Title: The Role of the Temporary Contracting and Visiting Doctor Program in

Supporting the Health System during and after COVID-19 Pandemic in Saudi Arabia

Faisal S. Alenezi 1, Aeshah I. Alsagheir 1, Lamya M. Alzubaidi 1, Wijdan S. Al-Saedi1,

Saleh S. Alharbi 1, Muna H. Hassanein 2, Tareef Y. Alaama 1

1
Therapeutic Deputyship, Ministry of Health, Riyadh, Saudi Arabia
2
Department of Public Health, General Directorate of Health Affairs, Riyadh, Saudi Arabia.

Corresponding author:
Faisal S. Alenezi, MSc PhD. Therapeutic Deputyship, Ministry of Health, Saudi Arabia.
Address: Ministry of Health, Tower 2, Digital City, Prince Turki Ibn Abdulaziz Al Awwal
Rd, Riyadh, Saudi Arabia. Phone: +966509280999. Email: FAlenezi@moh.gov.sa

ABSTRACT:
Background: Adequate supply of health workforce with proper skills is essential to deliver
appropriate health services in normal times and during disasters.
Aim: To describe the role of the Saudi Temporary Contracting and Visiting Doctors Program
in the provision of critical care during COVID-19 pandemic, and in the clearance of the
surgical backlog thereafter.
Methods: We reviewed reports of General Directorate of Health Services and Saudi Ministry
of Health annual statistical books to obtain the following data: number of temporary
healthcare professionals contracted from 2019 to 2022; number of intensive care unit beds
before and during COVID-19 pandemic; volume of elective surgeries before, during and after
COVID-19 pandemic.
Results: In 2020, intensive care unit beds increased from 6341 to 9306 in governmental
hospitals in response to COVID-19 pandemic. A total of 3539 temporary healthcare
professionals were recruited from April to August 2020 to contribute towards staffing the
added beds. During the recovery period from COVID-19 pandemic, 4322 and 4917
temporary health care professionals were recruited in 2021and 2022 respectively. Elective
surgeries volume increased from 5074 in September 2020 to 17533 in September 2021 to
26242 in September 2022, surpassing the volume of surgeries in pre-COVID-19 period.
Conclusions: In response to COVID-19 pandemic, and through the existing temporary
contracting program, the Saudi Ministry of Health was able to recruit temporary staff of
verified credentials in a timely manner, to supplement the existing staff, for activation of the
newly added intensive care unit beds, and for clearing the resulting surgical backlog.
COVID-19, temporary staff, intensive care unit, surgical backlog

