Health-care System and Accessibility of Dental Services in Kingdom of Saudi Arabia: An Update Abdullah M Alshahrani 1, Syed Ahmed Raheel 2

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1 Received: 03 rd March 2016 Accepted: 25 th June 2016 Conflict of Interest: None Source of Support: Nil Review Article Doi: /jioh Health-care System and Accessibility of Dental Services in Kingdom of Saudi Arabia: An Update Abdullah M Alshahrani 1, Syed Ahmed Raheel 2 Contributors: 1 Intern, Alfarabi Dental College, Riyadh, KSA; 2 Lecturer, Department of Oral Medicine and Diagnostic Sciences, Alfarabi Dental College, Riyadh, KSA. Correspondence: Dr. Alshahrani AM. Alfarabi Dental College, Riyadh, KSA. a_m_alshahrani@yahoo.com How to cite the article: Alshahrani AM, Raheel SA. Health-care system and accessibility of dental services in Kingdom of Saudi Arabia: An update. J Int Oral Health 2016;8(8): Abstract: Presently, various countries face significant challenges with regards to their health-care system, quality of care, health budget, and provision of universal health-care accessibility to its citizens. Kingdom of Saudi Arabia (KSA) is located in the South Western part of Asia and is considered to be one of the largest countries in the Middle East. According to the Saudi constitution, healthcare services are provided by the government, and all citizens and residents have the right for complete and free accessibility to the health services. The health-care system is consist of a mix between governmental and private health sector. Even though the government supplies dental care services free of cost for Saudi citizens, yet majority of the Saudi population choose to be treated in the private dental sector. 200 people in the KSA were questioned about dental health and the accessibility to care. Patients believe that with paid care they can get enough time with doctors and better care. In spite of the full governmental supported dental care services in KSA, the Saudi population faces difficulties to meet the proper dental care. Extending and promoting the dental care in primary governmental health institutions and increasing the number of advanced referral dental care centers can help to meet the demand of services between Saudis. For non-saudis, evaluating the present regulations and implementing new regulations are needed regarding the foreigners health insurance to insure their right to receive proper dental care services, as stated in the law of KSA. Key Words: Dental care, health-care system, Kingdom of Saudi Arabia Introduction Various countries face significant challenges with regards to the health-care system for improving their health-care quality, health care budget/finances, and provision of universal healthcare accessibility for society. 1 The Kingdom of Saudi Arabia (KSA) has no different in this regard. KSA is located in the South Western part of Asia and is considered to be one of the largest countries in the Middle East, with total area of 2.24 million km 2, covering nearly the four-fifths of the Arab Peninsula. 1-4 KSA is bordered by neighboring Kuwait, Iraq and Jordan from the North by Yemen and Oman from the South by the Arabian Gulf, United Arab Emirates and Qatar from the East, and Red Sea from the West. 2,3 KSA is one of the world s largest oil producing countries and has the vast and most extensive oil reserves. 5 It is a growing country with an economy mainly dependent on the oil exports and that shapes the most portion of the country s revenues and economic budgeting. 5 On March 2, 1992, the system of regions was issued, and according to that, the kingdom was divided into 13 administrative regions, each region has governorates. The governorates have a number of centers with population settlements which linked administratively to the governorate itself. The life expectancy rate in Saudi Arabia was around 74 years in the year 2014, which are 6 and 4 years ahead of the regional average and global average, respectively. 6 In addition, the birth rate was reported to be 22/1000 population which is lower than the regional (~31) and the global average (~24). 6 According to the annual report published by the Ministry of Health (MOH) in KSA in 2014, the infant mortality rate was 7.4/1000 people. 7 The majority of Saudi population is within the ages of years which represents 67.6% of the total population people from various walks of life in the KSA were questioned about dental health and the accessibility to care. This article discusses the structure of health services in KSA and the results from the people who answered regarding dental health and the ability to access care. Structure of Health Services in Saudi Arabia In KSA, providing health care is considered as a priority for the government toward the citizens. Therefore, health care had great developments during the past years. 2 According to the Saudi constitution, health-care services are provided by the government. All citizens and residents have the right for complete and free accessibility to the health services. 1,5,8 Health-care system in KSA is consisted of a mix between public (governmental) and private health sector. 6 MOH represents the government regarding the health-care services and manages, plans, implements, promotes, and evaluates the health services provided. On the other hand, the MOH also cooperates and coordinates with other governmental sectors; and also, monitors, advises, and evaluates the private sectors and supports all healthcare programs and the activities related in the country. 4,5 There are 20 regional directorates of health covering various parts of the KSA, connected administratively to the MOH 883

