Saudi Arabia's Demographic Shift and Healthcare

1.0 Introduction

1.1 Background and rationale

The kingdom of Saudi Arabia is the largest country in the Middle East, with a land area coverage of 2,250,000 square kilometers. Saudi's population since 1975 has been increasing rapidly till 1980 (see fig 1 below); since then it has been declining gradually, with an annual change of 2.0% (World Bank, 2020). The country's healthcare system is primarily affected by two factors, the high percentage of expatriates working in the country and the large percentage of the young population in the Country (Albejaidi, 2010). In 2010 almost 25% of the country's population represented foreign nationals (ibid). Besides, 40% of the country's population represents young people (below the age of 15 years) while only 3% is the percentage for people over the age of 65. From these demographics, it is clear that the previous two factors are affecting Saudi’s healthcare system significantly (ibid).

Currently, Saudi Arabia's healthcare service is free to all citizens and foreign nationals working in the public sector. The service is primarily dispensed by the Ministry of Health and enhanced by other governmental health amenities. However, the government necessitates that the foreign nationals working in the private sector should have their employers contribute some percentage into the healthcare fund to receive the service. In Saudi Arabia, healthcare is seen as a right, and if primarily funded by the public with an average of 75% or out-of-pocket expenses amounting to 25% (WHO, 2016). Private insurance involvement in the provision of healthcare has been distinctive in the country. Almost a hundred percent of private expenses have been out-of-pocket expenditures for services in private facilities. Funding of the healthcare facilities is done annually to individual ministries and programs. However, royal decrees might be issued for allocations of extra budgets for special health plans or projects (Albejaidi, 2010).Sometimes, the government fails to meet these runaway costs, and in some situations, it has been forced to cut the budget to meet other needs. All these challenges have led to the weakening of the quality of care offered to patients.

Even though Saudi Arabia’s healthcare system has undergone several changes to enable effective service delivery, it still faces crisis after crisis, especially with the quality and equity aspects. This disparity is brought by underfunding or inefficient operations or a combination of these two factors (Gershlick et al., 2015). For instance, healthcare costs have been increasing rapidly (see figure 2), forcing the government to adjust its budget to meet these needs (WHO, 2013). The rapidly growing population has been the primary cause of the increment in healthcare expenditures. Besides the population comprising of the young generation, it has been a major contributing factor for the escalating healthcare costs for all Saudis. Also, there has been an increasing awareness of the accessibility and growing demand for high specialty care and innovation services by patients. The increase in demand is followed by a slow construction of capacity for patients, which has increased the waiting times in many facilities. Regular waiting time for healthcare could exceed one month, even up to a year. In order to match this growing demand, the ministry of health requires to establish nearly 28,000 hospitals by 2021(WHO, 2020). Besides, in 2016, the government launched an ambitious plan with the primary objective of transforming the healthcare sector in the country. In this regard, it developed a National Transformation Program incorporating 24 government agencies in a bid to build capacity and ability to achieve an ambitious 2030 goals; among these goals are access to healthcare, enhanced quality of healthcare services, and promoting the prevention of healthcare risks (Saudi National Transformation Program, 2018).

Several attempts to solve the paradoxes within this multifaceted system have been undertaken. For instance, the National Transformation delivery report plan identifies the amount of savings that could be made if the need for patient-level information and costing and several other agencies could recognize the significance of better quality information and apply standard measures in providing accurate comparative data to propel quality outcomes (Kingdom of Saudi Arabia, 2018). The logic is to provide healthcare closer to their homes or in the community to cut unnecessary costs involved in hospital admission. Besides, it is crucial to note that the healthcare system cannot function properly without an equally operative and well-funded social care system along to integrate all attributes of care (Fulop et al., 2019).

