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International Journal for Quality in Health Care 2005; Volume 17, Number 4: pp. 331–346 10.1093/intqhc/mzi046 Advance Access Publication: 9 May 2005

International Journal for Quality in Health Care vol. 17 no. 4 © The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 331

Review Article

Quality of primary health care in Saudi Arabia: a comprehensive review HANAN AL-AHMADI1 AND MARTIN ROLAND2

1Institute of Public Administration, Riyadh, Saudi Arabia, 2National Primary Care Research and Development Centre, University of Manchester, UK

Abstract

Objectives. Little is known about the quality of primary care in Saudi Arabia, despite the central role of primary care centers in Saudi health strategy. This study presents an overview of quality of primary care in Saudi Arabia, and identifies factors impeding the achievement of quality, with the aim of determining how the quality of Saudi primary care could be improved.

Method. Using a systematic search strategy, data were extracted from the published literature on quality of care in Saudi primary care services, and on barriers to achieving high-quality care.

Results. Of the 128 studies initially identified, 31 met the inclusion criteria for the review. Studies identified were diverse in methodology and focus. Components of quality were reviewed in terms of access and effectiveness of both clinical and inter- personal care. Good access and effective care were reported for certain services including: immunization, maternal health care, and control of epidemic diseases. Poor access and effectiveness were reported for chronic disease management programs, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care including those caused by language barriers. Several factors were identified as determining whether high-quality care was delivered. These included man- agement and organizational factors, implementation of evidence-based practice, professional development, use of referrals to secondary care, and organizational culture.

Conclusion. There is substantial variation in the quality of Saudi primary care services. In order to improve quality, there is a need to improve the management and organization of primary care services. Professional development strategies are also needed to improve the knowledge and skills of staff.

Keywords: access, assessment, effectiveness, performance improvement, primary health care, quality, quality improvement, Saudi Arabia

In 1978, the Alma Ata Declaration issued by the World Health Organization (WHO) General Assembly identified primary health care as the means to achieve health for all by the year 2000. In accordance with the Alma Ata declaration, Saudi Arabia identified the development of primary health care as one of its most important strategies. Today, the Ministry of Health (MOH) operates 1787 primary care centres throughout the country, each serving an average of 8727 people [1].

Variations in quality of care exist in many countries includ- ing the United States [2], United Kingdom [3], and United Arab Emirates [4]. Like other countries, Saudi Arabia is facing challenges due to growing demand on health services, rising costs, and public pressure for better services.

Quality of health care is a multidimensional concept that has been defined in various ways [5–7 ]. Recently, components of quality were identified as a combination of access (whether individuals can access health structures and processes of care

that they need) and effectiveness (the extent to which care delivers its intended outcome or results) [8]. Effectiveness has two elements: clinical care and interpersonal care [8].

Promotion of quality has always been an integral part of primary health care programs in Saudi Arabia. In 1993, national guidelines for quality assurance in primary care were estab- lished. These guidelines cover the main aspects of primary care including: community participation, child health care, immuni- zation, referral, chronic disease management, prescribing, health education, maternal health care, management of commu- nicable diseases, and environmental health [9]. A management development program (Supporting Supervision) was launched in 1995 to prepare regional supervisors to be key players in qual- ity improvement efforts in primary care [10]. Other quality improvement measures were also taken, including treatment protocols and new approaches to staff training.

Twenty years after the implementation of primary health care programs, and 10 years since the initiation of the quality assur-

Address reprint requests to Hanan Al-Ahmadi, PO Box 703, Riyadh, 111421 Saudi Arabia. E-mail: [email protected]

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H. Al-Ahmadi and M. Roland

332

ance program, little information is available on the quality of primary health care in Saudi Arabia. This study seeks to use a comprehensive review of the literature to present an overview of the quality of primary care in Saudi Arabia, and identify barriers that impede achievement of quality in primary care organizations.

Methods

Search strategy

A search was conducted of Medline and Embase databases for the years 1985–2004 using the keywords: ‘primary care’, ‘primary health care’, ‘general practice’, ‘community medi- cine’, and ‘family medicine’ along with the term ‘Saudi Ara- bia’. The indexes of the Saudi Medical Journal and Annals of Saudi Medicine were also hand-searched for relevant articles. Six additional papers were identified from the reference lists of these papers, and more were obtained through personal contacts with experts in the field. These searches produced 126 publications on primary care in Saudi Arabia.

Eligibility of studies

Studies were included if they addressed aspects of primary care services covered by the national quality assurance guide- lines. Only studies published in peer-reviewed journals were included. Audit of clinical records, analysis of official reports, observational studies, and surveys of opinions and attitudes (of patients, members of households, health professionals, and managers) were included. Articles presenting individual personal assessments or reflections, or those which were principally educational, e.g. describing clinical procedures, were not included. Studies with a sample size of less than 100 were also excluded. No attempt was made to score methodol- ogies used in these studies due to their heterogeneous nature. A summary of the types of study identified is presented in Table 1.

Analysis

Each article was carefully read by the main author and the following data were extracted: method, data collected, sampling methods, sample size, response rate, number of organiza- tions, region, and results. These are presented in Table 2. The findings were then organized into coherent themes using a narrative review approach, which identified common elements in the studies reviewed.

Results

Thirty-one papers fulfilled the eligibility criteria. The studies were variable in terms of their scope and methodology. While most focused on clinical care, some focused on administrative or interpersonal aspects of care. The results are classified into two main categories: quality of care provided, and barriers to providing quality.

