Food safety in hospitals is an important issue in preventing food poisoning which can result in negative impacts on the economy, individuals and the hospital sector in Saudi Arabia (Griffith et al. 2010). Consequently, the Saudi government through its MOH, is committed to ensuring public health and there are continuous food or premise inspections and various regulations that have been put in place to reduce the risk of consuming unsafe food. Food contamination due to mishandling remains to have a critical role in the spread of food-borne illnesses hence the Saudi hospitals are constantly alert to minimize any chances of food contamination through complying with food safety regulations and HACCP systems (Tomohide, 2010).
In this literature review, a number of indications have been provided and existing literature discussed in order to understand the management of food safety as well as the role of HACCP implementation in hospitals. In essence, the main sections in the chapter include the review of Ministry of Health and Saudi Arabia, discussion of food safety practices in the hospitals, Saudi Legislations on food safety and the HACCP. The chapter ends with indications of the objectives, research questions, purpose and the study assumptions/limitations. The first section concerns the overview of Ministry of Health and Saudi Arabia.
1.1.1 Saudi Arabia and Ministry of Health
Reports by Mousa (2015) notes that in the GCC, Saudi Arabia plays a critical role and is regarded as most influential country with US$ 20,327 in per capita GDP. There are over 27m people in Saudi Arabia and the government provides free health services. Generally, its economy is considered as oil-based and one of the fastest growing in the region over the past decade with GDP growth of over 4.15% yearly. According to MOH (2015) the Saudi government regards health as an important factor in overall development of the country and spends over US$ 19.3bn on health annually. Hence health expenditure per capita amounts to over US$ 714 and total expenditure translates to about 3.6 percent of the country’s GDP. Moreover, the increase in Saudi population directly relates to the increase in health service demand by citizens and increase in expenditure by government given that most health services are provided by MOH (MOH 2015).
The health expenditure annually by the Saudi government accounts for 6.5% of government budget. In essence, 6% of total Saudi population is covered mainly by public health insurance, public health service or the social insurance (Mousa 2015). However, the remaining 31% are accounted for by the private insurance thus private sector also plays a major role in health service to the Saudis. Public health is critical to reducing disease incidences and disease prevalence (Kassa 2010). Therefore, the MOH regards disease prevention to be vital in attaining its strategies towards achieving health for all population in Saudi Arabia.
Ministry of Health
The MOH in KSA is committed to attaining to disease control and public health is among the top priorities of the Saudi government. Moreover, the projects, policies and objectives of the MOH are aligned towards attaining its vision of delivering comprehensive, integrated and best quality healthcare services to the citizens (MOH 2015). Consequently, the strategy of MOH in KSA is to consider various elements that are vital in attaining its vision which conforms to other health services globally. Since WHO requires that food organizations should implement HACCP, the MOH also complied with this requirement in major food organizations and has also introduced the HACCP system to be implemented in the Saudi healthcare sector and the hospitals in particular since they are under its supervision (Prianka 2012).
In essence, healthcare services in KSA are provided by both government and private sector (MOH 2015). There are 249 hospitals in KSA which are directly operated and owned by MOH and this represents 60 percent of all the hospitals. Nonetheless, the remaining 40% are operated and owned by the private sector under the regulations and supervision of MOH. In total, the MOH has 20 directorates to help in the enforcement of health regulations. Knowledge on HACCP implementation among staff in both private and public hospitals is vital for the hospitals to successfully implement the system. In particular, the food handlers in the Saudi hospitals require proper training on food hygiene to support the disease prevention efforts.
1.1.2 Food Safety in Saudi’s Hospitals
Indications of Getachew (2010) were that food-borne illnesses are a public health challenge globally especially in the developing countries compared to the developed countries due to the poor measures of food safety and low personal hygiene. In particular, Giritlioglu et al. (2011) notes that outbreaks of food-borne illnesses in hospitals cause more negative effects on the patients who consume the food given their weakened immunity and disease status. Despite the fact that provision of safe food is the obligation of the hospital’s top management, the practices of food handlers during food preparation and processing have the major link to the cause of the unsafe food.
