HEALTH SITUATION The population of the country has incr.docx

HEALTH SITUATION
The population of the country has increased by 45.8% in the
past 25 years, reaching 29.9 million in
2015. It is estimated that 17.5% of the population lives in rural
settings (2012), 17.2% of the
population is between the ages of 15 and 24 years (2015) and
life expectancy at birth is 76 years
(2012). The literacy rate for youth (15 to 24 years) is 99.2%, for
total adults 94.4% (2013), and for
adult females 91.4% (2012).
The burden of disease (2012) attributable to communicable
diseases is 12.6%, noncommunicable
diseases 78.0% and injuries 9.4%. The share of out-of-pocket
expenditure was 19.8% in 2013 and
the health workforce density is 26.5 physicians and 53.73 nu
rses and midwives per 10 000
population (2014).
HEALTH POLICIES AND SYSTEMS
The National Transformation Program 2020 identifies
interventions for health system
strengthening, health promotion and control of
noncommunicable diseases, control of
communicable diseases, health security, and improving
partnerships for health development. In

addition, the National Transformation Program 2020 aims to
improve the planning, production
and management of the health workforce. It has also prioritized
the growing private sector with a
focus on better regulation and public–private sector
partnerships. Promoting health in all policies
and greater intersectoral collaboration at national and
subnational levels have been identified as
national priorities for the current planning cycle.
Decentralization needs strengthening and the
strategy has identified mechanisms for empowering the
subnational level. Capacity-building and
greater investments are other interventions outlined in the
National Transformation Program
2020. The strategy also includes the strengthening of the
monitoring and evaluation of national
health plans, using a user-friendly set of indicators. The health
system is largely funded through
the government budget, which is mainly financed by oil
revenues. However, due to the drop in oil
revenues, there is a risk that the decrease in national revenues
will adversely affect national
expenditure on health. Identifying alternative sources of
funding such as cost -sharing and
premium payments or implementation of health insurance is
therefore advised. In addition, the
private sector needs to introduce some sort of social insurance.
The Ministry of Health provides primary health care services
through a network of health care

centres, hospitals and primary health care facilities. The
network of health infrastructure has
improved the access of populations in remote areas to health
services and a referral system
provides curative care for all members of society from the level
of general practitioners and family
physicians at centres to advanced specialist curative services in
general and specialist hospitals.
New national policies and strategies for primary health care
have been developed that are patient
centred and focus on health promotion and protection, with an
emphasis on the social
determinants of health. The national agency for accreditation of
health care institutions oversees
mandatory accreditation of all hospitals and the improved
quality and safety of services; this is
being extended to primary health care centres. The demands on
human resources for health are
also immense, with qualified health personnel and others below
the standard needed for primary
and curative services, including a lack of extensive training
programmes for existing personnel.
There is a shortage of local health care professionals, such as
physicians, nurses and pharmacists,
with a high turnover rate, leading to instability in the health
workforce. The “Saudization” of the
human resources for health needs therefore requires further
commitment. There is also a lack of
consistency and quality of health care, with suboptimal
distribution of health care services and

health professionals across geographical areas.
The country is introducing a corporate approach to the health
sector by transferring the
responsibility for health care provision to a network of public
companies that compete both
against each other and against the private sector. The country’s
National Transformational Plan
2030 is promoting the following: a transition from pap er-based
to electronic recording systems;
revisiting the team composition at primary care level; scaling-
up the training and absorption of
family physicians; ensuring full integration of
noncommunicable diseases into primary care;
ensuring state of the art primary health care; introducing
competition and results-based financing
to incentivize the private sector; earmarking “sin taxes” for
health as an alternative to oil revenue;
rationalizing resource allocation between hospitals and primary
health care centres;
institutionalizing monitoring and evaluation; and implementing
total quality management tools.
The country has an independent regulatory authority for health
products and public health
qualified national staff. The government is committed to access
t o medicines and there is
availability of advanced technologies and facilities, as well as
the presence of a public medicine
information centre. In addition, there is a Gulf Cooperation
Council joint procurement system.

The Ministry has invested in an electronic-data capturing
system and has established a strong e-
health unit to ensure that facilities are linked and the
information flow is efficient and timely. The
Ministry collects cause-specific mortality from all sectors and
produces an annual statistical report.
However, the data only comes from the public sector’s tertiary
level.
COOPERATION FOR HEALTH
The Kingdom has provided WHO with humanitarian funds to
support its work in different
countries (US 48 Million in 2014 for Iraq, US15 million to
Yemen in 2015. US $ 10 million to
Somalia and US $ 2 million to Syria) and has expressed its
willingness to strengthen this
cooperation and contribution. The provision of US $ 2 million
in support of WHO’s work related to
MERS-CoV control activities has also been timely. It is worth
noting that Saudi Arabia reported to
the Financial tracking of OCHA 482 million USD in
humanitarian aid in 2015, 68.6% as response to
appeals with the highest % to food (WFA 30%) while health
received 12.7%.The United Nations
Country Team (UNCT) is represented by the following
agencies: UNDP, UNICEF, UNHCR, FAO and
WHO, as well as the World Bank/IFC. Non -resident Agencies
include ESCWA, UNESCO, ILO, UNEP,
UNIDO, UNFPA, OHCHR, OCHA, IAEA, UN Women, UN
HABITAT and UNIC. The UNCT members, the
Office of the UN Resident Coordinator and the Government, has

prepared this UN Common
Country Strategic Framework (CCSF) as a basis for increased
collaboration, coherence and
effectiveness of UN resident and non -resident agency activities
in the perio d 2012-2016.
Saudi Arabia
http:// www.who.int/countries/en/
WHO region
Eastern
Mediterranean
World Bank income group High-income
Child health
Infants exclusively breastfed for the first six months of life (%)
()
Diphtheria tetanus toxoid and pertussis (DTP3) immunization
coverage among 1-year-olds (%) (2015)
98
Demographic and socioeconomic statistics
Life expectancy at birth (years) (2015)
73.2 (Male)
74.5 (Both sexes)
76.0 (Female)

Population (in thousands) total (2015) 31540.4
% Population under 15 (2015) 28.6
% Population over 60 (2015) 5
Poverty headcount ratio at $1.25 a day (PPP) (% of
population) ()
Literacy rate among adults aged >= 15 years (%) (2007-2012)
87
Gender Inequality Index rank (2014) 56
Human Development Index rank (2014) 39
Health systems
Total expenditure on health as a percentage of gross
domestic product (2014)
4.68
Private expenditure on health as a percentage of total
expenditure on health (2014)
25.48
General government expenditure on health as a percentage of
total government expenditure (2014)
8.21
Physicians density (per 1000 population) (2012) 2.491

Nursing and midwifery personnel density (per 1000
population) (2012)
4.867
Mortality and global health estimates
Neonatal mortality rate (per 1000 live births) (2015) 7.9 [4.8-
10.9]
Under-five mortality rate (probability of dying by age 5 per
1000 live births) (2015)
14.5 [8.7-25.6]
Maternal mortality ratio (per 100 000 live births) ( 2015) 12 [
7 - 20]
Births attended by skilled health personnel (%) (2013) 98.0
Public health and environment
Population using improved drinking water sources (%) ( 2015)
97.0 (Total)
97.0 (Rural)
97.0 (Urban)
Population using improved sanitation facilities (%) ( 2015)
100.0 (Urban)
100.0 (Rural)
100.0 (Total)
Sources of data:
Global Health Observatory May 2016
http://apps.who.int/gho/data/node.cco

http://apps.who.int/gho/data/node.cco
WHO COUNTRY COOPERATION STRATEGIC AGENDA
(2017–2021) under development
Strategic Priorities Main Focus Areas for WHO Cooperation
STRATEGIC PRIORITY 1:
Health systems strengthening
d governance.
provision of quality health care.

rengthening data quality, surveillance and research.
and programmes; and document best practices.
Prevention and control of diseases
ies particularly in the areas of NCD
and RTI prevention as well as the evidence and
information need to manage better these programs and relevant,
effective interventions.
-sectoral and multi-stakeholder collaboration
to coordinate national prevention and control action
for health.
and mechanisms targeting decision makers for policy
change and targeting the public for social mobilization and
awareness raising.
vigilant surveillance to prevent and control
communicable diseases, such as MERS - CoV and during mass
gatherings.
Contribute to regional and global health
agendas
Somalia, Syria, and Yemen in addressing heath issues
including disease outbreaks and humanitarian crisis.

Pl eas e note that the 3
rd
generati on CCS 2014-2018 i s bei ng fi nal i ze
© W orld Health Organization 2017 - All rights reserved.
The Country Cooperation Strategy briefs are not a formal
publication of WHO and do not necessarily represent the
decisions or the stated policy of the Organization. The
presentation of maps
contained herein does not imply the expression of any opinion
whatsoever on the part of WHO concerning the legal status of
any country, territory, city or area or of its authorities, or
concerning the
delineation of its frontiers or boundaries.
WHO/CCU/17.01/Saudi Arabia
Updated May 2017
EMHJ • Vol. 17 No. 10 • 2011 Eastern Mediterranean
Health Journal
La Revue de Santé de la Méditerranée orientale
784
Review
Health care system in Saudi Arabia: an overview
M. Almalki,1,2 G. Fitzgerald 2 and M. Clark 2

