Preparedness to Implement “A Family Physician for Every Family,” which is the Magic Recipe for Cost-Effective Health Care for All: Viewpoint

Abstract

The Saudi Vision 2030 endorsed health-care models emphasizing promotion, prevention, and effective treatment. The 2008 World Health Organization report, “Primary Health Care: Now More Than Ever,” also encouraged reform. The objective of this study was to highlight the evidence and benefits of scaling up PHC capacity to implement “a family physician for every family” model. PubMed, Google Scholar, the Saudi digital library, theses, conference proceedings on family medicine, primary care, general practice, family physicians, government reports, policy documents, and press releases in Arabic and English were searched from September 2021 to September 2022. The search terms included: Saudi health care, health-care transformation, family medicine, primary care, general practice, family physician, family doctor, Saudi Arabia, Saudi Vision 2030, phone consultation, virtual clinic, electronic medical records, public–private partnerships, and privatization. Vision 2030 endorses the transformation of the public sector to implement international best practices. Saudi Arabia is ready to implement “a family physician for every family” model to reduce morbidity and mortality from noncommunicable diseases while improving quality and cost-effectiveness. The extensive network of health centers, growing number of family physicians, and advanced digitalization can accelerate this. In addition, mobilizing resources and incentives can optimize health promotion and disease prevention.

INTRODUCTION

Saudi Arabia is likely to be one of the world’s fastest-growing economies as reported by the International Monetary Fund.^[1]

Since the Ministry of Health (MOH) was established in 1951, the public health authority expanded health facilities, moving from emergency services to a network of hospitals and health centers.^[2] There has been a huge expansion in primary, secondary, and tertiary care services. Saudi Arabia adopted the World Health Organization’s (WHO) Primary Health Care (PHC) 1980 initiative at Alma-Ata, Kazakhstan.^[3]

The PHC initiative was suggested by the WHO after global health challenges were presented in global health reports. The first initiative (1962) blamed a lack of generalists, unequal access to care, rising costs, and an inefficient system. The second initiative (1973) noted limited access to services, a health professional shortage, and insufficient engagement at community and other sector levels.^[3] Planning and distribution failed due to limited data and economic deterioration. In the 1960s and 1970s, specialization caused dissatisfaction and led to legal disputes due to a lack of general doctors, rising costs, and fragmented care. Later, family medicine gained popularity, becoming an academic discipline.^[4]

The WHO 1978 recommended PHC to overcome health-care barriers. PHC provides affordable health care based on feasible, scientific, and socially acceptable methods and technology to maintain self-sufficiency and self-determination. It is the first point of contact, as close to people as possible, and provides continuing care. The PHC’s eight services include health education, healthy eating promotion, environmental sanitation, comprehensive maternal and child care, immunizations, disease prevention and control, and managing common diseases and injuries.^[3,5]

In 2008, the WHO reemphasized PHC in developed and developing countries.^[6] Some countries, such as the United Kingdom, were at the forefront of improving primary care, coverage, access, affordability, acceptability, applicability, adaptability, and cost-effectiveness.^[7]

Saudi Arabia’s mortality rate has fallen faster over recent decades coincident with an improvement in the Healthcare Access and Quality Index levels and the socioeconomic situation. Saudis focused on preventing illness and disability. In 2021, the life expectancy at birth increased to 75, and infant and maternal mortality rates decreased to 6 per 1000 and 11.9 per 100,000, respectively.^[8,9] Currently, 497 hospitals and 77,224 beds serve the 35 million population in Saudi Arabia. Primary care center resources vary by region, rurality, and urbanity.^[8] Vision 2030 strengthens human resources, decentralization, and resource use. Saudi Arabia’s new model of care (MOC) prioritizes PHC to reduce the noncommunicable disease (NCD) burden.^[10] This article highlights evidence for scaling up PHC capacity and implementing “a family physician for every family” model and highlights benefits to the health-care system if it is used to counter threats and challenges [Table 1].

Table 1: Health Indicators in Saudi Arabia in 2021

SEARCH METHODS AND RESOURCES

The author searched PubMed, Google Scholar, the Saudi Digital Library, and the Internet for publications, theses, and conference proceedings on family medicine, primary care, general practice, and “family physician for every family” in both Arabic and English. The search terms included: “family medicine,” “primary care,” “general practice,” “family physician,” “family doctor,” “Saudi Vision 2030,” “Saudi healthcare,” “healthcare transformation,” “electronic medical records,” “phone consultation,” and “virtual clinic.” Moreover, the author looked for secondary data published in government reports, policy documents, government strategy documents, and pertinent press releases. The search was conducted from September 2021 to September 2022. The findings are presented mainly in narrative form.

