“Diagnosing” Saudi health reforms: is NHIS the right “prescription”?
This paper outlines the health context of the Kingdom of Saudi Arabia (KSA). It reviews health systems development in the KSA from 1925 through to contemporary New Health Insurance System (NHIS). It also examines the consistency of NHIS in view of the emerging challenges. This paper identifies the determinants and scope of contextual consistency. First, it indicates the need to evolve an indigenous, integrated, and comprehensive insurance system. Second, it highlights the access and equity gaps in service delivery across the rural and remote regions and suggests how to bring these under insurance coverage. Third, it suggests how inputs from both the public and private sectors should be harmonized – the “quality” of services in the private healthcare industry to be regulated by the state and international standards, its scope to be determined primarily by open-market dynamics and the public sector welfare-model to ensure “access” of all to essential health services. Fourth, it states the need to implement an evidence-based public health policy and bridge inherent gaps in policy design and personal-level lifestyles. Fifth, it points out the need to produce a viable infrastructure for health insurance. Because social research and critical reviews in the KSA health scenario are rare, this paper offers insights into the mainstream challenges of NHIS implementation and identifies the inherent weaknesses that need attention. It guides health policy makers, economists, planners, healthcare service managers, and even the insurance businesses, and points to key directions for similar research in future. Copyright © 2012 John Wiley & Sons, Ltd.
We observe a global tendency since the mid-1980s that identifies private health insurance (PHI) as a healthcare “financing option” (World Bank, 1987, 1993; Newbrander et al., 1992; Preker and Harding, 2003; WHO, 1995; Drechsler and Jutting, 2007; Preker et al., 2007a). As such, PHI is no more a strictly “capitalist” and a “developed” country phenomenon. The Kingdom of Saudi Arabia (KSA) is an affluent Middle-Eastern country, but we notice that owing to the role of PHI, being considered as a vital factor in its future health development, the contemporary Saudi Arabia has been viewed as an upper middle-income country (WHO, 1995). The National Health Insurance System (NHIS) in the KSA was introduced in 2002, as an integral component of the New Saudi Health System (NSHS). As such, the NHIS is viewed as an implementation strategy of the NSHS and synonymous to integrated health reforms in Saudi Arabia (Al-Sharqi, 2006).
Nonetheless, the privatization-oriented health insurance policies all over the world, such as the NHIS, have their own limitations, especially in implementation. Such limitations are specific to the contexts of the countries under study (Preker et al., 2007b). We therefore find a “diagnosis” of the Saudi health context to be mandatory to any “prescription” for health improvement – such as the NHIS. In this pursuit, we attempt to inquire into and examine the contextual viability of Saudi NHIS vis-à-vis the broader dynamics of healthcare services and the emerging public health concerns among the Saudi health researchers. We particularly attend to the essential indicators of equity, access, infrastructure, and resource capacities.
THE SAUDI HEALTH CONTEXT
While examining the consistency of privatization and health insurance reforms, we suggest the need to review and understand the unique Saudi health context through its history. In view of the contemporary challenges, the insurance reforms are required to be designed to cover the scope for both the curative and preventive healthcare.
The history of healthcare development is likely to influence any reforms, especially with regard to infrastructural support, the quality of and access to healthcare, and the challenges of implementation. We therefore examine the development of healthcare systems in the KSA over four evolutionary stages (Al-Sharqi, 2006).
Stage one: 1925–1941
Before 1925, the healthcare resources and infrastructure were scarce, and access to and quality of healthcare services were poor. The health status against the choice of services was quite diverse. Traditional practices were common. Because Saudi Arabia has been the home to Muslim pilgrimage over the history, only in the Alhijaz region that includes Makkah and Al-Madinah provinces, the resources for healthcare delivery were available to pilgrims owing to international commitment. Even in this region, the access to and the quality of hospital services were either poor or insufficient. In 1925, the Health Department and a Bureau of Health and Aid were created to improve the access to and quality of healthcare services (Alharthi et al., 1999). The 1926 Bill of Healthcare Services included 111 clauses on implementation of the new health system, and the structures and responsibilities of hospital services.
Stage two: 1941–1951
During this period, the access to and quality of healthcare services were improved. This stage was marked by the commercial production of oil in the KSA, whereby the financial resources became increasingly available for public service expenditures. The state also introduced policies for hospital capacity building and preventive health practices.