ABSTRACT The government of Saudi Arabia has given high
priority to the development of health care services
at all levels: primary, secondary and tertiary. As a consequence,
the health of the Saudi population has greatly
improved in recent decades. However, a number of issues pose
challenges to the health care system, such a
shortage of Saudi health professionals, the health ministry’s
multiple roles, limited financial resources, changing
patterns of disease, high demand resulting from free services, an
absence of a national crisis management
policy, poor accessibility to some health care facilities, lack of
a national health information system, and the
underutilization of the potential of electronic health strategies.
This paper reviews the historical development
and current structure of the health care system in Saudi Arabia
with particular emphasis on the public health
sector and the opportunities and challenges confronting the
Saudi health care system.
1College of Health Sciences, University of Jazan, Jazan, Saudi
Arabia (Correspondence to M. Almalki: [email protected]).
2Faculty of Health, School of Public Health, Queensland
University of Technology, Brisbane, Australia.
Received: 28/12/08; accepted: 05/01/10
‫ض‬ ‫عرا‬ ‫ت‬ ‫س‬ ‫ا‬ :‫ة‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫ية‬ ‫عرب‬ ‫ال‬ ‫كة‬ ‫ل‬ ‫لم‬ ‫ام‬ ‫ف‬ ‫ي‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫ة‬ ‫اي‬‫رع‬ ‫ال‬ ‫ظام‬ ‫ن‬
‫رك‬ ‫ال‬ ‫ك‬ ‫يل‬ ‫ش‬ ‫ي‬ ‫م‬ ،‫د‬ ‫ال‬ ‫ري‬ ‫ج‬ ‫تز‬ ‫ي‬ ‫ف‬ ‫ي‬ ‫ري‬ ‫ج‬ ،‫ي‬‫ك‬ ‫الل‬ ‫ام‬ ‫ممد‬‫ح‬
‫ودمال‬ ‫الرعاية‬ ‫الصحية‬ ‫عيل‬ ‫مسي‬ ‫مستويال‬ :‫الرعاية‬ ،‫ارلولية‬ ،‫الاانوية‬
‫السعو‬ ‫تجل‬ ‫اجتاممها‬ ‫اواللصةلتسمية‬ ‫لر‬ ‫ي‬ ‫ر‬ ‫حكومة‬ ‫اململكة‬ ‫العربية‬ ‫دية‬:
‫مت‬ ‫را‬‫د‬‫عد‬ ‫جساك‬ ‫رص‬ ‫لا‬ .‫ارلنرية‬ ‫العلود‬ ‫يف‬ ‫السعوديسي‬ ‫نحة‬ ‫ككرية‬ ‫بدًجة‬ ‫نر‬
‫حتل‬ ‫لالل‬ ‫ة‬ ‫ر‬‫س‬‫نتي‬ .‫الاالاية‬ ‫الرعاية‬ ‫نظام‬ ‫رمام‬ ‫حتديال‬ ‫جي‬ ‫التي‬ ‫املشاكل‬
ً‫ا‬ ‫د‬ ‫ارل‬ ،‫ي‬‫س‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫ي‬‫س‬ ‫ي‬ ‫صح‬ ‫ال‬ ‫ي‬‫س‬ ‫ل‬ ‫عام‬ ‫ال‬ ‫لص‬ ‫ن‬ ‫ال‬ ‫م‬ ،‫ية‬ ‫صح‬ ‫ال‬
‫ا‬‫وز‬ ‫ل‬ ‫عددة‬ ‫ت‬ ‫ل‬ ‫ام‬ ‫ف‬ ‫ي‬ ‫غري‬ ‫ت‬ ‫ال‬ ،‫دة‬ ‫حد‬‫ل‬ ‫ام‬ ‫ية‬ ‫الل‬ ‫ام‬ ‫لواًد‬ ‫ام‬ ،‫صحة‬ ‫ال‬ ‫ًة‬

‫لب‬ ‫ط‬ ‫ال‬ ،‫مراض‬ ‫ارل‬ ‫امط‬ ‫رن‬
‫ية‬ ‫س‬ ‫ط‬ ‫سة‬ ‫يا‬ ‫س‬ ‫ود‬ ‫ج‬ ‫دم‬ ‫ع‬ ،‫ية‬ ‫لسان‬ ‫ام‬ ‫لدمال‬ ‫او‬ ‫ت‬ ‫ع‬ ‫ج‬ ‫ساج‬ ‫ال‬ ‫ف‬ ‫لرج‬ ‫ام‬
‫ق‬ ‫مراف‬ ‫عض‬ ‫ب‬ ‫ل‬ ‫لي‬ ‫نو‬ ‫و‬ ‫ال‬ ‫ل‬ ‫عي‬ ‫لدًة‬ ‫ال‬ ‫عف‬ ‫ض‬ ،‫زمال‬ ‫ارل‬ ‫داًة‬ ‫لل‬
،‫ية‬ ‫صح‬ ‫ال‬ ‫ة‬ ‫اي‬‫رع‬ ‫ال‬
‫م‬ ‫فادة‬ ‫ت‬ ‫س‬ ‫اال‬ ‫عف‬ ‫ض‬ ،‫ية‬ ‫س‬ ‫وط‬ ‫ال‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫لومال‬ ‫ع‬ ‫لم‬ ‫ل‬ ‫ظام‬ ‫ن‬ ‫ود‬ ‫ج‬ ‫دم‬ ‫ع‬ ‫ص‬
‫جاه‬ ‫عرض‬ ‫ت‬ ‫س‬ ‫ج‬ .‫ية‬ ‫ون‬ ‫كرج‬ ‫ل‬ ‫الل‬ ‫حة‬‫ص‬ ‫ال‬ ‫يال‬ ‫يس‬ ‫اج‬ ‫سرج‬ ‫ا‬ ‫يال‬ ‫كان‬ ‫لم‬
ً‫تطو‬ ‫ال‬ ‫ة‬ ‫وًق‬ ‫ال‬
‫كة‬ ‫ل‬ ‫لم‬ ‫ام‬ ‫ف‬ ‫ي‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫ة‬ ‫اي‬‫رع‬ ‫ال‬ ‫سظام‬ ‫ل‬ ‫ية‬ ‫الل‬ ‫اح‬ ‫ية‬ ‫س‬ ‫ك‬ ‫ال‬ ‫ي‬‫ي‬ ‫تاًو‬ ‫ال‬
،‫ية‬ ‫عموم‬ ‫ال‬ ‫صحة‬ ‫ال‬ ‫طاع‬ ‫ق‬ ‫ل‬ ‫عي‬ ‫يز‬ ‫ك‬ ‫رج‬ ‫ال‬ ‫م‬ ‫ة‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫ية‬ ‫عرب‬ ‫ال‬
‫ه‬ ‫واج‬ ‫ج‬ ‫ي‬‫ت‬ ‫ال‬ ‫ال‬ ‫تحدي‬ ‫ال‬ ‫فرص‬ ‫ال‬
. ‫عودي‬ ‫س‬ ‫ال‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫ة‬ ‫اي‬‫رع‬ ‫ال‬ ‫ظام‬ ‫ن‬
Aperçu du système de santé en Arabie saoudite
RÉSUMÉ Le gouvernement d’Arabie saoudite a accordé une
priorité élevée au développement des services de
soins de santé à tous les niveaux : primaire, secondaire et
tertiaire. En conséquence, la santé de la population
saoudienne s’est grandement améliorée au cours des dernières
décennies. Toutefois, le système de santé est
confronté à de multiples défis tels que la pénurie de
professionnels de santé saoudiens, les rôles multiples du
ministère de la Santé, des ressources financières limitées,
l’évolution des tableaux de morbidité, la forte demande
générée par la gratuité des services, l’absence de politique
nationale de gestion des crises, l’accès médiocre à
certains établissements de soins, l’absence de système national
d’information sanitaire et la sous-utilisation du
potentiel des stratégies de cybersanté. Le présent article passe
en revue l’histoire du système de santé saoudien
et sa structure actuelle et met l’accent sur le secteur de la santé
publique, les opportunités qui s’offrent à ce
système et les obstacles auxquels il est confronté.

‫سط‬ ‫تو‬ ‫ل‬ ‫ام‬ ‫شق‬ ‫ر‬ ‫ل‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫لة‬ ‫لس‬ ‫شام‬ ‫ر‬ ‫ع‬ ‫ساب‬ ‫ال‬ ‫لد‬ ‫لس‬ ‫ام‬
‫ش‬ً‫عا‬ ‫ال‬ ‫عدد‬ ‫ال‬
785
Introduction
Health care services in Saudi Arabia
have been given a high priority by the
government. During the past few dec-
ades, health and health services have
improved greatly in terms of quantity
and quality. Gallagher has stated that:
“Although many nations have seen
sizable growth in their health care sys-
tems, probably no other nation (other
than Saudi Arabia] of large geographic
expanse and population has, in compa-
rable time, achieved so much on a broad
national scale, with a relatively high level
of care made available to virtually all seg-
ments of the population (p. 182).” [1]
According to the World Health Or-
ganization (WHO) [2], the Saudi health
care system is ranked 26th among 190
of the world’s health systems. It comes
before many other international health
care systems such as Canada (ranked
30), Australia (32), New Zealand (41),
and other systems in the region such as
the United Arab Emirates (27), Qatar
(44) and Kuwait (45). Despite these
achievements, the Saudi health care sys-
tem faces many challenges which require

new strategies and policies by the Saudi
Ministry of Health (MOH) as well as
effective cooperation with other sectors.
This review outlines the historical
development and current structure of the
Saudi health care system. A particular em-
phasis has been given to the public health
sector that is operated by the MOH,
including the key opportunities and chal-
lenges it faces. In addition, this review
highlights demographic changes and the
economic context of Saudi Arabia in rela-
tion to the Saudi health care system.
Demographic and
economic patterns
of Saudi Arabia
The last official census in 2010 placed
the population of Saudi Arabia at 27.1
million, compared with 22.6 million
in 2004 [3]. The annual population
growth rate for 2004 to 2010 was 3.2%
per annum [3], and the total fertility rate
was 3.04 [4]. Saudi citizens comprise
around 68.9% of the total population;
50.2% are males and 49.8% females [3];
67.1% of the population are under the
age of 30 years and about 37.2% are
under 15 years; the population over the
age of 60 years is estimated at 5.2% [5].
According to United Nation projec-
tions, it is estimated that the population
of Saudi Arabia will reach 39.8 million

by 2025 and 54.7 million by 2050 [6].
This is a natural outcome of the high
birth rate (23.7 per 1000 population),
increased life expectancy (72.5 years
for men, 74.7 years for women) [4] and
declining mortality rate among infants
and children [1]. The under 5 years of
age mortality rate fell 250 per 1000 live
births in 1960 [7] to 20.0 per 1000 in
2009 [4]. Apart from advancements
in health care and social services, these
improved statistics can mostly be at-
tributed to the compulsory childhood
vaccination programme implemented
by the government since 1980 [7]. This
unprecedented growth will increase
the demand for essential services and
facilities including health care, while
at the same time creating economic
opportunities.
Saudi Arabia is one of the richest and
fastest growing countries in the Middle
East. It is the world’s largest producer
and exporter of oil, which constitutes the
major portion of the country’s revenues
[8,9]. In recent decades, however, Saudi
Arabia has diversified its economy, and
today produces and exports a variety of
industrial goods all over the world. The
sound economy and well-established
industry base affects the Saudi commu-
nity by increasing their income, leading
to a per capita income of US$ 24 726 in
2008 [10] compared with US$ 22 935
in 2007, US$ 14 724 in 2006, US$

