A Case Of Health Care Management In Saudi Arabia

Introduction

1.1       Background

With a population of 24.9 million people as at 2007, Saudi Arabia has experienced robust economic growth over the past few decades, largely occasioned by the country’s immense oil wealth. According to IMF (2007), Saudi Arabia has a GDP per head of $16, 100. Its GDP growth increased twofold between 2002 and 2007 and now stands at 5.6 percent. The Human Development Index 2007-2008 by the UN puts the country’s literacy level at above 80 percent and it is ranked 35 out of 131 countries on the Global Competitiveness Index (Al-Amri, 2008; UNDP, 2008; CIA World Fact book, 2009)

Saudi Arabia boasts of a robust and modern healthcare sector with high standards of health (KSA, 2009). However, according to Al-Hamadi & Roland (2005), there are great regional discrepancies in the quality of health care offered. The Saudi government is the main provider of healthcare services in the country, meeting the needs of more than 75 percent of the population. Healthcare in the country is decentralized, with each district having at least 2 medical centers. The country has a total of 1, 925 primary care centers and the mean number of individuals served by each of these centers is 8,727 (MOH, 2002). In the recent past though, the government has initiated efforts geared at positioning the private sector to become a key player in this sector, what with the immense pressure on the existing facilities.

Even though the country has a relatively advanced health care system, it is encumbered by high costs, shortages in consultants, large number of referrals, a huge surface area and a population that is widely spread. Other problems facing the health care sector include challenges posed by the yearly pilgrimage (Al-Daig, 2004), a high incidence of lifestyle diseases such as hypertension, diabetes, and obesity (RNCOS, 2009) and a rapidly growing and aging population (Mourshed, Hediger & Lambert, 2008)

Population growth in the entire Gulf Cooperation Council (GCC) region is expanding at a compound annual growth rate (CAGR) of 3 percent and it is estimated that it will double by 2025. 40 percent of the Saudi’s population is composed of individuals below 15 years. The growth in the aged people is primarily attributed to the rise in life expectancy. As older persons are more expensive to take care of, this is expected to exert more strain on the country’s health sector (Mourshed, Hediger & Lambert, 2008). Estimates also indicate that by 2025, demand for hospital beds in Saudi Arabia will soar by a whooping 145 percent (see figure 1, appendix). Other challenges include financing, management, information technology and distribution (Al-Daig, 2004)

 In a bid to avert these challenges and hence give her citizens affordable and high quality health care, Saudi Arabia has started a restructuring program whose central tenet is the privatization of public services. Additionally, the country is initiating strategies that will see both its citizens as well as expatriate workers qualify for health insurance (Walston, Al-Harbi, Al-Omar, 2008). Numerous efforts have also been initiated in order to enhance the quality of health care provided in the country.

As Campbell, Roland and Buetow (2000) assert, quality of care encompasses individuals’ ability to access health services and the efficacy of the services offered. Two critical components of efficacy are vital and these include interpersonal and clinical care. A central tenet of the country’s health care system has been the advancement of quality. Formulation of a framework to enhance quality was carried out 15 years ago. According to MOH (1993), the framework was meant to enhance all the elemental facets of primary health care in the country. The country also initiated several other projects meant to enhance the quality of its healthcare system including a rejuvenated staff training program, newer treatment procedures and a sharpened management development plan that sought to place local superintendents at the heart of quality improvement. According to Al-Hamadi and Roland (2005), the quality levels of healthcare in Saudi Arabia have not been very well characterized, despite all the improvement efforts. However, their study affirmed that the quality of health care in the country varies greatly with some areas exhibiting very high quality levels and others low quality levels.

The vast availability of health care institutions provides particular challenge to the Kingdom as they face a shortage in skilful health care practitioners. For this reason, it is important that the Kingdom develop program to raise and improve the quality of Saudi graduates in medical educational. Under such circumstances, the Kingdom needs to increase the capacity of medical school, nursing, pharmacy, and applied sciences.