Stage three: 1951–1981
In 1951, the Ministry of Health was created to take over from the Bureau of Health and Aid (Alharthi et al., 1999). During the 1960s, the economic affluence led to work-related insurance coverage; however, this era was also characterized with a “fee” for private hospital care and changed the concept of “free” health services. Human and financial resources increased in both the public and private sector hospitals as well as the expenditure for improving healthcare service quality and preventive care programs. The 1978 Alma Alta Declaration on primary healthcare was also adopted during this era to expand healthcare coverage and improve the overall health status of the population.
Stage four: 1981-present
The Ministry of Health remains responsible for healthcare service provision to the population including general and specialized hospital care. The Ministry coordinates with several other state agencies in service delivery: hospitals of the National Guards, the Ministries of the Interior, Defense and Aviation, and the Royal Commission for Jubail and Yanbu. These organizations provide healthcare services not only to their employees but also to all Saudi citizens under special procedures. Other state agencies including the Saudi Red Crescent Society provide emergency services and medical assistance to pilgrims.
Until 1999, most Saudi citizens and expatriates had received free healthcare services, when, in response to two challenges, the Saudi government introduced the NSHS. These challenges were to increase availability of healthcare services and to join in the international trend of inviting the private sector for its contributions. In this pursuit, if the NSHS assured equality of access and service improvement in the private sector for the insured individuals, the public sector provided services where the private service delivery were inappropriate, unavailable, or inaccessible. It is in this context that the health insurance companies in the KSA are expected to develop viable infrastructure and act as buffer between healthcare services providers and the patients or their employers.
The first stage of the NSHS was implemented during mid-2002 for 3 years, requiring health insurance for all expatriates and Saudi citizens working in the private sector. In this stage, the Saudi citizens working in the public sector could either opt for healthcare services at public hospitals for free or visit the private sector and pay for the services by themselves directly. They could also purchase an insurance plan for private healthcare services. Reflecting on the lessons learned in the first stage, the second stage of the NSHS aimed at covering all Saudi citizens.
HEALTH DEVELOPMENT VIS-À-VIS CHALLENGES
We open up discussion in the fourth evolutionary stage of the Saudi Health system, especially from 1983 to 2009, that saw a significant progress in the key health indicators of the KSA. The life expectancy increased from 66 to 73.5 years (Ministry of Health, 2009); infant mortality rate and under five mortality rate decreased from 52 to 17, and from 63 to 20, respectively; and maternal mortality rate declined from 3.2 to 1.4. In spite of an increase in population, the prevalence of common infectious diseases fell considerably during 2003–2007 (Ministry of Health, 2009). The infection rate (/100,000 population) for polio was brought to zero in 2009, whereas the infection rate (/100,000 population) for tuberculosis declined from 52.2 in 1983 to 15.6 in 2009. Still, the NHIS faces a number of emerging “contextual” challenges that we discuss as follows:
- a.Increasing costs of health services: Costs of healthcare are increasing globally, and countries such as Saudi Arabia are induced to involve the private sector for positive changes: in contributing investment in health services market, quality improvement, and insurance coverage (Walston et al., ). The rising cost of state-of-the-art diagnostic technologies and equipments, pharmaceuticals, and demand for higher salaries for specialized medical staff have also increased the cost of healthcare. The high population growth rate adds further to an increase in demand and consumption of healthcare and the types of diseases. Therefore, healthcare costs are likely to continue increasing in the future because of the growing demand for “quality” of and “access” to healthcare services. In this context, the NHIS is expected to share the economic burden on the state rather than add to the budgetary expenses.
- b.A portfolio of rising public health concerns: In spite of a rise in costs, there is a rapid increase in public demand for state-of-the-art diagnostic as well as therapeutic technologies and more ICU beds. This requires expansion of existing healthcare services at all levels. There are several reasons for this rise in demand. As compared with 23.2 million in 2005, the Saudi population is estimated to reach 33.5 million in 2020. The number of elderly Saudis over 60 years is likely to more than double by the year 2020, adding further to the age-related illnesses.