13 639 in 2005 [11,12] and US$ 8140
in 2000 [13]. Based on 2010 informa-
tion, Saudi Arabia is ranked at a high
level in the Human Development Index
(0.75), which gives the country a rank
of 55 out of 194 countries [10]. The
improvement in the national income
is expected to impact positively on its
various services including the health
care services.
Brief overview of
health services
development
Health services in Saudi Arabia have
increased and improved significantly
during recent decades [14]. The first
public health department was estab-
lished in Mecca in 1925 based on a royal
decree from King Abdulaziz [15]. This
department was responsible for spon-
soring and monitoring free health care
for the population and pilgrims through
establishing a number of hospitals and
dispensaries. While it was an important
first step in providing curative health
services, the national income was not
sufficient to achieve major advances
in health care, the majority of people
continued to depend on traditional
medicine and the incidence of epidemic
diseases remained high among the
population and pilgrims [15]. The next
crucial advance was the establishment

of the MOH in 1950 under another
royal decree [15]. Twenty years later,
the 5-year development plans were
introduced by the government to im-
prove all sectors of the nation, includ-
ing the Saudi health care system [16].
Since then, substantial improvements
in health care have been achieved in
Saudi Arabia.
Current structure
of health services
Currently the MOH is the major gov-
ernment provider and financer of health
care services in Saudi Arabia, with a
total of 244 hospitals (33 277 beds)
and 2037 primary health care (PHC)
Health Journal
786
centres [4]. These services comprise
60% of the total health services in Saudi
Arabia [4]. The other government bod-
ies include referral hospitals (e.g. King
Faisal Specialist Hospital and Research
Centre), security forces medical serv-
ices, army forces medical services, Na-
tional Guard health affairs, Ministry of
Higher Education hospitals (teaching

hospitals), ARAMCO hospitals, Royal
Commission for Jubail and Yanbu
health services, school health units of
the Ministry of Education and the Red
Crescent Society. With the exception of
referral hospitals, Red Crescent Society
and the teaching hospitals, each of these
agencies provides services to a defined
population, usually employees and their
dependants. Additionally, all of them
provide health services to all residents
during crises and emergencies [16].
Jointly, the government bodies oper-
ate 39 hospitals with a capacity of 10
822 beds [4]. The private sector also
contributes to the delivery of health
care services, especially in cities and
large towns, with a total of 125 hospitals
(11 833 beds) and 2218 dispensaries
and clinics (Figure 1) [4].
The advancement in health serv-
ices, combined with other factors such
as improved and more accessible public
education, increased health awareness
among the community and better life
conditions, have contributed to the sig-
nificant improvements in health indica-
tors mentioned earlier. It has been noted,
however, that despite the multiplicity of
health service providers there is no coor-
dination or clear communication chan-
nels among them, resulting in a waste
of resources and duplication of effort

[17]. For example, there are consider-
able opportunities to take advantage of
equipment, laboratories, training aids
and well-trained personnel from differ-
ent countries. However, as a result of
poor coordination, the benefit of these
opportunities is limited within each sec-
tor. In order to overcome this and to
provide the population with up-to-date,
equitable, affordable, organized and
comprehensive health care, a royal de-
cree in 2002 led to the establishment of
the Council of Health Services, headed
by the Minster of Health and including
representatives of other government and
private health sectors [18]. Although
the aim of the Council was to develop a
policy for coordination and integration
among all health care services authorities
in Saudi Arabia [19], significant progress
has yet to be achieved in this area [20].
Figure 1 Current structure of the health care sectors in Saudi
Arabia (MOH = Ministry of Health) . Source of data: [4]
Employees &
their families
+
Emergencies

Armed forces medical services
Health services in the R oyal
Commission for Jubail & Yanbua
Red Crescent
Security forces medical services
National guard health affairs
% of hospital services provide by
various health care sectors in
Saudi Arabia
59.5%
21.2%
19.3%
MOH Other Govt. Private
Emergencies
Referral hospitals
Teaching hospitals

School health units
ARAMCO health services
Saudi health care system
Govt. sector (free) Private sector (fee)
MOH (public)
Other agencies
All levels of health care
All levels of health care
All levels of
health care
787
Public health care
system (Ministry
of Health)
In accordance with the Saudi constitu-
tion, the government provides all citi-
zens and expatriates working within the
public sector with full and free access
to all public health care services [7,21].

Government expenditure on the MOH
increased from 2.8% in 1970 [18] to
6% in 2005 and 6.2% in 2009 (Table
1) [4]. According to WHO the total
expenditure on public health during
2009 was 5% of gross domestic prod-
uct [22]. The MOH is responsible for
managing, planning and formulating
health policies and supervising health
programmes, as well as monitoring
health services in the private sector [23].
It is also responsible for advising other
government agencies and the private
sector on ways to achieve the govern-
ment’s health objectives [16].
The MOH supervises 20 regional
directorates-general of health affairs in
various parts of the country [18]. Each
regional health directorate has a number
of hospitals and health sectors and every
health sector supervises a number of
PHC centres. The role of these 20 di-
rectorates includes implementing the
policies, plans and programmes of the
MOH; managing and supporting MOH
health services; supervising and organiz-
ing private sector services; coordinating
with other government agencies; and
coordinating with other relevant bodies
[23]. Figure 2 illustrates the organiza-
tional structure and the relationship of
departments within the Saudi health care
system from the community to MOH
level. “Health friends” is a selective com-
mittee consisting of useful and influential

community members, including repre-
sentatives from PHC centres, who are
knowledgeable about common social
norms and the potential of the commu-
nity. The essential role of this committee
is to liaise between PHC centres and the
communities they serve [24,25].
Levels of health care services
The MOH provides health services at 3
levels: primary, secondary and tertiary
[4]. PHC centres supply primary care
services, both preventive and curative,
referring cases that require more ad-
vanced care to public hospitals (the
secondary level of care), while cases
that need more complex levels of care
are transferred to central or specialized
hospitals (the tertiary level of health
care).
Transition to PHC services
Until the 1980s, in line with the expecta-
tions of population, health services in
Saudi Arabia were largely curative, em-
phasizing the provision of treatment for
existing health problems [18,23]. The
curative care model, however, can be
costly to health providers, when many
diseases can be prevented or minimized
through developing a preventive strat-
egy. A variety of preventive measures
were run by the MOH through former
health offices and to some extent
through maternal and child health care
centres. A number of disease control

activities were performed by vertical
programmes, e.g. malaria, tuberculosis
and leishmaniasis control [18,23].
In accordance with the Alma-Ata
declaration at the WHO General As-
sembly in 1978 [26], the Saudi MOH
decided to activate and develop the
preventive health services by adopt-
ing the PHC approach as one of its
key health strategies. Consequently, in
1980, a ministerial decree was issued to
establish PHC centres. The first step was
to establish suitable premises through-
out the country. Existing facilities lo-
cated in adjacent areas were integrated
into single units. These included former
health offices, maternal and child health
centres and dispensaries. The health
posts in small and rural districts were
upgraded to PHC centres [18,23]. The
health centres aimed to focus on the 8
elements of the PHC approach: educat-
ing the population concerning prevail-
ing health problems and the methods of
preventing and controlling them; provi-
sion of adequate supply of safe water
and basic sanitation; promotion of food
supply and proper nutrition; provision
of comprehensive maternal and child
health care; immunization of children
against major communicable diseases;
prevention and control of locally en-
demic diseases; appropriate treatment
of common diseases and injuries; and

provision of essential drugs [24,25].
Focusing on a PHC strategy and
applying a logical referral system has
helped to reduce the number of visits
to outpatient clinics [23]. About 82%
of client visits to MOH facilities during
2009 were to PHC centres comprising
more than 54 million PHC clients [4].
The creation of individual and family
health records inside each PHC centre
has reduced duplication of consulta-
tions. The use of the essential drugs list
and documentation of prescriptions in
patient health files has not only reduced
the costs of medications, but also im-
proved prescribing practices.
Table 1 Budget appropriations for the Ministry of Health
(MOH) in Saudi Arabia in
relation to the government budget, 2005–09
Year Government budget (SRa) MOH budget (SR) %b
2005 280 000 000 16 870 750 6.0
2006 335 000 000 19 683 700 5.9
2007 380 000 000 22 808 200 6.0
2008 450 000 000 25 220 200 5.6
2009 475 000 000 29 518 700 6.2
Source: [4].
aUS$ 1 = 3.75 SR; bAs a % of the total government budget.

SR = Saudi riyals
Health Journal
788
In recent years, the MOH has con-
tinued to develop the number of PHC
centres (Figure 3) and has initiated fur-
ther projects aimed at developing health
care in general and PHCs in particular.
For example, the project of the Custo-
dian of the Two Holy Mosques aims to
establish 2000 advanced PHC centres,
and to develop the existing ones in terms
of buildings, workforce and services.
Health services in the
pilgrimage (hajj) season
Saudi Arabia has a unique position in the
Islamic world, as it embraces the 2 holi-
est cities of Islam, Mecca and Medina.
About 2 million pilgrims from all over
the world perform the hajj annually.
During the 2009 season, there were 2.3
million pilgrims, 69.8% of whom came
from foreign countries [4]. Hosting such
an event annually is a major challenge
that requires a planned and organized
effort across numerous agencies and
departments to ensure adequate essen-
tial services, such as housing, transport,

safety and health care [21].
Health care services in the hajj season
provide preventive and curative care for
all pilgrims, irrespective of their nation-
ality. Preventive care includes health
education programmes, vaccination
and chemoprophylaxis for all pilgrims
via quarantine services at airports and
land ports. The provision of emergency
and curative services takes place through
a network of health care facilities. For ex-
ample, in 2009, there were 21 hospitals,
of which 7 were seasonal, with a total of
3408 beds and 176 beds for emergency
admissions. There were also 157 PHC
centres, of which 119 were seasonal. On
average, each PHC centre treated 4734
pilgrims. The total workforce recruited
to work in these facilities during 2009
was 17 886; an increase of 5% on the
previous year. Of these, 69% were physi-
cians, nurses and allied health personnel
[4]. On average, each physician treated
about 612 pilgrims, while each nurse
treated about 372.
Figure 2 Organizational structure of the Ministry of Health
(public) health care system in Saudi Arabia. Source: [23]
2037
19251925
1905

