Foreign expertise and investment flow as Oman expands health coverage

Oman’s health sector has undergone a significant expansion over the past four decades. Underpinned by a series of five-year development plans, there has been sizeable government investment in facilities and services. At the same time, the sultanate is keen to increase the private sector’s role in health care provision, particularly in the treatment of lifestyle-related diseases, which are on the rise as the population ages and grows richer. Oman has thus enlisted foreign medical expertise and investment to help meet its goals for the health sector and improve outcomes for its citizens.

Historic Changes

It is difficult to overstate the transformation that the sultanate’s health care system has witnessed during the past 45 years. The average Omani born in 1970 could have expected to live for less than 50 years and would have had a one in five chance of dying before his or her fifth birthday and a one in three chance of contracting malaria in his or her lifetime. Up until 1970, when Sultan Qaboos bin Said Al Said came to power, the country had only two hospitals.

Since then, the quality of and access to health care has improved vastly. As of 2014, life expectancy was 76.6 years, and the under-five mortality rate was one in 100 (9.7 per 1000 births), according to statistics from the Ministry of Health (MoH). Only 11 cases of malaria – and no deaths from it – were reported in 2013.

The country had 67 hospitals with a total of 6322 beds in 2014, offering general and speciality care in both public and private settings. There are more major projects in the pipeline. If all goes to plan, the health care landscape will have significant further capacity by 2017.

Improved Outcomes

The improvement in health outcomes is a result of a number of different factors. First and foremost among these is the emphasis that the government has placed on ensuring access to basic universal health care for all Omani citizens, which has been a priority since Sultan Qaboos ascended to the throne in 1970. In addition to building up the physical infrastructure of the health care sector, the government has also brought in the foreign expertise needed to expand and improve the skills of the country’s home grown medical professional workforce.

All Included

The government provides universal health coverage for Omani citizens and subsidised care for expatriates. State health care is free of charge for Omanis, but fees are incurred at private facilities, many of which are used by foreign residents. Most health facilities are owned and operated by the government, but efforts are currently under way to increase private participation and investment in the health care sector.

Expatriates make up almost half of the total population of the sultanate. At the end of September 2015, Oman’s population stood at 4.3m, of which Omani citizens made up 2.4m and expatriates 1.9m, according to statistics from the National Centre for Statistics and Information (NCSI).

Providing universal health care to a mixed population of Omanis and expatriates has been a challenge, one that is compounded by the dispersed nature of the population and the country’s large landmass and rugged terrain. But officials are nevertheless committed to offering quality care, even in sparsely populated rural areas.

As the minister of health, Ahmed Mohammed Al Saidi, told OBG in late 2015, “I have health centres serving populations of less than 700 individuals.”

Capacity Building

Universal health care is costly, however. The MoH is responsible for about 82% of total health expenditure in Oman, the highest percentage of any such ministry across the GCC. As a result, the ministry is looking for ways to finance its sector without sacrificing outcomes.

The 2015 national budget allocated OMR1.6bn ($4.1bn) for health spending – equal to some 11.3% of the state’s total expenditure. The funds will go towards building 11 new hospitals, refurbishing existing medical facilities and training medical personnel, among other activities. The government is emphasising durability as well as quality in its budgetary allocations for the health sector.

This goal is being underpinned by planned mega-projects, with the $1.5bn Sultan Qaboos Medical City (SQMC) as the flagship development. When completed in two years’ time, SQMC will contain five hospitals, an imaging centre and laboratory facilities. Another major project is the $1bn International Medical City (IMC), an integrated medical tourism centre in Salalah due to open in 2016 and consisting of a 530-bed tertiary speciality care hospital, a research and development (R&D) complex, diagnostic and organ transplant centres, and a health care resort. These facilities will help cut waiting times and increase the total number of medical staff to serve Omanis and other residents, while also acting as magnets for the growing medical tourism sector (see analysis).

In The Plan

The new hospitals, centres and clinics in the pipeline all support Oman’s Health Vision 2050, a long-term strategy issued in 2014 that aims to support the government’s goal of having a healthy and productive population through a “well-organised, equitable, efficient and responsive health system”. The vision, which the MoH has been tasked with implementing, encompasses health planning for the sultanate on a very detailed level, with close analysis of the current health system and how future cross-sector collaboration may improve health outcomes.

The World Health Organisation (WHO), in its 2013 “Research for Universal Health Coverage: World Health Report”, commended Oman for its health research system governance, saying that of 10 countries in the WHO eastern Mediterranean region, only Oman met all eight indicators for good governance practices.