1. INTRODUCTION
Health workers are essential for the functioning of the health systems, and their availability
and equitable supply are vital to achieve universal access to healthcare at all levels(1). Those
responsible of health planning and decision-making in any country should ensure the
availability of an adequate supply of healthcare workers, with the proper skills, to deliver the
required health services for the population(2). The adequate supply of health workforce
should also be ensured for the effective response of health systems to disasters caused by
natural or man-made hazards(1). In this regard, it is essential that each country should adopt
and apply evidence-based policies and strategies for health workforce supply, that are
tailored to the local context(1).
In Saudi Arabia (SA), the number of health workers has increased steadily over the past
decade. The total number of health workers, of both Saudi and non-Saudi nationalities,
increased by 54% from 303,578 in 2011 to 467,650 in 2019(2). According to recent data, the
density of healthcare workers(physicians and nurses) in Saudi Arabia is around 9 per 1000
population, which is more than the level required to manage the burden of disease in the
country(2). However, there are two factors that undermine the ability of the health system to
preserve a sustainable supply of healthcare professionals in all regions of the country. First,
the observed high density of the healthcare professional per population is not uniform across
the different regions of SA specifically for physicians with subspecialties, who tend to be
concentrated in main urban centres(3). Owing to the vast area of SA this affects the
accessibility to specialised medical services among the inhabitants of the remote and
peripheral areas. The consequence of this was a high referral rate of patients from hospitals
lacking subspecialty services to hospitals with such services resulting in long waiting lists
and waiting times at these later hospitals(4). Second, the reliance of the Saudi health system
on foreign health workers results in high staff turnover and gaps in service delivery(3,5).
These two factors make the Saudi health system vulnerable to any unpredictable high demand
for healthcare professionals such as in situations of man-made or natural disasters. In
response to these challenges, the Saudi Ministry of Health (MoH) established the Temporary
Contracting and Visiting Doctors Program (TCVDP) in 2012. The program addresses the
health workforce challenges through availing healthcare professionals for temporary
contracting to fill vacancies during absences of permanent staff, to provide subspecialized
health services on an outreach basis in remote and peripheral areas, and to respond to any
unpredictable demand for healthcare professionals.
In Saudi Arabia, the first COVID-19 case was announced on March 2, 2020(6). Based on the
risk assessment of the COVID-19 transmission at the international level, a plan was instituted
by the Saudi government to increase the number of intensive care unit (ICU) beds by 30% to
accommodate the expected number of hospitalized COVID-19 patients(6).
In addition to that, in order to reduce the spread of the virus and to ensure the availability of
beds when needed, elective operations in government and private healthcare institutions were
suspended when hospital bed occupancy rates reached a certain level (6). This resulted in a
reduction in the volume of elective surgeries (from 17769 in October 2019 to 5074 in
October 2020) and in an increase in the volume of patients in waiting lists for elective
surgeries (from 127418 in October 2020 to 171291 in October 2021). By the end of 2020, a
campaign was initiated by the Saudi Ministry of Health to restore the health services to their
pre-pandemic levels and to reduce elective surgical wait times.
As a high income country, the health infrastructure and equipment in SA were adequate and
the surge capacity was high. However, the challenge was to avail adequate number of
healthcare professionals to staff the added ICU beds and to contribute to the clearance of the
resulting surgical backlog. Therefore, as with the situation in other countries all over the
globe during COVI-19 pandemic, there was a dire need to avail adequate supply of healthcare
professionals during a short period of time to meet the high demand, and at the same time
avoid overstretching and over-working the existing staff.
2. AIM
The aim of this paper is to describe the role of the Saudi Temporary and Visiting Doctors
Program in enhancing the surge capacity of staff for the provision of critical care during the
crisis phase of COVID-19 pandemic, and for the clearance of the surgical backlog and the
reduction of the waiting time thereafter.

3. SUBJECTS AND METHODS

Setting and Source of data
Saudi Arabia is the largest country in the Arabian Peninsula in western Asia. Its population is
estimated at 34 million people, including Saudi nationals and expatriates. SA is divided into
13 administrative regions, and twenty health regions. The Regional Health Directorates
(RHD) are responsible of planning and delivering health services at the level of the health
regions. The economy of SA is the largest in the Middle East and North Africa (MENA)
region, with a gross domestic product of 833.5 billion USD, representing 25% of the gross
domestic product of the countries in the MENA region combined(6).
The Temporary Contracting and Visiting Doctors Program was established by the
Therapeutic Deputyship in the Saudi MoH in 2012 with the main aim of enhancing access to
quality health care, by bringing it as near as possible to the population. A central committee
was established in the program to set guidelines and standards, to allocate the budget to the
Regional Health Directorates according to the results of staffing needs assessment, and to
oversee the processes of recruitment and hiring of temporary staff by the RHDs. In 2017 an
electronic platform, the VISITORS, was established to act as a staff bank and an e-
recruitment system. The VISITORS platform is linked to the system of the Saudi
Commission of Health specialties (SCFHS), the body responsible of the credentialing and
licensing of healthcare professionals.
For the data of this paper, we reviewed the official statistical reports of the General
Directorate of Health Services in the MoH, and the annual statistical books of the MoH to
obtain the following types of aggregated data: the number of healthcare professionals
contracted on temporary basis during and after the COVID-19 pandemic; the number of ICU
beds during 2019 and 2020; the volume of elective surgeries performed during September
month of the years 2019, 2020, 2021 and 2022. We also reviewed unpublished official
governmental reports and published literature to gain insight about the steps of the country’s
response to COVID-19 and to complement and triangulate our data.

