ABSTRACT

Introduction

The Kingdom of Saudi Arabia (KSA) is experiencing an increasing demand for healthcare due to a growing population and unhealthy changes in lifestyle, fostering the need for critical examination of the current status of primary healthcare in the KSA with analysis of health-related trends among its growing population.

Methods

A review of the literature was therefore undertaken, followed by a survey of primary healthcare centers at three facilities in Riyadh, to assess the current activities, understand challenges, compare existing practices with international best practices, and asses the level of patient satisfaction. The level of satisfaction with primary care services was examined by using observational surveys and retrospective reviews from the previous 20 years.

Results

The more rural areas with populations with lower education and income ranked factors such as cleanliness, competence of staff, and environment the highest (82–95%), whereas urban areas with populations with higher education and income rated their level of satisfaction lower (74–82%). The influence of population diversity and the country's unique cultural sensitivities on the awareness and uptake of cancer surveillance services available in the community was examined. The incidence of diabetes, asthma, obesity, along with breast and cervical cancer trends, has illustrated the importance of health education and disease prevention.

Conclusion

An investment in resources for primary healthcare staff and medical facilities is strongly recommended to support primary care providers in becoming the accepted and preferred community frontline for healthcare needs' assessment and care delivery. With its nursing staff comprised predominantly of expatriates, the emphasis needs to be on recruitment and training of a Saudi national workforce in line with succession planning strategy toward a sustainable Saudi workforce.

INTRODUCTION

The Kingdom of Saudi Arabia (KSA) has the largest and fastest growing population in the Gulf Cooperation Council countries, with 50% of its population younger than 40 years,[1] which has led to serious demands for healthcare in KSA. Until 2014, healthcare was free to all Saudi nationals but has since been limited to eligible Saudis, shifting to the US model of privatization, and is no longer available to Saudis in the private sector. The leading private healthcare organizations in the KSA are Al Mouwasat, Elaj, Dallah, National Medical, and Dr Sulaiman Al Habib facilities, which are located across the Kingdom. The Ministry of Health and the Saudi Food and Drug Agency are responsible for the governance of healthcare agencies in the KSA.[2] The Kingdom's Vision 2030 program delineates its future economic and social vision involving economic diversification and promotion of private sector investment through increased exports.[3,4] Vision 2030 acknowledges that there may be shortfalls in achieving the set targets of ease of access to appointments and health education as part of disease prevention, and therefore realizes the need for strategies to support this initiative. This may be achieved by raising public awareness of primary care services and making access to care easier by online booking of appointments. Currently, community opinion of primary healthcare (PHC) is challenged, with evidence of many seeking direct secondary care, bypassing what should be their first line of consultation and care.[5]

PHC is a relatively new concept in Saudi Arabia, initiated following the Alma-Alta conference in 1978 during which the World Health Organization urged countries to adopt PHC to improve health education and disease prevention, and to promote healthier lifestyles and well-being with an emphasis on investments into PHC. These issues have been taken into account in Vision 2030 directives.

As many of the more rural populations in KSA remain tribal and mobile, there are varying levels of literacy. This presents a challenge for community care with poor compliance with healthcare advice related to prevention of infection. The proximity to and ingestion of camel byproducts remains a significant issue.[6] The interaction with camels among rural communities has been linked to the transmission of MERS-CoV (Middle East respiratory syndrome coronavirus).[7]

Set against this dramatic and somewhat nebulous geopolitical backdrop of change, KSA government agencies recognized the need to examine current activity in primary care units across all regions to understand the pressures and challenges faced by frontline staff and to determine how the existing practices compared with international best practice standards. This is the rationale for the present examination of current literature and PHC provision in Saudi Arabia.

Outside the capital city of Riyadh, primary health clinics serve the staff and family members of government-run military healthcare facilities across the regions of Hail, Najran, Al-Qassim, Rafha, and Arar. The healthcare facilities in these regions primarily serve the military and their families, while other facilities are available for nonmilitary personnel, serving populations that number from 91,000 to 311,000 across rural areas and the inner city.

