Strategic analysis of clinical pharmacy education in Saudi Arabia

Purpose: To analyze the strategic position of clinical pharmacy education in Saudi Arabia and ensure that it meets the needs of the current industry in the country. Methods: A comprehensive and structured analysis of strengths, weaknesses, opportunities, and threats (SWOT) was performed with more than 100 clinical pharmacists, academic staff, and students as participants. An internal factor evaluation (IFE), external factor evaluation (EFE), and SWOT matrix were conducted to compare the provisions of the current system with market needs. Results: The analysis involved more than 40 academic staff members, 35 clinical pharmacists, 50 students, and several administrative staff members. The EFE and IFE were calculated as 2.06 and 2.2, respectively, and were lower than the accepted international standard. The internal and external analyses involved 37 and 20 items, respectively. Finally, a SWOT matrix was constructed to help for proposing the strategies. Several strategies were recommended to address eventual shortcomings. Conclusion: The great paradigm shifts in the pharmaceutical market warrant an equal paradigm shift in clinical pharmacy education. More strategic data are needed to further analyze the market in the next five to ten years. Adopting the current educational modality to best match the needs of the pharmaceutical market is also essential.


INTRODUCTION
There are almost 30 pharmacy schools in the Kingdom of Saudi Arabia (KSA), all equally eager to align with global standards in clinical pharmacy education and cope with the country's expanding pharmaceutical industry [1,2]. These schools must adopt a holistic approach to comprehensive development, enhance their role in development, and improve their products and services in line with superior standards of higher education in the KSA [3,4]. Most schools have prepared their ten-year strategic plans (2016-2026) based on several scientific methodologies, resulting in significant variances between them and possible asymmetries with the needs of the clinical pharmacy industry [3,5].
The KSA's pharmaceutical sector has grown rapidly, partly because of government efforts by the Ministry of Health, job availability, grants for higher education, and local pharmacy training [6,7]. Notably, the pharmaceutical sector is the major provider of medicine in the KSA. It has also started exporting medicines to the global market following the recent increase in the number of manufacturers and establishment of research-based firms in the country. Thus, the sector shows great promise for developing the KSA economy [8]. Therefore, educational research is needed in the pharmacy field to improve opportunities for the industry's future development [9].
To better match clinical pharmacy education with the changing needs of the pharmaceutical industry, a strategic analysis is needed to explore related opportunities and avoid threats, as well as to harness associated strengths and mitigate weaknesses. In other words, a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of current pharmaceutical education is essential to understand how to tailor it to suit industry needs. However, a nonregulated SWOT analysis would add few quantitative measurements and a simple or traditional SWOT analysis might not be beneficial for healthcare institutions [10,11]. In this case, a comprehensive, model-based, and structural SWOT analysis may illuminate how best to modify clinical pharmaceutical services in the KSA [12]. This type of SWOT analysis addresses several factors (e.g., stakeholders, resources, and trends) and is connected to several matrices, including an internal factor evaluation (IFE), an external factor evaluation (EFE), and a Political, Economic, Social, Technological, Legal, and Environmental (PESTLE) analysis [10]. Therefore, this study asks: What is the strategic status of pharmacy education in the KSA? To respond to this question, a comprehensive SWOT model was employed.

METHODS
In this study, the strategic planning process began with a comprehensive analysis of internal and external audits. Specifically, a SWOT analysis was performed based on stakeholders, contextual factors, and resources [10,12]. Next, strategies were established, evaluated, and selected by constructing specific qualitative and quantitative matrices. The participants were Consultant Pharmacists, Associate Professors/Professors of Clinical Pharmacy, Associate Professors/Professors of Pharmacy Practice, Associate Professors/Professors of Pharmaceutics, or Student Interns who were primarily involved in pharmacy education. More than 100 clinical pharmacists, academic staff, and students (only final-year interns) participated in this analysis. All participants were carefully selected based on their expertise in either clinical pharmacy education or the clinical pharmacy profession. Several students from different universities were asked to agree/disagree with the established items.
Participants were first requested to conduct the traditionally structured SWOT analysis in groups. Unlike an open, unstructured SWOT analysis, this type focused on the following major domains: stakeholders, resources, trends, and finances. The analysis resulted in a list of items. Participants were then asked to score and assign a weight to each item. In the case of disagreement, participants voted to reach consensus. The mean ranks and weights of the items were recorded. The analysis was divided into three sections based on the input, matching, and decision stages.
In the input stage, two matrices, namely IFE and EFE, were constructed using information collected from the SWOT analysis. The average weights and scores were considered based on participants' judgments. For the IFE matrix, major weaknesses were ranked 1, minor weaknesses 2, minor strengths 3, and major strengths 4. For the EFE matrix, ranks indicated how effectively clinical pharmacy education deals with the provided factor (1 = poor and 4 = superior). The weighted scores in both matrices were equal to 1.
The matching stage involved combining the internal and external factors using a tool called SWOT matrix. Theoretically, internal factors should be able to control the stress induced by external factors. Therefore, the strengths were used to gain opportunities (S-O) and avoid threats (S-T). On the other hand, weaknesses were matched with opportunities (W-O) and threats (W-T) to enable better advance planning.
Significant effort and attention were given to the decision stage of the strategy formulation framework because matching external and internal critical success factors is key to the effective generation of feasible alternative strategies. Therefore, the IFE and EFE matrices and a SWOT matrix were used to formulate several strategies to solve or improve the analysis results.

