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77Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014 | 77-80

Public Health in the Saudi Health System: A Search for New Guardian

Waleed A. Milaat Department of Family and Community Medicine, College of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

Correspondence: Prof. Waleed A. Milaat, Department of Family and Community Medicine, College of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail: [email protected]

A B S T R A C T

Saudi Arabia has witnessed a signifi cant improvement in its health indicators. The kingdom has spent generously on the curative health services and established hundreds of hospitals and primary health care centers. However, we believe that this huge health expenditures and the presence of curative services is not the only reason for this improvement. Public health services have also had a significant impact on people’s health and that this improvement is due to a combination of public health programs such as immunization, environmental sanitation and health education with good formulation of sound health policies and health delivery systems. It is noted that health plans and expenditure in the health system are concentrating on the curative aspects and there is a signifi cant weaknesses in public health services. Additionally, most jobs are allocated for curative care and there is scarcity of job titles related to public health in the health structure, such as public health offi cers, public health inspectors and public health specialists. A suggested body namely, Ministry of public health, will work to confi rm that all issues related to health of the public in every aspect of daily life in the kingdom are within the genuine interest of all policy makers.

Key words: Public health, guardian, Saudi health system

الملخص: شهدت المملكة العربية السعودية تحسنا كبيرا في المؤشرات الصحية وأنفقت الدولة بسخاء على الجانب العالجي وتم إنشاء مئات المستشفيات

ومراكز الرعاية الصحية األولية. ولكننا نرى أن النفقات الصحية الكبيرة والخدمات العالجية ليست هي السبب الوحيد للتحسن في المستوى الصحي حيث أن برامج الصحة العامة كان لها أيضا تأثير كبير على صحة الناس وأن هذا التحسن هو نتيجة لمزيج من برامج الصحة العامة

كالتطعيم وتحسين المرافق الصحية البيئية وتحسن الثقافة الصحية مع صياغة السياسات الصحية السليمة وتطوير طرق تقديم الخدمات العالجية.

والمالحظ أن خطط النظام الصحي ومجاالت اإلنفاق ال زالت مرتكزة على الدور العالجي وبروز الضعف في الخطط الصحية الوقائية وبرامج الصحة العامة فإننا نعتقد أنه قد حان الوقت إليجاد هيئة مستقلة لرقابة الصحة العامة في النظام السعودي تسمى وزارة الصحة العامة بعيدا عن

وزارة الصحة من أجل العمل كضمان للصحة العامة للناس وتأكيدا بأن القضايا ذات الصلة بالصحة العامة في كل جوانب الحياة اليومية في المملكة هي محل اهتمام حقيقي لدي صناع السياسة والقرار ات.

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DOI: 10.4103/1658-631X.136973

PRELUDE

No one can question the impact of Public health interventions in the improvement of health status

and health indicators for every country in the world. Historical evidence of John snow work in controlling the London cholera Epidemic of 1854 is followed by many public health interventions in the city water system that proved to be of great impact on people’s health and quality of life.[1] Scotland, for example, after the Reform Act of 1832, worked to improve its sewage treatment, organize its water supplies from fresh Lochs, build clean water reservoirs in Edinburgh and by the 1860s Medical Offi cers of Health were appointed for Scottish cities.[2] This all led to a dramatic improvement of Scottish life expectancy and quality of life even before the era of medical and surgical innovations.

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Milaat: Public health in Saudi Arabia

Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 201478

Recent public health programs all over the world have led to a well appreciated decrease of human suffering and pains and reduction of high morbidity and mortality rates fi gures. Japan, for example has achieved a relatively rapid improvement in life expectancy through the 1960s until now,[3] passing other countries like England and Wales in the process through organized programs of public health nature mainly in the environmental issues. Finland has achieved a relatively rapid reduction in the lives lost to heart disease in the late 1980s after application of preventive measures related to life style changes.[4] The Initiative of “healthy cities” which started in developed countries such as Canada, USA and Australia has led to major positive health outcomes. These initial successes, were copied in many areas in the developing world such as Korea , Philippine and China which used the same implementation strategies to begin their own programs by involving many community members, various stakeholders, and commitments of municipal offi cials to achieve widespread mobilization and effi ciency. Today, thousands of cities worldwide are part of the “Healthy Cities network” and exist in all WHO regions. Vaccination programs are well recognized interventions that led to improvement of human health status. Although they have both medical and public health faces, these programs cannot work without real health planning, health management and public sectors partnership in a public health mood.

