Oil prices, climate change—health challenges in Saudi Arabia
Authors: Habida Elachola, Ziad A Memish
Journal: The Lancet (2016)

In December, 2015, Saudi Arabia reported a US$98 billion budget deficit (about 15% of gross domestic product [GDP]) in 2015 with no improvement projected for 2016.1AL-Khatteeb L Saudi Arabia's economic time bomb. The Brookings Institution.http://www.brookings.edu/research/opinions/2015/12/30-saudi-arabia-economic-time-bomb-alkhatteebDate: Dec 30, 2015Google Scholar Saudi Arabia has been resilient during oil price fluctuations in the past, so the new government budget came as a surprise. The new spending plan reflects several measures to curb subsidies, raise revenue, and improve healthy lifestyles.2Kerr S Riyadh plans radical surgery to rejuvenate Saudi health sector.Financial Times. Jan 11, 2016; Google Scholar Health and social affairs consume about a fifth ($45 billion, 5% of GDP) of Saudi Arabian Government spending.2Kerr S Riyadh plans radical surgery to rejuvenate Saudi health sector.Financial Times. Jan 11, 2016; Google Scholar, 3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar There are not many relevant examples of the health effects of recession and structural adjustments for countries with a similar development trajectory of Saudi Arabia. Economic growth in Saudi Arabia (19th highest GDP worldwide) contrasts with its position on the Human Development Index (39th in the world);3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar this gap indicates substantial development challenges. Further, the economic changes are occurring amid other challenges unique to the region. First, along with the rising oil revenues in recent decades, Saudi Arabia has seen a rapid epidemiological transition in the population (table).4Memish ZA Jaber S Mokdad AH et al.Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990-2010.Prev Chronic Dis. 2014; 11: 140176Crossref Scopus (96) Google Scholar The uptake of some health-promoting behaviours has been limited by Saudia Arabia's unemployment rate (11·7% in 2014), moderate levels of education, and climatic and sociocultural conditions.3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar, 5Central Department of Statistics and InformationKingdom of Saudi Arabia.www.cdsi.gov.sa/english/Google Scholar, 6El Bcheraoui C Basulaiman M Tuffaha M et al.Status of the diabetes epidemic in the Kingdom of Saudi Arabia, 2013.Int J Public Health. 2014; 59: 1011-1021Crossref PubMed Scopus (57) Google Scholar The high burden of undiagnosed and uncontrolled diabetes and hypertension,6El Bcheraoui C Basulaiman M Tuffaha M et al.Status of the diabetes epidemic in the Kingdom of Saudi Arabia, 2013.Int J Public Health. 2014; 59: 1011-1021Crossref PubMed Scopus (57) Google Scholar, 7El Bcheraoui C Memish ZA Tuffaha M et al.Hypertension and its associated risk factors in the Kingdom of Saudi Arabia, 2013: a national survey.Int J Hypertens. 2014; 2014: 564679Crossref PubMed Scopus (112) Google Scholar will consume a large proportion of the health budget.8Mokdad AH Tuffaha M Hanlon M et al.Cost of diabetes in the Kingdom of Saudi Arabia, 2014.J Diabetes Metab. 2015; 6: 575Google ScholarTableLeading risk factors for disease in Saudi Arabia, 2010% of total DALYsHigh body-mass index12Dietary risks10Raised fasting plasma glucose10High blood pressure8Physical inactivity5Ambient air pollution4Smoking3Iron deficiency anaemia3Substance use disorders2Occupational risks2DALYs=disability-adjusted life-years. Data are from Memish et al.4Memish ZA Jaber S Mokdad AH et al.Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990-2010.Prev Chronic Dis. 2014; 11: 140176Crossref Scopus (96) Google Scholar Open table in a new tab DALYs=disability-adjusted life-years. Data are from Memish et al.4Memish ZA Jaber S Mokdad AH et al.Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990-2010.Prev Chronic Dis. 2014; 11: 140176Crossref Scopus (96) Google Scholar Second, future temperature in the region is projected to increase consistently and exceed the threshold deemed unsuitable for human adaptability.9Pal JS Eltahir EAB Future temperature in southwest Asia projected to exceed a threshold for human adaptability.Nat Climate Change. 2015; (published online Oct 26.)https://doi.org/10.1038/nclimate2833Crossref Scopus (472) Google Scholar This changing climate will have an effect on the promotion of some healthy lifestyle habits, the country's production of fresh fruits and vegetables, and micronutrient deficiencies.9Pal JS Eltahir EAB Future temperature in southwest Asia projected to exceed a threshold for human adaptability.Nat Climate Change. 