An analysis of the Saudi health-care system’s readiness to change in the context of the Saudi National Health-care Plan in Vision 2030

Abstract

Change management studies have emphasized the significance of an organization’s readiness for change and transformation and have recommended strategies to affect change. Organizational readiness for change is a multi-faceted, multi-level, and multi-dimensional activity; its most important aspect is organizational members’ willingness to accept and implement change because ignoring the human factors may result in resistance and failure. Through its National Transformation Program 2020, the Saudi Arabian government is attempting to effect radical changes in the structure and function of its health-care system to achieve quality care and effective service delivery. The aim of the present review is to discuss the Saudi health-care system’s readiness to change that Saudi Arabia intends to implement by 2020, based on extensive review of different reports, documents, and empirical studies in the field of organizational readiness for change. The study concludes that if organizational readiness for change is high, resources are available, and situational factors are aligned, members of organizations will take the initiative to change, exert optimal effort, demonstrate greater determination, and engage in more cooperative behavior that may lead to efficient and effective implementation of the Saudi health-care transformational plan with fewer complications and less resistance.

Introduction

Change is inevitable and one cannot ignore the changing demands on health-care systems, as both internal and external changes on the health-care system require reconstruction and innovation. Health-care organizations function and operate to promote, restore, and maintain health in a country.[1] An effective system can justify its existence and the funds invested in it. However, if a system fails to meet society’s needs and requirements, then, it is necessary to modify the system. The system life cycle suggests that a system must be upgraded when it stagnates and burdens the national economy. Keeping in mind, the enormous pressure and financial constraints of the economy because of war and the decreasing prices of the oil in the international market, the government of Saudi Arabia must restructure its organizational mechanisms and services in the health sector.

Bringing innovation and change to a health-care system is a challenging endeavor because today’s organizations have complex structures and functions.[2,3] Introducing change is a challenge for management and organizational authorities in all establishments, small or large, public or private because of technical and human complexities.[4] Researchers have observed that innovation or change fails to bear fruit and wastes budgets and resources, which occurs if the existing system has not been effectively evaluated with respect to both human and non-human factors and subsequently modified.[5] The technical factors in a system are simple to modify compared to human factors. In some instances, systems analysts and developers ignore or minimize human factors and place primary importance on the technical dimensions of the organization. This may result in misalignment, and change management will succumb to controversies and issues and thus fail to realize its goals and objectives.[5]

Another critical aspect is the organization’s readiness for transformation with respect to its members’ willingness to adapt to the change. A closed system that does not welcome external changes will cease to function by comparison to an open and flexible system.[6] Such readiness requires education and motivation from stakeholders through financial incentives, promotion to higher ranks, and training.[7,8] Today’s organizations are considered learning organizations, i.e., they unlearn the old to learn the new.[9] This continuous learning environment plays a pivotal role in readiness for change and transformation.

Currently, Saudi Arabia follows the national health-care model, in which provision of health services is primarily the responsibility of the government, and patients enjoy treatment and health services free of charge.[10] Although there are some private hospitals and primary health-care centers, the private sector’s role is nominal by comparison to the government sector. Therefore, under the able leadership of the young Deputy Crown Prince Muhammad Bin Salman, the government has envisioned a national transformation plan referred to as Vision 2030.[10]

The purpose of this plan is liberalization that provides an opportunity for the private sector and reduces the pressure on the public sector. Moreover, the new reforms are expected to eliminate the complications and deficiencies of the existing system. Therefore, the new structure is likely to be more dynamic and service-oriented with respect to quality of care.

The goal of this study was to identify the major issues that the health sector could face in implementing the national health-care transformation plan successfully with respect to readiness for change in the context of the national health-care plan in its Vision 2030.

Literature Review

In quoting Kurt Lewin, Wittenstein[3] defined change as the process of altering the current state to the desired state. Similarly, Lewin[11] stated, “Change and constancy are relative concepts; group life is never without change, merely differences in the amount and type of change exist.” Thus, change and adaptation have long been considered the most critical factors in the fields of policy and research, including health.

However, despite the development in the field, the dynamics of change and adaptation are still a great challenge to understand, as the field is in its infancy. Repetto[12] reported that the lack of understanding of ways in which to innovate and adapt, and the factors that determine practical execution are some of the most significant issues. For example, researchers have identified various factors that can lead to success or failure. These may include assessing effects, investigating adaptive capacity, and identifying options for adaptation and knowledge of the extent to which administrative and governance systems are prepared to adapt.[13-17] Similarly, these studies have indicated further that frameworks for systematic examination of the extent to which health-care organizations are ready to adapt are also limited.

