There are similarities between the study sample and the expatriate population in Saudi Arabia. For example, the average age of the study population and the expatriate male working population in the private sector is not significantly different; the median age of the study population was 36 years old, similar to the Ministry of Labour data average of 34 years old . The percentage of expatriates under 30 years old in the study sample was 22.2%, whereas the Ministry of Labour reports around 21.3% of expatriates in the same age bracket. The top six nationalities of expatriate workers in the study correspond to the top six nationalities of expatriate workers in the private sector of the Riyadh region, as per the Ministry of Labour’s database . Due to the similarities between the sample size and characteristics of expatriates’ population, we are confident that the sample used for the study is representative of the expatriate population.
Saudi Arabia, like other GCC member countries, has a unique demographic composition in the private sector. Expatriate workers comprise around 90% of the total manpower in the private sector. Therefore, the burden of providing equitable access to health insurance for this group needs to be carefully considered. Specifically, major influences on workers’ access to health insurance are the characteristics of the potential recipients of the insurance and the characteristics of the providers of the insurance.
The Saudi government’s regulations designed to reduce the percentage of uninsured expatriates may not help to achieve its objectives. The regulations include the enforcement of employers to provide insurance to their expatriate workers and a unified health insurance package, along with strong government intervention through a Council and the imposition of penalties for those who fail to follow the regulations. However, this did not change the characteristics of expatriate employees who were uninsured or the employers’ characteristics because there are other influencing factors such as under-development of the health insurance industry in Saudi Arabia . The health insurance companies were the greatest source of complaints in healthcare for the last eight years [30–36]. Also, there have been reports of insurers providing fake insurance to employers acquiring residency visa renewal .
Similar to the characteristics of uninsured workers, as documented elsewhere [37–42], the majority of uninsured expatriate workers in Saudi Arabia are young, single and categorized as unskilled and usually uneducated. More than two-thirds of expatriate workers are low income and destitute people (see Table 2). The uninsured population spans all age groups, but younger adults (19–25 years) represent 30% of the uninsured, this could be because they usually begin their careers in positions offering relatively low incomes. Saudi Arabia is similar to other countries, where the risk of being on a low income means that not only is the employer more likely to offer a job without health insurance but also that the premium is unlikely to be shared [43–45].
Studies from the United States, such as Monheit and Vistnes , established that a firm’s size was not an indicator of the health status of its employees but uninsured employees in both large and small firms are predictably unhealthier than insured employees . However, their finding is contentious as the outcome could suggest health insurance was only offered to employees who were in good health . Moreover, the present study suggests that the health status of workers in Saudi Arabia is not found to be a significant factor; this is because expatriate workers undergo rigid medical tests before deployment to their work site .
Furthermore, this study found that married expatriate workers have better access to health insurance due to the additional income earned by their partner. This finding is supported by a study that found the health insurance of married respondents was more related to total income as the partner’s income augments the family income . Also, in Saudi Arabia, there are married expatriates with professional jobs that allow employees to bring their family with them (i.e. labour workers are not eligible to be accompanied by their family) . Therefore, marital status could be reflecting job status and not marital status.
Other studies have concluded that the higher the job status and the greater the possibility employees will be insured [51–54]. Moreover, research by Chatterjee and Nielsen  found that there was no association between the education of expatriate workers and insurance coverage . However, these studies have not considered the distinction between the job and job education requirements. Specifically, while education reflects the personal characteristics of the employee, the job education requirements reflect the importance of the job to the employer. On this basis, we investigated job and education requirements as one of the variables to assess the complexity of the job, its importance to the employers and its influence on an expatriate employee’s access to health insurance. Our study revealed a strong relationship between job requirements and insurance coverage regardless of expatriate workers’ actual education. By implication, job skills and job requirements are more important for Saudi employers when providing health insurance coverage to expatriate employees. This preferential treatment by Saudi employers in respect of health insurance can be attributed to the government’s policy of imposing conditions on the issuance of work visas. The majority of expatriate workers change their job status to ‘manual, labour’ jobs; while in their home countries, they would be in the market for employment requiring higher skills . This disparity, between the workers actual education and job requirements and its influence on employers’ preference for providing health insurance, has not hitherto been studied.