Quality of primary care

Quality of care is described in terms of access to care and effectiveness of care, including both clinical and interpersonal aspects of care [8].

Access

Good access was reported to prenatal care (67–95%) [11], vaccination programs (83–94%) [12], and screening and treat- ment of epidemic diseases (schistosomiasis) [13]. Access to programs targeting chronic illnesses was found to be below target [14–18]. For example, only a small proportion of regis- tered patients who have hypertension come for treatment in primary health care centers [15]. Low referral rates prevented appropriate access to specialist care [18], and access to health education was also low [16]. In order to improve access to services, 90% of primary care centers established appoint- ment systems, registers, and follow-up systems [14].

A study of patient satisfaction showed that patients were dissatisfied with several aspects of access, including waiting time (74.9%), waiting areas (58.1%), and the physical environment

Table 1 Summary of methodology used in the studies reviewed

Methodology No. ............................................. .............................................................

Inclusion Reviewed 57 Eliminated 26 Included 31

Type of study Retrospective records review 10 Cross-sectional survey 18 Other 3

Data collection Questionnaire 14 Interview 4 Audit of records 10 Other 3

Sample size <100 1 100–150 1 151–500 15 >500 11 Not applicable 3

Percentage response rate <25 0 25–50 0 51–75 1 76–100 12 Not reported/not applicable 18

Region Western 1 Central 14 Eastern 4 Southern 6 Northern 2 Several regions 4

Type of organization MOH 29 Military 2

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Quality of primary health care in Saudi Arabia

333

T ab

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H. Al-Ahmadi and M. Roland

334

T ab

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n ti

n u ed

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ud y

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.. ..

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al di

a n

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ar if

02 [1

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f p

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2y 98

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rg an

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% h

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n d

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se s

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n ed

t o

p ro

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% o

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rs h

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ia b

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re gi

st ri

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w -u

p s

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ly 2

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nd ed

t ra

in in

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s o

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a n

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i 20

03 [1

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t 32

0 N

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s H

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o f

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ul t

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ff er

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b er

o f

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( 80

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9% ),

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7% ).

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ei ve

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o n

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n d

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h ad

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io n

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ad eq

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re a

n d

p ro

ce ss

r he

al th

e du

ca ti

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co n ti

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Quality of primary health care in Saudi Arabia

335

T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

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p o

n se

( %

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tt in

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.. ..

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Si dd

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e t

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20 01

[1 7]

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ie w

o f

a ra

n do

sa m

p le

o f

ca se

n o

te s

o f

h yp

er te

n si

p at

ie n

ts .

C en

tr al

37 47

N A

A rm

fo rc

es O

n e

ce n

te r

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ec ti

ve n

es s

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er te

n si

o n

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o l o

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d p

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ve p

at ie

n ts

w as

b el

o w

rg et

s (c

o m

p ar

ed w

it h

t h

e B

ri ti

sh H

yp er

te n

si o

n S

o ci

et y

gu id

el in

es p

ub lis

h ed

in 1

99 9)

A l-

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al di

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al .

20 02

[1 8]

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or d

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ew o

f re

co rd

s o

f a ll

di ab

et ic

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n ts

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h 20

3 N

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es s

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b et

es In

ad eq

ua te

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l t o

s p

ec ia

liz ed

in ic

s, e

.g . o

n ly

4 0%

o f

di ab

et ic

s w

er e

re fe

rr ed

t o

e ye

c lin

ic in

1 99

6 an

d 68

% in

1 99

7. H

o sp

it al

f ee

db ac

k ra

te w

as 7

2% . P

re va

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w as

1 1.

3% .

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ar i a

n d

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19 99

[1 9]

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rv ie

w s

ur ve

y o

f a

ra n

do m

s am

p le

o f

h ea

ds o

f h

o us

eh o

ld s

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t 80

2 98

M O

H T

h re

e ce

n te

rs A

cc es

s/ ef

fe ct

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es s

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ie n

t sa

ti sf

ac ti

o n

Sa ti

sf ac

ti o

n w

it h

: a tt

it ud

es o

f st

af f

(9 6.

4% ),

o ut

co m

e o

f ca

re (

88 .4

% ),

ti vi

ti es

r el

at ed

t o

p at

ie n

t ca

(8 6.

2% ).

D is

sa ti

sf ac

ti o

n w

it h

: w

ai ti

n g

ti m

e (7

4. 9%

), w

ai ti

n g

ar ea

s (5

8. 1%

), c

o n

fi de

n ti

al it

y (6

2. 1%

b ui

ld in

g (6

3. 8%

), e

xp la

n at

io n

g iv

o n

v ar

io us

a ct

iv it

ie s

co n

du ct

du ri

n g

co n

su lt

at io

n (

64 .7

% ).

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et a

19 93

[2 0]

In te

rv ie

w s

ur ve

y o

f a

ra n

do m

s am

p le

o f

h ea

ds o

f h

o us

eh o

ld s

C en

tr al

90 0

N A

M O

H 14

c en

te rs

A cc

es s/

ef fe

ct iv

en es

s P

at ie

n t

sa ti

sf ac

ti o

n 61

–7 4%

o f

p at

ie n

ts in

di ca

te d

th at

e he

al th

c en

te r

is t

he ir

f ir

st c

ho ic

e w

h en

s ic

k; 4

0% w

er e

di ss

at is

fi ed

ec au

se : c

en te

r is

t o

o f

ar , w

o rk

in g

h o

ur s

ar e

un su

it ab

le , l

ac k

o f

sp ec

ia lt

y cl

in ic

s, la

n gu

ag e

b ar

ri er

de la

ys , a

n d

in ad

eq ua

te e

xp la

n at

io n

y do

ct o

rs .

