Distribution of Primary Healthcare Centers Between 2017 and 2021 Across Saudi Arabia

Background and aim: Access to adequate healthcare systems is seen as a fundamental human right. Therefore, healthcare services must be distributed and accessible in the most efficient way possible to those who need them the most. Primary healthcare centers are the backbone of any healthcare system as they provide essential healthcare services to the general population. Inequalities in the distribution of primary healthcare centers can lead to disparities in healthcare access and outcomes. This study aimed to assess the equity of primary healthcare centers distribution, we analyzed and evaluated the allocation of primary healthcare centers in Saudi Arabia from 2017 to 2021. Method: This cross-sectional study utilized data from the Health Statistical Yearbook published by the Ministry of Health, Saudi Arabia, during the period of 2017-2021. The number of primary healthcare centers per 10,000 population was calculated for the 20 health regions. We used the Gini index to measure inequality in the distribution of primary healthcare centers. The Pearson coefficient was calculated to assess the correlation between the number of primary healthcare centers and the population in each health region. Result: The overall ratio of primary healthcare centers to population decreased from 0.72 to 0.62 between 2017 and 2021. The Gini index showed relative equality in the distribution of primary healthcare centers from 2017 to 2021 with values between 0.2 and 0.3. There was a positive correlation between the population and the primary healthcare centers in Jeddah, Tabouk, and the Northern Region. However, in Riyadh, Makkah, Taif, Madinah, Qaseem, Eastern Region, Al-Ahsa, Aseer, Hail, Jazan, Najran, Al-Baha, and Al-Jouf, the correlation was found to be negative. Conclusion: From 2017 to 2021, primary healthcare facilities are distributed fairly throughout 20 health regions of Saudi Arabia. However, there are still some disparities between provinces, and efforts must be made to ensure that primary healthcare centers are distributed equitably across the country to improve healthcare access and outcomes for all.


