workforce.
4. Increasing training programmes; building more medical, nursing and allied
medical colleges in both the public and private sectors; and providing
more incentives for students.
5. Enhancing coordination between vanous health providers for better
utilization of available resources. (Fasano & Iqbal, 2003; Manpower
Council, 2003; Ministry of Economy and Planning, 2006)
However, analysis of the 2004-2005 figures for selected health personnel in the Saudi
Ministry of Health reveals that little was achieved. There was even a reduction in the
number of Saudis in some health categories during the two years following the
adoption of the strategy. First indications show the difficulty of achieving even the
long-term aims if present trends continue. For example, data for physicians show a
5.6% increase in total numbers in 2005 but a negligible increase in the number of
Saudis «0.20%). Indeed, there was a 1.1% reduction in the number of Saudi
physicians between 2004 and 2005 (see Table 18 below). It should be noted that
Saudi Arabia has a fairly low ratio of physicians in comparison to other GeC states
(15.3 per 10000 population). In the UAB and Qatar, the ratio is 20.02 physicians per
10000 population.
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Table 18 Ministry of Health selected personnel, Saudi and non-Saudi,
2004-2005
Category 2004 2005
Total Saudis % Non- % Total Saudis % Non- %
Saudi Saudi
Physicians 18621 3541 19.0 15087 80.0 20219 3773 18.7 16446 8l.3
Phannacists 1 167 712 6l.0 455 45.0 1 123 760 67.7 363 32.3
Nurses 41 356 14524 35.1 26832 64.9 42628 17068 40.0 25560 60.0
Allied
health 21 802 13342 61.2 8460 38.8 23 116 16 136 69.8 6980 30.2
personnel
Source: Adapted from Mmistry of Health, 2006a
It is possible to assume that either there is a national shortage of medical graduates or
there are medical graduates who prefer not to work for the Ministry of Health. The
first assumption is more likely because the ministry is the main health provider in the
country and medical personnel are paid the same in all public health providers. Data
from King Saud University, the largest university in Saudi Arabia, show 217 medical
graduates for 2004-2005: 155 male and 62 female; 193 pharmacists: 126 male and 67
female; and only 43 female nurses. No masters or PhD degrees were awarded for the
four categories in the same period. A senior Ministry of Health explained:
We have a severe shortage of Saudi doctors in the country. The main problem is the
small number of medical colleges in the country; therefore, both the intakes and
graduates are not sufficient to meet our needs. We must increase the capacity of our
medical colleges and open new ones soon to alleviate the severe shortage. (Marzook)
Nevertheless, additional medical schools have been established during recent years
and the number of medical students admitted has increased progressively. In 2004-
2005, 1840 medical students enrolled at King Saud University Medical College, 37%
of whom were female students. There are five other universities with medical colleges
in the country but they have even fewer students and graduates. These universities
produce a fraction of the country's needs for medical doctors. A senior SCHS official
reported current needs for doctors, pharmacists and allied medical personnel: "We
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need to train 20000 medical doctors and about 50 000 nurses and allied medical staff
to meet our current [2006] needs" (AI-Riyadh, 2007).
The situation in Oman is similar to that in Saudi Arabia although the various health
categories show higher percentages of indigenous employees. For example,
Omanization was 27% among physicians and 41 % among dentists at the end of 2005.
Moreover, Oman has achieved remarkable results in other health categories in
comparison to Saudi Arabia. At the end of 2005, Oman achieved 73% indigenous
worker rates among technicians and 86% among other paramedical personnel
(Ministry of Health, 2007). A senior Ministry of Health official in Oman explained:
We have sound and realistic plans to Omanize the majority of our health service
personnel. I am sure if you look to our achievements in five years time (this was in
2004) you will know what I mean. However, we have one very serious problem,
which is Omanizing our medical staff. We have a severe shortage in this area. As you
know, it takes time and huge resources to educate and train medical staff. (Zubair)
This contrasts with the Saudi official's earlier picture of the bleak current situation but
there are ambitious plans to increase the Saudization of the health service. Saudi
Arabia has recently requested WHO support for particular priorities such as
establishing more medical and nursing schools; developing more training
programmes; producing more qualified teaching staff; and improving the quality of
human resource management, leadership development and nursing administration
eN orId Health Organization, 2005). The Saudi government is coordinating, supervising and promoting education and training in the health service by increasing
support and enhancing the responsibility of the SCHS, founded by Royal Decree No.
Ml2 issued on 06/02/1413H. This national independent body was established to:
Develop the professional practice, and promote technical skills, enrich scientific
thought, and cater for sound practical applications in the field of various health
specialists through designing, approving and supervising profession health speciality
programmes and setting programmes for continuous medical education in health
specialities within the framework of the general policy of education. (Saudi
Commission for Health Specialties, 2006)
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The SCHS is responsible for evaluating and supervising all health institutions and
centres established for training and specialization purposes in both the public and
private sectors in order to ensure the quality of provided services.
Bahrain provides a model for the indigenization of a health service. It has attained the
highest percentage of indigenization in all health categories among all GeC states.
For example, Bahraini nationals comprised 81 % of physicians, 96% of dentists, 98%
of pharmacists and technicians, 93% of radiographers, 81 % of physiotherapists and
62% of nurses by the end of2005. This was a result of the health strategy adopted by
the Bahraini Ministry of Health. This framework for action was a result of a broad
consultative process among health providers, the private sector and government
departments. Manpower planning and development is a major focus of the Bahrain
National Health Plan (BNHP):
Recruitment, employment, deployment, continuous education and training strategies
are key factors in the continued success and ability to sustain the health system. Over
time these strategies should result in a Bahraini national workforce that will evolve by
targeting educational opportunities, integrating training programmes and work
experience, and improving incentives and contracted service obligations. (Ministry of
Health, 2005b)
A Ministry of Health senior manager explained:
We have one vision, many hands coming together which made all the difference. That
is why we are different from our Gee partners. We have also a system of accountability and evidence-based management practice that many Gee states lack. (Lona)
This clear and well-defined strategy is a decisive move away from the short-term,
limited approach to human resource planning in most Gulf states. It incorporates not
only a health-system design but articulates the key strategies, tactics and resources
necessary for reaching Bahrain's human resources goals. It also outlines a clear
operational intent and investment strategy for providing resources to meet these goals.
Also, it appears that coordination within government departments has produced a real
difference in Bahrain.
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4.6 Indigenization in nursing: where is the indigenous nurse?
For many decades, the nursing workforce in the Gulf states has relied on the
recruitment of foreign nurses. In particular, nurses recruited from the Philippines, the
Indian subcontinent and other Arab countries such as Egypt, Sudan and Lebanon.
Saudi Arabia currently appears to be the most dependent on migrant nurses but the
pattern is repeated throughout the Gulf.
The situation in the Saudi nursing workforce is unclear as different governmental
organizations provide different official statistics on the number and percentage of
indigenous nurses. The Ministry of Health reports that 40% of all its nurses in 2005
were Saudi (Ministry of Health, 2007a) (see Table 14) but the SCHS reports a figure
of 32% Saudi nurses for the same period (AI-Riyadh, 2007). This contradiction is
troubling when we know that these organizations are both governmental institutions.
The Saudi private health sector figure is more alarming - only 2% of the estimated
14000 nurses are Saudi (Ministry of Health, 2005a). This reflects the general
indigenization trends in the public and private sectors elsewhere. The situation is
serious - there are not enough indigenous nurses in the system to meet either current
or future requirements.
The Saudi nursing workforce is projected to reach 31 % by the end of the eighth SDP
in 2010, a 9% increase on its predecessor. However, if history is a reliable indicator,
even this modest projected increase might not materialize. For example, the
percentage of Saudi nurses in the total nursing workforce increased by only 5% in the
seven years between 1999 and 2006, from 17% to 22% (Marrone, 1999). It is difficult
to imagine that the 9% target of the present SDP will be achieved without drastic and
major measures. However, Ministry of Health analysis of the indigenous nursing
workforce reveals an increase of around 48% between 2000 and 2005, averaging 8%
annually. The biggest increase occurred between 2004 and 2005 (17%). In addition,
foreign nurses increased by around 2% between 2000 and 2004 but decreased for the
first time in many years in 2005 (by around 4.7%). Ministry of Health data and
statistics are disputed by various stakeholders, many whom are part of government.
Some argue that these data cannot be verified by an independent source and are
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produced for public consumption. One female sentor Saudi nursmg official
commented:
I do not trust any infonnation or data issued by any governmental organization. These
bureaucratic administrators usually come up with data and statistics out of the blue
and build a castle in the air to please their managers. I only trust it when it is verified
by an independent source which is very difficult to have in Saudi Arabia. (Shahena)
When asked what made her so doubtful about Ministry of Health data, she replied:
I believe it when I see it. When you go to any MoH hospital or facility who will you
see there? I only see foreign nurses and more of them. I do not see many Saudi
nurses. The question then should be asked where are these Saudi nurses the MoH
talked about? I have two answers to this question. First either they do not exist in the
first place or they work behind desks and have nothing to do with bedside nursing
duties. In both cases, it means we have not increased the number of Saudi nurses on
the ground, on paper maybe. (Shahena)
Other stakeholders indicated that even if the data are correct, the quality of the
graduates is very low and does not meet the requirements for nurses. As one female
Saudi nursing college explained:
Let's be optimistic and give the MoH the benefit of the doubt because we honestly do
not know whether the data is correct or no. But as a nursing education manager I say
that what matters is quality not quantity. Most if not all of MoH nursing school
graduates do not possess the right qualification to be a nurse. Why? Because they do
not have a bachelor's degree in nursing, they have a diploma. Most not only cannot
work with foreign nurses but also find it difficult to be trained by them because their
English is so poor. So at the end of the day to me these graduates can be called nurse
aids. (Rufaida)
Specialized education and training requirements will delay Saudization considerably
for many years. The Dean of College of Nursing and Allied Medical Sciences
(CNAMS) stated that: "It will take more than ten years before we can have a majority
of indigenous nurses in our health service" (AI-Riyadh, 2007). Nursing shortages are
projected to worsen with rapidly expanding populations and growing demand for
nurses in the Gulf. Current projections estimate that the current Saudi population of
27 million will grow to 45 million by 2025, an increase of more than 530/0. The
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proportion of Saudi nurses is projected to increase by only 13% to reach 35% of the
total nursing workforce in the same period (Al-Riyadh, 2007).
There are substantial differences between the data and projections from the Ministry
of Health, other governmental departments and independent sources. There is also a
lack of reliable data and information about the national nursing workforce and the
accurate situation of the national indigenous nursing workforce. Increases in the
percentage of indigenous nurses employed in the Ministry of Health between 2000
and 2005 have not been matched nationally. This makes it likely that the nursing
shortage will worsen as the demand for nurses is expected to increase dramatically.
However, Saudi Arabia is in the midst of a nursing reform that includes policies to
change nursing education; increase the number of nursing institutions; and encourage
masters- and doctorate-level education for Saudi nurses.
The Ministry of Health estimates that Saudi Arabia needs 100 000 nurses in the next
five years to staff its 255 hospitals and 2000 health clinics presently under
construction in various parts of the country (Al-Riyadh, 2008). On the basis that 2000
nursing students will graduate annually, it will take more than 40 years to fill the
national shortage of indigenous nurses. However, the number of nurses required will
rise considerably if the current nursing rate of 32.3 per 10 000 population is to match
that of other Gulf states (e.g. 54.8 per 10000 in Qatar). This will pose an even greater
challenge for the Saudi Arabian nursing workforce.
4.6.1 Indigenization strategies in nursing
The issues associated with the nursing workforce in the Gulf are complex, dynamic
and involve multiple stakeholders, including governments at all levels, community
groups, professional bodies and educators. Not surprisingly, all three Gulf states have
almost identical aims, with no significant differences in the interests and expectations
of the majority of their different stakeholders. They share the same goal of achieving
and maintaining an adequate supply of appropriately educated and trained indigenous
nursing personnel to meet the needs of their populations. Five main strategies have
been adopted to improve indigenization in the Gulf states.
1. Improved data, research and human-resource planning.
2. Appropriate education and training with further increases in nursing
school places.
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3. Support for nursing as a career choice for indigenous people.
4. Active promotion of recruitment and retention strategies.
5. Improved wages and working conditions.
Yet all three states lack suitable mechanisms and implementation procedures to put
these strategies into operation. For example, limited national data on all three nursing
workforces make it difficult to obtain an accurate assessment of the current situation
on the supply and demand for nurses. Limited data and lack of research on the nursing
workforce in the three states hamper the ability to understand present and future
requirements. One senior Gee manager explained: One of the main and critical factors in the Gee nursing workforce is the lack of
suitable data and information about the real situation of the nursing workforce in all
Gulf states. We do not know exactly what is happening in regard to supply and
demand. (Sarni)
The majority of stakeholders in the three states have called for the establishment of an
advisory committee to deal with human resource issues in the health service and more
research to identify gaps in human resource planning in general, nursing in particular.
A senior manager in the Saudi Ministry of Health pointed out:
We simply do not know the full picture of the nursing situation in the country. There
is no research that I am aware of that has identified and explained the profile of the
nursing workforce in the country. It is frustrating when you have to make a decision
while you do not have any reliable data to support your decision. (Marzook)
Bahrain has a relatively effective system for collecting and maintaining an adequate
human resources database. This may be because the workforce is much smaller than
those in Saudi Arabia and Oman. A Ministry of Health manager explained:
We have a good human resources database. We collect on a regular and systematic
basis vital human resources data that helps us to make crucial decisions regarding our
human resources planning. (Fatena)
There is a lack of projections of nursing supply and demand requirements in the Gulf
states. These are vital to ensure an adequate supply of skilled and knowledgeable
nurses to meet evolving health-care needs. In addition, improved nursing practices
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and workplace environments will encourage indigenous people to choose nursing as a
career and help to retain existing indigenous nurses. Women in general, and nurses in
particular, have many other employment options. Therefore, there is a clear need for a
predictive strategy for health human resources that will help policy-makers to act
proactively rather than reactively.
The strategy to develop appropriate nursing education and increase the number of
indigenous applicants to nursing schools has been a focus in most Gulf states. In
recent years, there have been strong calls to reform and upgrade educational
opportunities in general, and in nursing in particular. There is a realization that quality
education is a key factor in attracting and encouraging indigenous people to consider
nursing as a career. As one senior Omani nursing educator explained:
Those days when only intennediate or dropout students were the majority in the
nursing schools are over. Now, because we have upgraded and improved our nursing
education system we see more applicants who apply to nursing school. Demand for
our nursing school is increasing and education plays a major part in such a change.
(Rayan)
While it is true that demand for nursing education is increasing it is also true that the
pool of applicants is generally insufficient throughout the three Gulf states, although
the situation varies. Nearly all respondents stressed the importance of high-quality
nursing education and considered it a tool to address the problems of low self-esteem
among indigenous nurses by creating and strengthening nursing education
programmes, continuing education and mentoring programmes.
4.6.2 Nursing education
As indicated earlier, multidimensional sociological and cultural factors in the Gulf act
as barriers to education for women in general and potential nurses in particular.
Nursing education is a significant component of human resources development in any
health service. The production and retention of a competent nursing workforce
requires nurses to be educated using a curriculum based on the knowledge, skills and
competencies needed to practise (International Council of Nurses, 2006). Nursing
education is considered part of the education system but most nursing education
institutions do not fall under the jurisdiction or control of education ministries. For
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example, nursing education in Saudi Arabia was traditionally part of the Ministry of
Health's responsibility.
In recent years, a number of other government health providers (e.g. Ministry of
Defence; National Guard) and the Ministry of Higher Education have opened their
own nursing colleges that provide Bachelor of Science in Nursing degrees (BSN). The
College of Nursing and Allied Medical Sciences (CNAMS) at the National Guard in
Riyadh opened in 2001. In 2004, the first class of 12 women graduated with BSN
degrees and was employed in National Guard hospitals. The college also offers
bridging courses for nurses who hold a Diploma or Associate Degree in nursing. The
aim is to develop and prepare a well-educated nursing workforce to meet increasing
health service challenges and create satisfying professional career opportunities. Saudi
nursing graduates are encouraged to enrol in higher degree courses (including masters
and doctorates overseas) to prepare them for future positions of leadership. However,
so many different nursing education providers (each with its own system and
resources) results in duplication of efforts and programmes, creates confusion and
wastes resources. A head of a nursing college stated:
We have so many different nursing schools that belong to different organizations with no
coordination which make things very difficult not only to us but also to those who are
interested in nursing as a profession. We are making it difficult for everybody. It is a
strange situation. After all it is one country and all are under one government. (Nawal)
Health services now find their work subjected to greater scrutiny and criticism than
ever before and unsatisfactory practice often results in costly litigation (Clarke &
Copeland, 2003). However, the Ministry of Health nursing schools continue to offer
only diplomas or associate degrees in nursing. Some of the ministry's education
managers have called for these institutes to be replaced. One nursing director in one
of the government health providers commented on the quality of these nursing
graduates:
Even now I regret agreeing to take some of these graduates [MoH] into my nursing
establishment. Their nursing knowledge was very low, they spoke very little English
and could not cope with our work. I do not blame them, I blame the education system.
They were basically difficult to train; they had to start all over again in order to come
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up to our nursing standards. No such calibre of nurses can work in today's health
service environment. (Ahlam)
I asked if this participant knew about Ministry of Health graduate standards. Ahlam
replied:
[I am a Saudi nursing researcher] 1 had a good idea, but the reason 1 agreed to take
them, first, because they were Saudis and 1 strongly wanted to give them a chance to
train and second because 1 was under some pressure from hospital management who
themselves were under pressure from the top and maybe the media. You cannot
Saudize [indigenize] like that. You will do no good to both the individual and the
organization. (Ahlam)
This highlights the pressure exerted on human resource and nursing managers to
employ Saudi nurses regardless of their quality and the training they have received.
The increasing proportion of patients with more complex care needs increases the
demand for health personnel trained in critical specialties such as intensive care. In
addition, increased use of complex technology in health care has increased demand
for nurses with a higher skill mix. Abu-Zinadah (2006) points out that the low
educational standards in Saudi Arabia have impacted on the quality of nursing
services and the ability of some graduates to meet changing health needs and respond
to the complexities inherent in the care delivery system. Some indigenous nurses
have voiced concerns that their qualifications and skills do not meet the same
standards as foreign nurses, making them feel incompetent and unqualified.
The mismatch between national development goals and educational interest in the
country is often greater than policy-makers and planners expect (Wiseman & Alromi,
2003). In 2000, more than 70% of the students in their survey of 524 senior high
schools in Riyadh agreed that the general high school curriculum did not prepare them
for work in the labour market. They said they wanted extra training before graduation
to help them to succeed (Wiseman & Alromi, 2003). At a recent symposium held in
Saudi Arabia to discuss the future of higher education, one participant said:
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The output of Saudi higher education does not cope with the labour market and
graduates are weak in English language, computer applications and lack training in
jobs that they would undertake. (Gulf News, 2007)
The current study's findings revealed widespread support and interest in specialized
and continuing education among members of the nurse population in the Gulf states.
Specialized education refers to educational and training opportunities that focus on a
particular field of nursing practice (e.g. oncology, intensive care) with the purpose of
providing specific skills and qualifications.
Unfortunately, few studies have provided theoretical frameworks or any empirical
analysis to estimate the effects of education outcomes on the labour market in the
Gulf. Much of the literature relevant to education in the Gulf has focused on either the
status of women or the influence of Islamic principles (EI-Sanabary, 1992). The
performance of Saudi universities has also been attacked by a number of local media,
especially after the release of a global rating of the world's universities. In 2009 two
of the largest universities in Saudi Arabia - the King Saud University in Riyadh and
the King Abdulaziz University in Jeddah - were ranked at 292 and 1203 respectively
amongst 4000 universities worldwide (Ranking Web of World Universities, 2009).
Surprisingly there are no indigenous models for evaluating modem Saudi education or
training despite concerted recent attempts to indigenize systems, curricula and
personnel (Findlow, 2001). In addition, there is no effective coordination between
nursing schools, nursing organizations, government agencies and hospitals to
facilitate access to, or identify common outcomes for, all levels of nursing education.
This observation does not apply to Bahrain. It has one College of Health Sciences that
includes a nursing college among allied medical specialities and makes coordination
and planning much easier and more effective than in either Saudi Arabia or Oman.
The three states offer a wider range of educational opportunities for those who wish to
study nursing but there continues to be a severe shortage of nursing colleges and
programmes that offer BSN degrees, outside a few major cities in the three states. The
associate and diploma nursing programmes in Saudi Arabia and Oman are better
distributed but are not attractive to the majority of today's high school leavers. The
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expansion of nursing education into new geographical areas is therefore desirable and
will require additional financial resources, clinical facilities and qualified faculties. As
one Saudi nursing female manager explained:
While workforce recruitment strategies are important to increase the number of
national nurses, it is also as important to upgrade their quality to ensure that they are
capable of working in today's highly technological health service that requires well-
educated and trained national nurses. (Aisha)
Until recently, little attention has been paid to the shortage of nursing faculties that
has resulted from retirement, resignations and fewer nurses entering academia
(peterson, 2001; Valiga, 2002). This shortage is one of the major critical issues facing
most Gulf states as there are few indigenous professors and associate professors due
to low enrolment in doctoral nursing programmes. These shortages combine with the
part-time nature of teaching and low salaries to inhibit the ability to educate and train
nursing students. Many nursing schools have been unable to increase their intake of
indigenous applicants and have turned away many suitable applicants. An Omani
Ministry of Health officer explained the difficulty in recruiting faculty personnel:
We have plans to open more nursing schools in various areas in Oman but we have
been hampered by the lack of buildings and suitably qualified teaching staff. I am
talking about foreign faculty personnel because few indigenous personnel exist. We
need to accelerate enrolments in masters and doctoral programmes to meet some of
our needs. (Ali)
A nurse faculty is not created simply by erecting and equipping buildings and adding
the role of educator to that of the nurse. It requires changes in attitudes, knowledge,
skills, behaviour and experience to prepare for the new assimilated roles, settings and
goals of the personnel involved (Infante, 1986). In addition, all three Gulf states lack
coherent regulatory standards for education and clinical competence. The level of
education and training of many indigenous nurses does not necessarily match the
nature of their work and many are frustrated by their inability to compete or work
closely with foreign nurses who have higher qualifications and skills. This creates
tension and conflict.
