DOES UNCERTAINTY ABOUT PRIVATIZATION IMPACT EMPLOYEES' PERCEPTIONS? EVIDENCE FROM THE HEALTHCARE SECTOR IN SAUDI ARABIA

The study aimed to detect the relationship between the implementation of hospital privatization in Saudi Arabia and healthcare workers' perceptions regarding work conditions, the level of participation in decision-making, and the relationship between the privatized organization and the HRSD Ministry. The data was collected from 100 healthcare workers in various hospitals across Saudi Arabia. More than half of the healthcare workers believed privatizing the healthcare sector would hurt employment security and increase the workload and hours worked per week, whether the employees have permanent or temporary contracts. However, the workers have a positive perception of work conditions related to progression, teamwork support, the level of training, incentives, and other benefits. The employees also positively perceive the level of participation in decision-making, including training requirements and how assigned tasks are completed. Healthcare workers with fewer years of experience are more optimistic about privatization. Moreover, although the regulations left the authority to determine the appropriate privatization strategy for each governmental organization based on their specific needs and objectives, employees positively perceive the relationship between the privatized organization and the HRSD Ministry.


INTRODUCTION
There has been much debate about the right size of government to balance the economy.Many countries could be pressured to cut spending if the budget deficit exceeds 3% of GDP Sharma (2020), p65.The Saudi government provides free public healthcare to about 30 million people, and the pressure on healthcare will increase as the population rises to 39.4 million in 2030 (vision2030.gov.sa, 2022).Moreover, the actual health and social development coverage in 2019 was approximately 190 billion riyals of the budget (Mof.gov.sa, 2019).Considering the COVID-19 pandemic, Does Uncertainty About Privatization Impact Employees' Perceptions?Evidence from the Healthcare Sector in Saudi Arabia International Journal of Research -GRANTHAALAYAH 208 the extra funding provided for the healthcare sector resulted in spending growing to 52% of the budget in 2022 (Mof.gov.sa, 2022).The high cost of the healthcare sector, which mostly exceeds the national income, reflects a big challenge that the current healthcare model could face for many reasons.These reasons could be the private sector's limitations in financing and providing public healthcare, the dual service provision, and poor coordination between providers.
To decrease the pressure of public spending on healthcare and enhance the financial sustainability of national healthcare, the private sector, and non-profit institutions, according to Vision 2030, will play a strategic role in providing healthcare services in the Saudi economy Al-Hanawi et al. (2019).One of the main methods that help define the partnership between public and private sectors and support the latter's contribution to economic development is the privatization system and its mechanisms.Privatization means conveying ownership of an organization either partially or entirely from the government to private for-profit or private for-nonprofit sectors Rahman (2020).There are many opportunities to increase the private sector's participation in providing citizens healthcare, such as rehabilitation, long-term care, home care, pharmacy, extended care, primary healthcare, radiology, laboratory services, and service launches for hospitals and medical cities (vision2030.gov.sa, 2022).For example, in the United Kingdom, the cooperation between the private sector and the National Health Service assists in improving the health service.The NHS offers many private beds, while the private sector provides learning disabilities individuals with psychiatric and long-term residential care Doyle et al. (2000).However, engaging private facilities in providing healthcare services is a hotly contested topic among Saudis Alkhamis et al. (2021).The uncertainty about privatization has increased their concerns mainly for people who work in the healthcare sector, where the quality of care and competitiveness depend on the staff, which is affected by work conditions, level of participation in decision-making, and management-union relationships.
The uncertainty among Saudis has increased for many reasons, which could negatively affect employees' perception of privatization regarding the change in work conditions, level of participation in decision-making, and the relationships between the management of privatized organizations and the Human Resources and Social Development (HRSD) Ministry as a governmental entity that supervises workers and regulates the labour market.Anderson et al. (2019), Bordia et al. (2004) and Odum (2012) confirm that feelings and behaviors, both positive and negative, are associated with the perception of uncertainty in organizational settings.One of these reasons is related to Saudi privatization regulations.Al-Munif (2021), p365) stated that the Saudi privatization regulations were issued in 2021 to replace the privatization strategy, which faltered for several issues, including the weakness of its organizational structure.Moreover, the regulations left the authority to determine the appropriate privatization strategy for each governmental organization based on their specific needs and objectives.The other reason could be related to the trend in the global economy, where economic growth has slowly recovered since the 2008 crisis; however, it has created jobs in low-skill and low-paid occupations.For example, unemployment after the 2008 financial crisis pulled out wages in most of the twenty-five European countries, and the situation has been worse among Americans Kelton (2020), p194.
The main objectives of this study are twofold.The first aim is to explore whether the perceived change in the work conditions, level of participation in decision-making, and the relationship between the management of privatized organizations and (HRSD) Ministry can reveal employees' perceptions, expectations, worries, and desires about the upcoming privatization of public Asmaa Sadiq, and Hala Alqobali International Journal of Research -GRANTHAALAYAH 209 hospitals.The second objective of this study is to investigate the participants' expectations about their performance following privatization and whether there is a correlation between healthcare workers' performance, level of participation in decision-making, and the relationship between management of privatized organizations and the (HRSD) Ministry.
The paper is structured as follows: Section 2 covers the literature review and research hypotheses, and Section 3 outlines the study design and methodology.Section 4 discusses the main results.The conclusion and recommendations are presented in Section 5.