2015; (published online Oct 26.)https://doi.org/10.1038/nclimate2833Crossref Scopus (472) Google Scholar For example, vitamin D deficiency from inadequate exposure to sun and limited intake of enriched products is common in Saudi Arabia.10Tuffaha M El Bcheraoui C Daoud F et al.Deficiencies under plenty of sun: vitamin D status among adults in the Kingdom of Saudi Arabia, 2013.N Am J Med Sci. 2015; 7: 467-475Crossref PubMed Scopus (37) Google Scholar Finally, there is a need for sustained investment in the control of emerging infectious diseases in the region. Such control efforts are important given the risk of emerging diseases within Saudi Arabia, such as Middle East respiratory syndrome, and as a result of disease importation through the large expatriate workforce and the 2–3 million pilgrims for Hajj and 5–6 million pilgrims for Umrah who come to Saudi Arabia each year from more than 180 countries.3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar, 11Memish ZA Zumla A Alhakeem RF et al.Hajj: infectious disease surveillance and control.Lancet. 2014; 383: 2073-2082Summary Full Text Full Text PDF PubMed Scopus (232) Google Scholar Although economic recession is often feared as a "health tragedy", evidence from high-income countries is mixed and related to variations in social and political contexts.12Karamanoli E 5 years of austerity takes its toll on Greek health care.Lancet. 2015; 386: 2239-2240Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 13Bezruchka S The effect of economic recession on population health.CMAJ. 2009; 181: 281-285Crossref PubMed Scopus (68) Google Scholar In high-income countries, some health indices showed counter-cyclical effects with economic contractions (eg, increases in suicides, depression, and anxiety disorders and worsening reproductive health outcomes).12Karamanoli E 5 years of austerity takes its toll on Greek health care.Lancet. 2015; 386: 2239-2240Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 13Bezruchka S The effect of economic recession on population health.CMAJ. 2009; 181: 281-285Crossref PubMed Scopus (68) Google Scholar However, mortality is shown to be pro-cyclical and it decreases during rapid economic contractions. In high-income countries, there are generally slower declines in mortality during periods of economic growth and greater declines in mortality during recessions.13Bezruchka S The effect of economic recession on population health.CMAJ. 2009; 181: 281-285Crossref PubMed Scopus (68) Google Scholar In low-income countries, economic growth seems to improve health through improvements in basic services, until a country reaches $5000–10 000 GDP per person.12Karamanoli E 5 years of austerity takes its toll on Greek health care.Lancet. 2015; 386: 2239-2240Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Declines in mortality in high-income countries during recession could be related to decline in excess mortality from modifiable causes of death, such as those arising from alcohol abuse and motor vehicle accidents.12Karamanoli E 5 years of austerity takes its toll on Greek health care.Lancet. 2015; 386: 2239-2240Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 13Bezruchka S The effect of economic recession on population health.CMAJ. 2009; 181: 281-285Crossref PubMed Scopus (68) Google Scholar Given that Saudi Arabia has one of the highest rates of traffic-related deaths globally,4Memish ZA Jaber S Mokdad AH et al.Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990-2010.Prev Chronic Dis. 2014; 11: 140176Crossref Scopus (96) Google Scholar the country might benefit from the austerity measures in this regard. If Saudi Arabia maintains increased relief spending on child health, improvements in access to nutrition and health, and strong infectious diseases control then these approaches can also help reduce mortality. Since Saudi Arabia's sociodemographic and geopolitical foundation is different from that of the case studies available thus far, it is difficult to predict potential health effects of the present economic recession and newly proposed health-sector reforms. Saudi nationals (and pilgrims coming to Mecca for the Hajj) are entitled to free health care and the government accounted for 66% of health care spending in 2012 (about 5% of GDP).3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar The expatriate workforce of Saudi Arabia, which accounts for 56% of the total population and about 86% of the private sector workforce, are not covered by the government health-care system.3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar, 5Central Department of Statistics and InformationKingdom of Saudi Arabia.www.cdsi.gov.sa/english/Google Scholar The proposed nationalisation process to reduce the expatriate workforce by employing more Saudi nationals in the employment sector could adversely affect the health-care workforce since about 77% of physicians and 63% of nursing staff in Saudi Arabia are expatriates.3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar A much needed boost in the country's health promotion portfolio would require expertise in various public health disciplines that are currently in short supply in Saudi Arabia. The greatest burden of economic recession generally falls on the unemployed.12Karamanoli E 5 years of austerity takes its toll on Greek health care.Lancet. 