In this regards, Grintzali and Babatsikou (2010) adds that the prevention of food-borne illnesses in hospitals thus require the involvement of all the individuals involved in handling food including the individual patients. According to MMRA (2009) in Saudi Arabia, a number of efforts have been made in the hospitals towards improving the food hygiene and food safety conditions such as amending the conditions and terms of the nutrition contracts to hospitals. Generally, the hospitals in KSA contract food service providers or catering service companies to supply and prepare food hence they operate under the tendering system. However, such services are usually supervised by the nutrition departments in the hospitals which have about 20 nutritionists to 1 nutritionist employed by the MOH for large and small hospitals respectively (Kassa et al. 2010). Consequently, it was required that in the MOH hospitals, all the contracted food suppliers must comply with the requirements of HACCP principles. Nonetheless, such directives are yet to be fully implemented in the various MOH hospitals which could be linked to various challenges.
Specifically, it was required that the contracted food suppliers should have a HACCP coordinator to help in maintaining hygienic practices and ensure they implement the HACCP system in the hospitals operated by MOH (Kokkinakis et al. 2011). Other initiatives that contracted food suppliers were required to undertake to promote food safety included providing sufficient training and health education to their staff and particularly food handlers. In addition, the food handlers must possess health license which indicate that they are medically fit to handle food in order to avoid cross-contamination. Such health licenses for the food handlers are valid for 6 months (Martins et al. 2012). The supervisors and managers of the contracted food suppliers were also required to pursue courses in HACCP system and management of food hygiene. According to Oinee and Sani (2011), the requirement for further training implied that there are few individuals who are knowledgeable in HACCP system and its implementation which could be attributable to the few training institutions which provide course in management of food hygiene and food safety.
Study by Griffith et al. (2010) reported that having the education and training on promotion of food safety ensure that employees have the necessary knowledge and awareness on prevention of food-borne disease in the Saudi hospitals. Furthermore, food handler training is vital element of HACCP which is recognized by WHO and EU legislations. In addition, Tomohide (2010) confirmed that it is also vital for hospital staff to attain the necessary knowledge on HACCP in order for the hospitals in KSA to be effective in food safety like other hospital in developed countries which implement HACCP.
1.1.3 Codex Alimentarius and Saudi Arabia Legislation
Kassa et al. (2010) maintained that food standards are mainly guidelines which indicate the various requirements of microbial regulation, food products, the accepted contaminants levels, labeling and packaging requirements as well as the requirements for hygiene maintenance for the products that are manufactured. Consequently, Codex Alimentarius develops the food standards which serve as the main reference standards for trading food internationally. Generally, Prianka et al. (2012) posited that Codex Alimentarius aims at protecting the health of the consumers, ensuring the food trade practices internationally are fair, and coordinating the work by international organizations on the food standards. In this regards, a number of countries including Saudi Arabia have complied with the food standards set by Codex Alimentarius. In essence, Saudi Arabia developed its standards and requirements for agricultural and food products in line with the indications of Codex Alimentarius.
Reports by Getachew (2010) pointed that one of the major actions of Codex Alimentarius was the development of the regulations on HACCP system and recommendation for its implementation worldwide. However, indications of Giritlioglu et al. (2010) was that complying with food standards such as HACCP and other Codex Alimentarius standards involve high implementation costs which has been mentioned to be a challenge. Consequently, many food establishment and large organizations in Saudi Arabia have often embraced the standards of Codex Alimentarius such as HACCP in order to comply with the directives of the government and remain competitive in Saudi Arabia as well as globally. However, Grintzali and Babatsikou (2010)believe that the available financial resources and technical resources have not been adequate to successfully implement the requirements of Codex Alimentarius.
