Introduction

Ensuring public access to quality healthcare services relies on the fair distribution of health resources such as healthcare professionals across different geographical areas. The distribution of health resources in a specific geographical area greatly impacts people's access to healthcare [1]. Shreds of evidence indicate that a higher density of healthcare professionals has a positive correlation with health outcomes [2-3], healthcare accessibility [4-6], and healthcare utilization [7]. This underlines the significance of policies that aim at increasing the supply of healthcare professionals to improve health outcomes, healthcare utilization, and healthcare equity. Globally, ensuring fairness in distributing healthcare resources is considered a major challenge in the healthcare sector [8]. The allocation of healthcare resources in countries can be influenced by political factors that frequently dictate resource allocation, disregarding the populations' health needs in a specific area [9]. The knowledge of the distribution of healthcare professionals helps determine if the distribution of the healthcare professionals aligns with the population's health needs. This will shed light on broader health system challenges such as variations in the quality of healthcare, disparities in healthcare access, and informing strategies to improve health services [10-16].

Health services in the Kingdom of Saudi Arabia (KSA) have significantly improved in the last two decades, with greater access to healthcare resources nationwide. The Ministry of Health (MOH) is the major provider with about 60% of all services, and the remaining share is divided among other government and private sectors [17-18]. Since the early 1990s, the private sector, the main provider of health services for expatriate workers played a role in the enhancements of healthcare delivery through employer-contributed health insurance. With the improved health services, there has been a substantial increase in the number of healthcare professionals over the last few years. According to the MOH’s statistical yearbook, there were 105,332 physicians, 23897 dentists, 200,558 nurses and midwives, and 34,040 pharmacists in the Kingdom in 2022 [19]. Between 2010 and 2022, the Kingdom recorded a 95.8% increase in physicians (including dentists), 54.5% in nurses and midwives, and 128% in pharmacists. Even though the ratio of physicians, nurses, and pharmacists per 10,000 people increased in 2022, it is still lower than in other high-income countries [20]. Currently, the ratio of physicians per 10,000 people in the KSA (31) is lower compared to Germany (45), the USA (36), the UK (32), and the European Union (43). The number of 56 nurses and midwives per 10,000 people in the KSA is much lower compared to Germany (123), the USA (125), the UK (92), and the average for the European Union (77) [20]. However, the number of pharmacists in the KSA (9.35 pharmacists per 10,000 people) is comparable with countries such as the UK (9.06), the USA (9.6), and Australia (9.3). [20]. In comparison to other Gulf Cooperation Council (GCC) countries, the KSA has a higher physician-to-population ratio, whereas Qatar (72) and the United Arab Emirates (64) have higher nurse-to-population ratios [20].

Saudi Vision 2030 aims to transform the healthcare system in Saudi Arabia, with a significant focus on improving the distribution and composition of healthcare professionals [21]. The National Transformation Program (NTP) 2020 places a strong emphasis on achieving equal distribution of health resources across all regions of the Kingdom [22]. The aim is to create a more equitable healthcare system that provides high-quality services to all citizens and expatriates, regardless of their location within the Kingdom. This approach aligns with the broader goals of Saudi vision-2030 to improve the population’s health and well-being [23]. Moreover, the Saudi health system is significantly affected by the rising number of non-communicable diseases (NCDs) and the increasing aging population, specifically concerning the distribution of healthcare resources [24-25]. Additionally, chronic illnesses such as heart diseases, cancers, and diabetes, are becoming more prevalent due to changing lifestyles and aging, leading to a greater need for prolonged medical treatment and subsequently higher demand for healthcare professionals [24].