2 offices in the capital Riyadh, with each directorate supervising and supporting the health services in that area. 5 There are three categories of health services provided by the MOH: Primary, secondary, and tertiary. In the primary category, health services are provided by primary health centers, covering all cities, towns, and villages. It is mainly focusing on preventing sources of illness, enhancing and maintaining health, and educating people about their health issues. Simple treatment can be provided by the primary health centers, but when the patients require more advanced medical intervention, the patient will be referred to a general hospital which is the second category. In the second category, health services are supplied by general hospitals, specialized clinics, operating rooms for surgeries, which can give the patient the medical care that is much beyond the limits of primary health services. When patients need more advanced and complex treatments in multiphases, patients are referred to the tertiary level of health care and that includes specialized hospitals and oncology centers. 4 Currently, the MOH is the major government provider and financer of health-care services in Saudi Arabia, with a total of 270 hospitals, 40,300 beds and 2281 primary health-care centers. These services comprise 59.6% of the total health services in Saudi Arabia. 2,3,5,9 The MOH budget represents 7% of the total budget ( billion S.R) and 43.5% of the MOH budget is allocated for salaries (Table 1). 7 In Saudi Arabia, the health care can be provided by other governmental sectors, and these sectors receive annual budgets from the KSA government. These sectors provide health care to their recruits and their families, but in case of emergencies or crises, it provides health care to citizens and residents. 1,4,9 Other governmental sectors include: The Ministry of Interior (security forces medical services), Ministry of National Guard (National Guard Health Affairs), Ministry of Defense (Army forces medical services), Ministry of Education (University Teaching Hospitals and school health units), and Ministry of Petroleum and Mineral Resources (ARAMCO hospitals and Royal Commission for Jubail and Yanbu health services). Due to the small and particular population that receives health care via these sectors, health services tend to be with more highly advanced facilities. 5,9 Recently, the other government sectors shared and provided around 9% of the total health services in KSA. 2,5 In KSA, it is compulsory for the employers to provide a health care to their non-saudi recruits. 1 This health care could be paid directly or through the health insurance for the workers and their family members in private health sectors. 9 Since the loans from the government are free of interest supporting the establishments and constructions in private health sectors, the private health-care achieves a rapid grow and expanding in services. The private health sector is providing variety healthcare services from the basic clinics to specialized hospitals. 1,9 Hospitals, clinics, dispensaries, and pharmacies in private sector Table 1: The distribution of target population and the degree of comprehensive provision of health services among different government bodies. 6 Government body Targeted population Degree of comprehensive health services MOH Saudis All are eligible with no restrictions Non Saudis Only for legal residents The National Guard The armed forces The Interior Security Forces The Ministry of Education (university hospitals) The Ministry of Education The Saudi Intelligence Agency MOH: Ministry of Health National Guard and their dependent family members armed forces and their dependents interior security forces and their dependents Saudis All are eligible with no restrictions Non Saudis Only for legal residents who are under affiliations Governmental school children Saudi Intelligence Agency and their dependents Hospitals, medical, dental, medical (primary care), dental (primary care), and drugs medical, dental, have a referral network connecting them and coordinating with other health sectors in the country. 4 The private sector is supplying health care in cities and large towns, with a total of 141 hospitals (15,664 beds) and 2412 dispensaries and 125 clinics which made round 31.1% of the health services in the kingdom. 2,5 Private sector was primarily designed to deliver health care to foreign recruits but can provide health care to Saudi citizens by direct payment or through the health insurance. Recently, as result of the advanced private health sectors services, it has been more widely accepted and appreciated by Saudi citizens, who were eligible for the health care services provided freely by MOH or other governmental health sectors. 1 Today, health-care services become an industry to invest money and provenance. 10 This industry is facing challenges of providing better service with low costs. 11 The providers are trying to attract patients by focusing on the patient needs and influencing them positively to their institutions. Health-care institutions replace the traditional way of service that limited to diagnosis, treating diseases, and medical conditions and 884

