Comparative Analysis and Spatial Distribution of the Primary Health Care Centers and Health Manpower Across Saudi Arabia Using Shapiro–Wilk Test

Introduction

In line with the Alma Ata Declaration of 1978, Saudi Arabia has placed great importance on health care through primary health care centers (PHCCs). By 2021, the Ministry of Health regulates many PHCCs throughout the kingdom. These PHCCs provide primary services to all citizens of Saudi Arabia. With the growing demand for better healthcare services due to population pressure, Saudi Arabia faces the challenges of the required coverage in primary healthcare in all regions.¹ Over many decades, Saudi Arabia has implemented a number of development plans, centered on infrastructure development, as well as many ambitious development plans and initiatives, particularly in the field of health of.² Infrastructure plays a vital role in enhancing the health sector.³ These plans led to remarkable achievements in the field of health indicators, which reflect the progress in the health sector, and have a significant impact on the health and well-being of the population.

Regional disparities in Saudi Arabia involve the distribution of infrastructure, resources, and services across different regions. Major cities like Riyadh, Dammam, and Jeddah have advanced education, healthcare, and economic opportunities, while rural areas, particularly in the northern and southern regions, face challenges in accessing these services. These disparities are rooted in geographical, historical, and economic issues. The Saudi government’s Vision 2030 seeks to create equitable and improved access to services in all regions.^4,5 Many studies have focused on the major cities to improve healthcare services.^5–9 Almujadidi et al mentioned that there is a shortage of labor especially in rural areas of Saudi Arabia.⁹ Jamjoom, Gahtani, and Sharab found that medical personnel in Saudi Arabia are distributed differently.⁵

The strategic interest in developing primary health care has been one of the main pillars of successive development plans for Saudi Arabia. This stems from of the importance of providing healthcare components to support the development of the health levels and health capabilities of citizens across Saudi Arabia. Preventive, curative and rehabilitative healthcare services in Saudi Arabia are provided by a network of healthcare facilities headed by PHCCs. These centers are the main institution entrusted with providing integrated and comprehensive healthcare services to all regions of Saudi Arabia.¹⁰

The number of PHCCs reached 2121 centers in 2021.¹¹ These centers are spread across the regions of Saudi Arabia and linked to general and specialized hospitals. The services of PHCCs are integrated with hospitals through referrals and therapeutic care, starting from the first level to the specialized level.

The primary health care centers provide various integrated services such as maternal and child health care through follow-up during pregnancy, during and after delivery. They implement immunization programs for mothers and children against infectious diseases, in addition to the programs for prevention of communicable and endemic diseases. The primary health care centers also take care of people with non-communicable diseases, especially chronic diseases such as blood pressure and diabetes, to reduce their complications.¹

It is expected that the population per center will improve in all regions once the implementation of the PHCCs is completed. Saudi Arabia’s various development plans have prioritize, social development needs in order to provide basic services to the population, including PHCCs. The Ministry of Health made more efforts to provide PHCCs and their operations by constructing many centers and attempting to develop them and continuously improve their services.¹² Therefore, two main objectives are being pursued. The first objective is to determine the adequacy of PHCCs and health personnel (doctors, nurses, pharmacists, dentists, allied health professionals, and family medicine doctors). This selection is usually based on their role in patient care, their impact on healthcare outcomes and their fulfillment of the needs of the population in the different regions of Saudi Arabia. The second objective is to identify the differences in the spatial distribution of the services of PHCCs and health manpower.

The Shapiro–Wilk test is a useful test. Many disciplines, including the social sciences and healthcare, have adopted it. It assesses the kurtosis and skewness of a data set. For small- datasets, the Shapiro–Wilk test is a very useful tool for detecting deviations from normality. The disadvantage of the Shapiro–Wilk test is that it can lead to an unnecessary rejection of the normality assumption for large data sets and is limited to continuous data. This study relies on the Shapiro–Wilk test to assess the normality of spatial distribution of primary healthcare centers and health workers across Saudi Arabia.

