A comparison of access to medical care for insured and uninsured expatriates in Saudi Arabia

Background: Saudi Arabia is one of the Gulf Cooperative Council (GCC) countries which have common characteristics such as high-income governments, dominant expatriate populations, and under-developed healthcare systems, including healthcare financing. The dominance of the expatriate working population raises the question of how to find a mechanism that ensures expatriates have appropriate access to medical care whilst the employers bear the responsibility of healthcare expenses. Saudi Arabia is one of the few GCC countries to have reformed its private healthcare system through a Compulsory Employment-Based Health Insurance (CEBHI). The CEBHI was designed to mitigate some of the disadvantages of the Employment Sponsored Insurance scheme previously implemented in the United States; and this is the first study to investigate the impact of this form of private health insurance on access to medical care, in a country such as Saudi Arabia. The main aim of the study was to explore the influence of health insurance on access to medical care, in order to assist the Saudi Government in their deliberations about making CEBHI compulsory for all people (citizens and expatriates) within Saudi Arabia. This aim was investigated through the following objectives: 1) to review health financing in Saudi Arabia and compare it with other GCC countries and elsewhere in the world; 2) to compare the access to medical care of insured and uninsured expatriates in Saudi Arabia; 3) to develop a framework for understanding the complex relationship of health insurance and access to healthcare, 4) to make policy-relevant recommendations regarding the key question as to whether compulsory health insurance in Saudi Arabia should be expanded. Methods: Two methods were used to tackle the study objectives. Firstly, a framework for country-level analysis of healthcare financing arrangements was used to compare and analyse the national expenditure on healthcare within the GCC and other developing/developed countries. Secondly, a logistic regression analysis of data from a cross-sectional survey was undertaken to investigate the impact of health insurance on access to medical care, considering the main workplace and personal characteristics of the expatriates. Three access measures, access to usual medical care (Access 1), inability to access medical care (Access 2), and utilization of medical care (Access 3), were used to evaluate access to medical care for the expatriate population. Prior to the implementation of CEBHI the expatriate population accessed medical care through a variety of different avenues. These modes of access were used as classification of the expatriate population into four groups. Two of these groups were insured but had a different Previous Method of Paying for Healthcare (PMPHC) (Group B=insured, not paid, and Group D=insured and paid) and two groups were not insured but also had different PMPHC (Group A=not insured, not paid and Group C=not insured, but paid). A multistage stratified cluster sampling was used, and a sample selected from each sector and company size proportionately. The total sample size was 3,278. A simple conceptual framework for studying access to medical care was developed to guide the multi-variate regression techniques, and greatly assisted interpretation of the results. Results: The GCC characteristics impact on the healthcare financing strategies of GCC countries in three ways. First, GCC governments provide the majority share of the health budget, similar to high-income countries. Second, GCC countries use different strategies to control expatriates costs, but some of these strategies lead to increased out-of-pocket expenses, which is a characteristic of low-income countries. Third, health care financing systems in GCC countries are still being developed as they finance most of their public services, including health care services, with revenue from natural resources (i.e. oil or gas). Additionally, some of their health care indicators are identifiable with those from below upper-middle income countries. In addition, after CEBHI, private expenditure did not change but remained around 22.4%, which does not reflect the huge number of people having access to medical care though private sector only. However, there was a shift in the means of private sector expenditure from Out Of Pocket payments to private insurance expenditure. OOP expenditure decreased from 32.3% in 2006 to 28.4% in 2008, and private insurance expenditure increased as a percentage of private sector expenditure from 26.2% in 2006 to 36.7% in 2008. Analysis of the data from the survey demonstrates that health insurance is strongly associated with access to medical care, as measured by the three different access measures). Compared to uninsured workers, being enrolled in CEBHI increased the possibility of an expatriate’s access to usual medical care and utilisation of medical care by more than 10 (8.709-12.299, 95%), and 2.3 (1.946-2.750, 95%) respectively. However, the influence of PMPHC is greater than the influence of insurance alone on reducing the inability to access medical care (health insurance reduced the inability to access medical services by 42% (0.515-0.995, 95%), whereas PMPHC reduced the inability to access medical services by more than 65.% (0.273-0.436, 95%)).Therefore, the impact of health insurance on access to medical care is much greater for those expatriates previously having had healthcare costs met by their employer, than for those who had not. These impacts remained, when the odds ratios were adjusted for both workplace and personal characteristics. Conclusion: CEBHI has a clear positive impact on reducing out of pocket payments and increasing private insurance expenditure. However, overall, private healthcare expenditure has increased insignificantly. This indicates that the main impact of CEBHI on private expenditure, is the change in the mode of payment from out of pocket payments to private insurance expenditure. However, the actual impact on private sector expenditure is still minor. Access to medical care is influenced by health insurance. In addition, it is also influenced by PMPHC as a contributory role to play in the influence of health insurance on access to medical care. Workplace and personal characteristics play a small part in mediating the influence of health insurance on access to medical care. A framework was developed for understanding the complex relationship of health insurance and access to healthcare, which will be useful for further investigations regarding the influence of health insurance on access to medical care. Both long and short-term recommendations are proposed for increasing the expatriate population’s access to medical care, whilst reducing the burden on healthcare financing.