RESULTS
The use of temporary staff during COVID-19 pandemic:
In 2019 the total number of ICU beds in the governmental hospitals run by the Saudi Ministry
of Health was 5140 beds(7). At the beginning of 2020 and before the reporting of the first
case of COVID-19 in SA, the number of ICU beds increased to 6341. Responding to a Royal
Decree to enhance the health system surge capacity by 50% in response to COVID-19
pandemic(6), 2965 ICU beds were added starting from April 2020, to give a total of 9306
ICU beds by August 2020, in the governmental hospitals run by the MoH in all regions of SA
(figure 1). The increase rate of the ICU beds in the three months was 46.7%. To activate the
added ICU beds, the COVID-19 response plan recommended the use of temporary health
professionals to support the existing staff, and a total budget of around 50500000USD was
allocated by the Temporary Contracting and Visiting Doctors Program for this purpose (6).
As such, and the through collaboration between the TCVDP and the Regional Health
Directorates, a total of 3539 healthcare professionals were temporarily recruited in the period
from April to August 2020 to staff the newly added ICU beds (figure 1). These included 925
physicians with specialties such as intensive care, emergency medicine, anesthesia, chest,
infection control, communicable diseases and respiratory care(8), in addition to 1294
qualified practitioners with nursing titles(6). The source of the temporarily contracted
healthcare professionals was the VISITORS platform.
The use of temporary staff for post COVID-19 recovery period:
By the end of 2020 and as the COVID-19 control measures were eased, the Saudi Ministry of
health started a campaign to clear the backlog of elective surgeries and to reduce the surgical
wait time. Thirty-six days waiting time was set as the bench mark for elective surgery. In
2021 and 2022, using the VISITORS platform as a source, the Regional Health Directorates
recruited 4322 and 4917 temporary health care professionals respectively, compared to 3072
during 2019(4,9)(figure 2). The recruited healthcare professionals were deployed to hospitals
in all regions of the country as visiting doctors to perform elective surgeries.
Consequently, as shown in figure (2), the number of the performed elective surgeries
increased form 5074 in September 2020 to 17533 in September 2021 (increase rate of
245.5%). The volume of surgeries in September 2021 was comparable to the volume of
17769 surgeries performed during the pre-pandemic period in September 2019(figure 2). In
September 2022 the number of elective surgeries was 26242 (increase rate of 417.2% form
2020 level). The number of elective surgeries in September 2022 surpassed the volume of
surgeries in the pre-COVID-19 period (increase rate of 47.7%) (figure 2).