As shown by studies from other countries, small sized companies are less likely to provide health insurance to their workers [45, 49, 57, 58]. The same applies in Saudi Arabia. Health insurance companies in Saudi Arabia provide cover based on risk-pooling, similar to voluntary health insurance, whereby insurers charge premiums in relation to risk . However, during the sixth stage, in 2008, when the CEBHI mandated insurance for all companies, including those with less than fifty workers, insurance companies refused to participate unless their premiums were increased by 200% . This finding was supported by other studies, which found, due to an increase in health insurance premiums, some companies had either stopped providing health insurance to their employees or had changed the system, imposing all or most of the contribution to their employees . Also, one study in Saudi Arabia found the increase in premiums (due to high administrative costs) burdens and limits participation by small employers in the scheme .
Our study’s findings, relating to the influence of the economic sector on access to health insurance, are not consistent with those from other studies. We found that workers in the construction sector were more likely to be insured than workers from other sectors. However, findings from other studies suggest people in manufacturing jobs are more likely to be insured than other sectors [39, 61]. This variance could be linked to the competition among business sectors. For example, in the United States there is competition between manufacturing companies and, as a consequence, the employers provide benefits to attract workers. Alternatively, in Saudi Arabia, there is strong competition among construction companies; accordingly, employers provide an incentive package to attract workers, one of which is health insurance coverage. Construction companies also have difficulties acquiring foreign workers due to the work visa constraints set by the government. In contrast, construction companies are the largest employers by size in Saudi Arabia, whereas the manufacturing sector is the largest employer in the United States; therefore, these companies can give better health insurance benefits with a limited increase in the premium. Another study in the region found that expatriates working in construction are less likely to be insured . However, this finding is inconsistent with other studies in the region where it was found that expatriates working in the construction sector were less likely to be insured. Nevertheless, it is worth noting that the study of Joshi and others did not use quantitative methods to mediate the influence of skill requirements for the job to perform the job or workers’ education from the economic sector. However, this study is consistent with other studies that show workers from the agriculture sector are less likely to be insured than those in other sectors .
There are other reported reasons for expatriate workers not being insured. The main reason reported by more than one-fourth (27.4%) of respondents was that insurance was provided only to renew expatriate workers’ Iqama. Our findings are supported by another study, which suggests some employers pay insurers ‘under the table’ to renew employees’ Iqamas when in fact the employees do not have health insurance . This finding supports evidence that employers might play a major role in the provision of health insurance for minorities in Asia [45, 57]. The source of this behaviour could either be the employer as indicated or the employees who buy their visas from their sponsors (i.e. pay a monthly salary to their employers, to have freedom of movement) . In both cases, there is supporting evidence that self-employed workers are more likely to be uninsured .
Our study found that the second most common reason for expatriate workers being uninsured is that employees are sponsored by different employers. These workers have legal work permits but have either ‘run-away’ from their sponsors (for various reasons) and are classified as unskilled with no education [29, 56], or work independently from their employers (mainly small company employers), who brought them to Saudi Arabia under an employer sponsorship. The employer’s role, in this case, was only to sign all legal papers of the expatriate workers  and receive a monthly or annual payment from their now ‘independent employees’ for this service. These employers are called labour brokers, and this service is another form of labour brokering, in which a certain sponsor brings in expatriate workers and rents them out to other companies while workers stay under the sponsorship of the labour broker. It would appear that the first form is more common in the Saudi labour market .
The third most common reason for expatriate workers in Saudi Arabia being uninsured was that their visa was for another job. These employees could either have illegal residence status in Saudi Arabia or are self-employed with a visa under a Saudi employer. The motivation behind this is that some expatriate workers give money to Saudi citizens to acquire visas, and pay a certain amount of money annually as a gratuity for this service. This act is illegal. There is evidence to suggest that the main incentive for Saudis to do this is financial . At the end of 2013, the Saudi government undertook steps to rectify the labour market of these “labour corrections” . One of the main objectives of these steps is to reduce the number of illegal workers. Further studies may be required to assess the impact of these steps to reduce uninsured expatriates.
There are some limitations to this study, one being that the study only comprised male expatriates working in the private sector; female expatriates and children were excluded. However, if gender had been included as one of the variables, it would have been very difficult to obtain sufficient participants due to the small number of female employees (98.30% of all expatriates in the private sector are male) . Also, most females working in the private sector work in healthcare and all medical and non-profit sectors were excluded from this study.
One source of potential bias is the fear by study participants of recrimination from their employer, which could have resulted in invalid responses. However, an official letter and identification card from the research sponsor were provided to reassure employees that all responses would be for research purposes only, and the answers would be treated with the utmost confidentiality. In addition, research assistants administering the survey were selected from the same dominant nationalities and languages of the private sector workers, thereby ensuring that the survey could be understood and answered using the participants’ language. Finally, the study is cross-sectional, which may have increased bias with respect to the time ordering of events.