A l-

F ar

is e

t a l.

19 96

[2 1]

Q ue

st io

n na

ir e

su rv

o f

a ra

n do

m s

am p

o f

p at

ie n

C en

tr al

46 6

N R

M O

H Si

x ce

n te

rs A

cc es

s/ ef

fe ct

iv en

es s

P at

ie n

t sa

ti sf

ac ti

o n

H ig

h o

ve ra

ll sa

ti sf

ac ti

o n

( 90

% ).

en ti

fi ed

p ro

b le

m s

w it

h la

n gu

ag e

b ar

ri er

s (3

9% ),

in ad

eq ua

in fo

rm at

io n

b y

do ct

o rs

( 38

% ),

su ff

ic ie

n t

dr ug

s up

p ly

( 34

% ),

a n

d w

ai ti

n g

ti m

e (4

7% ).

co n ti

n u ed

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H. Al-Ahmadi and M. Roland

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T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

R es

p o

n se

( %

) Se

tt in

g N

o . o

rg s

D im

en si

o n

F o

cu s

R es

ul ts

.. ..

.. ...

.. ..

... ..

.. ..

.. ...

.. ..

... ..

.. ..

.. .. ..

.. ..

... ..

.. ..

B al

19 95

[2 2]

Q ue

st io

n na

ir e

su rv

o f

a n

at io

na l r

an do

sa m

p le

o f

h ea

ds o

f h

o us

eh o

ld s

F iv

e re

gi o

n s

63 06

N A

M O

H 15

0 ce

n te

rs A

cc es

s/ ef

fe ct

iv en

es s

M at

er n

h ea

lt h

In st

it ut

io n

al d

el iv

er ie

s 86

% ; 9

o f

de liv

er ie

s w

er e

at te

n de

d b

y a

p h

ys ic

ia n

o r

n ur

se . P

o st

n at

al c

ar e

b y

p h

ys ic

ia n

o r

n ur

se (

88 %

). R

el at

iv el

y h

ig h

c o

ve ra

ge o

f n

at al

a nd

p o

st n

at al

rv ic

es .

A l-

F ar

is a

n d

A l-

T aw

ee l

19 99

[2 3]

R ev

ie w

o f

a ra

n do

sa m

p le

o f

p re

sc ri

p ti

o n

s an

d re

co rd

C en

tr al

17 0

67 N

A M

O H

E ig

h t

ce n

te rs

E ff

ec ti

ve n

es s

P re

sc ri

b in

g 92

% c

o m

p le

te d

o cu

m en

ta ti

o n

o f

in fo

rm at

io n

in p

re sc

ri p

ti o

n s.

ve r-

p re

sc ri

b in

g o

f an

ti h

is ta

m in

es ,

an ti

b io

ti cs

f o

r p

at ie

n ts

w it

h U

R T

I (2

5% )

as U

R T

I w

as t

h e

di ag

n o

st ic

b el

u se

d o

n m

o re

t h

an h

al f

o f

th e

p re

sc ri

p ti

o n

s. N

o n

-e vi

de n

ce -b

as ed

re sc

ri b

in g

ac co

un te

d fo

r a

si gn

if ic

an t

p ro

p o

rt io

n o

f p

re sc

ri p

ti o

n s.

L ac

k o

f di

ag n

os is

a n

d tr

ea tm

en t

o f

m en

ta l i

lln es

s du

e to

la ck

o f

tr ai

n in

g an

d fr

ee do

m t

o p

re sc

ri b

e p

sy ch

ia tr

ic d

ru gs

N o

p re

sc ri

p ti

o n

s fo

r p

sy ch

ia tr

dr ug

D as

h as

h a

n d

M uk

h ta

r 20

03 [2

R ev

ie w

o f

al l p

at ie

n t

re co

rd s.

W es

t 20

6 N

A N

at io

n al

ua rd

O n

e ce

n te

r E

ff ec

ti ve

n es

s A

st h

m a

G ui

de lin

es a

re n

o t

fo llo

w ed

; su

b o

p ti

m al

c ar

e fo

r as

th m

at ic

ild re

n ; p

o o

r fo

llo w

-u p

a n

d co

n ti

n ui

ty o

f ca

re ; o

ve r-

a n

d un

de r-

p re

sc ri

b in

g; u

se o

f n

o n

-r ec

o m

m en

de d

dr ug

s; d

ru g

in te

ra ct

io n

E l-

G ila

n y

20 00

[2 5]

R ev

ie w

o f

a ra

n do

sa m

p le

o f

p at

ie n

t re

co rd

N o

rt h

12 00

N A

M O

H 20

c en

te rs

E ff

ec ti

ve n

es s

P re

sc ri

b in

g O

ve r-

p re

sc ri

b in

g o

f an

ti b

io ti

cs f

o r

p at

ie n

ts w

it h

a cu

te r

es p

ir at

o ry

fe ct

io n

s (8

7. 8%

o f

ca se

s) . T

h is

fe ct

s a

si gn

if ic

an t

n um

b er

o f

p at

ie n

ts a

s th

es e

in fe

ct io

n s

co n

st it

ut e

o n

e- th

ir d

o f

al l

p re

sc ri

p ti

o n

s in

p ri

m ar

y ca

ce n

te rs

co n ti

n u ed

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ic.oup.com /intqhc/article-abstract/17/4/331/2886563 by guest on 10 February 2019

Quality of primary health care in Saudi Arabia

337

T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

R es

p o

n se

( %

) Se

tt in

g N

o . o

rg s

D im

en si

o n

F o

cu s

R es

ul ts

.. ..