There is also a need for understanding and compliance with healthy lifestyles and disease prevention measures, in particular for effective screening of infectious disease and implementing isolation measures for patients presenting to primary care facilities. These factors require especially detailed examination in light of the 2015 MERS-CoV outbreak that affected Saudi Arabia.[8]

A review of the literature was therefore undertaken, followed by a survey of primary healthcare centers at three facilities in Riyadh, to evaluate the current activities, understand challenges, compare existing practices with international best practices, and assess the level of patient satisfaction.

LITERATURE REVIEW

Diversity of Patient Groups

The Saudi national population currently stands at more than 34.2 million and is increasing on average by 5% annually. Bedouin tribes of the Quarashi represent about one-tenth of the overall population. These tribal people retain their Bedouin lifestyle in line with the nomadic tradition. A large proportion of those who access PHC are poorly educated and illiterate. Less than 4% of the population has a high-school education and only 0.6% of the overall population has attained higher education. Most of the population is urbanized, with access to multiple healthcare agencies as well as PHC. Although public sector healthcare in Saudi Arabia remains free to all, with military hospitals providing care to their personnel and family dependents, there is growing interest regarding the cost burden, accessibility, standards of care, and treatment, similar to international concerns. There remain significant variations in the standards of care throughout KSA with its population seeking out organizations with superior reputations. Many may not be eligible to use the facilities assigned for military staff. National interest therefore focuses on access to care and private health insurance, similar to the US model.[10]

Chronic Diseases

Diabetes

A prevalence study conducted by Naeem[11] in 2015 showed that Saudi Arabia was now among the top 10 countries globally to list diabetes as having the highest incidence among its comorbidities, with 23.9% of the population having received this diagnosis. This increase in prevalence has been linked to a greatly sedentary lifestyle and poor diet.[12] Globally, diabetes is a large economic burden on healthcare systems, equating to an average 11% of the total healthcare costs per annum.[13] In Saudi Arabia this figure is estimated to exceed US $0.87 billion. This estimate does not take into consideration the added cost to the economy from loss of attendance at work, the increased burden on carers, unemployment, as well as the increase in mortality.[14,15]

Asthma

Asthma affects more than 2 million Saudis. Only 5% of diagnosed cases are known to be controlled, with at least 64% remaining uncontrolled. Cases of asthma represent the highest number of emergency department visits (61.6%) as well as hospitalizations.[16] This high incidence of poor asthma control has been directly linked to increased morbidity and mortality.[17] Between 1986 and 1995 pediatric and adolescent incidence of asthma increased from 8%–23%. This increase has been linked to environmental exposure to tobacco, indoor animals (allergens), dust, and sandstorms.[18]

Asthma is among the top 30 disabilities globally and ranks 19th in the KSA among disabilities limiting normal function and reducing the ability for sustained employment, as patients with asthma are more likely to have lost work days than nonasthmatic patients (3.8 vs 2.6 days in previous year, p = .024).[19] Asthma is acknowledged as the 26th highest cause of death, with figures showing an increase in the incidence of chronic respiratory disease in KSA.[20]

Obesity

Obesity has been recognized as a global concern related to health trends. Saudi Arabia has an obesity rate of 33.7% among its population, linked to increased urbanization and to lifestyle and dietary changes.[20] High-fat, high-sugar diets along with an increasing sedentary lifestyle have been recognized as the main factors, and links to metabolic, genetic, and behavioral factors have been examined in light of the unique genetic profiles of the population.

National response to chronic disease

The national response to chronic disease has been to introduce a National Transformation Program in line with the Kingdom's Vision 2030 with an emphasis on healthy lifestyle education. This has meant revising the current provision of care to address any future healthcare needs of the nation and moving away from the traditional state healthcare provision and toward considering a financial payment system against services that would no longer rely on government budget alone.[21]

Investment in healthy lifestyle educational programs is inherent in the Transformation Plan, targeting the younger generation through health awareness campaigns introduced to school children through the “JEELUNA” program (translated from Arabic as “Our Generation”).[22] A national school-based study was carried out in all 13 regions of the KSA to identify the health needs, health risk behaviors, and health status of adolescents in the Kingdom, revealing significant areas of concern. Through a multi-stage cluster random sampling technique, intermediate and secondary school students from all over the country were invited to participate. Over 12,000 adolescents participated in the study. Data were collected by means of a self-administered questionnaire addressing health risk behaviors and health status, clinical anthropometric measurements, and laboratory investigations. The sample size was n = 12,575; 28% reported chronic health conditions, 14.3% experienced depression, 30% were overweight, and 95.6% had vitamin D deficiency. In summary, respondents agreed that preventative health education along with surveillance and monitoring measures were essential to reduce health issues and monitor the effectiveness of any interventions.

