Vital signs: Massive investment into the sector has resulted in vastly improved health indicators

The rapid expansion of health care facilities in Oman is one of the most visible results of the modernisation programme enacted by Sultan Qaboos bin Said Al Said on his accession to power over four decades ago. In 1970 just two 12-bed hospitals and 10 clinics served the needs of a population with a life expectancy of only 49 years. Massive investment over the intervening period has resulted in a public health care system with extensive facilities distributed throughout Oman’s five regions and four governorates, and a significant improvement in the nation’s vital statistics.

Improvements And Setbacks

As of 2010, the most recent year for which the Ministry of Health (MOH) has published such data, life expectancy at birth had risen to 70.8 for Omani men and 76.2 for women, while infant mortality rates had improved from the 118 per 1000 in 1970 to 10.2 per 1000 over the same period.

Improvements in infrastructure and treatments have enabled the government to almost eradicate communicable diseases, such as measles, malaria and typhoid, which had hitherto remained stubbornly prevalent within the population. However, as the sultanate’s economy grew exponentially on the back of widespread reform and Omani lifestyles were altered by private car ownership and higher calorie intake, non-communicable diseases have emerged as a new threat to public health. By the MOH’s estimation, some 15% of the population suffers from diabetes while 25% is clinically obese. The modern health care sector, having achieved much, is now faced with a new set of challenges.

Structure

Citizens enjoy free access to one of the region’s most extensive networks of public medical facilities, which are operated by the MOH according to a three-tiered system. Primary health care is delivered largely through 150 health centres and extended health centres distributed throughout the country. Services offered at this level include mother and child treatment, the prevention of common ailments, and education and awareness about salient health issues. Some centres maintain a small number of beds (145 nationally), mostly for maternity care and observation in areas where patients would otherwise have to travel large distances. Each region also has one regional hospital and a number of wilayat (sub-regional) hospitals, through which secondary care is delivered. These referral institutions provide a wide array of secondary services (both ambulatory and in-patient) in fields such as general medicine and general surgery, cardiology, and obstetrics and gynaecology, among other fields. Some secondary institutions may also provide a number of primary health care services for patients within their catchment areas.

Tertiary care, sometimes referred to as super-speciality care, is delivered via the national referral hospitals: the Royal Hospital, Khoula Hospital, Ibn Sina Hospital and Al Nadha Hospital. Sultan Qaboos Hospital, although retaining its autonomy, has limited tertiary services and therefore supplements the main tertiary network. Each of the referral hospitals operates specialist facilities, such as the Royal Hospital’s oncology unit, while Ibn Sina is dedicated to psychiatric services.

The Royal Hospital, thanks to its position as regional directorate-general, is granted the status of apex institution within the MOH system, while the other national hospitals retain a degree of autonomy as they operate within the purview of the Directorate General of Health Services of Muscat Governorate.

Facilities like these, which are not run by the MOH, are still integrated into the ministry’s referral chain. In total, therefore, the public health care system comprises of 50 hospitals and 176 health centres (including extended care health centres) run by the MOH, as well as five hospitals, 45 dispensaries and primary health care centres operated by other ministries and agencies. In total there are 5847 beds per 10,000 people.

Private Practice

As well as its public health care system, Oman is home to a rapidly expanding private sector. “Health care in Oman is going through a transitional stage,” said Nigel R Weale, project director and Oman country manager at United Medical Group, which runs the Muscat Private Hospital. “Certainly the private sector landscape looks much different than it did five years ago, as there are more facilities and treatment options from which patients may choose.”

In 1995 the sultanate had just one private hospital with a total of six beds, compared to the current total of seven private hospitals with a combined bed capacity of 279. The largest of them is the Muscat Private Hospital, a 72-bed facility established in 2000 that has out-patient and in-patient services across the major specialties, which include a diagnostic centre with CT scanning and MRI capability. The Badr Al Samaa Group, launched by a number of Omani investors in 2002, is the largest private health care group in the sultanate, operating eight hospitals and polyclinics in population centres such as Al Khuwair, Sohar, Salalah, Al Khoud, Barka, Sur and Nizwa. More recent arrivals to the market include the New Life Healthcare Centre, which launched in early 2011 and focuses on genetic research, the Starcare Hospital, which opened in April 2011 by the UK-based Starcare Healthcare Systems, and the Sagar Polyclinic, also launched in 2011 as a joint venture between Oman Holdings International and India-based Sagar Hospitals. Meanwhile, more Indian investment into the Kerala Institute of Medical Services has resulted in a new 50-bed facility in Muscat.

