Saudi Arabia’s King Abdullah bin Abdulaziz al-Saud announced a series of spending initiatives in early 2011 intended to please the general public at a time when protests were spreading across the Middle East. Healthcare projects were at the centre of those initiatives, along with investment in low-cost housing and an increase in the minimum wage. The king detailed plans to spend SR16bn ($4.3bn) on five medical cities to be built across the country.

The programmes and services that are being provided are linked to the needs of the community

Jarvis Hoult, King Fahad Specialist Hospital

The new cities are expected to ensure that the entire country has adequate tertiary care facilities and that residents of rural areas will no longer have to travel to Riyadh for specialist care, such as cancer treatment or cardiac services. The health sector was also a priority area for investment in the 2012 state budget, receiving 13 per cent of the total allocation, or SR86.5bn. New projects announced in the budget include 17 hospitals and additional primary care centres. At present, more than 130 hospitals are under construction, with a combined capacity of 28,470 beds. In 2011, 22 hospitals were completed, adding 3,200 beds.

Community services in Saudi Arabia

“The Ministry of Health has recognised that there is a big gap between urban and rural healthcare services,” says Jarvis Hoult, consultant to the chief executive officer of King Fahad Specialist Hospital (KFSH) in Dammam. KFSH is playing a key role in the creation of the new medical cities, having been given responsibility for planning, designing and constructing the 1,500-bed King Khalid Medical City (KKMC) facility.

[Salaries] are even higher in other markets and competition for nurses is becoming increasingly intense

“What tends to happen is those living in a rural area will make their way to an urban area hospital, which is generally the wrong hospital to address their medical problem,” says Hoult, who is also project executive director for the KKMC scheme. “So there are more community hospitals being built and existing ones are being upgraded, with the objective of providing the right care in the community where the patient lives.”

The KKMC project management office has appointed the US’ Aecom to carry out the design work and US consultant Bamir to undertake project and construction management services. Local firm Arensco is carrying out studies such as traffic surveys, topographic analysis and ground investigation.

“We are the designated owner and operator and we have established a dedicated project management office here to oversee the design and construction,” says Hoult, who has experience of both running healthcare facilities in the kingdom and overseeing hospital construction. KKMC is his biggest project to date.

Detailed design is scheduled to begin in April, with site preparation commencing in July 2013. Construction contracts will not be awarded until 2013 at the earliest, with main construction due to begin in July 2014. The work is expected to take three years, followed by a nine-month commissioning period. The budget for the scheme, as allocated by the Ministry of Health, is SR 4.65bn.

Clinical needs of Saudis

Once the new facility opens in late 2017, the existing KFSH is expected to revert back to its original purpose, as a community hospital for Dammam, leaving KKMC, located just 20 minutes away, to provide the tertiary and quaternary services that it is being designed for. Clinical focus includes cardiology, oncology, transplant, neurosciences, genetic and metabolic diseases and ophthalmology.

“The way the Ministry of Health has developed these cities is that the clinical programmes are being allocated based on the demographic and clinical needs of the people in the region,” says Hoult. “So we are not building five medical cities with a full range of anything and everything. The programmes and services that are being provided are linked to the needs of the community, while at the same time strategically assigning the very expensive services that you can’t afford to duplicate in multiple locations.”

For those conditions for which demand for treatment is growing nationwide, such as heart disease and cancer, each of the medical cities will be able to provide care, but only certain cities will be equipped to handle more expensive, specialist treatment, such as neurosciences or organ transplants.

“Not all the provinces and regions have the same types of populations and there are significant differences in needs based on demographics and disease morbidity from one province to the next,” says Moalt. “One size does not fit all. We did a feasibility study to make sure that the programmes and services at KKMC reflect the community’s needs.”

High-quality healthcare

Feasibility studies are now under way for the other cities. Expansion of the existing King Fahd Medical City in Riyadh is expected to see the centre specialise in tumours, neurology and research. In Mecca in the west, the new 1,350-bed King Abdullah Medical City is expected to provide quaternary services, such as transplants, cancer care, maternity services, ophthalmology and rehabilitation. In the south, the new 1,000-bed King Faisal Medical City will also provide ophthalmology, cancer treatment and rehabilitation services, as will the new 500-bed northern medical city in Al-Jouf.