Prevalence of Cancer

Breast screening

Unfortunately, there are few baseline data on the incidence of female breast cancer in Saudi Arabia. A study undertaken by Saggu et al[23] mapped the increasing trend among young females of receiving a diagnosis of breast cancer between the years 1999 and 2014, ranking breast cancer as the most common cancer in women; it accounted for 27.4% of all newly diagnosed cancers among women (5378) during 2010, with an average age of 48 years. It is the most common malignancy in KSA among women and is the second most common cause of cancer-related deaths after lung cancer.[24,25] A triple diagnostic, new screening initiative comprising clinical examination, mammography, and ultrasonography has been recommended.[26,27] Studies have shown that mammography reduces death due to breast cancer by 23% through a program of early and routine screening.[28]

Lung cancer

Lung cancer in KSA is the fifth highest ranked cancer among both men and women, with 85% of cases due to chronic smoking and 10%–15% of cases among nonsmokers.[29] Thyroid cancer, colorectal cancer, non-Hodgkin lymphoma, and leukemia rank among the major cancers in KSA.[29] Prevention through screening is currently being implemented throughout the Kingdom, with primary and secondary approaches to tobacco control via smoking cessation programs and healthy lifestyle awareness programs through PHC and hospital campaigns with government support and direction. A national survey revealed that the incidence of smoking among males was 23.6% compared to 1.5% among females, with ages between 25–64 years.[20]

Cervical cancer

Cervical tumors are among the cancers affecting females in Saudi Arabia, with 92% linked to infection with human papillomavirus (HPV) through sexual activity and transfer of the virus between married couples.[30] Cervical cancer is the 12th most common cancer in KSA. Cervical cancer has been reported as low—although the incidence among females (2.1/100,000) may be considered significant—therefore requiring robust justification to gain government funding for a screening and vaccination program even though such programs are available internationally. This is somewhat paradoxical since there is a lack of health education on this topic in the country, which reflects the sensitivity inherent within the culture.[30] However, healthcare organizations throughout the Kingdom are making efforts to raise awareness of screening and early escalation of symptoms. HPV is closely associated with cervical cancer, the third most common cancer among women globally. The US Centers for Disease Control and Prevention recommends the vaccination of boys and girls between the ages of 11–12 years, with a second dose administered 6–12 months after the first one.[31] Since the rollout of the HPV vaccine, there has been a reported 86% reduction in related cervical cancers, along with a 40% reduction in precancerous cases. This is the lowest reported cancer among Saudi women, accounting for only 2.4% of new cancers.[32] Although the vaccine is available, there is a clear lack of awareness among the population, with most of the research on this topic being concentrated on females.[33]

The lack of national screening programs for this cancer is at best speculated to result in its underreporting and underdetection, as cytology screening is only currently permitted for married women. It is therefore unclear how many single females would benefit from early detection of cancer. Owing to the low reported incidence, justification for introducing the vaccine for females and males remains a major challenge exacerbated by cultural sensitivity, thus making a full cost analysis of the benefits of introducing a vaccination program extremely difficult.

Patient Satisfaction

Assessment of patient satisfaction had been undertaken as part of a national program to evaluate the degree of quality and performance achieved by the respective centers,[34] designed to measure quality of PHC services in the city of Riyadh through a survey from 300 patients across three geographic areas. The sample was obtained by presenting every fifth patient with a request to complete a satisfaction survey, using a 4-point Likert scale. The tool assessed accessibility, staff attitude, knowledge, and environmental factors such as equipment availability and hygiene standards within the clinics.