     In addition, there should be empowerment in the healthcare sector composing of both short and long-term goals as following:

• Together with the government efforts, private sector should be encouraged to establish medical schools and healthcare-related colleges
• Ruling that hospitals should set up their own training centers
• Improve the role of the Saudi council for Health Specialties

In addition, the healthcare organization in the Saudi Arabia must comply with effective organization management that suggests the need to get people accepting that cooperation to achieve organizational goals also helps them to achieve their own goals provided they are adequately rewarded through extrinsic and intrinsic rewards (1998). It means that healthcare institutions should be treated similar to business organizations that encourage excellent leadership and motivation since both drive people to achieve organizational goals.

1.2       Problem statement

Saudi Arabia’s health care sector is faced by numerous challenges which threaten to reverse the gains the country has made in the past few decades. Key among these challenges is poor healthcare management manifested by inadequacies in employee recruitment, performance management, career development and reward and compensation. Chronic shortage of competent Saudis and cultural and organizational difficulties are the other main challenges. There is need to increase the pool of qualified Saudi health professionals and for the adoption of HRM best practices which will help recruit, retain and develop world class health workers.

1.3       Purpose Statement

The purpose of this study is to investigate the levels of healthcare quality in Saudi Arabia and provide recommendations that would help enhance these levels

1.4       Aims and Objectives

Aim

To highlight current perceived quality of health care services throughout Saudi Arabia

Objective 1: To carry out a detailed secondary study of Saudi Arabia’s health sector in order to identify current service levels

Aim

To identify elements in health care services which need to be improved

Objective 2: to identify the expectations that patients and other stakeholders have with regard to provision of healthcare in Saudi Arabia, identify accepted best practices and from the literature obtained give an outlay of the service gaps that need to be filled

Aim              

To encourage medical school and health-related institutions in increasing the qualified health care professional

Objective 3a: To conduct a secondary study of human resource management in Saudi Arabia’s health care institutions

Objective 3b: to carry out studies of secondary data in order to identify HRM best practices

Objective 3c: to administer in-depth interviews to health education experts in order to identify ways through which the pool of qualified Saudi health professionals can be increased

Objective 3d: to give recommendations which will enable health care providers improve their level of service quality through adoption of HRM best practices and collaboration with training institutions

1.5       Significance of the study

The benefits offered by this study are manifold. First, by assessing the perceived healthcare needs, expectations and service gaps and giving recommendations that will help fill these gaps, this study will help improve the training of health professionals in Saudi Arabia. Secondly, this study gives proposals on how the pool of qualified and highly competent health workers in Saudi Arabia can be increased and thereby offset the acute shortage of competent health workers. The study also provides recommendations which will help hospitals and other primary care centers to improve their HR functions and thus enhance their service quality by leveraging the power of their employees. Finally, this study helps to fill gaps in literature that have to do with the quality of healthcare in Saudi Arabia.

1.6       Scope, Limitations and Delimitations

A key limitation of this study was financial constraints. As a result, very few site visits were carried out and a Delphi study of health care and HRM experts which would have provided deeper insight in the matter and was highly desired could not be conducted. Due to time limitations, a more exhaustive investigation of Saudi Arabia’s health sector could not be performed. Assessment of the PATH outcomes of Saudi hospitals would have provided a more detailed and current perspective of Saudi’s healthcare management. Another limitation is that most of the studies evaluated in the literature review originate from government hospitals. There is little research that relates to other providers of health care services such as the military hospitals, the National Guard hospitals and private hospitals.

2         Literature Review

Several studies have been carried out in order to assess the quality levels of Saudi Arabia’s health care system. With regard to access to care, El-Gilany & Aref (2000) found that there was a relatively good access to prenatal care with access varying from 67 to 95 percent. Access to vaccination programs was even better with between 83 and 94 percent of Saudi Arabians reportedly having easy access to these programs. Jarallah, al-Shammari, Khoja & al-Sheikh (1991) evaluated the extent to which access to treatment for schistosomiasis and found that access to this treatment was good.