3 go beyond that to supply a general and complete health and personal care. 11,12 Therefore, understanding and measuring the patient s perspectives become an important need for healthcare institutional managements to gain the patient s trust. 12 Patients perceptions become the cornerstone in assessing and evaluating the quality of the delivered health care. 13 Using the SERVQUAL survey, many studies were accomplished to evaluate the quality of the presented service from the patients perspectives, and most of it shows same results. 12,10,13 The SERVQUAL survey is a gap model was initially outlined by Parasuraman et al., in 1986, to measure the service quality. According to Parasuraman et al., gap model included the following factors: Tangible (equipment and facilities), reliability (performance), responsiveness (willingness to help), assurance (guarantee), empathy (caring), and accessibility (approachability). This model is commonly used to evaluate the health-care services, and it can be modified to meet the needs of the health institutions. 13 Local studies show that the factors playing the main rule in patient satisfaction are empathy, tangible, and accessibility. Factors of responsiveness, assurance, and reliability are considered to be the sources of defects and gaps that create disaffection to health services Furthermore, there are some other unmodified factors which have a significant effect on the patient choices such as gender, age, education, and income should be considered. 12,14,15 Males generally preferred private hospitals, higher educated, higher income, and adolescents preferred private medical services. On other hand, low or no education, lower income, governmental workforce, and older individuals preferred public services. 10 In a study conducted to evaluate the patient preference in dental care, males preferred to be treated by male dentist, whereas females they did not have any demand regarding the dentist gender. Male dentist was preferred in all dental specialties except in pediatric dentistry which was preferred to be female dentist. 15 Health services managements should improve all factors influencing the patients perception and not focusing in some and neglecting others because that can affect the whole view and attribution of the health institution. 12 When health-care managements understand the patient concern and how the health services evaluated, health care can reach the level of acceptance and appreciation. 13 In general, improving the quality of medical staff and caregivers can be the attractive element for patients. Training them to listen effectively, to communicate better, to pay attention, and to help when it is needed, adding to modern and advanced facilities and equipment can change patient s choices. 11,16 Out of the 200 people surveyed by us, about 80% were males and the rest 20% females. The youngest and the oldest age being 13 and 75, respectively, with the mean age being 30 (Table 2). The people were from 12 different countries with about 40% being Saudi nationals and the rest being expatriates. However, Table 2: Some relevant survey data from the population. Age Highest 75 Lowest 13 Average (mean) Sex Male 161 Female 39 Highest level of education Not educated 8 Primary school 33 Intermediate school 17 High school 33 Diploma 24 Bachelor degree 46 BDS 27 MBBS 6 Master degree 5 PhD 1 Employment Employed 136 Retired 3 Unemployed 61 Frequency of visiting dentist Never 5 Long time ago 7 Last visit since 1 year 35 Last visit since 1.5 year 3 Last visit since 2 years 36 Last visit since 3 years 17 Last visit since 4 years 4 Last visit since 5 years 2 Once a year 16 Every 6 months 51 Every 4 months 5 Every 3 months 13 Every 2 months 6 Private insurance plan for dentistry Yes 15 No 185 BDS: Bachelor of Dental Surgery, MBBS: Bachelor of Medicine and Bachelor of Surgery, PhD: Doctor of Philosophy it was interesting to note that the non-saudi subjects were all mostly from Middles Eastern and South East Asian countries. The most common level of education achieved was Bachelor s degree (~23%) with primary school and high school education being second most common with ~16% people having them. About 70% of the people were employed and working and ~30% unemployed with only 3 retired people (Table 2). However, the unemployed status was mostly due to the fact that 24% of the people surveyed were students and were not working. The occupations were a varied mix including physicians and skilled workers to cab drivers. The average household income of the people was about 4000 Saudi Riyals per month (1000+ US dollars) with the highest earners getting up to 30,000 Saudi Riyals (~8000 US dollars) monthly. When enquired as to how frequently people visit a dentist, it was noted that about 25% of them see a dentist every 6 months and about 17% had seen a dentist in the last 2 years (Table 2). There were only 5 people in total who had never been to a dentist, and these were from the lowest socioeconomic strata of the society. Only about 7% of the people had a private dental health-care plan with the rest being dependent on the governmental services or with plans that did not cover dental care (Table 2). For the Saudi 885