The need for healthcare services and hence healthcare professional requirements across regions vary depending on morbidity and mortality patterns. Moreover, the composition of morbidity and mortality may differ by region. The regions with lower population density may require a greater health professionals-population ratio [13]. Therefore, achieving a balanced and equitable distribution of healthcare resources according to demographic and geographical aspects is a real challenge in most countries [26]. Recent studies conducted in various countries used techniques like Gini coefficients and Theil index for assessing the geographical inequalities in the distribution of health resources including the health workforce. A study in Iran used Gini coefficient and Hirschman-Herfindahl index to assess fairness in the distribution of healthcare specialists [27]. Recent studies in China employed the Gini coefficients and Theil index to assess the geographical inequalities in the distribution of health resources [28-30]. In the KSA, existing studies show that resources are distributed fairly at the national level, but there are noticeable differences in the distribution of physicians, nurses, and pharmacists between regions, with urban areas typically having better access than rural areas [17, 24]. Few studies conducted in the KSA showed disparities in terms of healthcare access, and resources. For instance, a study in Riyadh showed that a significant proportion of the population had to travel long distances to access healthcare services [26]. A study by Hawsami and Abouammoh (2022) highlighted inequalities in the distribution of hospital beds in the private sector [31]. Similarly, a study on the distribution of primary healthcare centers in the KSA highlighted a significant regional disparity across various health regions [32]. However, another study by Kattan and Alshareef (2022) showed a relatively equitable distribution of hospital beds across various regions [33]. This study addresses a critical gap in the literature by measuring inequalities in the distribution of health professionals across health regions of the KSA using the Gini coefficients and Lorenz Curves. While other studies have used Gini coefficients and Lorenz curves to measure healthcare inequality globally, this research applies these metrics to the unique healthcare landscape of the KSA, offering country-specific insights. Moreover, in the KSA no attempt has ever been made to assess the current status of the distribution of healthcare professionals across different health regions.

Therefore, this research addresses the research question “to what extent do the 20 health regions in the KSA differ in their availability and density of healthcare professionals’. The research assesses the equity in the distribution of healthcare professionals in the health regions based on the recent data published by the MOH. The study pinpoints the deficiencies in the distribution of healthcare professionals and identifies the health regions that are not keeping pace with the overall development of healthcare professionals in the Kingdom. It also provides an estimate of additional requirements for healthcare professionals in regions based on global standards. The specific benchmark threshold levels for physicians, dentists, nurses, and pharmacists to achieve the universal health coverage (UHC) effective coverage index based on the Global Burden of Disease Study 2019 was used. By addressing these gaps, the study contributes valuable country-specific data to inform targeted interventions and policies aimed at improving health equity in the KSA. It is also expected that the findings of the study could aid in implementing necessary policy interventions and promoting discourse on healthcare equity and resource allocation in the KSA.

Materials and Methods

Study design and setting

In this research, a secondary data analysis was conducted to assess the distribution of physicians, dentists, nurses and midwives, and pharmacists across the 20 health regions of the KSA in 2022. Data on the number of physicians, dentists, nurses (including midwives), pharmacists employed by the MOH and the private sector, and demographic information for each region were obtained from the statistical Yearbook of the MOH, which is viewed as an authentic source of information on health-related data in the KSA. The MOH statical yearbook provides detailed information on healthcare professionals of all regions in the KSA as reported to the Ministry at the end of each year. This study includes data on MOH facilities and private health facilities across 20 health regions. The analysis considered the population of both Saudi citizens and expatriates, across the health regions. The estimates of the population for 2022 in the regions were compiled from the MOH Statistical Yearbook [19]. This is the mid-year population estimate produced by the national statistical agencies. In this research population estimate for 2022 was used to estimate the density of healthcare professionals per 10,000 population in 20 regions [19]. This measure is regarded as a standardized unit of measurement for comparing the availability of healthcare professionals across different regions with varying population sizes [28]. It would also serve as a measure of the healthcare services access in different regions in the KSA.