1848
1986
1750
1800
1850
1900
1950
2000
2050
2100
2004 2005 2006 2007 2008 2009
N
o
. o
f
P
H
C
c
e
n

tr
e
s
Figure 3 Trends in the number of primary health care (PHC)
centres in the Ministry
of Health in Saudi Arabia, 2004–09. Source: [4]
789
Every year, the Saudi health care
agencies, particularly the MOH, seek to
improve the health care services to pil-
grims [21]. Nevertheless, the fact that all
the services are provided free of charge
for all pilgrims is creating considerable
pressure on the health care budget and it
may be necessary to seek ways to provide
better services at a lower cost. One sug-
gestion is to introduce a seasonal health
insurance for all international pilgrims.
Challenges for
health care reform
While many steps have been undertaken
by the MOH to reform the Saudi health

care system, a number of challenges
remain. These relate to the health work-
force, financing and expenditure, chang-
ing patterns of diseases, accessibility to
health care services, introducing the
cooperative health insurance scheme,
privatization of public hospitals, utiliza-
tion of electronic health (e-health) strat-
egies and the development of a national
system for health information.
Health workforce
The Saudi health care system is chal-
lenged by the shortage of local health
care professionals, such as physicians,
nurses and pharmacists. The majority
of health personnel are expatriates and
this leads to a high rate of turnover and
instability in the workforce [27]. Ac-
cording to the MOH the total health
workforce in Saudi Arabia, including all
other sectors, is about 248 000; more
than half of them (125 000) work in
the MOH [4]. Saudis constitute 38%
of this total workforce. Of these, 23.1%
are physicians, while 32.3% are nurses
(Figure 4). In the MOH, Saudis consti-
tute about 54% of the health workforce,
(physicians 22.6% and nurses 50.3%).
The rates of physicians and nurses in
Saudi Arabia are 16 and 36 respectively
per 10 000 population, lower than in
other countries such as Bahrain (30 and
58 per 10 000), Kuwait (18 and 37 per
10 000), Japan (12 and 95 per 10 000),

Canada (19 and 100 per 10 000),
France (37 and 81 per 10 000) and the
United States of America (27 and 98
per 10 000) [28].
The ability to formulate and ap-
ply practical strategies to retain and
attract more Saudis into the medical
and health professions, particularly
nursing, is a clear priority for effective
reform of the Saudi health care system.
Many efforts have been taken by the
government to teach and train Sau-
dis for health professional jobs. Since
1958 , a number of medical, nursing
and health schools have been opened
around the nation to meet this goal
[7]. Apart from private colleges and
institutes, there are a total of 73 col-
leges for medicine, health and nursing
as well as 4 health institutes in Saudi
Arabia [4]. Efforts to establish such
colleges are in accordance with train-
ing programmes that aim to substitute
the largely expatriate workforce with
qualified Saudi Arabian nationals in
all sectors, including health [18,29].
The budget allocation for training and
scholarships has increased and many
MOH employees are offered a chance
to pursue their studies abroad [18].
This strategy could improve the skills
of current employees, raise the quality
of health care and, it is hoped, decrease
the rate of turnover among health pro-

fessionals. However, these efforts may
not be enough to solve the challenges.
The proportion of Saudi Arabian health
professionals in the MOH workforce
is expected to decrease in the future as
the expansion in health care facilities
around the country has the effect of
spreading a scare resource even more
thinly [17,30].
0
10
20
30
40
50
60
70
80
90
100
MOH Other govt. Private Total

%
Physicians
Nurses
Allied health
Figure 4 Distribution of Saudi health personnel in the Ministry
of Health (MOH), other government and private health care
sectors in Saudi Arabia, 2009. Source: [4]
Health Journal
790
More realistic plans and long-term
strategies need to be consolidated by the
MOH in cooperation with government
and private sectors. A good example of
such cooperation is the King Abdullah
international scholarship programme
which was established by the Minis-
try of Higher Education. In its stage
4, priority has been given to medical
specialists including medicine, nurs-
ing, pharmacy and other health majors
[31]. However, more medical colleges
and training programmes need to be
established around the country. New
laws and regulations to develop and
reorganize medical human resources by
the MOH are urgently required.

Reorganization and
restructuring of the MOH
The public health sector is overwhelm-
ingly financed, operated, controlled,
supervised and managed by the MOH
[32]. This model of management may
not able to meet the population’s health
care needs into the future unless seri-
ous and well-planned steps are taken to
separate these multiple roles. Possible
solutions include giving more authority
to the regional directorates, applying the
cooperative health insurance scheme
and encouraging the privatization of
public hospitals.
Decentralization of health
services and autonomy of
hospitals
To meet increasing pressure on the
MOH, more autonomy has been given
to the regional directorates in terms of
planning, recruitment of professional
staff, formulating agreements with
health services providers (operating
companies) and some limited financial
discretion. It has been suggested that the
functioning of the regional directorates
is adversely affected by the lack of indi-
vidual budgets and spending authority
[16]. Expenditure for the majority of
their activities must be authorized by
the MOH, thus affecting the autonomy
of regional directorates and hampering
effective decision-making.

In terms of hospital autonomy, the
MOH has tried a number of strategies
for improving the management of public
hospitals during past decades, including
direct operation by the MOH, coopera-
tion with other governments such the
Netherlands, Germany and Thailand,
partial operation by health care compa-
nies, comprehensive operation by health
care companies and the autonomous
hospital system [33]. Considering the
advantages and disadvantages of these
approaches, the MOH has standard-
ized an autonomous hospital system for
31 public hospitals in various regions
[34]. The autonomous hospital system
for public hospitals is expected to raise
the efficiency of their performance in
both medical and managerial functions,
achieve financial and administrative
flexibility through adopting a direct
budget strategy, apply quality insurance
programmes and simplify the con-
tractual process with qualified health
professionals [33]. In 2009, the MOH
issued new regulations for self-operating
public hospitals to ensure a high level of
management practices and to improve
the quality of services provided [35].
Giving more autonomy to hospitals will
help the transition to full privatization of
public hospitals in Saudi Arabia. It gives
public hospitals more experience in the
management of their budgets, health
care quality and workforce.

Health insurance in Saudi
Arabia
Funding health care services is a central
challenge faced by the MOH [32]. Since
the total expenditure on public health
services comes from the government
and the services are free-of-charge, this
lead to considerable cost pressure on
the government, particularly in view of
the rapid growth in the population, the
high price of new technology and the
growing awareness about health and
disease among the community [14]. To
meet the growing population demands
for health care and to ensure the qual-
ity of services provided, the Council
for Cooperative Health Insurance was
established by the government in 1999
[19]. The main role of this Council is
to introduce, regulate and supervise a
health insurance strategy for the Saudi
health care market.
The implementation of a coop-
erative health insurance scheme was
planned over 3 stages. In the first stage,
the cooperative health insurance was
applied for non-Saudis and Saudis in the
private sector, in which their employers
have to pay for health cover costs. In the
second stage, the cooperative health
insurance is to be applied for Saudis and
non-Saudis working in the government
sector. The government will pay the

cooperative health insurance costs for
this category of employee. In the final
stage, the cooperative health insurance
will be applied to other groups, such
as pilgrims [36]. Only the first stage
has been implemented to date, with
the cooperative health insurance being
implemented gradually in a 3-phase
programme to employees of the private
sector and their dependants [14,37].
The first phase covered companies with
500 or more employees, while the sec-
ond phase applied to employers with
more than 100 workers. The third phase
included employees of all companies in
Saudi Arabia as well as domestic work-
ers [14,37]. The government is now
working systematically to apply the re-
maining 2 stages—for employees in the
government sector and for pilgrims—
before they privatize the state-owned
health care facilities [14]. No informa-
tion is available yet regarding the coop-
erative health insurance scheme for the
population of Saudi Arabia other than
employees and expatriates.
While the market for cooperative
health insurance in Saudi Arabia started
with only 1 company in 2004, it cur-
rently involves about 25 companies.
The introduction of the scheme is in-
tended to decrease the financial burden
on Saudi Arabia due to the costs as-
sociated with providing health services
free-of-charge. It will also give people

791
more opportunity to choose the health
services they require [14]. The real chal-
lenge for policy-makers in Saudi Arabia
is to introduce a comprehensive, fair,
and affordable service for the whole
population. Clearly lessons can be
learned from the experiences of other
countries, including the advantages and
disadvantages of different schemes.
Privatization of public
hospitals
Privatization of public hospitals has been
seen by policy-makers and research-
ers as the best way to reform the Saudi
health care system [38,39]. Steps to
implement a privatization strategy have
been initiated and related regulation
has been passed by the government. As
a result, a number of public hospitals
are likely to be sold or rented to private
firms over the next few years [14]. Priva-
tization of hospitals is expected to bring
a number of advantages to the govern-
ment and to the nation. It is hoped that
privatization will assist in speeding up
decision-making, reducing the govern-
ment’s annual expenditure on health

care, producing new financial sources
for the MOH and improving health
care services [38].
On the other hand, privatization
may affect the current integrated system
between hospitals and PHC facilities
[14]. As hospitals become privatized,
they will focus on attracting patients,
even those who may not require hos-
pital-level care. Moreover, people with
health cover may prefer to access big
hospitals directly instead of via PHC
centres or community hospitals. Ad-
ditionally, private hospitals will have
incentives to shift non-refundable costs
back to the public PHC [14]. Such
practices will place financial burdens on
the government.
A further drawback of privatization
is that the traditional state/public hos-
pitals will not be able to absorb enough
of the health care market compared
with private companies, unless they
upgrade at all levels (e.g. management,
infrastructure and workforce) before
starting to privatize [14]. In the move
to privatization, private companies are
likely to focus their activities within
cities and larger communities, leaving
people in rural areas at a disadvantage.
The government should set regulations
that protect the rights of rural commu-
nities and provide them with fair and

equitable health care services.
Finally, if the government does not ap-
ply adequate control over the health care
market, expenditure on health care may
increase dramatically as a result of higher
pricing and profit-seeking behaviour [14].
Accessibility to health services
Optimizing the accessibility of health
care services requires equity in the
distribution of health care facilities
throughout the nation and equity of
access to health professionals, includ-
ing transport to services and providers.
Accessibility is also affected by the level
of cooperation between related sectors
[23,39]. The current MOH statistics
indicate that there is a maldistribution
of health care services and health profes-
sionals across geographical areas [4].
People experience long waiting lists for
many health care services and facilities
[14]. Additionally, there is a dearth of
services for disadvantaged groups such
as the elderly, adolescents and people
with special needs such as disability,
particularly in rural areas [39]. Finally,
many people do not have the ability to
access health care facilities, particularly
those living in border and remote areas.
In order to improve accessibility to
health care services in all parts of the
country, a holistic strategy for the redistri-
bution of health care services, involving

