A growing population finds a health care system ready to meet: its needs On the rise

 

Oman boasts a universal health care system, which offers free primary health care to Omanis and subsidised care for the foreign population of the sultanate. Over the past four decades greater access to medical facilities and doctors has greatly improved the lifespan of Omani citizens, who have seen their life expectancies increase from 49.3 years in 1970 to roughly 76 years in 2016.

However, the cost of the public health care sector in Oman is increasing steadily, and future public health care investment will need to continue to rise in order to match this demand. This could prove challenging in the years to come, and may see the private sector tasked with playing an increasing role in supplying medical treatment and care in the sultanate. Indeed, there are already signs of this happening. Talk of a national insurance scheme or the introduction of nominal fees for doctor visits could help the Ministry of Health (MoH) continue to offer free universal health care, as well as greater access to specialised treatment.

OVERSIGHT: The health care sector in Oman is overseen by the MoH, with Ahmed bin Mohammed bin Obaid Al Saidi serving as the current minister of health. Following his predecessor, who focused on expanding access to health services across the sultanate via investments in new health care facilities, Al Saidi has prioritised the elevation of quality in the sector. This has led to a strong focus on signature projects that should add high-end facilities to the existing health care landscape.

In addition to the MoH, the Central Quality Control Laboratory is responsible for ensuring the quality, safety and efficacy of pharmaceutical products in the country, while the Oman Medical Specialty Board, established in 1994 through collaboration between the MoH and Sultan Qaboos University (SQU), is the supervisory body for all postgraduate medical training programmes in the sultanate.

INFRASTRUCTURE: Oman’s population is steadily rising, and by August 2016 it stood at 4.5m, with roughly 2.5m Omani citizens and 2m foreigners, according to data from the National Centre for Statistics and Information (NCSI). This was up from a total population of 4.2m in August 2015.

This rise in the sultanate’s population is putting additional pressure on the health care system. In 2015 the MoH expanded the number of primary health care institutions under its management to 235 in order to continue to provide comprehensive primary health care to everyone in Oman. These included health centres, facilities and local hospitals managed by the MoH. It is estimated that upwards of 95% of the country’s population now live within five miles of a medical centre.

Oman has 69 hospitals, with a total of over 6400 beds, which works out to roughly 15.5 beds per 10,000 people. This is a dramatic increase from the two hospitals that existed when Sultan Qaboos bin Said Al Said came to the throne in 1970. However, according to a 2016 health care industry report issued by Alpen Capital, hospital bed requirements in Oman are forecast to grow at an annual rate of 3.1% over the next five years, reaching a demand of more than 7600 beds by 2020.

New hospitals, medical centres and clinics are expected to meet much of the anticipated increase in demand, with a host of new facilities in the pipeline. These include major projects like the $1.5bn Sultan Qaboos Medical City (SQMC) in Muscat, which comprises five hospitals as well as other medical facilities,along with the $1bn International Medical City (IMC) in Salalah, which is billed as an integrated medical tourism project with 530 beds located in a specialty care hospital, organ transplant centres, research and development (R&D) complexes as well as a health care resort. Once all of these facilities come on-line they should go a significant way towards easing the pressure on existing facilities and cutting patients’ waiting times.

RISING COSTS: Oman spends the equivalent of 2.6% of its GDP on health care, according to World Bank development indicators, slightly lower than the GCC average. This proportion has not changed significantly number in recent years; between 2000 and 2010 the average amount spent by Oman on health care in a given year was 3% of GDP.

At present, more than 80% of Oman’s total health expenditure comes from the MoH, which had a budgetary allocation of OR1.3bn ($3.4bn) in 2016, down from OR1.6bn ($4.2bn) in 2015. This sum represented roughly 11% of the entire budget of Oman, which was OR11.9bn ($30.9bn) in 2016.

However, Oman’s health care expenditure is expected to rise by 12.9% a year until 2020, according to Alpen Capital, which forecasts that total health care outlays will hit $4.3bn by 2020, up from $2.3bn in 2015. Health care spending was estimated to be $2.6bn in 2016, with outpatient care accounting for $1.6bn and inpatient care $1bn.

The Alpen Capital report cautioned that with low global oil prices, government budgets in GCC countries could come under increasing pressure. This proved true as low oil prices have led the government to cut health care spending in 2017 to just OR613m ($1.6bn). The cuts in health are part of countrywide austerity measures, which saw 2017’s budget estimated at OR11.7bn ($30.4bn).

At a September 2016 Oman Health Exhibition and Conference held at the Oman Exhibition Centre, a number of health industry insiders expressed concerns over rising health care costs in the sultanate, which are impacting, among other things, the ability of smaller clinics to continue to operate. Speaking to the Times of Oman, Sanjay Dalal, the manager of a clinic in Muscat, said high rents, unnecessary quality control standards by the ministry and health insurance are the major reasons for the rise in health care costs. “Smaller clinics face a very difficult time with current trends and have to put the burden on their patients to stay in operations. High rents with quality standards in line with large hospitals are an unfair expense for smaller clinics,” he said.

MODERN TECHNOLOGY: Oman has been pushing for the implementation of modern technological solutions to boost efficiency in the health care sector and ultimately keep costs down and cut waiting times. This has been notable in the digitisation of the country’s medical records, with 86% of all government hospital and health care facilities having been linked electronically to a central database by the beginning of 2015.

