Can’t get the staff – medical recruitment in GCC nations

Proposed new healthcare projects have multiplied in the Gulf Cooperation Council (GCC) nations in recent years, and while last year’s fall in oil revenues saw some cuts to expenditure, expanding provision to meet the demands of the region’s growing and ageing populations remains a priority.

In fact, in line with moves by governments in the region to shift some of the funding burden to the private sector, including a greater emphasis on private medical insurance, many commentators have outlined the potential for the healthcare industry to allow such oil-focused nations to diversify and expand their revenue sources. Dubai’s plan to welcome 500,000 international medical tourists by 2020 is a case in point.

Supply and demand

Overshadowing the region’s endeavours to meet patient demand and build a stronger healthcare infrastructure, however, is one looming issue: staffing. Expatriate populations in the GCC nations are high overall – around 48.1%, according to Gulf Labour Markets and Migration (GLMM), based on available national statistics of 2010–2015 – and in the healthcare workforce this is no exception. In the UAE, for example, where GLMM puts non-nationals at 88.5% of the population, expat workers make up a similar proportion of physicians and dentists (87.0 and 88.0%), and nearly 99.0% of midwives and nurses, according to an April 2014 article in Frontiers in Public Health.

This reliance on foreign-born workers in the absence of strong local medical expertise has raised concerns that GCC nations will struggle to recruit the staff required by desperately needed new health facilities.

Choucrallah Karam is co-founder and managing partner at advisory firm Improstat, where he leads the healthcare and life sciences consultancy. While acknowledging the issue of a lack of a sustainable local supply, he feels that commentary on staff shortages is at times too focused on intended growth.

“Some of the reports that forecast shortages in medical staff are based on prospective planning for facilities in the future,” he says. “There are reports out of Saudi Arabia, for example, that state 100-plus hospitals will be built – but we have to be careful, because these are only statements, not reflecting the reality on the ground.”

According to Deloitte’s 2015 Health Care Outlook, Saudi Arabia included funding for 24 new projects in its 2014 budget, including hospitals, medical centres and complexes, on top of 132 facilities already under construction at the time. But, as the Economist Intelligence Unit reported in December 2015, Saudi Arabia’s 2016 budget outlined a reduction of more than a third on its health and social development budget from the preceding year – suggesting that some projects may not be realised in full.

That’s not to deny, however, that hospitals across the GCC are facing staff shortages already. Part of the problem, Karam perceives, is that current organisational structures do not allow the most effective use of staff.

“Right now there is a lot of misalignment of healthcare practitioners – by which I mean many of them aren’t being used effectively,” he says. “In the shorter term, one could think about making sure that the right doctors are working in the right places, nurses are being used to do the right things – that they are not burdened by a list of administrative tasks.”

In some cases, staff are also restricted from working across regulatory boundaries, Karam reveals.

“In Saudi Arabia there are seven different healthcare systems in place; in the UAE, there are three, for what is essentially a very small country,” he says. “This means that, in some instances, doctors and nurses are not allowed to work even within the same emirate.

“More liberation of the system would definitely help in allowing medical staff to work in different places.”

A more attractive profession

Karam also believes that redirecting the metrics by which performance is measured towards patient outcomes will be essential if hospitals are to engage and ultimately retain staff.

“One important solution would be healthcare providers providing a clear career path, and performance assessment based on health outcomes, where the focus is really on patients rather than a list of tasks.

“At present, doctors, more often than not, are burdened with a lot of administrative tasks and are actually losing some of the passion for patient care with their existing providers. That’s obviously something that healthcare administrators around the region need to be really focused on, and that’s also an unfortunate outcome of the explosive growth of health insurance in some places.”

In tackling some of the present organisational challenges, governments are looking to improve health infrastructure, whether digitalising patient records, implementing big-data approaches, or introducing new platforms that allow available staffing to go further. In January 2014, for example, the UAE’s Ministry of Health signed a deal with telecommunications companies Du and Etisalat to provide mobile health (mhealth) services to help support patients with non-communicable diseases.