Other studies carried out have focused on the levels of patients’ satisfaction. Qatari & Haran (1999) determined that waiting times, appearance of health facilities and the waiting bays of health centers scored the least with close to 75 percent, 58 percent and 64 percent of respondents respectively reporting dissatisfaction with those. 40 percent of respondents surveyed by Ali & Mahmoud (1993) and Al-Faris et al (1996) reported the inability of most health workers who are expatriates to converse in Arabic as a major obstacle to health delivery. Even though majority of patients surveyed by Ali & Mahmoud (1993) reported primary care centres to be their first option in case of illness, 40 percent of the respondents decried the inconvenient opening times, long waiting times and inaccessibility of specialized care. According to Al-Khaldi, Al-Ghorabi, Al-Asiri & Khan (2002), this inaccessibility can be attributed to the low referral rates prevalent in the country. Besides the low referral rates, it has also been determined that access to health care in Saudi Arabia is largely influenced by poor access to health education Al-Khaldi & Khan (2000).

            The efficiency of the country’s health care sector has also been evaluated by several investigators. The most successful interventions are those that target maternal health care, endemic illnesses and vaccination programs (Al-Teheawy & Foda, 1992; Baldo, 1995; Jarallah, al-Shammari, Khoja & al-Sheikh, 1993). On the other hand, there is less efficiency with regard to interventions meant to manage chronic ailments (Al-Khaldi & Al-Sharif, 2002; Al-Mustafa & Abularhi, 2003; Siddiqui, Ogbeide, Karim & Al-Khalifa, 2001; Al-Khaldi, Al-Ghorabi, Al-Asiri & Khan, 2002)

2.1       Obstacles to provision of quality healthcare in Saudi Arabia

2.1.1       Management factors

Poor training of technical supervisors has hampered their ability to ensure the delivery of high quality health care. According to Jarallah & Khoja (1998), 65 percent of these supervisors have had no formal training in management. Even worse, only a paltry 15 percent of the supervisors had attained postgraduate qualifications. Whereas majority of the supervisors surveyed had a fair knowledge of the managerial duties bestowed upon them, less than 6 percent did not think that employee motivation and enhancement of quality of health care were vital aspects of their role. Additionally, a good majority of those surveyed described their main duty as that of problem resolution and identification of mistakes.

Khoja & Khabash (1997) conducted a survey of mid-level managers in Saudi Arabia’s health care sector. Among the factors identified as hindering the delivery of quality health care were the gross inability to arrive at independent decisions and unavailability of clear information. Others were incompetent supervision, high staff turnover, indistinct chain of command, career stagnation, and disparities in employees’ expertise. Poor working conditions, asynchrony between similar fields and inability to involve the community were cited as the key operational factors affecting quality health care delivery.

2.1.2       Organizational factors

Even though there has been a drastic improvement in the organization of health facilities in the country, several factors are still listed as playing an important role in hampering the delivery of quality health care in Saudi Arabia. These factors include mediocre information systems, poor working conditions, high staff turnover, inadequate facilities, outdated technology and overburdened medical personnel. Additionally, the country has a chronic understaffing of health educators and cooperation between different health providers and organizations is very poor. The poor cooperation was seen to result in delays in and improper disposal of waste and sanitation services (Al-Khaldi, Al-Sharif, Al-Jammal & Kisha, 2002; Al-Shammari, Khoja & Al-Subai, 1995; Al-Khashman, 2001)

2.1.3       Professional development

            According to studies, there are very few opportunities for primary care workers to develop themselves professionally. Only about 30 percent of all physicians working in the primary care field possess postgraduate qualifications. Close to 60 percent of the respondents surveyed have had no education leave and half had no access to medical journals and related publications (Al-Shammari & Khoja, 1994; Jarallah, Khoja & Mirdad 1998)

2.1.4       Organizational culture

Collectivism is a pervasive cultural attribute in Saudi Arabia. As such, team work is highly valued and this is no exception in the country’s health sector. According to Kalantan, Al-Taweel & Abdulghani, (1999), this has contributed to good work ethic among care providers in the country. However, 33 percent of primary care workers have negative attitudes about their work, with the overriding perception that their work was of less importance compared to other areas of expertise. Close to 67 percent of respondents affirmed their belief that they were looked down upon by society and regarded as being lesser physicians. Besides, they appeared to be little motivated, citing the lack of incentives, inadequate facilities and management systems as key demotivators (Al-Shammari, Khoja & Al-Subai, 1995). Al-Ansary & Khoja (2002) determined that the primary care providers had inordinately high levels of stress.

