Practicing Neurosurgery in Saudi Arabia

Saudi Arabia’s quest to establish a modern healthcare system that provides the best healthcare possible for all of its citizens began in 1970 with the launch of its first long-range plan. The constitution of the Kingdom of Saudi Arabia, adopted and approved by royal decree in March 1992, declared that the state is to guarantee the rights of its citizens and their families in the event of emergency, disease, disability and old age, take charge of all aspects of health, and ensure that healthcare is provided to all citizens.

Saudi Arabia has since invested heavily in healthcare. A number of initiatives and measures were introduced to provide excellent healthcare around the country; establish modern hospitals; acquire new facilities and equipment; support staffing, training, education and establishment of new programs; enhance healthcare networks, referral systems and outreach programs; introduce a credentialing body; and improve medicolegal legislation.

According to the 2008 budget, heralded as the largest in the kingdom’s history, the government allocated 10.8 percent to health and social affairs, an increase from about 6 percent allocated in recent years. The healthcare sector now ranks second only to the education sector, which garners 25 percent of the budget. The increase in funding reflects the growing demands of steady population growth, increased public awareness, changing patterns of diseases, expansion and promotion of new programs and facilities, proliferation of high-tech medical equipment and increased costs overall.

The provision of healthcare is led by the Ministry of Health but is shared with other autonomous government agencies, the Armed Forces and Security Forces health services, the National Guard hospital, university hospitals and Royal commission, King Faisal Specialist Hospital and Research Center, and with the private sector.

Two major reforms have been proposed: the implementation of a health insurance system and engagement of the private sector in healthcare. Regarding the former, the recently enacted health insurance law will require employers to purchase approved health insurance; the government is now in the final stage of setting the regulation for implementation. With respect to the latter, the private sector is being encouraged to undertake a greater role in financing, construction and management of health facilities.

Neurosurgical practice in Saudi Arabia during the past 30 years has progressed to internationally recognized high standards. The total estimated number of neurosurgeons is 323, including 136 in the Ministry of Health, 142 in other governmental health facilities and 45 in the private sector. Although evaluation, diagnosis, and general and emergency neurosurgical interventions are widely available throughout the country, neurosurgeons are concentrated in Riyadh in the central region, in Jeddah, Mecca and Medina in the west, and in Dammam and Alkhobar in the east. In these areas, advanced neurosurgical equipment, sophisticated diagnostic laboratories, and modern imaging facilities are available to perform simple and complex neurosurgical interventions. The number of neurosurgical operations performed during 2006 was reported to be 4,003 interventions in the autonomous governmental sector hospitals and 2,499 in private sector hospitals.

A great amount of attention has been paid to the national training program in neurosurgery. The first fellowship program was initiated in the early 1990s, a fruitful collaboration among King Faisal Specialist Hospital and Research Center, King Faisal University and the Armed Forces Hospital. In later years, when the Saudi Council for Health Specialties was established, the Saudi training program in neurological surgery was initiated. The program has attracted many high-scoring graduates who have pursued certification by the Saudi Board of Neurological Surgery. The neurosurgical training program welds the European and the North American training guidelines into one modified system that consists of two parts, a junior and an advanced stage, for a total training period of six years. There are strict admission and selection guidelines, an annual evaluation examination, and a final qualifying complex examination toward the Saudi board certification.

The residents in training have several rotations, including neuropathology, neuroradiology, intensive care unit and emergency medicine, neurology, and elective rotation in addition to their rotation among the different aspects of neurosurgery. Trainees work approximately 40 hours per week. A strong involvement in research projects and contribution to scientific publications are highly recommended. The Saudi Council for Health Specialties is responsible for registration, monitoring and recognition of training in the kingdom as well as licensing and license renewal every two years.

All of the above mentioned measures are geared toward safe and excellent patient care. Medical liability is governed by the Islamic rules and Ministry of Health regulations. Medicolegal cases are evaluated by a committee that consists of an Islamic legal judge, a Ministry of Health representative and an invited expert from a recognized health facility as a third party.

Greater efforts for early diagnosis and public health awareness recently have been made. The most important challenges for neurosurgeons are: (1) delayed referral, and dealing with the resultant advanced stages of neurological diseases; (2) the shortage of qualified medical and paramedical staff generally and of nurses specifically; and (3) the need for more advanced facilities, resources and homogenous distribution throughout the country.