4 citizens who reported that they do not use the governmental dental care although they are eligible for it cited the long waited lists, particular procedures not available, option for only basic treatment or the perception that private care is better being some of the reasons being cited. A vast majority of the people (~75%) reported as to using the regular manual toothbrush and ~18% used the traditional miswak. It was interesting to note that around 5% of the people did not brush their teeth at all and none of the 200 subjects use any mouthwash. Since cigarette smoking has an adverse effect on the medical and dental health, the subjects were asked whether they smoked or not. Half of the people were smokers and the other half non-smokers with the smokers using normal cigarettes and some also using the hookah. Health-care services budget is one of the challenges faced by the MOH in KSA. It is becoming difficult for MOH to compensate between the rapid growing population and maintaining the desired level of health services with free health services. 2,5 In 1999, the Council of Cooperative Health Insurance was established to introduce the health insurance to public, and to regulate and supervise the health insurance services presented by insurance companies. 2 The cooperative health insurance was planned and applied for non-saudis who work in private companies. The government allows insurance companies to extend their services to cover the Saudis working in private companies who prefer to be treated in private health sectors and planning to cover all Saudis in future. 1,2,5,8 Health-care insurance usually covers consultations, laboratory tests, diagnostic radiographs, medications, and follow-up. Medical conditions such as dental treatment, pregnancy, and delivery are regulated by specific roles and policies. Other medical related conditions such as AIDS treatment, sexual transmitted diseases, cosmetic interventions, hair fall treatment, contraception pills, obesity, herbal medicine, fertility, and sterility treatment are not covered by the health insurance. 17 Inappropriately, there are some policies and regulations in health insurance still vague and need to be reviewed, corrected, and improved to avoid systemic faults and to protect patients from the misconduct of insurance companies. 8,17,18 Conclusions and Recommendations In KSA, health services are provided to all the population through governmental and private sectors. It serves Saudis and non-saudis, respectively. Even though the government of KSA supplies dental care services free of cost for Saudi citizens, yet the majority of the Saudi population chose to be treated in the private dental sector. This attraction of private dental sector is due to many reasons and issues related to the dental care in government and private sectors. In governmental primary dental care, the provided care is at the basic level of treatment; simple composite or amalgam restoration, scaling, and first phase of randomized controlled trial. Procedures such as implants, dentures, cosmetic dentistry, and other complicated procedures are not available in primary governmental dental care. When patients need more than just simple treatment, patients will be referred to higher governmental dental centers which have long waiting lists. On other hand, the patient can receive the needed treatment and desired procedures in private dental sector in one place and in less time. Patients believe that, with paid care they can get enough time with doctors, better care and expect an enhancement in the way they look and not just treating a dental problem. As mentioned previously, it is requisite for non-saudi workers to be covered by health insurance. This health insurance is secured by the owners of companies as part of the governmental policies regulating the private business in the KSA. Unfortunately, some companies are not providing the health insurance that covers dental care for its workers because it is usually expensive. The other case, some health insurance companies create obstacles to minimize the use of insurance in dental care for the previous reason. All these issues play a role in demoting the level of dental health between foreigners, especially in low educated category of workers. In spite of the full government supported dental care services in KSA, the Saudi population faces difficulties to meet the proper dental care. 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