Methods

Saudi Arabia is located in south-west Asia. The country is characterized by arid climatic conditions. Consequently, human life is severely affected by the dry and dusty climatic conditions. This study included some comparisons and focused on selected key indicators. The study is based on secondary data. The dataset is available in the statistical yearbooks published by the Ministry of Health for the period 2017–2021.¹¹ This study covers six of the most important health and demographic indicators in Saudi Arabia. These indicators were carefully selected from a set of health indicators available in the statistical yearbooks of the period 2017–2021.¹¹

The data were organized and tabulated using the SPSS package, version 23, and used to analyze the descriptive statistics of the selected indicators. These data were processed and tested using the Shapiro–Wilk test to determine the normality distribution of the data. In addition, a correlation coefficient was used between the regions in Saudi Arabia (independent factors) and the number of PHCC, doctors, nurses, allied health professionals, dentists, and family medicine doctors (dependent factors).

Results

Table 1 shows the population, area and density in the regions of Saudi Arabia in 2021.¹³ The area of Saudi Arabia is administratively divided into 13 provinces. The population distribution is mainly concentrated in three provinces: Riyadh (capital city), Makkah Al Mukarramah and the Eastern Province. The population in these areas is 8,175,378; 7,692,188; and 4,879,962 respectively.

Table 1 Population, Area, and Density in the Saudi Region in 2021

Table 2 shows the distribution of health workers in the Saudi Arabia region. The table shows that in most regions, the number of PHCCs, doctors, nurses, allied health professionals, dentists, and family medicine doctors increased between 2016 and 2018. However, between 2019 and 2021, there was a decrease or stability in the same variables in the regions of Saudi Arabia.

Table 2 Distribution of PHCCs and Health Manpower in PHCCs in the MoH in All Regions

Table 3 shows the Shapiro–Wilk test of health indicators to determine the significance of the health indicators dataset. The results of the test show that the PHCCs of 2020, the dentists of 2021, and the Allied Health Personnel of 2017, 2020 and 2021 were normally distributed. However, the distribution of the population and all datasets of the other health indicators is a non-normal distribution with degree of freedom of 13 and a p-value of 0.05.

Table 3 The Shapiro–Wilk Test of the Health Indicators

Table 4 shows the correlation between the health indicators and the regions based on population. The correlation (ratio) between the number of PHCCs and the region is significant in all regions, as shown by the “tr” values, which are greater than the critical value of 2.13 at degrees of freedom 4. Moreover, the correlation between = dentists and = region was significant in all = regions= except Riyadh, Makkah and Jazan. In contrast, the correlations between the number of doctors and allied health professionals and the region were not significant in the regions. The correlations between the number of nurses and the region were also not significant in all regions except Tabuk. The correlation between the number of family medicine doctors and the region was also not significant in all regions, with the exception of the northern borders at degree of freedom 4.

Table 4 Correlation Between Health Indicators and Regions Based on Population

Table 5 shows the spatial distribution of the population, PHCCs and health personnel in 2021. The spatial distribution of the population shows a concentration in three major regions, namely Riyadh (26.5%), Makkah (25%) and the Eastern Province (15.8%). The spatial distribution of health indicators is related to the spatial distribution of the population.

Table 5 Spatial Distribution of the Population and Health Indicators Among Regions During 2021

Table 6 shows the distribution of health indicators in groups based on concentration. The spatial distribution of health indicators can be divided into 3 groups. The first group consists of 3 regions (Riyadh, Makkah and Eastern Province) with a total of 67.3% of the population served by 41.1% of PHCC, 46.4% of doctors, 45.3% of nursing, 40.1% of dentists, 43.7% of allied health professionals, and 52.4% of family medicine doctors. The second group consisted of 4 regions (Madinah, Asser, Qaseem and Jazan) with a total of 21.6% of the population served with 36.2% of PHCC, 35.1% of doctors, 33.9% of nursing, 37.9% of dentists, 38.4% of allied health professionals, and 31% of family medicine doctors. The third group was composed by 6 regions (Tabuk, Ha’il, Al-Jouf, Najran, Northern Borders, Al-Bahah) with a total of 11.1% of the population served with 22.7% of PHCC, 18.5% of doctors, 20.8% of nursing, 22.0 of dentists, 17.9% of allied health professionals, and 16.6% of family medicine doctors.