.. ...

.. ..

... ..

.. ..

.. ...

.. ..

... ..

.. ..

.. .. ..

.. ..

... ..

.. ..

A l-

F ar

is e

t a l.

19 94

[2 6]

O b

se rv

at io

n al

s tu

o f

p at

ie n

ts a

tt en

di n

g h

ea lt

h c

en te

rs .

C en

tr al

90 2

N A

M O

H E

ig h

t ce

n te

rs E

ff ec

ti ve

n es

s C

o n

su lt

at io

n A

ve ra

ge c

o n

su lt

at io

n le

n gt

h w

as 5

m in

ut es

, c o

n si

de re

d sh

o rt

b y

in te

rn at

io n

al s

ta n

da rd

s. L

o n

g co

n su

lt at

io n

s di

d n

o t

di ff

si gn

if ic

an tl

y in

t er

m s

o f

p re

sc ri

p ti

o n

s, in

ve st

ig at

io n

, o r

re fe

rr al

. V ar

ia b

le n

um b

er o

f co

n su

lt at

io n

s: 1

0 co

n su

lt at

io n

s p

h o

ur in

t h

e ev

en in

g co

m p

ar ed

w it

5. 58

c o

n su

lt at

io n

s p

er h

o ur

in t

h e

m o

rn in

M ah

fo uz

e t

a l.

19 97

[2 7]

R ev

ie w

o f

re co

rd s

(p re

sc ri

p ti

o n

ra n

do m

ly s

el ec

te d.

So ut

h 66

4 38

N A

M O

H 23

c en

te rs

E ff

ec ti

ve n

es s

P re

sc ri

b in

g T

w o

-t h

ir ds

o f m

ed ic

al c

o n

su lt

at io

n s

en de

d b

y p

re sc

ri b

in g

m ed

ic at

io n

T h

e av

er ag

e n

um b

er o

f dr

ug it

em s

p re

sc ri

b ed

w as

1 .4

4. P

re sc

ri p

ti o

n s

la ck

ed in

fo rm

at io

n o

n : d

ur at

io n

o f

m ed

ic at

io n

( 32

.9 %

), p

at ie

n t’

s n

am e

(1 5.

8% ),

r ec

o rd

n um

b er

( 6.

5% ).

re sc

ri b

in g

dr ug

s b

y ge

n er

ic n

am e

w as

m in

im al

a m

o n

g p

h ys

ic ia

n s

(2 .9

% ).

M ed

ic at

io n

s p

re sc

ri b

in cl

ud ed

: a n

al ge

si cs

–a n

ti p

yr et

ic s

(6 1.

9% ),

a n

ti b

io ti

cs (

56 .2

% ).

M an

so ur

a n

d A

l- O

sa im

i 19

93 [2

In te

rv ie

w s

ur ve

y o

f a

ra n

do m

s am

p le

o f

p at

ie n

ts .

C en

tr al

30 0

N R

M O

H T

h re

e ce

n te

rs A

cc es

s/ ef

fe ct

iv en

es s

P at

ie n

t sa

ti sf

ac ti

o n

P at

ie n

ts a

re m

od er

at el

y sa

ti sf

ie d.

ti sf

ac ti

o n

s co

re s

(o n

a f

iv e-

p o

in t

sc al

e) r

an ge

d as

f o

llo w

s: w

ai ti

n g

ti m

e (1

.7 3)

, d is

ta n

ce (

3. 18

), w

o rk

in g

h o

ur s

(3 .9

7) , r

ef er

ra l (

3. 55

), li

st en

in g

(3 .1

1) , e

du ca

ti o

n p

ro vi

de d

b y

n ur

se s

(1 .8

7) , p

h ys

ic ia

n e

xp la

n at

io n

( 3.

3) ,

p h

ar m

ac is

t ex

p la

n at

io n

( 3.

8) ,

th o

ro ug

h n

es s

(2 .7

4) .

co n ti

n u ed

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H. Al-Ahmadi and M. Roland

338

T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

R es

p o

n se

( %

) Se

tt in

g N

o . o

rg s

D im

en si

o n

F o

cu s

R es

ul ts

.. ..

.. ...

.. ..

... ..

.. ..

.. ...

.. ..

... ..

.. ..

.. .. ..

.. ..

... ..

.. ..

A l-

K h

al di

e t

al .

20 02

[2 9]

Q ue

st io

n na

ir e

su rv

o f

al l m

em b

er s

o f

pr im

ar y

ca re

t ea

m s.