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The governments of these three Gulf states are largely aware of these problems and
some have introduced a number of initiatives to improve and maintain educational
standards. However, many senior policy-makers and education managers have
hesitated and failed to introduce frameworks for training, education and practice for
indigenous nurses. There has been little effort to reform nursing education. The lIMe has focused on identifying the core commonalities across the Gulf states in areas such
as: material resources; quality of nursing programmes; quality of faculties; criteria for
student admissions and graduation; shared policies; standardization of curricula; and
evaluation of outcomes. However, fundamental issues such as providing care
standards and guidelines; defining professional roles; and providing in-service
training and continuing career development have not yet been addressed
systematically.
4.7 Recruitment and retention
Recruitment and retention of indigenous nurses is one of the most important factors in
the development of nursing workforces in the Gulf. It is important to review the
practices used to recruit indigenous people into nursing. In the absence of
comprehensive national planning policies, the number of indigenous nurses has been
determined by other factors, such as the number and capacity of the nursing schools.
It is surprising to see the huge influx of high school graduates who maj or in (for
example) the humanities, despite little prospect of finding a job after graduating,
while nursing schools struggle to find students despite guaranteed jobs on graduation.
The supply of indigenous nurses relies heavily on nursing education programmes in
nursing institutions and colleges. However, as previously stated, nursing education in
the three Gulf states has not expanded rapidly enough to keep pace with the increasing
demand for more indigenous nurses. The three states in general, and Saudi Arabia and
Oman in particular, are in great need of indigenous nurses to overcome the shortages
caused by increased international competition for foreign nurses. Some stakeholders
have voiced their concern over the implications for patient care. One nursing director
in a Saudi hospital suggested that limited staffing may affect the quality of patient
care offered by her hospital and has suggested that international recruitment must not
be looked at as the only solution:
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We are desperate for more nurses. It is quite a struggle and stressful when you are on
a daily basis trying to respond to increasing demands from various departments for
more nurses. It will be great if we can get Saudi nurses, but where can we find them?
There are not many around. In addition, foreign nurses are hard to get these days. But
we must not rely on international recruitment; it should be looked at as a quick short-
term staffing solution. We must Saudize [indigenize] as fast as we can while keeping
an eye on quality or we will face a crisis soon. (Jamila)
Demand for nurses, particularly indigenous nurses with advanced skills, is climbing
steeply in all three Gulf states. International data suggest an increasing overall trend in
international flows of nurses (Royal College of Nursing, 2004). Hospitals across the
three states are finding too few nursing candidates to fill the large number of
vacancies. Also, increasing demand for care is straining current nursing resources and
raising concern of a significant negative effect on the quality of health care provided.
This situation is likely to persist because the pipeline of undergraduate nurses cannot
meet even present demand. The majority of stakeholders across the three Gulf states
shared the anxiety that without active indigenization policies the health services might
be brought to a crisis that produces complete dependence on foreign nurses. Similar
concerns were voiced by a nursing director in an Omani hospital. She showed me her
nursing establishment figures to illustrate the problem:
As you can see I am about 20% less than my approved establishment. How can any
nursing director work in these difficult circumstances? I worry every day about what
is going to happen. I am almost begging any nurse who considers leaving to stay a
little longer. In Oman, and I expect in your country too [Saudi Arabia], one of our
major strategies for filling nursing shortages is importing nurses from other countries.
However, recently we could not recruit enough to meet our needs. The future depends
on how we can attract more Omanis to nursing. Omani nurses will be our last hope to
survive as a health service. I am hoping that our Omanization [indigenization]
strategy will deliver good results. (Layla)
Given the time it takes to train highly skilled nurses, significant relief of the current
nursing shortage is unlikely in the foreseeable future. Both Oman and Saudi Arabia
have continuously recruited foreign workers to fill crucial gaps. This has contributed
to shortages in poor countries - for example, Bangladesh has sent many doctors and
nurses to the Gulf for many years (Dussault & Franceschini, 2006). Spectacular
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increases in the total number of nurses in the Gulf states is the result of a massive
migration of foreign health workers, especially those from India, Pakistan, the
Philippines and Korea (Ball, 2004). For example, Saudi Arabia is still the second most
popular destination for nurses from South Mrica and the Philippines (Buchan et aI.,
2005). However, a strict focus on increasing the number of indigenous nurses ignores
the potential of the existing nursing workforces in the three Gulf states. At present
these are not employed to maximum benefit in their health services. One Saudi
nursing director explained:
The problem is that our existing nurses are not utilized fully and many of them are
not performing nursing duties. It is a waste of resources. Many of our nurses carry the
title while working in other capacities such as clerks and similar administrative
works. (Jamila)
There is no accurate estimate of overall retention of both indigenous and foreign
nurses in the three states but there seem to be limited retention strategies such as peer
support groups, opportunities for continuing education or incentives that address
quality of work-life issues. In addition, a large number of respondents reported that
decreased levels of job satisfaction among indigenous nurses lead them to pursue
other careers. Retention of indigenous nurses is currently a significant problem in all
three states and some hospitals report annual turnover rates approaching 25%. A
Bahraini head of nursing in one major hospital explained:
Many indigenous nurses are leaving and unfortunately most will stay home. They are
not transferring to other hospitals so we as a country are losing their talents. I would
say that between 20%-25% is our turnover rate. This is alarming when you combine it
with turnover among foreign nurses. The situation is getting worse. Indigenous nurses
are leaving for many reasons including religious, wages and mostly for difficult
working conditions. (Bedoor)
4.7.1 Factors inhibiting recruitment and retention
Health service and nursing school stakeholders across the three Gulf states identified
several social and organizational factors that directly affect indigenous nurses and
nursing student turnover, including:
• low wages and benefits
• long working hours and shifts
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• family commitments and social pressure
• religious reasons (working with opposite sex)
• inadequate training
• few opportunities for career development
• lack of respect from physicians and managers
• working conditions (lack of facilities)
• limited participation in decision-making.
The recruitment and retention of nurses and nursing students are major concerns for
health-care providers as they may contribute to increased costs and problems with the
quality of care. Numerous, mainly media, reports in recent years have described the
inability of health-service providers to recruit and retain adequate numbers of
indigenous nurses in all three Gulf states. One Saudization manager explained:
There is going to be a crisis in this country if they do not act quickly. They are not
proactive in their recruitment but rather reactive. There is no clear vision or strategy but
rather hasty decisions based on hunches and reams of ideas. (Liz)
There has been little analytical research to assess the nature and overall magnitude of
the current nursing shortage. Nevertheless, health service actors in all three Gulf states
agree that the entire Gulf is facing a shortage of nurses that is exacerbated by the lack
of recruitment and retention strategies. Initiatives to improve indigenous nurse
recruitment and retention in the Gulf should include: (i) improved salaries and
benefits; (ii) the development of nursing education, training opportunities and
ongoing training; and (iii) additional employee support, including improved working
conditions and organizational and social support. One Saudi nursing manager
summarized what is needed:
Improving the work environment is the key to retaining existing nurses and attracting
new indigenous students to nursing. Nurses need reasonable working conditions,
supportive management, flexible work schedules, fair promotion and training
opportunities, respect and reasonable wages and benefits. (Aisha)
The Bahrain Nursing Society cites low pay as one of the main reasons for nurses
leaving the country (Gulf Daily News, 2007). The head of the Bahrain Nursing
Society warned policy-makers of the consequences of low wages:
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Our best nurses are quitting and leaving for other countries where they are offered
more wages. I urge the King and the government to look into this matter because I
would hate to see Bahrain suffering a severe shortage in the coming years. (Gulf
Daily News, 2007)
In addition, most stakeholders in the three Gulf states view increasing job satisfaction
for indigenous nurses as the key strategy for addressing the nursing shortage.
However, little has been done. The vast majority of solutions fail to address the real
problem and there is little evidence that nurses are experiencing improved working
conditions. This might be attributable to a lack of cooperation between health-care
professionals or a lack of human resource policies and accountability. Decision-
makers may not have the evidence required for change.
4.8 Implementation of indigenization policy in nursing: what and where are the problems?
Given the imbalance of indigenous nurses and the greater demand for high-quality
and motivated indigenous nurses, it is essential to identify the range of potential
barriers that may deter indigenous people from considering this career. Changing
lifestyles, new chronic diseases, greater longevity, the shortage of indigenous nurses
and new treatment technologies have all prompted significant changes in health-care
delivery. Health systems in the Gulf are facing increasingly complex challenges that
require innovative solutions.
Rys (1964) cited in (Higgins, 1981) identifies a wide range of variables that have
influences upon social policy, especially internal factors including the demographic,
economic, social structure, political, pressure group, institutional evolution and social
psychology factors. The body of evidence reported here indicates that a nursing
shortage occurs when there is a unique, complex interrelationship of human resource
policies and practices, social and cultural factors and image attributes. These factors
include the contextual (politics, religion and culture; gender relations; discrimination
against women; family influence; foreign nurses), organizational (working conditions;
relationships with other health professionals) and situational factors that are impeding
the indigenization policy for nursing in the Gulf states. These are examined in detail
in the following sections.
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4.8.1 Contextual factors
A policy's success is largely detennined by political power and influence and the
level of importance that political leaders attribute to it. Political decisions have a
direct impact on the provision of health care and the development of the nursing
profession in the Gulf. Higgins (1981) argues that the political factor represents the
most important environmental element in the evolution of social policy; therefore the
political dimension cannot be ignored and should not be underestimated when looking
at the social policies of different countries. The success of the indigenization policies
in nursing in the three states depends on collaboration between various government
agencies, nursing associations and interest groups and requires indigenous nursing
leaders to develop a greater awareness of politics and indigenization. Robinson
suggests exploring the relationship between nursing and policy alongside the
exploration of: " ... the backdrop of the social and economic circumstances in which
the activity of nursing is practised" (Robinson, 1997).
The current governments in the three states have generally demonstrated a greater
commitment to indigenous nurses than their predecessors. The status of actors and
their relationships with indigenization have been found to be distinctly different in the
three states but many actors have expressed dissatisfaction at government inefficiency
in implementing these policies. Increasing unemployment (especially among young
people) and internal pressure in recent years has increased the Saudi leadership's
interest in the indigenization policy and its potential for the country's economy and
stability.
Saudi Arabia's political leaders have more importance and influence than their
equivalents in Bahrain and Oman. Moreover, the various Saudi stakeholders have a
loose coordination structure and do not seek common objectives - hence different
government agencies clash over aspects of policy. Some actors within the government
believe that the commitment to Saudization is not sincere or may be motivated by
reasons other than the stated aims of indigenization. Other actors have questioned the
intentions and motivation behind Saudization and argued that the government's main
intentions are to regain legitimacy among Saudis, avoid conflict and maintain
stability. A manager in the Saudi health service said:
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The only thing the government is interested in is its own internal security. Therefore,
it is using Saudization as a tool to silence those critics who say that the government is
not doing anything about foreign workers and unemployment. It also seeks to shift
the blame of the high rate of unemployment among Saudis to other entities in either
the public or the private sector. (Saif)
Reflecting on the usual reluctance to speak out in Saudi Arabia, 1 made the following
memo after this interview: "I am surprised that someone who works for the
government and sits in his office in the ministry is so brave and bold as to give me
this analysis about the government's aim of its Saudization policy" (Memo 36).
Abdelkarim (1999) points out that politics and security factors (rather than
economics) were and may remain the main determinants of attitudes to the presence
and employment of Saudis and expatriates. He further points out that these political
factors are also applied to the manipulation of the national population and decisions to
increase the number and power of particular groups are responses to internal power
struggles between different groups. Hall et al (1975) point out that social policy is
partly a history of conflict between interests which have often concentrated In
different social classes. They further point out that social policy is a history of
conflicts being resolved, of accommodation, compromise and of agreements which
cut across class boundaries. In this study a senior Ministry of Health manager
explained:
I have to be frank with you; there is a lack of commitment toward Saudization not
only in the health service but in all sectors. There is a lack of vision and leadership.
Nobody knows why we need to Saudize and more importantly how we are going to
Saudize. (Marzook)
The Saudi case demonstrates that political leaders can exert significant influence to
promote the achievement of policy objectives and it is very important to identify ways
in which such power and influence can be strengthened. The whole process is
complicated by clashes between government agencies over the objectives and
implementation of the indigenization policy.
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Bahrain and Oman seems to have stronger coordinating structures that allow various
actors to work toward common objectives. A senior Bahraini in the Ministry of
Labour explained:
In Bahrain we share a common vision and aim of Bahranization in all sectors. Being a
small country, coordination among various agencies is easier because we know each
other. (Dawood)
There is an explicit policy commitment to indigenize and develop nursing practice in
Bahrain and the high profile of indigenization produces a more sympathetic climate
for the policy. In Saudi Arabia, there has been an expectation that indigenization will
be implemented as planned without taking account of the factors that might affect
this. The content of the indigenization policy has received more attention than
understanding of the processes, which explains why desired and expected outcomes
fail to emerge. Policy-makers may be reluctant to push through reforms that are often
unpopular, especially in the private sector, as this can cause economic and social
instability. Policy reform is a political process that affects the formulation and
implementation of policy (Reich, 1994a). Indeed the challenges facing the three Gulf
states may prove insurmountable without fundamental reform of political institutions.
Religious ideas and practice have had considerable influence on social policy,
different religious ideas and beliefs have resulted in a wide variety of policy responses
(Higgins, 1981). Higgins (1981) argues that the teaching of Catholicism has
influenced social policy, especially in countries in which Catholicism is the dominant
religion. She cites Ireland as an example of a Western country in which the influence
of religious beliefs has had a profound and lasting impact upon the organization of the
whole of contemporary society, not only in the field of social policy.
In the Gulf, religion plays a major role in society and exerts great influence upon
social policy development and implementation. In Saudi Arabia, religion has greater
influence and power over all aspects of life and its impact is felt more widely than in
Bahrain and Oman. In some areas of policy the religious establishment has direct
influence, especially those involving family and women's welfare. The influence of
the religious establishment (especially in Saudi Arabia) has also been felt in
education, where control of girls' education still rests with the religious establishment.
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However, recently a series of factors have contributed to the decline of the influence
of religion on social policy, especially in Saudi Arabia. Violence and violation of
basic human rights by some religious authorities; terrorist attacks by extremists on
Saudi soil; the considerable growth on expenditure on education, especially for
women; and the new moderate leadership that took over in 2005 have all contributed
to the decline of the religious establishment's influence on social policy.
Nursing is considered women's work as caring for and about others is historically
associated with women and nursing (MacDougall, 1997). The majority of indigenous
nurses in the three Gulf states are women and therefore religion and culture play an
important part in shaping attitudes towards nurses' role in the public sphere. Gray
(2005) argues that indigenization is essentially about culture. Therefore,
indigenization in the Gulf was adopted in the context of the Gulf people and their
culture.
Various passages in the Quran stress the spiritual equality of men and women and the
duty of both sexes to meet the requirements of Islam. Different social roles are
ascribed to men and women as a consequence of their different natures. However,
some Muslim women believe that certain interpretations of Islamic doctrine degrade
the conception of women. They argue that a belief in men's superiority over women is
not congruent with the teachings of Islam but merely a reflection of culturally-bound
opinions (Memissi, 1991). A clear majority of indigenous nurses in the three Gulf
states agree that the Quran accords women more specific rights and privileges than
those granted by their societies. However, they find themselves caught between a
rigid interpretation of Islamic law and the cultural norms of a society with a
patriarchal understanding of gender roles.
The three Gulf states are characterized by extremely restrictive codes of behaviour for
working women, rigid segregation and a powerful ideology that links family honour
to female virtue. The principles of Islam apply to the conduct of everyday life for
indigenous nurses. Islam guarantees a woman's right to seek education and
employment but Gulf tradition dictates that her role should be limited to that of
mother and wife. This study has revealed the many barriers to a woman's rights in all
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three Gulf states. Saudi Arabia is the most strict and conservative concernmg
women's issues. One Saudi cleric commented:
Women in this country are lucky because they are treated according to Islam rules.
We did not invent these rules. They have been sent by God through Prophet
Mohammad. What do you prefer? God's rules or human beings' rules? The problem
is that some liberals and secular advocates have been trying to impose Western
culture and ideas on our society. Praise to God they failed and women understand
their role and will never change or trade their God's rules and directions for human
rules and principles. (Abdullah)
The researcher reported that some women respondents believe that rigid
interpretations of Islam limit their freedom and hamper their career. He smiled and
replied:
I hope that when you met these women a male relative was present in that meeting
otherwise what they have done was wrong [referring to the Islamic rule that a male
should not be alone with a non-related female]. Islam does not limit their freedom,
women can go anywhere they wish but must be accompanied by a close male relative.
This is Islam. Listen to me we cannot change Islam to suit people's circumstances.
These rules are there to protect women and not like what is happening in the West
where women have nobody to protect them as you know yourself. (Abdullah)
In another example, a Saudi Islamic scholar who represents the traditional view of
conservative Islam said:
We [meaning himself and those who hold the same views] are not against women
going to work as nurses but with some conditions. Our interest is to see Saudi nurses
working in our health service, but they must be segregated from males, both staff and
patients. When we gave our approval to nursing schools, our expectations were that
graduates will work according to Islam and the norms and customs of this country.
(lbraheem)
When asked to clarify what he meant by "when we gave our approval", he replied:
This meant that whenever there is any proposal or policy initiated by the government,
especially those related to women and their role in the public life like opening a
nursing school for girls, our institutions [religious institutions] must be involved to
ensure that such a proposal or policy is according to Islamic law and does not conflict
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with Saudi traditions and nonns. Therefore, our approval is necessary for any policy
of that kind to be implemented. (Ibraheem)
These quotations represent the reality in Saudi Arabia. Article 7 of the Constitution
states: "Government in Saudi Arabia derives power from the Holy Quran and the
Prophet's tradition" (Saudi Arabian Constitution, 1992). Under Article 45 Sunni
scholars who form the body of scholars (ulema) are responsible for the interpretation
of Quran and the Prophet's tradition:
The sources of the deliverance of fatwa in the Kingdom of Saudi Arabia are God's
Book and the Sunnah of His Messenger. The law will define the composition of the
senior ulema body, the administration of scientific research, deliverance of fatwa and
its [the body of senior ulema] functions. (Saudi Arabian Constitution, 1992)
The present ulema are the most conservative scholars in Saudi Arabia, a country in
which conservative views are not uncommon. Studies routinely attribute Saudis with
more conservative attitudes than people in other Gulf states (Zuhur, 2005). However,
in recent years (especially after 11 September 2001 attack on the USA) the role and
influence of fundamentalists and conservative groups have diminished considerably.
A growing number of religious individuals with more liberal and pragmatic views on , . .
women s Issues are emergmg:
We should be realistic. The world around us is changing and we cannot live in
isolation. Our interest is to increase the number of Saudi nurses in our hospitals to
take care of our people. No way can we continue relying on others to do the job for
us. Nowadays, we cannot separate sexes especially in the health service. However, it
is absolutely crucial to adhere to Islamic rules but not in a very rigid way. (Abdul-
Aziz)
This liberal view on some social issues is gathering momentum in Saudi society but
many liberal voices fear reprisal and stigmatization for standing against conservative
groups. Nevertheless, the Saudi media are full of articles in which liberals attack
conservative attitudes and challenge some of their Fatwa. This was unthinkable a few
years ago. The following extract from an article by a Saudi journalist is one example:
... our education system does not stress tolerance of other faiths - let alone tolerance
of followers of other Islamic schools of thought. It is one thing that needs to be re-
evaluated from top to bottom. And the fact that from fourth grade we do not teach our
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children that there are other civilizations in the world and that we are part of the
global community and only stress the Islamic empires over and over is also worth re-
evaluating. (Arab News, 2004)
The majority of Saudis are disillusioned and shocked by what is happening on their
streets. As one Saudi journalist said: "Terrorist incidents in Saudi Arabia are more or
less becoming everyday news. Every time I hope and pray that it ends, it only seems
to get worse" (Daily Arab News, 2004). However, segments of the population
sympathize with the cause and doctrine of these extremist groups, for both religious
and political reasons.
In Bahrain and Oman, religious scholars and institutions have less influence on
policies. In Bahrain, the majority of the populations are Shiites while the rulers and
the political elite are Sunni. There have been sectarian tensions and clashes with the
Shiite population who feel that their grievances have not been addressed by the Sunni
government. The majority of Shiite scholars tend to have more liberal views on
women's issues than their Sunni counterparts. Their interests and expectations of the
indigenization policy are similar to those of other stakeholders as their interpretation
of the Quran is less rigid, with recognition and understanding of the role of women in
public life. The researcher asked a Bahraini colleague to arrange an interview with a
Shiite religious clerk to talk about the role of women and women's issues. He was
reluctant because the researcher belongs to a rival sect (Sunni) and would be seen as a
journalist who might twist what he said. It took five days to arrange such an interview
and a copy of the audiotape was required. One Shiite Islamic scholar from Bahrain
commented:
As far as we are concerned, we fully support what the government is doing by
indigenizing our nursing workforce. When it comes to education and work we do not
differentiate between sexes. After all, this [indigenization] is a policy issue, we leave
it to policy-makers who know and understand the issue better than us. Frankly
speaking, my preference is to see Bahraini nurses working in our hospital rather than
foreign nurses. Islam recognizes the contribution of working women regardless of
their professions. (Hasan)
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Sunni and Shiite doctrines have religious and cultural differences and doctrines
despite their common Arab ethnicity. Hence, the minority Sunni scholars in Bahrain
share views on social issues similar to their counterparts in Saudi Arabia, especially
those related to women's issues.
Oman's constitution states that Islam is the country's religion and the main source of
its law, but this Islamic state is more open and liberal. Women participate in public
life, have more freedom and are subjected to fewer restrictions than women in Saudi
Arabia. But religious and conservative groups still campaign against what they call
the corruption of Muslim women. An Omani religious cleric explained:
We [religious clerics] understand that times have changed and there is a need to
accommodate various new ideas to develop our country. However, this does not mean
that we forget about our customs and principles. Men and women must adhere to
Islam's rules. (Jaber)
When asked where he stood on women's freedom and the right to work, he replied:
Oh, I see. Now I understand. Recently there has been extensive and heated debate
about the role of women in Oman. Let me tell, we do not oppose women working if
they adhere to and follow Islam. We are not like other countries who are very strict
and treat women unfairly like your country [Saudi Arabia] treats women. No. Here
we respect women and tolerate them but we think sometimes some women go too far
and this is not good for any of us. (Jaber)
When he was asked to elaborate, he continued:
I think you know what I mean. However, what I meant was that some brain-washed
Omani and others want us to open to everything coming from outside and tolerate
certain non-Islamic customs such as relationships between men and women. There
are those who are pushing for more freedom for women to do whatever they like.
