Policy Discourse: Shifting the burden of healthcare from state to market in the Kingdom of Saudi Arabia

Saudi Arabia has modied from a predominantly free, public and comprehensive system under a welfare model to more of a mixed-economy model of healthcare. The welfare state slowly moved to a liberal model, emphasising market forces to dominate, and the private sector was trusted to provide better provision of healthcare. The country has confronting enormous problems in the health sector due to population growth, lifestyle changes, shift of disease pattern, elevated expectations, escalated healthcare costs, limited infrastructure and resources, and poor management practice in the provision of healthcare. Moreover, the government has been emphasizing on the need to bring in private sector investment to improve quality and eciency, development of manpower, and standardization of services. As the current pattern of healthcare is unsustainable, the country is planning to restructure the present healthcare system towards institutionalizing it to meet the future challenges. The governments must make an appropriate amount of effort to build its healthcare systems by transforming and modifying the challenges faced by the society and its political-economic systems. The government should encourage equity, and fairness in the provision of healthcare.


Introduction
Internationally, many countries have shifted from a predominantly free, public and comprehensive system under a welfare model to more of a mixed-economy model of healthcare and further advanced to a liberal model emphasizing on market forces to dominate where the private sector was trusted for development [1]. This shift is not due to government policy alone and can be attributed to a variety of national and international attributes. The oil-rich Gulf Cooperative council (GCC) countries [Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates (UAE)] embraced a public sector welfare system nanced by its oil economy. Most of these countries included health in their constitution as a basic right.
Government facilities provided free services to patients [2]. For example, Saudi Arabia established its public health system and the Ministry of Health (MOH) in 1925 and 1949, correspondingly, to dispense unrestricted healthcare to its population [3,4] and accepted the primary healthcare approach [5]. Similar policy was accepted by other GCC countries. Kuwait and United Arab Emirates established a comprehensive public health system in 1950 based on the principle of generous welfare system and catered free healthcare services to all citizens [2]. Oman also established free services for its population.
Discovery of oil and subsequent social and economic plans promoted to develop public healthcare system [2]. The development of healthcare in these countries is impressive and their governments have done a lot to improve the health status of the populations [6].
This article focuses on the factors that have promoted in shifting the burden of the state to market forces and allow the private healthcare sector to grow in Saudi Arabia. The author followed the political economy approach to analyse private sector growth fostered by allowing the market to play a prominent role [7,8]. This approach helps shed light on connections between the political and economic means of advancement [9]. The current article examines the enhancement of private sector healthcare not only within the healthcare context, but also within the wider social, economic, international, and political contexts of Saudi Arabia.

Inclusion and exclusion criteria
The current study's initial search strategy helped nd 967 articles. This was followed by scanning and screening of 23 peer-reviewed journal articles and other documents. The literature search was carried out between May 2019 and December 2019 and the collected literature was analysed. The review involved two stages: the author rst conducted an extensive search of the existing literature, and then screened it in terms of its relevance to issues of private sector healthcare growth and development. During the review process, efforts were made to synthesize relevant material to gain a comprehensive understanding of the various challenges and issues. Scoping literature review is used in nd the appropriate articles for the study [10]. This study is based on literature and documents published in English and made available in Google, Google Scholar, PubMed Central, Web of Science, Current Contents and Directory of Open Access Journals. The Boolean operators AND, OR and NOT were used in synthesizing the search. Relevant keywords such as "Saudi Arabia" "health" "healthcare" "health sector" "state" "policy" "market" "liberal" "reform" "private sector" "development" and "quality" "{state" AND "healthcare"} {"health" AND "development"} {"market" and "private sector" NOT "public sector"} were used in the search. The search helped to nd relevant documents; including journal articles, government reports, policy and planning documents of Kingdom of Saudi Arabia. In addition, available secondary non-government documents were minutely reviewed.

Data extraction and composition
Before complete revival of the full version of the selected texts, the author screened prospective abstracts based on the precise information. Descriptive design and analytical methods were used to complete the study. Thematic data analysis techniques were used, which involves nding informative segments in the text, rearranging them, and nally reducing them to interpretive truth through focused reading and rereading of the text as well as coding and category development [11,12]. It helped to identify, analyze and report patterns (themes) within data [13,14]. The study provides authentic and valid results, where the researcher maintained high levels of objectivity and sensitivity [11].