Kassa et al. (2010) affirmed that in any country, the action plan for food safety indicates the minimum standards expected or the approaches employed and outlines the objectives or targets which the food safety systems must achieve. The legislations in Saudi Arabia on food safety require certain food items to satisfy all the consumer, legal and customer requirements so as to attain the minimum safety and quality standards (SFDA 2015). Although food quality standards involves all the product characteristics that affect the value of food in the viewpoint of consumers, the food safety standards encompasses all measures to protect public health. These standards in Saudi Arabia are in line with ISO and Codex Alimentarius.
In Saudi Arabia, the nationwide safety and food quality systems are controlled legally by different government agencies or departments of various ministries (SASO 2015). For example, regulatory agencies include SFDA and SASO which rely on Codex Alimentarius. In addition, health certificate must be obtained for certain food products such as poultry or meat. There also various standards such as SSA 630/1990, SA9019, GS9/1995, SSA 457/2005, GS654/1996, and GS707/1997 among others which are followed in Saudi Arabia for food products (EPD 2015). In particular, such standards concern, for example, Halal slaughter license, product registration, import documentation, labeling, general requirements, nutrition, colours, biotech and preservatives. The main objective of these specific and general hygiene legislations are to ensure consumer protection specifically protection against issues arising from lack of food safety. Moreover, compliance with HACCP is also a requirement to enhance hygiene and food safety in Saudi Arabia.
1.1.4 Hazard Analysis and Critical Control Points (HACCP)
Kokkinakis et al. (2011) emphasized that public health involves mainly disease prevention and it has been found that prevention of disease is vital for populations than curing diseases. Hence, there are various international agencies and national agencies which encourage better measures towards the protection of people against the occurrence of food-borne illnesses. Consequently, understanding of Martins et al. (2012) was that one of the main achievements has been HACCP development and enacting of regulations on HACCP by UN Codex Alimentarius. HACCP refers to a rational and structured approach towards the prevention of hazards and analysis of potential points for occurrence of hazards at each food preparation stage. In essence, HACCP requires that the operators must identify and also enumerate the various steps involved in their operations which are deemed critical to attaining food safety, besides; the operators must also evaluate and identify the various safety measures. In the hospitals, Oinee and Sani (2011) claimed that ensuring food hygiene involves thoroughness when it comes to the implementation of the preventive measures aimed at minimizing hazards and food poisoning. Thoroughness in hospitals is essential given that the consumers (patients in hospitals) tend to be more vulnerable if they consume unsafe food compared to people who are healthy.
Study by Giritlioglu et al. (2011) noted that the HACCP system helps to attain food safety thus it is a program which is proactive and an ideal approach in the hospitals. This approach can identify the likely hazards before the occurrence of the problems which is the ideal aim of illness prevention. Getachew (2010) affirmed that HACCP ensures the nutrition products and the food are safe and also helps in the development of strategies for corrective measures and improvement overtime instead of depending on impromptu checks on the food preparation processes and checking finished products at random to attain food safety. In essence, Prianka et al. (2012) revealed that HACCP concentrates mainly on the strategies of preventing the known hazards and places great focus on the control during preparation process and the various steps involved, instead of the layout and the structure of the premises.
HACCP develops the necessary procedures which are vital in eliminating and minimizing the hazards and it also requires these control approaches are verified and documented. Tomohide (2010) noted that the CCP determined by the HACCP systems have been found to enhance food safety by analyzing the different sources of hazards including the physical hazards, biological hazards and chemical hazards which affect the safety and ensure they are controlled in the food chain right from the beginning to the final consumption of the food product.
Consequently, Oinee and Sani (2011) view was that HACCP is recognized internationally as a system for assurance of food safety in both large organizations and small organizations. In this regards, food businesses a part from the food produces, have been implementing the management procedures to ensure food safety based on the principles of HACCP. Complying with every indication of the HACCP principles is vital for high consumer protection when it comes to consumption of safe food.