Introduction
Health is a crucial aspect of daily life for all individuals, regardless of demographic factors, such as age, gender, socioeconomic status, or ethnicity. It plays a crucial role in determining one's ability to attend school or work, fulfill family responsibilities, and participate in community activities. People will often make significant sacrifices in pursuit of a longer and healthier life. Adequate access to healthcare systems is considered a basic human right. Therefore, healthcare services must be delivered to those who need them most in the most efficient manner possible [1]. The right to the highest attainable standard of physical and mental health was first recognized internationally in the 1946 Constitution of the World Health Organization (WHO), which defines health as a state of complete physical, mental, and social well-being and not just the absence of disease or infirmity. This right was further affirmed in the 1948 Universal Declaration of Human Rights and the 1966 International Covenant on Economic, Social, and Cultural Rights [2]. Primary healthcare centers are the backbone of any healthcare system as they provide essential healthcare services to the general population. Inequalities in the distribution of primary healthcare centers can lead to disparities in healthcare access and outcomes [3].
Primary healthcare centers supply the tools and services necessary for maintaining the health of citizens and improving their quality of life. The rational distribution of these centers is essential for ensuring fair distribution and optimal utilization of healthcare resources and for attaining the national aim of equalizing basic public services. Proper spatial distribution of these facilities in health regions guarantees that all demographic groups, especially the elderly and vulnerable populations, have greater access to crucial healthcare services, which leads to better overall health outcomes in urban communities and enhances the capacity to handle public health emergencies [4].
The government in Saudi Arabia made healthcare accessible by implementing a comprehensive and unified system for health-related licenses, which is closely linked to other government agencies. The regulations in the country guarantee that everyone, regardless of their condition, is entitled to top-quality healthcare without discrimination based on disability by providing universal access to healthcare through its welfare policy. The public sector offers free healthcare services to Saudi citizens with no additional financial support. The government also strives to improve the overall well-being and quality of life for individuals and their families [5]. It has a healthcare system that combines public and private services. The government's Ministry of Health is responsible for about 60% of healthcare services, which include primary care centers, hospitals, specialized services, and outpatient services [6]. To effectively increase access to primary healthcare services, it is vital to understand the distribution of primary healthcare centers in 20 Saudi health regions [7].
The Ministry of Health introduced the Ehalati system in 2017, but it only recently gained widespread use among primary healthcare providers. E-referral involves using an electronic platform to transfer patient information from a primary to a secondary or tertiary healthcare provider. This may shorten the distance between primary and tertiary care centers and improve the quality of care and efficiency of the referral process. However, the impact of this system has not been thoroughly assessed yet. A review of the literature on primary healthcare (PHC) referral services in Saudi Arabia showed that crucial information about the reasons for patient referrals is frequently under-reported. Upgrading the resources of primary healthcare centers is crucial for enhancing the quality of primary care services. To improve accessibility, implementing appointment systems, registers, and follow-up protocols are recommended [8].
Given that the National Transformation Plan 2030 aims to optimize the distribution of resources between primary healthcare centers and hospitals, it is crucial to assess primary healthcare centers and adapt them to meet the needs of the population [9]. However, research on primary healthcare capacity in Saudi Arabia is limited and often focuses on specific regions or sectors.
Similar studies from other countries have focused on the distribution of hospitals and healthcare centers aiming to assess inequality in resource distribution applying the Gini index. A Chinese study, for example, used data from the Chinese Statistical Yearbook (1999-2017) from 2008 to 2016, the Gini coefficients for healthcare institutions fluctuated between 0.150 and 0.200, fell by 0.048 (39.5%) and 0.058 (40.9%), respectively. At the same time that the number of nurses is growing at the fastest pace (109.0%), the distribution of nurses is also of the utmost importance [10]. In another study conducted in 18 states of Sudan using state-level data on health resources and health outcomes from the Sudan Health Statistical Report of 2016, the Gini coefficient values vary from 0.32 for hospitals and 0.36 for healthcare centers [11].
In Saudi Arabia, PHC has been prioritized as a core component of the newly proposed model of care, with the aim of tackling the increasing burden of non-communicable diseases. Despite this, there is a limited number of publications that review PHC capacity in Saudi Arabia, with a focus on specific regions and sectors. To address this gap, recent studies have analyzed the published PHC research conducted in Saudi Arabia quantitatively, with a focus on the distribution of research publications according to topic, time, geographical location, and institution [7]. Other studies have leveraged electronic health records to improve PHC in the country and examined patients' awareness of their rights regarding PHC [12,13]. In this context, this research aims to analyze the distribution of primary healthcare centers in Saudi Arabia from 2017 to 2021 using the Gini index and Pearson correlation, with the goal of evaluating the equity of PHC distribution and informing future policies and initiatives for enhancing PHC in the country.

Study design and setting
This study aimed to assess the distribution of healthcare centers across the 20 regions of Saudi Arabia from 2017 to 2021. The data used in the study, including population and sociodemographic information for each region, was obtained from the annual Statistical Yearbook published by the Ministry of Health [14]. The study followed a cross-sectional design. The study included all healthcare centers that fall under the regulations of the Ministry of Health in 20 regions of Saudi Arabia. The entire population, both Saudi and non-Saudi, residing in the health regions were taken into account in the analysis.

Tools and data extraction
This study used a Microsoft Excel 2016 spreadsheet to gather data from the Ministry of Health's Statistical Yearbook. The information extracted included the year, city, population, and number of primary healthcare centers. Researchers used this data to calculate the number of healthcare centers per 10,000 population in each of the 20 regions for the years 2017-2021. This study outlines the definition of healthcare centers as defined by the WHO, stating that primary healthcare centers are a comprehensive approach to health that aims to achieve the highest level of health and well-being for all, through addressing individuals' needs and providing services ranging from health promotion and disease prevention to treatment, rehabilitation, and palliative care, in a location that is easily accessible to the community. This definition is in line with the vision for primary healthcare in the 21st century, which is to work towards universal health coverage and the Sustainable Development Goals (SDGs) as defined by WHO and United Nations International Children's Emergency Fund (UNICEF) [15].

Statistical analysis
The population of 20 Saudi health regions was tracked throughout 2017-2021. The ratio of primary healthcare centers per 10,000 people was determined using the following formula: number of primary healthcare centers/10,000 population. The researchers analyzed the changes in healthcare services by determining the rate of change in the overall population and the rate of change in the total number of PHCs between 2017 and 2021.
This study aimed to assess the equity of primary healthcare centers distribution among 20 health regions. To accomplish this, the researchers employed the Gini index and Lorenz curve as analytical tools. These measures were calculated and constructed using Excel. The Gini index is a statistical variable commonly used to measure inequalities as shown in Table 1, while the Lorenz curve is a visual representation that compares disparities about a hypothetical state of "perfect" equality [11,[16][17][18].