2.1.5       Execution of evidence based medicine

Another factor which has lowered the quality of health care is the disregard of evidence based medicine occasioned in part by poor access to journals and the internet by medical personnel (Al-Faris & Al-Taweel, 1999; Dashash & Mukhtar, 2003; Al-Khashman, 2001)

Lack of expertise among medical personnel resulting in errors in diagnosis and or management of chronic ailments especially diabetes, hypertension, upper respiratory tract infections and asthma (Al-Khaldi & Al-Sharif, 2002; Al-Mustafa & Abularhi, 2003; Siddiqui, Ogbeide, Karim & Al-Khalifa, 2001; Al-Khaldi, Al-Ghorabi, Al-Asiri & Khan, 2002)

2.2       Mitigating measures

To enhance access to health care, hospitals are resorting to the following measures

Creation of suitable appointment, registration and follow up structures – Al-Khaldi & Sharif (2002)

2.3       Gaps in Literature

The data available is only for government hospitals. Data for private hospitals, military hospitals, security forces hospital, universities hospitals and National Guards Healthcare System (NGHS) is unavailable. Therefore, this study will fill this yawning gap by evaluating the quality levels across the different divides.

3         Research Methodology

3.1       Nature of study

This study was a grounded theory research in the grounded theory method, the researcher is called upon to conduct the study and perform the analysis of gathered data without having formulated a prior hypothesis. This method involves the investigation of the elemental principles of the research problem through assessment of codes, concepts, and categories. The resultant outcomes are free from bias since the investigator does not rely on preconceived ideas but starts the research with an open mind (Fritz, 2008).

3.2       Research method

The research made use of the qualitative approach. According to Creswell (2001), the distinguishing feature of qualitative research is its exploratory focus. This is in contrast to quantitative research which primarily focuses on explanatory inquiry. Another key characteristic of the qualitative approach is the subjectivity of the researcher. Stated differently, qualitative research is preferred when the researcher’s inquiry is based on the respondent’s opinion about a particular occurrence. In that method, the researcher wants to gather subjective data, therefore the researcher’s personal knowledge and research methodology influences the research to a considerable extent (Herndl & Nahrwold, 2000). One of the striking outcomes obtained with this method is that it highlights the researcher’s views during the research process. In this study, qualitative data was obtained through a study of secondary data and in-depth face to face interviews. This enabled us to determine the main factors hindering the provision of quality health care in Saudi Arabia.

3.3       Target population

1. Health education experts
2. Justification for selecting this target group

This population was selected principally because they have prior experience in training the country’s health workers. As such, they were adjudged to be in a better position to give deeper insights on the workings of health training in Saudi Arabia. Secondly, the respondents have had extensive experience in clinical settings and were as such deemed as being able to evaluate the training needs of the health workers and project them back to the academic setting.

1. Sampling and sample size

A convenience sample of 5 health education experts was selected. Inclusion criteria for the study were that the respondents must have been engaged in training medical personnel in Saudi Arabia for the past five years. Additionally, the selected respondents had to be in possession of postgraduate qualifications with clinical experience. The sampling frame was the faculty of Dar Al Hekima College and the King Faisal Hospital and Research Center.

3.4       Survey instruments

The following survey instruments were used to collect data from the specified respondents

3.4.1       In depth interviews

A total of 5 face to face interviews, one each on individual respondents, were administered on the target population. Face to face interviews were preferred as they enabled the investigator to obtain direct responses from the respondents as well as get non-verbal cues that were critical in the subsequent stage of formulating appropriate recommendations

3.5       Research Strategy

The research was conducted according to the steps detailed in table 1 below.