So ut

h 30

4 N

R M

O H

68 c

en te

rs O

rg an

iz at

io n

lt ur

e O

bs ta

cl es

O b

st ac

le s

fa ce

d b

y p

ri m

ar y

ca re

am s:

la ck

o f

m ed

ic al

f ac

ili ti

(2 2%

), la

ng ua

ge a

nd c

ul tu

ra l b

ar ri

er s

(1 2%

), ro

ug h

ro ad

s (1

5. 4%

), co

m m

un ic

at io

n ba

rr ie

rs (2

7% ),

no n-

co m

pl ia

nc e

(9 .3

% );

8% in

di ca

te d

cu lt

ur al

b ar

ri er

s, c

o m

m un

it y

ed uc

at io

n le

ve l,

h ab

it s

an d

tr ad

it io

n s,

a n

d p

at ie

n ts

’ i n

si st

en ce

n d

ru gs

a n

d re

fe rr

al a

s o

b st

ac le

Ja ra

lla h

a n

d K

h o

19 98

[3 0]

Q ue

st io

n na

ir e

su rv

o f

al l r

eg io

n al

p er

vi so

A ll

re gi

o n

s 15

9 85

M O

H N

A M

an ag

em en

t R

o le

97 %

o f

su p

er vi

so rs

a re

a w

ar e

o f

th e

qu al

it y

as su

ra nc

e m

an ua

l a n

d gu

id el

in es

. S up

er vi

so rs

’ c o

n ce

p t

o f

su p

er vi

si o

n : d

ev el

o p

in g

st af

f sk

ill s

(9 7%

), c

o o

rd in

at io

n (

92 %

), lo

o ki

n g

fo r

de fe

ct s

(8 3%

), s

o lv

in g

st af

f p

ro bl

em s

(7 8%

Su p

er vi

so r

ro le

: 4 2%

a re

in vo

lv ed

p la

n n

in g

h ea

lt h

se rv

ic es

, n o

n e

ar e

in vo

lv ed

in p

o lic

y, 4

1% n

o t

in vo

lv ed

in r

ec ru

it m

en t

o f

st af

su p

er vi

so ry

v is

it s

to e

du ca

te s

ta ff

4% ),

t o

c h

ec k

p er

fo rm

an ce

( 94

% ).

85 %

o f

su p

er vi

so rs

h ad

n o

p o

st -

gr ad

ua te

q ua

lif ic

at io

n , a

n d

o n

ly 3

h ad

m an

ag em

en t

tr ai

n in

co n ti

n u ed

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ic.oup.com /intqhc/article-abstract/17/4/331/2886563 by guest on 10 February 2019

Quality of primary health care in Saudi Arabia

339

T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

R es

p o

n se

( %

) Se

tt in

g N

o . o

rg s

D im

en si

o n

F o

cu s

R es

ul ts

.. ..

.. ...

.. ..

... ..

.. ..

.. ...

.. ..

... ..

.. ..

.. .. ..

.. ..

... ..

.. ..

K h

o ja

a n

d K

ab b

as h

97 [3

Q ue

st io

n na

ir e

su rv

o f

al l m

id -l

ev el

an ag

er s

A ll

re gi

o n

s 15

2 95

M O

H N

A M

an ag

em en

t O

b st

ac le

s O

b st

ac le

s fa

ce d

b y

m an

ag er

s: la

o f

in de

p en

de n

t de

ci si

o n

-m ak

in g

(6 0.

7% ),

la ck

o f

in fo

rm at

io n

( 53

% ),

ig h

s ta

ff t

ur n

o ve

r (7

3% ),

la ck

o f

ca re

er d

ev el

o p

m en

t (7

2% ),

b st

ac le

s to

c o

m m

un it

y pa

rt ic

ip at

io n

(8 8%

), st

re ss

fu l w

or k

co n

di ti

o ns

7. 6)

, l ac

k o

f co

o rd

in at

io n

(6 6%

), la

ck o

f te

am s

pi ri

t ( 32

.4 %

), po

te ch

no lo

gy (4

9% ),

un cl

ea r

ac co

un ta

bi lit

y (2

9% ),

un cl

ea r

jo b

de sc

ri pt

io n

(2 9%

), va

ri at

io n

in s

ta ff

ill s

(5 6.

6% ).

K h

o ja

a n

d A

l- A

n sa

19 98

[3 2]

Q ue

st io

n na

ir e

su rv

o f

a ra

n do

m s

am p

o f

di re

ct o

rs o

f a

ra n

do m

s am

p le

o f

p ri

m ar

y ca

re c

en tr

C en

tr al

99 96

M O

H 99

n te

rs O

rg an

iz at

io n

R es

o ur

ce s:

th m

a M

o st

c en

te rs

w er

e re

as o

n ab

st af

fe d,

2 5%

h ad

p ro

to co

ls f

o r

as th

m a,

m o

st (

66 .7

% )

fo llo

as th

m a

p ro

to co

l, 38

% h

ad c

ri te

ri a

fo r

m o

n it

o ri

n g

ap p

lic at

io n

o f

p ro

to co

St ru

ct ur

e b

el o

w s

ta n

da rd

. O n

e th

ir d

h ad

a p

p o

in tm

en t s

ys te

m fo

r a st

h m

m o

st (

55 %

u rb

an , a

n d

68 %

ru ra

l h

ea lt

h c

en te

rs )

do n

’t h

av e

h ea

lt h

uc at

o r,

n o

e du

ca ti

o n

al m

at er

ia ls

A l-

Sh am

m ar

i et

a l. 1

99 5

[3 3]