Shifting Burden From State To Market
Saudi Arabia has delivered comprehensive and universal access to healthcare for many decades to its entire population, including non-nationals, without external aid or collection of taxes due to the country's welfare state model of governance enabled by oil revenues [4,15]. However, this has also brought about its own set of challenges including increasing costs of healthcare, dip in oil revenues, changes in the country's demographics, changing lifestyles and disease patterns, and lack of management in the delivery of healthcare services [16,17]. Moreover, provision of healthcare services to the expatriate community that comprises almost a third of the country's population has also posed an issue. To tackle these, the Saudi government has been pushing through reforms to provide the best health services at affordable costs while meeting the changing needs of its growing population [18].

Government Policy
In 1999, the government invited the private health sector to contribute citing the need to improve availability and establish parity with international medical advances [4]. This led to the establishment of New Saudi Health System (NSHS). Under NSHS, insurance companies, both local and foreign, were given permission to deal with expatriates and Saudi nationals who work in the private sector. "Health insurance companies act as a buffer between healthcare service providers and patients or their employers" [4].
Health insurance is also seen as a solution for greater access to healthcare [19].
Private health insurance in Saudi Arabia was founded through the enactment of Labour Law in 1999. This legislation allowed private healthcare providers to enter the healthcare market [19], while making it compulsory for both expatriates and Saudi employees to be insured by their private employers for health insurance [20]. The Compulsory Employment Based Health Insurance (CEBHI) was recommended by the Cooperative Health Insurance Act of 2003 [21,22]. This has helped lift the burden off the public health system to a large extent. While insurance companies are ourishing, private hospitals are mushrooming and generating more income from the out ow of private patients. This is evidenced by the sector's growth from SAR14.61 billion [1US$=3.75 SAR] in 2009 to SAR21.104 billion in 2012, marking a compounded annual growth rate of 13.04% [23]. As of December 2018, there were 35 operational insurance companies providing coverage to 11 million bene ciaries for provision of healthcare from the private sector [24,25].
Leadership plays a contributory role in shifting the burden from state to market in the policy process. A turning point in the nation's development trajectory was the year 2016, when the new leader laid out a visionary outlook to uplift the nation from its traditional way of thinking and modernize its people by establishing a new economic system of self-reliance away from oil-dependence [26]. Following the declaration of Vision 2030 and National Transformation Plan (NTP) of 2020, the leadership rea rmed the role of the private sector's in meeting healthcare demands from a growing population by encouraging its involvement [27]. The Crown Prince advocated reforms in the rentier welfare state such as privatizing state assets and withdrawing subsidies [26]. Moreover, the King, Ministers, Shura Council memebers and other important functionaries underlined the importance of the private sector in reliasizing the Vision of 2030, which is expected to contribute to economic growth and sustainable development [28,29]. The government wanted to break the cyclical nature of its expenditure pattern and overcome 'oil addiction' to build a self-reliant economy. The government believes a self-reliant economy would encourage its private healthcare sector to ourish along a path of accountability, transparency, communication and public engagement. Vision 2030 highlights the role of the private sector as an engine for social and economic reforms to transform its economy towards multi-dimensional growth with improved competitiveness [30].
It also emphasizes on fostering private investment in sectors previously funded by the government [30]. Besides, it expects the private sector to contribute to sustainable development by connecting the public and private sectors. This connection will help improve the levels of care, increase patient satisfaction, and reduce nancial risks in the public sector [28].
Around the world, governments are looking for means to strike a balance between rising healthcare costs and dipping government budgets [31]. Pushing for a greater role for the private healthcare sector based on its perceived exibility, managerial capacities and entrepreneurship [2,16], Saudi Arabia, offered incentives to private investors in the form of tax credits and other bene ts [32]. While Saudi Arabia's public healthcare system is nanced by oil revenues, expenditures on private sector healthcare are borne through a combination of employee insurance and out-of-pocket payments [16]. It is expected that Public Private Partnership model will help to unlock greater value in the healthcare system and allow private sector contribution to total healthcare spending. A market-based healthcare system is seen to be more bene cial for the Saudi economy, and international entrepreneurs and healthcare providers. It enables entrepreneurs to access investment and venture into the largest healthcare market in the region. This liberalization will lead to provision of quality healthcare for both Saudi [33] and foreign nationals, giving a boost to medical tourism as well. While provision of basic health services will be ful lled by the government, the Ministry of Health will gradually shift towards a largely policymaking and regulatory role. The ministry is expected to establish standards for affordable, quality and appropriate care [28].
The government also plans to privatize all public hospitals and build public-private partnerships. At present, the public sector contributes to 80% of the total bed capacity, which is expected to increase to 73,768 beds in 2020. Meanwhile, the private sector is expected to add 26,000 beds by 2020. It was reported that a private group of investors is building eight 130-bedded hospitals, 60 out-patient clinics, and other necessary amenities in a medical village in Riyadh. On its part, the government is constructing 36 new hospitals with 8,950 beds, and two medical cities. Moreover, the government plans to build another 18 hospitals, adding 9,904 beds over the next two years. In April 2018, Saudi Arabia announced an ambitious privatization plan involving 14 PPPs investments to be completed across 10 sectors, including healthcare, by 2020. In July 2018, the government signed an agreement with the private sector for a SAR407 million-loan to establish hospitals and medical facilities to ful l the objectives of Vision 2030 [34].

