Health care and nursing in Saudi Arabia - Wiley Online Library

Short Communication

Health care and nursing in Saudi Arabia A. Aldossary1 BSN, MSc, Dip HSM, A. While2 & L. Barriball3 BSc, PhD, RGN

BSc, MSc, PhD, RGN, RHV, CertEd

1 Lecturer in Nursing, Prince Sultan Military College of Health Sciences, Dammam, Kingdom of Saudi Arabia, currently Doctoral Student at King’s College London, 2 Professor of Community Nursing, King’s College London and Associate Dean (External Affairs), Florence Nightingale School of Nursing and Midwifery, London, 3 Senior Lecturer, King’s College London, Florence Nightingale School of Nursing and Midwifery, London, UK

ALDOSSARY A., WHILE A. & BARRIBALL L. (2008) Health care and nursing in Saudi Arabia. International Nursing Review 55, 125–128 Aim: This paper reviews healthcare provision in Saudi Arabia and the development of nursing together with its current challenges. Background: Health care in Saudi Arabia is developing fast with multiple governmental and independent service providers. Economic growth has impacted upon health needs through population and health behaviour change. The development of the indigenous nursing workforce has been slow resulting in much nursing care being delivered by migrant nurses. Conclusion: There is a need to increase the proportion of indigenous nurses so that culturally appropriate holistic care can be delivered. Without shared culture and language, it will be difficult to deliver effective health education within nursing care to Saudis. Keywords: Healthcare, Nurse Migration, Nursing, Saudi Arabia

Health and health care in Saudi Arabia The Kingdom of Saudi Arabia is one of the largest countries in the Middle East at 2.24 million km2 [World Health Organization – Eastern Mediterranean Region (WHO-EMRO) 2004] and has one of the largest oil reserves in the world. Oil wealth has precipitated a rapid socio-economic transition over the past years causing a marked impact on health and lifestyle. Latest population figures show that Saudi Arabia has reached a population of 24 573 000 with 10 690 being under the age of 18 years. The annual population growth rate is 2.7% and the total fertility rate is 3.8. Because of advancements in both health care and social

Correspondence address: Alison While, King’s College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, Waterloo Road, London SE1 8WA, UK; Tel: 44-020-78483022; Fax: 44-020-78483506; E-mail: [email protected].

© 2008 The Authors. Journal compilation © 2008 International Council of Nurses

services, life expectancy has increased from 52 years in 1970 to 72 in 2005 and because of the compulsory vaccination that took place in the 1980s, the under 5 years of age mortality rate has dropped dramatically from 250 per 1000 live births in 1960 to 26 per 1000 in 2005. All the urban population in Saudi Arabia has access to good sanitation and 97% have access to clean water (UNICEF 2005). The Saudi Arabian government has committed enormous resources to improving health care, with the ultimate goal of providing free and accessible healthcare services for every Saudi national and expatriate working within the public sector. While expatriate workers within the private sector are sponsored by their employers, healthcare financing in Saudi Arabia is provided primarily from the government budget, which is largely based on oil and gas revenues (Al-Yousuf et al. 2002). The total expenditure on health is 3.8% of GDP with 77.1% from government and 22.9% from private expenditure (World Health Organization 2005).

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Hospitals and primary healthcare centres in Saudi Arabia are operated by governmental agencies and private organizations. The Ministry of Health, as the major governmental agency, bears the primary responsibility for the Kingdom’s health care with the provision of preventive, curative and rehabilitative services. The Ministry of Health provides primary health care through a network of primary healthcare centres throughout the Kingdom and with a referral system to acute and advanced health care through a broad base of general and specialist hospitals. The Ministry of Health is the lead government agency, which is also responsible for strategic planning, formulating health policies, supervising and monitoring all health-related programmes and activities within the Kingdom.While the Ministry of Health is the main source of national health services provided by the government, other governmental agencies such as the Ministry of Defence and Aviation, the Ministry of Interior, the Saudi Arabian National Guard and the University Teaching Hospitals also deliver health care directly to their employees and a segment of the general population. Health care in the private sector has significantly increased in the Kingdom and is coordinated within the referral network that includes hospitals, clinics, dispensaries and pharmacies (Al-Yousuf et al. 2002; United Nations 2007). Thus, while the Ministry of Health provides 60% of the healthcare services, the other governmental agencies and the private sector together provide the remaining 40% (Abu-Zinadah 2006). Physical and human resources for health care in Saudi Arabia have increased corresponding to the population growth rate. Latest figures show that physical resources include 331 hospitals, 47 018 beds and 2838 primary healthcare centres (Abu-Zinadah 2006), which are staffed by 19.0 physician, 2.10 dentists, 3.40 pharmacists and 35.0 nursing and midwifery personnel per 10 000 of the population (WHO-EMRO 2004). Economic growth, modernization and globalization in Saudi Arabia have a significant impact upon Saudis’ health-related behaviours. For instance, because of the increasing availability of food (meat by 313%, and oil and fat by 200%), the per capital consumption has increased from 1807 to 3128 k between 1974 and 1995 (Madani et al. 2000) which is in excess of dietary recommendations. A study has shown the per capita requirements of energy and protein at the national level (Saudi Arabia) to be 2100 k and 53 g of protein per day (Khan & Al-Kanhal 1998). In addition, the consumption of soft drinks and the expenditure on dining out has also increased (Euromonitor 2007). Compounding this situation, some studies have shown that the total rate of inactivity among Saudi nationals in different age groups and gender ranged from 43.3% to 99.5% (Al-Hazzaa 2004). Unsurprisingly, overweight and obesity has not only increased among Saudi adults but also among children (Abalkhail 2002). Consequently, Type 2 diabetes, hypertension and hypercholesterolemia


