Wholesale outsourcing to the private sector looks set to go ahead in Saudi Arabia.

Hospital management, radiology, pathology, and primary care outsourcing pilots are underway. We were told to expect completion of some of those in the first quarter of 2018 and long-term partnerships announced in the next. An imminent PPP law to protect FDI was also discussed but some now think this might not happen – or even be needed if local institutions finance – anymore.

Consultants and operators we’ve talked to say there is a mass of works to be done: “The whole things needs tearing up and starting again, while not utterly destroying what healthcare provision there is at the moment.” Others say that often the Saudi authorities have rudimentary data on the state sector. “You can talk to two hospital managers and they will disagree on the number of beds or employees in a hospital.”

The emerging model is PPPs with international players managing and GCC banks funding. Wholesale privatisation is problematic because most assets won’t be demonstrably sound financially. Doubts about payment mechanisms and the wider business environment’s transparency plague the sector’s image. It’s near impossible to fire Saudi employees.

But most of those we talked are cautiously optimistic. They say that the Saudi authorities are keen to proceed and are consistently following a plan. We are also told that the health minister is safe from the purges: “he is one of the good guys” we were told.

The absence of a PPP law which would enable operators to sue the government for failing to honour a contract is a concern but GCC operators say that regional banks are happy to lend to government-backed schemes. They also say that the Saudi authorities understand the need to build trust. “They know they can get huge leverage and access to a lot of private finance if they behave. And they also get that operators want long-term contracts.”

There is plenty to play for. Saudi Arabia (government and private pay) spent around $30bn on health in 2016, according to the WHO. That in fact is a surprisingly low figure for a population of 32m. Operators are moving in. The latest are Air Liquide (see separate story).  London-listed NMC Health has also been buying hospitals in the Kingdom, with a source there saying that while things are moving quickly, it all seems to be in favour of large international providers like them.