Economic Factors
Constant uctuations in oil price in the international market have posed a challenge to most oil-reliant gulf economies. Heavily dependent on oil revenues since the 1970s, Saudi Arabia's oil revenue comprises about 80% of the government's total earnings [35]. This resulted to minimise subsidies and limited spending in different sectors of its governance [35].The country's oil exports account for about 88% of all export earnings and the sector accounts for about 35% of Saudi Arabia's GDP [36]. Private investors were recently asked to expand their roles in the health, education and tourism sectors as well [37].
As of 2019, Saudi Arabia's GDP per capita stood at US$20,912, while its rate of in ation was 2.46%. Though GDP grew at 0.33%, the country's public debt stood at 18.98% of GDP. Saudi Arabia is one of the largest economies in the region with a national budget of SAR1020 billion (US$272 billion) as of 2020 [38]. Yet, the country faced a budget de cit of SAR367 billion in 2015 and SAR297 billion in 2016, SAR174 in 2018 and SAR187 billion in 2020 [38].
Saudi Arabia's healthcare expenditure was approximately US$35.4 billion in 2014 and increased to US$46.66 billion in 2020 [38]. The country aims to attain a balanced budget by 2020. To stabilize its economy in this direction, the government withdrew welfare bene ts and subsidies from different sectors, while also warning its people about more radical changes in the o ng, including reduction in government spending and plans to stimulate increased e ciency, scal discipline, and non-oil revenues [17,26,39,40]. The budget de cits of GDP amounted to 2% in 2014, 15% in 2015, 17.3% in 2016 and 6.4% in 2020 [38]. Saudi Arabia experienced 22 budget de cit years in the range of 2-25% between 1998 and 2017. In the same time period, there were 13 scal years with budget surpluses between 1% and 32% [40]. Besides, the government introduced a value added tax to tackle the scal de cit [41]. The political instability in the region also adversely affected Saudi Arabia's nancial stability. The current war with Yemen and proxy war threat from Iran pursue Saudi Arabia's government to invest in war equipment and ammunition for protection. The defence budget of the government is SAR242 billion compare to SAR174 billion for health and social development in 2020 [38]. Unable to maintain sustainable budgets and tackle economic uncertainties, the government shifted a part of the burden of managing the country's health system on to the consumers [16]. Policy that was subsequently made favoured the shifting burden to the market from the state.
The ability and desire of Saudi nationals to pay for healthcare are contributing factors in the development of the private sector in healthcare [42]. Statistics available currently show that total government expenditures increased from US$1.6 billion in 1970 to US$158.9 billion in 2010 and US$287 billion in 2020 to meet the demands of a growing population and their rising standards of living [36,38]. People are increasingly dependent on the private sector for their healthcare needs due to demands driven by accessibility and essential parameters such as better life expectancy, population growth and patients' need for treatment [18]. Private hospitals are equipped with necessary instruments, and have medical and administrative personnel who facilitate quality and timely healthcare. Moreover, patients nd it easier to book an appointment for a time of their convenience at a private clinic or hopsital [43]. A study revealed that 52.2% citizens of the country preferred paying a mandatory health insurance fee on a monthly basis, while 62% citizens felt health insurance will help reduce the current load on the public sector [44]. As much as 75% of the patients use private healthcare [45], contributing to reduce burden on the state.