Table 1: the research strategy

4         Data Analysis and Findings

Objective 1: To carry out a detailed secondary study of Saudi Arabia’s health sector in order to identify current service levels

Objective 2: to identify the expectations that patients and other stakeholders have with regard to provision of healthcare in Saudi Arabia, identify accepted best practices and from the literature obtained give an outlay of the service gaps that need to be filled

            In order to fulfill objectives one and two outlined above, the following results were obtained and condensed in table 2 below

Table 2: expectations, perceptions and service gaps of Saudi Arabia health care sector

Objective 3a: To conduct a secondary study of human resource management in Saudi Arabia’s health care institutions

From the review of literature conducted, the following were identified as the main HRM issues bedeviling the provision of quality health care in Saudi Arabia

1. lack of managerial training for the health care heads
2. lack of technical training leading to neglect of evidence based medicine by physicians
3. lack of clear-cut and well documented responsibilities resulting in inadequate supervision
4. inability of managers to make independent decisions
5. High staff turnover
6. Indistinct chain of command
7. Lack of career development leading to frustration and stress among workers
8. Poor working conditions
9. Inability to marshal community participation
10. outdated information systems and manual HRM systems leading to waste of time and effort in paperwork
11. Use of outdated technology
12. Shortage of competent staff
13. High staff burnout occasioned by excessive working hours
14. Poor collaboration between different health providers and organizations
15. Limited professional development opportunities
16. No incentives
17. Poor organizational culture which encourages collectivism and negative attitudes

Objective 3b: to carry out studies of secondary data in order to identify HRM best practices

Literature reviewed suggested that employees in the healthcare service can become the most valuable resources of healthcare institutions. In order to obtain the benefits of proper human resource management in healthcare institutions, 7 steps of managing human resources as proposed by Stoner, Freeman and Gilbert (1995) were identified. These steps are

1) Planning

2) Recruiting

3) Selection

4) Socialization

 5) Training and development

 6) Performance evaluation

7) promotion, transfer, demotions and cut-offs.

The degree of each step may vary from one healthcare institution to another since each may have different requirement and need in a given period. For example, an established hospital in the Saudi Arabia may focus on quality enhancement and spend their financial resources to hire and train new employees to achieve the corporate vision. Meanwhile, a new entrant will start from human resource development (step 1 in the Stooner, Freeman, and Gilbert) and may rely only on several experienced managers to perform on the job training for new recruits.

After performing the first five steps, the next critical step is to maintain the competitive advantage by strictly control the recruitment in order to ensure that the hired personnel are in line with the company’s needs and skill requirements. In addition, Miles and Snow (1984) reveal five elements of strategic HRM that form the core of best practices and which any organization should take into account:

Table 3: Miles and Snow HRM Strategy

Source: Miles and Snow 1984

Objective 3c: to administer in-depth interviews to health education experts in order to identify ways through which the pool of qualified Saudi health professionals can be increased

            A total of 5 in-depth interviews were conducted on health education experts from Dar Al Hekima College and King Faisal Specialist Hospital and Research Center. A response rate of 100 percent was obtained and the results are summarized below:

It was determined that the low level of qualified health personnel is occasioned by

1. High costs of health care training which the government alone is finding hard to meet
2. Limited options for students in public universities
3. Preference for local institutions as opposed to foreign universities by many families in Saudi Arabia
4. Less than adequate response by universities in Saudi Arabia on the needs of the job market
5. Private not for profit training institutes are not aggressive in attracting willing students as they derive no financial benefits from them
6. Limitations in the number of medical faculty
7. Inadequate scholarships on offer
8. Lack of enough training facilities

The following are ways through which, according to the respondents, the pool of qualified Saudi health professionals can be increased

1. Matching the health needs of the country to training initiatives so that the number of training slots available for Saudis for medical training in universities is increased
2. Increased funding to medical training centers
3. Increasing the number of scholarships available for medical studies
4. Involvement of medical alumni in mentorship of students
5. Evaluation of education curricula to ensure that they meet the demands of the job market
6. Networking between training institutions, health professionals, health care students, health organizations and policy makers
7. Secondment of medical personnel to foreign countries to help enrich their experience
8. Public-private collaboration between academia and industry
9. Integration of community-based teaching strategies