As the study noted, patients felt that PHC centers lacked sufficient equipment and reported feeling challenged when trying to book suitable date/time for appointments (as females were unable to drive and culturally, should be accompanied by a senior male member of the family). Overall, the sample groups were satisfied with the standards of treatment they received. Most in the sample group were females, married, housewives, and predominantly illiterate so were unable to complete written questionnaires themselves, but provided verbal feedback. The reliability of the questionnaires therefore remains controversial, as the method used to distribute the questionnaires appeared to lack reliability in terms of knowledge of the literacy level and demographics. This is indeed an area for further investigation, and it will be essential to establish a reliable baseline against which to make comparisons related to improvement.

A more recent comparative study was undertaken by Mohamed et al[35] using a sample size of 370 patients from a PHC center. The cross-sectional facility-based study yielded an 82% satisfaction score in relation to the general environment, cleanliness, and competency of healthcare staff. The sample group was subdivided by sociodemographic characteristics of the respondents. There was an increased level of satisfaction from the PHC services in Hail, a more remote location with a higher incidence of illiteracy among patients. This contrasted with respondents from Riyadh, with a higher degree of socioeconomic wealth and education, who expressed a significantly lower level of satisfaction with their PHC experience.[36] The comparative results over 2 decades suggests there had been no significant improvements in patient satisfaction, supporting the argument for more investment into community care and prevention of illness through health education. Consequently, KSA government agencies have recognized the need to examine current activity in primary care units across all regions to understand the pressures and challenges faced by frontline staff, as well as how the existing practices compare with international best practice standards. The level of satisfaction with primary care services was examined by using observational surveys and retrospective reviews spanning a 20-year period.

OBSERVATIONAL SURVEY METHODS

Study Design

Ethical approval to conduct the study was obtained from the University of South Wales. Consent was obtained from participants who were interviewed. A cross-regional observational survey of PHC centers was conducted at three facilities located in northern and central regions within Riyadh, Saudi Arabia during October 2017. Riyadh is the capitol city of Saudi Arabia and is subdivided into 19 subgovernorates, each having an appointed prince as its governor.[37]

Population and Sample Size

Within the city itself, PHC centers that include clinics in Iskan-Yarmouk, Arar, and Dirab, along with employee, family, and academic staff clinics, form part of a national military organization. These centers were selected for visits and interviews because of their geographic location and accessibility to patients. The hours of operation are 7 days a week: Sunday to Thursday from 8:00–24:00; and Friday to Saturday (weekends) from 16:00–24:00. Iskan-Yarmouk sees 1500 patients daily during the winter months from October to March and is the busiest clinic across all regions to apply a focused, direct observational method. Little is known about exact staffing ratios within the clinics, although some reports have noted an improvement in manpower resources.[9] However, there was an overall 5% deficit in unfilled vacancies, upon examination of local staffing levels, when compared with approved budgeted positions required to operate the services.

All facilities were selected from the PHC unit for the catchment areas in each region. These were examined in terms of their environments, provision of care, and educational support in relation to prevention of illness through healthy lifestyle education and support. The facilities were visited, applying a focused, direct observational method over a period of 1 month. Time of day and day of week were standardized to establish an equitable assessment based on average peak activity during evenings within the winter months between October and March, as indicated by the facilities being visited. During the observational analysis of the selected clinics, average staffing consisted of one nurse assistant per physician clinic. Additional staff were noted to be present at the screening desk along with an assigned nurse to take and record vital signs, weight, and height.

A summary report was completed from the findings of the visiting team, which included a physician as well as a nursing and infection control staff. Staffing ratios were reported by the clinic's managers as being satisfactory; however, after examining nurse to patient group ratios against average hourly and daily attendance rates, the number of patients seen and prolonged waiting times would suggest that this comment was subjective.

Data collection and analysis

The assessing team used Ministry of Health Screening Standards and Saudi Central Board for the Assessment of Hospital Standards (CBAHI) in reference to PHC facility standards of operation and practice.[38,39] Core standards were used to achieve safe delivery of care to the highest standard within the PHC environment, in line with the CBAHI manual relating to PHC facilities, along with Joint Commission International of America (JCIA), as the organizations are assessed and accredited by both national and international agencies. The team conducting the observational analysis used paper-based checklists to establish a baseline for current performance in relation to the aforementioned standards.