Social Factors
Saudi Arabia has a population of more than 34.4 million. The country's life expectancy is expected to increase to 75.2 in 2020 [46]. That portion of the population aged between 40 and 59 years is expected to increase 1.5 times and over the age of 60 is forecast to increase more than 3 times. With 44% of its population over the age of 40 and 14% over the age of 60 in 2035, there will be huge demand for healthcare to deal with lifestyle and NCDs [24]. With NCDs expected to account for 73% of all deaths by 2025 [47], WHO has indicated that this trend will trigger a renewed demand for specialized medical and surgical care in the country [48] which will possible meet by the non-state resources.
Beyond existing human resources, the government needs additional 13,700 doctors by 2030 [49]. To meet the needs of its growing population, the country will need 5,000 more beds by 2020 and 20,000 beds by 2035. As of 2016, Saudi Arabia faced a shortfall of 14,000 beds in 2016 based on the global average for bed density. This gure is expected to rise to 40,000 by 2035 [24]. On the other hand, the government will face di culty in providing access to e cient and quality healthcare for all residents even if it is successful in nancing healthcare through privatization and public private partnerships [50]. It is suggested that the government should accelerate the shift from its current government-led economic model to a more market-based approach [51] which will be lled by private sector.
Saudi Arabia has one of the highest prevalence rates for non-communicable diseases (NCDs). With increased awareness about public healthcare services, consumers are now demanding better effectiveness, improved quality of services, advanced hospital management systems, enhanced organizational factors, provision of adequate levels of evidence-based medicine, and expansion of professional development strategies for secondary care [32]. The public sector is currently confronting the twin challenges of high prevalence of NCDs and renewed public demand for better care. This lead to demand of care moved to market forces where private sector currently caters to health needs brought about by lifestyle diseases [52].