In total, Oman’s private hospitals have added 279 beds to the national total, bringing it to over 6000, but it is in the polyclinic segment that the private sector has made the most impact: today, some 814 private clinics operate in Oman, according to MOH data, compared to 471 in 1995. The pharmaceutical and dental sectors are also dominated by private players – 74% of pharmacists operate from the 400 private pharmacies distributed across the country, while 60% of qualified dentists work within the private sector.

New Infrastructure 

Both the public and private health care systems continue to expand on the back of increasing demand for quality health care services in Oman. In the public segment, the new Sultan Qaboos Hospital project in Salalah is to add 723 beds to the national total. Construction on the new facility began in 2012, and, once completed, the five-storey hospital will include facilities for paediatric emergency services, general medicine and surgery, orthopaedics, psychiatry, neurosurgery and radiology. A second major public hospital addition is currently at the planning stage: the proposed Muscat General Hospital will be established near the international airport and is intended to act as a secondary hospital servicing the capital region – home to a fifth of the Omani population. Although no time frame has been established for its development, fiscal provision for it has been made in the nation’s current economic five-year plan (see below).

Other ongoing public sector projects as of 2012 include an expansion of the oncology centre at Muscat’s Royal Hospital, as well as an expansion of its cardiac centre to incorporate 160 beds, four theatres and four labs. The MOH also plans to construct a number of new facilities in Dhofar governorate by 2015, including replacement infrastructure for the hospitals at Tiwi Ateer, Al Mazyounah and Al Haq.

Further Development 

Private sector development in Oman continues apace. In February 2012 the Saudi-based Apex Medical Group announced the successful conclusion of a market, operational, regulatory and feasibility study for a proposed Medical City in Salalah. The development will be constructed over 500,000 sq metres and will consist of a chain of multi-speciality 530-bed tertiary care hospitals, a transplant and rehabilitation centre, and a dialysis centre – all of which will be integrated with a health care resort (to be developed on land donated by the Ministry of Tourism), wellness centre, four-star medical hotel, mall and recreational facilities, patient and staff accommodation, medical and nursing colleges, and a research and development centre. The project has potential for private investment, particularly in specialised tertiary care and organ transplantation – areas identified with a growing gap between supply and demand.

Regulation And Oversight 

As the agency responsible for the provision, coordination and regulation of health care in Oman, the MOH has played a key role in the sector’s rapid development. It acts as the principal architect of health system design, develops new policies and programmes, and works with other ministries and public systems to generate favourable legislation and regulation. As well as providing in-country curative care up to tertiary level through the national referral chain, it sponsors patients to travel abroad in cases where the required facilities are not available domestically. It is also responsible for the nation’s preventative health care activity.

The MOH also acts as the drug control agency for the nation through its Directorate General of Pharmaceutical Affairs and Drug Procurement, and is responsible for the registration of drug manufacturers and products, regulation of controlled drugs and the issuance of Customs clearances for the import and reexport of drugs. Of particular importance to the largely private pharmaceutical segment, the MOH is not only responsible for the licensing of businesses and staff, but has also enacted a new drugs policy by which it retains control over pharmaceutical prices in the retail market. The wider private health care sector is also subject to MOH scrutiny via its Directorate of Private Establishments, which monitors private hospitals at the planning, construction and operational stages in terms of technical protocol and the licensing of doctors, nurses and paramedical staff. Through its publishing and monitoring of protocols and periodic on-site assessments, the MOH is therefore able to establish a comprehensive oversight of patient care across both the public and private health care segments.

Development Strategy

In overseeing the development of Oman’s health care sector, the MOH operates within a national strategy that has been outlined in a series of five-year plans since 1976. The recently completed five-year plan (2006-10) focused on, among other things, the enhancement of the primary health care level through an increase in infrastructure and services, the improvement of secondary and tertiary health care through increasing hospital autonomy and improving human resources, boosting blood services and attracting non-remunerated donors. The current five-year plan (2011-15) builds on the progress made in these areas and has established a goal to reduce mortality due to disease to the lowest international level.

