[This article was originally published in World Health and Population, 13(3)]

The article by Khaliq (2012) reminds us that healthcare systems around the world are in a state of tremendous change and evolution. Driven by a complex web of social, ecological, political and economic factors, the global healthcare landscape is transforming at a remarkable pace. On the one hand, a large proportion of structural adjustments to health systems are undoubtedly the result of careful and thoughtful planning based on explicit policy decision-making frameworks. On the other hand, a proportion of recent policy decisions are being implemented with an appreciation that these global economic factors are driving a pragmatic approach to healthcare restructuring. There appears to be a need to do more with less across the spectrum of high-, middle- and low-income countries. A cursory review of the massive and sweeping cuts (the largest since World War II) in workforce and public-sector spending within the United Kingdom's National Health Service, or within Greece's planned 40% cut in hospital expenses and 45% cut in mental health services, sheds new light on the health restructuring process. In the last decade, the proverbial "carrot" may have been used at the local, national and international levels as incentive to stimulate change, but given the fairly consistent, pessimistic economic growth projections, the carrot may be replaced with a stick as the stimulus for health reform.

While not all countries are experiencing sweeping austerity measures, the mere fact that some nations are undergoing particularly difficult economic times has created an incentive (or possibly an opportunity) to examine and implement profound reforms. In his paper, Khaliq (2012) provides a unique perspective on the sequence of events that underpin the evolution of the health system in Saudi Arabia and highlights two critical reform strategies: first, an increased focus or adoption of primary care; and second, a shift away from a publicly funded health system modelled after the National Health Service in Britain and toward a free-market employer-based financing system similar to that in the United States. We will briefly examine each separately.

The rapid development of the publicly-funded Primary Care Centers across Saudi Arabia is not unique to the region (Al- Kubaisi et al. 2010). Primary care has been touted globally as a partial solution to healthcare challenges including (but not limited to) inappropriate usage of expensive emergency departments as the locus of access to the health system (McCusket et al. 2012), and poor management of chronic diseases that can lead to multiple hospital re-admissions (Dean 2012). Khaliq reveals that it is not yet clear which sector would finance an evolving primary care infrastructure, but in either case, a shift towards a healthcare delivery model built on primary care signals a positive reform direction. However, effectively emphasizing primary care requires a strong inter-disciplinary health care team, beyond simply nurses and physicians, who can function as a collective to meet the needs of patients within a patient-focused approach. Although most stakeholders would likely agree in concept with a team-based care approach, the reality is that there are significant challenges in implementing this concept. Barriers range from understanding the scope of practice of each discipline, issues that surround possible licensure and regulation, and even the unwillingness to relinquish what is perceived to be power and control over patient care. Although Khaliq did not address the extent to which inter-disciplinary teams practicing within a patient-centered approach is part of the future Saudi health system, we are skeptical given our experience in the region that this concept will figure prominently.

Khaliq also reports that Saudi health reform includes a transition to private free market employer-based financing, and that this process began close to a decade ago under the government's divestment plan. Whether driven strategically by internal approaches, or externally under the auspices of global health reform, it appears that Saudi Arabia will aggressively adopt a US-style healthcare financing model. This structure would be unlike its neighbors in the Gulf region. For instance, the countries of Kuwait and Qatar do not appear to have adopted this policy direction, nor have they exerted an overt attempt to sell off public institutions. Given their influence in the region, it would be plausible that when Saudi's planned shift from public to private financing is complete, other countries may also move in a similar policy direction. The experimentation with 'privatization' of healthcare financing and delivery that is being contemplated by Saudi Arabia has been controversial, and there are agents on both side of the debate (Devereaux et al. 2004; Oh et al. 2011). The published peer-reviewed literature appears to be heavily weighed in opposition to this policy direction; however, given the global fiscal trends, it may not be a question of 'to privatize' or 'not to privatize' but rather how to blend the positive aspects of both approaches to meet growing healthcare demands.

There may be a middle ground in this privatization debate, and in Khaliq's (2012) article on the Saudi health reform approach, we gain perspective on a unique country's approach to aligning supply and demand in the healthcare arena. Saudi is not alone in adopting primary care or in shifting towards private markets. In fact, countries such as Romania (Bunduc 2012), Georgia (West et al. 2011) and even Sweden (Arnell 2011) are to some extent migrating towards a US-style healthcare system. It is ironic that while many countries are moving towards more private involvement, the United States is attempting to implement policy measures, such as the 2010 Patient Protection and Accountable Care Act (PPACA – also referred to as 'Obamacare') that will address the shortcomings of their system. Health reform such as the one being undertaken by Saudi Arabia does not necessarily solve problems, rather it creates new ones – and the test of success is the extent to which one prefers the new problems over the old ones. Whether the Kingdom of Saudi Arabia and its residents will prefer the new problems created by adopting primary care as a model along side an employer-based financing strategy remains to be seen. There is much to be learned from the Saudi approach and experimentation with health reform, and only time will tell if their approach has created more socially desirable problems that then ones they have now.

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