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By Alexander Woodman, Faculty Member of College of Sciences and Humanities at the Prince Mohammad Bin Fahd University, Saudi Arabia.
Dr. Zohair Sebai, in conversation with Alexander Woodman, discusses the history and current development of the public health status of Saudi Arabia.
Saudi Arabia is a cost-effective country with a per capita GDP of $ 22,713. 40. Oil revenues makes up 80% to 90% of fiscal earning. Spending on healthcare services increased by 26% since 2010. During the 1950s there were only a couple of hospitals in Saudi Arabia that had 10 Saudi physicians which did not even represent 10% of the total number of physicians in the country. Five decades later, the country witnessed a rapid growth in public health and currently there are 462 hospitals and 21,000 Saudi doctors taking the ratio from less than 10% to more than 25% of overall.
Saudi Arabia is experiencing demographic and epidemiological transition, represented by a growing burden of chronic non-communicable diseases, while population expectation of quality care services is expanding. Since 2004, the number of primary healthcare centres has increased by 8.9%. The number of hospitals, physicians and nursing staff has also increased. In addition, quantitative and qualitative development of healthcare services has led to improvement in the areas of reproductive health, maternal and child health which has reduced mortality rates, led to an increase in immunisation rates and a decrease in vaccine-preventable diseases as well as eradication of poliomyelitis at the national level. During the past decade, vaccination of mothers against neonatal tetanus increased from 88% to 97% and maternal mortality per 100,000 live births declined from 48 to 14.
Alexander Woodman: As an expert in public health, could you please provide us with a brief history of healthcare services in Saudi Arabia?
Dr Zohair Sebai: It was in 1950 that healthcare services first emerged in Saudi Arabia. At that time, we had only a couple of hospitals with no more than 1000 beds in the entire Kingdom. The total number of physicians was 111 including no more than 10 Saudi physicians. At present after only 64 years, the country has 462 hospitals, 69,000 beds (1 bed for 450 people), 2200 health centres, 82,000 doctors (1 doctor for every 450 people) including 21,000 Saudi doctors. This is quite an achievement. Public health activities in Saudi Arabia started slowly with the help of Saudi Aramco company which helped in the control of trachoma, malaria and schistosomiasis. Soon, the eastern province of the country also saw for the first time, a health education and maternal and child health programmes being held among Aramco employees. Soon the Ministry of Health took over.
AW: What is the life expectancy at birth in Saudi Arabia?
ZS: The estimated figure is around 72 years.
AW: How much is the total expenditure on health per capita in Saudi Arabia?
ZS: It is rather difficult to calculate it since there are over 10 different governmental organisations delivering health services. The Ministry of Health provides about 60% of the health services, whereas other governmental agencies deliver 20% and the private sector, 20%. The budget of the Ministry of Health for the year 2016 is about SR 67 billion. If you consider the other 40% and divide the total sum by the number of population, the per capita expenditure would be about SR 3700. The world per capita expenditure on health ranges from US$ 9900 in Norway to US$ 12 in an African country. The global average is US$ 1008. In Saudi Arabia, our per capita health expenditure is far above the global average. What is important is not how much is being spent, but how it is being spent. The comprehensive approach combining prevention, promotion and treatment is the best alternative.
AW: According to the World Health Organisation, over 800,000 people die due to suicide every year. Thus, millions of people are affected by suicide bereavement every year. What is the rate of suicide in KSA and does the Saudi government takes this matter seriously?
ZS: There is no available or reliable data for this issue that I know about in Saudi Arabia or in the whole region. I believe that it is not a national problem.
AW: The total number of Arabic speaking people living in the Arab nations is estimated to be around 400 million. Arabs share the same language, history, culture, and health conditions. Do you think there are different health concerns among Sham Arabs, Maghreb Arabs, and Gulf/Khaliji Arabs?
ZS: With the prevailing wars, instabilities and social and political conflicts, humanitarian needs (food, medicine, shelter, water supply and safety) have become the number one health concern in the region.
AW: Since the publication of your first book (Health in Saudi Arabia Vol.1, 1985), what changes have occurred in the overall healthcare scene in the country?
AW: It is recommended to stop eating when 80% full. Do you think Saudis are following this recommendation or is there a lack of health education amongst the general public?
ZS: Obesity and its related health problems have become a global epidemic. The people of Saudi Arabia are also following the global pattern. A proper health education can help to a great extent in solving this problem. However, health knowledge should be translated into healthy lifestyles. This is the most difficult part of health education.
AW: What is the role of Islam in promoting public health in Saudi Arabia?
ZS: Islam calls for the adoption of many acts which all lead to a healthy lifestyle. Islam calls for moderation in life. It prohibits alcohol, drugs, adultery and gambling. It emphasises cleanliness - “cleanliness is part of faith”. Islam calls for love, understanding and acceptance of others. As Prophet Muhammad (PBUH) says: “Nobody (both genders) is considered a believer unless he loves for his brother what he loves for himself”.
AW: What are the major public health differences that you have observed between Saudi Arabia, other GCC nations, and the rest of the Arab world?
ZS: We all share a common culture, history and faith. The differences I would say are not between nations but rather between individuals. Those who are better educated and have better standard of living usually lead a healthier life no matter what nationality they belong to.
AW: Is there a difference in the health status within the different ethnic groups in Saudi Arabia and the Arab world?
ZS: Both genes and the environment influence the health status of people. I would say the role played by the environment (education, standard of living, social status) is bigger than the role played by genes. This is why the differences between individuals in the same ethnic group are often greater than the differences among different ethnic groups. Educated people in Saudi Arabia, Morocco, Egypt and Syria would share similar health knowledge, attitudes and practices compared to people of different socio-economic and educational backgrounds coming from one nation.