The National Transformation Healthcare strategy report, however, identifies that despite the increased efforts in improving healthcare both in public and private facilities in Saudi Arabia, the country still relies heavily on expatriates to provide health professionals. This situation might develop into high turnover rates regardless of the government's undertakings to improve the healthcare system, especially with the opening of new training centers and supporting the medical professional and staff in foreign institutions (WHO, 2013). Eventually, all these efforts are aimed to attain a value-based health care system. According to Porter (2014), value-based healthcare is a framework where service providers, including hospitals and physicians, are compensated according to patient outcomes. These recompenses are awarded after assisting a patient in improving their health, and also enabling them to live healthier. Patient outcomes are measured through a stout evidence-based model that focuses on patient's experience, mortality rates, and timeliness of care through the treatment cycle and is understood by prioritizing health outcomes that matter to the patient over the cost of delivering the outcomes (Lakdawalla 2013). This places the patient's experience at the core focus of a value-based health system. This results in a reallocation of resources to meet the patient's outcomes and thus creating cost-effectiveness. This move puts value-based healthcare as a promising model to enhance health among patients and manages their conditions. This promise warrants examination of whether an evidence-based healthcare system is indeed valid and the experience of the patients in value-based healthcare is increased. Additionally, understanding how value-based healthcare can tackle the pressures associated with technological advancements and increasingly complex and multiple health complications of patients (Porter 2014). Besides, wasteful spending by the government, especially during budgetary allocation, should also be looked at to achieve the required results effectively (OECD 2017). A value-based healthcare system strives to restructure the healthcare system and healthcare delivery by shifting the inclination and approach to health service delivery (Porter 2014). However, the system needs to be tailored for every patient needs to provide the value expected.

Several studies have examined the aspect of value-based healthcare, especially chronically ill patients and older people (Porter, 2010; Haas, 2015). These studies examine the management and performance in healthcare and uncover that value-based healthcare is contested by balancing economic necessities against patient's satisfaction and needs. Just like other organizations, healthcare facilities seek to maintain and collect resources and avoid any loss. Resources in these facilities include various types, including human resources, capital, technology, and knowledge (Grol et al., 2013). While organizations are increasingly facing difficulties in maintaining these resources, they are also pushed to offer high-quality services to their customers. Therefore, resource orientation and patient-centeredness are sometimes conflicting corporate objectives (Haas et al., 2015). While, for example, capital spending in quality of the healthcare providers as an approach of increasing human resources might be beneficial for patient-centered care, task overload for these people might hinder patient-centered care outcomes (Lakdawalla et al., 2018). The relationship between resource orientation, value-based healthcare, and its effectiveness has been discussed in several studies (Porcheret, 2014; Saas, 2016). Quality and performance go hand in hand, and a performing healthcare system should have tailored healthcare to fit its purpose. According to EFPIA (2019), value-based healthcare can facilitate the timely provision of health services by directing efforts such as prevention and interventions that bring the most value to the patients. Accessibility of health care enhances the quality of service delivery since the patient will have a crucial role to play in evaluating the services provided (OECD 2017). Furthermore, a value-based health system creates an environment for championing preventive interventions and integrating innovative solutions in the provision of healthcare. However, OECD (2017) points out moving from free-for- service of payment models to outcome-based could reduce access to access to interventions that are low value to the patients. These interventions include the cesarean section and percutaneous coronary intervention in stable patients. Organizational and administrative attributes relating to their effect on value-based healthcare and patient outcomes such as staff quality, health literacy, among other factors, have also been studied widely (Driessen, 2010; Kampstra et al., 2018). But value-based healthcare has not yet been studied extensively, especially with its benefits, faults, and association with cost, accessibility, and quality. Therefore, this study will examine the aspect of value-based healthcare, considering all issues affecting it.

1.2 Study objectives

This study sought to achieve the following objectives

Examine the benefits of value-based healthcare

Investigate value-based healthcare models

Explore patient experience in the value-based health system

To identify and analyze the challenges faced in the implementation of a value-based healthcare system in Saudi Arabia.

2.0 Materials and Methods

2.1 Context of the study

This study sought to discuss value-based healthcare as a practical approach to improving healthcare in the Kingdom of Saudi Arabia. Following this, it employed a systematic analysis of various works of literature, highlighting the need for value-based healthcare in the country.