Discussion
The socio-political and economic-administrative factors shape the health system of a country [53]. In Saudi Arabia, the government has been in uencing various ways and means to shift the burden to market forces, due to prioritisation of effectiveness, e ciency, and rationality of choice [16]. Moreover, successive budget de cit, uctuation and turmoil of oil prices, corona pandemic together with looming economic uncertainties, the government focused on shifting some of the burden to the consumers. This contributes to inequity, limited access, and disparity in overall distribution of healthcare services [16]. If the market plays a dominant role, it establishes state-of-art technologies and equipment and the consumer will bear the burden of increased cost of healthcare and public healthcare will be left over to the state to provide services. Currently, public sector healthcare pronounces that it will engage with only policy planning, regulation and provide only public health aspect of healthcare services [27] which means the state wants most of the burden on the market. This shift of healthcare does not provide positive bene ts to consumers [54,55].
Increased use of private healthcare facilities is linked to consumer dissatisfaction, various constraints and poor management practice with the public sector [18,56,57]. A study in Taif found that 77% of patients who sought treatment at private healthcare facilities were satis ed with the level of care, whereas it was only 59% in the public sector [58]. The private sector in Saudi Arabia has been engaged in a range of activities related to direct provision of healthcare services, administration and management of healthcare facilities, manufacturing of healthcare products and nancing of the healthcare systems [59]. These are carried out by various non-state actors; including national and multinational companies, nongovernmental organizations, non-pro t entities and private individuals working as a general practitioners and consultants in the provision of healthcare services [18]. There seems to be an increasing reliance on private actors to provide nance, and supply of healthcare goods and services. The private sector is preferred due to management ine ciency of the public sector [60], consumer dissatisfaction with public sector services [61], organizational behaviour of private sector [62], improved performance in terms of access [63], better drug supply and responsiveness [64], greater patient satisfaction or competence [65] as well as user friendliness [64].
However, complaints are several about the many inadequacies of the private sector; including poor infrastructure without registration [66], poor quality of equipment [67,68], lack of quali ed personnel [68], poor service conditions [66], higher treatment costs [69], wrong diagnosis of diseases, commission-based services, over-servicing, excessive prescription of drugs and tests [70], overuse of technology [71], feesplitting, pro t motivation, negligence in patient care, poor quality and standards [54,65], lack of business ethics, dearth of accountability [72] and overall de ciency in the expected service quality [55,73]. In global context, evidence on the relative effectiveness, e ciency and overall advantages of private sector healthcare has been largely inconclusive with no study bringing in clear ndings in support of or against increased private sector participation [42,55]. Therefore, there is no consistent manner in which one can measure the value of the private sector's contribution to the provision of healthcare [42,74]. Overall, studies have found that the Saudi healthcare system is suffering from issues rising due to long waiting periods, shortage of required human resources, medical errors, poor communication between physician and patent, and deteriorating services [75,76]. A study revealed that in 2009, there were 1,510 cases reported medical errors which increased to 2,002 in 2012. Most cases, i.e. 163 out of 356 cases, were in the public sector [77]. A survey of both public and private hospitals indicates that about 70% of hospitals do not have medication safety committees and 90% of studied hospitals do not have medication safety o cers [78]. Medical errors are common in both public and private hospitals [79]. It is found that multiple factors impede the quality of care being provided by health professionals [80]. Cooperative Health Council announced a decree to overcome problems with quality and medical error in the provision of healthcare services [81] Conclusion Driven by several social and economic factors, the Saudi Arabian government has taken persistent efforts to develop its private healthcare system. These factors include economic reforms, public-private partnerships, the rising middle class and its demand for better health, challenges faced by the public sector as well as macroeconomic stability and liberalization. Though successive regimes continued to implement policy that boosted private sector growth, several inadequacies have been identi ed within the private sector healthcare. Besides failing to bring about equity, cost-effectiveness and accountability in its provision of services, the private healthcare sector has also seen more frequent violations of medical standards of practice and poorer patient outcome [42]. The public sector has an important role to play in nancing and delivering universal health coverage. The government should, therefore, bring about reforms in administration, management, governance and stewardship such that quality healthcare can be provided to all. Growth of the private health sector is not the panacea for sub-optimal healthcare services in Saudi Arabia. On the other hand, it contributes to increased costs, widened inequity and overall consumer dissatisfaction. It is pertinent that the government intervenes in a timely manner to mitigate the detrimental effects of this growth. However, inadequacies within the public sector in terms of delivery of quality services, patient safety and clinical effectiveness can be mitigated only by actions stemming from strong political will [59,82,83].

POLICY RECOMMENDATIONS
Thanks to limited partnerships, insu cient structures and processes, lacking political commitment and inadequate resources, the improvement of healthcare quality, performance management and accreditation have not yet been fully institutionalized in Saudi Arabia [84]. The government should try to tackle new challenges in socio-political, economic, nancial and cultural elds to build a better and e cient healthcare system that protects the values of equity and fairness in the dispensation of services. The leadership may face problems in different sectors of the economy, but MOH must continue playing its role in the health sector's development in coordination with other government ministries; agencies and stakeholders; including academia, professional associations, the private sector and civil society organizations. In socio-economic development context, healthcare must be placed at the centre of all development though the private sector assumes a greater role in nancing and delivering healthcare services [85]. However, care should be taken to ensure that such development initiatives are implemented under strong leadership and good governance [2]. The government should emphasise qualitative improvement of the system to improve equity, access and to minimise disparity through structural and nancial reforms of the system. Studies suggested that commercialization of healthcare failed to improve the performance of the healthcare system. Moreover, the preference of private sector over the public sector healthcare may not be the answer for the growing di culties confronting public sector healthcare services [55].

Declarations
Con ict of interest: The authors declare no con ict of interest Scoping literature review to determine appropriate articles for review