Foreign bodies

The race to nationalise the healthcare sector has got off to a slow start. Medical Times reports on an industry struggling to present a national front.

Stand in the corridor of many local hospitals, and you could be forgiven for forgetting you are in the Middle East. The doctor you will see is likely to be an expatriate. Your consultation is likely to be in English.

The nurse that takes your notes will almost certainly be south Asian. More than in any other industry sector, the lack of national employees in the healthcare field is staggering.

The industry presents a unique problem to local governments. The sector is almost exclusively dependent on foreign labour, and most roles demand specialist training.

For this reason, the nationalisation quotas that have been rigorously enforced in other sectors are still being skirted around in healthcare.

Recruitment is partially a numbers game. In Dubai, for example, the national population is outnumbered by south Asians alone.

Lobbying for better representation in a field historically unattractive to nationals (in 2005, less than 1% of healthcare employees were Emiratis) is no easy feat.

Still, regional governments are clear that healthcare must start to present a more national front. So how is this being implemented?

Walk, don't run

For Saudi Arabian facilities, the change has been abrupt. The 'Saudiisation' bill rests on three pillars; to cap the number of non-technical foreign staff in facilities, to up the number of Saudis in the sector, and to smooth the path for a minimum national quota among clinical staff.

The government raised hackles by originally announcing quotas of 30% for small healthcare centres, and 35% for larger clinics and hospitals.

While these have slumped in the face of hiring hitches (to 10 and 15% respectively), hospitals are still frustrated at experiencing the sharp end of a politically driven decision.

"We are all for Saudiisation, but it should not be forced," explains Dr Mazen Soliman Fakeeh, director general of Dr Soliman Fakeeh Hospital. "There are steps that need to be taken to qualify Saudis before private institutions are obliged to employ them."

Blind enforcement of quotas will breed resentment among healthcare facilities, he argues; a backwards step for a country keen to lure private investors.

"Private institutions need to function and to generate profit, revenues and expand to accommodate jobs. If you force saudiisation...you are damaging the economy."

The issue is less clear-cut for the foreign physicians slotting in around nationalisation bids. Doctor opinion is typically divided over backing a more homegrown workforce, and fretting over whether quality checks are taking a back seat to quota filling.

"Many physicians became fed-up with the deteriorating standards once Saudiisation started," reveals Dr Dee McCormack, a consultant perinatologist formerly employed at King Faisal Specialist Hospital.

"People were pushed into jobs that they were not qualified for."

The demand for nationals is also outstripping the number of qualified employees available. ‘We don't have Saudis available for all the specialty areas," says Khalil Bhaksh, head of recruitment at King Fahd Military Hospital in Jeddah.

"At best, in perhaps 20 years we can aim for a 40 or 50% presence."

Exacerbating the dilemma is the number of new projects currently underway. Hospitals, caught between a rock and a hard place, are forced to recruit from abroad to ensure they can deliver on services.

"We are trying to cut the non-clinical staff, and encourage more Saudis to qualify for these administrative positions," Bhaksh reports.

All quiet on the national front

Back in the United Arab Emirates, the government has opted more for light encouragement than hardline enforcement. The lack of hustling has made private hospitals more receptive to a slow slide to nationalisation.

The Emirates National Development Programme (ENDP) has honed in on the healthcare sector, persuasively arguing that a ready-made local workforce may provide a flexible solution to the spiraling costs of wages, housing, and overseas recruitment fees.

Welcare World Health Systems was one of the first to hitch on, manning an in-house nationalisation scheme aimed at filling non-clinical posts.

"It makes sense to have locals, who are settled in Dubai, need no visa and other support; to be part of the team," explains director of human resources, Danie Meintjes.

Aside from serving up a headstart on future emiratisation quotas, the scheme is also set to broaden the firm's appeal to national patients (Emiratis have traditionally clung to public sector providers.).

"More than 45% of our clients are Arabic-speaking," Meintjes says. "We need Arabic-speaking staff."

Meintjes admits that recruitment has been tough. Several candidates from the first intake have already dropped out. But the hospital is ploughing ahead with a second wave.

"It's a long-term process with no quick fixes," he sighs.

Class action

On the domestic front, public sector hospitals offer an idea of how a fully-fledged Emiratisation scheme might look in action.

As government-owned facilities, they are arm-locked into hiring and retaining more national staff, but recruitment is hampered by the small number of local students currently plumping for careers in healthcare.

Tawam Hospital in Al Ain tours local colleges and universities flagging up its staff vacancies in a bid to drum up interest in the sector.

"Nationals are still shying away from this type of job and I think that will continue," explains Aysha Al Darmaki, human resources manager at the Johns Hopkins managed hospital.

It may be that governments are trying to force an unlikely pairing. Hisham Al Muthanna, senior employer relations executive at ENDP admits cultural boundaries come into play with the healthcare sector, but stresses; "It is just a case of breaking the barriers between nationals and healthcare."

The crux of the problem, according to local hospitals, is a gap between the quality of local education and the needs of hospitals aiming for internationally benchmarked standards.

"We struggle to offer nationals jobs they are qualified for," Al Darmaki says flatly. "We don't have enough schools that deliver the right education."

This perceived imbalance can cause friction in the workplace with existing staff, if not handled carefully.

"The key for success is that [recruitment] should never be done on the basis of ‘tokenism'," reports Welcare's Meintjes. "The staff joining must be equipped to add value to the organisation."

Slow and steady...

Current reports have raised the question; Is nationalisation really an achievable goal in healthcare? It's a difficult discussion, but experience suggests substantially more funding at a grass roots level combined with a realistic timeline would help smooth the path.

"We need investment in education," stresses Dr Mazen. "The number of medical schools and the number of graduates will not allow us to achieve our current needs, let alone our future needs."

Dr Ianny Kornfeld is a consultant in obstetrics and gynaecology at King Faisal Hospital, Riyadh.

His experience hints that nationalisation has promise. He is seeing renewed interest from Saudi physicians, trained abroad, in returning home to practice and believes a gradual raise in national numbers is underway.

"There are many Saudi physicians who have come back from the States who are very well trained, and I'm happy referring to them," he says.

"It should be everybody's goal to have their own people working in healthcare. It's their country. Yes, the numbers are not huge, but it's starting."