Objective 3d: to give recommendations which will enable health care providers improve their level of service quality through adoption of HRM best practices and collaboration with training institutions

            The recommendations deriving from this study are discussed in chapter 6

5         Discussion

From the study of secondary data, it is obvious that the main factors afflicting health care in Saudi Arabia have to do with management. Other factors such as financial incapacitation are not as acute. In turn, the poor management can be directly attributed to inadequacies in human resource management of the health institutions. These inadequacies are manifested in the obvious lack of managerial and technical training. A direct result of this lack of training can be seen in the neglect of evidence based medicine by the physicians as they have no access to medical journals and other current publications, have limited internet access and there are few training opportunities and education leaves to help acquaint them with emerging practices.

Since staff are not motivated by incentives and given competitive performance-based pay, there is a high staff turnover and negative attitudes about their work which only serves to lower the quality of service that they provide to patients. Another aspect of HRM which contributes to poor management of these hospitals is the lack of clear-cut and well documented responsibilities and the chronic inability of managers and supervisors to make independent decisions. These, together with the oft seen indistinct chain of command have spawned confusion, lowered accountability and hence contributed to the dilution of service quality.

The lack of career development and poor working conditions have similarly contributed to the low morale among the health providers and impacted negatively on the quality of service offered. Shortage of competent staff has largely contributed to the high staff burnout occasioned by excessive working hours. Whereas collectivism has fostered team work, it has worked against the recruitment and promotion of competent personnel as meritocracy is sacrificed. People who are less qualified but with good social and political connections may be preferred to competent personnel who don’t ‘belong’.

The net effect of all these practices has been to reduce the quality of service provided by health care centers in Saudi Arabia, led to poor management and threaten to roll back the gains that the country has so far made in provision of healthcare. Clearly therefore, the suitable solution needs to entrench accepted HRM practices in the country’s health institutions as a first step in improving the management of these facilities and consequently the quality of service offered.

Enhancement of the training of Saudis will also help matters, especially with regard to the shortage of competent health personnel. Besides, a key factor behind the perceived poor quality of healthcare is the inability of many care providers to communicate in Arabic. Competent Saudi personnel will help to overcome this drawback to the provision of quality care.

6         Conclusion and Recommendations

6.1       Recommendations

From the outcomes obtained, the following recommendations are proposed. These recommendations will help entrench HRM best practices in health care institutions in Saudi Arabia thereby helping enhance the quality of services provided.

6.1.1       HR Organization and policies and procedures

1. Adoption of clear and unambiguous definition of functions and processes. This will explicitly detail the responsibilities and duties of each and every person in the workplace
2. Clear communication of HR policies to the employees through use of suitable media such as e-mails, staff handbooks, hospital intranet and internet, manuals and induction programs
3. Automating the entire HR functions in hospitals. This will help to save time and release the supervisors and other administrative staff so that they can help reduce the backlog caused by the high number of patients
4. Adoption of online Human Resource Management Systems (HRMS). This system will compel all the members of staff to take part in ensuring that their information is up to scratch thus reducing the time that would have been spent in paper work
5. Introduction of well-documented policies and procedures will enable employees to obtain handy references for the hospital policy and procedures

6.1.2       Organization design

1. Hospitals should introduce detailed, descriptive and up to date job descriptions for the primary care workers and all the other employees of the hospital. This will help define the duties and responsibilities of all employees thus eliminating confusion and increasing productivity. This is essentially important especially for the technical supervisors in Saudi’s primary care sector who have been shown to be ignorant about their supervisory duties. In this way, they will better appreciate their duties in enhancing the quality of health services. The job descriptions will also help in recruiting competent people as they outline the key competencies demanded for each job
2. Care should be taken to ensure that all jobs which have similar responsibilities and duties are graded together. This will help reduce the negative feelings of the primary care workers that their positions are not as valuable as those of their colleagues with similar duties in secondary care