The cities are expected to open around 2017 and will go a long way towards improving rural healthcare for the local population, where both the public and private sector have failed to meet demand. Even wealthy citizens have struggled to find high-quality private care outside the major cities as private providers have been reluctant to set up facilities in areas with low population densities.

Although the private sector is growing, boosted by the introduction of compulsory expatriate insurance in 2005, there remains a lack of private hospitals outside Riyadh and Jeddah.

According to figures from the Cooperative Council for Health Insurance, of the 2,177 public and private healthcare facilities authorised to treat insured patients at the end of 2010, 1,691 were in Riyadh, Mecca or the Eastern Province. There were just 17 in the Northern Province and 22 in Al-Jouf. New facilities are desperately required.

Recruiting staff in the medical sector

Building new facilities is one challenge; staffing them is another. The next task is to ensure that the new hospitals, medical cities and health centres have the right personnel in place. This challenge is all the more difficult because the government has increased its Saudisation efforts and is seeking to employ local staff wherever possible. For the health sector, this is especially complex due to cultural issues, such as physical contact between different sexes remaining forbidden. In addition to this, societal influences mean that many nationals will only seek highly paid physician roles or technical specialisms. Despite the major investment being directed towards education, it is clear that Saudi Arabia will remain reliant on foreign healthcare staff for some time to come.

This is especially true if it is to meet strategic targets to double the number of nurses and physicians between 2009 and 2014, bringing total nurses to 131,051, and physicians to 66,135. This will not be easy with global demand for healthcare professionals rising fast.

Placing professionals

Specialist healthcare recruitment company Helen Ziegler & Associates has been supplying staff to Saudi hospitals for more than 30 years. The company works with the kingdom’s leading institutions, including the KFSH in Riyadh, the KFSH in Jeddah, the Aramco Hospital in Dhahran and the Dr Soliman Fakeeh private hospital in Jeddah.

“We are still recruiting a lot, partly because we have been doing it for such a long time. But it is getting trickier,” says Ziegler, who lived in the kingdom in the early 1980s and estimates that the company has placed 8,000 healthcare professionals over the past 30 years.

One challenge is that although Saudi hospitals still need to recruit expatriate staff, the compensation they are paying is not keeping up with salaries in Canada, the US or Australia. But, contrary to perception, Ziegler believes salaries offered in Saudi Arabia are competitive for Western-trained nurses. While the Saudi salary can be lower, with Western critical care nurses working in the kingdom typically receiving about $60,000, compared with $60,000-90,000 in North America and Canada, other benefits need to be factored in. “[The salary] is tax free, with 7.5 weeks’ vacation, accommodation and everything paid for,” she says. “If you make $60,000-70,000 in Toronto, you save nothing. In Saudi Arabia, you can travel and do lots of things and still save $45,000-50,000.”

Western staff only make up a small percentage of the market. Employees from the Philippines, Malaysia and India are much more prevalent. According to the Philippines Overseas Employment Administration, the country supplied 8,513 nurses to the kingdom in 2010, adding to the 9,623 supplied in 2009. This makes Saudi Arabia its biggest market for nursing staff. Tax-free salaries for Philippine nurses in the kingdom are about $10,000 a year. This is considerably more than the local salary and includes accommodation and medical care, leaving nurses able to remit large portions of their income back home.

“Based on the Nursing Act of 2002, the entry level salary for a newly qualified nurse [in the Philippines] is $6,717.98 annually,” says Michael Duque, president of the Philippine Nurses Association UK branch.

Salary levels in Saudi Arabia

Although the salaries are better in Saudi Arabia, they are even higher in other markets and competition for nursing staff is becoming increasingly intense.

“Our salary rates are a lot higher than they were three to four years ago,” says Hoult, who recognises that staffing KKMC will be a challenge. “We have learned that we need to compete on both a national and international level.”

The project management team has already drawn up a manpower model to identify staff numbers and the disciplines required for the new facility. “The majority of our new employees are going to be Saudis [nationals] so we have to start thinking about training and education to ensure we have the right people in the right services when we open the doors. We are looking and training now,” he says.

Such forward planning is exactly what the kingdom needs to meet its ambitious objectives and close the quality-of-care gap between rural and urban services.

The good news is that progress is accelerating and investment is forthcoming. By 2017, the Eastern Province will have a range of new tertiary and quaternary services and other regions are set to follow.