Perspective on Global Transformational Management Models

The literature on transformation or change management models has revealed two primary models for transformation and change–planned and emergent–the major models Lewin[11] proposed. According to Lewin,[11] in the planned approach, there are four concepts and theories applicable to effective change management: Field theory, group dynamics, action research, and the 3-step model.

A thorough review of the existing literature revealed that, among the models of emergent change management used, the most common is Hinings and Greenwood’s model of change dynamics.[18] Further, Pettigrew’s process/content/ context model is also useful and effective in successful transformation and change processes.[19] Inter alia, the most significant in the health sector are Lukas et al.’s organizational model for transformational change in health-care systems, the Canadian Health Services Research Foundation’s evidence-informed change management approach, and more recently, the Canada health info way’s change management model.[20]

Analysis of Change Management Models in Health care

Lukas et al.[20] have developed a conceptual model to guide health-care organizations in effecting sustained, organization-wide patient care improvements. This model emphasizes facilitating the impetus to transform, leadership commitment to quality, and initiatives to involve employees in a meaningful way. In his study, “State of Population Health Analytics” Bennett[5] reported the complicated fabric of multi-dimensional, interdependent components. His model focused on three main areas with respect to health-care transformation and change: Organizational/people aspects; technology, data, and workflow, and aspects of an organization’s processes.

Overview of the Saudi Health-care National Transformation Program (NTP)-2020

The health-care services system in Saudi Arabia has evolved significantly over the past 20 years. The Saudi Ministry of Health provides 60% of these services free of charge, while others, including the private sector, provide the remainder.[21] To cope with future challenges successfully, the Saudi health system is expected to undergo transformation and change by 2020.

According to the WHO officials, the “Saudi health-care system has well-equipped hospitals designated to serve that surpassed many of the world-class hospitals.”[22] Similarly, according to Bloomberg, Saudi Arabia ranked 29^th with respect to the efficiency of health-care systems around the globe. Recently, the Saudi government approved a 10-year strategic plan for the period covering 2010–2020, which emphasizes tertiary and quaternary care in each region to make them independent of provision of care.[23]

Numerous studies have identified the weaknesses of the existing Saudi health-care system and offered methods to achieve cost-effective, quality health-care services. For example, a study by Sebai et al.[24] found that Saudi Arabia is incurring high costs, as well as facing concerns about quality of care. To resolve these issues, the government plans to restructure and reform the health-care system through its Vision 2030. This includes the plan to involve the private sector and increase its share from 25% to 35% in the coming years.[25]

To achieve successful implementation, the government has reserved 6 billion SAR to support the transformation of the health sector.[25] The goals of the NTP 2020 include: Increasing the share of the private sector through alternative financing and supervision; increasing the efficient use of existing resources; improving the efficiency and effectiveness of health care with information technology and digital transformation; improving governance in the health-care system through accountability mechanisms; addressing the quality of patient safety issues; and improving the infrastructure and safety standards in health-care facilities as well as in facility management.[10]

Barriers to Readiness for Change Process

In the context of the Middle East in general, and Saudi Arabia in particular, there is no specific framework to address management issues with respect to readiness for change and adaptation. However, there are numerous studies available in the literature that describe existing frameworks to guide nations including the efforts of the United Nations Development Program, which identified and developed four components through which we can assess readiness for change: The ability to plan, access, deliver, monitor, and report.[4]

An organization’s readiness for change is a multi-level, multi-faceted, and multi-dimensional construct.[1,8,9] Readiness for change may refer to the preparation, willingness, and commitment of the organizational members, and their resolve to implement a change by developing the collective ability to achieve an effective change process.[1] Studies have shown that organizational readiness for change varies as a function of how much organizational member’s value the change and how favorably they appraise three key determinants of the ability to implement change resource availability, task demands, and situational factors.[1]

Researchers working in the field of change management have emphasized the significance of establishing organizational readiness for national transformation and change and have advocated various strategies to do so. Like an individual’s willingness to change, organizational preparation, and willingness are also critical. Changes may be multiple and simultaneous, and areas of change may encompass staffing, workflow, decision-making, communication, and reward systems.[1]

Barriers to successful implementation may include lack of political will on the part of the leadership, legal obstacles, limited, or weak coordination among the actors involved in the transformation and change process, lack of financial resources required to support successful program implementation, uncertainty about information for readiness with respect to decision-making, lack of clarity about who is responsible for action, conflicting objectives among the stakeholders and interest groups, and finally, failure in collective decision-making.[26]

Researchers have reported widely that when organizational readiness for change is high, its members likely will initiate the change by exerting greater efforts, and exhibiting more determination and greater cooperation, as well as positive attitudes and behavior that result in smooth, disciplined, and effective implementation with minimal resistance to change.[1]