6.1.3       Recruitment and Selection

1. Hospitals in Saudi Arabia need to put in place formal manpower planning processes which would guide them in the selection and recruitment of employees.
2. hospitals must always assess the minimum qualifications for vacant posts
3. hospitals need to have an official induction process
4. hospitals need to carry out exhaustive background and reference checks before employing new workers
5. interviews need to be carried out by skilled parties

6.1.4       Compensation and rewards

1. To ensure that the complaints by the primary care workers and indeed other employees to the effect that they are poorly remunerated and discouraged, hospitals in Saudi Arabia need to establish non-discriminatory and competitive remuneration schemes
2. Hospitals need to conduct regular market evaluation in order to determine the most competitive rates in the market
3. Hospitals need to have well articulated salary bands for all the employees
4. Periodic and systematic job evaluations should be carried out by hospitals to ensure that the work being done is aligned with the strategic intents of the organization and is in line with current market and patient demands
5. Hospitals should introduce formal incentive strategies for all the employees. These incentive plans must be open and simple
6. Key performance indicators must be defined and linked to incentives
7. Hospitals should introduce incentive plans that are not only based on teamwork but also on individual performance

6.1.5       Performance management

1. Hospitals should design and implement effective appraisal system which evaluates the workers and gives criticism, advice and pointers regarding their performance. Feedback given to the employees need to be periodic and opportune so that they have ample time to redress any mistakes
2. appraisals should be conducted at regular pre-stated periods
3. appraisals should encompass all the four key areas of setting targets, measurement and evaluation, review and acknowledgement and feedback
4. Employees should be assessed based on defined key performance indicators (KPIs) and practical and behavioral aptitude. These should then be weighted and scores awarded
5. The feedback process should not be neglected as it fosters openness besides enabling the participants to learn and rectify any mistakes
6. Reward and recognition is equally important as it will enhance competition among the primary care workers thus improving the productivity of each individual and thence the quality of health services

6.1.6       Training and development

1. all the primary care centers need to establish an official training and development program in their institutions
2. Identification of the physicians’ and other personnel training needs should be done every so often based on such important considerations as the employees’ competency and the performance appraisal gap. The hospitals could also create a fixed training schedule that is dependent on the individuals’ level in his or her career
3. Once the training needs have been established, hospitals need to design training programs which factor in both general and technical training
4. The hospitals should identify the best means through which training will be delivered to their employees from time to time. These could be in house training, on the job or external training and induction and orientation,
5. Hospitals should also consider introducing official mentorship programs for its employees and the top management involved in their training
6. Periodic reviews should be carried out in order to ascertain the efficacy of the training programs and feedback obtained from the trainees

6.1.7       Leadership development

1. Hospitals need to come up with effective leadership development programs which encompass all other HRM functions
2. Such programs should at the outset seek to identify star performers and fast track their career, give them challenging tasks, and provide differential compensation. The programs also need to identify the leadership development requirements of each worker and seek to meet those requirements through mentorship, secondments, coaching, and job rotation.

6.1.8       Increasing the pool of qualified Saudi health professionals

In order to encourage medical school and health-related institutions to increase the pool of qualified health care professional in Saudi Arabia, the following measures are proposed

1. collaboration of hospitals with training institutions so that
   • the medical students can be exposed to current practices and their capacity built from the outset
   • the medical students are oriented to an appropriate culture and good working ethics
   • trainees are exposed to the techniques of evidence based medicine
2. creation of collaborative networked environments as illustrated in the figure below

Figure 1: Collaborative networked environments

Source: Majali, 2005

6.2       Conclusion

Efforts to improve the quality of services offered by health care institutions in Saudi Arabia must go hand in hand with the enhancement of training of Saudis in the health field. As the results of this research demonstrate, most of the problems in the health sector can be overcome through the prudent application of HRM practices. These would entail recruitment of competent personnel, continuous and well-thought out training of the employees to help them improve their managerial and technical abilities and effective performance management that rewards high achievers. Additionally, effective HRM practices need to incorporate clear leadership development programs that will groom high flyers. The personnel need to be given incentives and competitive performance-based remuneration in order to help shore up the service levels. Increased collaboration between these institutions and centers of learning will prove critical in improving the pool of qualified Saudi health professionals.

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