Q ue

st io

n na

ir e

su rv

o f

a ra

n do

m s

am p

o f

p h

ys ic

ia n

C en

tr al

51 5

97 M

O H

N A

O rg

an iz

at io

cu lt

ur e

jo b

st re

ss So

ur ce

s o

f st

re ss

: j ob

d em

an d

o n

m ily

li fe

( 50

% ),

p ro

fe ss

io n

is o

la ti

o n

( 40

% ),

w o

rk e

n vi

ro n

m en

t (3

9% ),

p at

ie n

t co

m p

la in

ts (

41 %

la ck

o f

ap p

re ci

at io

n (

38 %

), p

re ss

ur e

o n

f am

ily a

n d

so ci

al li

fe (

50 %

in co

m e

(3 0%

), c

ul tu

ra l d

if fe

re n

ce s

(2 6%

), p

at ie

n t

lo ad

( 50

–6 0

p at

ie n

in 8

w o

rk in

g h

o ur

s) .

co n ti

n u ed

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ic.oup.com /intqhc/article-abstract/17/4/331/2886563 by guest on 10 February 2019

H. Al-Ahmadi and M. Roland

340

T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

R es

p o

n se

( %

) Se

tt in

g N

o . o

rg s

D im

en si

o n

F o

cu s

R es

ul ts

.. ..

.. ...

.. ..

... ..

.. ..

.. ...

.. ..

... ..

.. ..

.. .. ..

.. ..

... ..

.. ..

A l-

K h

as h

m an

01 [3

4] Q

ue st

io n

na ir

e su

rv ey

f a

ra n

do m

s am

p le

f p

h ys

ic ia

n s

C en

tr al

10 7

90 M

O H

ce n

te rs

E ff

ec ti

ve n

es s/

p ro

fe ss

io n

de ve

lo p

m en

C o

m p

et en

ce 91

% o

f ph

ys ic

ia n

s h

ad f

av o

ra b

at ti

tu de

s to

w ar

ds s

cr ee

n in

g fo

r h

yp er

te n

si o

n .

M o

st h

ad li

tt le

k n

o w

le dg

e o

f Q

st an

da rd

s fo

r ca

re a

n d

p o

o r

kn o

w le

dg e

o f

sc re

en in

g cr

it er

ia f

o r

h yp

er te

n si

o n

. O n

ly 5

6% w

o ul

d sc

re en

p at

ie n

ts >

35 y

ea rs

f o

r h

yp er

te n

si o

n e

ve ry

( 3–

5 ye

ar s)

. O

n e-

th ir

d kn

ew t

h e

cu rr

en t

de fi

n it

io n

o f

h yp

er te

n si

o n

, a n

d 57

kn ew

o f

co m

p lic

at io

n s

as so

ci at

w it

h h

yp er

te n

si o

n .

K al

an ta

n e

t a l.

19 99

[3 5]

Q ue

st io

n na

ir e

su rv

o f

al l p

h ys

ic ia

n s

C en

tr al

33 0

91 M

O H

N A

O rg

an iz

at io

cu lt

ur e

Jo b

ti sf

ac ti

o n

/ at

ti tu

de s

M o

st w

er e

sa ti

sf ie

d w

it h

te am

w o

rk ,

an d

w er

e w

ill in

g to

p ar

ti ci

p at

e in

n ti

n ui

n g

ed uc

at io

n (

83 %

D is

sa ti

sf ac

ti o

n w

it h

: w o

sc h

ed ul

e (7

1% ),

in ce

n ti

ve s

(8 7.

9% ),

f in

an ci

al in

ce n

ti ve

s (7

8. 3%

), a

dm in

is tr

at iv

e su

p p

o rt

2% ),

m ed

ic al

f ac

ili ti

es (

56 %

M an

y (6

0% )

in di

ca te

d in

ab ili

ty t

im p

le m

en t

p ro

m o

ti o

n a

n d

p re

ve n

ti ve

c ar

e du

e to

w o

rk lo

co n ti

n u ed

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nloaded from https://academ

ic.oup.com /intqhc/article-abstract/17/4/331/2886563 by guest on 10 February 2019

Quality of primary health care in Saudi Arabia

341

T ab

le 2

n ti

n u ed

R ef

er en

ce St

ud y

de si

gn R

eg io

n Sa

m p

le s

iz e

R es

p o

n se

( %

) Se

tt in

g N

o . o

rg s

D im

en si

o n

F o

cu s

R es

ul ts

.. ..

.. ...

.. ..

... ..

.. ..

.. ...

.. ..

... ..

.. ..

.. .. ..

.. ..

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Quality of primary health care in Saudi Arabia

343

of the premises (63.8%) [19]. More than 60% of patients indi- cated that primary care centers were their first choice when they were acutely ill, however; 40% were dissatisfied with opening hours, lack of access to specialist clinics, and delays in accessing care [20]. Similarly, because most primary care professionals are not Saudi, and may not speak Arabic, 40% of patients complained of language barriers [20,21].

Effectiveness

Several studies indicate that some primary care programs have been effective, including: maternal health care [22], vac- cination [12], and control of endemic diseases [13]. As a result of the expanded immunization program a decline was reported in the incidence of targeted diseases, for example, the total number of cases of tuberculosis was reduced from 97 to 56 between 1984 and 1989, and measles from 502 to 84 [12]. Programs targeting endemic diseases such as schistosomiasis were also found effective, as prevalence dropped from 13% to 0.17% in the population between 1983 and 1989 [13].