When it comes to religion, there are red lines that cannot be crossed by anybody.
(Jaber)
Nevertheless, women in Oman have achieved many positive results and gained the
respect of large segments of society. International organizations have also recognized
the positive developments in women's conditions. A senior member of an
international organization commented:
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I am so happy about the progress and development of women in Oman, not only in
the health service but in all fields. They participate in all aspects of life. They are
members of parliament and one has been appointed recently as a minister. So in
comparison to some other Gulf states, they are among the top in terms of
development and achievement. (Sharf)
A Shiite religious cleric who was asked about his VIew of the role of women,
explained:
The principles of Islam are the same. However, the interpretation is different. We
[Shiite] respect women and feel that women have the same rights as men, but each
has a different role to fill in life. However, women must behave as Islam orders them
to behave. To wear modest clothes, wear the veil, but not the veil you have in your
country [referring to Saudi Arabia where women are required to cover their faces],
and follow the rules of Islam. (Hasan)
When asked about Shiite men's opinion of working women, he said:
As I explained to you, women have so many rights in Islam. They can buy and sell,
work and go to school and so on. We do not object to women working outside home.
God created men and women to help each other, but each has hislher role to play. In
this regard we are no different than Sunnis, but what you see in Saudi Arabia, I mean
the restrictions and discriminations, this has nothing to do with Islam. Most are
traditions and culture. So we need to separate culture from religion. (Hasan)
Most religious scholars in Saudi Arabia would certainly disagree with such an
interpretation and comment. They argue strongly that Saudi Arabia follows the true
version of Islam and is the custodian of Islamic teaching and principles. These
fundamental differences between the two religious actors in the three states cannot
simply be attributed to differences in terminology and concepts. These two views
represent a battlefield on which two influential forces fight to influence and dominate
Gulf society in all aspects of life.
Saudi Arabia is concerned with social issues and holds more conservative attitudes on
most of these. In such countries, the stakeholders who belong to conservative
religious groups will have more power and legitimacy and their claims will be viewed
with greater urgency. However, there are constant debates and calls for modernization
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and different interpretations of Islamic rules to meet people's aspirations and needs.
Saudi Arabian society is gradually easing many barriers and restrictions due to the
proliferation of satellite media, the influence of the West and information technology.
Within these contextual influences, conservatives have found the Anglo-American
invasion and occupation of Iraq a great opportunity to legitimize their views and
power and assume a more active role within Saudi society. Internally, the Saudi
government faces a crisis of legitimacy from fundamentalists with whom it shares
power. This is a dilemma for both modern Muslims and liberal forces in the country.
The USA IS a strong ally of the Saudi government and preaches freedom and
liberalism but the Saudi government cannot break the powerful ties with
fundamentalists for fear of catastrophic internal consequences.
Nursing is the most feminized of professions and has long been regarded as one of the
most extreme examples of gender's influence on career choice (Ball, 2004). The
dominant culture in Saudi Arabia has defined maleness and femaleness as points of
opposition and difference with the male in a position of power and domination. While
similar attitudes still exist in both Bahrain and Oman, their women's movements are
more advanced and women have gained more rights and privileges than their Saudi
counterparts. One female Bahraini nursing manger described her experience:
Here in Bahrain the majority of people treat women with respect and dignity not like
the way they are treated in your country [Saudi Arabia]. Women can move freely
without any major restrictions. Yes, we have some conservative and less tolerant
religious groups who do not accept such liberal views, but they are a minority who
are entitled to their opinion but cannot impose it on others. [Laughing] I think that
most of them are still influenced by your country, sorry to say that, but this is the
truth. (Be door)
When asked if women could work alongside men without discrimination or
harassment, she replied:
You have seen it yourself. Women can work anywhere they wish. Certainly, there is
some discrimination. Tell me anywhere in the world where women are not subject to
one form or another of discrimination. Do not forget that Bahrain is an Arab and
Muslim country. We have our culture and traditions but we have achieved so much. I
cannot say we are perfect. I must also stress the fact that women have choices. This is
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much better than any other country in the Arab world with some few exceptions and I
am proud of that. (Bedoor)
Bahrain's rapid modernization is said to have eroded the patriarchal aspects of society
and women have made significant progress (Seikaly, 1994). The changing gender
relations in Bahrain are reflected in the different environments in two nursing colleges
in Saudi Arabia and Bahrain. In Bahrain, this is an open college like any other college
found in the West or in other more tolerant Arab countries. Male and female nurses
study side by side and share the same facilities; females can come and go as they
wish, without mentors or restrictions. A Bahraini female nursing student explained
how she was treated in her Bahraini school:
We are all treated the same [males and females]. We share classes, labs and other
facilities. We respect each other but we keep distant from each other. You know we
are still a Muslim society. However, here you have choices. It is up to the individual
to do what he/she wishes to do. My family trusts me and is proud of me. (Sana)
When asked how her family feels about her studying in a mixed environment, she
replied:
To be frank with you, they would prefer [her family] if it was a female only college.
But they have accepted what is on offer and adapt to the situation. As I told you, they
trust me. For me, I prefer it mixed because I want to know the other sex's point of
view and learn from each other. (Sana)
In contrast, the Saudi nursing school is a restricted zone for males and very difficult to
access. Female students are isolated and their movements restricted. One Saudi
nursing student described her life in nursing school accommodation:
Oh my God. You cannot imagine the kind of problems we are facing every day in our
accommodation. We are like prisoners. We cannot leave our accommodation for any
reason. Even in an emergency situation we must have a female minder with us all the
time and we are not permitted to leave without written permission from our
accommodation supervisor. (Torfah)
Another said:
Even if I wanted to visit my relatives in the city, I had to go through so many
bureaucratic regulations. One of them was that in order to get out of the compound
184
one of my close relatives or guardian must come down here and sign a form that he
will be responsible for my welfare and return me back after the visit. It is too much
hassle and humiliation. We were treated like children, even worse. What is annoying
is when you object to such treatment you will be accused of not following Islam's
rules. (Mohaira)
A third student said:
Because I am from another city, I cannot go anywhere because I do not have anybody
who can come and collect me. I am married and have a child, but I was treated like a
number not as a human being. I stay in my room cut off from the outside world until
my husband or father come in some weekends to take me to the airport to travel and
see my family. This is the regulations, what we can do? We need the education so we
have to obey the rules. (Reem)
When asked why she did not travel to her family by herself, Reem replied: "Why are
you asking me this question like you are from a different country? You are Saudi and
you should know the rules." She was referring to both the school regulations, which
prohibit students from leaving without a male relative, and the travel rules in the
Kingdom that prohibit women from travelling alone. A close male relative or a
guardian must accompany them.
In Oman, women have achieved remarkable progress in a short time. Since the 1970s,
Oman has witnessed impressive transformations in health, education and equality.
The government has initiated various programmes to educate and raise the status of
women in society. A senior nurse elucidated:
The position of women in Oman is progressing and there has been much progress, but
still we have long way to go. Discrimination and disrespect for women is still widely
common, especially in rural areas, as some people look at women as a social burden.
That's why Omani families prefer to have boys than girls. (Hind)
Another Omani nurse described society's treatment of women and nurses:
We [women] are scrutinized all the time by the society. On the top of that, we are
nurses. This makes it more difficult for us. Whenever we do anything people will say
is it Islamic or not, you can do this and you cannot do that. The problem in our
culture is that as a woman you are not expected to ask questions just follow the rules.
185
Most of these restrictions and rules stem from traditions not Islam but they tell us this
is Islam. What can you do in a male dominated society? (Zaina)
Another Omani nurse said:
When I started working in the hospital, some people in the community and some
patients accused me of being immoral and corrupt because I work with men. I and
some of my female colleagues have been subjected to many abuses especially from
those conservative religious individuals who consider themselves as the custodians of
Islam. (Asma)
Women in the Gulf are inevitably imbued with a notion of isolation and a suspicion of
the public sphere. Modernization depends less on advances in technology and
scientific knowledge and more on a sense of freeing women and providing them with
similar powers and opportunities to their male counterparts. Gender is sometimes
overlooked but in the Gulf states it is an important factor in explaining the relative
underinvestment in the nursing profession and may be one of the major factors in the
shortage of indigenous nurses in the Gulf.
Policy-makers' own values and ideologies affect policy-making and implementation
(Walt & Gilson, 1994). Radebaugh (1975) recognizes cultural and societal attitudes as
factors that influence a country's development of policy objectives, standards and
practices. Religion could be considered as an ideology. Therefore, because the
majority of the indigenization policy-makers in the three Gulf states adopt and follow
Islam, actors can make the difference between effective and ineffective policy choices
and implementation eN alt & Gilson, 1994).
Religion is intermingled with tribal traditions and customs in the Gulf states. The
traditional disadvantage of women is part of an Arab tradition that limits their roles to
mother and wife. Thus, women are visible in society but unable to influence decisions
related to their affairs. Analysts of Gulf society blame the indigenous conservative
forces such as Wahhabism, tribalism and patriarchal ideology for the slow pace of
change in women's status (Meriwether & Tucker, 1999). Social attitudes to working
women are conservative, especially for employment in mixed environment sectors
such as the health service.
186
In Saudi Arabia, women are subject to discrimination and restrictions on their
mobility in the name of Islam. Rigid interpretation of Islamic rules and doctrine has
been used to restrict women's mobility and degrade their position. It is interesting that
the religious clerics interviewed in the three Gulf states expressed similar views on
most women's issues. For example, all talked about tolerance towards women and the
many rights granted to them by Islam. However, they also talked about the
importance of women adhering to Islamic rules and behaving accordingly. The Saudi
and Omani clerics stress that internal and external forces are trying to corrupt Muslim
women - what some Arab and Muslim scholars refer to as a conspiracy theory. One
Saudi nurse said:
Relationships with the opposite sex are very sensitive here; women have to be careful
of existing gender codes. For example, just shaking hands with a man is forbidden
according to Islam and many times I find myself in a situation where I have to shake
a man's hand. Just a simple gesture could send the wrong message about you.
(Buraida)
In Bahrain and Oman, religious institutions and cultural attitudes are more accepting
of women who aspire to freedom. These countries have a more tolerant environment
and thus Bahraini and Omani women have more obvious advantages than their
counterparts in Saudi Arabia. This does not mean that religion plays a marginal role, it
simply reflects the lessening of religious authority in Bahrain and Oman in recent
years and more enlightened attitudes towards women among the clerics. It is true that
the majority of the populations in both states follow sects of Islam that differ from
those in Saudi Arabia. It has been suggested that gender roles and accompanying
attitudes toward the division of labour between spouses might differ across religious
groups depending on the groups' strictness (Heineck, 2004). However, gender
inequalities are likely to decline as these Gulf states develop, the demand for qualified
indigenous nurses increases and discriminatory practices become costly for the states
and entrepreneurs (Morrisson & Jutting, 2005).
To a large extent, decisions pertaining to education, employment and marriage are
made at family level. In the Gulf states, a father holds sole parental authority and his
approval is necessary for a daughter to be accepted into an educational institution.
Therefore, family traditions may prevent women from working in certain
187
environments or certain occupations, regardless of job opportunities and economic
need. All nursing students who were interviewed indicated the importance of family
in their choice of career. A Saudi nursing student said: "It will be very difficult for me
to enter this [nursing] college if I did not have the support of my family" (Torfah).
An Omani nursing student said: "It took me a long time to convince my family to be
trained as a nurse. If my family and especially my father refused I would not be here
now talking to you" (Amal).
Women's participation in the labour market has greatly increased in recent years.
Three main factors explain this trend. Firstly, economic development and the ensuing
shift of population from rural and agricultural sectors means that more women want to
work. Secondly, women are more highly educated and want to capitalize on their
educational status. Recent data show that more female graduates will be entering the
workforce in Saudi Arabia and by 2015 there will be five women candidates for every
civil bureau position vacated as a result of another woman's retirement or death (Al-
Watan, 2006). Thirdly, the falling real incomes of households and rising poverty in
certain countries seem to have persuaded women to participate in the labour force in
greater numbers. Yet discrimination persists, health service employers in the Gulf
countries perceive that women have high turnover and absenteeism rates as a result of
family responsibilities. Some health service decision-makers are hesitant to promote
women or provide training opportunities.
It is not hard to understand why the Gulf health-care system is reliant upon foreign-
trained health workers. The three Gulf state governments regulate immigration
policies but the proportion of foreign nurses in these states remains high. Oyowe
(1996) claims that highly qualified professionals choose to leave their country of
origin for political or economic reasons. This study argues that the most important
factor that motivates qualified professionals to choose the Gulf is economic. The
region is not politically stable and offers less peace and security than some other parts
of the world. Other motivating forces could include improved learning opportunities
and a higher standard of living.
Strong push factors drive nurses from developing countries to migrate to the Gulf,
these include relatively low pay and poor employment conditions in source countries
188
(World Health Organization, 2003). All respondents felt that pull factors are
influencing foreign nurses to leave their countries and most respondents felt that the
large numbers of foreign nurses would be reduced only by dealing with one of the
strongest of these - financial incentives.
Respondents described how foreign nurses are actively recruited In the source
countries. One Saudi recruitment manager explained:
We basically recruit nurses from all over the world. Whenever there is an experienced
nurse, especially in critical areas and willing to come, we take her. Our recruitment
agency is very active internationally and has offices and agents in many countries.
(Mohammed)
Most of the health servIce managers In the three states emphasized that the
international recruitment of nurses is positive and makes an important contribution to
the development of the Gulf health services in general and nursing in particular.
However, Smith and Mackintosh (2007) argue that migration of nurses in part acted to
reinforce disadvantage based on gender, class, race and ethnicity. They identify the
influence of changes in nursing structure and commercialization of care in these
processes and demonstrate that employment conditions of foreign nurses have
reinforced patterns of disadvantage. The majority of foreign nurses see their
employment in the Gulf as a stepping stone to employment in other nations.
Consequently, many are willing to endure difficult, often abusive, working conditions
in order to accumulate the necessary capital and experience to facilitate this future
employment (Ball, 2004). One Saudi recruitment manger commented:
We have to be fair with foreign nurses . For years, they have been the backbone of our
health service. We would not be able to provide health care for our people without
their contribution. They also have played a major role in training our Saudi nurses.
(Mohammed)
Kingma (2001) suggests that international recruitment campaIgns often delay
effective local measures to improve recruitment, retention and long-term human
resource planning. Like other labour markets, the nursing labour markets respond to
opportunities for employers to exploit patterns of employee vulnerability (Smith &
Mackintosh, 2007). Some respondents raised the impact of international recruitment
189
on the development of indigenous nursing workforce in the Gulf as a crucial issue. A
Saudi nurse commented:
When you can have an easy way by recruiting an experienced and easy to manage
foreign nurse why should you take the hard way by training and recruiting a Saudi
nurse? It is also easy for them [managers in hospitals] to avoid clashes with the
religious authorities who, some of them, oppose Saudi females to become nurses.
(Hayat)
Numerous respondents stressed the dangers of continuing to rely on foreign nurses.
One Omani, head of a nursing department, noted:
For how long are we going to depend on foreign nurses? They are here as long as we
can pay them. Sooner or later we will face a crisis when we either cannot afford
paying them or when there are not enough of them around. (Layla)
The majority of respondents believe it is obvious that foreign nurses look after their
own interests and may consider indigenization as a threat to their job security.
Furthermore, they have been blamed for failing to support indigenous nurses or their
training. One foreign senior nurse who is in charge of the Saudization department in a
major health service provider commented:
Foreign nurses have done a tremendous job In this country. However, I can
understand some of the criticisms directed at foreign nurses by Saudi nurses. Yes,
there are foreign nurses who hesitate and have no interest in training Saudi nurses
because they fear that they will replace them. It depends on the system you have in
place. It is in the job description that they have to train Saudis, however, if it is
enforced or not, this is a management problem not the fault of the foreign nurse. (Liz)
However, some respondents believe that foreign nurses have been used as a scapegoat
for government failure and a lack of proper planning in the labour market and human
resource policies.
The majority of respondents believe that the current recruitment and retention efforts
for indigenous nurses are inadequate for the needs of these three states. Many are
dissatisfied with limited work and educational opportunities and the continued
isolation from bedside and clinical activities. In addition, most feel that there are too
190
few opportunities to upgrade to nursing positions for which they are qualified and that
foreign nurses reduce the number of senior positions available to indigenous nurses.
International migration can have positive effects on local training, knowledge and
professional development but these must be weighed against some of the potential
negative consequences for the indigenous nursing workforce. Smith and Mackintosh
argue that in most countries, including the Gulf states, foreign nurses playa key role
in the delivery of frontline care to patients. However, they conclude that professional
foreign nurses have repeatedly acted both as a highly valued labour force on which
patients and the service have relied and as involuntary contributors to the remaking of
disadvantage - their own and that of others (Smith & Mackintosh, 2007).
Nevertheless, in the case of the Gulf states this requires a delicate balance between
recognizing the benefits that foreign nurses bring to health-care delivery and a
collective concern for the indigenous nursing workforce. The success of interventions
to support the positive impact of international recruitment, while minimizing its
negative consequences, depends on the level of socio-economic and technological
development in each of the Gulf states and long-term strategy commitments from
professional and political leaders (Kingma, 2001).
4.8.2 Organizational factors
Modern nursing has been a systematically disadvantaged and divided profession since
its origin (Smith & Mackintosh, 2007). Management styles, incentives, salaries,
working conditions and career structures are some of the organizational factors that
can influence the recruitment and retention of indigenous nurses. However,
remuneration and incentives seem to constitute the most basic influence on their
retention in all three Gulf states. Nurses in both Oman and Bahrain have expressed
dissatisfaction with low remuneration, inflexible working hours, shifts, heavy
workloads, poor career development, poor working environments and workplace
deficiencies such as the lack of childcare and family facilities. One Omani nurse
explained:
There is a shortage of facilities such as babysitting, children's playgrounds and family
facilities. We used to have two months maternity leave but recently this has been
reduced to only forty-five days. These things are important incentives for improving
191
nursing's image with the public. There is also a need to increase a nurse's salary and
benefits to encourage more people to join nursing especially in critical areas. (Zaina)
There are similar problems in Bahrain:
We have a problem with night shifts and weekends especially for married female
nurses. For example, our primary care is staffed with Bahraini nurses because it is
only a day shift [7am to 3pm].That's why we have a higher demand for primary care
from local [indigenous] nurses. (Fatena)
The high demand for work in pnmary care reflects the internal and external
difficulties and constraints faced by indigenous nurses. Family commitments and the
lack of proper facilities (such as childcare) put huge pressures on nurses who are
trying to fulfil their responsibilities. Job satisfaction diminishes considerably when
there is conflict between work and family commitments. Some studies have found
that work-family conflict is negatively correlated with job satisfaction for both men
and women (Allen et aI., 2000). A Bahraini head of nursing pointed out: "In most of
our health service institutions there is a shortage of facilities, such as childcare,
breast-feeding and rest rooms" (Bedoor).
Some nurses have expressed their frustration with such working conditions and
warned of the negative consequences. A Saudi nurse explained: "Frankly speaking, if
the internal and external pressures, work conditions and destructive environment
continue as they are, then many Saudi nurses would leave and some will change
career" (Hay at). A lack of appropriate facilities can deter indigenous nurses from
accepting positions in some health organizations. This was a primary problem raised
by some nurses in Saudi Ministry of Health hospitals. Hussah explained: "I have been
trying to transfer from this hospital for the last two years because they do not have
childcare and breastfeeding facilities. It is very difficult for mothers with new-born
babies and young children (Hussah).
Many indigenous nurses in the three Gulf states recognize that promotion and career
development are influenced by personal connections and accompanied by a lack of
transparency. The right connections can open numerous promotion and career
192
opportunities for an individual in Gulf society but this unfairness provokes anger and
dissatisfaction. One Saudi nurse talked about her frustration:
I have been trying to get a scholarship to go abroad for my Master's for more than a
year but without luck. Some of my colleagues have their scholarships. Some finished
and came back, and I am here suffering all this because of connections (wasta). It
makes me angry but there is little I can do about it. (Buraida)
Wasta is a way of life and a force in most decisions in the Gulf. It serves as an
affirmative action for the advantaged but excludes the less privileged and hinders
conscientious officials trying to treat people equally. However, family obligations
oblige people to help their own (Cunningham & Sarayrah, 1993).
Job satisfaction among indigenous nurses is determined largely by their interactions
with other health-care workers, especially physicians. Most indigenous nurses in the
three Gulf states reported ineffective and sometimes stressful relationships with
physicians. Indeed, attitudes are influenced by the stereotyped roles of male authority
and dominance in Gulf society. Bates (1970) noted that male physicians in most
health settings limit the development of the nurse's role. Moreover, nurse training
upholds the tradition that a nurse must always obey the physician. Interestingly,
relationships between indigenous nurses and Arab physicians in the Gulf often do not
follow tradition. The majority of respondents reported difficult relationships. One
Saudi nurse commented:
Oh, physicians. What can I say? It is a strange relationship especially with Saudi and
Arab doctors. They do not support us or encourage us. They treat us like other women
in the society. No respect for what we do. Western doctors are different. The majority
treat us in decent way. Maybe because they understand our circumstances as women
first and nurses second. It is really sad when you get negative treatment from your
own people. (Hussah)
Some indigenous nurses felt that the more powerful medical profession had denied
nurses the opportunity to advance. This was reinforced by organizational inequalities
which inevitably affect nurses in general and indigenous nurses in particular. A Saudi
nurse commented:
193
We are treated here as servants by physicians. No respect for what we do and the
problem is such an attitude is tolerated by the management. Doctors here can do
whatever they like, especially Saudis. (Buraida)
A Bahraini head of nursing reinforced this opinion:
I always receive complaints from our nurses about the way they are treated by
doctors. Some doctors treat nurses very badly and in an inhumane way, degrading
their service. It is a shame. I have suggested to the medical school in Bahrain to teach
and inform doctors about nursing work. It should be part of their curriculum.