Apart from an aging population, the “diseases of affluence” in the KSA that include chronic illnesses, such as diabetes and obesity, are also on their rise. The KSA ranks third in the global list (WHO, 2009) of both diabetes (prevalence 16.7%) and obesity (prevalence 35.6%). The sedentary lifestyle of Saudis in general and a high prevalence of smoking (24%) among Saudi males are the contributing factors toward a rise in chronic diseases such as diabetes, coronary heart disease, and cancers. The psychiatric illnesses among all age groups are also on the rise. Morbidity and mortality due to traffic accidents have been on a rise (Ministry of Interior, 2008). The WHO (2009) has the world's highest road accident fatalities in the KSA. In addition to the emerging diseases, a growing public awareness of personal health among the growing middle-class and customary medical checkups has also contributed to an increased demand for healthcare services.
- c.Limited available resources: The limited financial resources allocated to the Health Ministry appear to be insufficient in meeting the growing public demand for better and more health services. The state healthcare expenditure is only 8.7% of the annual budget. KSA trails behind the developed countries with regard to important healthcare indicators (WHO, ) including the following: hospital bed capacity (2.2 per 1000 capita), physicians (2.18 per 1000 capita), and nurses (4.1 per 1000 capita). The private healthcare sector funds only 22% of the healthcare services, which is very low as compared with many of the developed and developing countries, for example, the private sector funds 75% and 55% of the total healthcare expenditure in the case of India and the USA, respectively.
The large annual influx of over 2 million Hajj pilgrims creates a seasonal demand for healthcare services. Through an international commitment, the KSA disengages its medical staff from all over the country over this period. The foreign pilgrims add to workload not only in their number that continues to grow but also for a diversity of public health problems associated with this large group (Al-Yousuf et al., 2002).
- d.Need for resource optimization and appropriation: An optimum utilization of the existing healthcare facilities and resources is vital for minimizing wastage and unnecessary paperwork. Currently, the efficiency of small public hospitals (50 beds and over) is unsatisfactory, and the hospital occupancy rate of 71% of small hospitals is less than 60%, whereas the occupancy rate of only 7% of the larger (more than 400 beds) is also less than 60%. Internationally, an occupancy rate of less than 60% is not an acceptable standard. Also, healthcare delivery involves loads of unnecessary paperwork that not only leads to delays in treatment but also adds to overlapping and duplication and hence, wastage of key resources such as time, equipment, and staff. Several factors are found to be responsible for this: management and organizational cultures, a lack of evidence-based practice, the need for professional development, and lesser referrals to secondary care (Al-Ahmadi and Roland, ).
- e.Topographical and geographical limitations: The difficult geographical terrain and large areas of the KSA also pose challenges for equity, access, performance, and standardization of quality in healthcare. The distance between cities and a rough desert and mountainous terrain in many areas also contribute to regional imbalances in healthcare provision across the entire population. About more than 2000 villages have a population of 500 to 5000 and another 150 small towns have a population of more than 5000 to 25000. Also, the KSA is characterized with low population density of 12 persons per square kilometers, which ranks 216th in the world (Al-Borie and Abdullah, ).
- f.Lack of standardization: Another challenge is not adhering to international standards for quality of healthcare services. Currently, great disparity exists among the hospitals in infrastructure and standards of service. This makes accreditation of many hospitals quite difficult. There is a need to standardize and accredit hospitals on internationally acceptable quality of care. This requires periodic situational analysis followed up by systems and procedures for appropriate monitoring and evaluation.
The KSA health system is also unique for its predominantly doctor-oriented and patient-oriented medical care. Most health centers and some hospitals operate in rented buildings that do not meet the design requirements of a model healthcare facility. Some buildings are old and unsuitable. On the other side, there are a number of distinguished facilities that serve as centers of excellence, such as the King Faisal Specialist Hospital and Research Centre, and the King Khalid Specialist Hospital for Eye Diseases in Riyadh. The military hospitals, university hospitals, and some private hospitals also have state-of-the-art equipment, and highly qualified and professional staff (Al-Yousuf et al., 2002).
- g.Equity gaps and disparity: Although the KSA is an affluent country, still the ongoing NHIS reforms need to be cautioned for the equity gaps and disparity unique to Saudi health context. The healthcare insurance coverage is likely to take a longer time to deliver across urban–rural imbalances, large hospital versus primary healthcare center-related care, and regional disparities evident in resources and infrastructure, medical technology and equipment, professional expertise, the quality of care, and standards of practices (Al-Borie and Abdullah, ).