RESULTS

PHC facilities reported the daily average patient attendance at between 700 and 1500, with patients of both genders and predominantly adults. Three facilities were visited: Iskan, Sharmouk, and Dirab, located within the city of Riyadh; and Arar, located in the northern region, which is predominantly rural—its inhabitants include mainly farmers and their families. Manpower in these facilities was limited in comparison to tertiary centers, with on average three physicians and six nurses as well as a lead nurse per shift. Shifts were staggered between staff, each of 9 hours, factoring in an overlap for peak activity during late evening hours. While the role of the nurse was to triage the patients, there were currently no nurse practitioners available or recognized as such under Saudi Commission for Health Specialties. Subsequently, all patients were required to be seen and examined by a physician, placing great pressure on the physician and this resource. On occasion these examinations were declined as no female physician was available. Female patients requiring intimate examinations would routinely have a female nurse present as the male chaperone waited outside.

The facilities included waiting areas, with the required segregation of males and females, along with bathroom provisions. Each patient was triaged at the point of entry to the clinic, with each doctor working from their own room; a separate room was used to carry out prescribed treatments, such as dressings or administration of medication, undertaken by assigned nursing staff. The clinic space in all locations was dated, in need of considerable upgrading and expansion to address the challenges related to overcrowding. Equipment appeared old and in disrepair, such as infant scales and vital signs equipment. The overall standard of cleanliness varied but on balance, required improvement.

Small areas were assigned as waiting rooms, with insufficient room to place chairs adequately apart to prevent the spread of infection as prescribed by JCIA and CBAHI regulations. Females and children were crammed into small areas as were males, each in their assigned waiting rooms. No prayer room was evident, such that the ritual washing in preparation for prayer time was conducted in crowded bathroom facilities and prayers were performed in any space available either inside or outside the clinic facility. There were no baby-changing or breastfeeding facilities to accommodate the needs of mothers and children. In some more rural facilities, queues extended outside of the clinics in the heat with little shelter, with priority given to mothers and elderly persons who were allowed into the clinics first.

Technologic advances had only recently been implemented, such as patient self-scheduling and health information management systems, a fact that the visiting team took into account. They considered that the clinics were still adapting to the recent changes and were working through some teething problems that would, in future, undoubtedly provide a more reliable source of data collection to better connect with other facilities; for example, to allow physicians to view test results following patients' hospital appointments, relying only on the details included in the referral documents. Previously, computer systems had not supported the ability of patients to book appointments online, thereby forgoing the benefits of patient self-scheduling, including slightly improved waiting times for patients who book in advance as opposed to those who present without appointments.

In one instance, a clinic installed an outside porta cabin to accommodate emergency medical services workers and their medical equipment. They were assigned to a semirural location of Arar, to optimize response times and provide support to the clinical staff, in an attempt to create more space for patients inside the clinic. On average, emergency resources were used three to four times per week, mainly in cases of acute cardiac symptoms or pregnancy.

An additional challenge noted was the issue of communication, with very few Arabic-speaking nursing staff available, most being expatriates from Malaysia and the Philippines. Communication with patients and families presented an ongoing challenge, and while staff were able to speak in broken Arabic, using learned keywords and expressions, the specific dialects of some regions gave rise to misinterpretation. This is one of the main reasons that PHC services had a need to attract Arabic-speaking staff. At the time of the visits, of which three were made, no Saudi nursing staff were seen and one Saudi nurse assumed a managerial position rather than a clinical role. All physicians however were Saudis, making communication with their patients less challenging.

The clinical area visited by the team in each location was assessed in terms of environmental safety and efficiency. The clinical areas were found to be cluttered and disorganized, with insufficient ability to screen patients and optimize patient flow. Triage staff attempted to determine the patient acuity levels but this task was challenging as tight queues of patients presented in order of arrival time. Lack of structured patient assessment and of flow process in place led to confusion among patients, which in turn resulted in congestion in the immediate triage areas of the clinics and waiting rooms. Patients who presented with confirmed appointment schedules were frequently observed in queues alongside patients who had walked in without an appointment. Congestion peaked during the evening and late night hours as most females relied on male relatives for transportation to the clinics and as chaperones. There was little evidence of screening of potentially infected patients, specifically screening for MERS-CoV acute respiratory infection.[40] There was inadequate space within the facilities to enable staff to isolate any suspected infectious cases.