have increased dramatically in recent years (Al-Nuaim et al. 1996; El-Hazmi & Warsy 2000; Osman & Al-Nozha 2000; Warsy & El-Hazmi 1999). Overeating and inactivity are not the only negative heathrelated behaviours that are increasing in Saudi Arabia. Cigarette smoking is widespread and increasing, despite the fact that Saudi Arabia does not grow tobacco or manufacture cigarettes. While there has been no national study explaining the prevalence of smoking in Saudi Arabia, some small-scale studies and a WHO survey have indicated a prevalence rate of between 8% and 57% (Jarallah et al. 1999; WHO-EMRO 2003). Smoking is one of the serious risk factors for chronic obstructive lung disease and coronary artery disease in Saudi Arabia (Al-Nozha et al. 2004; Dossing et al. 1994).

Religious and cultural context in Saudi Arabia The socio-economic development in Saudi Arabia has taken place within the framework of Islamic religious beliefs (Littlewood & Yousuf 2000). The Holy Quran (the Islam holy book) and Sunna (prophetic tradition as interpreted by Prophet Mohammed – peace be upon him – PBUUH) are the leading code for the Islamic religion. Saudi nationals do not practise any religion other than Islam. Therefore, Islam is the main aspect that shapes the Saudi culture. However, economic status, level of education and environmental factors are also responsible for shaping the culture (Al-Shahri 2002). Islamic practice is connected to spirit, behaviour, food, language and social traditions. Muslims believe that health, illness and death all come from Allah (the Arabic name of God) (Rassool 2000). Thus, they do not perceive illness as a form of punishment but rather as a way of atonement for one’s sins (Al-Shahri 2002). This kind of belief may pose some problems for healthcare providers if individuals do not adopt an active role in promoting their own health. However, Muslims are encouraged to seek care and treatment during illness. Generally, Islam promotes health through encouraging, for example, moderate eating, regular exercise, no alcohol, tobacco or substance misuse, personal hygiene and breastfeeding (Rassool 2000).

Nursing in Saudi Arabia History

There is a long history of nursing in Saudi Arabia, which began in the time of Prophet Mohammed, PBUH, under the guidance of Rufaida Al-Asalmiya in the service of the Muslim armies during the holy wars (Miller-Rosser et al. 2006; Tumulty 2001). Rufaida and a group of Muslim women participated in the holy wars to provide first aid and drinking water, and to protect the wounded and dying of the armies from desert wind and heat, in addition to

Health care and nursing

emotional support (January 1996). With the permission of Prophet Mohammed, PBUH, Rufaida erected a tent in a mosque to continue providing nursing care in peace time in order to train women as nurses and to deliver health education and social support in the community. Rufaida learned and developed her nursing skills from her father who was a prominent healer and she nursed both male and female patients (January 1996). Thus, Rufaida Al-Asalmiya has been acknowledged as the first nurse and the founder of nursing in the Islamic era. After Rufaida’s death many Muslim women carried on her role by nursing people during wars and peace time (January 1996, Miller-Rosser et al. 2006). Nursing education