Health Vision 2050 is also expected to lay the groundwork and act as a guide for the country’s next five-year health plan (its ninth), which will run from 2016 to 2020. The current five-year plan, which covered 2011 to 2015, aimed to carry out a decentralisation of the health care system, a policy that has been in the works since the 1990s.

Under decentralisation, the control of and responsibility for regional health services was transferred to local officials at the wilayat ( province) level. This led to the formation of 10 regional general health directorates that were empowered to authorise the distribution of finances and maintain administrative control of local facilities. Then, in the year 2000, further decentralisation saw hospitals become self-administering.

Omanisation

Along with the decentralisation of health and hospital services, the MoH has placed an emphasis on advancing the Omanisation of the MoH’s human resources. The 2011-15 Health Plan identified a shortage of Omani staff as the main challenge facing the MoH, and one that has been exacerbated by the rise of new health issues (such as non-communicable diseases) that call for highly trained specialists with expertise in specific fields.

With current staff levels for medical specialists below demand, greater attention is being paid to training and retaining qualified Omani medical staff with experience in advanced specialties. Indeed, only about 29% of the country’s doctors were Omani nationals in 2012.

“We are experiencing a vacuum in the labour market for skilled medical professionals,” Abhilash S Pillai, chief operating officer of Apollo Medical Centre, told OBG. “Oman’s health care proficiencies lie in technology and skills;   if the sector is to grow we need to create an ecosystem which incentivises and attracts skilled doctors.”

According to reports published in the local press, MoH studies estimate that Oman will require 7000 more doctors by 2050. In the meantime, the country will need to fill the gap by hiring staff from abroad. It is expected that majority of the 400-500 employees at the new SQMC hospital will be Iranian, for example.

Technical Solutions

Along with the new hospital complexes and the Omanisation of its workforce, technical solutions are considered key to maintaining the correct balance between health expenditure and outcomes. One of the first such technical solutions to be implemented has been digitising the country’s medical records.

As of January 1, 2015, 86% of government hospitals and health facilities had been electronically linked to a central cloud-based database. The database, which registers patients by their civil numbers, enables all government hospitals to share patients’ health files and histories with each other.

This information-sharing platform is expected to help the MoH reduce costs while boosting efficiency, such as by avoiding duplicate diagnoses. It will also assist with data collection and analysis. For the first time, medical and governmental officials will be able to monitor and report on health care data for quality and safety purposes. Private hospitals also plan to add their patient files and records to the database in the near future.

Medical Supplies

Another issue affecting the sector is the fact that Oman imports more than 93% of its medical supplies, including essential laboratory and surgical equipment and pharmaceuticals. A ministry official told the local press in June 2015 that the sultanate’s dependence on imports threatens “the sustainability of Oman’s health care system” and that the ministry is considering alternative funding sources, such as taxing pharmaceuticals, tobacco and alcohol sales.

Pharmaceuticals have been a particular topic of debate within the industry in recent years, as the government has worked to lower prices for medications with an eye to reducing overall health care costs, with mixed results.

Drug prices in Oman, and indeed in the broader GCC region, are considered to be high by global standards. This is due at least in part to factors including the limited number of drug manufacturing facilities in the region, GCC laws requiring that local agents import pharmaceuticals, and a lack of availability of generic medicines.

Over the past two years, the MoH has reduced prices on 2600 medications – almost 90% of all pharmaceuticals sold in Oman. The intention was to lower drug costs to reduce the number of patients failing to fill prescriptions or taking incomplete dosages, as well as to cut insurance costs. However, the recent price reductions have prompted some pharmaceuticals manufacturers to suspend imports due to concerns over profitability. As a result, hospitals and pharmacies have been unable to procure certain medications, sometimes for months at a time.

The issue of pharmaceuticals pricing is likely to remain a matter of discussion going forward. V T Saileswaran, managing director of Apollo Hospital Muscat, told OBG, “Recent pricing measures coupled with existing and new players expanding their health care capability will ultimately improve access to health care.” However, he added, “At the moment, we have a struggle between cost and care, whereby insurers and hospitals do not agree on prices. More competition and medical services will help to rectify this situation.”

Private Sector Involvement

Given the remarkable progress that has been realised in Oman’s public health care sector, the MoH believes that similar strides can be made by encouraging foreign investment in the industry, with the aim of improving the current system. This includes, but is not limited to, transferring knowledge and skills from abroad that are currently lacking in Oman.