PHC staff appeared to lack robust and up-to-date knowledge of the principles for safe and effective personal protection equipment (PPE) use, as was evident through direct observation and questions related to knowledge of PPE guidelines. This raised concerns about safe screening for and management of suspected infectious cases within the community, which was of significant importance in light of MERS-CoV and the most recent COVID-19 cases. There were no designated isolation rooms and no application of sound fundamentals for screening acute respiratory illness, with clear evidence of significant knowledge deficits among both nursing and medical staff.

Health education and health promotion appeared limited, with gaps in delivery to patient groups in each of the PHC centers. While there were posters and health education leaflets indicating that the period from October 1 to October 30, 2017, had been dedicated to promoting breast screening, no routine breast examination and screening was as yet implemented in any of the PHC centers. Therefore, the previously reported statistics are most likely grossly underreported. In Saudi Arabia routine mammography for women older than 50 years has so far not been encouraged.

There was little control of waiting times; the team attempted to gain information related to average waiting times but this information was not forthcoming. However, the clinical teams across all regions had recently implemented an electronic patient information system with the expectation that this improvement would facilitate extraction of this valuable information for comparison and for benchmarking performance with other facilities of similar capacity.

A series of meetings were conducted with nurses and physicians of the PHC facilities. A total of six physicians and 14 nurses took part. Brief (not exceeding 15 minutes) interviews were carried out in a quiet location of the clinics as directed by the staff themselves. Questions related to workflow and efficiency of their service in relation to the volume of patients who attended the clinics. Environmental factors were discussed that affected their ability to effectively identify and isolate patients who were suspected of being infectious. Challenges related to language barriers between healthcare worker and patient groups, staff training, and educational programs, as well as safe staffing levels were discussed. Notes were taken following informed consent to take part in the interviews whereby anonymity was assured.

The following areas of concern emerged from the open dialogue:

  1. Communication

  2. Poor environment in terms of size, layout, and flow to support patient safety

  3. Lack of streamlining and flow model

  4. Nursing staff from PHC do not report to a nursing hierarchy and therefore have no unified governance

  5. Inadequate nursing and physician continued education support.

While each clinic served a designated geographic catchment area, frequently patients presented to clinics outside of their designated location(s) and their condition, or their insistence, meant they were added to the “walk in” cases without appointments, thus adding to overcrowding.

There was evidence of attempts to schedule specific population and condition clinics, such as for diabetes and hypertension, run by general practice physicians. The lack of compliance among the general population of patients rendered these efforts inefficient and patients would frequently either default on appointments or present to the incorrect clinic, expecting to be seen by a general physician.

Poor understanding of infection control screening and standard precautions was evident. A nurse in charge of one clinic was interviewed to elicit a better understanding of the challenges faced, of the patient groups who presented at the clinic, and of the standards of training among staff. Nursing staff were reported to lack a standardized and therefore satisfactory level of training in terms of triage techniques, most of which had been provided as part of a rudimentary “in house” program. No staff member had undertaken any form of advanced assessment, triage or life support training. There was evidence of basic orientation to the clinical area; however, little evidence of continued professional updates was found.

There was evidence of attempts to provide health awareness and education to patients as demonstrated by the posters and dates such as International Asthma Day, Diabetes Day, and Stroke Day. The staff were unable to articulate a clear strategy in relation to how these days were being organized along with the delivery of educational sessions/materials to patients. Apparently the educational sessions were delivered in an ad hoc fashion with no baseline data against which to measure improvements following the sessions. Nursing staff ratios were considered insufficient in most locations related to the high volume of patients along with varying levels of acuity.

DISCUSSION

The findings of four site studies were examined in relation to the standards and variables among and between PHC facilities in the Kingdom of Saudi Arabia, namely, Iskan, Sharmouk, Dirab, and Arar. It must be acknowledged that the concept of PHC in Saudi Arabia is relatively new; demands on these resources are immense, and there remain many challenges to effective and efficient care and management. Vision 2030 sets out a directive to invest in improved access to care within the community and hospital facilities.[3] While the background to this work attempted to address the major issues in the primary care system, owing to lack of information and organization, it was difficult to establish exactly how these were being routinely addressed.