Study tools and data extraction

A spreadsheet was created using Microsoft Excel 2016 to retrieve data such as health region, year, population, physicians, nurses, and pharmacists from the MOH Statistical Yearbook. To evaluate the equity in the allocation of healthcare professionals such as physicians, dentists, nurses, and pharmacists across 20 health regions, the Lorenz curve and Gini coefficient were computed and visualized with Excel, 2016. While the Lorenz curve is a graphical tool that allows for comparing inequalities about a state of perfect equality, the Gini coefficient is a statistical measure utilized to evaluate disparities in the distribution of resources in society [34]. The Gini coefficient is the most commonly used measure of inequality, making it easily understood and comparable across different studies and contexts. The Gini coefficient is independent of the size of the economy and the size of the population, making it suitable for comparing regions with different population sizes. This measure is more sensitive to changes around the middle of the distribution than at the very top and bottom, which can be useful for capturing changes in the distribution of health professionals [35].

In the Lorenz curve, the x-axis shows the cumulative percentage of the population, the y-axis depicts the total percentage of healthcare professionals in the regions. The graph displays a diagonal line to represent perfect equality, with the Lorenz curve typically situated beneath it. The Gini coefficient is computed from the graph by comparing the area below the diagonal line with the curve to the total area under the line of equality [34]. The interpretation of the different Gini coefficient values is presented in Table 1.

In this research, additional requirements for physicians, dentists, nurses, and pharmacists in regions were estimated based on a threshold level established based on the Global Burden of Disease Study 2019. For the first time, Haakenstadsed et al (2022) calculated healthcare professionals thresholds for physicians, dentists, nurses and midwives, and pharmacists using the universal health coverage (UHC) effective coverage index [36]. These thresholds are essential to reach target UHC levels if countries efficiently utilize the healthcare professionals for UHC. To achieve a score of 80 on the UHC effective coverage index, for every 10,000 people, a minimum of 20.7 physicians, 8.2 dentists, 70.6 nurses and midwives, and 9.4 pharmaceutical personnel would be required.

Results

Table 2 shows the overall availability of physicians, dentists, nurses and midwives, and pharmacists in The KSA during the last five years (2018-2022). The country, which houses about 32.2 million people, has 32.74 physicians, 7.43 dentists, 62.33 nurses and midwives, and 10.58 pharmacists per 10,0000 people in 2022. This number only reflects the overall healthcare professionals capacity in the Kingdom, but hides significant regional differences in the distribution of various categories of health professionals.

Source: Compiled from the Annual Statistical Yearbook, MOH, KSA,2022

Note: * This data includes physicians, dentists, nurses and midwives, and pharmacists employed in the MOH health facilities, other government ministries/agencies, and the private sector

Table 3 provides region-wise distribution of physicians, dentists, nurses and midwives, and pharmacists employed in the facilities owned and managed by the MOH and the private health sector in 2022.

Source: Compiled from the Annual Statistical Yearbook, MOH, KSA,2022.

(Data relates to health professionals employed by the MOH and private sector)

A thorough examination of the distribution of healthcare professionals 10000 people in 20 health regions in the KSA provides valuable information about the healthcare system (Table 4).

Source: Calculated by the authors based on MOH data (Data relates to health professionals employed by the MOH and private sector)

A comparison between ratios of regional and national healthcare professionals highlights significant disparities. When it comes to regional distribution, 7 health regions have a physician population ratio below the national average, 9 regions have dentists below the national level, and 4 regions have nurses and midwives population ratio below the national average, and 14 health regions have a pharmacists-population ratio below the national average. Health regions such as Riyadh, Makkah, and Madina, have low physician-population ratios compared to other regions, whereas regions like Bishah, Northern, Al-Baha, and Al-Jouf show the highest ratios at the opposite end of the spectrum. This is in sharp contrast to the country's average, showing a notable lack of physicians, dentists, nurses, midwives, and pharmacists in some regions. Further investigation is needed on the distribution and accessibility of resources for each population and their impact on the effectiveness of delivering healthcare services. The policymakers need to carefully consider the empirical data to achieve the goals of Saudi Vision 2030 and meet the needs of the expanding Saudi population.

