Noura A. Abouammoh

1.5 IMGs in Saudi Arabia

IMGs are mostly referred to as “expatriate physicians” in the published literature from SA; however, the current study refers to them as “IMGs” as in most international literature. “IMGs” in this study refers to physicians who were born, and graduated from medical schools outside SA, and who do not share the cultural background of the local people.

1.5.1 The general situation of the IMGs in Saudi Arabia

Immigration policies in SA do not permit people, in general, to visit the country for tourism. Pilgrims are allowed to stay in the country for a relatively short period of time. Thus all non-Saudi nationals are either workers or dependents of workers in SA (Searle and Gallagher, 1983).

These non-Saudi nationals are mostly manual workers involved in construction projects or routine activities such as building maintenance (Searle and Gallagher, 1983). Additionally, a large number of non-Saudi workers share households with local citizens and perform roles such as chauffeurs for female family members, as women are not allowed to drive, or female housekeepers who are responsible for cleaning, cooking and/or taking care of children. Most high and middle class households employ at least one expatriate domestic worker. These workers usually come from South Asia, Indonesia and Philippines, and rarely from the Arab world.

Expatriate workers are also found in professional fields such as petroleum production, engineering and health care. These expatriates enjoy more privileges than less-skilled expatriate workers, such as owning a vehicle and bringing dependents into the country (Searle and Gallagher, 1983).

The first group of non-Saudi workers entered SA more than 45 years ago, as engineers and geologists who worked in petroleum production. At that time they were welcomed by the local citizens as they contributed as “income producers”. However, as the years progressed, less skilled expatriate workers were employed to participate in the huge projects that evolved as a result of rapid economic development. The national citizens did not see these expatriate workers as “income producers” any longer (Searle and Gallagher, 1983).

1.5.2 IMGs in the primary health care centres

In relation to the healthcare workforce in SA, the number of IMGs greatly exceeds that of Saudi physicians. IMGs form around 80% and 75% of the total physicians working in the PHCCs and the MOH hospitals around the country, respectively (MOH, 2012). They are particularly concentrated in the Riyadh region, where there are 789 IMG GPs, compared to 297 of their Saudi counterparts, working in 435 PHCCs.

The MOH considers the presence of a majority of international workers in the health profession as a challenge, as they cause instability to the system due to their high turnover rate (WHO, 2006). Nevertheless, the MOH employs IMGs on annually-renewed contracts, which may add to this high turnover rate, and do not treat IMGs with longer experience of working in SA any differently to newly-arrived IMGs in terms of remuneration. Salaries for IMGs who work under the MOH are much lower than those given to their Saudi counterparts, while the duties involved are the same. The MOH does not provide a structured programme to train IMGs, however IMGs are required to complete a number of hours attending conferences and workshops of their choice each year. Additionally, when discussing quality of care in SA, most authors acknowledge the fact that the majority of physicians are IMGs as a challenge to the health care system. They also mention the MOH plan to train national physicians, in SA and abroad, as a way to improve the quality of care and increase the number of national physicians (Khaliq, 2011, Almalki et al., 2011) although it has been shown that Saudi medical graduates tend to specialize in the major disciplines of medicine, such as surgery, leaving the country more reliant on IMGs to provide primary health care (Jarallah et al., 1994, Gallagher and Searle, 1985).

In recent years, the Saudi government has been encouraging Saudi people to enter the medical field by establishing more medical schools around the country, which only accept nationals. However, although the number of Saudi physicians has increased, the proportion of IMGs among the total number of physicians has barely changed because of the increasing demand on health care services (MOH, 2012, MOH, 2009, MOH, 2005, Gallagher and Searle, 1985).

Finally, it worth noting that in SA dietitians and health educators are found in secondary and tertiary care hospitals but not in PHCCs. This makes GPs in the PHCCs, who are mostly IMGs, responsible for all aspects of management, including educating patients about their conditions and supporting self-management including giving lifestyle advice.

1.5.3 IMGs’ eligibility to work in SA

Typically, the Saudi MOH advertises their need to recruit physicians in specific countries. They specify a time and a venue where applicants can register and undergo an interview by a recruiting committee that is sent by the MOH. To be able to apply to work in SA, IMGs are required to pass the Saudi licensing exam (SLE), the exam taken by Saudi medical graduates to work in the health care service under the MOH.

The SLE exam is prepared by the Saudi Commission for Health Specialisties (SCHS). IMGs take this exam outside SA in order to apply for a permit to work in SA. The exam is conducted in the English language for all applicants, including Saudis, and it tests medical knowledge of the main medical specialties. IMGs are not required to speak Arabic to be able to pass the exam or work in SA, as English is the operational language used in all hospitals. Nonetheless, most of the Saudi population does not speak English and state school students are introduced to basic English only after elementary level.

According to the SCHS, IMGs who wish to work as GPs in the PHCCs are required to have a bachelor’s degree in medicine while those who work in the hospitals are called “family physicians” and are required to have a bachelor’s degree in medicine with residency or a postgraduate degree in family medicine.

Most IMGs working in PHCCs in SA come from Egypt, Sudan and Syria, from the Arab world; and Pakistan, India and Bangladesh from the non-Arab world. Unlike IMGs working in Saudi hospitals, IMGs selected to work in the community-based PHCCs are required to be Muslims.