2.2Literature search

The study conducted a literature search through online sources such as MEDLINE, EMBASE, and Google Scholar databases to find relevant evidence for this study. According to Christmals et al. (2017), a literature search is a process of searching and selecting shreds of evidence linked to the subject under discussion to conclude on the argument presented. The search process was systematic and organized, as highlighted by McGowan & Jessie et al. (2016), enabling an active identification and selection of relevant researches to the subject.

2.3Search strategy

The Nursing and Midwifery Council (2015) highlights that conducting a literature search requires a search strategy to locate the most relevant evidence to a subject. Therefore, this study sought the most recent primary journals in MEDLINE, EMBASE, and Google Scholar databases. These databases were selected since they formed part of the fundamental research process. The PRISMA diagram was used narrow down the search and identify relevant sources to be used in this study. Sources identified from these sites were ranked based on their originality and validity. This process involved answering two primary questions: 1) are the data valid? 2) Are the research methods reliable? These two questions helped the author determine which material was credible and reliable (Sarantakos & Sotirios, 2012). Various subject title headings were identified and used during the search process. These headings included a Value-based, practical model, improving healthcare, health system, health care, and patient experience. The author employed Boolean operators such as and, in to combine the keywords enabling selection of appropriate evidence (Coughlan et al., 2013). The process looked for peer-reviewed journals and articles because they are more reliable and of a higher standard than non-peer reviewed sources; besides, they contain the most recent evidence (Aveyard & Helen, 2010). This search process was motivated by the nursing and midwifery council requirement, which recognizes the need for competence in valuing the worth of evidence in practice and also the ability to understand, evaluate studies, and also to identify specific areas that need further research (NMC, 2015).

2.4Inclusion and exclusion criteria

The inclusion criterion for this research included selecting all forms of peer-reviewed journals such as qualitative, quantitative, and mixed methods pieces of evidence linked to value-based healthcare. Secondly, the study sourced for evidence published in the last ten years (2010- 2020). These works of literature were also published in English. Newer sources ensured that the evidence obtained and findings were relevant to the current times. Additionally, the exclusion criterion included all works of literature not related to the topic under investigation, and abstracts. This approach ensured that the research had logical precision, and only relevant evidence was used to make the study credible.

2.5Main themes

The primary themes for these studies were the effectiveness of a value-based healthcare model in enhancing patient health. In the results section, terminologies related to value-based models such as accountability and transparency, E-health, community participation were used. These terms were put in the perspectives of the participants, increasing their understanding of value-based healthcare in improving their health.

2.6Critiquing tool

This study employed a structured critique approach for works of literature used in the research. The study also employed a systematic analysis of all literature to conclude the findings presented. A structured critique approach enabled the author to ascertain the strengths and weaknesses of every material used in this research. In this regard, the author evaluated the research questions and aims of each study to determine if they were stated clearly to qualify in being used as evidence in this study. Besides, the author also looked at the research design of the literature to see whether they were appropriate (Aveyard & Helen, 2010).

2.7Limitations of the search

It was not possible for the author to review all selected, relevant literature linked to the topic, and this circumstance might have limited the validity of this study. Additionally, there was little research on the value-based healthcare system in the Kingdom of Saudi Arabia, which prompted the author to use works of literature with other countries' origins, in the Gulf region such as Qatar since their health system is quite similar and transferrable to the Saudi Arabia’s (Acerete et al., 2012).