SOME PRIORITIES FOR VIABLE HEALTH REFORMS
In view of the KSA context, prior to implementation of NHIS, its scope and direction must be effectively integrated with mainstream health systems development. The state healthcare planning and policymaking needs to be evolved around the following concerns:
- 1.Integrated and comprehensive healthcare: Health promotion and preventive care need to be aligned with the curative services as a public right. Similarly, a provision of and access to rehabilitative healthcare services at affordable costs to the entire population should also be a clear state priority. Such services need to be organized on the basis of patients' profile catering to efficient and effective referral systems across all levels of care. Currently, the Saudi healthcare system revolves around the hospitals and lacks well-defined structure and regulation of catchment areas vis-à-vis effective referral. Having realized the importance of integrated and comprehensive healthcare, the government has already launched a project that aims at enabling easy access across all levels of the healthcare system and ensuring equitable deployment of service delivery. A workable link between the three tiers of healthcare delivery should be promoted through a functional referral system and continuing medical education. The health information systems and subsequent data collection should be integrated across the three levels (Al-Yousuf et al., ).
An integrated and comprehensive approach is likely to increase coordination among service providers across horizontal and vertical levels of care alongside coverage in all specialties. It is also expected to improve quality of care, enhance performance levels and help in managing available resources effectively. It can also ensure self sufficiency up to the tertiary level in all regions across the KSA.Forty billion SR (US$10.67 billion) are reported to have been added to the project to establish new healthcare facilities including hospitals, diabetic and dental care centers, laboratories and blood banks, and primary healthcare centers (Al-Borie and Abdullah, 2013). Another 16 billion SR (US$4.27 billion) have been allocated to establish five medical cities in the central, eastern, western, northern, and southern regions of the KSA. The medical cities are expected to provide highly specialized medical services. The project is emphasized to develop primary healthcare services through 750 new primary healthcare centers in the country. The distribution of these new centers are required to be designed and structured on principles of equity, affordability, accessibility, and social acceptability across the regional health contexts. To make the most out of these initiatives, an integration and collaboration with other health and non-health sectors, ministries, and departments must also be emphasized for long-term sustainability.
- 2.“New” public health: Public health policy in the KSA needs a revision. The “new” public health policy must be based on research evidence of emerging disease patterns and should focus on disease prevention through health education and promotion. KSA has a fairly respectable quantity of public health research literature produced in its leading universities and medical schools. However, that is mostly quantitative data. What is missing is the focus on developing “policy tools” for effective implementation and for bridging the inherent gaps in the macro-level policy environment and the individual-level lifestyles – to minimize the economic burden of insurance costs. Here, we discuss a few disease patterns that need alignment to the policy tools.
Hospital-acquired infections are a rapidly growing health concern (Memish, 2002). Containing and controlling public health risks at the annual Hajj gathering of 3 million pilgrims continue to challenge; infections include meningococcal meningitis, respiratory tract infections, and blood-borne and zootoxic diseases, all have implications when pilgrims return home. For the extraordinary pace of modernization in the KSA, deficiencies in infection control are being redressed to, but only slowly.Similarly, there is an alarming prevalence of obesity among both genders (Al-Nozha et al., 2005). Obesity and overweight are increasing in the KSA with an overall obesity prevalence of 35.5%. Reduction in overweight and obesity are of considerable importance to public health. Therefore, there is a need to develop and implement a contextually consistent national obesity prevention program and characterize obesity as a public health risk, and equally educate and promote the benefits of healthy eating along the disease implications of obesity at the community and early school levels (Al-Nozha et al., 2005). Smoking and heart diseases are also prevalent among Saudis, which require intervention for eradication or reducing the prevalence to minimum acceptable levels. A clear association between cigarettes smoking and heart diseases is evident, particularly among men, requires aggressive educational and promotional programs for health hazards related to smoking particularly for preventions at an early age (Al-Nozha et al., 2009).Mental health disorders such as anxiety, depression, and stress among Saudi school boys are also reported to be prevalent (Al-Gelban, 2007). A study indicated that of 1723 men students recruited, 59.4% had at least one of the three disorders, 40.7% had at least two, and 22.6% had all the three disorders. More than one-third of the participants (38.2%) had depression, whereas 48.9% had anxiety and 35.5% had stress. Depression, anxiety, and stress were strongly, positively, and significantly correlated. Hence, there is an urgency to pay more attention to mental health of adolescent secondary school boys. Further studies, especially qualitative and cohort research, on lifestyles and behavioral modifications, are needed to explore knowledge and attitudes of students, parents, and teachers concerning mental health.