(Bedoor)
Clearly, nurses need to be assertive and self-confident in order to protect their
interests and gain respect. Writing in the UK, Davies (1995) called for nurses to
regroup and take a stand on the feminine values of caring while rej ecting the
masculine doctrines of the medical profession. However, this might not be applicable
for indigenous nurses in the Gulf environment where the male is in a position of
power and domination supported by religious discourse. Nursing training in the Gulf
is still governed by the traditional relationship between medical staff and nurses in
which nurses are trained in the values of routine submission and deference to doctors.
4.8.3 Situational factors
This research shows that the nursmg shortage is part of an overall shortage of
qualified indigenous workers in the Gulf. However, nursing shortages occur in most
countries, especially those that lack human resource planning. In addition, this
research argues that female nursing shortages are exacerbated in countries with
restrictive environments for female workforces. Shortages of indigenous women in
the workforce would therefore appear more likely in countries that have limited
freedoms for women, restrictions on gender relations and a lack of proper human
resource planning. A Saudi female nursing manager commented on her role as a
nursing manager:
I obey and follow Islam's rules and instructions. As you see I wear the veil and cover
my face and this has not prevented me from carrying out my responsibilities. I believe
that our culture, not religion, is the main problem for women. As you know Saudi's
culture is biased against women and always takes men's side. Look at me here,
isolated just because I am a woman. Otherwise I should be down there [in the
194
organization's headquarters]. When you ask them why I cannot be there, they say it is
against Islam to work with men. (Aisha)
The researcher expected to interview this senior female manager at her organization's
headquarters. However, her office is five miles from the main building - because she
is a woman. It is even more puzzling that she shares her office with a male (her
deputy). When asked why a man was sharing her office when she was not pennitted
to work at headquarters because she should not mix with the opposite sex, this female
manager replied: "I know. It is a strange situation as you can see. However I cannot
comment on this. You should ask this question to my manager in the main office.
Maybe he has an answer for you" (Aisha).
Government regulations stipulate that a male and a female should not work in the
same place - the main reason why this female manager was working five miles away
from the main building. Managers and decision-makers try to find ways around
certain rigid policies that are imposed (usually by an outside organization, in this case
the religious authority) on organizations in Saudi Arabia.
Gulf governments frequently express and defend the sovereignty of their countries but
in reality they, and some of their people, accept the proposition that they are subject to
the overriding authority of other countries. A number of stakeholders across the three
Gulf states believe that a psychology of dependence on foreign skills reflects a
genuine and, in some cases, complete abandonment of belief in the capability and
skills of indigenous people. This belief that indigenous people cannot survive and are
incapable of sustaining development without the help of foreign workers is another
significant barrier to achieving indigenization.
Gulf states dependence on foreign workers' expertise has existed for a long period but
has become particularly extensive over the last three decades. For example, every new
project (such as building a hospital) seems to require the importation of foreign
workers to design, build and staff it, whether public or private sector. A Saudi
Ministry of Health official explained:
We still have the tum-key mentality. We like everything to be done for us. It is a
culture that has haunted us for a long time. It is also the mentality that importing
195
things is better and easier than trying to make them at home. It is the same mentality
that applies to human resources. We trust foreigners more than our own people and
we prefer to employ them at the expense of our people. This is the reality. (Zaher)
One Saudi nurse commented:
I have been working in this hospital for the last six years. However, everybody still
considers me as a trainee although I have trained many Saudis and foreign nurses. It
is frustrating your own people do not trust you no matter what you do. What makes it
hurt, is that all management, foreign nurses and patients alike treat you the same.
Nobody trusts us or is willing to give us a chance. It is demoralizing. (Buraida)
On the individual level, those who require help in the house tend to import domestic
helpers from abroad. This suggests that the policy of international recruitment is
primarily a tool for promoting the weakness and dependency of indigenous people
and ensuring their dependence on foreign workers and expertise. Walton and Abo El
Nasr (1988) contend that indigenization is a transition from an importing stage to one
of authentication, by which a domestic discourse of social work is built in the light of
the social, cultural, political and economic characteristics of a particular country. It is
almost 20 years since this dependency on foreign workers began but it continues to
grow and pose more difficulties for indigenization.
Other difficulties, motivations and factors also hinder the promotion of the nursing
profession in the Gulf. These are shown in Fig. 6 below. However, it should be noted
that most of these difficulties are more relevant and specific to Saudi Arabia,
especially those that relate to the image of nursing, respect for nurses, family
influence and, more importantly, the freedom of women.
196
•
Fig. 6 Causes and consequences of indigenous nursing shortage
High
./ school! coll ege
graduates
~ Motivatio ns for Diffi culti es Factors
studying ---+ facing ... hinderin
nursmg indigenous g study nurses of
nursmg
"
Shortage of indigenous
nurses
Motivations for Difficulties facing Factors hindering study
studying nursing indigenous nurses of nursing
Guaranteed employment
Attractive student
allowances and benefits
Good prospect of being
accepted to continue
higher education
Lack of:
respect
job satisfaction
adequate training
career development policy
confidence
Weak communication tools :
English language
Lack of essential facilities : day
care , rest and breastfeeding
rooms etc
Unfair competition from
foreign nurses
Family pressure and
commitments
Night and weekend shifts
Lack of freedom of movement:
transportation
197
Negative image
Low quality of nursing education
Lack of:
nursing instructors
career development
adequate support from decision-
makers
Weakness of English language
Lack of:
family support
information about nursing prospects
effective media campaign
role models
respect and encouragement
4.9 Chapter summary
This chapter has examined and analysed the ongm and formulation of the
indigenization policies and variations within and between various stakeholders in the
three Gulf states, as well as the rhetoric and reality surrounding the content, context
and implementation of indigenization policies. It has also analysed the factors that
influence how the three states use indigenization policies to develop their national
(particularly health) workforces and reduce their reliance on foreign workers.
Although the three Gulf states share and use the same concept they have different
perspectives and have adopted different implementation strategies. Most respondents
agreed that indigenization remains an ambiguous concept in most of the Gulf states.
The aim of indigenization policy in all these states is to reduce dependency on foreign
workers but foreign worker numbers have increased in some of these countries. The
three Gulf states differ in their vision and strategies regarding human resources. For
example, Bahrain has sought international professional assistance to develop its
labour force market.
The chapter examined and analysed the implementation of the indigenization policy
in the public and private sectors; the bureaucratic response; and resources, incentives
and penalties for implementation. Indigenization in the health service and the global
competition has been analysed in detail for health-care workers in general and nursing
in particular. Especially when countries can offer compatible or even better terms and
conditions than the Gulf states, such competition makes it very difficult for the Gulf
states to recruit foreign health-care personnel. Therefore, nursing shortages in these
states are projected to worsen rapidly over the coming years. All three Gulf states
strive to deal with this complex situation by designing and implementing various
strategies to increase their indigenous nursing populations but various issues and
factors hamper their success. Nursing education is key for achieving good outcomes
from the indigenization strategies. However, vague nursing education strategies in
some of these countries and the shortage of nursing faculties were identified as major
problems that hinder the recruitment of more indigenous nurses. There is a lack of
198
research and studies that can provide the theoretical framework and empirical analysis
required to shape education strategies and their outcomes.
The strategies for recruiting and retaining indigenous nurses and the factors that
inhibit them were also highlighted and analysed. In addition, this chapter identified
and analysed various factors (including contextual, organizational and situational) that
are impeding or hampering the indigenization policy for nursing in the three Gulf
states. By analysing in more detail religion's impact on nursing it has been shown that
this is an important determinant of the development and implementation of social
policies in the contexts of the three Gulf states. Although the religious establishment
in each of these countries is only one interest group among many, religious groups
have the most powerful and striking influence on the development of social policy.
Despite important variations in religion's influence and impact on nursing in the three
countries, it remains a very powerful factor in the development and implementation of
certain social policies which include nursing. Finally, the chapter highlighted and
analysed the main motivations and difficulties that promote or hinder nursing careers
for indigenous women in the three countries, supported by a framework (Fig. 5)
which examines and analyses these factors.
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Chapter 5
Image of nursing in the Gulf: "What is an indigenous
woman like you doing working as a nurse?"
5.1 Introduction
One key challenge facing the GeC states is how to create an informed, long-term
strategy to ensure that there is an adequate supply of qualified, skilled and
knowledgeable indigenous nurses to meet the growing health-care needs of their
people. Several of the GeC states are facing severe shortages of health-care
personnel, especially in nursing. Most Gulf states continue to recruit foreign health
workers to fill critical gaps and as an interim strategy until sufficient numbers of
indigenous people can be recruited over the long term.
Currently, there is international consensus that more nurses are needed in community
and acute care settings. The shortage of indigenous nurses in the Gulf states is critical
because few indigenous people take up nursing. Also, overseas recruitment is
challenging as many international nurses may prefer to migrate to Europe, the USA
and Canada (International Nursing Labour Market, 2004). However, it is difficult to
identify the precise nature of supply problems. A lack of accurate, consistent, current
and sensitive information in most Gulf states makes it impossible to describe or
analyse the nature of the nursing shortage or make accurate projections for the future.
The poor image of nursing continues to be a major problem in most of these states. In
countries such as Saudi Arabia the profession has low status and an unfavourable
image as nursing involves domestic work and low levels of nursing education
(Kearsey, 2002). Some countries have improved the professional status of nursing.
For example, Bahrain has legally defined a baccalaureate degree as the minimum
prerequisite for entry to practice and other Gulf states are considering similar options.
The purpose of this chapter is to present the findings on the image of nursing in the
three Gulf states. It documents the trends of indigenous nurses and highlights the
detenninants of indigenous labour force participation. Attention is drawn to
200
systematic and cultural bias in understanding indigenous nurses' real contribution to
the development of the health service and nursing profession in the three Gulf states.
Various factors (e.g. religious prevalent social nonns and discriminating practices)
which limit the scope of indigenous nurses and underlie the gap between potential and
actual perfonnance are highlighted.
The chapter includes findings on the socio-economic development and religious and
cultural values in the three Gulf states. The main theme drawn from these research
findings is that Gulf women in general, and indigenous nurses in particular, are
underutilized human resources who are capable of contributing towards the process of
national growth and the development of the nursing profession. The gaps between the
options available to men and women are unjustifiably large in most Gulf states. As a
result, women have a limited range of choices and face many impediments to their
full human development. This has profound implications for the social and economic
development of the Gulf states. There is increasing consensus that gender is a key
variable in the development equation and must be taken into account at all levels of
programme fonnulation and policy-making (Moghadam, 1993).
Some authors attribute the low number of applicants to Gulf nursing schools to the
negative image of nursing as a career (International Council of Nurses, 2001; Irwin,
2001). It is crucial to identify and understand the main causes for such a phenomenon.
As stated in the literature review chapter, the shortage of indigenous nurses in the
Gulf poses a threat to the future of the health service. An ideal workforce largely
reflects the client groups served. The nursing shortage ratio ranges from 37% in
Bahrain to 91.75% in Qatar (Shukri, 2005). Approximately 78% of nurses working in
Saudi Arabia's health service are foreign (Abou-Zinadah, 2006).
The Gulf nursing profession is trying to improve capacity and encourage the
indigenous population to participate but the situation is strongly influenced by social,
cultural, religious, managerial and economic factors. However, one of the most
important issues highlighted in this study has been how the image of nursing impacts
on recruitment and retention. This chapter presents the findings of the perceptions of
nursing as a profession among various Saudi Arabian, Bahraini and Om ani
stakeholders. It also aims to detennine the extent of stakeholders' knowledge and
201
understanding of nursing in general and as a career and the nature of the factors that
shape their thinking. A number of questions will be addressed - What image of
nursing is held by key stakeholders within Gulf societies? How does the image of
nursing vary between the three Gulf states? How do economic, social, religious,
gender, media and role models constrict and constrain the image of nursing?
Stakeholders spoke about these different factors that affect the image of nursing in
their countries throughout their interviews. These are critical factors for both the
positive and the negative image of nursing.
The Oxford dictionary defines image as a: "general impression of a person, firm or
product as perceived by the public" (pearsall, 1998). Several factors contribute to
shaping an image and it is a long and arduous process to reshape an existing image
(Kalisch & Kalisch, 1986). Generally, the available literature from the Gulf states
suggests that the public holds a negative attitude towards the nursing profession
(Meleis, 1980). However, the socio-cultural perspective of this image is crucial for
understanding nursing in the region.
There is little doubt that nursing in the Gulf has undergone significant changes over
the last decade but it is not easy to define if, and how, the public image of nursing has
changed over this time. However, the findings of this study confirm that the image of
nursing in most Gulf states continues to be a maj or concern for health policy-makers.
Medicine, teaching and computing are the most preferred occupations among women
in most Gulf states. In the 12 years between 1980 and 1991 only 63 nurses graduated
from one Saudi Arabian nursing school attached to a large university. Only 24 nurses
graduated from the nursing section of King Saud University (the largest university in
the country) between 1975 and 1992 and not one nurse graduated from a nursing
college in a university in the east of the country in the 5 years of its establishment
(Hamdi & AI-Haider, 1996). It is very costly to sustain such programmes with very
low intakes and few graduates. However, limited job opportunities have encouraged
more women to consider nursing as a career.
Nurses in the Gulf face similar problems to their peers in other countries as well as
specific difficulties and disadvantages. These include the economic and socio-cultural
disadvantages related to their gender and social prejudices associated with their roles
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providing health-care services to patients. Smith and Mackintosh (2007) argue that
gender has always played a significant part in reproducing disadvantage among nurses
who are generally poorly paid for their work, irrespective of specialty and position.
The career has low status and an unfavourable image in countries such as Saudi
Arabia, where nursing involves domestic work and low levels of education (Kearsey,
2002).
Inkson (2004) points out that sociologists emphasize the roles of social class, gender,
and ethnic categories in defining the values and aspirations that children develop; the
career modelling they experience; and the educational and financial opportunities they
receive. Bedouin tribes constitute the majority of the Gulf populations. While major
changes accompanied the growth of the oil industry in the 1950s and many nomadic
Bedouin settled in villages and around cities, manual and domestic work is performed
exclusively by social outcasts or immigrants. Nursing is considered to be such an
occupation.
Although recruitment and the retention of nurses have been placed high on agendas in
the Gulf states, the nursing profession has been subject to a plethora of influencing
factors since health-care services were first established in this region over 50 years
ago. In general, it has proved impossible to attract an adequate number of indigenous
Gulf people, mainly because of low salaries, shift schedules and the social perception
of nurses (Al-Ahmadi, 2002). Also, Gulf individuals are not accustomed to taking
orders, especially from foreigners. This chapter explores the public image of
indigenous nurses and presents the findings on the factors that have influenced the
way in which the roles and responsibilities of the indigenous nurse are perceived.
5.2 Economic issues
The Gulf region is the largest exporter of oil in the world. Its countries have an oil-
based economy and their governments exercise strong control over all raw materials.
However, high rates of unemployment and limited job opportunities for indigenous
popUlations, especially women, have continued to be major problems in most states.
Ironically, all three Gulf states considered in this study have large numbers of foreign
workers, primarily because of the shortage of qualified and skilled indigenous
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personnel and the lack of interest tn certain professions among indigenous
populations.
Despite nursing's poor image, these limited employment opportunities have played an
important factor in attracting indigenous people (particularly women) into the
profession. A Saudi female head of a nursing unit pointed out that economic factors
are among the most important pull factors: "Due to the fact that a graduate nurse will
be guaranteed a job makes it very attractive to young people, especially females, who
have limited job opportunities to join nursing schools" (Aisha).
In Saudi Arabia, economists have not reached consensus on the unemployment rate.
Official figures estimate unemployment at around 7.4% among men and 21 % among
women (Ministry of Economy and Planning, 2005b). In Saudi Arabia such
information is usually vague and at best unreliable and sceptics believe the true rates
are much higher. A senior male official in the Ministry of Labour explained:
... but there are those who are not convinced of such figures produced by the
government and predict that unemployment is higher than that, and some put it as
high as 30%. I think unemployment is still high especially among women in the
largest exporter of oil in the world. We are not trying to hide the fact that we have
high unemployment among women and the rate of women's participation in the
labour force is very low. (Waleed)
However, women in Saudi Arabia prefer certain careers and occupations which do not
include nursing. The majority of those who consider nursing as a career have either
not been accepted elsewhere (e.g. universities) or are attracted by the economic
incentives offered by nursing education institutions. A female director of a nursing
college explained:
Unfortunately few choose nursing as a career. To be frank most or a large number of
those who enrol in nursing are divided into three categories: those who could not be
accepted somewhere else or couldn't find other opportunities; those who enrol for
economic reasons to get a job; and those who are interested in the incentives that
nursing colleges provide for their students. (Nawal)
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The incentives include generous student allowances, free books, accommodation and
transportation. One Saudi female nursing student agreed that these incentives and the
prospect of finding a job after graduation are attracting more students, especially
females, to nursing:
I could not find any job in my home town [Riyadh] and my father refused for me to
go and work outside Riyadh. I heard about this college and the prospect of being a
nurse with a guaranteed job, I decided to apply to this college and have been fortunate
to be accepted. (Torfah)
It should be noted that public nursing education programmes in the three Gulf states
are usually attached to public hospitals. In addition, the graduates of these
programmes are often employed as nurses in the public health service. Some
stakeholders argue that it does not matter why indigenous high school graduates are
attracted to nursing as long as there is an interest in this career. One female Saudi
senior nursing college manager commented:
It is acceptable at the present time that most people who wish to enrol in nursing
schools have been refused places somewhere else, and some are attracted by
economic incentives. I am confident that in the future more people will be interested
in choosing nursing as a career. (Rufaida)
This comment indicates that most students had not considered nursing to be their first
choice career and some had applied only because of the incentives provided. This
supports the previous finding that most high school graduates do not consider nursing
as one of their top choices. Similar stakeholders in Oman indicated that the rising
demand for places in nursing schools among young people is also driven by economic
incentives. As one non-Omani female senior Ministry of Health official explained:
"Nursing is a guaranteed job in Oman and with the unemployment problem it is a safe
haven for young people" (Hind).
Oman is facing similar unemployment problems that pose very difficult challenges for
creating more jobs and developing new sources of income to augment and reduce
dependency on oil revenues. Unemployment in Oman is relatively high - estimated at
approximately 15% among males and 22% among females - and considered one of
the highest unemployment rates in the Gulf (Central Intelligence Agency, 2006a).
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Moreover, the government has limited capacity to employ new entrants to the labour
force. However, nursing is one of the professions that attract young Omanis as it
provides a promising opportunity to secure a job. An Omani male nursing school
official pointed out that the economic factor is one of the most important reasons why
young people join the nursing profession, although it might not be their first choice:
I must stress the importance of the economic incentives which encourage more
people to be interested in nursing. Securing a job after graduation is crucial for
choosing a career and nursing has benefited from this trend. Recently we noticed high
calibre students showing an interest in nursing. Certainly incentives playa major part
in this trend. (Hamdan)
High school graduates comprise the majority of nursing school intakes in the three
Gulf states and economic incentives are important elements in attracting this group,
especially females, to nursing. One Omani female student emphasized the importance
of such incentives: "If you are a nurse you have an international passport which
allows you to work anywhere in the world. Many people know that nursing as a career
will secure a person a job" (Arwa).
Similar comments were made by male and female nurses and nursing students across
the three countries. Nevertheless, while it is true that nurses can secure jobs in many
countries, cultural and religious restrictions (such as restricted freedom of movement
for women) create obstacles that prevent them leaving their home countries or even
moving and working within their own country. However, it is not clear how much this
influences females who consider nursing as a career. Further research is required to
understand what inspires indigenous nurses to consider this profession.
Bahrain has a very similar unemployment situation but lacks the economIc
capabilities of Saudi Arabia or Oman. Oil production is small and the economy
depends more on sectors such as commerce, banking and tourism. Emphasizing the
importance of economic factors for those choosing nursing as profession, especially
women, one senior nursing manager commented: "The economic situation in the
country is another factor that encourages people to consider nursing as a career.
Nursing guarantees a job, especially for women" (Fahad).
206
This finding has been echoed by respondents across the different country contexts but
Bahrain offers few economic incentives for nursing students. Allowances to nursing
students have ceased in the last few years but this has not had a significant negative
impact on the image of nursing in the country. Limited career opportunities and
higher numbers of high school graduates have played a role in attracting more people
to nursing. A senior female Ministry of Health official pointed out:
In the past, students at the Bahrain Allied Medical College used to receive a student
allowance but not any more. Some of the students, especially the poor ones, used to
depend on this allowance to help them buy books and materials. Now it is free
education without any allowance, I expect as a result of increasing demand for
nursing school. This may change in the near future and students might have to pay for
their education too. I also expect that interest in nursing will continue to grow with
the increase in the numbers of high school graduates and limited job opportunities in
the market, especially for women. (Lona)
Oman especially has a strong desire to advance the status of nursing and nurses'
salaries have recently increased in both Bahrain and Oman. A female Bahraini
nursing school director stated: " ... recently, the government has raised the salaries for
nurses to be comparable with other allied medical professions. This has helped the
image of nursing and has encouraged more people to enrol in nursing schools"
(JIardia).
In Bahrain, the long-awaited salary increase was received without much enthusiasm.
Nursing salaries still lag behind those in Saudi Arabia and Oman and have had a
negative impact on the retention of indigenous nurses in Bahrain, especially among
male nurses working in the Ministry of Health.
Our main problem is the nursing salary and benefits system. Our nurses' salaries are
the lowest among the Gulf countries. As a result we noticed recently an increase in
the turnover rate among local nurses, especially male nurses. They leave for the
private sector which pays higher salaries than the Ministry of Health. (Wardia)
Salaries and benefits for health-care workers vary among the Gulf states. The richest
states (e.g. Saudi Arabia, Kuwait, Qatar and the UAB) offer higher salaries and better
incentives than the poorer states of Bahrain and Oman. However, these anomalies
have not produced major reductions in nursing shortages in the richer countries.
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Ironically, the less rich states (Bahrain, Oman) have the largest number of indigenous
nurses in the Gulf. This indicates that financial incentives are very important but non-
financial incentives, such as job satisfaction and career development, are important
factors for improving nursing's image in the Gulf states, and in Saudi Arabia in
particular.
5.3 Social attitudes
The image of nursing is strongly influenced by Islam and the role of women. The
Gulfs culture is one of well-established tradition based on strong family, religious
and social values. Most of these values influence the role of women, their ability to
work and the type of career they choose but their level of influence varies. Saudi
Arabian society is founded on strict conservative interpretation of and adherence to
the Quran and male-female contact is strictly limited. Bahrain and Oman are less strict
- women have more freedom of movement and opportunities for interaction with the
opposite sex are tolerated. The gender interaction issues and strict cultural values that
restrict the movement of women have deterred many Saudi women from considering
careers in the allied medical professions, particularly nursing.