Chapter 3: Results

3.1 A systematic review of individual studies

Dobbs & Warriner (2018) published an editorial seeking to identify various principles in Value-based healthcare that could be of benefit to a healthcare system (see figure 4). In this regard, they identified five basic approaches of value-based healthcare service delivery which include

Organizing into integrated practice units – this approach seeks to organize healthcare into built-in practice units that deal with specific conditions. For instance, for in diabetes, a group could comprise of physicians, surgeons, psychologists, and all other specialists who could provide assistance to diabetic patients. This approach could enable the patient to meet all needs in one location with the convenience of the patient. Measure outcomes- Measuring outcomes that are significant for the patient and costs during the whole treatment cycle for every patient would allow easy identification of duplication and wastage of resources. The main objective in this attribute, according to Dobbs & Warriner (2018), is to apply time-driven activity-based costing, which is the main attribute of a value-based healthcare model that seeks to understand costs at the patient level. Looking at payment methods- The third assumption by Dobbs & Warriner (2018) highlights the approach through which patient interactions are funded. In this argument, they conclude that payments by a fee for service or by capitation approach do not enhance value. They suggest a bundled payment system that enables making payment for a complete cycle of care. For instance, hip replacement, including all recovery costs,' this approach allows for the care provider to be compensated for enhancing health outcomes and efficiency of its services. Integrated services - According to Dobbs & Warriner (2018), integrating services across all facilities in a country means that the patients will have the opportunity of looking at services provided across multiple organizations and choose which services offer the best value and also less proximity to their place of residence. Spreading excellence- According to Dobbs Warriner (2018), providers need to spread success across locations. This approach could be achieved through creating a hub and a spoke approach where clinical standards are applied by all clinicians and those working in performing centers visit underperforming facilities and vice versa. The primary assumption is to working collaboratively to attain the highest standards of practice.

E-health- Lastly, the whole process needs to be supported by an enabling Information Technology system such as telemedicine, teleconsultations, among other practices. This approach seeks to improve the efficiency of the healthcare system and access to all. Another study by Porter (2014) discusses the value-based healthcare system and the function of results and opportunities available for the Organisation for Economic Co-operation and Development (OECD) countries. In his report, Porter identifies that at least about 10% of monetary allocations to healthcare in most states do not provide the value it is supposed to give to patients. In this regard, Porter identifies that a value-based healthcare model is expected to decrease healthcare costs by reducing wastages and shifting resources from a lower to a higher value activity. Further, Porter notes that the value-based model is placed as a promising approach to improving patient's health and managing their health conditions since it is tailored to meet individual needs. Another study by Putera (2017) finds that World Health Organization identifies a value-based healthcare model as an approach to drive providers in evaluating their businesses to consider not only pricing and cost but also emphasize patient outcomes. According to Putera (2017), results are something significant to a patient and needs to encompass all necessary aspects in the full cycle of treatment. The author further emphasizes that the idea could be realized if the implementation of suitable health payment schemes, introducing integrated and collaborative work by providers, and also the application of IT to provide efficient services. A new approach- Lastly, the author identifies that the Value-based model is a new initiative that focuses on prevention and goes beyond disease treatment. In this perspective, it combines the role of individuals, community, and institutions with the function of health service providers to increase access to healthcare in conformance with best practices. Gentry & Badrinath (2017) also highlights that the demand for healthcare is increasing because of the increase in aging populations, rising prevalence of chronic conditions such as dementia and diabetes, and technological advancement. In this regard, there are more effective and cost-effective measures present, which can be implemented using a limited budget. In this line of thinking, Gentry & Badrinath (2017) proposes the value-based model, which they assume to put the available resources into optimal use. They argue that this approach ensures that available resources are used for strategies that offer results patients most value. They conclude that value-based healthcare puts what patients value at the core of healthcare. It assists in ensuring that they obtain the service that provides them with results that they deem vital and that the limited resources are dedicated to high-value interventions. They recommend the value-based approach because they believe the healthcare sector needs flexible, personalize, and tailored services to patient values. Verma and Bhatia (2016) have also examined how countries could benefit significantly through the triple Aim approach by the Institute for Healthcare Improvement (IHI), reflecting the difference in the health services in countries such as the UK and the USA. The authors identify the triple Aim approach as an intervention that constitutes fundamental goals that guide the health system transformation. In this regard, they determine that the UK has benefited from adopting a more patient-centered approach that has improved population health, promoted patient experience, and reduced healthcare costs. Further, they highlight that just like all other universal healthcare systems, the Ministry of Health in Saudi Arabia has an overt and legally obligated commitment to take provide for health needs for its population within a predetermined and fixed budget.