LITERATURE REVIEW
Most studies have reported the economic consequences of applying privatization to several organizations.However, in healthcare organizations, the quality of care and competitiveness depend on the staff, which is affected by work conditions, level of participation in decision-making, and management-union relationships.Therefore, studying the potential effects of significant market changes and contributing to the knowledge about the possible consequences of privatization on the staff is crucial.
Employees worldwide express their fears about potential privatization because it involves organizational restructuring, which could lead to job loss and changes in working conditions.A survey of 308 privatized companies in developing countries revealed that employment was minimized after the sales, without any corresponding job gains for the remaining workers Odum (2012).Olsson & Tåg (2023) prove that while privatization may improve the performance of firms using Swedish data covering two decades, it can also lead to income losses and unemployment for workers which make social safety net plays an essential role in mitigating these negative consequences.Moreover, Al-Mutairi et al. (2014) conducted a study aimed to detect the attitude of employees and managers towards privatization programs in 21 privatized companies in Kuwait.The findings reveal that the employees agreed that a successful Kuwaiti privatization program should be limited to deregulation, outsourcing, and joint project partnership privatizations.Also, the results established that the privatization procedure would face numerous difficulties because of the absence of profit incentives and competition in public sector projects.Privatization eventually could lead to the dismissal of workers.
Conversely, Swai (2014) reported a significant positive impact of privatization on employees' quality of work life regarding work conditions, supervisorsemployee relationships, attributes, safety, and health situations.Furthermore, privatization positively affected the services accessed by employees and improved the relationship between unions and employees, leading to a more comfortable working climate and higher quality of work life.Fallatah & Halawani (2023) measured how workers perceived privatization could impact quantitative and qualitative job insecurity in the Saudi healthcare sector using a sample of 136 employees.They define quantitative job insecurity as perceived threats to the continuity of the job, while qualitative job insecurity indicates the danger of losing essential job features such as any job-related prestige or financial benefits.The results show a negative relationship between quantitative job insecurity and comprehension of the privatization process.In other words, workers' fears about losing their jobs decreased as their knowledge of the effects of privatizing on the healthcare industry increased.However, the results also show that understanding how the healthcare industry's privatization affects job insecurity quantitatively but not qualitatively.Many employees are also concerned about planned privatization because it involves less participation in the level of operational and strategic/departmental decision-making process.The issues related to operational decision-making are training requirements, pay and benefits, hours worked, and the way assigned tasks are completed.On the other hand, the strategic/departmental decision-making issues are related to hiring, dismissal, promotion, and transfer of employees, and problems also related to the hospital budget and finances Odum (2012).For example, Zhang et al. (2023) argue that one of the main reasons for the gap between the private and public hospital workforce is the imbalances within medical teams in skill, experience, and coherence, which leads to increased staff turnover rates between private and public hospitals.The public hospital staff have technical