The fundamental methodologies of patient flow embedded in a service and systems redesign would undoubtedly lend itself to streamlining existing processes of patient assessment, screening, and flow.[41] This would comply with Ministry of Health Guidelines in relation to the effective identification of suspected cases of infection such as MERS-CoV, which had effectively reached epidemic proportion and forced the closure of one its largest hospitals in the Middle East.[42] MERS-CoV is endemic to the region since August 2015. The continued risk of contagion is very real and a threat against which healthcare surveillance can never afford to lower its guard.

The observational assessment identified significant deficiencies in the basic understanding of screening, the use of PPE, and isolation standard requirements. Immediate remedial work was undertaken in relation to these basic requirements. This deficiency varied between the facilities visited but the essential surveillance protocols were deficient in all PHC facilities.

An analysis of staff training needs was identified as an essential requirement to establish a clear baseline of knowledge deficits upon which immediate action could be taken to enhance skills, knowledge, and performance; this should be targeted at both nursing and primary care physicians.

Patient socioeconomic groups appeared to influence their perception of satisfaction. It was recommended that international standards of care delivery and performance targets be introduced and used as key performance indicators as a measure of best practice.[43]

Patient education, health awareness, and health promotion are considered key to improving well-being and reducing unnecessary returns to the already pressurized service. The standard of care patients receive or the environment in which it is delivered must not depend on geographic location or the level of education of those who use the service.

It is however worthy to note that efforts have been made to try and educate the public in relation to healthy lifestyles and sickness prevention as well as the use of technology to facilitate online appointment booking.[44] This initiative was launched during the second quarter of 2019 and shows evidence of success by a reduction of walk-in patients by almost 1000 compared to 3000 per month. It is however prudent to suggest that further research into this commendable initiative would be useful to determine the age group of those using the application, as it might be suggested that the younger patients are more likely to be familiar with modern technologic applications.

Owing to the high incidence of breast and cervical cancers in KSA, female breast screening along with cervical smear testing must be given careful consideration in parallel with respect for cultural sensitivities related to access to certain diagnostic screening and marital status. Currently, unmarried females do not have access to cervical cancer screening. Although the HPV vaccine is available to female teenage school children in the United Kingdom, there is currently no vaccination program available in Saudi Arabia.[45] Highlighting the need for female health awareness and access to routine screening and vaccination programs is therefore required.

Encouraging health awareness must equate to access to surveillance and treatment. To deliver safe and equitable healthcare to PHC patients in Saudi Arabia, health education and screening must be designed to deliver the message of prevention rather than cure. Healthcare staff must exercise professional accountability to maintain up-to-date skills and knowledge in line with the most recent information and evidence-based practices. An investment in Saudi national nurses to bridge the communication gap is a fundamental requirement toward improving services, being in line with the Saudization plan that will support a sustainable workforce.[46] Government spending should consider the cost benefits related to prevention and this would align with an investment into PHC throughout the Kingdom.

Some limitations of the study were related to time constraints and the availability of the team to visit more facilities within a wider geographic radius. Future research would benefit from conducting patient and staff satisfaction surveys and identifying any common themes that may emerge.

CONCLUSION

In conclusion, the results of the study indicated a national drive to review and invest into community-based initiatives of PHC. With advances in technology, the potential to reach a wider population is possible. The emphasis must be on health education and the prevention of illness. Screening programs for cancers and awareness of vaccination programs are essential to mitigate the risk of disease and its progression in identified cases.

An investment into attracting Saudi national nurses would certainly go far to bridge the communication gap that has resulted in having a predominantly expatriate workforce among nurses and many physicians.

Investing in PHC as a community-based program will eventually reduce the demands on treatments as inpatients and therefore reduce the cost burden on healthcare organizations through comorbidities such as diabetes, obesity, and heart disease.

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Competing Interests

Source of Support: None. Conflict of Interest: None.