It also places an emphasis on improving mother and child care and draws special attention to the provision of sanitary drainage services. Projected spending over the plan’s duration includes OR10m ($26.1m) on the rehabilitation of Sumail Hospital, OR140m ($364.85m) on the planned Muscat referral hospital, OR48m ($125.1m) on Salalah Hospital, OR55.5m ($144.64m) for the construction of new hospitals in As Suwaiq, Mahout, Sinaw, Dhalkut and Al Muziunah, OR8m ($20.85m) for new health centres in various wilayat in the sultanate and OR7.2m ($18.76m) for the construction of polyclinics in Al Kamil, Liwa, Mutrah and Nakhal. The 2012 national budget allocates a total of OR500m ($1.3bn) to health care spending, or 5% of overall spend – an indication that the government views health care as an area of great importance.

Pursuing Efficiency

While the strategy outlined by the national five-year plans focuses on capacity building and infrastructural development, the MOH has also turned its attention to seeking new efficiencies within the existing system. One way in which it has sought to accomplish this is by equipping primary health care centres (PHCs) sufficiently to reduce the pressure on the overburdened secondary and tertiary systems. For example, the ministry has identified cardiology patients as a segment that might usefully be serviced at the PHC level, so that follow-ups for chronic patients could be done at local facilities, which would be in the interests of both patients and the health system. Plans within the current five-year strategy to extend 28 new health centres across the country will significantly advance the MOH’s objective in this area.

Hospitals have also been encouraged to identify new efficiencies, and as Oman’s apex health care facility the Royal Hospital has expended significant effort in this regard. “It’s about the maximum utilisation of resources,” Dr. Kadhim Jaffer Sulaiman, the deputy director-general of medical at Royal Hospital, told OBG. “For example, we have equipment which in the past was utilised for just seven hours a day. Now we have introduced a shift system, morning and afternoons, to replace the single shift during which some machines were used previously. We have also started to use resources over the weekends and after working hours. In this way we are becoming more efficient in our overall utilisation.”

Challenges And Solutions

Continued government spending and the MOH’s efficiency initiative play a central role in addressing the challenges with which Oman’s health care sector is faced. One of the most salient concerns for the ministry’s planners is the rise in non-communicable disease brought about by increasing affluence, car usage and sedentary lifestyles. Obesity, heart disease and diabetes have all risen as Oman’s economy has expanded, and accounted for around 50% of outpatient morbidity in the sultanate in 2011, according to MOH data – up from 42.5% in 1996.

The MOH’s attempts to reverse this trend are centred on a number of projects. Screening and treatment programmes at hospitals and clinics are meant to address diabetes, from which around 15% of Omanis now suffer. There are also media campaigns aimed at raising awareness, while a National Centre for Diabetes and Endocrine Systems currently in development is due to be completed under the eighth five-year plan (2011-15). National screening programmes for other non-communicable diseases, such as hypertension, hypercholesterolemia, kidney disease and obesity have also been in place since 2007, and have benefitted from similar awareness and education programmes.

Private Sector Opportunities

Nevertheless, the fiscal burden of providing health care to a growing population has grown exponentially over recent decades, and that is why the government has taken steps to encourage the growth of the nation’s private health care sector. Government-sponsored incentives such as the granting of free land for infrastructural development, technical support and soft loans have already played a part in the rapid expansion of private health care facilities. The ability of senior medical consultants to work part-time in the private sector has also helped to sustain the growth of Oman’s private health care framework. In its Country Cooperation Strategy for the World Health Organisation (WHO) and Oman 2010-15, WHO recognises the steps taken with regard to developing a private health care sector in Oman.

Outlook

With demand for services in the public sector steadily growing, a trend most evident in increased referral queuing at secondary and tertiary hospitals, government investment in the public health care system will remain a prominent feature of national budgets for the medium to long term. However, turning to the private sector for health care investment, which the government has done on a large scale in the case of the Salalah Medical City project, points to a future in which private providers will play a larger part in care. Ensuring the anticipated rise in private sector activity interacts with that of the public sector efficiently will be one of the MOH’s primary concerns in coming years, as will the development of a supervisory framework.

Another issue likely to become more prominent in the short to medium term is the potential role of private insurance. While private health insurance is voluntary and lightly regulated, proponents of increased private care activity, as well as external agencies such as the WHO, have suggested that it might play a larger part in the development of the sector in years ahead.