Equity in the distribution of healthcare professionals

The distribution of physicians in different regions of the KSA is even as shown by Gini coefficient of 0.11. Fig 1 shows the Lorenz curve, demonstrating the distribution plotting the cumulative share of physicians against the cumulative share of regions. The distribution of dentists in health regions shows a Gini coefficient of 0.08 denotes an even distribution of dentists across different regions (Fig:2). The shape of the curve to the line of equality indicates a perfect equality in the distribution of dentists across all health regions. The Gini coefficient of nurses and midwives of 0.16 is slightly higher than physicians and dentists (Fig 3). Similarly, the Gini coefficient for pharmacists is 0.12, showing an even distribution across the regions. These Gini coefficients suggest a fair distribution of physicians, nurses, and pharmacists across regions, ensuring reasonably fair healthcare access nationwide.

Figure 1: Lorenz Curve showing the distribution of physicians per 10,000 people in KSA

Figure 2: Lorenz Curve showing the distribution of dentists per 10,000 people in KSA

Figure 3: Lorenz Curve showing the distribution of nurses and midwives per 10,000 people

Figure 4: Lorenz Curve showing the distribution of pharmacists per 10,000 people

Projection on the Enhancement in Healthcare Professionals Distribution

An analysis was conducted to assess healthcare professionals' density across health regions in the KSA compared to the global threshold level [36 ] aiming for a minimum of 20.7 physicians, 8.2 dentists, 70.6 nurses and midwives, and 9.4 pharmacists per 10000 people to achieve the UHC index of 80 out of 100. The analysis shows that all 20 health regions have achieved the threshold level of physicians. However, except for 2 regions namely Qaseem, and Al Baha all regions registered a shortfall of dentists below the threshold level. While 16 health regions have nurses and midwives below the threshold level of 70.6 nurses and midwives per 10000 people; 15 regions have pharmacists fall short of the threshold level of 9.4 pharmacists per 10,000 people. Table 5 shows the current gaps in distribution by region and the additional number of dentists, nurses (including midwives), and pharmacists required for each region to reach the threshold level to achieve the UHC index of 80 out of 100. Figure 5 shows the shortage of health professionals by administrative regions of the KSA.

Note: + refers to not required or excess.

Figure 5: Administrative regions with shortage of healthcare professionals

The research highlighted the additional requirements for 4493 dentists, 69551 nurses and midwives, and 2811 pharmacists to adhere to the global threshold level of 8.2 dentists, 70.6 nurses and midwives, and 9.4 pharmacists per 10000 population in different regions to reach the UHC index of 80.

Discussion

To the best of our understanding, this is the initial research that assesses the equity in the distribution of healthcare professionals based on population size among different health regions in the KSA in 2022. From the analysis and results of the Gini coefficient, it appears the distribution of physicians, dentists, nurses, and pharmacists is equitable across various regions in the KSA. The Gini coefficients obtained for physicians, dentists, nurses, and pharmacists are 0.11, 0.08, 0.16, and 0.12 respectively. Nevertheless, a stark contrast in terms of healthcare professionals is apparent when analyzing the 20 health regions in comparison to the national averages of doctors, dentists, nurses, and pharmacists. Roughly 65% of the regions have physicians below the national average, whereas 50% of regions have dentists below the national level. While 30% of regions have nurses and midwives below the national level, a majority of the health regions (85%) have pharmacists below the national average.

Notably, regions such as Riyadh, Makkah, and Madina exhibit significantly lower physician population ratios in contrast to regions such as Bishah, Northern, and Al Baha. This underscores the geographical inequalities in the distribution of physicians. The distribution of dentists across regions reveals regions like Qaseem, Bishah, and Al Baha have a higher number of dentists per 10,000 people, in contrast to regions like Mecca, Jazan, and Qunfudah. While regions like Jeddah, Makkah, Riyadh, and Qunfudah have a lower nurse and midwives population ratio compared to the national average, Qurayyat and Al-Jouf regions have nurses and midwives double the national average. This highlights the uneven distribution of healthcare professionals across different geographical regions in the KSA.