Gender has a huge impact on the choice of career in Saudi Arabia. Women have a
traditional role which centres on home and family. They live in privacy from men,
other than immediate family members. The official view of the ideal woman tends to
elevate her public separation from men as the hallmark of Islamic society. It defines
the particular Muslim society of Saudi Arabia as something distinct from, and morally
superior to, the West and to other Muslim countries in which women are less rigidly
separated (Doumato, 2000). This ideology emanates from religious scholars and
conservative writers and is nurtured within state agencies and incorporated into public
policy, sometimes with the explicit objective of correlating Saudi rule with the
preservation of Islamic morality. Certain careers are barred for most women at present
and gender segregation persists in most jobs. A male Saudi Ministry of Health official
explained:
There are those with very conservative views on the role of women who think women
should not work at all and should stay home to take care of the family. On the other
hand, others are more flexible and believe that women can work in jobs that suit
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them, such as teaching, medicine and others that do not require mixing of genders
unless it is necessary, as is the case in the health service. (Marzook)
A senior Saudi manager in the Ministry of Labour commented: "Our culture values
and certain interpretations of the Quran do not approve of women working alongside
men. As a result women have limited career and job opportunities in the labour
market" (Waleed).
A large section of Saudi society holds these restrictive views but similar views are
found in Bahrain and Oman. The fundamental difference is that such views are
backed and encouraged by government policy in Saudi Arabia, supported by the
religious elite on whom the government depends for its legitimacy. Saudi Arabia
signed the United Nations convention that gives women more economic, civil and
social rights but religious clerics continue to determine laws and conduct and
reinforce practices that limit the freedom of women in public life. Some authors
suggest that a narrow and restricted interpretation of Islamic teachings has restricted
gender equality in Saudi Arabia (Hamdan, 2005).
However, since 2001, external and internal pressures have encouraged the Saudi
government to allow those with liberal views on social issues to question more
conservative views. For example, women have been allowed to participate in the
election and nomination of the Chamber of Commerce Councils and participate as
consultants in the Saudi Consultative Council (parliament) when women's issues are
debated. Another very important step for Saudi women was the appointment of the
first women as a deputy for the Minister of Education in February 2009. This is a
major step in Saudi Arabia and will have very positive consequences on the status of
women in the country.
In Saudi Arabia, almost all respondents raised the image of nursing as an important
issue. Most stressed that nursing's negative image should be addressed as the starting
point for any positive changes. The majority of Saudi people do not understand the
role of a nurse in the health-care service There is a long history of portraying nurses
as domestic helpers or, at best, assistants to physicians with the main duty of taking
orders from medical staff. The media have played an important role in this negative
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image, as explained later in the chapter. Nursing's negative image has fostered low
social- and self-esteem among those who choose this career. One of the main factors
in this is the absence of professional independent or governmental nursing bodies to
inform the public about the profession, the real nature of nursing and the role of
nurses in the health of the society.
Nurses in all Gulf states have low status and little access to power within the male and
medically dominated health system (Littlewood & Yousuf, 2000). Historically,
nursing care in most Arab countries was carried out by untrained women and servants
and combined with the conservative religious interpretation of the role of women to
diminish respect and recognition of nursing as a valid, worthy career. One female
Saudi nursing student explained:
The common image of a nurse in our culture is a maid or at best an aid to the doctor
and most people do not show any respect toward nurses. In my case, even my family
feels ashamed to tell others about what I am studying to be. They like to pretend that I
am going to be a doctor and they spread such a lie to relatives and friends of the
family. (Reem)
Such remarks and attitudes illustrate the social stigma that certainly affects the self-
esteem of indigenous nurses. Doctors and nurses are afforded different status, rewards
and prestige. Medicine is universally judged as an elite profession and doctors are
well-respected and well-paid. Saudi families encourage both male and female children
to study medicine (Vidyasagar & Rea, 2004) although the latter are subject to the
discrimination and restricted mobility common to all women in Saudi Arabia. Nursing
does not enjoy a similar status and families discourage their children (especially
females) from considering this career. A Saudi nursing education officer in a hospital
talked about her experience in nursing college:
I did not really choose it [nursing], it was a coincidence. I joined the allied medical
college. Not until later, I found out that I was studying nursing. At the beginning I did
not like the idea that I was studying nursing, and tried to change to a different course.
Fortunately, one of my teachers asked me if I liked what I was studying and I replied
yes, she said then forget it is nursing and call it whatever you like and continue with
it. I followed her advice and have never regretted it since. Now, I think I made the
right decision. (Hussah)
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Most of the stakeholders in all three countries mentioned nursing's poor image in
Gulf society. The majority felt that the general public did not recognize and appreciate
the professionalism of nurses. One female Omani nurse commented:
From my own experience, I feel that there are some people who still cannot accept
Omani women to work as nurses. Our culture and religious beliefs have traditionally
been against working women. To work as a teacher, clerk or a social worker in an all-
women working environment is acceptable but to work as a nurse where you must
work with the opposite sex is a taboo. (Zina)
Nursing's image in most Arab countries is strongly influenced by social, cultural,
economic and religious factors. A WHO representative in the Gulf pointed out "What
you see in the Gulf is no different than what you find in many other Arab countries.
Nursing has not been recognized fully as an important profession by both policy-
makers and the public" (Sharaf).
Both Bahrain and Oman have made very positive progress in improving nursing's
image and more people have begun to recognize the important role of nurses in both
the health service and the community. For example, the Bahraini Minister of Health
worked as a nurse for a number of years before her appointment. Oman has also
witnessed noticeable improvements over a short time. One Om ani female nurse
explained: "Nursing's image is changing, but not as fast as we wish it to be. People
are beginning to accept the local [indigenous] nurses in the community and recognize
their role better than before" (Samia).
Oman is learning from Bahrain's experience. For example, a number of Om ani nurses
have been appointed to senior nursing positions in the Ministry of Health and a
number of senior nursing positions have been created solely for Omani nurses.
Nursing's image has improved in the last few years, especially among young people.
It is difficult to measure the changes but some useful indicators include higher
demand for nursing school places and increases in the numbers of indigenous nurses
in public and private health-care facilities. However, it must be acknowledged that
economic factors play a maj or part. As indicated in Chapter 1, Oman (like the other
two countries) has a young population with limited career opportunities. Young
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graduates, especially women, tend to look for careers that offer the opportunity of
employment and are needed in the labour market.
Traditionally, Bahrain has been known in the Gulf for its liberal views and tolerance.
The different cultures in its cosmopolitan population have shaped its social structure
and women enjoy far more freedom than those in Saudi Arabia and Oman. Women in
Bahrain are allowed to drive and work in mixed environments, with very few
restrictions. One Bahraini nurse's husband noted:
Here things are different from other Gulf countries in the way they perceive and treat
women. We respect women and the government has granted them more rights than
any other Gulf states. As you know my wife is a nurse and some of my relatives are
studying nursing, nursing to us is like any other occupation. (Hani)
Such liberal views are rare in Saudi Arabia. This might be attributed to the progress
and speed of modernization in Bahrain which has impacted positively on all aspects
of life in the country. It also might explain why Bahrain has the highest number of
indigenous nurses in the Gulf.
Evidence suggests that nursing's image in Bahrain is far more advanced than in Saudi
Arabia and Oman. A Bahraini nurse's husband commented:
I understand that nursing is a noble job. Helping sick and weak people and providing
health education to the community. People appreciate nurse's work. For example, my
wife is dedicated to her work and loves her job as a nurse. (Hani)
Since the 1980s, Bahrain has developed a policy of investing in programmes aimed at
communities, families and schools to promote nursing and strengthen the role of
nurses in the community. A female Bahraini senior Ministry of Health official
explained:
I believe that society has recognized the role of a nurse as a result of hard work by
both the Ministry of Health and nurses themselves. The Bahraini nurse has initiated
such change by the services she offers to the community. A Bahraini nurse
contributes to the community and does voluntary work and participates in
immunization and health education programmes through visiting schools, poor and
elderly people. Such work is rare or even unknown in other Gulf countries. (Fatena)
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Like Oman, Bahrain has limited capacity m its nursmg colleges. Despite the
withdrawal of financial incentives (e.g. student allowances, free books) demand for
nursing places remains high and many applicants are turned down. A senior female
nursing manager explained:
Although we have high interest, our capacity is very limited and this might create a
severe shortage of indigenous nurses in the future if we do not act quickly. In 2004,
1000 applicants applied to our nursing college, we accepted only 120 of them. This
was our maximum capacity; this constituted a very small number of our needs.
(Lona)
Earlier in this thesis I presented evidence on the lack of coordination and cooperation
between various institutions within the Gulf states. Effective coordination and
cooperation could enable prospective nurses who are rejected because of a lack of
nursing college places in one Gulf state to be redirected to other states that have spare
capacity. After all, such coordination and cooperation is one of the main objectives of
the Gee.
Bahrain has the highest percentage (63%) of indigenous nurses in the Gulf but
officials recently warned of a rising nursing shortage. This is partly the result of a
relaxed and complacent attitude towards nursing in the past few years. Also, Bahraini
nurses are becoming increasingly dissatisfied with their pay and incentive packages.
Bahraini officials admit this complacency and are aware of the increasing complaints
about low salaries in comparison to other Gulf states. One senior nursing official
explained:
I know that some people have said that Bahrain's interest in Bahrainization has
declined over the past few years. It is true that for the time being we are recruiting
more foreign nurses to meet our needs. We have laid back for a while. We thought
that we had done enough. This was a huge misjudgement on our part. However,
the interest is still there and we can do it again, but I must admit it is going to be
very difficult especially with the present nursing salary scale. We need to review
our present salary and benefit scale if we want to maintain interest in nursing.
(Fahad)
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5.3.1 Role of the family
Within the Gulf States the concept of family is passing through a fast transition that
affects its functions, roles, authority and structure (EI-Haddad, 2003). Gender roles
and the accompanying attitudes toward the division of labour between spouses might
not differ much across the three countries. There is evidence to suggest that a
woman's decision to seek employment is affected by her families' religious beliefs. In
Saudi Arabia's conservative society the majority of people strongly believe that it is
the man's responsibility to be the breadwinner while the woman takes care of the
family. This attitude differs across and within countries according to family
background, socio-economic status and the occupations of other family members.
Traditionally, people in the Gulf place a high value on time with their families.
Working in shifts and/or late nights is unacceptable to either sex because it interferes
with family time. This adds to families' reluctance to consider nursing as a job for
their daughters. The requirement to provide physical care to members of the opposite
sex is also considered to be in direct conflict with strongly held cultural and religious
beliefs. Islam prohibits members of the opposite sex from touching one another unless
it is a matter of life and death.
There are gender differences in nurse employment. Female nurses can work in both
female and male wards but male nurses are restricted to male wards. The Saudi
Ministry of Health reported that more than 3000 male nursing graduates were on
waiting lists for jobs at the beginning of 2007(Arab News, 2007) and projected that
the number of jobless Saudi male nurses would have increased to 7000 by the end of
the same year. Conversely, there is a severe shortage of female nurses. The Deputy
Minister for Planning and Development in the Saudi Ministry of Health said:
I'm ready to employ within two weeks any Saudi female nurse, regardless of whether
she has graduated from a government college or a private one but on condition that
she cannot choose the location of her placement. (Arab News, 2007)
It should be noted that the majority of these unemployed male nurses hold nursing
diplomas rather than BSN degrees and therefore find it difficult to find jobs in either
government or private health facilities. The Ministry of Health has faced a lot of
pressure to phase out existing nursing schools that offer only diplomas and replace
214
them with nursing colleges that offer degrees. Recently, Ministry of Health nursing
schools were ordered to reallocate training places for male students to female
students.
No clause in Saudi labour law prohibits women from working alongside males but
local norms and religious tradition restrict work in mixed environments. The Saudi
Labour Law states: "Work is the right of every citizen. All citizens are equal in the
right to work. Women shall work in all fields suitable to their nature" (Ministry of
Labour 2005b & 2005c). However, an ambiguous article states: "When implementing
the provisions of this law, the employer and the worker shall adhere to the provisions
of sharia (Islamic law)" (Ministry of Labour, 2005b). This clause is subject to various
interpretations. Conservative Islamic scholars argue that it prohibits women from
working in a mixed environment and therefore they should not be allowed to work
alongside men. However, there is some flexibility to this rule in the health service
where the nature of the work requires women to work alongside men.
Female health workers in general and nurses in particular, believe that their
professions reduce their chances of marrying. Professional women who cannot or do
not marry risk lonely lives as the extended family disappears (EI-Haddad, 2003). Gulf
society views unmarried and divorced women as a threat to moral and existing social
codes. They are seen as predatory, come under more scrutiny and are subject to more
restrictions than married women. Therefore, marriage is not only recommended but
married women have more freedom and acceptance in society. A Saudi female doctor
commented:
I know many of my colleagues and friends who are in their thirties or forties and
could not get married because of their occupations. However, you will find those men
who only want to marry a doctor or a nurse to benefit fmancially from her salary.
Most young people prefer to marry a woman who works but preferably a teacher or
someone who is not required to work with men. (Malak)
In a study of Saudi women doctors, those who dropped out of medical college cited
pressure from their husbands as important causative factors - the husbands objected to
their wives spending time alongside men (Vidyasagar & Rea, 2004). Religious
traditions and local norms prohibit any interaction between the two sexes if they are
215
not closely related by either mamage or blood. In the Gulf, the numbers of
unemployed women include those who have chosen not to work after marriage. The
necessity for working shifts and weekends requires a nurse to commute to and from
work at times when her family expects her at home. In Saudi Arabia, married and
unmarried women require written consent from either their fathers or their husbands
in order to enrol at college or work. A senior manager in the Ministry of Labour
explained: "A Saudi working woman, regardless of her occupation, will work until
she gets married. Then it is up to her husband if he allows her to continue or not"
(VIaleed).
In Saudi Arabia, women have high levels of education and professional opportunities
but Saudi law prevents gender equality by restricting their freedom to travel and
requiring the agreement of a male relative before they can seek further education and
work (Al-Fayez, 1978). A female Saudi nurse complained bitterly about this:
This discriminatory law prevented me going for higher education in Australia. I am
single and I do not have a free male relative to accompany me, which is a requirement
for a government scholarship. This means two things. Either I find a husband quickly
or drop my ambition to go abroad. I chose the latter. (Hayat)
Restrictions on women's movements in Saudi Arabia have had an adverse impact on
their participation in the workforce. Women are not allowed to drive or to travel alone
and most are forced to hire foreign drivers to take them to work. A Saudi sentor
manager in the Ministry of Labour explained:
A Saudi woman cannot travel by herself to go and work in towns other than her own.
In some parts of the Kingdom, we have many job vacancies for women, but because
of such restrictions on Saudi women we have no choice but to employ foreign women
instead. (Waleed)
It is more difficult for a Saudi female nurse who is required to work nights and
weekends - a father, husband or driver is required to transport her back and forth to
work. Some nurses, especially married women, find it hard to work in these
conditions and are forced to quit. A director of one nursing college pointed out:
The most common problems facing local [indigenous] nurses are those related to
night shifts and weekends. Many nurses find it difficult to fulfil their job duties and
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requirements. A nurse's family member might refuse to drive her. This creates
tensions within the family and disturbs the work flow in the health service. I have
heard about many unfortunate incidents of abuse and divorce as a result of disputes
over these issues. (Nawal)
A head of a nursing department in Saudi Arabia reported that 70% of Saudi nurses
experience hostility from their families (Khaleej Times, 2006).
Oman and Saudi Arabia have similar approaches to women's issues in that women
face greater discrimination in access to education and training. However, the
important difference is that the Omani government has adopted a liberal view towards
women's issues. Om ani women occupy high positions as ministers and members of
parliament. Unlike in Saudi Arabia, Omani women can work, drive and have more
freedom of movement. However, culture and attitudes towards working women are
slow to change as Omani society is religious and conservative. Nurses still have low
social status and negative public perceptions predominate. As in Saudi Arabia, nurses
and other women health-care workers find it difficult to balance careers and family
responsibility as husbands or families fail to accept the changing responsibilities and
duties of working women. An Om ani female nurse explained:
Some families would think twice before allowing their sons to marry a nurse because
of the nature of our work, especially the late night shifts and working with the
opposite sex. Working different shifts for me is still not a problem because I am
single but married nurses find it difficult to carry their duties in such environment.
(Amal)
About 40% of Omani female medical students and residents do not go on to practise.
They effectively drop out after graduation, succumbing to societal pressures to marry
and raise children at an early age (Mahmoud, 2004). Women in the Gulf generally
choose work that has regular, predictable hours and a decent income to protect the
health and well-being of the family. Women's economic choices are more likely to
reflect their need to fulfil homemaking responsibilities than to enhance their
professional aspirations (Sethuraman, 1998).
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Bahraini society is more tolerant towards working women. Conservative segments of
the population prohibit their daughters from becoming nurses but more people seem
to accept nursing as a valuable and worthy profession. Among the three Gulf states,
Bahrain shows the most respect for nurses. One female Bahraini nurse commented:
I never felt I am subject to any fonn of discrimination. Actually, my family and I
have the respect of our community. My children are proud of me and other children
respect them because I am a nurse. This is because they recognize my contribution in
the community. (Mona)
Nevertheless, Bahrain shares some characteristics with the other two states, especially
men's growing preference for marrying working women in order to share domestic
financial responsibilities. A head of a nursing department explained:
In some Gulf states young people hesitate to marry a nurse, but in Bahrain we do not
have a serious problem with such an issue. This is one of the positive changes of a
persistent effort to educate people about the positive role of nursing. Nowadays,
young people prefer to marry working women regardless of their occupations to share
with them financial obligations. (Bedoor)
5.3.2 Knowledge
Some Gulf families find particular aspects of a nurse's job unappealing, for example-
washing patients and working with the opposite sex. In addition, many students and
parents are unaware of specific career and educational opportunities within the
profession. Many stakeholders identified knowledge and information about the
nursing profession as an important element in recruiting indigenous people. The
majority of people in the Gulf believe that the health service is all about doctors,
others (including nurses) are merely their subordinates. This attitude has marginalized
the role of the nurse in the health-care process. One Saudi male nurse explained:
The majority of people in Saudi Arabia lack a basic knowledge about what we do.
What they know is that a nurse is there to assist the doctor and follow his instructions.
That is why as you have seen many non-medical staff wear a white robe to gain
respect from patients. (Moath)
A Saudi female nurse complained bitterly about society's view of nursing:
Even the closest family members do not understand what I do. They say to me what
all you nurses do is wipe bums and clean beds. Sometimes when our house-cleaner is
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on holiday, they make a remark that "We have another one to take her role", meaning
me. I really have a hard time with such views but I am not going to give in. (Hayat)
People in Bahrain, particularly young graduates, are more knowledgeable about the
role of a nurse. A Bahraini nursing college director explained: "Bahraini applicants
apply to our college knowing what they are going to study and the career they are
choosing" (Fahad).
Learning from the Bahraini experience, the Omani health authorities have recently
started to advertise nursing in the public domain. However, some stakeholders believe
that this process will take time and more resources. One Omani female nursing
director noted:
Being in contact with the public, I am aware that people lack the proper knowledge
about nursing. People still do not trust our nurses because they do not understand
their role. Certainly, things have improved compared to ten years ago. However, we
have a long way to go. We need to invest more in our campaign to draw people's
attention to what nursing is all about. (Layla)
5.4 Religion
Higgins (1981) points out the important role of religion and its influence upon social
policy which, in her opinion, has received relatively little attention in the literature on
comparative social policy. Many writers who have examined religion in its social
context have shown it to be of great significance in the development of societies. It
must be considered as one of a range of possible factors that shape the development of
systems of social policy (Higgins, 1981).
Some critics argue that Islam is a patriarchal religion which subordinates women and
does not tolerate women's liberation. However, Islam depends upon how specific
verses in the Quran are interpreted and by whom. Some interpretations seem to
devalue the role of women; others confer equality and dignity. Regardless of such
views, however, religion is one of many institutions that influence people's lives in
the Gulf.
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The vast majority of people in all three Gulf states are Muslims. Some argue that
Saudi Arabia uses religion incorrectly to suppress women, keep them indoors and
restrict their movements. It is one of very few countries in the Muslim world where
women cover their faces with veils. Some Saudi women believe that wearing the veil
is an individual choice but this is contradicted by the fact that some state religious
institutions require women to cover their faces. The government has initiated many
positive steps to give women more rights in the last few years, although this
modernization process has been slow.
Saudi Arabia aims to create a population of indigenous nurses who are qualified to
provide care within the existing customs and religion. This is difficult and challenging
in the face of strong religious opposition which advocates the segregation of the
sexes. One Saudi Islamic scholar explained:
According to Islam, women should not interact or work with the opposite sex unless
it is very necessary. What I mean by necessary is only in emergency cases. Women
must not mix with men in work or in public. A nurse can only work in female wards.
A Moslem woman should cover her face in the presence of men. I am one of the
people who think that the government should do more in segregating men and
women. In the health service, I wish the government could do more in segregating
health-care facilities and create a women-only health service. It can be done. An
example is the education sector where complete segregation is implemented. I do not
understand why they can't do it in the health service. (Abdullah)
Most stakeholders interviewed in Saudi Arabia disagreed with such interpretations
despite such strict and narrowly defined Islamic rules. A senior officer in the SCHS
commented:
No way that the country can afford two health services one for male and another for
female. It is neither economical nor practical to do so. In education the situation is
completely different. Two different education systems started separately one for each
sex and now are joined together, they are not separated any more. In addition, Islam
and our customs do not forbid women from working as long as they follow certain
customs such as covering their heads (hejab) and behaving morally. Unfortunately,
some people believe women working in a mixed environment are disturbing the
social order, and creating an environment for immoral behaviours. (Salem)
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When the religious scholar was asked why most respondents disagreed with his
comments and said they believed women should be allowed to work in mixed
environments, he replied:
I know that some disagree with what I have said, but the majority of Saudi people
agree. I am aware that in the last few years many things have changed in this country.
Those liberals and seculars who believe in women's liberty and freedom have raised
their voices as a result of recent events both internally and externally. I think they
have been brainwashed by the propaganda of the West. (Abdullah)
Some stakeholders believe that such a view is one of the most important barriers to
the development of the Saudi nursing profession. Religious elites are highly respected
individuals, people listen to them and they influence public attitudes and opinion.