AW: Could you please elaborate on the major public health milestones Saudi Arabia has achieved in the past 30 years? What are the declines, if any?
ZS: Saudi Arabia has achieved several laudable milestones in the last three decades. Chief among these is the legislation that immunisation should be completed before school admission. This has raised the levels of immunisation considerably. The second is the influence of high income. In the last 30 years, we started to observe a high prevalence of health problems such as diabetes, hypertension, issues related to road traffic accidents and psychosomatic diseases. All of these are the result of adverse change owing to diet, less exercise, sedentary lifestyles and stress. In the meantime, we have seen an improvement in the incidence of infectious diseases, infant and maternal mortality rates. The third factor could be the tremendous increase in the number of medical schools. However, I believe, we have to revise our medical education system in order to be more relevant to our needs.
AW: The current trend in the U.S. is the biopsychosocial approach.
ZS: Yes, this is a natural development. I am personally a believer in this model since it became popular in the mid-seventies. It simply goes along with the definition of health as stated by the World Health Organisation which is: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
AW: Do doctors in KSA consider the biopsychosocial theory as a holistic approach when addressing public health issues?
ZS: Doctors all over the world study this concept in their medical schools. Unfortunately, in practice, they become busy treating patients after they become sick. They do not have the time to apply logic. This is the general attitude of practicing physicians almost everywhere. Going back to the definition of health by WHO, the holistic approach to health is what we should adopt in practicing medicine anywhere and everywhere.
AW: What changes do you think are necessary, in terms of diet, way of life and governmental involvement, that would bring about positive changes in Saudi Arabia?
ZS: We need to adopt a balanced diet, exercise more and maintain a healthy lifestyle in general. We need to reorient our medical education towards comprehensive healthcare. We need to produce members of the health service, who believe in and practice healthcare in terms of prevention, treatment and promotion as an integrated entity. We need to reorient our primary healthcare to play a bigger role in promoting health in the society. Our hospitals should be health promoting hospitals. Finally, we need to involve people to play an active role in planning, implementing, follow up and evaluating the health services provided to them. Let me remind you that this is the stereotype of healthcare, which needs to be improved in almost every corner of the world.
AW: Does the current geo-political situation hinder, or advance the public health programmes in the region?
ZS: There is no doubt that the current geo-political situation hinders public health programmes. I can see that Saudi Arabia still enjoys better health services compared to many other countries around us. This goes without saying that it is due to the stability that we enjoy.
AW: War causes displacement, and it affects a population’s physical and psychological wellbeing. In what way does the geo-political situation affect life expectancy, infant mortality and longevity?
ZS: Wars bring untold disasters for innocent people. More civilians are usually affected than military. Look at what is happening in Syria and Iraq. Thousands of infants are dying because of lack of nutrients, medicine and shelter. I pray to Allah to give us all peace and stability.
AW: Are there differences in these variables in an area that is politically stable?
ZS: During political instabilities, you should expect a higher infant, pre-school and maternity mortality rates. You would expect a higher morbidity and mortality rates amongst almost all sectors of the population. It is not only the shortage of medical care but insufficient nutrition, environmental factors and stress that contribute to these figures.
AW: The influx of foreigners into the Gulf region has been tremendous. What is their impact on public health in Saudi Arabia?
ZS: Foreigners bring with them different cultures, habits and ways of life. No doubt, some of these will, in time, infiltrate into the Saudi health attitudes and practices. This issue deserves more in-depth applied research.
AW: Does Saudi Arabia have to constantly change its health regulations to meet the demands and challenges expatriate workers bring into the region?
ZS: Let me remind you that the first steps taken in applying for the health insurance system was directed at the expatriates. Many labour regulations have been issued to suit the needs and demands of our guests.
AW: In your book, you have remarked that the Saudi Arabia health service has a curative-centred approach. What model do you think is suitable for KSA?
ZS: The comprehensive approach (preventive, curative and promotive) model is what we need. This is to be applied not only to Saudi Arabia, but rather to the entire Middle East region. Most of our health problems, acute and chronic as well, are preventable. So why should we wait until people become sick to treat them? Lately, we have taken good measures towards implementing the comprehensive healthcare through the 2,200 primary health care centres we have, but we need to do more.
AW: Will this model promote preventive measure and also focus on future public health issues and their solutions?
ZS: I believe if you spend 10% of your health budget on health promotion (health education, better environmental, occupational health, safety measures, maternal and child health, etc.) you would gain a lot by minimising the cost of healthcare as well as improving the health of the people. You will never be able to solve problems such as diabetes, bilharzia, tuberculosis, health issues arising from road traffic accidents, cancers and many others by only treating victims. You have to deal with the causation of these problems i.e. preventing them from occurring.
AW: Research and the availability of data are the foundational components to framing policies to promote public health. Where does Saudi Arabia stand on public health research?
ZS: Lot of medical research is going on. Hundreds of papers are being published every year in local and international journals. However, we need to emphasise also the type of research which would answer the question how, not only the questions of what and why. This type of research (operational research) would help us to solve our current and future health problems. Take for example, primary health care. We have a wealth of data about its importance and why it should be supported. What we lack is a practical model of applied research that takes into consideration the WHO recommendation spelled out in the Declaration of Alma-Ata.
AW: Finally, what kind of public health changes can we expect in Saudi Arabia in the next 10 years?
ZS: Saudi Arabia has adopted its 2030 health strategy. The main tool to implement this ambitious strategy is to prepare the right healthcare personnel, who would carry the holistic approach to health. The process has already started and we are looking for dramatic changes in the health services system.