Another study conducted by Levesque et al. (2013) sought to conceptualize the value-based healthcare system and how it increases access to healthcare among populations. The study employed a synthesis of published works of literature related to access to healthcare using a patient-centered approach. The authors conceptualize five themes to describe accessibility; they include approachability, acceptability, availability, affordability, and suitability. In this regard, the authors find that a more patient-centered approach to healthcare increases the ability to seek, perceive, access, pay, and engage healthcare in patients. Meinert et al. (2018) identify potential difficulties that could affect value-based healthcare service delivery. The authors employ a synthesis of published pieces of evidence to major their argument. Their aim was to weigh the benefits and risks associated with security, confidentiality, and implementation of innovation in a value-based healthcare system. In this regard, they highlight several challenges, including a lack of scale-up plans and timely assessment of patient's information to enhance treatment. Besides, they identify other risks, including noncompliance with data protection regulations among experts, poor data governance, and overrated anticipations from the fast-developing of technology. All these factors and risks contribute to the unsustainability of value-based services. The authors conclude that technology could be one of the potential factors contributing towards the success of value-based healthcare system, but also could potentially bring to its failure. In this regard, they acknowledge that healthcare organizations are faced with various problems and threats that arise from the usage of innovation. Therefore, they should prioritize the most positive impact, which is an optimized cost for maximized patient satisfaction (Meinert et al., 2018). On the same page is El-Seoud (2013), who tries to increase understanding of whether a country will improve patient health outcomes by introducing technology in value-based pricing, R&D in facilities, and patient access programs. The author argues that technology introduces added uncertainty that will affect Research and Development in facilities because the researchers will not be able to increase certainty on the underlying cost-effectiveness of the innovation itself by amassing evidence and use. Another study by Almalki et al., (2011) looks at the various policies that could increase healthcare access; in their overview, they identify that a healthcare system could be enhanced by adopting 'Equity and excellence' policies introduced in the National Transformation Program of 2016. These policies emphasized the preventive, predictive, and tailored medicine aspects of a patient. In this regard, they emphasize that precautionary measures have created a more responsive, patient-centered system that has resulted in better patient health outcomes.

A study conducted by Mohamed et al. (2015) aimed at ascertaining patients’ satisfaction with primary health care centers’ services in Majmaah, Saudi Arabia. The study used a survey in collecting information from 370 participants who were selected by stratified and systematic sampling at two selected facilities in the city of Majmaah. The results were categorized into two attributes, they include; Connection and communication levels- All respondents liked it when doctors allowed and encouraged them to share their stories; besides, they valued even more when the doctors actively listened during consultation since it allowed them to describe their symptoms and how they felt in detail. Some respondents likened such encounters to chatting with a friend, and such connection promoted disclosure of concerns that were crucial to the patient. Also, a serene environment where consultations would occur was deemed as necessary by most of the respondents. Some identified that they always felt relaxed and open in such settings. A third of the respondents thought that a practitioner being polite or welcoming them with a smile at the onset of a conversation made them feel at ease and could develop an open and friendly attitude. Half of the respondents associated 'no eye contact' with not listening or not loving and disliked doctors or nurses who did not observe eye contact instead kept writing on books or looking at computer screens. The above results were also backed by a study conducted by Alshammari (2014) in Hail City, Saudi Arabia, which found out that patients were more satisfied by human qualities from doctors as compared with thoroughness and continuity of care. Supporting this argument is another study by Almoajel et al. (2014), which also sought to examine patient satisfaction with primary healthcare in Jubail City, Saudi Arabia. The study found the following outcomes. Most respondents deemed factors such as showing concern, being kind, and compassionate were characteristics of a good doctor. When a doctor expressed such attributes, they deeply valued them. Also, the respondents regarded these personalities as more trustworthy and were more open to sharing their concerns. Only a quarter of the respondents mentioned the level of training for doctors as a crucial aspect in determining whether a doctor was good. Instead, the factor of showing care from doctors, especially during the consultation, was a fundamental measure of differentiating between a good and a bad doctor. A third of the respondents pointed out that they appreciated when the doctor physically examined them. Most of the participants perceived the act as a factor of a caring and thorough healthcare personnel and a crucial aspect of diagnosis, thus getting a 'full picture' of the illness in a patient (Almoajel et al, 2014). Most respondents considered a ‘good doctor’ as one who had a positive approach, and this aspect gave them hope. In this regard, a good doctor was likened to have qualities such as providing direct advice, clearly diagnosing a patient, the likely time, and eventually, the outcomes of the treatment. This argument was closely linked with the ability of articulation within a doctor, especially when giving advice which is also identified in Alshammari (2014)’s study. The study also reports that most respondents identified this attribute as a primary factor of a good doctor and their satisfaction during the consultation. The essentiality in explanations to patients was not linked to whether they attended public or private healthcare facilities.