1.1.5 Principles of HACCP
Reports by Martins et al. (2012) considered that the successful implementation of HACCP in organizations involves producing food for consumption which is completely free from any biological hazard, chemical hazard or physical hazard. Hence, this is the main objective of implementing HACCP in organization; however, there are seven principles which must be ensured during the HACCP implementation. These include: 1) identifying the various hazards which may be present during preparation of food and assess the potential risk of these hazards and their level of severity; 2) identify the CCP during the preparation of food; 3) determine the critical limits required for the preventive measures required for each of CCP identified; 4) develop the required procedures for monitoring of the CCP identified; 5) establish the necessary corrective action which must be taken when monitoring outcomes reveals that CCP is exceeded; 6) develop an effective system for keeping records and documenting HACCP; and 7) establish appropriate procedures for verifying that HACCP approach is actually working. Refer to table 1 for HACCP principles
Table 1: HACCP principles
|Principle no.||HACCP principles|
|Principle 1||Conduct analysis of the hazards|
|Principle 2||Determine CCP|
|Principle 3||Develop CCP limit|
|Principle 4||Develop monitoring systems for CCP|
|Principle 5||Develop corrective action required when CCP is exceeded|
|Principle 6||Develop verification procedures to confirm whether HACCP is effective|
|Principle 7||Establish documentation on all procedures involved and their application and keep the records|
Source: CAC (2013)
Revelation by Kokkinakis et al. (2011) was that HACCP principles are used widely as the main reference standards with regards to safe practices in food preparation and handling. Due to the fact that the HACCP principles require the enforcement of rigorous documentation and procedural governance practices in the organizations implementing the HACCP regulations, it serves both as the model for risk assessment and the model for effective communication of risk control measures. Although there have been controversies on the use of HACCP in the hazard identification and their prevention in food establishments, explanation by Kassa et al. (2010) was that the HACCP guidelines have been recognized in hospitals as having the advantage of enabling patients to receive or consume safe food.
Several countries globally embrace the implementation of HACCP principles given that it is also recommended by WHO (Griffith et al. 2010). For instance, in Europe, all the countries since 2006 have been obligated to implement HACCP with the exception of the primary producers. Similarly, Prianka et al. (2012) provided that a number of countries in Asia are also implementing HACCP. A major reason for the increasing implementation of HACCP principles in various countries can also be attributed to globalization and increased trade in food items between countries. Consequently, some countries impose regulations on HACCP for importers requiring them to comply with HACCP system. Getachew (2010) wrote that such requirements have also been extended to the local suppliers of food services to major organizations such as those supplying food services in hospitals. In addition, it was found that in countries that implement HACCP principles, there were reduced cases associated with food-borne illnesses.
1.1.6 Benefits and Limitations of HACCP
There are a number of benefits to organizations such as hospitals that can be associated with HACCP besides the fact that it helps to reduce cases of food-borne illness among the public (Giritlioglu et al. 2011). Implementing HACCP and all its stages results in having a comprehensive understanding of issues concerning food safety which may affect an organization and hence the organizations develop confidence in their food products or service. Such confidence enables the management to address demands from external auditors, law enforcers and other stakeholders. Studyby Grintzali and Babatsikou (2010) notes that it also enables the organization to use their experience and knowledge in refining and reviewing their systems. Consequently, HACCP implementation empowers firms. Reduction of costs is also associated with HACCP in that it enhances better manpower use, reduces wastage and less record keeping when focus has been achieved. Kokkinakis et al. (2011) established that focus is also enhanced by HACCP since attention is given on the food preparation aspects which can affect the food safety. Moreover, filtering out controls which are less essential enables management to give full attention on CCP of production processes.
Oinee and Sani (2011)’s viewpoints was that team building is also associated with HACCP in organizations since all the individuals in the organization work together to attain HACCP systems. In this regards, organizational development is enhanced which enables it to deal with changing demands. Furthermore, indication of Martins et al. (2012) was that achieving HACCP system successfully necessitates certain changes in approaches towards using knowledge and skills of employees, solving problems by managing employees and developing the organization culture which is focused more on safety instead of purely costs and output.