2015; 386: 2239-2240Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 13Bezruchka S The effect of economic recession on population health.CMAJ. 2009; 181: 281-285Crossref PubMed Scopus (68) Google Scholar About a third of the 30 million population of Saudi Arabia are younger than 15 years, and the child dependency ratio is 44% (ratio of people below working age to workforce).3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar In 2013, the rate of unemployment in Saudi Arabian nationals was 28·4% for people aged 15–29 years (men 17·5%, women 60·3%).3De Bel-Air F Demography, migration and labour market in Saudi Arabia, Explanatory note no. 1/2014. Gulf Labour Markets and Migration.http://gulfmigration.euDate: 2014Google Scholar, 5Central Department of Statistics and InformationKingdom of Saudi Arabia.www.cdsi.gov.sa/english/Google Scholar A recent emphasis on privatisation of health and preventive care, or even cost sharing of preventive care, could lead to an increase in overall health-care costs if people forego essential medications, immunisations, or routine clinic visits such as antenatal care. We do not know how long the current economic downturn will last in Saudi Arabia. Anticipating potential effects of recession at an early stage of the crisis can inform health-sector reforms to diminish or avoid its harmful consequences on nation's health. Despite Saudi Arabia's unique challenges, the Ministry of Health has so far been successful in providing state-of-the-art medical services to its citizens. For example, Saudi Arabia's premarital sickle cell screening is a unique initiative.14Memish ZA Saeedi MY Six-year outcome of the national premarital screening and genetic counseling program for sickle cell disease and β-thalassemia in Saudi Arabia.Ann Saudi Med. 2011; 31: 229-235Crossref PubMed Scopus (130) Google Scholar Despite free health care, Saudi Arabia's shortcomings are in the control of non-communicable diseases and mitigation of risk factors for disease.4Memish ZA Jaber S Mokdad AH et al.Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990-2010.Prev Chronic Dis. 2014; 11: 140176Crossref Scopus (96) Google Scholar Only 23% of Saudi adults have had a preventive care visit.15El Bcheraoui C Basulaiman M Wilson S et al.Breast cancer screening in Saudi Arabia: free but almost no takers.PLoS One. 2015; 10: e0119051Crossref Scopus (82) Google Scholar, 16El Bcheraoui C Tuffaha M Daoud F et al.Low uptake of periodic health examinations in the Kingdom of Saudi Arabia, 2013.J Family Med Prim Care. 2015; 4: 342-346Crossref PubMed Google Scholar There is a need to consider multipronged approaches to health promotion and avoidance of risk factors, including those that fall outside the services of health ministry (eg, enforcement of motor vehicle accident prevention advisories, point of sale restrictions on tobacco). By training primary care providers to serve as advocates for health promotion, each encounter between the provider and patient can be used as an opportunity to educate patients about a set of prevention messages. Informed personal decision making is important to increase the uptake of healthy lifestyles and prevention recommendations; this is a process achieved through education and a sense of personal empowerment that comes with employment. Outreach to civic organisations for partnerships in health promotion initiatives can help increase visibility and uptake. Beyond the immediate effects of the current economic crisis, Saudi Arabia needs to target its policies to mitigate the effects of climate change. Agricultural approaches such as hydroponics, vertical farming, and landscaping with food-producing plants can increase food production, enable healthy eating habits, and improve air quality. Additionally, enrichment of food products (vitamin D, folic acid, iodine) is an easy and cheaper alternative to promotion of supplement use by individuals. The transition in the country's health-care delivery to the private sector and cost-sharing should be implemented without compromising services for the unemployed and uninsured. Similarly, efforts to nationalise the health labour force should consider continuity in essential service delivery. Saudi Arabia's religious leadership can encourage the population to adhere to guidance on health promotion, which is particularly important for mental health where health-care infrastructure is not adequate. Health security cannot be achieved by focused efforts from the health ministry alone; nations that offer greater social safety nets are better positioned to diminish the health effects of economic recession.12Karamanoli E 5 years of austerity takes its toll on Greek health care.Lancet. 2015; 386: 2239-2240Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Finally, implementation of evidence from case studies on the health effects of the economic crisis are useful and can contribute to the emerging body of literature on economics and health. Health-care reform was long overdue in Saudi Arabia and the current crisis affords the country an opportunity to do it right. Saudi Arabia's future health security will rely on the choices made today by its health policy makers. We declare no competing interests.