Chapter 4: Discussion

The research outcomes upon going through synthesis resulted in four major themes.

Positive outcomes of the value-based healthcare system

Potential difficulties of the value-based healthcare system

Association of the value-based healthcare system with accessibility, costs, and quality

Healthcare and prevention of health risks

4.1 Positive outcomes of the value-based healthcare system

The ongoing works of literature by distinguished researchers provide a deep insight into the general feeling of a value-based healthcare system. Dobbs & Warriner (2018) compare the volume-based healthcare system with value-based care and finds that the latter is potentially radical since it involves putting the patient at the forefront of the healthcare fashioning process. (Putera (2017) also notes that the Saudi Arabian patients have been working alongside the service providers to determine the outcomes they need from their healthcare. In this regard, positive results have been identified as any changes for better in patient's health, including being able to walk again after a bad fall, or regaining control after being mentally ill. The value-based healthcare system is linked to promoting the quality of service. According to Sussex et al., (2013), the precept of his model is based on the patient's right to hold health care providers accountable for the consequences that arise from a service. Therefore, the value-based model integrates information regarding patients' outcomes and medical expenses data in a significant and actionable approach. Ideally, this approach seeks to ensure that patient outcomes are satisfactory to the patient, the insurers, and this makes healthcare providers capably in a competitive environment (Putera, 2017). The Value-based healthcare model has been linked to patient satisfaction. According to Latif (2013), this model encompasses reducing medical errors and recompensing the competent care provider in a facility. Such rewards could be overall price discount negotiations, among other incentives. In this regard, since patient satisfaction is a factor of the value-based approach, most practitioners and care providers would wish to increase their efforts to satisfy as many patients to receive rewards. Also, according to the survey results, patient experience is primarily determined by the approach of the health practitioners to the patients and examination and explanation of the entire process of healthcare to the patients. Most respondents argued that they will always prefer a physician who initiates an interaction, maintains eye contact, and advice more. Further, they explained that such kind of communication improves connection and communication between them, thus enhancing patient satisfaction. The European Federation of Pharmaceutical Industries and Associations (EFPIA) (2019) also notes that a value-based health system appears to offer a commitment to improving the patient experience with the system. This is due to the fact that value-based healthcare advocates for patient engagement, staff engagement and measurement and reporting of the health care provider and the patient's perspective or feedback. These are pointed out by WHO (2013) as critical measures of improving a patient's experience. According to WHO (2016), the patient-centred approach in healthcare is one of the ways of enhancing the positive patient experience. This is achieved through effective communication, engaging the patient in all aspects of healthcare, and collecting patient's feedback through surveys and other methods. This feedbacks enable the health practitioners to evaluate if the healthcare provided satisfied the patient (Lakdawalla et al. 2018). It is worth noting that patient experience is personal, and thus the health facility will not possibly satisfy all the patients; however, value-based healthcare seeks to meet the greatest percentage possible of the patients (EFPIA 2019).