RESULTS

Saudi vision 2030

The Custodian of the two holy mosques, King Salman Ibn Abdulaziz AlSaud, launched his Royal Highness, Crown Prince Mohammed Ibn Salman AlSaud Vision 2030 in June 2016. Saudi Arabia began public, economic, and social reforms by capitalizing on the country’s God-gifted strengths, including a top-20 world economy and a young population. The government has decentralized health care through stewardship, good governance, accountability, and transparency. Vision 2030 has increased the effectiveness, responsiveness, and expansion of health-care services. Five-year plans have facilitated infrastructure construction which has been expedited to reach 2030 goals.^[10]

The Kingdom’s 2030 vision supports efficient health-care models, such as MOC, and promotes health, disease prevention, and effective treatment of diseases. Furthermore, it aspires to improve Saudi Arabia’s health-care system and population and prioritizes evidence-based care reform. The giant transformation and reform plan of Vision 2030 has a great capacity to solve shortcomings in practice, particularly resource supply and promotion of efficacy.^[10]

Family physicians and cost-effectiveness

A study reported that primary care improves health, lowers costs, and increases equity. This same study recommended a primary care-oriented system with equitable resource allocation, government-sponsored health care or insurance, low or no copayments for medical services, and little or no private health insurance.^[11]

Family medicine doctors tend to be more holistic compared to subspecialists, who typically focus on a single organ system [Figure 1]. They are the patients’ first contact and coordinate care that promotes patient satisfaction and provides continuity of care. Direct doctor–patient communication boosts prevention, and premature deaths improve outcomes and reduce chronic disease costs. Family medicine reduces drug use, emergency department visits, hospital admissions, and laboratory and imaging tests. PHC evidently improves mental, maternal, infant, and neonatal health,^[12] and has high clinical benefits in diabetes^[13] and depression at a low incremental cost.^[14] Training more primary care physicians (PCPs) in office-based colonoscopies could help improve colorectal cancer screening compliance with favorable cost-effectiveness.^[15] Finally, evidence showed that every 10 additional PCPs per 100,000 people correlated with a 51.5-day increase in life expectancy from 2005 to 2015.^[16] More young physicians must be trained and incentivized to become PCPs.

Figure 1: Holistic approach of the family physician

Family medicine and training programs

Numerous support activities were associated with implementing PHC in Saudi Arabia. One was preparing locally edited guidelines and instructions for health center personnel to follow. It was also linked to various levels of on-the-job training. Eventually, all health-care centers’ personnel underwent orientation programs, refresher courses, and advanced courses. In addition, staff knowledge in those centers was evaluated annually before contract renewal.

Undergraduate training

Nationally, all 40 colleges of medicine in Saudi universities designed their curricula to include family medicine. This course included didactic and clinical training and highlighted the concepts, principles, and implementation of family medicine. These efforts were made to address staff shortcomings and increase the number of graduating doctors exposed to family medicine who would join the growing number of family medicine training centers. This led to an annual intake of over 600 family medicine residents. Nationally, a substantial literature has supported teaching and training at undergraduate and postgraduate levels, largely in a national context. In addition, students and professionals have access to the international literature on areas of interest.

Role of the Saudi commission for health specialties

The Saudi Commission for Health Specialties (SCFHS) organized the family medicine residency curriculum, training, and accreditation to improve the quality of family physicians. In addition, SCFHS ensures that Saudi/Arab board residents from Saudi Arabia receive adequate training so they will be eligible to take board examinations.

SCFHS requires doctors to complete continuing medical education hours, conference, lecture, and workshop counts. King Faisal’s Family and Community Medicine Fellowship and King Saud’s Master of Science in Primary Care began in 1983 and 1984, respectively, with the help of international experts. In the year 1990, King Saud University pioneered the first batch of Residents in the Arab Board of Family Medicine and then in 1992 joined the postgraduate program in Jeddah.

King Saud University accepted its first Saudi Board Family Medicine residents in 1996, followed by institutions in Jeddah in 1997, Tabuk, Madinah Munawwarah, and Abha in 1998. The MOH in collaboration with Egypt initiated a family medicine residency program in Cairo in 2007, and in 2008, the MOH launched another residency program in Sudan.^[17]

Saudi Board in Family Medicine training centers has now expanded to 24 centers; with 608 residents and recruiting 1222 trainers in the year 2021.^[18] The number of family physicians working in MOH health centers in Saudi Arabia exceeds 1,418.^[8] These achievements prepare Saudi Arabia to implement “a family physician for each family.”

Primary health care and digitalization

The MOH launched a project to connect family medicine and hospitals.^[17] The COVID-19 pandemic demonstrated the efficacy of Vision 2030-enabled digitization, where the MOH launched 19 health apps, innovative telecoms, social media, websites, and SMS.^[19] Wasfaty’s e-service helps to arrange free medicine. This e-service detects drug interactions and typo errors while allowing easy monitoring, responding, referring, and consulting with other professionals. It saves time and money while protecting patient privacy and confidentiality. Patients valued pharmacist availability, instructions, privacy, and confidentiality.^[20] Absher, an e-government app, has 23 million registered users. Health-related information is available through e-government platforms, as are the prevalence of NCDs and risk factors.^[21] Tawakkalna is another e-health application. E-service integration boosts physician productivity several folds.

