But a new longitudinal analysis suggests the story behind those aggregate numbers is far more complicated, and in some ways the opposite of what health equity experts usually fear. While the family medicine workforce expanded dramatically, the distribution of those physicians across the Kingdom’s fourteen health administrative units became measurably more unequal over the same period. The Gini coefficient, a standard measure of inequality, rose 31.5 percent between 2014 and 2022, while the Theil index climbed 39.1 percent and the coefficient of variation increased 28.6 percent.

The study, published in Frontiers in Health Services, constructed a retrospective panel from Ministry of Health Statistical Yearbooks covering 2014 through 2022, dividing the timeline into three phases: a pre-reform period from 2014 to 2016, a transformation phase from 2017 to 2020, and a post-reform consolidation from 2021 to 2022. The researchers measured family physician density per 10,000 residents in each unit and applied three complementary inequality indices, supported by bootstrap confidence intervals drawn from 1,000 resamples. Phase comparisons used the Kruskal-Wallis test with Bonferroni-adjusted pairwise comparisons, while temporal trends were assessed with the Mann-Kendall test.

What emerged from the data was a pattern that defies the urban bias documented in most international health workforce literature. Rather than concentrating in major metropolitan centers, the fastest relative growth occurred in peripheral and less populous regions. Bisha recorded a staggering 262.1 percent increase in family physician density, rising from 0.88 to 3.18 per 10,000. The Northern Borders region saw a 122.9 percent gain, while Madinah, Tabuk, Qassim, Taif, Asir and the Eastern Province all posted substantial increases of 26 to 83 percent. Meanwhile, several large urban units stagnated or declined outright: Jeddah’s Ministry-employed family physician density fell 11.5 percent, Hail dropped 12.4 percent, and Hafar Al-Batin declined 12.9 percent.

Hierarchical clustering on standardized density trajectories confirmed three distinct regional fates. One cluster of major urban units, including Jeddah, Makkah, Al-Ahsa, Hail and Hafar Al-Batin, showed stagnant or declining ministry workforce density. A strong-growth peripheral cluster encompassed Bisha, Northern Borders, Madinah and others. Riyadh stood alone as a singleton, following a peak-and-decline path: density climbed to 1.41 per 10,000 during the transformation phase, then fell to 0.99 in the post-reform period, ending only 15.1 percent above its 2014 baseline.

The authors caution against reading the urban stagnation as a literal shortage of family physicians in those cities. The dataset covers only Ministry of Health employees, and private, military and university providers are concentrated precisely in the metropolitan areas showing stagnation. A physician who moves from a ministry clinic in Jeddah to a private polyclinic a few kilometers away disappears from the series without leaving the city. The findings therefore describe ministry provision, not total family physician supply, and should not be interpreted as a reversal of urban bias across the whole health system.

One of the most consequential findings concerns 2021. National density dropped sharply that year, from 1.58 per 10,000 in 2020 to 1.02, before rebounding to 1.47 in 2022. The study attributes this to an administrative reclassification tied to the migration of services into regional health clusters, part of the Vision 2030 governance restructuring, rather than a genuine loss of workforce. When 2021 is excluded or modeled as a structural break, the endpoint widening in inequality between 2014 and 2022 remains intact, but the statistical significance of the year-on-year trend dissolves. The Mann-Kendall p-value for the Gini coefficient rises from a borderline 0.048 to a non-significant 0.108, leading the authors to describe the widening inequality as suggestive rather than statistically robust.

The phase-level comparison tells a cleaner story. Mean regional density differed significantly across the three reform phases (Kruskal-Wallis H = 15.21, p < 0.001), rising from 1.13 per 10,000 pre-reform to 1.48 during transformation and 1.61 post-reform. But inequality rose in lockstep: the phase-mean Gini climbed from 0.140 to 0.167 to 0.231. Each successive phase delivered higher density alongside a more uneven distribution. Rank stability analysis reinforced the sense of a system in flux, with the regional ordering changing substantially during the reform itself and settling into a stable configuration of peripheral winners and urban laggards only after 2020.

The timing of the divergence points toward the decentralization that accompanied the clinical reform. From 2021 onward, regional health clusters took over clinical and operational responsibility for services while the terms and conditions of physician employment remained largely centralized. Drawing on Bossert’s decision-space framework and Kolehmainen-Aitken’s work on decentralized health workforces, the study suggests that clusters gained the authority to reorganize services faster than the capacity to compete for staff, and that staffing equity is often the first casualty when authority and capability fall out of sync. In that light, the recent and concentrated nature of the inequality widening reads less like a gradual drift and more like an early-stage turbulence of a multi-speed transition.

The policy implications are concrete. The study recommends region-specific retention incentives targeting the five lagging units rather than national pay uplifts, protecting the fragile recent gains in high-growth peripheral regions, reconciling Riyadh’s anomalous 2021 figure against cluster payroll records, and routinely publishing the Gini coefficient of regional family physician density alongside national workforce ratios. Aggregate growth, the authors argue, is no longer the binding constraint; distribution is. As Saudi Arabia’s reform moves into its consolidation phase, the question is not whether the Kingdom can produce more family physicians, but whether it can place them where every family can actually reach one.

Subject of Research: Changes in the regional distribution and equity of Saudi Arabia's Ministry of Health family medicine workforce during the 2014–2022 primary care reform

Article Title: Primary care reform and concurrent changes in the regional distribution and equity of the ministry of health family medicine workforce in Saudi Arabia: a descriptive longitudinal analysis, 2014–2022

Article References: Primary care reform and concurrent changes in the regional distribution and equity of the ministry of health family medicine workforce in Saudi Arabia: a descriptive longitudinal analysis, 2014–2022. (n.d.). https://doi.org/10.3389/frhs.2026.1962491

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1962491

Keywords: family medicine, Saudi Arabia, Vision 2030, primary care reform, health workforce, health equity, Gini coefficient, regional inequality, Ministry of Health, workforce distribution, health policy, longitudinal analysis