Table 6 Spatial Distribution of Health Indicators into Groups Based on Concentration

Discussion

This study found that the PHCCs of 2020, the dentists of 2021; and allied health professionals of 2017, 2020 and 2021 were normally distributed. However, the distribution of the population and all data sets of the other health indicators is a non-normal distribution with the degree of freedom 13 and p-value 0.05. In addition, the correlation (ratio) between the number of PHCCs and the regions based on population is significant in all regions. Moreover, the correlation between the dentists and population was significant in all regions except Riyadh, Makkah and Jazan. In contrast, the correlations between the number of doctors and allied health professionals and the population were not significant in all regions. It The correlation between the number of nurses and the population was also not significant in all regions except Tabuk. The correlation between family medicine doctors and the population were also not significant in all regions, with the exception the northern borders. Finally, the spatial distribution of the population shows a concentration in three major regions, namely Riyadh (26.5%), Makkah (25%) and the Eastern Province (15.8%). The spatial distribution of health indicators is related to the spatial distribution of the population.

Primary health care is the cornerstone of any health care system as it provides vital services such as general medical care, early diagnosis, chronic disease management and preventative care.¹⁴ The majority of PHC facilities in Saudi Arabia are under the Ministry of Health (MoH). Although significant progress has been made in improving access to healthcare services, there are still large disparities in the number and distribution of PHC centers across the country.¹⁵

Due to geographic differences, rural and remote areas are underserved as primary healthcare facilities are concentrated in urban areas. Due to longer traveling times to health facilities, people in rural areas have less equitable access to care. The lack of PHC facilities in the less populated regions of Saudi Arabia, where a large proportion of the population lives, exacerbates health inequities, especially for the elderly and people with chronic diseases.¹⁶

There is a shortage of healthcare workers in Saudi Arabia, particularly doctors, nurses, and allied health professionals. This shortage affects access to and quality of healthcare. The shortage of PHC facilities and medical staff affects access to and quality of healthcare both directly and indirectly by increasing the burden on hospitals, limiting access to healthcare, and jeopardizing health outcomes.^17,18 In addition, we need to retain qualified professors in universities to ensure that graduates in healthcare fields have sufficient skills to improve the healthcare sector.¹⁹

There are several levels of health assessment in the PHCCs. Experts agree that there are three main levels proposed by Donabedian, namely structure, process and outcome.²⁰ The evaluation’s structure level components emphasize the significance of health staff, facilities, and equipment.^21,22 However, many research studies conducted in different countries have shown that there are significant differences between PHCCs in terms of in the health personnel and equipment. This fact can be seen as the primary hindrance to the successful delivery of healthcare services by PHCCs. The process evaluation depends on (a) the way resources can be utilized to improve the interaction between patients and health workers; (b) the care goals achieved by the scope of health services provided by PHCCs; (c) the specific technique and procedures used in responding to people’s demand in primary care; and (d) the good coordination between health workers of PHCCs.²³ Quality of care with higher validity of process measures are the most important practices of outcome evaluation.

A study by Al Fraihi, Famco and Latif (2016) concluded that the quality of care gap model is valid and needs to be prioritized and addressed through targeted health management improvement efforts.²⁴ In addition, the results of the evaluation of PHCCs in Riyadh based on users’ views show the patient satisfaction due to the good order in health care.¹²

Conclusion

Although the number of PHCCs and health workers has increased and is spread across all regions of Saudi Arabia, more PHCCs need to be established to meet the actual needs of the population for basic health services. In addition, there are differences in the spatial distribution of PHCCs services and health personnel across Saudi Arabia.

Healthcare decision-makers need to not only increase the number of healthcare providers and PHCCs, but also focus on a more equitable distribution. Strategic, data-driven resource allocation is essential to ensure that underserved regions receive adequate healthcare support. Eliminating these disparities will be critical to achieving equitable healthcare across the country and meeting healthcare goals.