Some believe that Saudi society is the most homogeneous in the world (Al-Adaily,
1983) but Saudi society is not homogeneous. Islam is the only religion practised in
Saudi Arabia and Saudis are predominantly Sunni. However, a considerable segment
of the east and south of the country includes Shiite and Ismaili sects. Sunnis dominate
the Gulf region but there are different degrees of adherence to its teaching. Certain
religious practices and laws differ between the sects - cultural traditions such as
gender segregation at work and school are fully upheld in the Sunni sect but Shiites
are more relaxed. A Shiite female Saudi nurse explained:
Shiite families are more open and tolerant towards women in general. Shiite women
joined the oil company health service (ARAMCO) as doctors and nurses a long time
ago. We have no problem working in a mixed environment but that does not mean we
are not good Muslims. The main difference is in the interpretation of the Quran which
distinguishes each sect. (Buraida)
However, Islam is the main source of legal, political and social authority in Saudi
Arabia. It is considered a way of life and its role and influence touches all aspects of
Saudi life, including nursing. One Saudi female doctor commented: "Unless those
religious scholars who are respected in the society speak out in favour of working
women, especially doctors and nurses, things will never improve" (Malak).
As in Saudi Arabia, issues such as veiling, working in a mixed environment and the
role of women in society are matters of great debate in Oman. Each of the three states
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has been influenced by religion but the influence appears stronger in Oman and Saudi
Arabia. However, Oman's experience of colonialism and the influx of expatriates
have produced a stronger liberal tradition and religious groups have less influence.
Fundamentalism and conservatism have strong rote and history in the Gulf. In the late
1970s a narrowly defined set of Islamic beliefs developed into a movement within the
Gulf Islamic community. This movement has stood in opposition to modernism and
espoused strict adherence to conservative Islam, especially since the Iranian
revolution. Many criticisms of fundamentalist positions have centred on the
irrationality of its doctrine - some of its claims cannot be proven and are contrary to
scientific evidence. However, the main variation across these three states stems from
Islamic beliefs and the extent to which each country upholds these beliefs in their
respective social and legal systems. One Omani senior Ministry of Health manager
explained that Omanis are not segregated by gender in workplaces:
As you have seen yourself there is no segregation between men and women here in
the Ministry . We work together and respect each other. Gender segregation is
something of the past in Oman. Having said that, it doesn't mean that Oman doesn't
have conservative religious groups who oppose any unnecessary contact between
males and females, including working together. (Zubair)
However, one nursing manager in an Omani hospital contradicted this liberal view of
mixing and working alongside men. She admitted that some female nurses find it
difficult to work in a hospital environment: "It is a problem for us here [hospital], we
cannot force a female nurse to work in a male ward. Working with the opposite sex is
a dilemma, as you know, in the health service; it is very difficult to separate sexes"
(Layla).
Bahrain is the only Gulf state with a Shiite majority population and is more tolerant
and open toward women. The country has been exposed to Western traditions, values
and business practices for a long time and to a much greater degree than Saudi Arabia
and Oman. Bahraini women who wear mostly Western dress are worried that Saudi
ideas might enter society and affect their rights. This tolerant environment is one of
the important factors behind Bahrain's positive nursing image and, more importantly,
the positive role of religious scholars who support working women. However,
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Bahrain has conservative religious individuals similar to those in Saudi Arabia and
Oman. They oppose certain women's rights including the right to work. In exit
interviews some Bahraini nurses quoted religion as a strong reason for leaving
nursing. A female assistant director of nursing in a major hospital pointed out:
Religion is very important in our society; some nurses have resigned as a result of
pressure from their families. We interviewed some of them about the reasons for
leaving. Some indicated that they don't feel comfortable working in a mixed
environment where men work alongside them. (Saida).
5.5 Gender relations in the Gulf
It should be noted that the limited and fragmented literature related to gender and
women in the Arab world in general, and the Gulf in particular, has been one of the
main limitations on the intended depth of this and related sections. Academic studies
and researches on the subject of women and gender in the Arab world are scarce.
Gender is a concept that deals with issues related to all aspects of men's and women's
lives - their different opportunities, needs and concerns in a specific culture. A United
Nations' report defines gender roles as those that are socially assigned,
interchangeable and may vary with class, race, ethnicity, religion, age and time
(United Nations, 2001). The construction and reproduction of these roles take place at
both individual and societal levels. Therefore, gender analysis explores relationships
and inequalities in the private and public sectors of society (United Nations, 200 I).
Valverde, cited in Ceci (2004), argues that gender, gendering discourses and practices
work to produce us as particular men or women, though they never do so completely,
fully or all by themselves.
Some argue that the actions of people or individuals have to be understood within a
wider societal setting in which structures, symbols and discourses - all imbued with
gender - are taken into account (Davies, 2001). Davies stresses the importance of
studying gender and that gender has become a useful and widespread concept in
feminist theory and gender research. It suggests active performance and subjectivity -
bringing our attention to the ways in which gender relations are constantly created,
maintained and contested in interaction and daily life. By studying gender we are able
to understand that gender and gender relations are not a static pre-given but are
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moulded in ongoing actions that require at least two partners to be present (Davies,
2001).
The study of gender in the Gulf concerns the ways in which the dominant cultures in
these societies have defined maleness and femaleness as points of opposition and
difference in which males occupy positions of power, decision-making and
domination. In recent years, many gender scholars have shown an interest in the study
of gender relations in Islam. Meriwether and Tucker (1999) point out that historians
and sociologists want to understand how the male-privileging "Islamic" discourse on
male and female has evolved; to be able to recognize it when they see it; and, if they
have feminist goals, to struggle against it. As historians they find an intriguing
intersection between present Islamic discourse (on a monolithic and immutable Islam
that dictates certain gender roles) and an Orientalist discourse that also stresses the
unchanging and, in its version, oppressive gender system imposed by Islamic law and
thought. Mernissi (1991) raised a call for feminist scholars to engage in serious study
of the Islamic tradition and not to leave the representation and interpretation of this
tradition entirely in the hands of those who would emphasize its more conservative
and even antifeminist side.
The Quran assigns different social roles to men and women because of their different
natures. Men are seen as the protectors or guardians of women because God has given
them more power or strength and because they provide bread for the family.
Prevailing Islamic practices and interpretations have made gender a subject of great
debate in the Arab world in general and the Gulf in particular. During the early days
of Islam women moved freely and held prominent positions in business and as Islamic
scholars. Some scholars believe that the present practices of veiling and gender
segregation in Gulf societies are influenced by cultural traditions. Most women do not
cover their faces and some are unveiled in many Arab and Muslim countries.
Moreover, there is no gender segregation in educational institutions and workplaces.
In addition, some Arab and Islamic countries (including Gulf states such as the UAE
and Kuwait) have a female prime minister and/or ministers.
Discrimination between male and female is more apparent in daily life in Saudi
Arabia than in any other country in the Gulf. Amnesty International considers that the
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abuse of women's rights in Saudi Arabia is not simply the unfortunate consequence of
over-zealous religious police, but results from a state policy that gives women fewer
rights than men and allows men to exercise authority without fear of being held to
account for their actions (Amnesty International, 2006).
Women have become an important issue for planners in the Gulf states because they
represent an untapped human resource. Some respondents suggested that public
prejudices about the nursing profession have to be eliminated in order to build a Saudi
nursing workforce. A male senior manager in the SCHS pointed out:
We need to change the negative perceptions in the society about working women in
general. There are many wrong perceptions about working women especially about
those who work in mixed workplaces as is the case in health-service facilities.
(Salem)
One Saudi female doctor explained: "We [women] need to struggle and work hard to
change people's attitudes toward working women. It is very difficult for a woman in
this society and it is more difficult if you are working women" (Malak). An expatriate
head of the Saudization department in Riyadh explained how it is difficult for women
to challenge the present culture: "Saudi nurses don't speak up for themselves. As you
know in the Saudi culture a woman will never challenge a man" (Liz).
Gender relations also impact on the relationship between nurses and Arab male
physicians. Regardless of nationality, Arab physicians are more likely to differentiate
between Arab and Western nurses. The Associate Dean of a Saudi nursing college
pointed out:
The way local [indigenous and Arab] physicians treat foreign and local [indigenous]
nurses is different. While they show more respect to Western nurses, they do not
show any respect to us and other Arab and Far Eastern nurses. (Rufaida)
Other stakeholders believe that most medical personnel lack knowledge and
understanding of the nurse's role in health care. A Saudi director of nursing in a large
hospital in Riyadh commented:
Medical staff do not understand the responsibility and contribution of the nursing
staff in the patient care process. Some are ignorant in the way they treat my staff, and
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think they have the right to intervene in nursing management. When I was appointed
as the first Saudi nursing director in this hospital, some considered this as an
opportunity for them to control nursing. Because, I am a Saudi woman they thought
that they could take advantage of me. (Ahlam)
This lack of understanding among medical staff and other health personnel is among
the most important factors that contribute to the negative image of nursing (Hamdi &
AI-Haider, 1996). This might be attributed to the fact that Saudi culture restricts any
social interaction between the sexes and therefore there are only minimal and
necessary interactions between the two sexes in the workplace. In addition, men in the
Gulf are more likely than women to be exposed to Western traditions and values.
Arab and Far Eastern nurses are more exposed to Western cultures and know their
rights but many choose to avoid confrontation, fearing serious negative consequences
such as termination of contracts or harassment. A Saudi female nurse explained:
"Lebanese and Philippine nurses are scared of Saudi doctors. They will obey orders
and listen to what they are told. They fear that by not doing so they will be terminated
and deported" (Buraida).
This problem is not confined to Saudi Arabia, it is also found in Bahrain. One female
Bahraini director of nursing commented:
The existing relationship between medical personnel and nurses should be evaluated.
We have received complaints from some of our nurses about the behaviour and the
way some doctors treat them. I believe medical schools should think seriously about
educating medical students about the role of a nurse and to show more respect for
nurses and treat them as colleagues not as assistants. (Bedoor)
In both Bahrain and Oman, the concept of gender-differentiated lives is less prevalent
and women have more freedom. However, in Oman the local traditional masculine
culture is still dominant. Increased gender equality represents a threat to such
masculine dominance and might result in conflicts of interest between men and
women.
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5.6 Media influence
The mass media comprise the print industry (magazines, newspapers) and electronic
media (television, radio, Internet). They serve several vital functions as agents of
socialization that instruct people in the values and customs of society; sources of
information; and propaganda mechanisms that persuade the public to support
particular issues (Walt, 1994). Most mass media in the Gulf are directly owned or
controlled by governments and are very powerful tools (especially radio and
television) in those societies with significant uneducated and illiterate populations.
For example, in the Gulf states 33% of women and 16% of men aged 15 years and
over are illiterate (Population Reference Bureau, 2008).
Traditionally, the media have been accused of portraying a negative image of nursing
in the Gulf. For example, old Egyptian films often depict a nurse as a maid or, at best,
a doctor's aid who is willing to obey orders. As the nursing profession is dominated
by women, the media in Saudi Arabia find it difficult to communicate and interact
with them. Until recently, Saudi television and newspapers were unable to show
pictures of woman and few Saudi women are willing to talk or be interviewed on
television. The cultural and religious restrictions reported above limit women's
participation in the media. One male Saudi nurse pointed out:
People do not know much about nursing. Infonnation can make a huge difference in
improving recruitment of locals [indigenous]. In my case I wasted four years of my
life by entering an allied medical school instead of just going straight to a nursing
college, and the reason was a lack of knowledge about nursing prospects and
opportunities. (Moath)
Recently, however, there have been positive changes in the media's role in nursing in
Saudi Arabia.
The maJonty of stakeholders in the three countries stressed the importance of
promoting nursing. Some stakeholders feel that the media have not done enough to
inform people of the positive prospects of a nursing career. One senior female hospital
manager in Oman pointed out:
I wish we could advertise more to encourage people to consider nursing as a
profession and tell young people about the potential and the opportunities which are
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waiting for them in nursing. Many people in the country do not know a great deal
about nursing and the role a nurse plays in patient care. (Layla)
A female Omani nurse explained:
When something is vague, you will have a lot of doubts about it. But when you are
provided with information about it, you feel comfortable. It is the same with nursing.
In the past, nursing as a job was not common in Oman; most people do not know
enough information about it. (Samia)
In Bahrain the media have more freedom to report on women's issues. Yet nursing
issues have not received proper attention. One female Bahraini director of nursing
remarked:
The media has not done enough to help the nursing image. For example, there is a
television health programme hosted by a doctor. It would be a good idea if a nurse
was invited to talk about health in the community and the role of a nurse in both the
health service and the community. (Bedoor)
5.7 Role models
Many stakeholders emphasized that positive role models could playa major role in
improving the image of nursing. Although the three countries have different
experiences of the potential impacts, most agree that positive role models could
influence people's attitudes in conservative Gulf society. In Saudi Arabia, most
stakeholders recognize the importance of role models but it is difficult to find nurses
who could act as such. This is again attributed to the limited role of women in public
life. One expatriate nurse who is also head of the Saudization nursing department
explained:
I think we [foreign nurses] need to act as role models. You have got to portray the
goods of nursing. I think we should look at the image of nursing in Saudi Arabia and
start to look for role models, get Saudi nurses to schools and the community to preach
about nursing as profession and the important role a nurse plays in the health-care
service. (Liz)
However, practlsmg nurses with generally lower standards of education are
considered negative role models. One Saudi nursing education officer said:
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We have few role models; unfortunately most of our nurses are either high school or
college drop-outs or graduates of nursing institutions with nursing certificates. Few
are those Saudi nurses who have bachelor or postgraduate degrees in nursing. (Hussa)
Shortages of qualified and experienced nurses who can act as positive role models
make it difficult for policy-makers and nursing advocates to promote the image of
nursing in a large country like Saudi Arabia. For example, a newly opened nursing
college has only one Saudi nurse who teaches. She explained her role: "I am the only
qualified Saudi clinical researcher in the country. They [nursing school] hired me here
to teach and act as a role model for Saudi students" (Rufaida).
The Bahraini government and media do the most (among the three countries) to
promote a positive nursing image. This is primarily because nursing is a more
advanced profession and has a longer history in this country. Also, there are obvious
variations in gender relations and the status of women between the three countries.
Women in Bahrain run for, and are elected to, political and judicial offices. A woman
was recently appointed as a judge - a huge step for women as only a very few Muslim
countries have taken such a controversial decision. A director of a nursing college in
Bahrain proudly explained:
... we have good role models who have contributed positively to the image of nursing
in Bahrain. For example, when we interviewed some new applicants and asked them
why do you want to be a nurse many indicated that they want to be like so and so [the
minister] who was a nurse and now is a public figure. The Minister of Health was a
nurse. Students recognize the important role of a nurse, and that nursing as a career
could lead to better opportunities. (Wardia)
Donaldson & Carter (2005) found that groups of nursing students stressed the
importance of access to good role models in order to observe and practise their skills
and behaviour. Good role models were seen to have a major influence on the
development of students' competence and confidence. Bandura (1977b) argues that
role modelling is much more than imitative behaviour as it has a major influence on
the observer's behaviour. However, the influence of the role model is related to the
number of times that the student is exposed to the experience (Bandura, 1986).
Gibson (2004) states that career theory proposes the importance and influence of role
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models in helping to guide individual development. He points out that the traditional
idea of a role model is that of an individual in an influential position, such as a parent,
teacher or supervisor who provides an example for individuals to imitate.
Some regional and international organizations have recognized Bahraini nurses'
contributions to the nursing profession and their positive role in improving nursing's
image in both Bahrain and the Gulf. A female Bahraini Ministry of Health official
explained:
One of the most important turning points in promoting the image of nursing happened
when the World Health Organization (WHO) chose a Bahraini nurse to be the (WHO)
Chief Nurse Scientist. She was chosen out of 12 applicants from different countries.
This caused people to talk about her as a role model. Another example was when the
Eastern Mediterranean Regional Office (EMRO) appointed a Bahraini nurse as the
director of this sub-organization of the WHO in Cairo (Egypt). Changing the nursing
image from negative to positive is not an easy task. It is difficult and it takes time and
effort. (Fatena)
Therefore, in Gulf culture, the mere physical presence of a smartly dressed indigenous
nurse radiating enthusiasm and satisfaction in her work will prove a far better
recruitment tool than any number of leaflets, pamphlets and radio or TV programmes.
5.8 Chapter summary
The findings in this chapter suggest that nursing has a poor image and offers a far
from desirable career, especially among young graduates. Most of the stakeholders
participating in this study mentioned the lowly status of nursing among Gulf people.
There is a lack of knowledge and understanding of a nurse's role and its vital
contribution to health-care.
Clearly, any strategy to promote nursing as a career must address its poor image.
Targeted work will be necessary as there are limited channels through which
indigenous students in the Gulf can access information about nursing and its role in
the health-care process. Analysis of the three cases indicates that the public have
prejudices and negative attitudes not only about nursing but also about working
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women in general. Nursing is in a very awkward position - it remains predominantly
female but women are still prohibited from engaging in any social activities that
require close contact with men in some Gulf states. The three states have major
variations especially in those factors related to society, gender, religion and role
models. Gender and religious factors appear to be particularly important in the
negative image of nursing in Saudi Arabia.
Governments will have important roles in raising the image of nursing and the
development of the nursing workforce. Vigorous marketing of nursing's real and
positive contribution to the health service is essential for informing the wider
community. Higher education and health institutions need to establish marketing and
recruitment strategies to encourage high school graduates to consider nursing as a
career. This will require (and, in turn, produce) better-educated, well-qualified and
self-confident nurses. Recruitment of high calibre indigenous graduates will reduce
reliance on those who choose nursing by default.
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Chapter 6
Discussion and conclusion: fate of the indigenous
nursing workforce in the Gulf
6.1 Introduction
The indigenous nursing shortage sweeping through the Gulf states is at a critical level
and could change from a health crisis to a national security concern. This thesis has
utilized a number of different approaches (such as cross-national comparisons of
human resources) to highlight why a shortage of health workers occurs and how
human resource policies and strategies influence indigenization policies. It has also
utilized policy framework to emphasize the context, actors and policy process while
examining the policy of indigenization. The thesis has highlighted economic, social
(including religious) and political factors.
A variety of approaches were used to provide a framework to explain diversification
in indigenization and human resource practices in the three Gulf states. Stakeholder
analysis was undertaken to identify the main actors and their interests. A grounded
theory process of analysis included a number of distinct features (e.g. drawing
constant comparisons, use of a coding paradigm) to ensure conceptual development
and density. This research has outlined the different policies by which indigenous
nurses and nursing students were recruited to work in the three Gulf states. These
indigenization policies have been discussed particularly in relation to the image of
nursing, cultural differences and the role of women. Also, the barriers to considering
nursing as a career, career progression and career development have been examined.
This research triggers questions and discusses issues that relate to the deeply rooted
prejudice and discrimination towards women that prevails within the social and health
systems. The realities and difficulties of unmasking such discrimination against
women in general, and indigenous nurses in particular, are underlying factors.
The research has also raised further questions about the extent to which
misperceptions and misunderstanding of the nursing profession can impact on nursing
as a career choice, especially among women in the three Gulf states. It is important to
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note that certain practices and difficulties are continuing in these states. Over the
years, shortages of indigenous nurses in the health service have been addressed by
recruiting overseas rather than training and enhancing the quality of indigenous
nurses. This is supported by the fact that foreign nurses comprise more than 40% of
the nursing workforce in two of the three Gulf states - Saudi Arabia and Oman (Table
5). One of the major problems for indigenous nurses is the requirement to fit into an
established work environment that has been designed for foreign nurses. Many
indigenous nurses devise ways to fit in and adjust to the existing environment, mostly
to their detriment, but remain outsiders in the system with little hope of ever really
fitting in.
The purpose of this research was twofold: (i) to elucidate further the reasons and
consequences for the shortage of indigenous nurses in the three Gulf states; and (ii) to
formulate a logical and systematic explanation of indigenization policies and their
role in the indigenous nursing workforces in the three countries. The case study
research method was chosen because it seeks to uncover all issues relating to the
phenomena under investigation, taking consideration of relationships, context and
meaning. However, major limitations in the existing literature on the indigenous
nursing shortage and indigenization policies in the three countries should be noted.
There are few studies about the phenomena under investigation and most published
works on the subject are basic, exploratory in nature and lack an explication of rigour.
6.2 Empirical research literature
The literature review presented in Chapter 2 offers a general overview of the situation
of shortages of indigenous nurses in the three countries and describes what is known
about nursing shortages and indigenization policies within these Gulf states. This
research posed two primary questions that are now discussed in more detail.
What are the main causes inhibiting or promoting the development of nursing as a
career among indigenous women of the Gulp.
Implicit in this research question is the issue of whether or not the image of nursing;
religion and culture; flexible work practices; nursing education and training;
organizational factors; and other aspects of human resource development are valued
234
as critical elements of strategies to overcome the shortage of indigenous nurses in the
three countries. The question sought to identify cultural and organizational enablers
and barriers to decisions about effective practices to increase the number of
indigenous nurses. I analysed the situation in the three case studies and found that the
image of nursing; certain religious and cultural factors; and various human resource
practices affect the overall policy strategy to increase the number of indigenous
nurses.
What are the main factors facilitating or inhibiting the formulation and
implementation of an indigenization policy in the nursing workforce in Saudi Arabia?
Responses to this question indicated a lack of understanding of the indigenization
policy among most stakeholders (especially those in Saudi Arabia) and limited
coordination and commitment to sharing information among the various stakeholders
concerned with indigenization. These respondents reported that implementation (or
encouragement) of indigenization policies and other human resource practices in their
own organizations is hampered by a lack of leadership commitment and the absence
of a national strategy. In contrast, respondents in both Bahrain and Oman reported
that indigenization policies and other human resource practices are implemented in
their own organizations as part of an overall national strategy. Strong leadership
commitment and better coordination between indigenization stakeholders in the two
countries were reported as the main factors that are increasing the number of
indigenous nurses.