Electronic health records (EHRs) improve data accuracy and access, allowing for earlier detection and treatment of chronic diseases and encouraging healthy eating and physical activity. EHR use was influenced by socio-organizational and systemic factors. Saudi PHC center doctors prefer EHRs. Large-scale implementation requires expertise, knowledgeable users, technical support, and interoperability. In many countries, EHRs improve primary care quality while lowering costs. Primary care reform is centered on EHRs and telehealth. The 937-Call Center for COVID-19 aids Saudi Arabia in disease prevention. COVID-19 counseling and education are constantly available.^[22] Planning patient-centered virtual clinics are critical. Using the Sehaty telemedicine app and call center may help to reduce emergency room visits^[23] and support rural PHC centers, available constantly.

Challenges and difficulties

In-depth PHC evaluations in 1989 and 2006 revealed challenges and solutions.^[24,25] Saudi Arabia’s 2 million km²and 13 administrative regions, governorates, and centers present challenges for the health-care system. The growing population, chronic diseases, other health threats, and poor health among at-risk individuals also contribute. Health planners faced the maldistribution of PHC centers due to population density, distance, road types, improper buildings, and rising medical costs. Furthermore, primary care centers rely on hospitals for supplies. Inadequate training programs for workers, including medical and administrative staff and inappropriate workplace guidelines, policies, and procedures are problematic. Diagnostic imaging, laboratory testing, and dental services are underutilized. Treatment, preventive measures, and referral procedures are inadequate. Lack of community involvement causes underutilization of PHC.^[17] Novel disease patterns, especially contagious diseases, and development and behavior disorders pose a threat. However, recruiting adequate PCP is the biggest challenge worldwide. For example, the U. S. demand for PCPs is expected to rise until 2032. The shortage is attributed to low comparative compensation; therefore, standardizing physician pay may reduce the deficit.^[26] Other challenges may attribute to the multiplicity of health sectors with different accountability. Public and private health facilities have different systems of responsibilities. Clinical frameworks define treatments, procedures, policies, and practices. In addition, health-care workers need time to change. Moreover, Saudi Arabia, home to Islam’s two holiest mosques, has opened a network of free health centers and hospitals to accommodate about 2 million visitors coming for Haj.

The improvement in PHC after the 1989 assessment and the progress after the 2006 assessment show that these challenges required significant effort to overcome and reduce their impact. In 2021, the life expectancy at birth increased to 75 and infant and maternal mortality rates decreased to 6 per 1000 and 11.9 per 100,000, respectively.^[8] Furthermore, work to achieve Saudi Vision 2030 and health transformation aimed to improve many services, including PHC, and we expect these challenges to pass.^[27–29]

Study limitations and the scope of further research to address these limitations

The lack of published health system research in scholarly journals – especially cost-effectiveness research – may explain some of the studies’ limitations. Further, owing to the number of health sectors, some crucial statistics are unavailable or inaccessible. Finally, because primary care changes in the Kingdom are relatively new and are undergoing rapid and ongoing reform, there has been little time for an in-depth evaluation and documentation of these changes in peer-reviewed literature. Therefore, I based my opinion on what I have read and my colleagues’ observations over the past 40 years.

As we are in the midst of the ambitious vision of 2030 and the rapid transformation of the health-care system, I recommend that researchers, especially those from academic and research institutions, assess all steps before and following implementation and publish so that future researchers and decision-makers have good insight into what was achieved, what modifications are needed, and how cost-effective each method used were. Such steps are essential for the provision of health care, dissemination of knowledge, and preparation of future health professionals.

CONCLUSION

The Kingdom is ready to implement “a family physician for every family” in PHCs. Although the number of family physicians needs to be increased, the highly qualified number of them and their primary care team can lead the change in existing centers [Figure 2]. Widespread health centers increase access to socially and scientifically acceptable health services. More family physicians and health centers will eventually join. They can develop more therapeutic, laboratory, diagnostic, and rehabilitation capabilities with resources and support. Crown Prince Mohammed Ibn Salman AlSaud strongly supports Vision 2030, which aims to transform all public sector services so that the Kingdom can apply international best practices and set an example. The Kingdom’s excellent Internet infrastructure and successful digital transformation in many service sectors put it among developed countries in service speed and quality. This advanced digitization is anticipated to enhance patient management, safety, the referral and appointment system, and intersectoral collaboration. With the same ambitious steps, PHCs can be accelerated, facilitated, and developed to attain the Vision’s goal. Despite significant progress in reducing vaccine-preventable diseases and infant and maternal mortality, chronic NCDs negatively impact patient quality of life and the health-care system.

Figure 2: Primary health care team and the services they can provide

Family physicians are trained to address their patients’ physical, social, and psychological needs, to promote health and disease prevention, and to treat or refer as needed. Applying the concept of a family physician to every family will reduce morbidity and mortality among Saudis and raise quality and effectiveness while minimizing costs. The health-care system should reward family physicians for preventing disease and promoting health. An incentive will encourage them to cover all registered patients and boost cost-effectiveness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.