Meanwhile, Saudi Arabia’s Integrated and Comprehensive Healthcare Programme aims to link healthcare facilities in order to allow better public-health and crisis management.

Electronic means alone will not be sufficient to meet present demand, though. Specialist care in particular is inadequate – from oncology and paediatrics, to treatment for lifestyle-related conditions often associated with predominately affluent populations, such as obesity, type 2 diabetes, and rehabilitation.

“Patients often travel out of the region back to their native countries for care in specialty areas,” Karam says. “Increasingly, though, investors are noticing those gaps and reversing that tendency by opening up specific facilities to cater for these specialties.”

Investment in so-called ‘medical cities’ is leading the charge in this – sites where a select few specialist fields can be catered to with the expert staff and facilities required.

Saudi Arabia is planning five such cities, with the largest projects in Riyadh and Jeddah, both with a planned 1,000-bed capacity.

In countries where patients are already accustomed to travelling a long way for specialist care (whether internally or abroad), travelling to a medical city provides a more practical option. What’s more, education is also being designed into the complexes, with foreign medical institutions often engaged to help.

Take Dubai Healthcare City, where the new Mohammed Bin Rashid University of Medicine and Health Sciences (MBR-UMHS) is based, which will help to establish medical education within the region. Within this, a dental school offering postgraduate programmes will be accredited by the country’s ministry in collaboration with the Royal College of Surgeons of Edinburgh.

Such projects will be vital in engaging medical staff locally, and helping to provide the pathways to specialism that are needed. Nurturing scientific and medical research, with a particular emphasis on investigations into health conditions affecting local populations, will also be an essential step in improving patient care. However, basic graduate medical education is also missing in a region that, on paper, seems curiously underserved.

Research and education

As the authors of the earlier-mentioned Frontiers in Public Health article point out, the GCC nations, which make up WHO’s Eastern Mediterranean Region Group 1 (EMR1), clearly “have the financial resources to carry out research, but lack the higher education systems to generate new knowledge”. Meanwhile, the middle-income countries comprising the organisation’s second group (EMR2: Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Palestine, Syrian Arab Republic and Tunisia) “have mature education systems, good science and technology human resources, and good output of scientific publications”, despite comparatively lower wealth.

In fact, it’s many of these nations that the GCC countries currently rely upon to staff their hospitals.

“Some nations are basically exporters of medical graduates, like the Levant countries Lebanon and Jordan, and unfortunately, in the past, Syria,” Karam says. “And then there are the countries that do not have enough local talent – Saudi Arabia, UAE – where the medical profession is not an enticing profession to be working in.

“I’m not just talking financially, but there are also societal and cultural reasons behind that. A practical example is the fact that Saudi nurses require private local transportation, and healthcare providers look at the costs and then aren’t enticed into recruiting Saudi nurses.”

Karam draws attention to the fact that developing school-level education has taken priority in the GCC nations in recent years; but he is optimistic that universities will follow.

“I think the next shift will start focusing on graduate education in any field, and here, specifically, we’re talking about health and medical education. But there are other stages to consider – namely, how you tie-up education and medical provision, in terms of capacity planning.”

He cites Oman as an example of a more harmonised approach. Here, from the early 1990s, the Ministry of Health sought to build up its educational infrastructure, while mapping the numbers of doctors and nurses trained locally with the projected future needs of its health systems.

Capacity planning in this vein, together with a focus on raising the profile of health as a profession in the region, will need to be done in tandem with developing a sustainable supply, Karam feels – but it won’t be easy.

“Encouraging medical research, making intellectual research part of the region – as opposed to being imported – would definitely change the attitude towards the medical field among local people,” he says. “If you are also able to fund medical research programmes using local staff, then that will start to change the opinion and perception of the field itself.

“But it’s a tough one. Nobody has cracked it yet.”