Clear vision and practices have enriched indigenous employees' productivity and
commitment to their jobs and their employers. They described an alignment between
their commitment to, and understanding of, an effective indigenization policy and
human resource practices and the actual national indigenization policy. Bahraini and
Omani nurses praised the value of their country's nursing education and training and
other human resource practices. Their responses indicated that their professional
training, combined with the strong role of women in public life and the positive image
of nursing in these two countries, contributed to an understanding of the value of the
indigenous nurse and therefore produced a positive impact on recruitment. Rather
than feeling threatened by religious and cultural rhetoric (the case in Saudi Arabia),
stakeholders in Bahrain and Oman understood the benefits that would accrue to their
235
countries and organizations by providing opportunities to expand nursing education
and training and strengthen the role of women in public life. This attitude was
enhanced by stakeholders' abilities to contribute to their country's health service and
their own organizations.
The data from these two research questions allowed me to identify enablers and
barriers to the indigenization of the nursing workforce in the three countries.
6.3 Key findings
Human resource professionals, scholars, economists and labour market specialists
have studied and written little about the benefits of a sufficient indigenous nursing
workforce or the consequences of a shortage of indigenous nurses. Studies by
Budhwar and Debrah (2003) and Adams and Dussault (2003) and a WHO report
(2006) were referenced in Chapter 2. These authors found that very little work has
been undertaken on comparative human resource management in developing
countries in general, the Gulf states in particular. In addition, health workforce issues
have become more prominent in many countries in recent years but human resources
for health is still in its infancy in the Gulf states. Researchers and scholars found the
GeC states to be characterized by a significant proportion of foreign workers and
segmented labour markets. Interestingly, Sassanpour et al. (2004) found that these
segmentations occur in several dimensions - between indigenous and foreign workers
in the public and private sectors; and between the public and private sectors.
This research has produced a number of important findings that the three Gulf states
should consider in order to improve their nursing professions. These findings, and the
implications for indigenous nurse recruitment and retention, are discussed below.
6.3.1 Image is a key to improving indigenization of the nursing workforce
The findings of this research suggest that economic incentives are very important
motivators for encouraging indigenous people to consider nursing as a career but it is
argued here that they are not the primary satisfier and motivator for advancement,
recognition and job satisfaction. Accordingly, economic incentives should not be seen
in isolation as the primary means by which to increase the number of indigenous
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nurses. They can produce a good short-term response but should not be considered
"the" solution to the shortage of nurses, as some suggest (Spetz & Given, 2003).
A striking finding of this study is the extent to which indigenous people in the Gulf
continue to hold negative perceptions of the nursing profession. It is argued here that
the Gulf nursing profession is attempting to improve capacity and encourage
indigenous people to consider nursing as a worthy career in the face of the poor image
and status of nursing in each of the three countries. Many Arabs, especially those
from the middle classes, perceive nursing to be too close to domestic service to be a
respectable career (Hijab, 1988). It will be a long and arduous process to reshape
existing images in some of these countries, especially Saudi Arabia.
The findings of this research suggest that an improved image of nursing is one of the
key factors for encouraging indigenous people to consider this career. This supports,
for example, those many authors who attribute the low rates of admission to nursing
schools to the negative image of nursing as a career (International Council of Nurses,
2001; Irwin, 2001). The majority of stakeholders reported that nursing is not the first
choice of career and that (given the opportunity) many nursing students would have
chosen a different path.
It should be noted here that analysis of the data suggests that the image of nursing is
improving in both Bahrain and Oman, but remains poor in Saudi Arabia. Other
evidence in this study suggests that practising indigenous nurses in most of the Gulf
states considered this devalued image to be one factor that led many students to
question their decision to consider nursing as a career. This resulted in a lack of good
role models for new entrants and a lack of support for indigenous nurses.
Most stakeholders in the three Gulf states emphasized the importance of positive role
models in improving the image of nursing. It is argued here that Gulf countries that
work to promote a positive image of nursing recruit and retain more indigenous
nurses than those who have weak and ineffective promotion strategies. Among the
three Gulf states Bahrain does by far the most to promote a positive nursing image;
Saudi Arabia does the least. Bahrain has the most indigenous nurses and Saudi Arabia
the least (see Table 5).
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Studies of mass media in the Gulf have analysed the representation of nursing and
indigenization issues. Restrictions on all types of media, especially in Saudi Arabia,
have minimized their role in pursuing issues of nursing and indigenization in the
nursing workforce. The Gulf states retain a monopoly over all types of media and
individuals are not allowed to publish their own newspapers or publications.
Information ministries in all the Gee countries run the broadcast media and enforce
press censorship through licensing of publications, obligatory submission of
newspapers before distribution and registration of journalists (United Nations
Development Programme, 2002).
Bahrain is the only Gulf state to have used the media intensively to promote the image
of nursing, in conjunction with mechanisms such as community participation in health
service delivery. The relatively free and active media have helped to broaden the
debate on issues regarding the image of nursing and indigenous nurses. Furthermore,
this has produced a well-established means of public engagement that Saudi Arabia
and Oman lack. The openness in Bahrain has also enabled the media to take an
effective and sensitive role in monitoring and reporting government performance in
human resource issues, including the indigenous nursing workforce. In Saudi Arabia,
the media continue to undermine or neglect any issues related to women, including
nursing. Several labour market and human resource issues have attracted some
attention in recent years (usually related to unemployment and the presence of foreign
workers) but have not opened up any debates on indigenization policies in health
human resources in general or nursing in particular.
The media can playa crucial role in encouraging the public to extend their vision of
nursing as a career. The production of appropriate materials such as pamphlets, films
and radio programmes could raise awareness of the role of nursing and indigenous
nurses in the health care of the people. Gulf governments should encourage the media
to provide prominent coverage of cases of mistreatment, sexual harassment and poor
working conditions experienced by working women, and nurses in particular, in the
workplace. This might discourage some women (especially indigenous women who
are reluctant to expose mistreatment and harassment in the workplace) but could also
work as a deterrent for those who consider women to be inferior to men.
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There is a lack of workshops to train human resource managers, nursing managers and
other nursing stakeholders on how to deal with the media or develop suitable
campaigns to advance the nursing profession in the region. There is also no
comprehensive archive of media material to promote nursing careers among the
young indigenous population, especially women. Celebrities, well-known media
personalities and professional media agencies could assist in this.
This research also found that nursing was rarely shown positively. Newspapers in all
three countries, especially in Saudi Arabia, often commented on potential problems
with the shortage of nurses and indigenization but rarely on the benefits of recruiting
or training local nurses. Nurses have been portrayed as low class, unclean and
sexually available and commonly associated with humorous and sexual story lines in
fictional television programmes. However, over the period of this research there has
been a slight improvement in the way in which nurses are portrayed.
6.3.2 Human resource practices inhibit career progression for indigenous nurses
Researchers have demonstrated that organizations achieve better outcomes when they
encourage and promote practices that encourage workers' abilities, motivation and
opportunities. This includes those in the health-care sectors (Gunnarsdottir &
Rafferty, 2006; West et aI., 2002). Inadequate human resource planning and
management, poor working conditions, high attrition, inadequate compensation, low
professional satisfaction and underinvestment in human resources are just some of the
critical issues that drive indigenous nursing shortages and no one action will resolve
the current crisis in the three Gulf states.
Furthermore, it is argued here that work conditions such as shift work, especially
night shifts, and the mixing of genders in the hospital environment promote a negative
image of nursing in most Gulf states (Al-Kandri & Lew 2005; Mansour, 1992).
Promotion systems are not always transparent and can institutionalize disadvantage
and create environments which facilitate discriminatory behaviours. It appears that
promotion, particularly to nursing management positions, is not based on merit but
involves systems of patronage (wasta) and satisfaction of subjective and culturally
specific criteria - a process which facilitates various forms of discrimination. Henry's
(2007) analysis of the experiences of career progression among a number of Ghanaian
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nurses working in the UK's National Health Service (NBS) is an example of how
patronage can jeopardize nurses' promotion and career progression. The process of
promotion experienced by these nurses is based on interplay between the limited
interview skills and discriminatory practices that hinder their progress and a process
of institutionalization through employers' inadequate or inappropriate support
mechanisms (Henry, 2007). Such processes and practices institutionalize
disadvantages and have negative outcomes which could explain the under-
representation of indigenous nurses in senior positions in the three Gulf states.
6.3.3 Local cultures and religion: impact on indigenization of nursing
The findings of this study lead me to contend that cultures and religion do impact on
the indigenous nursing shortage in the Gulf region because the articulation and
practice of a mixing environment where men and women work and blend together is
culturally and religiously contingent. Thus, working women/female nurses, culture
and religion are not mutually exclusive categories. Davies (1995) argues that
traditional cultural constructions of gender have identified emotional and practical
ability as feminine attributes and associated intellectual abstract abilities with
masculinity. Such a construction is more highly visible in the Gulf which inhibits
indigenous women's early participation in higher education in general, and nursing in
particular.
Clearly, indigenous nurses in the Gulf face a set of difficulties and challenges similar
to that experienced by many nurses in other countries. However, they also occupy a
unique position within a highly conservative and restrictive culture that limits their
freedom and participation in public life. Gender roles have been shaped by a rigid and
conservative interpretation of Islam that affects women negatively and limits their
education and labour opportunities. A workforce that is educated and trained
appropriately, compensated fairly, respected and committed would appear to be an
essential component for meeting the multiple challenges facing Gulf health care and
to optimize performance.
The three Gulf states share many commonalities in the experiences of indigenous
nurses but also significant differences. The most notable of these were seen In
women's varying roles in public life, their freedom of movement, the image of
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nursing and gender discrimination. Local culture and tolerance of the role of women
played a crucial part in shaping experiences within the workplace and elsewhere.
Saudi Arabia on the one hand and Bahrain and Oman on the other show striking
contrasts in issues of social isolation, forms of discrimination, the role of the religious
establishment and sources of support. The research also found significant differences
in the quality of support, marginalization of indigenous nurses and image of nursing.
The research findings of this study indicate that the factors and conditions discussed
above deter indigenous women from considering nursing as a career and have real
consequences. The data in this research stress the importance of greater managerial
attention and recognition of the vital roles of indigenous nurses in health-care
outcomes. The organizational climate in health service organizations, specifically
organizational support for indigenous nurses, has been an undervalued determinant of
nurse recruitment and retention failure in most of the three Gulf states. In addition,
this research argues that female nursing shortages are exacerbated in countries that
inhibit female participation in the workforce. It is likely that those countries that
restrict women's freedom and gender relations and lack proper human resource
planning will experience shortages of indigenous women in the workforce more often
than other settings.
During the last few years, governments have focused increasingly on women's issues
and given some priority to the integration of women in social development policies.
Women in the Gulf and elsewhere have questioned the conditions of women in Gulf
societies and whether their interests, experiences and contributions are being
considered. Women in the Gulf have been deliberately excluded from most social
issues and considered only as mothers and housewives. They have also been excluded
from the labour market and received disproportionately few development benefits.
This lack of visibility in most social issues and limited participation in the workplace
indicates a certain degree of social inequality, stemming from men's stereotyped
expectations and encouraged by a lack of equal employment legislation.
6.3.4 Indigenous female nurses and multidimensional discrimination
Indigenous nurses are at greater risk of poor working conditions, little psychological
support and limited job satisfaction, particularly those who work rotating and night
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shifts. The study data show that discrimination in the workplace takes various forms ,
including direct gender discrimination and indirect discrimination embedded in
organizational cultures, structures and practices.
Tensions and allegations of discrimination were evident amongst a range of
indigenous nurses in the three Gulf states. Such discrimination not only has negative
implications for indigenous' nurses welfare but also limits their feelings of loyalty to
their countries, resulting in diminishing productivity and alienation. Middle Eastern
nurses outlined hidden and clear discrimination as well as outright racism among
foreign nurses, especially those from Western nations (Hawthorne, 2001). A Saudi
nurse said: "I remained always as an outsider not accepted among foreign colleagues
and administration" (Amal). Evidence from this study suggests that explicit policies
regarding discrimination are rarely enforced in any of the three Gulf states.
In addition, indigenous nurses experience a lack of social connectedness in health
organizations. This affects people's lives as the support of colleagues and superiors
has an important impact on the quality of life at work (Gunnarsdottir & Rafferty,
2006). Inadequate support from colleagues and management is evident in this study-
the evidence suggests a low degree of social cohesion in most of the health-care
organizations in the three Gulf states. This has important impacts on work quality and
leads to high turnover.
Dissatisfaction with wages and benefits was another important issue. There is
evidence of widespread wage discrimination against indigenous nurses in health-care
organizations across the three Gulf states. Indigenous female nurses respond to these
difficulties by resisting and re-negotiating and overcoming discriminatory conditions
but repeated failure to achieve career progression results in alienation from the
workplace and deep demoralization. Evidence suggests that efforts to create better
working conditions must include better staffing decisions, better communication and
teamwork and safe working environments that facilitate healthy choices, supported by
adequate resources (Baumann et al 2001).
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6.4 Is there a GCC policy process?
This researcher has found no evidence of a Gulf-wide policy process. It is argued here
that the policy processes in the three Gulf states have many similarities, one of the
most important of which is the fragility of their regimes. This often brings state
legitimacy into question and it is evident that many policies and regulations have the
objective of enhancing government legitimacy. Also, large state structures grant
governments far more importance than their people, particularly in Saudi Arabia and
Oman.
All three states also share a weakness in policy capacity. For example, Saudi Arabia
has national capacity but either non-existent or underutilized local capacity. This
means that there is little technical capacity and too little analytical ability to conduct
high-quality participatory policy processes. Often, large groups of people are
excluded from participation in the policy process and decision-making in most of
these countries is informed by, and strongly dependent on, foreign expertise and
knowledge. Finally, the process of policy implementation in all three Gulf states is
particularly problematic.
6.5 Implementation of indigenization policies: challenges and
constraints
6.5.1 Slow policy response
Analysis of the indigenization policy actors has illuminated contrasting power
relationships within each of the three Gulf states in this study. Delayed policy-making
responses may have been responsible for past shortages of indigenous nurses but
current and future nurse shortages may also be driven by a broader set of cultural,
economic, image and sociological factors. These include fewer nursing schools~ fewer
young indigenous people entering the profession~ a greater range of other professional
opportunities for young indigenous people; the negative image of nursing~ poor
recruitment and retention strategies; and poor pay and working conditions for
indigenous nurses.
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In the Gulf states there are signs that nurse shortages will worsen in the near future if
action is not taken. This will require policy responses that focus on the introduction of
mixed policies to initiate innovative approaches to nurse education as well as career
opportunities which offer strong incentives to recruit and retain indigenous nurses and
improve their image, pay and working conditions.
This analysis has demonstrated the multifaceted scope of issues surrounding
indigenization policies and human resources in the three Gulf countries. Weakness
and imbalances between the indigenous and foreign nurse workforces may arise from
multiple sources, impact on various aspects of the health service and affect multiple
outcomes.
6.5.2 Recruitment and retention strategies
Effective recruitment and retention strategies are critical for increasing the number of
indigenous nurses. Indigenous nurses are recruited to ease shortages of foreign nurses
and fill growing nursing vacancies but are given very little (if any) career
development, progression, promotion or social and organizational support. Gulf
policy-makers, health managers and community leaders need to rethink their
strategies for recruiting, training and retaining indigenous nurses in the present
competitive market of global migration. These cannot and should not focus only on
human resource strategies to manage the workforce. They will also need to consider
those practices that form the norms of behaviour and attitudes toward women and
their roles in public life in these countries. Indigenous nurses should not be seen as
commodities, human resources or victims of the process but as human beings and
partners in the development of their societies and countries.
Indigenous nurses should be respected as they offer the potential for the growth and
development of the nursing profession in the Gulf. This requires a willingness to
adopt, implement and continually evaluate how certain practices and policies impact
on managing workplace differences between indigenous and foreign nurses. This
research recognizes that neither government policy nor legislation can replace mutual
respect, the sharing of ideas and acceptance between genders and professions.
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Investment In strategies to improve basic amenities, infrastructure and working
conditions could greatly improve the recruitment, retention and motivation of
indigenous nurses. These include strategies that affect management styles; incentives
and career structures; salary and benefit scales; and posting and training practices.
6.5.3 Indigenous workers lack skills and experience: myth or fact?
One of the most important findings of this study is the shortage of suitably qualified
and skilled indigenous health workers. It is argued here that a number of factors
contribute to this. First, few (if any) agencies or external institutions can train
unskilled workers in a short enough time or to a level acceptable to (especially private
sector) employer. Second, the private sector does not support in-service training
although governments consider this the most helpful skill-development method. It is
evident that much of the education and training that the workplace requires is general
in nature and does not meet the requirements of private sector employers. Low levels
of education, little exposure to technical expertise and lack of experience are among
the main deficiencies of indigenous workers. Most employers in the three states are
unwilling to incur training costs and would pay significantly lower salaries in order to
recoup these expenses. One Saudi businessman explained: "Education and training
are not our responsibility. They are the responsibility of the government. If we
provide training to Saudis then they must accept low salary and benefits. We cannot
offer both" (Arab News, 2004).
Without sufficient training and suitable wage and incentive scales indigenous workers
are likely to become dissatisfied, reduce their work effort or simply seek employment
elsewhere. In turn, employers question the loyalty of indigenous workers and find that
they do not take long-term views of career opportunities and training prospects.
Hence, private sector employers are unwilling to train indigenous workers and show a
strong preference for recruiting and retaining foreign workers whenever the law
permits. Given the labour market situation of a rapidly increasing demand for skilled
labour and the potential loss of such labour to other employers, it is argued here that
there is little incentive to provide training. This has resulted in a labour market that
undervalues in-service training and over-emphasizes formal education and training.
Indigenous workers are being asked to accept low salaries on the basis that their
salary and benefits will rise as their skills and experience increase.
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6.6 Gulf education and training systems cannot meet the needs of
the labour market
The education system is an important factor in labour market supply. It is evident that
the oil boom has financed huge investment - new schools, universities and vocational
training centres have been built in the last three decades. This has resulted in a
significant increase in the number of college graduates that has not been matched by
better quality education or more provision of the specialties needed in the labour
market. Students have viewed college certificates as passports to good jobs in the
government sector, regardless of the quality or field of their degree. Public service is
considered to be a safe haven and increasing numbers enter college as a way of
guaranteeing such a job for life. Governments are no longer able to employ large
numbers of new recruits and therefore there are surplus college graduates who cannot
find jobs. This has produced high unemployment rates in some Gulf countries -
reported to be as high as 20% in Saudi Arabia for example (Hardy, 2006).
It is evident from the findings of this study that the existing education systems in most
of the Gulf states do not produce the graduates that the labour market requires.
Unemployment is reaching alarming levels and has implications for stability and
security in some countries. It is argued here that a number of significant developments
in the labour market highlighted throughout this study underline the urgent need to
transform the skills and roles of indigenous workers, especially health-care staff.
Their education and training must keep pace with the changing requirements of the
labour market and technological advances. The strategic actions required relate
primarily to continuous realignment between education and training programmes,
health service needs, evolving roles and work practices (Dubois et aI., 2006).
Hiltrop (1996) suggests that a strategic approach requires organizations to take a long-
term view of the skills, knowledge and levels of competence that staff will need and
to treat their staff as an important resource that needs training and development. It is
argued here that the three Gulf states, but especially Saudi Arabia, are facing strategic
challenges which include the establishment of quality control systems to educate and
train health-care personnel, especially nurses; development of a sustainable
educational infrastructure that takes consideration of the lack of suitable teaching staff
246
and the shortage of nursing colleges; and the implementation of common Gee
mechanisms to exchange expertise, training programmes and students.
6.7 International recruitment can be beneficial
The levels of indigenization among nurses and other health professionals are likely to
remain variable as each country's social, political, economic and human resource
practices will have different impacts in the three Gulf states. At the Gee level, the
aggregate effect of foreign workers in general, health-care professionals in particular,
is likely to become more prominent in the next few years as demographic, political,
economic and labour market changes alter the overall balance. Gulf governments and
private sector organizations have not been clear about their indigenization policies.
The positive effects of international migration (e.g. on training, knowledge,
professional development) must be weighed against the potential negative
consequences on the indigenous nursing workforce. This requires a delicate balance
between recognition of the benefits of foreign nurses and collective concern for the
indigenous nursing workforce. Successful interventions to support the positive impact
of international recruitment and minimize its negative consequences will depend on
the level of socio-economic and technological development in each of the Gulf states
and long-term strategy commitments from professional and political leaders (Kingma,
2001).
International recruitment can playa positive role in Gee countries if it is utilized to
raise the profile of the nursing profession's needs in the Gulf and influence
indigenous students to select nursing as a career.
6.8 Availability, accessibility and transparency of data in human
resources for health
Accurate and reliable data are critical for planning and for strategic decisions in
human resources, both in general and in the health service. The Gulf states have very
limited adequate and reliable data on demographic, macroeconomic, labour market
247
and human resource indicators. These are vital for any effective human resource
planning and for strategic labour force decisions. As indicated in this research no , accurate data on health professionals and the health workforce are available in some
of the Gulf states, especially Saudi Arabia.
Bahrain and Oman have acted to improve data collection. For example, the Bahraini
health ministry has established a comprehensive data system for its health service
workforce, covering their distribution, qualifications and training and other related
information. The information is being used for staffing health organizations and in
staff planning. In addition, accurate data are being used to assess available educational
and training programmes and career planning. Such data are urgently required in
Saudi Arabia.
6.9 Conclusions and recommendations
The evidence reviewed in this research confirms what many scholars and writers have
noted about the Gulf region - severe shortages of indigenous health workers in
general and in the nursing workforce in particular. Since the 1970s, the Gee states
have relied heavily on foreign health-care personnel to sustain development in their
health-care services. However, recent global shortages of health-care workers and
severe competition from developed countries have made international recruitment
very difficult and costly to sustain. Gulf states seeking other alternatives and solutions
to fill these gaps have pursued policies and strategies (indigenization) aimed at
increasing the supply of qualified indigenous health-care professionals. These
indigenization policies have been discussed in this thesis, particularly in relation to
the image of nursing; cultural and social differences; and the role of women.
However, these measures have seen uneven development and variable success within
these three Gulf countries. Bahrain and Oman, the comparative countries in this
research, have introduced some successful indigenization policies to meet their
shortages of health-care workers. The indigenization practices in Saudi Arabia
suggest that little, if anything has been learned from over three decades' experience of
indigenization policy especially in nursing.
