Tuesday, May 5, 2015

Uncertain Health in an Insecure World – 38

“Game of Thrones”

Ex pats and foreigners alike know Saudi Arabia as ‘The Kingdom’. Its ruling family is the largest (>7,000 princes & princesses) and wealthiest royal house in the world. But these days, the crown weighs heavy on the throne.

The House of Saud's wealth differential with the public is the greatest in the world. And while the royals deny the existence of poverty in their country, one quarter of 16 million native Saudis live on <$17 per day. Three-quarters of the Kingdom’s unemployed are in their twenties. Ninety-three mostly poor young Saudi militants were just arrested for plotting terror against in-country targets.

New King Salman recently suffered a stroke and is rumored to have post-stroke dementia. He just removed the ruling dynasty's long serving foreign minister and his heir-apparent, appointing tough interior security official Mohammed bin Nayef (“America’s Favorite Saudi”, below) as the Crown Prince and next in line to the throne.
The new Deputy Crown Prince is Salmon’s 30-something son, Mohammed bin Salmon, who recently became the youngest Defense Minister in Saudi history. This shake-up concentrated power in the conservative wing of the royal family, and is thought to be in response to growing domestic turmoil and regional chaos in Iraq (ISIS) & Yemen (Houthi rebels, Al-Queda in the Arabian Peninsula).

Despite this, The Kingdom provides universal healthcare coverage for its citizens. The public healthcare system offers primary care clinics and urban hospitals. Specialized care is available at referral centers in so-called economic cities. A private sector of 127 hospitals, including a growing number of public-private partnerships and for-profits, has also emerged.

The demand for highly skilled healthcare workforce is high, and foreign-trained physicians and nurses are commonly recruited. Medical career training of local talent is a key target for the government, which has long contracted for specialist training of Saudi doctors abroad in the Europe Union and Canada.

Since the Arab Spring of late 2010 (above), Saudi healthcare spending has ballooned to a projected 4.9% of GDP in 2016 (below), representing a 2011-2016 compounded annual growth rate (CAGR) of +9.3% which still places The Kingdom behind the U.S. (+18.5%), Germany (+11.7%), Japan (+7.9%) and China (+5.9%). By comparison, its population increased by 3.2% to 32.8M over the same period, as compared to only 2.3% growth in the prior decade.

In 1970, there were just 74 hospitals and 9,000 inpatient beds in Saudi Arabia; by 2009, there were 415 hospitals and 58,000 beds. In an effort to placate the poor and underserved masses, the Ministry of Health has built >130 new hospitals with >100,000 additional beds. This cash outlay (there is no capital financing in Islam) combined with lower oil revenues has placed an unusual strain on the royal family’s reserves.

The House of Saud is also stressed by the growing healthcare demands of an aging population that is experiencing a higher prevalence of western world chronic diseases. Life expectancy will increase from 74.1 years in 2011 to 75.3 years in 2016. Unhealthy eating habits and inactivity in 68.8% of the population are driving up obesity and diabetes rates. NCD’s contribute to 71% of all deaths, the majority of which are due to cardiovascular diseases.

Foreign healthcare systems have entered the market, and major global consulting firms have helped to introduce innovative technologies and social media to help staunch these adverse health trends. But the screening infrastructure has not kept pace with the burden of disease, nor with the rapid expansion of healthcare facilities. Some 21,000 mammograms were done in 2013 when population health estimates indicate that >2 million mammograms were needed. As a result, breast cancer is frequently not diagnosed until very advanced stages.

Ironically, in The Kingdom the disconnect between royal wealth and public wellness is a great as the association of regional insecurity to uncertain health is strong. 

The Royals' subjects are being subjected to the best and the worst of healthcare. Benevolent princes are facing the realities of regional strife and global markets, still ruling in ways that may have worked for the last 70 years in The Kingdom.

But we in the Square see that shining healthcare palaces are no defense to the blood in the streets.

And unlike Queen Daenerys Targaryen, there are no dragons to quell the unhealthy masses. 

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