PHC centres, general hospitals, central
and specialist hospitals as well as the
health professionals, should be adopted
by the MOH. The MOH should also
liaise with other sectors such transport,
water and power companies and social
security services in order to develop
services in deprived areas and to care for
people with the greatest needs.
Patterns of diseases
The change in disease patterns from
communicable to noncommunicable
diseases in Saudi Arabia is another
challenge that needs more attention
from the MOH [21]. There has been
an alarming increase in the prevalence
of chronic diseases, such as diabetes,
hypertension, and heart diseases, can-
cer, genetic blood disorders and child-
hood obesity [28,40,41]. Treatment of
chronic diseases is costly and may even
be ineffective [40]. For example, the
annual cost for treatment of diabetes
mellitus in Saudi Arabia was estimated
to be 7 billion Saudi riyal (SR) (US$
1.87 billion) [42]. Early prevention is
the most effective way to reduce the
prevalence of chronic diseases and the
costs and difficulties associated with
treatment in the later stages of disease.
Any projected reforms in the health care
system must involve plans to address
this change in emphasize.
Promotion and prevention

programmes for crises
Development and implementation
of practical plans and procedures to
meet national crises in Saudi Arabia,
such as wars, earthquakes and fires and
explosions at petroleum factories, are a
further important need. Road traffic ac-
cidents, for example, killed more than 39
000 and injured about 290 000 people
between 1995 and 2004 [43]. Accord-
ing to WHO, road traffic accidents are
now the highest cause of death, injury
and disability in adult males aged 16 to
36 years in Saudi Arabia [32]. Caring
for people affected by road accidents
consumes a significant proportion of
the MOH budget; for example, the cost
of treating injured people during 2002
was estimated to be SR 652.5 million
(US$ 174 million) [43]. These funds
could be used to develop the health
system and improve services. Plans to
manage issues of this kind need to be
comprehensive and well-coordinated
among the related sectors in order to be
achievable.
Health Journal
792
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As a result of the continued attention
to and support from the government,
Saudi health services have advanced
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markedly. The MOH has introduced
many reforms to its services, with sub--
stantial emphasis on PHC.
Despite these achievements, health
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diseases; development of practical poli-

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an efficient national health information
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In order to address these challenges and
continue to improve the status of the
Saudi health care system, the MOH
and other related sectors should coor-
dinate their efforts to implement and
ensure the success of the new health
care strategy.
Acknowledgements
This paper is part of the first author’s
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cessed 28 June 2011) [in Arabic].
Country cooperation strategy for WHO and Saudi Arabia 2006–
32.
2011. Cairo, World Health Organization Regional Office for the
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public
hospitals: the transition from companies’ operating system to
self-
operating system. Paper presented at the Conference on Recent
Trends in the Management of Private and Public Hospitals in
the Arab World, 12–14 March 2002. Cairo, Arab Administrative
Development Organisation, 2002.
[34. Achievements of the Ministry of Health]. Ministry of
Health,

Saudi Arabia [website] (http://www.moh.gov.sa/Ministry/
MediaCenter/News/Pages/NEWS-2007-9-24-001.aspx, ac-
cessed 28 June 2011) [in Arabic].
Al-Zahrani S. [Requiring employees of self-operating public 35.
hospitals to work for six days per week instead of five]. Al-
Madinah Daily, 26 July 2009 [in Arabic].
Alsharif AI. 36. Health system and insurance in Saudi Arabia.
Paper
presented at the Board of Healthcare Funders Southern African
Annual Conference, Durban, 3-16 July 2008. Port Elizabeth,
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Al-Shaikh S. Saudi health care sector: need for more invest-37.
ment. Arab News, 7 August 2006.
Saati A. [Privatisation of public hospitals: future vision and 38.
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[in Arabic].
[New strategy for health services in Saudi Arabia]. 39. Al-
Egtisadia
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Saudi children and adolescents: a community-based survey.
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[42. Allocation of 110 million riyals for establishment of 20
diabetes

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77Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue
2 | May-Aug 2014 | 77-80
Public Health in the Saudi Health System: A Search for New
Guardian
Waleed A. Milaat

Department of Family and Community Medicine, College of
Medicine, King Abdulaziz University, Jeddah, Kingdom of
Saudi Arabia
Correspondence: Prof. Waleed A. Milaat, Department of Family
and Community Medicine, College of Medicine, King Abdulaziz
University, Jeddah, Kingdom of Saudi Arabia. E-mail:
[email protected]
A B S T R A C T
Saudi Arabia has witnessed a signifi cant improvement in its
health indicators. The kingdom has spent generously
on the curative health services and established hundreds of
hospitals and primary health care centers. However,
we believe that this huge health expenditures and the presence
of curative services is not the only reason
for this improvement. Public health services have also had a
significant impact on people’s health and that
this improvement is due to a combination of public health
programs such as immunization, environmental
sanitation and health education with good formulation of sound
health policies and health delivery systems.
It is noted that health plans and expenditure in the health
system are concentrating on the curative aspects and there is a
signifi cant weaknesses in public health services. Additionally,
most jobs are allocated for curative care and there is scarcity
of job titles related to public health in the health structure, such
as public health offi cers, public health inspectors and
public health specialists. A suggested body namely, Ministry of
public health, will work to confi rm that all issues related
to health of the public in every aspect of daily life in the
kingdom are within the genuine interest of all policy makers.
Key words: Public health, guardian, Saudi health system
:‫لنص‬ ‫م‬ ‫ال‬

‫شرال‬ ‫مؤ‬ ‫ال‬ ‫ي‬ ‫ف‬ ‫يرا‬ ‫ك‬ ‫ك‬ ‫سا‬ ‫س‬ ‫ح‬ ‫ج‬ ‫ة‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫ية‬ ‫عرب‬ ‫ال‬ ‫كة‬ ‫ل‬ ‫مم‬ ‫ال‬ ‫شهدل‬
‫شاء‬ ‫لن‬ ‫م‬ ‫ج‬ ‫ي‬‫س‬ ‫عال‬ ‫ال‬ ‫ب‬ ‫سان‬ ‫ال‬ ‫ى‬‫ل‬ ‫ع‬ ‫سناء‬ ‫ب‬ ‫ة‬ ‫ل‬ ‫د‬ ‫ال‬ ‫لر‬ ‫ف‬ ‫رن‬ ‫ية‬ ‫صح‬ ‫ال‬
‫يال‬ ‫ف‬ ‫ش‬ ‫ت‬ ‫س‬ ‫م‬ ‫ال‬ ‫ئال‬ ‫م‬
‫ية‬ ‫صح‬ ‫ال‬ ‫لال‬ ‫ف‬ ‫س‬ ‫ال‬ ‫رص‬ ‫رى‬ ‫ن‬ ‫سا‬ ‫س‬ ‫ك‬ ‫ل‬ .‫ية‬ ‫ول‬ ‫ارل‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫ة‬ ‫اي‬‫رع‬ ‫ال‬ ‫ز‬ ‫راك‬ ‫م‬
‫ست‬ ‫تح‬ ‫ل‬ ‫ل‬ ‫يد‬ ‫وح‬ ‫ال‬ ‫كب‬ ‫س‬ ‫ال‬ ‫جي‬ ‫سر‬ ‫ي‬ ‫ل‬ ‫ية‬ ‫س‬ ‫عال‬ ‫ال‬ ‫ندمال‬ ‫ال‬ ‫يرة‬ ‫ك‬ ‫ك‬ ‫ال‬
‫م‬ ‫ال‬ ‫ي‬ ‫ف‬ ‫توى‬ ‫س‬
‫ير‬ ‫ك‬ ‫ك‬ ‫ير‬ ‫أث‬ ‫ج‬ ‫يا‬ ‫ري‬ ‫ها‬ ‫ل‬ ‫اص‬ ‫ك‬ ‫عامة‬ ‫ال‬ ‫صحة‬ ‫ال‬ ‫ج‬ ‫رام‬ ‫ب‬ ‫رص‬ ‫يث‬ ‫ح‬ ‫ي‬‫صح‬ ‫ال‬
‫صحة‬ ‫ال‬ ‫ج‬ ‫رام‬ ‫ب‬ ‫مت‬ ‫ج‬ ‫مزي‬ ‫ل‬ ‫يسة‬ ‫ت‬ ‫ن‬ ‫جو‬ ‫ست‬ ‫تح‬ ‫ال‬ ‫جاا‬ ‫رص‬ ‫ساس‬ ‫ال‬ ‫نحة‬ ‫ى‬‫ل‬ ‫ع‬
‫عامة‬ ‫ال‬
‫ة‬ ‫لاف‬ ‫ا‬ ‫ال‬ ‫ست‬ ‫ح‬ ‫ج‬ ‫ية‬ ‫ئ‬ ‫ي‬ ‫ك‬ ‫ال‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫ق‬ ‫مراف‬ ‫ال‬ ‫يت‬ ‫س‬ ‫ح‬ ‫ج‬ ‫يم‬ ‫ع‬ ‫تط‬ ‫ال‬ ‫ك‬
‫رق‬‫ط‬ ‫ر‬ ‫طوي‬ ‫ج‬ ‫يمة‬ ‫ل‬ ‫س‬ ‫ال‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫سال‬ ‫يا‬ ‫س‬ ‫ال‬ ‫ياغة‬ ‫ن‬ ‫م‬ ‫ية‬ ‫صح‬ ‫ال‬
‫ية‬ ‫س‬ ‫عال‬ ‫ال‬ ‫ندمال‬ ‫ال‬ ‫م‬ ‫لدي‬ ‫ج‬.
‫كزة‬ ‫مرج‬ ‫ر‬ ‫زال‬ ‫ا‬ ‫فاق‬ ‫س‬ ‫الل‬ ‫ر‬ ‫ساال‬ ‫م‬ ‫ي‬‫صح‬ ‫ال‬ ‫سظام‬ ‫ال‬ ‫طط‬ ‫و‬ ‫رص‬ ‫حظ‬ ‫مال‬ ‫ال‬
‫ية‬ ‫ائ‬ ‫وق‬ ‫ال‬ ‫ية‬ ‫صح‬ ‫ال‬ ‫نطط‬ ‫ال‬ ‫ي‬ ‫ف‬ ‫عف‬ ‫ي‬ ‫ال‬ ‫ز‬ ‫ر‬ ‫ب‬ ‫ي‬‫س‬ ‫عال‬ ‫ال‬ ً ‫د‬ ‫ال‬ ‫ى‬‫ل‬ ‫ع‬
‫ج‬ ‫رام‬ ‫ب‬
‫لة‬ ‫ل‬ ‫ت‬ ‫س‬ ‫م‬ ‫ئة‬ ‫ي‬ ‫ج‬ ‫يساد‬ ‫لل‬ ‫ر‬ ‫وق‬ ‫ال‬ ‫اص‬ ‫ح‬ ‫د‬ ‫ق‬ ‫ه‬ ‫رن‬ ‫لد‬ ‫ت‬ ‫ع‬ ‫ن‬ ‫سا‬ ‫إن‬ ‫ف‬ ‫عامة‬ ‫ال‬ ‫صحة‬ ‫ال‬
‫صحة‬ ‫ال‬ ‫زاًة‬ ‫ى‬‫سم‬ ‫ج‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫سظام‬ ‫ال‬ ‫ي‬ ‫ف‬ ‫عامة‬ ‫ال‬ ‫صحة‬ ‫ال‬ ‫ة‬ ‫اب‬ ‫رق‬ ‫ل‬
‫ع‬ ‫يدا‬ ‫ع‬ ‫ب‬ ‫عامة‬ ‫ال‬ ‫ص‬
‫يدا‬ ‫أك‬ ‫ج‬ ‫ساس‬ ‫ل‬ ‫ل‬ ‫عامة‬ ‫ال‬ ‫صحة‬ ‫ل‬ ‫ل‬ ‫يماص‬ ‫ك‬ ‫عمل‬ ‫ال‬ ‫ل‬ ‫رج‬ ‫مت‬ ‫صحة‬ ‫ال‬ ‫زاًة‬
‫ياة‬ ‫ح‬ ‫ال‬ ‫ب‬ ‫وان‬ ‫ج‬ ‫ل‬ ‫ك‬ ‫ي‬ ‫ف‬ ‫عامة‬ ‫ال‬ ‫صحة‬ ‫ال‬ ‫ب‬ ‫لة‬ ‫ص‬ ‫ال‬ ‫ذال‬ ‫ا‬ ‫ياي‬ ‫ل‬ ‫ال‬ ‫أص‬ ‫ب‬
‫ي‬ ‫ف‬ ‫ية‬ ‫يوم‬ ‫ال‬
. ‫ال‬ ً‫لرا‬ ‫ال‬ ‫سة‬ ‫يا‬ ‫س‬ ‫ال‬ ‫ساع‬ ‫ن‬ ‫دي‬ ‫ل‬ ‫ي‬‫ل‬ ‫ي‬ ‫ل‬ ‫ح‬ ‫تمام‬ ‫اج‬ ‫حل‬‫م‬ ‫جي‬ ‫كة‬ ‫ل‬ ‫مم‬ ‫ال‬
INVITED ARTICLE
Access this article online
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Website:
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DOI:

10.4103/1658-631X.136973
PRELUDE
No one can question the impact of Public health
interventions in the improvement of health status
and health indicators for every country in the world.
Historical evidence of John snow work in controlling
the London cholera Epidemic of 1854 is followed by
many public health interventions in the city water system
that proved to be of great impact on people’s health and
quality of life.[1] Scotland, for example, after the Reform
Act of 1832, worked to improve its sewage treatment,
organize its water supplies from fresh Lochs, build clean
water reservoirs in Edinburgh and by the 1860s Medical
Offi cers of Health were appointed for Scottish cities.[2]
This all led to a dramatic improvement of Scottish life
expectancy and quality of life even before the era of
medical and surgical innovations.
[Downloaded free from http://www.sjmms.net on Tuesday,
November 14, 2017, IP: 188.248.190.3]
Milaat: Public health in Saudi Arabia
Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2
| May-Aug 201478
Recent public health programs all over the world have led
to a well appreciated decrease of human suffering and
pains and reduction of high morbidity and mortality rates
fi gures. Japan, for example has achieved a relatively rapid
improvement in life expectancy through the 1960s until

now,[3] passing other countries like England and Wales in
the process through organized programs of public health
nature mainly in the environmental issues. Finland has
achieved a relatively rapid reduction in the lives lost to heart
disease in the late 1980s after application of preventive
measures related to life style changes.[4] The Initiative of
“healthy cities” which started in developed countries such
as Canada, USA and Australia has led to major positive
health outcomes. These initial successes, were copied
in many areas in the developing world such as Korea ,
Philippine and China which used the same implementation
strategies to begin their own programs by involving
many community members, various stakeholders, and
commitments of municipal offi cials to achieve widespread
mobilization and effi ciency. Today, thousands of cities
worldwide are part of the “Healthy Cities network” and
exist in all WHO regions. Vaccination programs are well
recognized interventions that led to improvement of
human health status. Although they have both medical and
public health faces, these programs cannot work without
real health planning, health management and public
sectors partnership in a public health mood.
SAUDI HEALTH SITUATION
Historically, preventive services started in the early
1950s when the ARAMCO oil company, in collaboration
with the WHO, helped the MOH to control malaria
in the eastern region of Saudi Arabia.[5] Programs to
control bilharziasis, leshmaniasis, trachoma, tuberculosis
and other endemic diseases followed suit in the various
regions of the country on both vertical and horizontal
levels.[6-8] The country also adopted the new concept of
Primary Health Care (PHC) developed in 1978 and in
1983 began to promote it as the basis of its health care
delivery system. This strategic step has been most fruitful

with the immunization of over 90% of the children in
Saudi Arabia against infectious childhood diseases in the
EPI program.[9]
The basic law of the Saudi citizen rights, article 31 states
that the government is responsible for public health in
the Kingdom and should provide healthcare services
to every citizen. Saudi Arabia had experienced huge
improvements in the health indicators which speaks of
a good achievement in the health of the population. The
kingdom has spent a lot on health mainly on the curative
aspects as hundreds of hospitals and primary care centers
were established all over the kingdom [Table 1].[10] This
was associated with major contract with medical and
paramedical staff from all over the globe for service
delivery [Table 2].[11]
Big health expenditures and curative services are not
the only reason for these major improvements in health.
Clearly, the country is not an exception from the rest of the
world and public health programs had also great impact
on health of population. It is the combination of many
public health programs that worked on all determinants
of health, being social, economical, environmental, health
delivery and health policies which made the change. A
critical analysis of infant mortality rates over the last
50 years in the kingdom [Table 3][12] when tied to the
economic boom in the country and the social changes
that took place in the living situations all over the country
speaks of a real effect of public health programs such
as vaccination programs, better environmental sanitation
and female education.
Life expectancy has increased dramatically, and the
birth rate remains one of the highest in the region. The

continuous presence of hereditary and infectious health
problems in certain areas in the country (malaria in the
south, Dengue fever in the west and hereditary blood
diseases in the east and south), has been compounded by
the emergence of new acute and chronic infections (such
Table 2: MOH manpower, health centers and bed
expansion over the years in Saudi Arabia
Years 1970 1990 2010
Hospitals 74 257 415
Hospital Beds 9030 41123 58126
PHC Centers 591 3028 4594
Physicians 1172 22136 66014
Nurses 3261 48477 129792
Paramedical 1741 22410 68705
Table 1: Budget appropriations for the Ministry
of Health (MOH) in Saudi Arabia in relation to the
government budget, 2005-2009
Year Govt budget MOH budget %
2005 280 16.9 6.0
2006 335 19.7 5.9
2007 380 22.8 6.0
2008 450 25.2 5.6
2009 475 29.5 6.2
US$ 1 – 3.75 Saudi riyals (SR); ( %) Percentage of the total
government
budget (in billions)
November 14, 2017, IP: 188.248.190.3]

79Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue
2 | May-Aug 2014
as avian infl uenza, rift valley fever and resistant types of
tuberculosis). Additionally, such morbidities as diabetes
mellitus (type II), hypertension, cardiovascular diseases,
road traffi c accidents and various types of cancers
resulting from sedentary unhealthy life-styles are reaching
alarming rates. Furthermore, Saudi Arabia is expected to
face new challenges with the continuing demand for health
care for special groups such as the handicapped, geriatric
population and the increasing number of pilgrims visiting
the Islamic holy places in the country. To cope with all
these challenges simultaneously a reform of the health
system is necessary.[13]
The Saudi health system was built on a curative
orientation and this was noted literally in the Saudi MOH
10 years health strategy.[11] The strategy recognized
the concentration on curative services and the lack of
preventive application as one of the defi ciencies and
weakness in health plans. In fact the strategic plan was
titled with a curative slogan (patient comes fi rst). Curative
services dominated expenditure in the Saudi health
budgets and most jobs in this system were reserved for
curative purpose. Jobs like district public health offi cers,
public health inspectors, health educators, environmental
sanitary workers and similar in the public health arena
are rarely mentioned in the Saudi health cadre for a
long time. The carrier path for public health and public
health work force is not well formulated in the MOH job
hierarchy.
It is until recently when the ministry decided to change
the look towards public health by creating a separate
“Ministerial Agency of public health” headed by a vice

