THE UNIVERSITY OF HULL The Influence of Economic, Political and Socio-cultural Factors on the Development of Health Services in Saudi Arabia being a Thesis submitted for the degree of Doctor of Philosophy in the University of Hull by Abdrabalamir Abbas Alshammasi BSc (Pharmacy) Hons. (Leicester) MSc (Health Administration) July 1986 Summary of Thesis submitted for Ph.D. degree By Abdrabalamir Alshammasi on The Influence of Economic, Political and Socio-cultural Factors on the Development of Health Services in Saudi Arabia In this thesis I examine the influence of economic, political and socio-cultural factors on the development of health services in Saudi Arabia. There are four main parts and a conclusion. In Part One I review the situation in developing countries. Many commentators have argued that economic factors, and to some extent political factors, are the main determinant of health services development in developing countries. Socio-cultural factors are generally neglected in these analysis. In this thesis I redress the balance by examining the relationship between economic, political and socio-cultural factors in the development of the Saudi health care system. In Part Two I analyse the Saudi resource situation. Although the health service is not considered a priority in the overall Saudi development strategy, the government provides generous financial resources for its development. However, non-financial resources remain a problem. Relatively abundant financial resources can provide a short-term solution to some of the resource shortages, such as the lack of skilled manpower, but the use of expatriate 1 health personnel may have unanticipated negative consequences. In Part Three I examine the resource allocation process. The Saudi political system contains a mixture of modern and traditional elements, and the decision making process is affected by traditional social relationships. The King and public bureaucrats play a key role in the allocation process, but local leaders and Governors have wide scope to influence their decisions. While health provision is not a political issue in the country, it contributes to the social cohesion between the government and the general public. In Part Four I examine the influence of socio-cultural factors on the development of the Saudi health service. In the Saudi society socio-cultural factors affect the behaviour of individuals in their interaction with the health system. For example, the annual pilgrimage to Mecca by millions of moslems from all over the world presents a formidable challenge to health authorities. Health authorities accept the importance of socio-cultural factors, and respond by compromising policies. In the conslusion I consider the policy and theoretical implications of the study. In particular I examine the need for the formal recongnition and incorporation of socio-cultural factors into health policy decision making. This would lead to the generation of 1 alternative policy options which complement other options based on economic and political considerations. The socio-cultural oriented approach can contribute significantly to the improvement of the long term prospect for health services in Saudi Arabia, and developing countries generally. i ACKNOWLEDGEMENT I am particularly grateful to Dr Andy Alaszewski, my supervisor, for his guidance, helpful criticisms and constructive comments. I would like to acknowledge the ready co-operation of those health and public officials in Saudi Arabia who devoted time and effort to respond to my requests for information and interviews. I especially want to thank those officials from the Ministry of Health with whom I worked during my fieldwork. I also wish to thank Val Hurst for her advice on the use of the word processor, and especially her assistance in the final editing of the thesis. ii Contents page Acknowledgement i Contents ii Preface iii List of tables and figures vii Part One Background to the Study 1 Chapter 1 Health Services in Developing Countries: Defining the Problem 3 Chapter 2 Saudi Arabia 51 Chapter 3 Methodology 67 Part Two Economic Influences 96 Chapter 4 Saudi Health Resources 99 Chapter 5 Hospital Development in Saudi Arabia 165 Part Three Political Influences 216 Chapter 6 The Allocation of Health Resources 219 Chapter 7 The Ministry of Health 252 Part Four Socio-cultural Influences 290 Chapter 8 The Socio-cultural Environment of Health Provision in Saudi Arabia 293 Chapter 9 The Impact of Socio-cultural Factors upon Health Provision 335 Chapter 10 Health Services of Charitable Societies 382 Chapter 11 Conclusion 416 Appendices 436 Bibliography 463 I iii Preface The growing disillusionment with existing systems of health care in developing countries is generating demands for new policies to meet the health needs of the people. The provision of health services to poverty-striken communities, especially in rural and remote areas, presents a formidable challenge for health policy makers. The recognition of the influence of economic factors has resulted in the development of the primary health care approach in the late 1960s and the 1970s. Since the beginning of the 1980s there has been a gradual change in attitudes towards traditional medical practices and in some developing countries they are revived and incorporated into the formal systems of health care. These trends in the development of health services in developing countries reflect a gradually increasing change in the perception of health problems and their solution in developing countries. They emphasise a need to involve people in the provision of services which are to be provided in their local communities to make them accessible and acceptable to the people. This indicates an important shift towards a recognition of the influence of socio-cultural factors on health provision. In this thesis I examine the prospect for this development, and use the case of the Saudi health system to illustrate the emerging trend and argue for an explicit socio-cultural-oriented approach to health iv provision in developing countries. It is, however, too early to predict specific policy consequences from this approach, and more research is needed to identify areas of health provision where the socio-cultural oriented approach can contribute positively. There are four parts and a conclusion in this study. The first part consists of three chapters. In the first chapter I present the objectives of the study in the context of health services development in developing countries, and review the situation in terms of the influence of economic, political and socio-cultural factors on health services development. In the second chapter I give a brief introductory description of Saudi Arabia with emphasis on its similarities and differences with other developing countries, and their implications for health provision. In the third chapter I explain and justify my methodology. Part two deals with the issue of resources available for health services in Saudi Arabia, and the impact of different resources on the present and future direction of the Saudi health system. There are two chapters in this part; number four and five. In chapter four I consider the influence of economic factors on the development of the Saudi health system and compare it with other developing countries. The analysis is at the macro level, and is primarily concerned V with health development in the last two decades. In chapter five I concentrate on hospital development in the country. The features of the Saudi hospital policy are examined and their future implications are explored. Part three examines how Saudi health resources are allocated, and brings out the effects of political factors on the development of the Saudi health system. This part also contains two chapters; number six and seven. In chapter six I consider the relationship between politics and health provision at the national level. The political and health decision making processes are examined and their effects on health services development are assessed. In chapter seven I analyse the politics of health in the Ministry of Health. The relationship between the Ministry and other government agencies is described, and its effects on the functioning of the Ministry is analysed. Part four evaluates the process of health provision through the response of the patients and their pattern of utilization of health services, with emphasis on the role of socio-cultural factors on the behaviour of patients. There are three chapters in this part; number eight, nine and ten. In chapter eight I examine the impact of socio-cultural factors on health provision at the national level. In chapter nine I analyse the provision of primary health care vi services and health provision during the annual pilgrimage to Mecca. In chapter ten I investigate the growing contribution of charitable societies to health provision in the country, and assess their potential and prospect. In chapter eleven I consider the policy and theoretical implications of the study. I suggest some prescriptions for exploring an alternative path for the development of the Saudi health system in the future. I also consider the implications of the Saudi case to the wider issue of health services development in developing countries. Finally, there is one point relevant to my research that I want to mention. It complements my discussion of the methodology presented in chapter three. The official fiscal and calender years in use in Saudi Arabia are different from the Gregorian year. Almost all data available in the country, including government statistics, are based on the Hijra (lunar) calender. To avoid complications and preserve comparability I simplified the presentation by equating one Gregorian year to one Hijra year though one Gregorian year is actually one Hijra year and 11 days. The government fiscal year starts in the middle of the Hijra year, and I consistently used the end of the fiscal year rather than its beginning. For example, I refer to the fiscal year 1404/05 (1984/85) as simply 1405 (1985). vii List of Tables and Figures Page Figure 2.1 Saudi Arabia 53 Table 2.1 Members of Al-Saud royal family who ruled Saudi Arabia since 1932.