SAUDI HEALTH SITUATION

Historically, preventive services started in the early 1950s when the ARAMCO oil company, in collaboration with the WHO, helped the MOH to control malaria in the eastern region of Saudi Arabia.[5] Programs to control bilharziasis, leshmaniasis, trachoma, tuberculosis and other endemic diseases followed suit in the various regions of the country on both vertical and horizontal levels.[6-8] The country also adopted the new concept of Primary Health Care (PHC) developed in 1978 and in 1983 began to promote it as the basis of its health care delivery system. This strategic step has been most fruitful with the immunization of over 90% of the children in Saudi Arabia against infectious childhood diseases in the EPI program.[9]

The basic law of the Saudi citizen rights, article 31 states that the government is responsible for public health in the Kingdom and should provide healthcare services to every citizen. Saudi Arabia had experienced huge improvements in the health indicators which speaks of a good achievement in the health of the population. The kingdom has spent a lot on health mainly on the curative

aspects as hundreds of hospitals and primary care centers were established all over the kingdom [Table 1].[10] This was associated with major contract with medical and paramedical staff from all over the globe for service delivery [Table 2].[11]

Big health expenditures and curative services are not the only reason for these major improvements in health. Clearly, the country is not an exception from the rest of the world and public health programs had also great impact on health of population. It is the combination of many public health programs that worked on all determinants of health, being social, economical, environmental, health delivery and health policies which made the change. A critical analysis of infant mortality rates over the last 50 years in the kingdom [Table 3][12] when tied to the economic boom in the country and the social changes that took place in the living situations all over the country speaks of a real effect of public health programs such as vaccination programs, better environmental sanitation and female education.

Life expectancy has increased dramatically, and the birth rate remains one of the highest in the region. The continuous presence of hereditary and infectious health problems in certain areas in the country (malaria in the south, Dengue fever in the west and hereditary blood diseases in the east and south), has been compounded by the emergence of new acute and chronic infections (such

Table 2: MOH manpower, health centers and bed expansion over the years in Saudi Arabia Years 1970 1990 2010 Hospitals 74 257 415 Hospital Beds 9030 41123 58126 PHC Centers 591 3028 4594 Physicians 1172 22136 66014 Nurses 3261 48477 129792 Paramedical 1741 22410 68705

Table 1: Budget appropriations for the Ministry of Health (MOH) in Saudi Arabia in relation to the government budget, 2005-2009 Year Govt budget MOH budget % 2005 280 16.9 6.0 2006 335 19.7 5.9 2007 380 22.8 6.0 2008 450 25.2 5.6 2009 475 29.5 6.2 US$ 1 – 3.75 Saudi riyals (SR); ( %) Percentage of the total government budget (in billions)

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Milaat: Public health in Saudi Arabia

79Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014

as avian infl uenza, rift valley fever and resistant types of tuberculosis). Additionally, such morbidities as diabetes mellitus (type II), hypertension, cardiovascular diseases, road traffi c accidents and various types of cancers resulting from sedentary unhealthy life-styles are reaching alarming rates. Furthermore, Saudi Arabia is expected to face new challenges with the continuing demand for health care for special groups such as the handicapped, geriatric population and the increasing number of pilgrims visiting the Islamic holy places in the country. To cope with all these challenges simultaneously a reform of the health system is necessary.[13]

The Saudi health system was built on a curative orientation and this was noted literally in the Saudi MOH 10 years health strategy.[11] The strategy recognized the concentration on curative services and the lack of preventive application as one of the defi ciencies and weakness in health plans. In fact the strategic plan was titled with a curative slogan (patient comes fi rst). Curative services dominated expenditure in the Saudi health budgets and most jobs in this system were reserved for curative purpose. Jobs like district public health offi cers, public health inspectors, health educators, environmental sanitary workers and similar in the public health arena are rarely mentioned in the Saudi health cadre for a long time. The carrier path for public health and public health work force is not well formulated in the MOH job hierarchy.