- c.Balancing roles of public and private sectors: Balancing the roles of the public and private sectors seems to be a relevant policy direction in the Saudi health context. The “quality” of service provision could be regulated by the state and international standards, whereas the private sector should be involved for its share in the insurance industry, to be based primarily on open-market dynamics. In this regard, Sekhri and Savedoff () are of the view that the regulatory approaches can structure PHI markets in ways that mobilize resources for healthcare, promote financial risk protection, protect consumer interests, and reduce inequities. Hence, the policy makers need to define the role that PHI would play in the health systems and regulate the private sector appropriately so that it serves public goals of a universal coverage and equity in Saudi Arabia.
- d.Viable insurance infrastructure: The institutional infrastructure for the insurance sector in the KSA needs to be viable. It requires an optimal expansion. While there is a need to reform and institutionalize the growth in the insurance market, it is equally important to monitor capital reserves, solvency margins of all insurers to protect the interests of the clients, public, and other shareholders (Sekhri and Savedoff, ). These institutions in the insurance sector are required to promote operational-level cooperation between brokers and insurance companies. Also, there is the need for these institutions to educate the public on the benefits and principles of insurance and how insurance businesses do not conflict with any social and religious thoughts of the Saudi population.
CONSISTENCY OF THE NHIS: DISCUSSION
The Saudi insurance market experienced significant growth during 2003, whereby the major structural changes introduced insurance law for regulating insurance activities. The Ministry of Commerce and Industry deals with issuing licenses for insurance and reinsurance companies, whereas the Saudi Arabian Monetary Agency regulates the insurance market. The by-laws stipulate that insurance companies must offer at least 25% of their capital for public subscription. The minimum capital requirement is US$26.6m (SRl00 million) for insurance firms and $53.3m (SR200 million) for those offering reinsurance. Existing insurance companies were required to have 8 months to comply with the requirements of the law. At least 30% of the staff was required to be Saudi nationals at the beginning, rising to 70% in 5–8 years.
Now, for the existing and potential role of PHI in low and middle-income countries, there are two views of technical experts and policy analysts (Sekhri and Savedoff, 2006; Preker et al., 2007a, 2007b). One claims that it leads to overconsumption of care, escalating costs, diversion of scarce resources away from the poor, “cream skimming,” adverse selection, moral hazard, and an inequitable healthcare system. The other view holds that it provides access to care when needed without the long waits, low quality, and resource mismanagement. This view asserts that the problems of the PHI were equally observable in social health insurance (SHI) and government-subsidized health services. As discussed earlier, the KSA is unique for its economically affluent status but is also characterized by health problems that are typical of a developing nation. Therefore, we find both the views to be relevant in the Saudi context.
First, through the evolutionary history of health development in the KSA, discussed earlier (and the annual Muslim pilgrimage factor, in particular), the insurance industry needs to be aligned along the religious beliefs of the population that is 100% Muslim. Health insurance in some form may not be easily acceptable to the conservative mindset. This would equally apply to the influx of Muslim pilgrims visiting the KSA. Second, for its affluent economy, driven by rich petroleum reserves, the KSA may not be typified as a developing country that is short of resources and dependent on foreign aid. The state could afford to subsidize or partly cover for insurance, especially for the well-defined groups of the unprivileged population. Third, insurance coverage is mandatory for all expatriates in the KSA. Through the “Saudization” policy (Ramady, 2010), the Saudi government has been progressively minimizing its dependence on expatriate staff and prioritizes employment for Saudi nationals. Still, employment-related insurance of a large size of expatriate workforce could help increase funding.
Hence, there is a need to re-examine and diversify the range of insurance portfolios within the Saudi NHIS – with regard to their merits and disadvantages, starting with establishment or improvement in the insurance infrastructure. Jumping into the insurance-based reforms without first creating and later aligning these within the prevailing health systems across the country would be “putting the cart before the horse” (Al-Borie, 2011); whereby the insurance sector in the country still needs to be expanded and upgraded in its own way. We recommend a “mix and match” of some options that need to be examined for their contextual relevancy to the NHIS reforms.