1: Interpretation of Gini index values
In the context of the study, the cumulative percentage of PHC centers was illustrated on the y-axis, while the cumulative percentage of the population was illustrated on the x-axis (charts available on request). The graph also featured a diagonal straight line indicating ideal equality. The smaller the gap between the equality line and the Lorenz curve, the more equal the distribution of primary healthcare centers, the Gini index can be calculated from the graph as it represents the ratio between the area beneath the diagonal line and the curve in comparison to the entire area beneath the line of complete equality. Additionally, the researchers used Excel to calculate Pearson correlation coefficient (r) to analyze the relationship between changes in population and changes in the number of PHC centers in each region from 2017 to 2021.

Results
In Saudi Arabia, there were 0.72 PHC centers for every 10,000 population nationwide in the year 2017; however, by 2021, that ratio had slightly declined to 0.62 PHC centers. Table 2 presents the demographic characteristics of the population of Saudi Arabia as of 2021, with a total population of 34.1 million and an annual growth rate of 0.1298%. Data from the Health Statistical Yearbook from 2017 to 2021 was analyzed, and the results are shown in (Tables 3-7). It can be seen that the trend for the number of healthcare centers per 10,000 population is decreasing over time, with fluctuations present. The total number of healthcare centers has decreased in the population, from an average of 2,361 for a population of 3,255,2336 in 2017 to an average of 2,121 for a population of 3,411,0821 in 2021 across all 20 health regions.         Tables 3-7). This decrease is particularly notable in the availability of government-run centers in both urban and rural areas. A smaller decrease was observed in Riyadh, Makkah, Tabouk, Northern region, Al-Jouf, and Eastern region, while Taif, Qaseem, Al-Ahsa, Hafar Al-Batin, Aseer, Bishah, Tabouk, Hail, Jazan, Najran, Al-Bahah, Qurayyat, and Qunfudah experienced the largest declines in number of primary healthcare centers.
The Gini indexes for the distribution of PHCs in all 20 health regions were calculated and these are summarized in Table 8. It is worth noting that the Gini index is a measure of inequality where a value of 0 represents complete equality and a value of one represents complete inequality. The Gini index of 0.27 for the 20 health regions suggests relative equality in the distribution of primary healthcare centers. The correlation between population and the number of PHCs was determined for various regions in Saudi Arabia from 2017 to 2021. The results revealed a weak positive correlation between population and PHCs in Jeddah, Tabouk, and the Northern region. However, in Riyadh, Makkah, Taif, Madinah, Qaseem, Eastern region, Al-Ahsa, Aseer, Hail, Jazan, Najran, Al-Baha, and Al-Jouf, the correlation was found to be negative. For Hafar Al-Batin, Bishah, Qurayyat, and Qunfudah regions, the correlation was not applicable as the number of PHCs did not change during the five years as shown in Table 9.   Additionally, Table 9 shows that the number of PHCs in the Jeddah, Tabouk, and Northern regions increased as the population increased, but in the Riyadh, Makkah, Taif, Madinah, Qaseem, Eastern region, Al-Ahsa, Aseer, Hail, Jazan, Najran, Al-Baha, and Al-Jouf regions, the number of PHCs decreased as the population increased. This indicates that there may be a need to re-evaluate the distribution of PHCs in these regions to ensure that the population has adequate access to healthcare services. Overall, the data suggests that there is a complex relationship between population and the number of PHCs in Saudi Arabia, and further research may be needed to fully understand and address this issue.