In addition, the sector is expected to benefit from the entrance of new private sector players that will compete with the public networks on the basis of quality, to the benefit of both.

“What will move the private sector along now is to follow the UK model, where the National Health Service contracted out patient services with growing waiting times to the private sector,” John Clarke, director of Muscat Private Hospital, told OBG. “That reduced the burden on the government to provide health care and developed the private sector’s competencies.”

Investment

Indeed, as Oman’s health care sector begins to diversify and expand into the private sphere, several new investment opportunities for foreign investors are becoming visible on the horizon. The SQMC complex in Muscat, for example, will be a mixed public and private sector system.

Currently, there are 11 private hospitals in Oman, two of which are multi-specialty facilities accredited by the Joint Commission International: UK Starcare Health Systems’ Starcare Hospital in Muscat and United Medical’s Muscat Private Hospital. At Al Azaiba, in Muscat, Burjeel Medical Centre acts as a primary health care facility hosting specialty clinics such as diabetes care, neurology, paediatric and sleep medicine.

In addition, the Badr Al Samaa chain of private hospitals has facilities in Ruwi, Al Khuwair, Al Khoud, Sur, Barka, Al Tarif Sohar, Salalah and Nizwa, offering medical services to the corporate sector and the general public. The firm has more than 850 corporate clients, including HSBC, Oman LNG, Oman Air and Bank Muscat.

“We are keen to promote hospitals in the private sector,” Sayyid Sultan bin Yarub Al Busaidy, advisor for health affairs at the MoH, told the local press in late 2014. “Any plans that can add momentum to the health sector’s progress are welcome. We want all small clinics to grow into hospitals.”

Insurance On The Rise

The development of the private health care sector has helped to ease some pressure on the public system. Waiting lists for surgery and other procedures at public hospitals are among the reasons cited by Omanis for choosing private treatment at home or travelling abroad for care (see analysis). A recent study found that Omanis accounted for almost 50% of all patients seeking care at the sultanate’s 11 private medical facilities. The increasing number of Omanis receiving private treatment has seen take up of medical insurance grow as citizens seek cover for costs incurred at private facilities.

Medical cover has seen healthy growth in the past few years, as have premiums. Gross health insurance premiums rose by 34% in 2014 and 32% in the first half of 2015, from OMR47.96m ($124.2m) to OMR63.07m ($163.3m), according to a report issued by Oman’s Capital Market Authority (CMA). “Life group and health insurance achieved the highest ratios in growth in the first half of 2015, increasing by 55% and 54%, respectively, compared to the same period in 2014,” the CMA said in a statement. It added that Omani companies such as National Life and General Insurance Company, Dhofar Insurance, Oman United Insurance and Al Ahlia Insurance currently comprise the largest insurers in the country (see Insurance chapter).

Hereditary Health

As a result of long-standing cultural practices regarding marriage, GCC countries face health problems associated with consanguinity. Oman is no exception in this regard, with statistics showing that nearly a quarter (24%) of marriages occur between first cousins, 12% are between second cousins and 20% are between couples from within the same tribal grouping. Such couples are at a high risk of passing on sometimes-fatal recessive genetic disorders.

“Every population has genetic disorders, so in themselves they are not peculiar to Oman,” Salma Al Harassi, a laboratory expert at the National Genetic Centre, told local press in late 2013. “However, one of the main ways for propagating these disorders has been found to be through consanguineous marriages and, in our country, 45-54% of marriages are familial,” she said.

To boost public awareness, research involving extensive molecular studies has been taking place at the Oman Centre for Community Genomic Studies in collaboration with Sultan Qaboos University in Muscat, St. George’s Hospital in London and University of London. Additional research is being conducted at Oman’s National Genetic Centre, which opened in November 2013 and will soon offer free screening for certain common genetic disorders, with an emphasis on identifying high-risk couples before they marry and begin families.

Outlook

While Oman’s health care sector still faces sizeable challenges, the government has made major strides in recent years in its drive to supply free quality basic health care, and the sultanate is not stopping there. It is pushing ahead with every new medical centre it introduces, stressing the need for excellence in all areas.

However, the MoH also recognises that much of what it aims to achieve will require outside assistance, and has it therefore been welcoming to foreign investment, private hospitals and expatriate medical professionals. If it is to achieve greater Omanisation of its health care system, however, it still has a long way to go. Educating a cadre of medical professionals, especially specialists, is thus foremost on its list of priorities, with its efforts in this area creating a number of opportunities for both investors and health care staff.