- Item 1. The “case study” approach: There is still a need to examine the role of NHIS and learn from similar experiences in the developed countries, such as the USA and Australia (Al-Sharqi, 2011), and also from countries that are considered to have highly reputable insurance systems in place, such as Germany, Sweden, and Denmark (Sekhri and Savedoff, 2006). The KSA may then need to define a health insurance system of its own, rather than taking up a “cut and paste” approach to institutional systems development that is observed quite often in the design of health systems. In this regard, several World Bank studies have also pointed to the need of essential variation in different countries and different groups of population in these countries. For instance, in terms of the balancing the role of the public and the private sectors in the KSA, the purpose should be on how the state regulatory frameworks should serve the population better. The private health sector should be viewed as a partner (and not a competitor or opponent) that serves a common purpose and should be encouraged for its contributions to the specific healthcare needs of a variety of population segments.
- Item 2. Social Health Insurance: The concept of SHI (Wagstaff, 2010) that is re-emerging in many parts of the developing world could be examined in the KSA health context where it was practiced in the 1960s, but only to cover work-related injuries. In the past, many countries that have relied mostly on tax finance (and out-of-pocket payments) have opted for SHI, or have been thinking about it. Countries with SHI already in place have also been attempting to add coverage to the informal sector. Interestingly, this revival is taking place at a time when the traditional SHI countries in Europe have either already reduced payroll financing in favor of general revenues or are in the process of doing so. Wagstaff (2010) also points to the negative labor market effects of SHI. Here, the KSA health policy makers must learn lessons from experience of other countries and become conscious of the negative effects of SHI.
- Item 3. Community Financing: The World Bank review series (Preker and Carrin, 2004) outlines the role of community financing schemes and their contribution to financial protection against illness. It allows access to healthcare of the low-income and rural-based population. Such schemes may mobilize only a few resources from the poor communities, whereby the KSA government could offer some form of subsidy to the poorest among these. Such schemes have smaller risks, possess limited management capacity, and cannot offer more comprehensive benefits that are often available through more formal health financing mechanisms and provider networks. As such, this approach could cover the essential levels of primary and preventive care.
- Item 4. Social Reinsurance: Another approach in the World Bank review (Preker and Carrin, 2004) that could be consistent to the KSA is “Social Reinsurance,” for a universal coverage of the Saudi population in the rural and remote regions that do not have any access to and quality of healthcare. This approach is based on communities rather than individuals. The review suggests how standard techniques of reinsurance can be applicable to micro-insurance in healthcare, as these are especially relevant when the risk groups are too small to be protected against an expenditure variance.
- Item 5. General Health Insurance System: This model has been implemented in Turkey since 2008 (Yasar and Ugurluoglu, 2011) and could be examined to assess whether it could achieve the objectives of universal coverage in the KSA, both in its breadth and depth. This model could also address to some socio-economic problems of the KSA, such as growing unemployment, inadequacy of and inefficiency in creating employment opportunities, and inequitable income distribution. In this regard, the state could add an insurance-based system along a tax-based system.
This paper aims at opening up a debate on the contextual consistency of insurance-related health reforms in the KSA. It points to the deficiencies in NHIS institutional infrastructure, especially regulatory frameworks, operational documentation, and public awareness, which could eventually constrain the effectiveness of any such reforms. We have highlighted the challenges of mainstream health systems development in the KSA vis-à-vis the NHIS capacity building, raising the questions, Will the NHIS help reduce the cost of healthcare services? and Whether the quality of healthcare services would improve in the rural and remote areas under the NHIS? We also point to the need for further multidisciplinary research into the portfolio of options we have suggested, and have attempted to engage the attention of Saudi policy makers and economists to bring viability into ongoing health reforms.
The authors acknowledge a research grant (2011 No: 10–58) toward this research project by the King Abdulaziz University through the office of Vice Deanship of Postgraduate Research, Faculty of Economics and Administration. The authors are grateful to Dr. Mohammad Khoshaim, Deputy Minister of Health for Planning, Riyadh, KSA; Dr. Hussein M. Al-Borie, Vice Dean of Scientific Chairs at the Research and Consultancy Institute and Assistant Professor, Department of Health Services and Hospital Administration, and Dr. Khadija N. Abdullah, Lecturer, Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, KSA, for their help in provision of data. The authors have no competing interests.