Besides, Kokkinaki et al. (2011) felt that legal protection is also a benefit of HACCP as many countries sue firms which do not comply with HACCP guidelines yet their operations involve food business. Moreover, Grintzali and Babatsikou (2010) confirmed that during food-borne illness outbreak, complying with HACCP can act as legal defense against prosecution. Trading opportunities is also enhanced when a firm that implements HACCP seeks to expand their operations to international markets. In addition, food businesses that implement HACCP cab supply other organizations which contract only firms implementing HACCP in their operations.
Despite the various benefits that have been reported in organizations that implement HACCP, there are also limitations that have been linked to HACCP system. In the first place, Getachew (2010) believed that HACCP requires that the process must be understood comprehensively, consequently, this implies that it tends not to be suited ideally for processes and hazards which are little known. Another limitation which has been reported by Priankaet al. (2012) was that HACCP does not actually prioritize or quantify the risks involved and the impact of having additional controls for eliminating the said risks are also not quantified. Since implementing HACCP is complex, it requires additional material, human and technical resources which may not always be adequate in an organization. Other limitations which have been mentioned by Kassa et al. (2010) include the constant updating of technical data as well as involvement and sincere effort of all individuals handling the food which may not be the case. Nonetheless, it was argued by Tomohide (2010) that limitations are often overshadowed by the benefits.
1.1.7 Challenges of Implementing HACCP
Although the food manufacturing sector and large firms in catering and hospital sector in many countries have adopted HACCP and implemented its various guidelines, revelations by Griffith et al. (2010) was that there are concerns when it comes to HACCP implementation in smaller organizations such as hospitals. Consequently, a number of scholars have doubted its efficiency and reported various potential reasons for the reduction in HACCP efficiency and failures. The analysis of challenges faced in HACCP implementation revealed that elements such as management commitment, competence and knowledge, planning, training, resources, human resources and documentation were the main challenges identified. Each of these elements was ranked based on their effect on the efficiency of HACCP (Kassa et al. 2010).
There have also been reports by Prianka et al. (2012)that lack of regulations or inadequate legal requirements, attitude, financial constraints and lack of competence were major challenges in the HACCP implementation in organizations. The practical experience has also demonstrated that to successfully install, verify, develop and monitor HACCP system effectively requires individuals and organizations to overcome the complex combination of technical, managerial and organizational hurdles which impede HACCP implementation. Getachew (2010) indicated that even the well equipped and largest food manufacturing companies that have significant resources, management skills and technical expertise also face the challenge of implementing HACCP, on the other hand, the small organization often consider the HACCP implementation challenges as potentially insurmountable.
In particular, Giritlioglu et al. (2011) noted that HACCP implementation in hospitals also faces the same challenges faced by other operators of food businesses. In essence, lack of training, inadequate finances and inadequate tools and equipments were reported as hurdles in hurdle implementation in hospitals. Besides, various food product range also limit efficiency of HACCP since there are many CCP which must be considered. Moreover, the systems involved in hospital food service is very complicated than other production processes. Grintzali and Babatsikou (2010) noted that in their study, only 4 hospitals out of 99 hospitals established a system for HACCP implementation. In addition, survey by Kassa et al. (2010) involving 27 hospitals reported HACCP implementation in half of sampled hospitals.
Food consumption changes, emergence of microbes, modern lifestyles, increase in travel and global trade as well as the frequent changes in food production technologies have been found by Kokkinakis et al. (2011)to be challenges of HACCP implementation. In the small businesses, the challenges to HACCP implementation were mentioned to include financial constraints and poor resources. In addition, some managers or owners do not believe that HACCP are practical or effective for businesses. Sentiments of Martins et al. (2012) were that this could be because such managers may have insufficient knowledge about safety requirements for businesses involved in food product manufacturing and thus they do not educate their staff as well. It is important for organizations to consider their need for HACCP training and involve competent educators who can change the employee attitudes and their performance in terms of implementing HACCP. An increase in food handler knowledge may not necessarily reflect in their behavior of handling food which depends on individual attitude. Hence, poor attitude towards HACCP implementation among food handlers is also a significant challenge in implementation of the HACCP guidelines.
1.4 Research Questions
The following were research questions assessed in the study:
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