Discussion
Primary healthcare centers serve as the starting point for patients in accessing healthcare services. Many countries measure the performance of their primary healthcare system using health indicators. WHO emphasizes the importance of primary healthcare, viewing it as a crucial factor in promoting overall health and a vital component of an effective healthcare system. Regardless of resource availability, countries that prioritize primary healthcare have made significant progress toward the SDGs [7]. This study aimed to investigate the current state of PHCs distribution among 20 regions in Saudi Arabia from 2017 to 2021 and to evaluate the fairness of PHCs distribution with population growth. Results revealed a general decline in the number of PHCs in both urban and rural regions. However, the decline in the ratio of PHCs per 10,000 people was more gradual and varied over time, indicating that there has been a slight reduction in the ratio of PHCs to population over time.
Additionally, in this study, we found disparities in the distribution of PHCs across different regions, with some regions having a higher or lower number of PHCs per population than others. Furthermore, the study observed no correlation between population growth and PHC distribution, areas with higher population growth having a greater need for PHCs to ensure adequate healthcare services. Overall, the study highlights the need for further investigation and efforts to ensure that PHC distribution is fair and sufficient to meet the healthcare needs of the population. Such studies should be conducted on a regular basis to assess progress in the equality of distribution of health facilities.
The evidence from this study suggests that health authorities are able to reach residents in Saudi Arabia despite the geographic spread of health services. Similar results were seen in Saudi Arabia in a prior research by El-Farouk to assess the geographic distributional inequality of health centers, hospitals, hospital beds, and physicians between 1997 and 2013, the average Gini index for PHCs was 0.224 for the time period [19]. This show that Saudi Arabia's healthcare policymakers have been able to maintain a roughly equal distribution of PHC facilities throughout all the regions despite the country's expansion.
The study identified that among the 20 health regions in Saudi Arabia, Jeddah, Tabouk, and the Northern region have low increases in the ratio of PHCs to population. However, it is worth noting that these regions have a smaller increase in population compared to other regions. On the other hand, some regions with larger populations have a fluctuating pattern in the ratio of PHCs to the population due to disproportionate increases in both the number of PHCs and population size. The regional disparities in the population-tocenter ratio suggest that certain areas of the country may be underserved in terms of primary healthcare services. Policymakers and healthcare providers should prioritize these areas and invest in the establishment of new primary healthcare centers to address the unmet needs of the population.
The ideal ratio of PHCs to population depends on several factors, such as the healthcare needs of the population, the geographic distribution of the population, and the availability of healthcare resources. There is no universal standard for the ideal ratio of primary healthcare centers to population, as this can vary depending on the context. However, PHCs should be easily accessible to the population they serve to ensure that essential health services are available to all. Ultimately, the ideal ratio of primary healthcare centers to population should be determined based on a comprehensive assessment of the healthcare needs and resources of the population being served [20]. The quality of healthcare services provided by PHCs is not solely determined by the number of centers available. Other factors such as the availability of healthcare resources, the training and qualifications of healthcare providers, and the overall healthcare system infrastructure can also influence the quality of care provided. In the current era of PHCs providing only access to healthcare is not enough, the goal is to provide quality care that is safe, effective, people-centered, timely, efficient, equitable, and integrated [21].
It is important to understand that this analysis is limited to primary healthcare centers and does not take into account other forms of healthcare, such as hospitals or specialty clinics. A more comprehensive analysis of healthcare accessibility would take into account all forms of healthcare, not just primary healthcare centers. Additionally, this analysis is limited to the years 2017-2021 and the distribution of primary healthcare centers may change over time. It is also important to consider other factors that may affect the accessibility of primary healthcare centers, such as transportation and socioeconomic status. Overall, the Gini index provides valuable insights into the equity of PHCs distribution across Saudi Arabia, but it is important to consider other factors and conduct a more comprehensive analysis to fully understand the accessibility of healthcare in a given region. Using secondary data for the study may have limitations; however, the data used for the study was provided by government institutions. It is still valuable in providing insight into the issue of distribution and accessibility of PHCs to inform policy decisions and guide future research in this field.

Conclusions
From 2017 to 2021, primary healthcare centers are distributed fairly throughout 20 health regions of Saudi Arabia. The Gini index showed relative equality in the distribution of primary healthcare centers from 2017 to 2021 with values between 0.2 and 0.3. However, there are still some disparities between provinces and efforts must be made to ensure that PHC centers are distributed equitably across the country to improve healthcare access and outcomes for all.
It is important to note that the quality of healthcare services provided by PHCs is not solely determined by the number of centers available. Other factors such as the availability of healthcare resources, the training and qualifications of healthcare providers, and the overall healthcare system infrastructure can also influence the quality of care provided.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.