and professional development opportunities within the public hospital's management structure.On the contrary, private hospitals have limited opportunities for healthcare workers to build their careers and grow.Odum (2012) confirmed the negative impact of privatization on the employees' perception of governmentowned sugar companies at the level of operational and strategic/departmental decision-making issues.The outcomes observed may be related to the belief that privatization frequently leads to decreased managerial layers and the establishment of business units based on market principles.These units have specific and measurable performance targets via encouraging lower-level managers to monitor and control employee decision-making closely.As a result, employees feel less involved in the decision-making process at work.
In most countries, employees in government-owned organizations have a degree of empowerment in decision-making processes through unions.However, privatization could disrupt such empowerment, negatively affecting their wellbeing, job security and work conditions.According to Cai et al. (2020), workers' unions opposed complete privatization because they believed it would harm workers' welfare.They prove that social welfare is higher before privatization than post-privatization when unions equally emphasize wages and employment numbers.As a result of this, the government should refrain from applying privatization to public organizations.
Moreover, Arrowsmith (2003) confirms that privatization impacts the ability of trade unions to act as an influential voice for employees' opinions.This decline in the relationships between unions and employees could increase the negative perception of workers about privatization, which was proved by Odum (2012).In Saudi Arabia, many governmental organizations play a vital role in organizing the transformation process in targeted sectors.These include the National Center for Privatization & PPP (NCP) and the Human Resources and Social Development (HRSD) Ministry.1For example, the (HRSD) Ministry helps different ministries and institutions organize labour regulations for privatization based on their needs, consistent with Visions 2023.Yet, lacking detailed rules about the labour market during and after privatization could increase employees' fear in various sectors.
After considering the above mentioned, the concerns about potential privatization can affect employees' performance because of the change in work conditions, the less participation in the decision-making process at the operational and strategic/departmental levels, or the change in the relationship with worker unions.Although Pamacheche & Koma (2007) argue that employees obtained considerable benefits from privatization, such as the increase in the level of employment rate after privatization, and many workers had the opportunity to 211 purchase shares in the privatized firms at discounted prices, which led to increasing their wealth when share prices eventually rose.However, privatization could have a significant negative impact on workers' performance.For example, privatization increases workers' psychological stress and is significantly associated with poor job performance in Thailand.Moreover, employees of large healthcare providers in Canada experience higher stress and delay due to reduced job control following privatization Khan et al. (2012).
Based on previous studies, the following hypotheses are created to specify the healthcare workers' perceptions about privatization in the Saudi health care sector.
Hypothesis 1 Employees in the Saudi healthcare sector have a negative perception of the impact of privatization on their employment conditions.
Hypothesis 2 Employees in the Saudi healthcare sector have a negative perception of the impact of privatization on their participation in the decision-making process at the operational and strategic/departmental levels.