4.2 Potential difficulties of the value-based healthcare system

Despite these benefits, the value-based system has potential challenges. For instance, patient satisfaction could not necessarily mean the quality of service. Therefore, healthcare administrators will have to develop rigorous measurement techniques such as regular patient satisfaction surveys to measure organizational performance (Sussex et al., 2013). Another potential difficulty is that the value-based healthcare system is centred on expert coordination, easy access to patient data, and records a successful service delivery. Unobtainable patient data develops a substantial barrier to practitioners to coordinate adequate healthcare making it hard to provide preventative care (Sussex et al., 2013). Similarly, El-Seoud, (2013) connotes that the adoption of more efficient ways of sharing patient information such as technology adds another potential challenge, especially with data security and confidentiality of patient's information. Inadequate resources are also another factor posing a potential challenge to the value-based healthcare system. This model depends on sufficient staffing and adequate healthcare software to operate. Without sufficient resources to create and support the switch to this system, it might not be sustainable for several practitioners. For instance, with insufficient healthcare software, healthcare providers won't access and implement vital population health ingenuities essential to the attainment of value-based care. Besides, shortage in staffing needed for value-based care wraparound care, including physicians, nurses, among others, would make it unviable to meet the parameters of the value-based system (Putera, 2017).

4.3 Association of the value-based healthcare system with accessibility, costs, and quality

Gentry & Badrinath (2017) expresses that Value-based healthcare is expected to reduce the healthcare costs by minimizing wastages through identifying waste by reducing the costs, shifting resources from lower to higher-value activity, and ensuring that the right persons are treated at the right time. This notion is also supported by Dobbs & Warriner (2018) who argue that quality and performance are intertwined aspects of a healthcare system. The healthcare system should have tailored services to fit its purpose. In this regard, WHO (2013) argues that a patient-centred approach results in meeting aspects of quality, increased performance and accessibility for patients. EFPIA (2019) supports that value-based healthcare can facilitate the timely provision of health services by directing efforts such as prevention and interventions that bring the most value to the patients. Accessibility of health care enhances the quality of service delivery since the patient will have a crucial role to play in evaluating the services provided (OECD 2017). Furthermore, the value-based health system creates an environment for championing preventive interventions and integrating innovative solutions in the provision of healthcare. However, OECD (2017) points out moving from free-for- service of payment models to outcome-based could reduce access to access to interventions that are low value to the patients. These interventions include the caesarean section and percutaneous coronary intervention in stable patients. In 2020, government efforts of increasing accessibility to healthcare services have been elevated, especially with the advancement of technology. For instance, the insured citizens no longer need to present their insurance company card when seeking medical attention. Instead, they can now use their national identification card. This move is one of the strategic objectives of the government adopted in the 2020 healthcare program vision 2020 (Saudi National Transformation Program, 2018). In this regard, the move seeks to increase access to health access by improving the use of digital transformation in the private health sector.

4.4 Healthcare and prevention of health risks

Almalki et al. (2011) point out the effectiveness of the value-based healthcare system in preventing healthcare risks. The authors highlight that the introduction of a more patient-centred approach with policies such as tailored medicine to meet patient's needs have increased the recovery rates among patients and also reduced health risks among people. WHO (2013) also highlights that preventive and personalized medicine services have been part of diagnosis and treatment procedures in the Saudi Arabian healthcare system. In this perspective, clinicians who have engaged in this process have been termed 'good' and useful by patients. Besides, this practice has been linked to predict a patient's response to healthcare, which improves their health. Dobbs & Warriner (2018) also identify that personalized medicine has increase attention on quality, including patient safety, experiences, and clinical efficacy. In this perspective, they also argue that this approach has supported innovation in early diagnoses, such as telemedicine, which has reduced health risks among patients.