The study also highlighted those significant economic regions such as Makkah, Jeddah, Riyadh, and Madina showed a lower healthcare professionals population ratio compared to other regions. Makkah region, the Holiest place for Muslims attract millions of pilgrims and surge in visitors put enormous pressure on healthcare system in the region [37]. It should also be noted that this region recorded the high prevalence of COVID-19 cases in 2020, constituting 49.3% of all cases in the Kingdom. Makkah region faced inadequate availability of healthcare resources including physicians, and ICU hospital beds during the pandemic [38]. Therefore, enhancing the availability of healthcare resources including healthcare professionals distribution in this region should be given higher priority.

Similarly, the study showed that health regions such as Jeddah and Riyadh have a low ratio of physicians, dentists, nurses and pharmacists, highlighting a notable shortage of the health professionals. Several factors like population growth, increasing economic activities, and urbanization in these health regions pose challenges in effectively providing access to healthcare services [31,39]. Despite their economic significance, these regions lag in health professional distribution [32].While specific numbers of health professionals employed in the OGH sector in Riyadh and Jeddah are not provided, it can be inferred that these cities may have a better supply of health professionals compared to other regions due to their urban status.

Furthermore, imbalanced allocation of healthcare resources such as hospital beds, healthcare professionals and primary healthcare centers could significantly influence health outcomes. Earlier studies have identified the issues of access to healthcare services such as inadequate capacity of primary healthcare centres, and hospital beds in Jeddah region [38]. A rapid urbanization in Riyadh region also poses challenges in equal distribution of healthcare resources in all clusters [40]. Therefore, a more detailed comprehension of the causes of disparities in health resources distribution in densely populated areas like Jeddah and Riyadh regions is needed.

The Gini coefficients showed good indicator of equality in the distribution of healthcare professionals among the 20 health regions. The coefficients for physicians, dentists, nurses and midwives, and pharmacists falls under perfect equality, which implies the health regions in the KSA have relatively fair distribution of healthcare professionals comparable to their population. The proximity to the line of equality suggests minimal disparity in the distribution of healthcare professionals. Few studies have highlighted disparities in the distribution of primary healthcare centres, and hospital beds across various regions in the KSA. Al Sheddi et al (2023) estimated the Gini coefficient, which measures inequality, indicated relative equality in primary healthcare centre distribution across the 20 health regions, with values between 0.2 and 0.3. The study found certain regions exhibited disparities, suggesting the need for more equitable distribution to improve healthcare access and outcomes [41]. A study by Saffer et al (2021) showed variations in the distribution of primary healthcare centers across health regions, and within regions, specialized healthcare professionals are concentrated in urban areas [42].

The disparities in the distribution of health professionals have significant practical implications for healthcare delivery in underserved regions. These implications manifest in various ways, affecting both the quality and accessibility of healthcare services. The shortage of health professionals in the regions may cause longer wait times for appointments, increased travel distances for patients seeking care, reliance on emergency services for non-urgent care, delayed diagnoses and treatments, particularly in critical and emergency cases. The shortage of health professionals would also lead to overworked healthcare providers, potentially leading to burnout and reduced quality of care [43-45]. Studies have found the shortage of health professionals may cause limited time for patient consultations, affecting the thoroughness of examinations and treatments, and insufficient provision of preventive and primary care services [45]. There are challenges in providing culturally competent care, which is crucial for effective healthcare delivery, and limited access to specialists and advanced treatments in underserved areas [44].