Hypothesis 3 Employees in the Saudi healthcare sector have a negative perception of the impact of privatization on the relation between privatized organization and (HRSD) Ministry.
Hypothesis 4 There is a relationship between Saudi healthcare employees' perception of privatization regard work's conditions, level of participation in decisionmaking, the relation between privatized organization and (HRSD) Ministry, and their performance.

METHODOLOGY
The descriptive survey data were collected from among healthcare workers in random hospitals in Saudi Arabia from 4 November to 25 November 2022, using the online application -Google Forms-via social media.A study in Kenya initially designed this survey questionnaire to investigate the employees' perceptions of the privatization of Sugar Companies owned by the government: The case of Muhoroni Sugar Company Ltd Odum (2012).Academic members in health care and public administration judged the questionnaire.The survey was distributed in Arabic and English language.The survey is divided into two sections.The first section will explore whether the perceived change in the employees' conditions, level of participation in decision-making, and management-HRSD Ministry collaboration or relationship can reveal employees' perceptions, expectations, worries, and desires about the upcoming privatization of public hospitals.The second part will investigate the participants' expectations regarding their performance following privatization and whether there is a correlation between healthcare workers' performance and the perceived change in employees' conditions, level of participation in decision-making, and the relation between privatized organization and (HRSD) Ministry.The employees' performance has been measured by using the Individual Work Performance Questionnaire (IWPQ) according to Koopmans et al. (2014).

RESULT
Table 1 shows the descriptive analysis of the demographic characteristics of 100 workers in different Saudi hospitals.It includes the respondents' distribution by gender, age, years of experience, level of education, and job title/category.Around 65% of the respondents who participated in the study were female.There is a possibility that employees' perception of privatization could be affected by the Does Uncertainty About Privatization Impact Employees' Perceptions?Evidence from the Healthcare Sector in Saudi Arabia International Journal of Research -GRANTHAALAYAH 212 gender of the respondents.Moreover, 91% of the participants were younger than 50, which could reflect the attitude and feelings of employees away from retirement.Based on academic qualifications, more than half of the sample (57%) had a university degree, and 41% were postgraduate.It reveals that all the participants had high educational levels, with most holding high certificate-level qualifications.Participants with proven education-based skill sets could experience decreased uncertainty regarding privatization.About 55% of the participants in the study were married, and almost two-thirds (63%) had managing and administration jobs.This could increase fears about privatization regarding their family responsibility and job security.The situation also applies to workers who are employed on temporary contracts.About 36% had a monthly income of 11000-15000 riyals, and 31% had a monthly payment of more than 15000 riyals, which could increase the fears about reducing their monthly amount within privatization.

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Table 2 reports the healthcare workers' perceptions and attitudes towards the planned hospital privatization in Saudi Arabia regarding work conditions such as job security, workload, payments and remuneration, career progression, level of teamwork, training, and incentives.The sample was stratified according to job title, which includes workers in management and administration jobs, physicians, and healthcare professionals.Around 60% of respondents expected decreased job security in administration, physician, or healthcare jobs.However, the high rate of negative perception about privatization comes from workers who are in the level of management and administration jobs.This result could enhance the negative perceptions about privatization among hospital employees who are influenced by the opinions of their managers, who have a vague view about privatization.Moreover, around 79% of the respondents expected increased workload and pressure.This result is also in line with the findings of Odum (2012), where most sugar company workers expected to lose their jobs within privatization.Such negative perceptions and attitudes about privatization can arise because of adverse outcomes associated with privatization practices worldwide.On the other hand, around 50% believe that the hospital privatization system will increase recruitment and promotion, the level of teamwork and training will increase as well.
Overall, around 49.22% of respondents believe that the privatization of the healthcare sector in Saudi Arabia will improve work conditions, contrary to the findings of Odum (2012), while 22.33% feel there will be deterioration after privatization.Table 3 shows a statistically significant relationship between the type of contract, whether the employees have permanent or temporary contracts and job security, which is a crucial aspect of the study, based on the value of P-Value= 0.001 and compared with the 5% significance level.The strength of the relationship is estimated at 71%, meaning that the relationship is strong, which could indicate that the employee may feel threatened with dismissal from work because they may be laid off and not needed for the organization's sufficiency after privatization. Figure 1 indicates that the most significant percentage of both categories of contracts answered with certainty that the security of employment would decrease.5 indicate the perceived change of employees regarding the level of decision-making participation in the Saudi healthcare sector privatization.Table 4 shows how adopting privatization in Saudi hospitals impacts the degree of involvement in the operation's decision-making.More than half of the sample positively perceives participation in decision-making regarding training requirements and how assigned tasks are completed.Employees believed the situation would be the same without changes in the case of involvement in operational decision-making regarding pay, benefits, and hours worked.Overall, privatization positively impacts employees' perceptions regarding participation in the operation's decision-making.Data are presented as numbers and %