The Ministry of Health in collaboration with WHO initiated the first Health Institute Programme in 1958 in Riyadh, the capital city. Fifteen Saudi male students enrolled, all had elementary school preparation comprising 6 years of schooling and were admitted to a 1-year programme. Subsequently, another two Health Institute Programmes, one in Riyadh and one in Jeddah, the largest seaport and commercial centre, opened to enrol Saudi women (Tumulty 2001). Men and women who graduated from these Health Institutes were appointed as nurses’ aides (Miller-Rosser et al. 2006). As nursing education developed, the Ministry of Health extended the 1-year programme to 3 years and opened more institutes, which recruited students with secondary school preparation, that is, 9 years of schooling (Miller-Rosser et al. 2006). By 1990, there were a total of 17 Health Institutes for females and 16 for males offering nurse education. The total number of female graduates has increased from 13 graduates in 1965 to 476 in 1990; the total number of male graduates increased to 915 in 1990 (El-Sanabary 1993). In 1992 Junior Colleges were established to upgrade the training level of Saudi nurses and to train high school prepared students, that is, 12 years of schooling (Abu-Zinadah 2006). Thus, the Ministry of Health operates two levels of nursing education through the Health Institutes and Junior Colleges. However, nurses from both levels obtain a Diploma in Nursing as a qualification and are classified as technical nurses (SCFHS 2007 – Classification Academic Certification). In parallel, the Ministry of Higher Education initiated the first Bachelor of Science in Nursing (BSN) programme in 1976 and introduced a Master of Science in Nursing in 1987 at King Saud University in Riyadh. Later, BSN programmes were initiated at King Abdulaziz University in Jeddah in 1977 and at King Faisal University in Dammam, the largest city in the Eastern Province in 1987 (Tumulty 2001). Nurses who obtain a BSN are classified as professional nurses, while nurses obtaining a Master of Science


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in Nursing are classified as specialists (SCFHS 2007 – Classification Academic Certification). In addition, a PhD scholarship programme was established in 1996 to enable Saudi nurse leaders and educators to study abroad. There is also an in-country scholarship programme. For instance, Monash University in Australia, in collaboration with King Faisal Specialist Hospital and Research Centre offer in-country higher degree programmes for Saudi nurses who are unable to study abroad (Abu-Zinadah 2006; Miller-Rosser et al. 2006). Recently, some governmental agencies in collaboration with national universities have begun to deliver their own nursing education programmes to train high school prepared students. For instance, the Medical Services Division of the Ministry of Defence and Aviation runs a nursing education programme that graduates students with a diploma in nursing (Abededdin 2007 – Riyadh Military Hospital) while the private sector runs programmes at the both levels, diploma and BSN (Abu-Zinadah 2006). As a result, the latest figures show that 67% of the Saudi nurses graduated from Health Institutes, 30% from Junior Colleges and 3% from BSN programmes, while there are also 28 graduates with a master’s degree and 7 with a doctorate (Abu-Zinadah 2006). Nursing workforce

Despite the majority of patients and their families being Saudi nationals with Arabic as their first language, most healthcare providers including nurses communicate in English. Many nurses do not speak English as their first language and neither are they competent in Arabic (Simpson et al. 2006). The nursing workforce in Saudi Arabia relies primarily on expatriates who are recruited from different countries (Aboul-Enein 2002; Luna 1998; Tumulty 2001). For instance, the majority of expatriate nurses working in Ministry of Health facilities are Indian and Filipino (Tumulty 2001). In addition, expatriate nurses are also recruited from North America, United Kingdom, Australia, South Africa, Malaysia and the Middle East countries (AboulEnein 2002; Luna 1998). The latest figures show that the number of Saudi nurses has increased from 9% in 1996 to 22% of the total nursing workforce. However, despite increasing interest in enrolment in different nursing education programmes, it has been estimated that 25 years will be needed to train enough Saudi nurses so that they comprise of 30% of the Kingdom’s nursing workforce requirements (Abu-Zinadah 2006).

Discussion The healthcare system in Saudi Arabia is developing rapidly in response to changing healthcare needs in the population arising from the adoption of increasing affluent lifestyles. Of particular

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note is the threat arising from obesity and its associated diseases such as Type 2 diabetes and cardiovascular diseases. The pattern of service delivery is complex with a variety of funders underpinning the different care delivery organizations. This may present challenges regarding effective cross-boundary working and the development of expertise across the nursing workforce. These challenges need to be seen within the context of a largely migrant nursing workforce.

Conclusion The challenges for Saudi Arabia are increasing its proportion of indigenous nurses who will be able to deliver culturally appropriate high quality care and to share the Arabic language of their patients. Without this, it may prove difficult to deliver effective health education within nursing work.

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