In contrast, programs targeting chronic disease manage- ment were often less effective [14–18]. Several reasons were sited for this including poor professional skills reflected in misdiagnosis or mismanagement of major chronic conditions such as hypertension [17], diabetes [18], mental disorders [23], and asthma [24]. Similarly, problems were documented in diagnosis and management of common conditions such as upper respiratory tract infections [24,25].

Effectiveness of clinical decisions was reported in terms of prescribing patterns [23–27], and diagnostic and referral practices [18]. Studies reported over-prescribing due to the fact that medications are provided free of charge [24,25,27]. Most patients attending primary care centers (85%) leave with a prescription (an average of 1.44 drugs per prescription) [27]. One-third of prescriptions were for acute respiratory disease, and 87% of these contained antibiotics [25]. An audit of prescribing for asthmatic children identified other concerns such as under-prescribing of necessary preventive medica- tions in 65% of children, use of inappropriate medications in 27% of cases, and overlooking of drug interactions [24]. Pre- scriptions often lacked complete information, including dosage [24], strength, and duration of treatment [23,27]. Poor diag- nostic and referral practices were also observed, for example, despite a high prevalence of diabetic retinopathy, only 40–68% of diabetic patients were referred to eye clinics [18].

Few papers directly examined the quality of interpersonal aspects of care or doctor–patient interactions during the consultation. One study reported that consultations were 5 minutes on average which is considered short by international standards [26], especially bearing in mind the need for inter- preters in many consultations. Interpersonal effectiveness could be assessed indirectly from studies of patient satisfac- tion. Dissatisfaction was often expressed in relation to poor communication and exchange of information between patient and providers including physicians, nurses, and pharmacists [19–21,28,29]. Eighty percent of primary care physicians are expatriates who may not speak Arabic, and communication is often compromised due to language barriers and differences

in culture, habits, and traditions [19,21,28,29]. In a survey of health teams, providers indicated that their ability to provide high-quality interpersonal care was jeopardized by the level of education in the community, lack of compliance, and patients’ insistence on receiving medication or being referred to hospital [29]

Barriers to quality of primary care

The review of the literature identified six factors that impede the achievement of quality primary care in Saudi Arabia. These include: management factors, organizational factors, implementation of evidence-based medicine (EBM), profes- sional development, problems at the interface with secondary care, and organizational culture.

Management factors

Little information is available on management functions at the health center level; however, two studies addressed mana- gerial functions of mid-level regional managers and district technical supervisors. Technical supervisors are responsible for overseeing the activities of health centers and usually report to the mid-level managers. Supervisors are considered key to implementation and maintenance of the quality assur- ance program in primary care [30]. A survey of technical supervisors showed that the majority of supervisors (65%) had received no managerial training, and that 85% had no post-graduate qualification [30]. Most had a reasonable under- standing of supervision as a process that involved developing the professional skills of personnel (97%), coordination of their activities (91%), training and education (85%), and team development (82%) [30]. However, few thought of motiva- tion of staff (5.9%) or improving the quality of care (4.4%) as aspects of supervision [30]. Some supervisors still consider supervision as a process of inspection, focusing mainly on solving problems (79%), looking for defects (83%), and discovering mistakes (22%) [30].

A survey of mid-level managers identified several manage- rial obstacles preventing optimal delivery of primary health care including: lack of independent decision-making (97%), poor information (53%), unclear lines of accountability (29%), and lack of qualified supervision (28%) [31]. Managers also report problems with high staff turnover (74%), lack of career development (72%), and variation in staff knowledge and skills (57.7%) [31]. Operational obstacles included: diffi- culty in developing community participation (88%), stressful working conditions (87%), and lack of coordination between health-related sectors (66%) [31].

Organizational factors

The organization of primary care services has improved over recent years, as most centers are now reasonably staffed [32], 90% have records, disease registers, and follow-up systems, and 74% have clinics for chronic illnesses [14]. Studies, how- ever, point to several organizational obstacles including poor information systems, staff turnover, stressful work conditions

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[29,33], overload oof physicians [34,35], poor technology [31], and shortage of resources[14,31]. One study estimated the availability of essential drugs and laboratory items as between 10 and 86% [14]. There is a particular shortage in health edu- cators as only 8% of centres are adequately staffed for health education [14,32]. Poor coordination with other agencies was also reported, especially with municipalities for proper provi- sion of environmental health services, including sanitation of water and food sources and proper disposal of waste [31].

Inadequate implementation of EBM

National guidelines have been established for some common conditions; however, several studies indicated that clinical decisions are not sufficiently evidence based [23,24,36]. This has contributed to wide practice variations, inadequate diagnoses and management of a range of medical conditions [24,27,34], inappropriate clinical decisions, and unsafe pre- scribing patterns [23,24,27,34]. Obstacles to the implementa- tion of EBM include: poor dissemination of guidelines [34,36], and a low level of awareness among physicians of journals, review publications, and databases. Most physicians have limited access to the internet [36].

Interface with secondary care

The referral system in Saudi Arabia was established in 1986 to improve coordination between primary care centres and hospitals [37]. Evidence shows that since the implementation of the system hospital outpatient visits have been reduced by 40% [37]. Several studies examined referrals and identified important deficiencies, mainly low referral of patients for diagnostic purposes and specialized care [18], and poor exchange of information between secondary and primary care providers [37,38]. Referral letters often did not include important information [38], were handwritten, and some- times illegible [38]. Hospitals sent feedback for only 22–39% of patients [38]. Feedback reports lacked essential informa- tion including details of the advice given (100%), diagnoses (15%), or findings on investigations (21%) [38].