Table 2
Table 5 reports the perceived change of employees regarding the level of strategic/departmental decision-making issues in the privatization of the healthcare sector.Less than half of the participants perceived a positive change in employees' participation in strategic/departmental decision-making issues during privatization, particularly those related to the dismissal or transfer of employees.In comparison, 35.16% believed the situation would be the same without changes, while 22.83% reported decreased employee participation in strategic/departmental decision-making on privatization.Such results disagree with the finding of Odum (2012), how shows a negative perception of privatization in employees' participation in strategic/departmental decision-making issues.Table 6 reports, based on the P-Value= 0.001 and compared with the 5% significance level, a statistically significant relationship between the number of years' experience and the ability to participate in decision-making regarding wages and benefits.The result confirms the strength of the relationship is estimated at 59%, meaning that it tends to be of medium strength.Figure 2 shows a diversity of opinions across employees with different years of experience.The most significant percentage of those with 6-10 years of experience believe that they will not influence decision-making regarding benefits and pay, unlike those with 1-5 years of experience who are optimistic that they will influence decision-making.

Variables P value Pearson correlation
Years of experience and pay and benefits 0,001 0.599

Figure 2
Figure 2 Table 7 shows employees' perceptions of the relationship between hospital management and HRSD Ministry after privatization.More than half of the sample has a positive feeling about the collaboration/relationships between principles/and management and HRSD Ministry after the privatization of hospitals in Saudi Arabia.In comparison, 13% felt that management would not consider cooperation with HRSD a vital tool in running positive changes in hospitals post-privatization.Table 8 shows participants' expectations regarding their performance following privatization.The highest scores were for the following items: 54% reported" I will never make problems at work more considerable than they were", followed by 40% reported "I will not focus on the negative aspects of the situation at work" and "I will be able to carry out my work efficiently" equally.The last items were 8% for "I will take on challenging tasks when they are available" and 7% for "I will be able to set priorities".Data are presented as numbers and % Table 9 reports a significant positive correlation between healthcare workers' performance and participation in decision-making (p= 0.023).On the other hand, there was a non-significant positive correlation between healthcare workers' performance and employment condition and Management-HRSD relation.

CONCLUSION AND RECOMMENDATION
Even though privatization has clear benefits for the economy, it is essential to detect its influence on employees as key stakeholders.Employees' worries regarding their work conditions must be considered to run a successful transformation to privatization.More than half of the healthcare workers believed that privatizing the healthcare sector in Saudi Arabia would hurt employment security and increase the workload and hours worked per week.The fears and concerns grow whether the employees have permanent or temporary contracts.However, the workers have a positive perception of work conditions related to progression (recruitment and promotion), teamwork support, the level of training, and the incentives and other benefits.Moreover, the employees perceive positively the level of participation in decision-making, including training requirements and how assigned tasks are completed.Healthcare workers with fewer years of experience are more optimistic about privatization.
Although the regulations left the authority to determine the appropriate privatization strategy for each governmental organization based on their specific needs and objectives, employees positively perceive the relationship between the privatized organization and the HRSD Ministry .
The government could design regulations that could enhance the participation of healthcare workers in the decision-making process, including hiring, dismissal, promotion, and transfer of employees, and problems related to the hospital budget and finances.

Does
Uncertainty About Privatization Impact Employees' Perceptions?Evidence from the Healthcare Sector in Saudi Arabia International Journal of Research -GRANTHAALAYAH 216 Table 5

Table 1 Demographic Data Distribution by Gender, Age, Years of Experience, Level of Education, and Job Title/Category (N=100).
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