Future ambitions are to coordinate and integrate the provision of healthcare by the various agencies, to ensure regional balance regarding healthcare services, and to coordinate with educational and training institutions to meet the need for national healthcare.

Imad N. Kanaan, MD, FACS, FRCS, Ed., is chair of the Department of Neurosciences, professor and senior consultant neurosurgeon at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. The author reported no conflicts for disclosure.

For Further Information

• Saudi Arabia Ministry of Health Statistical Yearbook 2006, www.moh.gov.sa/statistics/S1427/default.htm
• Saudi Arabia’s 2008 National Budget: Highlights & Analysis (report by Al Rajhi Bank), www.alrajhibank.com.sa/reports/Documents/2008Budget11final11.pdf

King Faisal Specialist Hospital and Research Center King Faisal Specialist Hospital and Research Center in Riyadh reflects the high level of neurosurgical healthcare offered in the Kingdom of Saudi Arabia and serves as an inspiration to other national and regional institutions. The hospital is an 850-bed tertiary care facility with 400 medical consultants who cover approximately 20 departments, including several highly qualified subspecialty sections. The facility averages annual patient referrals of over 35,000 patients. The Department of Neurosciences consists of five sections with 35 medical consultants and encompasses neurosurgery, adult neurology, pediatric neurology, neurophysiology, psychiatry and psychology. Six board-certified neurosurgeons cover a broad spectrum of neurosurgical practice. There are 30 neurosurgical beds, with an additional five epilepsy surgery/emergency medical unit beds. The 750 neurosurgical interventions annually include skull base and pituitary surgery, brain and spinal cord tumors, pediatric neurosurgery, neurovascular surgery, functional neurosurgery including epilepsy and movement disorders, neuroendoscopy, stereotactic surgery, and minimally invasive spinal surgery. The service is involved in a multidisciplinary approach to stereotactic radiosurgery and radiotherapy and is approved for acquiring intraoperative MRI capability. The Department of Neurosciences has a neurosurgical training program toward certification by the Saudi Board in Neurosurgery, residency programs in neurology and neurophysiology, and a fellowship program in pediatric neurology. The hospital also was approved recently by the World Federation of Neurosurgical Societies as a center for the International Skull Base Training Fellowship. Neurosurgery has two dedicated operating rooms five days a week that are fully equipped with special tables, three modern surgical microscopes with digital recording systems and navigational facilities, two stereotactic systems, power drill sets, skull plating systems for fixation and reconstruction, modern endoscopes with high definition cameras and digital recording, a carbon dioxide laser, and hardware for spinal fixation and spinal artificial disc implant. In addition, there is a complete setup for epilepsy surgery including invasive recording, awake resection, intraoperative mapping and vagus nerve stimulation, and deep brain stimulation and lesioning for treatment of movement disorders. The hospital has several trained and competent neuroanaesthesists and qualified operating room nursing staff with great experience in preoperative, perioperative and postoperative care of neurosurgical patients. The surgical intensive care unit has 30 beds for adults, 15 beds for children, and a specialized unit for neonatology that is supported by highly trained medical intensivists and equipped with quality monitors and ventilators as well as intracranial pressure monitoring systems. The Department of Pathology and Laboratory Medicine has two dedicated neuropathologists and state-of-the-art diagnostic facilities. The Section of Neurophysiology has a modern laboratory with expertise and facilities in electroencephalography, electromyography, monitoring for motor evoked potentials and somatosensory evoked potentials, and intraoperative monitoring. The Department of Radiology has a dedicated Section of Neuroradiology with three consultants. There are four helical computed tomography scanners, two magnetic resonance scanners, two angiography suites for diagnostic and interventional procedures performed by two interventionalists using different modalities (stents, coils, balloons), several ultrasound and fluoroscopy machines, three gamma cameras and a positron emission tomography/computed tomographic scanner. The Oncology Center has several sections including: medical oncology, radiation and stereotactic radiation using a micro-multileaf system as well as intensity modulated radiation therapy supported by the Department of Medical Physics. The hospital has its own linear accelerator and a state-of-the-art Pharmacy Department. In the Research Center senior scientists and doctoral students collaborate with the medical staff and perform clinical and basic science research, biomedical, biostatistics and bimolecular research. The center also has an animal laboratory for research and training. A stem cell research project and neuronal stem cell research program were approved recently. The hospital uses integrated clinical information systems technology, and PACS, the picture archiving and communication system. It was recently reaccredited by the Joint Commission International, an affiliate of The Joint Commission.