RESULTS
The analysis involved more than 40 academic staff members, 35 clinical pharmacists, 50 students, and several administrative staff members. Table 1, Table 2 and Table 3, and 4 present the results of the SWOT analysis. Table  1 shows the IFE matrix for strengths, Table 2 shows the IFE matrix for weaknesses, Table 3 shows the EFE matrix for opportunities, and Table 4 shows the EFvE matrix for strengths.
The IFE and EFE matrices were calculated as 2.06 and 2.2, respectively. The internal analysis involved 37 items, including 15 strengths and 22 weaknesses. The external analysis involved 20 items, including 11 opportunities and 9 threats. Tables 5, 6, 7, and 8 show the SWOT matrices and several recommended strategies that were formulated based on the S-T, W-O, W-T, and S-O matchings, respectively.

DISCUSSION
There are significant differences between pharmacy schools in the KSA, and each tends to apply the best-matched strategies based on its IFE and EFE matrices. As per standard theory of strategic planning processes, the average score for IFE and EFE matrices is approximately 2.5, with the highest score being 4. In this study, the EFE matrix scored 2.2 (in the "poor" range) and the IFE matrix scored 2.06 (in the "minor weakness" range), indicating that clinical pharmacy education in the KSA is neither effective nor ineffective at exploiting opportunities or defending against threats. Likewise, many strengths are insufficient to address existing weaknesses and opportunities. This emphasizes balancing the cost invested with the required clinical pharmacy outcomes. Since clinical pharmacy is essential in the country, formulating evidence-based strategies is a crucial step in obtaining the best possible outcomes [13]. In the future, numerous educational strategies and modalities should be considered to keep up with the clinical pharmacy market [14]. Therefore, clinical pharmacy education should be improved by pursuing new institutional and educational strategies and focusing more on taking advantage of favorable opportunities in the country [15][16][17].
The pharmaceutical market in the KSA has demonstrated a growth trend in recent years [18]. Specifically, changing lifestyles due to urbanization and an increase in per capita income has escalated the demand for drugs, thereby creating a gap in clinical pharmacy education [6]. Moreover, because pharmaceutical products respond to basic needs, the industry is unlikely to decline in the future. Certainly, the KSA's growing population has expanded the health care market, creating more opportunities for pharmaceutical products and hospitals [19]. While the growth of this market offers an opportunity for clinical pharmacy in the KSA to expand [20], the number of clinical pharmacists in the country is currently growing at a low rate and may soon fall short of its required target [21,22]. This slow growth presents a great challenge for the fast-growing KSA market and, as shown in the matrices, may result in unmet needs. Another risk highlighted in the analysis is that clinical pharmacists with minimal clinical experience and low salaries may be redirected from clinical pharmacy to other pharmacy specialties [23].
Previously, the government played a substantial role in the growth of clinical pharmacy in the KSA. In particular, the government through the Ministry of Health facilitated the growth of clinical pharmacy by continuously evaluating the clinical pharmacy market and its needs, enhancing clinical pharmacy services in government hospitals, and approving more clinical pharmacy education programs [6,24]. However, with clinical pharmacy currently undergoing a privatization process in the KSA, the government now offers few jobs to clinical and hospital pharmacists, increasing the risk of job insecurity and sending passive messages about the changes needed regarding education [7]. Both points are addressed in the analysis and may be weighted more highly in the near future.
Currently, the strategic positioning and direction of clinical pharmacy and pharmaceutical care innovation is insufficient in the KSA. Here, the shortage of locally trained clinical pharmacists has been a major industry concern for decades [6,7,23].
Furthermore, clinical and pharmaceutical research is limited by the deficits of time, resources, and incentives. Regarding the latter factor, it is noteworthy that the few trained clinical pharmacist professionals in the KSA are able to migrate relatively easily to different regions in the Gulf Cooperation Council and Western countries after working in the KSA. Consequently, attracting and retaining the limited human capital available is financially and socially costly for the clinical pharmacy industry.
Finally, investment in clinical pharmacy research and development (R&D) activities is quite expensive. High investment in R&D does not produce expected levels of fast cash and revenue. Thus, investors tend to shy away from start-up activities in healthcare and related innovations [25]. As a result, there are very few registered clinical trials in the pharmaceutical field to match considering the massive expansion in the market overall, hindering job growth and education for clinical pharmacists [26].

Limitations of the study
The scarcity of data on the strategic pharmacy analysis is a major limitation of this study. Likewise, the expressive variability between schools should be considered when interpreting this analysis. The strategies are proposed based on the existing SWOT analysis, which was conducted by the participants in this study. Thus, strategies and suggestions may be amended by other schools based on their analysis.

CONCLUSION
The new era of clinical pharmacy education will likely witness educational institutions adopting new educational modalities to overcome the weaknesses and threats highlighted in this paper. Moreover, these institutions should invest strongly in their existing strengths and opportunities. Adopting education that matches the clinical pharmacy market will optimize the funding procedure and enable the adoption of a more cost-effective strategy.

Acknowledgement
I would like to acknowledge all the participating professionals and students for their help in making this work a success.

Conflict of interest
No conflict of interest is associated with this work.

Contribution of authors
I declare that this work was done by the authors named in this article and all liabilities pertaining to claims relating to the content of this article will be borne by the author.

Open Access
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