The impact of health insurance programme on the quality of the private hospital's services in the Kingdom of Saudi Arabia

This study is a first step in the exploration of the impact of the implementation of health insurance programmes on the quality of service within private hospitals in the Kingdom of Saudi Arabia.The Kingdom of Saudi Arabia (KSA) has a population of 22.7 million (2002 Census), and is situated between the Red Sea and the Arabian Gulf. It has a land area of 2.2 million square miles that consists of vast deserts, the date palm oases of legend, as well as steep mountains and cool green valleys.The history, economic, social and political development of KSA is dominated by the culture of Islam, which permeates every aspect of a Muslim's life, and also permeates every aspect of the Saudi Arabian state. The basis of government is Shariah law, and within this legal system there are different views among Shariah scholars on the subject of "Insurance". At the time of writing whether insurance is 'legal' is still a subject for debate.The Ministry of Health (MOH) is the agency with the overall responsibility for health care in KSA. But there are 16 other health care providers that provide health care mainly for their own staff, for example, the Ministry of Defense and Aviation. Within the health service sector the private health sector has grown very quickly in recent years. In 2002 there were 101 private hospitals with the capacity of 9834 beds, which constituted 19.35% of the total number of beds in the Kingdom.Within this sector the Al-Hammadi Hospital has been chosen as the context of the study, firstly because it is one of the largest general hospitals in the Kingdom, and secondly for the practical reasons that it was the only hospital of those approached that agreed to the research project being carried out in the hospital.In private hospitals the patient treatment model that used has been the cash model that has two members, a physician who provides the services and a patient who pays directly. The introduction of a health insurance programme changes the patient treatment model, and introduces a third member, the insurance agent. The duties of this third member are firstly, to make sure that services provided are essential and included in the agreed insurance policy coverage. Secondly to pay the expenses according to the amount of money paid by patient in advance. The investigation starts from the premise that the introduction of third member will affect the whole system of providing medical care.The development of methodology started with the development of a new metaphor rooted in the Islamic culture of KSA. The "JAR" metaphor has three components Jassad (Body), Aqel (Mind) and Rouh (Soul) which derive from the concept of worship in Islam and Shariah Law. This metaphor was subsequently used in the development of the project methodology and the development of a 'Quality Model' which was used to analyze the health care process.The 'Quality Model' is based on the 'Quality Cube' model developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) which introduced a process of accreditation for healthcare organizations based on their model. By using the JAR metaphor a new quality model was developed composed of 33 quality elements grouped into three groups, performance dimensions, care dimensions, and organizational dimensions. This model was then used as the basis of an investigation into changes in health quality due to the change from a cash funded health system to an insurance funded health system. A survey was selected as the most suitable instrument to conduct the study where the target populations of the survey are the doctors, outpatients, and inpatients.Two questionnaire data collection instruments were designed which were validated by firstly by a group of jurors, and secondly reliability was tested using a pilot study. These were found to have an acceptable level of reliability. Samples of doctors and patients from the populations within the Al Hammadi Hospital were selected. The return responses from the survey process were 66.7% for doctors, 84% for inpatients, and 70% for outpatients. The results were compiled and analysed.The main result of the data analysis was that there is significant agreement among the study groups that the impact on private hospitals due to the change of funding model is positive. This result can be converted to the JCAHO Accreditation grid score of 2 which corresponds to 'significant compliance to our quality model standards'. The coefficient analysis results shows that 50% of the influence on quality can be attributed to the combination of 'medical technology', 'patient respect and caring', and 'nutrition care'. It is therefore concluded that private hospitals and insurance companies should give more attention to these particular factors.This positive result was not expected since Saudi culture appears to be unsupportive of insurance implementation, therefore some concern may be directed to Islamic issues in the implementation process and warrants further research. The use of the JAR metaphor in the quality model and the selection of appropriate research methods, shows that the metaphor has potential of introducing a new model into system thinking which is also an area for further studies and research. Finally, introducing an instrument that can be used in Kingdom of Saudi Arabia for identifying quality compliance to standards as well as evaluating the impact of some issues on quality such as health insurance is one of main contributions of the study