Authors have estimated that additional requirements for 4493 dentists, 69551 nurses and midwives, and 2811 pharmacists to adhere to the global benchmark of 8.2 dentists, 70.6 nurses and midwives, and 9.4 pharmacists per 10000 people. This research has also revealed that all health regions in the KSA have achieved a threshold level of physicians of 20.7 per 10,000 people to achieve a UHC index of 80%. However, there are geographical inequalities, particularly highly populated regions have lower physician-population ratios compared to other regions. The distribution of dentists across health regions shows that Qaseem and Al Baha have achieved a threshold level of 8.2 dentists per 10,000 people. With regard to the distribution of nurses and midwives regions such as Hafr Al Baten, Northern, Qurayyat, and Al Jouf have achieved a threshold level of 70.6 nurses and midwives per 10,000 people. Regions like Jeddah, Makkah, Riyadh, Qaseem, and Aseer have achieved a threshold level of 9.4 pharmacists per 10,000 people.

Policy Implications

The study provides several actionable insights that directly support Saudi Vision 2030. It helps to identify potential shortages or surpluses in health professionals in the health regions. This information is crucial for planning the healthcare workforce to meet the changing needs of the population in health regions. It also provides a roadmap for policymakers to address future imbalances between healthcare supply, and demand, directly supporting the healthcare transformation goals of Saudi Vision 2030. Future research incorporating GIS in the spatial distribution of healthcare facilities may provide a deeper understanding of accessibility challenges. This data could be extremely valuable for making precise policy decisions and determining where to invest in new healthcare infrastructure and improve access to healthcare services. Future research should also offer a foundation for a continuous dialogue and investigation on methods to achieve a fairer allocation of healthcare resources including healthcare professionals in the KSA and create a system that can adapt to the changing healthcare needs of its people.

Study Limitations

Despite providing valuable information on the distribution of healthcare professionals in the KSA, this study has certain limitations. The findings of this study dependent on the accuracy and comprehensiveness of the data from the MOH's Statistical Yearbook 2022. Despite being a reliable source, the MOH Yearbook may lack the ability to accurately represent current changes or the details of the health professionals. Moreover, this research mainly focused on quantitative data, neglecting qualitative insights into the reasons behind workforce disparities. Qualitative data is crucial for understanding the context and underlying factors contributing to workforce disparities. Secondary data often fails to account for cultural and social factors that may influence workforce disparities, such as gender roles or regional differences in employment opportunities. The Gini coefficient does not consider that individuals may utilize health services in nearby regions. This constraint is especially concerning in areas with varying population densities, as it could overestimate inequality in sparsely populated regions.

Furthermore, the focus of this research is restricted to 2022, offering a snapshot rather than a longitudinal view. Thus, the analysis does not consider the trends in the distribution of healthcare professionals over time or the effects of recent reforms in the Saudi healthcare system. To address these limitations, it would be beneficial to complement the MOH data with qualitative studies that explore the experiences and perspectives of healthcare professionals, employers, and policymakers. This approach would provide a more comprehensive understanding of workforce disparities and help inform more effective policies and interventions in Saudi Arabia's healthcare sector.

Conclusion

This research highlights a critical component in the progress of the KSA's healthcare system, characterized by the challenge of balancing rapid economic development with the equitable distribution of health resources. The results showed notable differences in health professionals’ availability in various regions, especially in densely populated areas such as Makkah, Riyadh, and Jeddah, underscoring the shortfall in addressing the healthcare requirements of the whole population. This imbalance not only reflects the current state of healthcare availability but also raises concerns about the system's readiness to manage the growing NCDs and the requirements of an aging population. Therefore, addressing these inequalities will be crucial for achieving Saudi Vision 2030 and improving overall healthcare provision across the country. Nonetheless, this research provides valuable insights into the present status of healthcare professionals' distribution in the KSA. The existing inequalities amongst the health regions can be reduced by introducing strategies such as providing additional incentives, increasing the retirement age in remote regions, introducing bridge programs to upgrade the skills of diploma-holding nurses, and expanding digital health services. Additional strategies may include investing in medical education, adopting policies to increase the number of Saudi nationals in the workforce, and implementing measures to improve distribution across regions and between urban and rural areas. These strategies collectively aim to create a more equitable distribution of health professionals across Saudi Arabia and improve access to quality healthcare for all citizens regardless of their location.

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