Organizational culture

Studies point out several positive features of organizational culture in primary care centres including a strong spirit of teamwork, and favorable attitudes among staff towards improvement through either continuing education [35] or implementation of EBM [36]. One study, however, suggested that the status of primary care in general, and physicians’ sense of job significance was poor [35]. This study found that one-third of physicians perceived primary health care to be inferior to other specialties, and two-thirds thought they are underestimated as physicians by the community [35]. Physi- cians were also dissatisfied with management practices, incen- tives, and medical facilities [35]. A study of stress among primary care physicians identified several sources of stress including the impact of job demands on family life (50%), professional isolation (40%), work environment (39%),

patient complaints, lack of appreciation by patients, patient pressure (38–50%), and patient load (50–60 patients in 8 working hours) [33]. For expatriates, additional sources of stress were reported as income (30%), contract conditions, and cultural differences (26%) [33]. Results also indicated lack of awareness among physicians of pressing primary care issues such as the high prevalence of chronic illness and cost of care [39].

Professional development strategies

Evidence indicated inadequate professional development strategies in primary care [40,41]. One study reported that only one-third of primary care physicians have post-graduate qualifications, none of which were in primary care [40]. Another found that many physicians (57%) had never had any educational leave, and that only 50% had access to local periodicals. Even fewer had access to international journals [41]. Major additional obstacles to professional development were work pressure and lack of time [40,41].

Discussion

The primary care program in Saudi Arabia is a pioneering program that has achieved considerable success within a few years of its establishment. This success is reflected in good access to and effectiveness of some traditional primary care services including immunization, maternal health, and control of endemic diseases.However, the results of this review point to substantial variations in quality of care for other aspects of care, mainly management of chronic illness. In the UK, Australia, and New Zealand, similar variations in quality of clinical care have been observed [42].

Quality of clinical care is affected by failure to adhere to evidence-based guidelines, poor prescribing practice, and inappropriate referral patterns (mainly under-referral). In Saudi Arabia, there have been several attempts to promote evidence-based practice in primary care. However, these efforts have yet to achieve their potential due in part to poor dissemination of guidelines and poor professional develop- ment strategies. In some studies, doctors reported never hav- ing had any educational leave, and most did not have access to the internet. There is an increased belief that implementation of evidence-based clinical guidelines in primary care will contribute to improvement [43]. This review identified posit- ive attitudes among Saudi physicians towards implementation of EBM, but lack of training prevented implementation. This is similar to Australian general practitioners, who had positive attitudes towards EBM but were similarly unfamiliar with the terminology and tasks surrounding the implementation of EBM in daily practice [43].

Substantial variations were found in the quality of interper- sonal care. This was strongly related to language barriers and to cultural gaps between doctors and patients. Most primary care doctors are expatriates and may not speak Arabic, the language of the majority of their patients. In addition, doctors found it difficult to relate to some patients because of low

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levels of education in the community. They also found that the demands of patients were sometimes poorly aligned with what they wanted to provide. Short consultations exacerbated these difficulties.

The papers reported in this study identified a lack of effective leadership in primary care, an essential element of quality improvement. Primary care managers had limited roles, limited training, and unclear expectations, factors that have previously been found to be obstacles to quality improvement. In the UK, limited managerial roles, unclear expectations and responsibilities of managers within the organizations have also been found to be obstacles to quality improvement [44].

Isolation of primary care workers and their inability to maintain knowledge and skills is a major concern. Professional development is an integral part of quality improvement. Improving physicians’ access to medical information, to evidence-based guidelines, and to planned professional devel- opment are essential prerequisites for quality improvement.

The morale and motivation of staff could also be improved by focusing on working hours, patient load, and salaries, and by improving resources and facilities. The employment conditions of expatriate physicians and their contribution to quality improvement need to be examined. Contract conditions should provide a sense of job security, and the motivation and empowerment necessary to improve performance.

Quality improvement can be driven both internally through organized effort within the health care system, and externally through public pressure. Neither internal nor exter- nal forces are well formulated in Saudi Arabia. The com- munity has yet to play any significant role in shaping the vision of primary care provision and steering it to meet chan- ging health needs.

This study has a number of limitations. Most of the studies included were conducted in a Ministry of Health setting, which is the main provider of primary care. However, little is known of primary care provided elsewhere, such as in military or school settings, or in the private sector. The studies reported in the paper also showed wide variation in the meth- ods used and aspects of care studied. This limited the options for pooling evidence.

Despite these limitations, the conclusion of this review is that primary care in Saudi Arabia faces significant chal- lenges, and the findings of this study have significant impli- cations for the primary health care agenda in Saudi Arabia. Many of the problems identified in this review could be addressed by establishing a comprehensive quality assess- ment and improvement system in primary health care. Quality improvements should be an integral part of all aspects of primary care, but existing quality improvement strategies are fragmented and uncoordinated. Saudi primary care will be unable to fulfill its potential unless the chal- lenges identified here are addressed. Future research is needed to make more objective evaluation of the quality of clinical services, and to identify interventions that are effective in improving care.

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Accepted for publication 22 March 2005

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