4. DISCUSSION:
Human resources were an important aspect of the health system capacity needed to respond
effectively to the unparalleled demand placed on health services by COVID-19 pandemic
(10).
Through the temporary contracting program, the Saudi MoH was able to supplement its
existing health workers by 3539 temporarily recruited staff to activate the added ICU beds
during a short period of time, bringing the ratio of staffed ICU beds per100,000 populations
to 26.7. These staffed ICU beds were made available to meet the demand in the worst case
scenario expected in SA, and at a time of uncertainty about the emerging disease and the
absence of effective preventive measures. The availability of these staffed ICU beds in SA
probably contributed, in addition to other factors, to the low COVID-19 case fatality
rate(CFR) of 1% (6), compared to the global rate of 4.9% (11), and to CFRs reported from
other countries such as 14% in Italy and France and 5% in China (6) .
Similarly, the temporary contracting of healthcare professionals contributed in supporting the
MoH campaign to tackle the surgical backlog and to reduce the surgical waiting time after the
crisis phase of COVID-19. The elective surgery activities were brought to levels higher than
the levels of pre-pandemic period, thus leading to a reduction in the backlog. These recovery
levels in SA are comparable to those achieved in some European countries such as Sweden
and the Netherland where the volumes of surgeries were restored to pre-pandemic levels(12).
Human resources for health were an indispensable aspect for the critical care of patients
during the crisis phase of COVID-19 pandemic. Merely securing an adequate supply of ICU
beds and equipment was not sufficient, and staffing was required to activate the additional
ICU beds (10,13,14,15). For example, despite the availability of 3440 and 67 additional
physical ICU beds in Australia and New Zealand respectively, the staffing was a challenge
that limited their potential as active ICU beds to surge in response to the pandemic(14,16).
Likewise, human resources for health are key factor in health system recovery efforts from
COVID-19 and for reversing the effects of service disruptions. Some of the measures adopted
for recovery were particularly demanding on the health workforce (12).
Health worker recruitment and surge procurement were the most common areas of technical
assistance requested from the World Health Organization (WHO) by countries for the
continuity of essential health services during COVID-19 pandemic(17). The measures that
were recommended by the WHO and that were used by countries to enhance the surge
capacity of human resources during COVID-19 included three main categories: first,
measures to increase the supply of health workers such as recruiting additional staff, bringing
back inactive or retired healthcare professionals, calling on volunteers, and deploying staff
from non-critical service areas(18,19); second, measures to maximize the utilization of the
existing staff such as repurposing, mobilizing, and changing the working patterns of the
existing workforce (13,19,20); third, methods that minimize the loss of staff such as
protecting and supporting the existing staff (13,20).
Saudi Arabia adopted the recruitment of additional temporary staff as one of the main
measures to enhance its human resources capacity in response to COVID-19. Many countries
around the world used temporary staff to meet the demand placed by COVID-19 and other
respiratory diseases outbreaks(21). In the United Kingdom (UK), the national health system
recruited more than 20,000 temporary healthcare professionals to front line care settings and
to staff the COVID-19 field hospitals during the first wave of the pandemic in 2020(22).
Hiring additional staff as a measure to increase the supply of health workers supports the
existing staff and prevent work overload. On the other hand, maximizing the utilization of the
existing staff, through increasing the work shifts for example, can lead to staff burnout and to
negative patient outcomes (12,23,24). In the United States of America (USA), a survey
reported that the main reason for hiring temporary staff reported by more than 70% of health
facilities during COVID-19 pandemic was to prevent the burnout of the existing staff (25).
The existence of an established temporary contracting program in Saudi Arabia played an
important role in enhancing the supply of the additional staff and in streamlining and
facilitating the process of recruitment during COVID-19 pandemic. The program has clear
guidelines and pathways for the recruitment and hiring processes. It also has an already
running project of outreach services provided by temporarily contracted subspecialized
physicians and surgeons.
Also, only healthcare professionals who have insurance for mal-practice and those who are
credentialed and licensed to practice by the Saudi Commission for Health specialties can
register on the VISITORS platform, the national staff bank established by the Saudi TCVDP.
This helped in avoiding the time-consuming processes of credentialing, licencing and re-
licencing of staff. These processes were reported as challenges facing the recruitment of
inactive healthcare professionals to increase the supply of health workforce in response to
COVID-19 (18). During the COVID-19 pandemic time was a vital factor, therefore it was
very important to try to speed and streamline the process of on-boarding of potential
temporary staff to staff banks, without compromising quality and safety, especially in
situations when demand for temporary staff exceeded the capacity of staff banks(22).
The pool of temporary healthcare professionals in the VISITORS staff bank can be
considered as an integral part and a reserve to the Saudi health workforce, enabling it to flex
up and down according to demand, a characteristic that was emphasized as very important by
the COVID-19 pandemic(22). The number of healthcare professionals registered on the Saudi
VISITORS platform increased from 2022 in 2019 to 4167 in 2020 with an increase rate of
106%, thus increasing the recruitment capacity for the MoH. In the absence of such staff
bank in Saudi Arabia, it would have been very difficult to find a source for the timely
recruitment of temporary staff with the relevant qualifications to ensure the provision of safe
and high quality care during and after COVID-19 pandemic.
The limitation of this paper is that it focused only on the role of temporary staff during the
COVID-19 pandemic and during the recovery. Other measures were employed that have
contributed to the enhanced surge ICU bed capacity and the clearance of the elective surgical
backlog. Further studies are needed to take all these measures into consideration.

5. CONCLUSIONS
In conclusion, the existence of a temporary contracting program in the Saudi MoH, facilitated
the recruitment of temporary staff of verified credentials in a timely manner during crisis
phase and recovery phase from COVID-19 pandemic. Through these temporary healthcare
professionals, the Saudi MoH was able to supplement its existing staff and activate the newly
added ICU beds in response to COVID-19 pandemic. The recruitment of temporary staff also
contributed to increasing the volume of elective surgeries and clearing the surgical backlog.
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Acknowledgements: Authors are grateful to the staff of the Hospital Services Directorate.

Patient Consent Form: The study utilized Secondary data that was anonymized.
Authors contribution: all the authors gave a substantial contribution to the conception and
design of the study. FA, LA, WA, TA gave a substantial contribution to the acquisition of the
data. All authors gave a substantial contribution the analysis and interpretation of the data.
FA, and MH participated in drafting the initial paper. All authors reviewed the final version
of the paper and gave final approval of it to be published and agreed to be accountable for all
aspects of the work in ensuring that questions related to the accuracy or integrity of any part
of the work are appropriately investigated and resolved.

Conflict of interest: The authors declare no conflict of interest.

Financial support and sponsorship: None