5.0 Limitations

This study encountered several limitations; for instance, because of time constraints, not all relevant kinds of literature were incorporated into this study, and thus the authors cannot be sure whether data saturation was reached regarding the identified themes. However, the objective of this research was not to generate results that could be representative of a general population; instead, its aim was to identify themes linked to value-based care that could be tested in broader significant studies. Therefore, the authors perceive that the research was successful and that the findings were valid and reliable. Thus, further research is recommended to investigate the efficiency and impact of these themes in promoting healthcare in Saudi Arabia and other Middle East Countries. Besides, a comparison of the efficiency of services between Saudi Arabia and other MEC could also be undertaken to increase the understanding and progress of the healthcare system in the region.

6.0 Conclusions

Prioritizing value in healthcare could assist in ensuring existing resources are expended to offer the most significant benefit to patients. While the aging population is growing along with chronic illnesses, demand for healthcare is increasing, and the budget is narrow. How much of a society's resources should be utilized is a value-based conclusion. Making sure that existing resources are managed to fit interventions that result in most value in patients instead of focusing on just effectiveness and cost-efficacy might assist in using them optimally. Health policymakers in Saudi Arabia should consider the disparity in the healthcare system and improve efficiency in the country. Besides, they should take advantage of the advancement in technology to reduce healthcare risks and inefficiencies in Saudi Arabia.

References

Acerete, B., Stafford, A., & Stapleton, P. (2012). New development: New global health care PPP developments—a critique of the success story. Public Money & Management, 32(4), 311-314.

Albejaidi, F. M. (2010). Healthcare system in Saudi Arabia: An analysis of structure, total quality management and future challenges. Journal of Alternative Perspectives in the Social Sciences, 2(2), 794-818.

Almalki, M., Fitzgerald, G., & Clark, M. (2011). Health care system in Saudi Arabia: An overview. Eastern Mediterranean Health Journal,17(10), 784–793

Almoajel, A., Fetohi, E., &Alshamrani, A. (2014). Patient satisfaction with primary health care in Jubail City, Saudi Arabia. World Journal of medical sciences, 11(2), 255-264.

Alshammari, F. (2014). Patient satisfaction in primary health care centers in Hail City, Saudi Arabia. American Journal of Applied Sciences, 11(8), 1234-1240.

Aveyard, H. (2010). Doing a Literature Review in Health and Social Care [electronic Resour. Open University Press.

Christmals, ChristmalDela, and Janet J. Gross. "An integrative literature review framework for postgraduate nursing research reviews." European Journal of Research in Medical Sciences Vol 5.1 (2017).

Creswell, J. W. (2011). Controversies in mixed methods research. The Sage handbook of qualitative research, 4, 269-284.

Dobbs, P., & Warriner, D. (2018). Value-based health care: the strategy that will solve the NHS?. British journal of hospital medicine (London, England: 2005), 79(6), 306-307.

Driessen, M. T., Groenewoud, K., Proper, K. I., Anema, J. R., Bongers, P. M., & van der Beek, A. J. (2010). What are possible barriers and facilitators to implementation of a Participatory Ergonomics programme?. Implementation Science, 5(1), 64.

European Union (2019): defining value in “value-based healthcare”; Report of the Expert Panel on effective ways of investing in Health (EXPH). Luxemburg. European Union.

Ham, C. (2018). Management and Competition in the NHS. CRC Press.

Kampstra, N. A., Zipfel, N., van der Nat, P. B., Westert, G. P., van der Wees, P. J., & Groenewoud, A. S. (2018). Health outcomes measurement and organizational readiness support quality improvement: a systematic review. BMC health services research, 18(1), 1005.

Lakdawalla D, Doshi J, Garrison L, Phelps C, Basu A, and Danzon P (2018): Defining Elements of Value in Health Care, A Health Economics Approach: An ISPOR Special Task Force Report. Elsevier Inc.

Meinert, E., Alturkistani, A., Brindley, D., Knight, P., Wells, G., & de Pennington, N. (2018). Weighing benefits and risks in aspects of security, privacy and adoption of technology in a value-based healthcare system. BMC medical informatics and decision making, 18(1), 1-4.

Porter M (2014)Value-Based Health Care Delivery, Harvard Business School.

Putera, I. (2017). Redefining health: implication for value-based healthcare reform. Cureus, 9(3).