minister under which two sub-agencies are included,
namely, primary health care and preventive health.
Although it is a good start to mention the word “public
health” for the fi rst time in the system and consider
its existence as an important component of health
maintenance in the country, but no clear objectives were
provided in the this change. Clearly from this move,
the specialty was recognized under the preventive and
curative moods only.
THE DREAM
The old look towards public health as group of horizontal
and vertical preventive programs connected to the
curative and preventive work in the primary health care
delivery system is far beyond its ideology and concerns.
Other domains of health planning, health legislation,
healthy life maintenance, safe health delivery and quality
of care evaluation from the public point of view are not
included in this move.
Health of the public is affected by decisions made by
people outside the health domain in other ministries.
We think it is time that this specialty be well recognized
and served in order to make the great impact on the
people in the kingdom. Saudi system should consider
an independent body for public health specialty away
from the domination of the ministry of health in order
to work as a guardian for the health of the public. The
American model of Surgeon General who safeguards
the health of the Americans and being accountable
to the congress or the British medical council who is
directly reporting to the parliament are some of the
ways in which the health of the public is well guarded.
Let us dream of a next move in which the health of the

public in Saudi Arabia and their related issues in every
aspects of life become the real concerns of each policy
maker in the system. We are dreaming of a day in which
all policies decided in every ministry in the kingdom be
under the veracious scrutiny of the guardian of a public
health body. Let us dream of healthy public policies
in all areas of our daily life. It is nice to dream and
act towards this dream. it is defi nitely better late than
never.
REFERENCES
1. Smith GD. Commentary: Behind the Broad Street pump:
Aetiology,
epidemiology and prevention of cholera in mid-19th century
Britain.
Int J Epidemiol 2002;31:920-32.
2. Warren MD. A Chronology of State Medicine, Public Health,
Welfare and Related Services in Britain 1066-1999. Published
by Faculty of Public Health Medicine of the Royal Colleges of
Physicians of the United Kingdom 2000. http://www.fphm.
org.uk.
3. Robine JM, Saito Y, Jagger C. The relationship between
longevity
and healthy life expectancy. Quality in Ageing 2009;10:5-14.
4. Laatikainen T, Vartiainen E, Puska P. The North Karelia
lessons for
prevention of cardiovascular disease. IJPH 2007;4:97-101.
5. Aramco Medical Department. Epidemiology Bulletin,
Dhahran,
Saudi Arabia. 1972;1-2.

6. Abdel-Azim M, Gismann A. Bilharziasis survey in south-
western
Asia; covering Iraq, Israel, Jordan, Lebanon, Sa'udi Arabia, and
Syria: 1950-51. Bull World Health Organ. 1956;14:403-56.
Table 3: Trend of infant mortality in SA
Year 1950 1955 1960 1965 1970 1975 1982 1985 1990 1995
2000 2005 2013
IMR 204 183 162 139 106 78 56 42 30 22 19 18 6
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Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2
| May-Aug 201480
7. Tarizzo ML. Schistosomiasis in Saudi Arabia Vemes.
Congres
Internationaux de Medicine Tropical et du paludisme (Expert)
1956.
8. Page RC. Progress report on the Aramco trachoma research
program. Med Bull Standard Oil Co (NJ) 1959;19:68-73.
9. Sebai ZA, Milaat WA, Al-Zulaibani AA. Health care services
in
Saudi Arabia: Past, present and future. J Family Community
Med
2001;8:19-23.
10. Almalki M, Fitzgerald G, Clark M. Health care system in
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Arabia: An overview. East Mediterr Health J 2011;17:784-93.
11. MOH. The book of the strategic plan for country (1431-1440
Hejri
years corresponding to 2010-2019). Riyadh: MOH Publication;
2010 (Arabic). p. 47.
12. The world fact book 2013-14. National Foreign Assessment
Center. United States. Central Intelligence Agency. Washington,
D.C: Central Intelligence Agency.
13. Milaat WA. Public health schools in Saudi Arabia: A
necessity or a
luxury? J Family Community Med 2007;14:89-90.
How to cite this article: Milaat WA. Public health in the saudi
health system: A search for new guardian. Saudi J Med Med Sci
2014;2:77-80.
Source of Support: Nil, Confl ict of Interest: None declared.
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‫ة‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫ية‬ ‫عرب‬ ‫ال‬ ‫كة‬ ‫ل‬ ‫لم‬ ‫ام‬ ‫ف‬ ‫ي‬ ‫ي‬‫صح‬ ‫ال‬ ‫يف‬ ‫ل‬ ‫ا‬ ‫ت‬ ‫ال‬
‫ية‬ ‫ي‬ ‫اًو‬ ‫ج‬ ‫لة‬ ‫م‬‫ح‬
‫ها‬ ‫ال‬ ً‫وا‬ ‫نم�ارن‬
abstract: This article provides a historical overview of the
evolution of health education in Saudi Arabia. It
outlines milestones in the development of the health education
profession and traces the roles of various health
sectors and their achievements in the health education field.
Additionally, this review seeks to describe the status
of health education professionals in Saudi Arabia.
Keywords: History; Health Educators; Healthcare Sector; Health
Promotion; Public Health; Government
Agencies; Saudi Arabia.

‫ي‬‫ا‬ ‫مال‬ ‫عال‬ ‫�ال‬ ‫ا‬ ‫جي‬ ‫تدد‬ ‫ح‬ ‫نا‬ � ‫ف‬ ‫ي‬ ‫كة‬ ‫ل‬ ‫لم‬ ‫ام‬ ‫ية‬ ‫عرب‬ ‫ال‬ .‫ة‬ ‫عودي‬ ‫ن‬
‫�ا‬ ‫جاه‬ ‫ة‬ ‫لال‬ ‫ل‬ ‫ام‬ ً‫تطو‬ ‫ال‬ ‫ي‬‫ن‬ ‫تاًي‬ ‫ال‬ ‫سة‬ ‫له‬ ‫م‬ ‫يف‬ ‫ل‬ ‫ا‬ ‫ت‬ ‫ال‬ ‫ي‬‫نح‬
‫عر�ل‬ ‫ت‬ ‫ن‬ �‫خ‬‫ل‬ ‫ل‬ ‫ام‬ ‫�ض‬ :‫ص‬
‫طوًجاه‬ ‫ج‬ ‫ف‬ ‫ي‬ ‫لهمة‬ ‫ام‬ ‫ا‬ ‫ال‬‫لطاع‬ ‫ال‬ ً‫ا‬ ‫ارد‬ ‫تاب‬ ‫ج‬ ،‫سة‬ ‫له‬ ‫�ام‬ ‫ية‬ ‫نح‬
‫ا‬ ‫يف‬ ‫ل‬ ‫ا‬ ‫ت‬ ‫ال‬ ‫ما‬‫ج‬ ‫ف‬ ‫ي‬ ‫ها‬ ‫سازاج‬ ‫الج‬ ‫فة‬ ‫ل‬ ‫ت‬ ‫لن‬ ‫ل�ام‬‫ا‬ .‫ي‬‫نح‬ � ‫ل‬ ‫الي‬ ‫ة‬ ‫ناف‬
‫ل‬ ،‫ل‬ ‫�ذل‬ ‫نف‬
‫ا‬ ‫يف‬ ‫ل‬ ‫ا‬ ‫ت‬ ‫ال‬ ‫ما‬‫ج‬ ‫ف‬ ‫ي‬ ‫ي‬‫س‬ ‫ل‬ ‫عام‬ ‫ال‬ ‫ة‬ ‫ال‬‫ح‬ ‫ة‬ ‫لال‬ ‫ل‬ ‫ام‬ ‫�جاه‬ ‫كة‬ ‫ل‬ ‫لم‬ ‫ام‬ ‫ف‬ ‫ي‬ ‫ي‬‫ح‬‫ن‬
‫ا‬ ‫ية‬ ‫عرب‬ ‫�ال‬.‫ة‬ ‫عودي‬ ‫ن‬
‫ا‬ ‫عامة؛‬ ‫ال‬ ‫ر‬ ‫اال‬ ‫وك‬ ‫ال‬ ‫ية؛‬ ‫كوم‬ ‫ل‬ ‫�اح‬ ‫ا‬ ‫نحة‬ � ‫ز‬ ‫عزي‬ ‫ج‬ ‫نحة؛‬
‫�ا‬ ‫ا‬ ‫ية؛‬ ‫نح‬ ‫ا‬ ‫ي‬‫ة‬ ‫يسي؛‬ ‫قطاع‬ ‫�ًعاية‬ :‫مفتاحية‬ ‫التاًيخ؛‬ ‫فسي‬ ‫ة‬ ‫ي‬‫ة‬‫ق‬‫ا‬‫ي‬‫ل‬‫ت‬‫م‬‫ا‬ ‫ة‬
‫ص‬
‫لمال‬ ‫ك‬
‫ا‬ ‫ية‬ ‫عرب‬ ‫�ال‬.‫ة‬ ‫عودي‬ ‫ن‬
Health Education in Saudi Arabia
Historical overview
Anwar Al-Hashem
review
Sultan Qaboos University Med J, August 2016, Vol. 16, Iss. 3,
pp. e286–292, Epub. 19 Aug 16
Submitted 23 Dec 15
Revision Req. 31 Jan 16; Revision Recd. 27 Feb 16
Accepted 13 Mar 16
doi: 10.18295/squmj.2016.16.03.004
The world health organization (who) defines health education as
“any combination of learning experiences designed to help
individuals and communities improve their health,
by increasing their knowledge or influencing their
attitudes”.1 Health education provides opportunities

for both individuals and communities to acquire the
necessary information/skills required to make health
decisions or change health behaviours.2 Between the
1970s and 1990s, many Gulf Corporation Council
countries witnessed a remarkable growth in their
healthcare sectors, including Saudi Arabia.3 Since then,
the government of Saudi Arabia has made efforts to
improve healthcare through health education and this
remains a focal point of healthcare policies today. In
this review, a historical overview of health education
in Saudi Arabia is provided, including more recent
milestones in this field, the role of various health
sectors in health education and the current status of
health education professionals in Saudi Arabia.
Historical Background of
Health Education Initiatives
In the early 1900s in Saudi Arabia, most people sought
help from local traditional healers to treat various
common health issues, such as back and abdominal
pain, flatulence, tooth pain, infertility, depression and
headaches. Common traditional practices included
reciting the Holy Quran, ingesting certain herbs or
teas, cautery and cupping.4,5 Before 1925, the territory
which now makes up modern-day Saudi Arabia was
not yet completely under the control of the ruler
King Abdulaziz Ibn Saud; as a result, some regions
were characterised by a lack of political stability and
security. During his reign, King Abdulaziz established
the Directorate of Public Health in the first Saudi
Arabian capital, Makkah, in the Hejaz region; this
directorate was the cornerstone of the Saudi Arabian
healthcare system and aimed to promote health and
safety during the Hajj season.6 The annual Hajj, or