It is until recently when the ministry decided to change the look towards public health by creating a separate “Ministerial Agency of public health” headed by a vice minister under which two sub-agencies are included, namely, primary health care and preventive health. Although it is a good start to mention the word “public health” for the fi rst time in the system and consider its existence as an important component of health maintenance in the country, but no clear objectives were provided in the this change. Clearly from this move, the specialty was recognized under the preventive and curative moods only.

THE DREAM

The old look towards public health as group of horizontal and vertical preventive programs connected to the

curative and preventive work in the primary health care delivery system is far beyond its ideology and concerns. Other domains of health planning, health legislation, healthy life maintenance, safe health delivery and quality of care evaluation from the public point of view are not included in this move.

Health of the public is affected by decisions made by people outside the health domain in other ministries. We think it is time that this specialty be well recognized and served in order to make the great impact on the people in the kingdom. Saudi system should consider an independent body for public health specialty away from the domination of the ministry of health in order to work as a guardian for the health of the public. The American model of Surgeon General who safeguards the health of the Americans and being accountable to the congress or the British medical council who is directly reporting to the parliament are some of the ways in which the health of the public is well guarded. Let us dream of a next move in which the health of the public in Saudi Arabia and their related issues in every aspects of life become the real concerns of each policy maker in the system. We are dreaming of a day in which all policies decided in every ministry in the kingdom be under the veracious scrutiny of the guardian of a public health body. Let us dream of healthy public policies in all areas of our daily life. It is nice to dream and act towards this dream. it is defi nitely better late than never.

REFERENCES 1. Smith GD. Commentary: Behind the Broad Street pump: Aetiology,

epidemiology and prevention of cholera in mid-19th century Britain. Int J Epidemiol 2002;31:920-32.

2. Warren MD. A Chronology of State Medicine, Public Health, Welfare and Related Services in Britain 1066-1999. Published by Faculty of Public Health Medicine of the Royal Colleges of Physicians of the United Kingdom 2000. http://www.fphm. org.uk.

3. Robine JM, Saito Y, Jagger C. The relationship between longevity and healthy life expectancy. Quality in Ageing 2009;10:5-14.

4. Laatikainen T, Vartiainen E, Puska P. The North Karelia lessons for prevention of cardiovascular disease. IJPH 2007;4:97-101.

5. Aramco Medical Department. Epidemiology Bulletin, Dhahran, Saudi Arabia. 1972;1-2.

6. Abdel-Azim M, Gismann A. Bilharziasis survey in south-western Asia; covering Iraq, Israel, Jordan, Lebanon, Sa'udi Arabia, and Syria: 1950-51. Bull World Health Organ. 1956;14:403-56.

Table 3: Trend of infant mortality in SA Year 1950 1955 1960 1965 1970 1975 1982 1985 1990 1995 2000 2005 2013 IMR 204 183 162 139 106 78 56 42 30 22 19 18 6

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Milaat: Public health in Saudi Arabia

Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 201480

7. Tarizzo ML. Schistosomiasis in Saudi Arabia Vemes. Congres Internationaux de Medicine Tropical et du paludisme (Expert) 1956.

8. Page RC. Progress report on the Aramco trachoma research program. Med Bull Standard Oil Co (NJ) 1959;19:68-73.

9. Sebai ZA, Milaat WA, Al-Zulaibani AA. Health care services in Saudi Arabia: Past, present and future. J Family Community Med 2001;8:19-23.

10. Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: An overview. East Mediterr Health J 2011;17:784-93.

11. MOH. The book of the strategic plan for country (1431-1440 Hejri years corresponding to 2010-2019). Riyadh: MOH Publication; 2010 (Arabic). p. 47.

12. The world fact book 2013-14. National Foreign Assessment Center. United States. Central Intelligence Agency. Washington, D.C: Central Intelligence Agency.

13. Milaat WA. Public health schools in Saudi Arabia: A necessity or a luxury? J Family Community Med 2007;14:89-90.

How to cite this article: Milaat WA. Public health in the saudi health system: A search for new guardian. Saudi J Med Med Sci 2014;2:77-80.

Source of Support: Nil, Confl ict of Interest: None declared.

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