Discussion and Analysis

Like any other organization, health-care organizations throughout developed and developing countries rarely are ready to implement and manage rapid organizational changes. The new knowledge economy has introduced opportunities, as well as tumult in the growth of health-care organizations.[27] Health-care institutions worldwide are faced with high costs, reduced reimbursements, governmental regulatory reforms, cutthroat competition, and demanding physicians, and patients. Radical and rapid changes within health care are the most significant factors driving organizational changes in these systems.[28-30] Similarly, in addition to these factors, an aging population, lifestyles, high prescription costs, and the scarcity of registered nurses, and other health-care service workers have compelled health authorities to institute more dynamic systems.[2,3]

Conditions that can promote organizational change include the change valence, change efficacy, and contextual factors.[6-8] With this background, we can conclude that an organization’s readiness is a shared condition in which its members are determined to implement a new system by innovating the existing one or instituting a new one with confidence through collective effort. If an organization’s members think in this way, it will be a great help in understanding and analyzing organizational changes. However, despite these facts, uniformity in behavior change is a prerequisite to execute the change effectively, and reap its anticipated benefits. Further, although there is no “one best way” to increase organizational readiness for change, organizational management experts have indicated that it is necessary to monitor the change process regularly and keep it as flexible as possible.

Both the logic and empirical evidence indicate a positive relationship between organizational members’ support of a change and new strategy and the effectiveness of its implementation. However, due to variations in organizations and their units, in addition to their nature,[31] objectives, and modes of operation with respect to organizational capabilities for implementation of the change also will vary. This implies that organizations may differ in their overall orientation to change with respect to competencies and general skills they might require to implement new processes.

Ray et al.[32] have described the general orientation in organizations, which they referred to as the “service climate.” According to these authors, this climate service in health-care organizations is related directly to their strategic efforts to improve patient service. The critical factors that determine the service climate are unrelated to any specific new patient service process, but rather to a general set of behavioral norms that exist within an organization. However, it has been observed that implementing strategic change normally requires the engagement of the stakeholders in different behavior than they have exhibited in the past. When organizational norms are inconsistent with the new behaviors, they may generate resistance to change. Caldwell and O’Reilly[33] have identified the characteristics and beliefs in approximately 2000 organizations, which, in their opinion, could help promote innovation within health-care organizations, and grouped these into four identifiable categories including teamwork, tolerance of mistakes, support for risk-taking, and speed of action. Similarly, Caldwell and O’Reilly’s findings about change readiness were consistent with those of Armenakis and Harris,[8] Eby et al.,[34] and Oreg.[35]

Conclusions and Recommendations

This study concluded that the Saudi government should address the human issues of a health-care organization rather than paying attention only to its economic and technical dimensions. Human interactions are the core element that constitutes and makes or breaks an organization. Therefore, ignoring these in planning, policy formulation, and decisions could be detrimental, as an organization’s readiness to change is valueless without the organizational members’ willingness to adapt and maintain consistency with the transformation required. Otherwise, resistance could destroy the entire exercise and efforts of NTP 2020.

It is believed generally that the impediments to an organization’s readiness to changes such as those in NTP 2020 may include the lack of political will and support from leadership, legal hindrances, lack of funds for change, and poor coordination among the people responsible for implementing reforms. Further, too much secrecy and uncertainty in the decision-making process, the absence of clarity about who is responsible for the action, conflicting objectives among the stakeholders and interest groups, and finally, the failure of collective decision-making, affect the outcomes. Until and unless these issues are addressed, we cannot imagine readiness for change and successful implementation of the plan.

Moreover, sufficient funding also is required, and although the Saudi government has allocated a considerable amount for transformation in NTP 2020, it must focus more on the priority areas. The second significant aspect is that of the targeting action, for example, the regions in which health-care organizations score poorly on readiness. Weiner et al.[36] suggested that priority must be given more to organizational improvement and building support for adaptation and must include stakeholder dialogue to facilitate the sustainable transformation in these areas effectively to achieve the goals of transformation like those in NTP 2020.

Similarly, monitoring and evaluation of the change process itself are critical for the successful execution of the plan, and the ability to track transformation is complicated if there are no measurable outcomes present to judge the transformation process. Therefore, experts recommend using a rigorous monitoring and evaluation mechanism to assess the progress of readiness for transformation by comparing them to the actual developments designed for transformation within the institutional and governance structures.

A supportive environment is a pre-condition to achieve the desired level of readiness for transformation. However, during transformation, the health-care organization could face a number of challenges, including procedural, conceptual, and political challenges, as identified by experts such as Weiner et al.,[36] Eriksen and Kelly,[37] and Madsen et al.[38] in several transformational cases. Therefore, these issues must be addressed to prepare the stakeholders and organizational members successfully to avoid complications and resistance and to implement the plan to transform Saudi health-care effectively.