pilgrimage season, attracts thousands of Muslims
to western Saudi Arabia to practice their faith. Due
to the large numbers of pilgrims gathering for Hajj,
both communicable and non-communicable disease
outbreaks still occur, including cholera, malaria,
poliomyelitis, meningococcal disease, respiratory tract
infections, blood-borne diseases, heat exhaustion and
heat stroke.7
In 1926, King Abdulaziz issued another decree
founding the Health and Emergency Department
(HED); this department included doctors and other
professionals, such as a general inspector, a chief
pharmacist and various administrative employees
Department of Health Education, King Saud Medical City,
Riyadh, Saudi Arabia
E-mail: [email protected]
Anwar Al-Hashem
Review | e287
(e.g. statisticians, record keepers and clerks).6 The
HED was responsible for promoting public and
environmental health, establishing hospitals and
healthcare centres, managing human resources within
these centres, legislating policies and procedures
to ensure public safety and promoting medicine
and pharmacology standards.8 Between 1926 and
1949, approximately 25 clinics, 34 health centres
and 11 hospitals were established throughout Saudi
Arabia, as well as one microbiology institute in Ta’if.6
Although the HED played a role in providing and

monitoring free healthcare access for Hajj pilgrims
and the general Saudi Arabian population, insufficient
funding and resources unfortunately limited its overall
achievements. Epidemics of certain communicable
diseases—such as smallpox, measles, meningitis,
diphtheria, scarlet fever, cholera, plague and mumps—
remained persistently high among both members of
the general public and pilgrims.9
In the 1920s, the Directorate of Public Health
identified the lack of health awareness among the Saudi
Arabian public as a key issue. Specifically, awareness of
life-threatening epidemic diseases and their modes of
transmission were viewed solely as the focus of health
professionals and few health education materials on
subjects such as personal hygiene, cleanliness and the
prevention of communicable diseases were available at
that time.6 As a result, several newspaper articles and
announcements on preventative measures, symptoms
and causes of communicable diseases as well as general
information on protection against malaria epidemics
were published in 1925, 1926 and 1930.6 During the
Hajj season in 1929, the Directorate of Public Health
issued a leaflet on various epidemic diseases, including
protection and control measures. It also published the
first guidelines on health-related personal hygiene,
sanitation and cleanliness during the Hajj season.6
In the 1940s, several announcements followed with
general instructions on the safe preparation/handling
of food and the cleanliness of food sale premises
as well as health instructions for barbershops (e.g.
cleanliness of equipment). Concurrently, the HED
conducted two free vaccination campaigns against
smallpox and typhoid targeted at members of the
public and pilgrims alike. Additionally, resident-
assisted cleanliness campaigns were initiated in Muna

every year before Hajj season.6 These health initiatives
were significant, as they helped to educate the public
without relying on written media—this was important
given that the literacy rate in Saudi Arabia was very low
up until the 1970s (approximately 15% for men and 2%
for women).10
Twenty-five years after the creation of the HED,
the Saudi Arabian Ministry of Health (MOH) was
established.8 During the 1950s, malaria control and
prevention campaigns/programmes were introduced
through the collaborative efforts of the MOH, World
Health Organization (WHO) and Arabian American
Oil Company (Aramco).11 These nation-wide progra-
mmes established a curative and preventative model of
healthcare that was then disseminated to the general
population. There were over 28 such programmes,
whose strategies involved spraying crops with
dichlorodiphenyltrichloroethane to reduce the
mosquito population as well as administering blood
tests and providing antimalarial drugs for infected
patients.6 In 1954, school health units were introduced
as another health education and prevention effort.
To begin with, these units focused only on male
pupils, teachers and employees of the Ministry of
Education; at that time, females were not allowed to
attend schools. Furthermore, school health units were
available only in urban areas such as Riyadh, Makkah
and Jeddah, and mainly provided curative services and
a few preventative services related to immunisation,
counselling and health lectures.6
Due to the scarcity of resources, the widespread
distribution of the population and the vast geographical
area of Saudi Arabia, the healthcare system in the

1960s faced heavy challenges, for example, the high
mortality rate among under-five-year-olds (250 deaths
per 1,000 live births in 1960).12 However, due to the
massive amount of oil revenue generated in the 1970s,
the government was subsequently able to dramatically
improve the industrial, agricultural, transportation,
communication, healthcare and education sectors.3
Beginning in 1970, the first five-year development
plan greatly improved the national healthcare system
and implemented compulsory vaccination plans for
infants and children; this in turn helped reduce the
under-five mortality rate (19.1 deaths per 1,000 live
births in 2011).12
The 1980s were a very successful decade for the
Saudi Arabian healthcare system, during which the
third development plan saw the construction of
numerous hospitals and primary healthcare centres.
From 1985–1987, a total of 377 healthcare facilities
were built, of which 65 were hospitals and the rest
were primary healthcare centres.13 However, in the late
1980s and mid-1990s, during the course of the fourth
and fifth development plans, both governmental and
private healthcare growth slowed.13 The two main
reasons for this decline were the expenses associated
with the curative model and the relatively flat MOH
budget, which did not allow for price fluctuations.
Notably, these factors contributed to the suspension
of one of the largest medical facilities in Saudi
Arabia, the King Fahad Medical City.13 Although
Health Education in Saudi Arabia
Historical overview

e288 | SQU Medical Journal, August 2016, Volume 16, Issue 3
previously the healthcare sector had concentrated on
communicable diseases, social and economic factors
in the 1980s contributed to a gradual shift in focus to
chronic diseases and quality of life-related conditions.6
Diabetes, acquired immune deficiency syndrome
and heart disease were among the first conditions to
be tackled; in 1984 alone, the MOH supervised 121
programmes intended to increase health awareness
among the public through mass media, symposiums
and meetings.6 Additionally, public health policy was
also changed after a royal decree was issued prohibiting
advertisements and publications supporting cigarettes
and increasing the duty on tobacco and its derivatives.6
Health education activities gradually increased
from 1985 to the late 1990s.6 By 1997, health educ-
ation was perceived much more positively by health
professionals and the public alike. This change
in perception was due to the success of certain
prevention and control programmes (e.g. tuberculosis
programmes) and the increased publicity and mass
media coverage of health education programmes and
activities around the country.6 In 1998, the school
health units expanded their services to cover female
schools in rural and urban areas. These units provided
preventative services by general physicians, dentists,
nurses and health educators to promote a healthy
lifestyle including information on nutrition and a
balanced diet, dental health, personal health/hygiene,
smoking cessation, physical activity, safety/injury
prevention and mental health.6
By the late 1990s, more than 16 Saudi Arabian
health and medical journals were in circulation,

targeting both health professionals and the general
public.6 These included the Health Education Journal
(1997), a monthly journal published by a security
forces hospital; the Nutrition Bulletin (1997), a
monthly leaflet issued by the MOH; and the Saudi
Heart Association Bulletin (1989), a quarterly
publication printed by the King Saud University.
Moreover, in 2014 alone, the MOH circulated more
than four million health booklets, leaflets, posters and
announcements and participated in 9,000 national and
international health awareness activities to combat
smoking, cancer and diabetes.14
Modern Milestones in the
Development of Health
Education
In 2001, the Health Education Symposium was
organised by the King Khaled Eye Specialist Hospital
in Riyadh.15 This was the first national gathering of
health educators in Saudi Arabia and was a significant
event in securing support and recognition of the
importance of health education. Between 2001 and
2011, nine symposiums were held.15 Various speakers
and workshop instructors at these symposiums were
key in influencing health education promotion in the
Arab world and most attendees were health educators
from different sectors. Recommendations arising from
these symposiums were recognised by the Ministry of
Civil Services and the Saudi Commission for Health
Specialties and helped mobilise efforts to acknowledge
health education problems and devise solutions.
Furthermore, these symposiums facilitated the deve-
lopment of major commissions and organisations,
such as the National Commission of Health Education

directed by the MOH and the Charitable Society of
Health Communication.15
Heightened recognition of the importance of
health educators has led to an increased number
of health education courses and seminars aiming
to further improve the understanding of health
education objectives. In 2007, a preventative medicine
department of the MOH created a programme to
provide primary health centre practitioners with
greater health education skills; they successfully
trained over 100 workers from different primary health
centres on health education principles.16 Furthermore,
in 2007, the MOH announced that more than 4,500
health education positions in primary health centres
needed to be filled.16
In terms of health education theories, most
activities and programmes conducted by health
education specialists in hospital settings in Saudi
Arabia since the 1990s have been based on medical
concepts.15 These usually involve the identification
and ranking of the various causes of mortality and
morbidity in a society and then targeting these causes
via medical interventions.17 In other settings, most
health education activities and interventions are based
on behavioural change theories; the dominant model
currently used by health education professionals is
the health belief model, a psychological model which
explains and predicts health-related behaviours at the
individual level.15
Healthcare Sectors and their
Role in Health Education
Healthcare in Saudi Arabia is divided into two main

sectors, governmental and private. In 2012, the MOH
operated 63% of all hospitals in the country, while 24%
were operated by other governmental agencies, such
as the Ministry of Defence and Aviation, Ministry of
Education and the National Guard. In contrast, 13% of
hospitals fell under the private sector.13
Anwar Al-Hashem
Review | e289
g o v e r n m e n ta l s e c t o r
Ministry of Health
The MOH is responsible for operating and monitoring
health systems in Saudi Arabia and is the biggest
healthcare provider in Saudi Arabia, receiving 7% of
the total governmental annual budget.14 It aims to
improve the health of the population by developing
health laws, regulatory legislation and policies to serve
the health system, conducting health research and
training professionals to work in the health system.8
The MOH plays a role in establishing, funding,
coordinating and delivering health education and
public health promotion programmes. In 1998,
the MOH established the Healthy Cities Project
which aimed to promote school and occupational
health in 20 cities with a focus on physical activity
and nutrition.18 The MOH also trains and educates
health professionals on health education and
health promotion strategies. Symposiums have been
conducted to educate and share information on health
education and its importance in healthcare. Recently,
the MOH has assumed administrative responsibility

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