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Higgins (1981) points out one of the curious and fascinating questions that arises
when comparing social policies in different countries - why should there be such an
enormous variety of responses to what on the face of it appear to be similar states of
need? Most of the Gulf states face the same problems of a shortage of health-care
personnel (especially nurses) and how to educate their workforce, yet this research
confirmed that no two countries have chosen the same solutions. The comparative
study indicates that there is no single strategy or policy for the application of an
indigenization policy; each state must adapt policy to local situations. This thesis
confirms the importance of comparative studies. These are necessary and useful for
systematic examination of attitudes to class, gender and religion and their impact on
the development and implementation of certain social policies in the three Gulf states.
The evidence reviewed in this study confirms indigenous women's low participation
in the labour market. Also, that the vast majority of those who are employed
experience discrimination, lack of recognition and very poor working conditions.
Discrimination reduces opportunities for education and training; career development;
and full participation in the labour market and in part explains the severe shortage of
indigenous nurses in the workforce in most Gulf states. Eliminating or reducing
discrimination against women, particularly working women; recognizing their skills;
and improving working conditions could increase their participation in the labour
market. In tum, this is likely to encourage both public and private institutions to
provide more incentives and employment opportunities for indigenous women. It is
also evident that the significance and importance of these interventions will vary with
the country context and type of organization or activity. For instance, it is unclear to
what extent indigenous women in Saudi Arabia would benefit from the interventions
mentioned above as no appropriate laws and regulations protect their rights and
interests.
The evidence presented here provides new insights into the mechanisms by which the
development of the indigenous nursing workforce is linked to inequality and
discrimination against women in general and working women in particular. The
evidence discussed here suggests that women's freedom of mobility and access to
various resources are important factors in determining the extent of future shortages
of health-care workers in general and indigenous nurses in particular. There are clear
249
indications (especially in Saudi Arabia) that restricted mobility and discrimination in
both public life and the labour market contribute to limiting women's access to
resources and their participation in the labour market.
Numbers of scholars identify a wide range of variables that influence social policy
especially internal factors. These include demographic, economic, social structure,
political, pressure group, institutional evolution and social psychology factors. These,
especially the social and cultural constraints, are considered the major factors in
limiting indigenous women's participation in public life and the labour market.
Religion plays an important role in all aspects of life in most of these Gulf states,
especially Saudi Arabia. It has received relatively little attention in the literature on
comparative social policy in the Gulf, partly due to the sensitivity attached to this
subject. However, religion and its influence and impact on the development and
implementation of various social policies in the Gulf states has been analysed and
examined in detail in many instances in this research.
This research confirmed that the considerable growth in expenditure on education
(especially for women) and the new initiatives to reduce discrimination against
women in recent years have contributed to the decline of the religious establishment's
influence on social policy development, especially in Saudi Arabia. This research
confirmed that social and cultural constraints in these Gulf states affect women more
than men and contribute to their invisibility and vulnerability.
In addition, this research has highlighted the deficiencies and uneven quality of data,
especially those related to human resources and labour markets. It confirms the lack
of standardized data and comparable databases and the poor quality of available data.
With no comprehensive systematic national database relevant to the health-care
labour market and employment statistics in most of these states it is very difficult to
make an adequate analysis of health-care supply and demand across these three
countries.
This thesis has confirmed and stressed the importance of image as a key to improving
indigenization in the nursing workforce. One important finding is that many
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indigenous people in most Gulf states continue to hold negative perceptions of the
profession of nursing.
Inadequate human resource planning, poor working conditions, inadequate
compensation, lack of career opportunity, unequal promotion management and other
human resource practices are critical issues that impact on indigenous nursing
shortages in these three states. Nurses in different Gulf states undertake similar roles
but show variations in their basic education, career structures, wages and titles. Many
indigenous and foreign nurses experience problems caused by poor working
conditions, discrimination and lack of recognition of their skills. These result in
employment on lower grades, irrespective of speciality and experience. Improved
access to education and training can help indigenous women to develop expertise and
expand their knowledge and experience to enable them to compete with foreign
workers. Efforts to raise women's participation in the labour market and improve the
quality of their employment will succeed only if they go beyond the social and
cultural constraints that bar women from full participation in public life.
Current strategies towards indigenization in the nursing workforce are neither friendly
nor accessible to indigenous women in general and working women in particular.
Clearest proof of this is seen in Saudi Arabia, where HRDF services and resources are
directed towards men - women are either excluded or allowed very limited access.
Other important issues such as gender-based discrimination in various sectors in the
Gulf states and differential access to resources and opportunities have been raised in
this research and also need to be addressed.
This research details how social and institutionalized discrimination in the Gulf
health-care sector may be internalized by indigenous and foreign workers, affecting
career progression and promotion opportunities. Currently, few interventions are
concerned with issues such as discrimination and differential access to education,
training, career development and employment opportunities in so-called male
dominated areas and activities. However, such actions will require policy-makers to
take difficult decisions and undertake measures with clear support from political
leaders in these Gulf states.
251
Recruitment and retention strategies for both indigenous and foreign nurses are
critical for increasing the number of nurses. Investment in strategies to improve
working conditions and reduce discrimination against women could greatly improve
the recruitment, retention and motivation for both indigenous and foreign nurses. This
thesis confirmed that much of the existing education and training is general in nature
and does not meet the requirements of the health service sector, especially in Saudi
Arabia. Low levels of nursing education, a lack of faculties, limited exposure to
technical expertise and lack of experience are among the main deficiencies for the
indigenous nursing workforce. This research emphasized the important role played by
foreign nurses in the three Gulf states. In addition, it confirmed that the employment
conditions of foreign nurses have reinforced patterns of disadvantage based on
gender, race and religion.
Evidence from this research suggests that both public and private sectors in most of
these Gulf states (especially Saudi Arabia) were unprepared for the implementation of
indigenization policies. Analysis of indigenization policies in their current formats
suggests that they face many challenges and have produced negligible results to date,
especially in the health service. Policy-makers and governments have been unable to
handle some of their adverse effects. Also, in some countries the public were
unprepared. They understood neither the content nor the objectives as the policies
themselves were ambiguous. Some decision-makers are reluctant to undertake reform
of human resources in the face of opposition from strong pressure groups such as
religious and business groups. Also, some governments are failing to pursue
aggressive indigenization reform programmes despite much favourable rhetoric. A
series of delaying tactics has been followed by a deal with strong forces rather than
reform programmes.
Slow policy responses in the past may have been responsible for the shortages of
indigenous workers in general and in the health-care service in particular in most of
the Gulf states. However, unemployment is reaching alarming levels and has
implications for stability and security in most of the Gulf states, especially Saudi
Arabia. It is argued here that a number of significant developments in the labour
market highlighted throughout this study underline the urgent need to transform the
skills and roles of indigenous workers, especially health-care staff. Their education
252
and training must keep pace with the changing requirements of the labour market and
technological advances.
Finally, this research has raised a number of potential policy impacts which are
summarized below.
1. The body of work and knowledge on human resources and nursing in Arab
countries in general and the Gulf in particular is currently very small in
comparison to that available for industrialized countries. This research aims to
contribute to that body of work.
2. Human resource issues in these Gulf countries are very important, particularly
in health care. Some of these issues (e.g. unemployment; shortages of
qualified personnel, particularly nurses) continue to be major public problems.
This research aims to contribute to understanding of the effects and
effectiveness of some measures and interventions in order to contain and limit
any negative impacts.
3. This research provides knowledge and information on the nursing profession
and the barriers that prevent indigenous women from becoming nurses in these
three countri es.
4. This research provides insights and information for policy and decision-
makers not only in the three countries concerned but for all Gee countries.
Also, it informs future human resource studies.
Many important and unanswered questions regarding indigenization remaIn,
including:
1. How realistic is the current policy on indigenization?
2. Should indigenization be implemented from grassroots level or from the top?
3. Is 100% indigenization in certain sectors practical and economical?
4. How can a balanced policy be achieved?
5. Will a mass departure of foreign workers have adverse effects on the economy
and the expertise that these countries need?
253
6.10 Future research
If officials in Gulf states were asked to pick the one thing that might bring about
major labour market change, what would they choose? Most stakeholders might opt
for their favourite - an indigenization policy. However, there is a need for modem ,
flexible and well-developed human resource laws and regulations to keep pace with
changing labour market conditions both internally and globally. Stakeholders should
also think of changing the way that people and organizations across the Gulf states
interact with each other and the decision-making processes. Increased levels of
coordination and cooperation between Gulf states could solve common and similar
problems related to the workforce, especially in the health service.
This research has concentrated primarily on the nursing work force and indigenization
in three Gulf states but would be complemented and expanded by future research in
four areas. Firstly, on the dynamic relations and collaboration between various public
and private health organizations. Secondly, to acquire greater understanding of the
policy and decision-making processes in the Gulf and the roles of various institutional
players. Thirdly, on evaluations of indigenization policies in the Gulf states. The
present research compared three cases of indigenization but a comprehensive
evaluation of indigenization policies in all six Gulf states is required. The fourth and
final area for further research is the need for greater focus on the roles of gender,
religion and culture and how they affect Gulf women's full participation in the labour
market.
This research has attempted to fill a gap between two distinct fields of literature -
human resources for health in the Gulf states and the role of social and cultural factors
in women's participation in public life and the labour market in the Gulf. There is a
natural alliance and close relationship between these two fields that has only recently
been recognized in the Gulf. Findings and analysis from this research hopefully will
encourage scholars from both fields and from other disciplines to examine further this
relationship. This would provide a broader foundation to enable indigenous people
(both males and females) to participate equally in the development of human
resources in general and the health service in particular.
254
I consider that the social and cultural barriers highlighted by this study are those that
lie within the nonns and spirit of the indigenous people of the Gulf. Human resource
barriers are those that relate to work and the organizational environment that shapes
and supports indigenous nurses. These barriers appear independent but do (at some
level) occupy the same space and are interdependent with potential huge impacts on
nursing development in the Gulf. I call the blending and interaction of these social,
cultural and human resource barriers: the barrier of modernization.
This study has also highlighted the tensions and problems embedded in research
undertaken in Gulf countries - limited available data, a lack of transparency and a
dearth of previous nursing research. This thesis ends by reporting a great step forward
- Saudi Arabia opened its first university for women in November 2008. Perhaps this
will herald a new era in education for Saudi women.
255
Appendices
Appendix 1: Selected social and economic indicators in three Gulf states, 2006-2007)
Category Saudi Arabia Bahrain Oman
GNP per capita (US$) 10 140 14370 9070
Population
Total (millions) 26.417 1.038 3.1
Female (0/0 of total) 46 64 43.4
Life expectancy at birth (years)
Male 72 75 73
Female 74 76 76
Adult (15+) literacy rate
Male (%) 87 .1 88 .6 86 .8
Female (0/0) 69.3 83 .6 73.5
Labour force
participation
Total labour force
(millions) 8 0.420 1
Female (0/0 of total
labour force) 15 19 16
Ratio of female to male
labour force
participation 23 34 27
Unemployment
Total (% of total labour
force) 13-25 15 15
Educational access and
attainment
Net primary school
enrolment rate
256
Male 77 96 77
Female 79 97 79
Youth (15-24) literacy
rate (%)
Male 97 97 97 .9
Female 95 97 96 .7
Health
Total fertility rate
(births per women) 3.17 2.4 4.5
Maternal mortality ratio
(per 100 000 live births) 33 28 87
Infant mortality rate
(per 1000 live births) 17.4 9 10
Total number of 338 9 48
hospitals
Sources : World Bank Group, 2006; Ministry of Health, 2006a; Ministry of Health, 2006b; Ministry of Health, 2006c .
257
Appendix 2: Main search methods
Key words and phrases
All key words and phrases were used to search for data for indigenization, nursing shortages, human resources for health, GeC health service, gender and women. Differing titles were found in the general search in both English and Arabic languages and were then used as search words. The list below gives examples and is not comprehensive.
Arab nursing labour market Gulf states labour market Nursing workforce Foreign nurses in the Gulf Shortage of nurses Shortage of nurses in the Gulf Globalization of nurse labour market Human resources for health International labour market
Sources
Databases
Published literature
Grey literature
International and national centres and organizati ons
International nursing labour market Labour market analysis Nurse retention Nurse job satisfaction Nurse turnover Workplace conditions Culture and religion in the Arab world Role of women in the Gulf states
Electronic databases Various educational institutions and libraries
Science Direct Healthstar/Ovid Various health journals (ArabiclEnglish)
Unpublished PhDs Unpublished reports (ArabiclEnglish)
International Labour Organization (lLO) Health Ministries Council in Gulf Countries
HMMC/GeC International research centres online library GeC Online International Council of Nurses International nursing organizations National Health Service (UK) Royal College of Nursing (UK) World Health Organization Bahrain Ministry of Health Oman Ministry of Health Saudi Arabian Ministry of Health Bahrain Ministry of Labour Oman Ministry of the Civil Service Saudi Arabian Ministry of Planning
258
Appendix 3: Indigenization (Saudization) legislation and development plans
Number and type of legislation
Labour Law(M/21) 1969
Subject and objectives
Terms and conditions of employment
Gives preference to indigenous workers
50/1995 Decree of Council of Ministers Sets national objective to replace foreign
workers with Saudis when possible
7/B/4010/1996 Royal Decree
M/8/1995 Royal Decree
107/2001 Decree of Council of
Ministers
Saudi Development Plans (SDPs)
Third SDP (1980-1985)
Fourth SDP (1985-1990)
Sets 5% annual Saudization target for any
company employing more than 20 people
Stresses importance and necessity of
implementing all terms and regulations of
Decree Number 50 issued by Council of
Ministers in 1995
Urges private sector to limit recruitment
of foreign workers and increase numbers
of Saudis
Sets fees and tariffs for foreign workers
e.g. for transfer of sponsorship and work
visas; increased recruitment costs
Establishment of Human Resources
Development Fund (HRDF) stipulating
responsibility for training, assisting and
providing funds to employ Saudis in the
private sector
Objectives related to indigenization
Ensure adequate supply of labour
Increase productivity
Reduce dependency on foreign workers
Introduce Saudization policy
Targets to reduce number of foreign
259
workers and increase number of Saudis
Fifth SDP (1990-1995) Stress importance of employing Saudis
Incentives to encourage private sector to
employ more Saudis
Sixth SDP (1995-2000) Prioritize important objectives in
development of human resources
Stress importance of quality in education
and training
Impose certain regulations on private
sector to reduce recruitment of foreign
workers
Seventh SDP (2000-2005) Increase private sector's role in applying
Saudization and incentivize by granting
more projects to firms that encourage
Saudization
Increase role of, and support for, HRDF
to absorb more Saudis and offer more
training opportunities
260
Appendix 4: HRDF mechanism for funding qualified Saudi candidates in the private sector
Funding training course (HRDF)
Potential employer contribution
(private sector) [share cost]
After successful completion of
training
Employment by private sector that
incurs half employee's salary
Government (HRDF) incurs other half
of employee's salary for two years
After two years employer becomes
fully responsible for employee
261
Appendix 5: Participant interview letter
Subject: Request for interview
From: Kasem AI Thowini
To: Stakeholders
I am contacting you about an interview I would like to conduct relative to my
PhD at the London School of Hygiene & Tropical Medicine on the shortage of
indigenous nurses and an indigenization policy in three Gulf states: Saudi Arabia,
Bahrain and Oman. The tentative title of my dissertation is "Toward the
indigenization of the nursing workforce in Saudi Arabia". My primary research
question is "What are the main factors inhibiting or promoting indigenous women to
consider nursing as a career in Saudi Arabia?" There are a number of other questions
related to the issue that I would like to discuss with you if possible. The interview will
take no longer than 60-75 minutes. Could you please let me know if you would be
willing to take part in the study and if so when it would be convenient for me to
contact you about conducting this interview?
I would like to conduct these interviews in the next several weeks. I look forward to
hearing from you.
Yours sincerely,
Kasem AI Thowini
E-mail: [email protected]
Contact numbers: London: 0044208 740 1424. Mobile: 7947472058
Saudi Arabia: 00966 1 05546 5614
262
Appendix 6: Participant interview letter in Arabic
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263
Appendix 7: Interview process
At the start of the interview, the researcher went through the research information
sheet, explaining the research purpose and guaranteeing anonymity. Each interviewee
read and completed a consent form and the researcher asked permission to audiotape
the interview. The structure and key themes of the interview guide were presented to
each interviewee before starting the interview. The interview guide had three sections:
(i) personal details; (ii) work life and experience, (iii) experiences working with
indigenous nurses and indigenization policy. Finally the interviewees were asked if
they had anything to add in respect of indigenization of the nursing workforce and
nursing profession in the three Gulf states.
In accordance with the qualitative interview technique and semi-structured approach
there was some flexibility in the way that the interview guide was followed. The
researcher was keen to explore stakeholders' own stated concerns and encouraged a
natural flow in the conversation. The researcher engaged in dialogue with the
interviewee to explore individual themes and viewpoints. Jackson (2005) suggests
that dialogue requires one to find something in one's own experience that is similar,
or approximate, to the experience of the other and therefore may bridge the gap
between the two.
Each interview generally lasted around one hour. In some cases the interviewer had to
compress questions when there was less time to explore detailed individual
experiences. Some interviews had no particular time constraints and some lasted more
than two hours, enabling the interviewee to describe and elaborate on particular
events. The only exceptions to these one-to-one semi-structured interviews were four
group interviews: (i) a group of three nursing female students in Saudi Arabia
preferred to be interviewed together in the college dean's office; (ii) four Omani
nursing education personnel preferred to be interviewed together because of time
constraints; (iii) three other Saudi female nurses preferred to be interviewed together;
and (iv) three Omani nurses wished to be interviewed together. The same interview
process was used. Most women, especially the young, preferred to be interviewed in
groups because of the local culture, shyness and religious requirements that a woman
should not be alone with a strange male.
264
Appendix 8: Interview guide
A- General questions
1- What is the nature of your job?
2- How long have you worked in this position?
3- What do you like about your job?
4- What do you not like about your job?
B- Specific questions
1- Do you have a shortage of staff? If yes:
2- What are the areas most affected by such a shortage?
3- Do you have a shortage of indigenous qualified personnel? If yes:
4- What are the areas or specialty most affected by the shortage?
5- How critical is the shortage and what effect does it have on health-care delivery?
6- What is the percentage of indigenous nurses in your nursing workforce?
7- Do you have an indigenization policy or programme? If yes:
8- How do you define indigenization precisely and how was it started?
9- What are the main objectives of this policy?
IO-Who are the stakeholders interested in this policy in your organization and why?
II-How do managers view the indigenization policy results?
12-Are there assessment or evaluation criteria in place for this policy or programme?
13-What types of human resource practice are used?
14-What tactics or policies are used?
IS-As a departmental manager what are your three greatest problems with the
indigenization policy?
I6-Which processes do you think need review and change?
I7-What role do human resource managers play in indigenization activities?
I8-What are the future plans of indigenization and what role will it play in increasing
the number of indigenous nurses?
265
19-Who has the overall responsibility for implementing indigenization?
20-Should indigenization programmes operate at the national or regional level?
21-What considerations influence the choice ofindigenization programmes?
22-What are the guidelines that policy-makers follow III designing
indigenization programmes?
23-What are the different models of human resource management related to
indigenization systems in the health sector in your country?
24-How are indigenization performances indicators applied and used?
25-What are the methods used to assess the effect of indigenization in your country?
26-What are the principal lessons to be learned from current applications of
indigenization policy?
27-What are the differences and similarities between the current indigenization
programmes in the health service and other sectors?
266
Appendix 9: Sample of translated interview questions (Arabic)
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267
Appendix 10: Data management and analysis
Shortly after each interview the researcher described the setting in a note and detailed
key themes emerging from the interview in order to capture immediate insights. The
audiotapes were transcribed verbatim and then coded as the researcher listened to the
audiotape and corrected the transcription where necessary. While coding manually,
the researcher made case-specific notes to capture the in-depth themes emerging from
the data. The purpose and content of each code were defined and noted in a logbook
to provide an audit trail of evidence. Each interview was given attributes detailing key
variables to allow grouping of cross-case data retrieval. The researcher held regular
meetings with his supervisors over the period of the study to discuss the coding
strategy and empirical and theoretical insights as the research progressed. Discussions
with supervisors and others stimulated a valuable richness and multi-dimensionality in
the analytical process. The ongoing analysis of data was supported by regular
meetings with supervisors who included people with knowledge of policy, nursing
workforce and career development issues relevant to the study.
268
Appendix 11: Fieldwork memo
Title:
Issue:
Date:
Location:
Memo 49
Differences in sociallife/role of women
Tuesday, 8 March 2005
Bahrain
When I visited the college of Allied Medical Science and Nursing, I was struck by the
differences of atmosphere between this college and ... one of the colleges of nursing
in Saudi Arabia I visited earlier. Although Bahrain is only half an hour drive from the
Saudi border, differences between the two countries (especially in social life), are
huge. Female students here have the freedom to come and go as they wish, interact
with other male students, use public transportation and are taught by male teachers. In
the Saudi nursing college, female students complained of the restrictions imposed on
their freedom. They are not able to leave their college accommodation unless
accompanied by one of their male relatives. Women in general in Bahrain have more
freedom and can drive and feel independent. Is there any correlation between freedom
for women and choosing a profession? Would Saudi nursing schools be more
attractive if female students enjoyed the same freedom as their counterparts in
Bahrain? In your next interview with ... raise the issue of role of women and freedom
of women on nursing.
269
Appendix 12: Consent participation form
Consent to participation in research
Title: Human resources practices in the Gulf: the recruitment of indigenous nurses
Researcher: Kasem Al-Thowini
Address: London School of Hygiene & Tropical Medicine
32 Keppel Street, London, United Kingdom WCIE 7HT
E-mail: [email protected]
Supervisors: Professor Anne-Marie Rafferty
Dr Jill Maben
Aim: you are being asked to participate in this research that seeks to study and
examine the shortage of indigenous nurses and the indigenization policy in three Gulf
states: Saudi Arabia, Bahrain and Oman.
Risks and benefits: there are no known dangers or risks from participating in this
research, nor will there be any direct benefit in terms of financial compensation.
Hopefully, however, there will be some benefits for the nursing development in the
Gulf after the research is completed.
Right to withdraw: you have the right to withdraw from this study at any time.
A summary of findings will be provided to you on request free of charge.
Voluntary consent: I, ................ , have read and understood what is being required
from me to participate in this study. I understand that I can withdraw from this study
any time I wish and I also understand that there will be no compensation or direct
benefits for me. I certify that I am agreeing to participate in this study.
Participant's signature: Country: Date:
270
Appendix 13
Arabic consent participation form
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