In early January 2017 the MoH began implementing a cashless transaction system at public health care centres, with both primary clinics and government hospitals now accepting card payments. This is part of a larger move towards a more comprehensive e-government platform and a more streamlined health care system. While there is no current deadline set for a move towards a completely cashless payment system, with many Omanis still preferring cash transactions, in the long term that is likely to be the overall target.

Speakers at the Oman Health Exhibition and Conference in September 2016 also suggested that embracing the use of big data could be an effective way for the sultanate to further improve its health care system, helping to better predict diseases based on an individual’s genes or lifestyle, among other epidemiological benefits.

According to Samra Al Barwani, director of risk management and patient safety at the MoH, there is a system in place for reporting adverse events and near misses or events at most government hospitals. However, the system is still in the process of becoming more integrated when it comes to data aggregations. The Directorate General for Quality Assurance Centre is working on centralising data collection covering all primary, secondary and tertiary health care sectors.

PLANNING AHEAD: Since 1976 Oman has gone through three distinct phases of development when it comes to the health care sector. The first phase, which ran until 1990, was directed at building the country’s health infrastructure almost from scratch. The second phase, which ran from 1991 to 2005, focused on the development of various components of the health system, with plans developed at a central, regional and local level. The third phase, which began in 2005, is now targeted at providing comprehensive health care coverage, and using high-level strategic planning to pinpoint and address the specific needs of the sector.

In 2014 the Omani government released a longterm plan for the country’s health care sector, entitled Health Vision 2050. The plan, which the World Health Organisation (WHO) says serves “as a model for strategic planning in health”, envisages large-scale investment in the health care sector to further create a well-organised, equitable, efficient and responsive health system.

With Oman’s population expected to double by 2050, Health Vision 2050 should establish up to 10,000 health centres to meet the demands of a growing and increasingly urban population.

In the first half of 2014 the WHO, in close partnership with a team from Oman that reviewed the key strategies of Health Vision 2050, helped facilitate a number of missions, covering health technologies, nutrition, primary care and professional development in order to provide recommendations to strengthen the strategic vision in each of the areas.

In September 2016 it was announced that the MoH was planning to introduce a national certification for patient safety and quality control in health care facilities. The MoH, working with the WHO, will award certificates to hospitals related to their overall level of patient safety practices, with guidelines set for hospitals to reach specified targets in patient safety. While not mandatory, the process will help reduce patient risk. It also hoped aims to foster greater trust in health care facilities within Oman and reduce the number of people going abroad for health care treatment.

FIVE-YEAR PLAN: In the short term, the country’s ninth five-year plan, which runs from 2016 to 2020, focuses on the building of integrated medical cities for the health care sector, investing further in human resource development, restructuring medical education and significantly boosting health care spending. “We are aware that the ninth five-year plan coincides with changing economic conditions and falling oil prices, but we are relying on the results of the previous achievements and the well-qualified human resources,” Al Saidi, minister of health, told the Oman Daily Observer newspaper in a statement. “Besides, the strategies of the ninth five-year plan are capable of coping with the rapidly changing conditions, as these strategies focus on finding sources of funding and investments so as to preserve the achievements while pushing ahead for more efficiency and productivity.”

In June 2016 the MoH announced it would continue to push for more decentralisation when it comes to the country’s health services. Under the decentralisation policy, which has been in the works since the 1990s, management and responsibility for regional health services has been transferred to officials working at the wilayat (province) level. As such, 10 regional general health directorates have been given administrative control over facilities in their areas, as well as control over the distribution of health care finances, and some 2000 hospitals became self-administering.

HEALTH ISSUES: The health of average Omanis has improved drastically since 1970, when someone born in Oman 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. By 2014 the under-five mortality rate had dropped to less than one in a 100 (9.7 per 1000 births, to be precise), while only 11 cases of malaria were reported in 2013 (with no fatalities). Oman has also been polio-free for over 16 years, thanks in large part to an almost 100% polio vaccination rate in the country.

While deadly infections and diseases have been successfully reduced, Oman is now contending with the rise in lifestyle diseases, such as diabetes, obesity and hypertension. The diabetes rate among Omanis has increased from 9% in 2009 to 16% in 2016, and is steadily rising. In fact, according to Al Saidi, unofficial records could elevate the prevalence of diabetes among the Omani population to 40% overall, representing a huge risk as well as a significant current and future expense for the sultanate. Part of the issue comes from the traditional Omani diet, which is high in sugar content.

The health care sector continues to largely focus on treatment rather than preventative care, with health and wellness education not prioritised to a large extent. “Diabetes and hypertension are major issues,” Abhilash S Pillai, COO at Apollo Hospital Muscat, told OBG. “A lot can be done in terms of collaboration between public and private players getting together, increasing awareness and engaging in key screening initiatives. We have a national diabetes centre, so there is awareness, but there is also a lot more to be done.”

In December 2016 Oman’s Supreme Council for Planning launched a national campaign to promote physical activity, with the physical inactivity rate standing at 37%; globally the rate is 28% among men and 34% among women. Taking the theme “Health Begins with a Step”, the year-long campaign aims to educate residents of Oman on the importance of physical activity, as well as raise awareness of available sports and recreational facilities.

According to Khalifa Al Essaei, director general of sports activities at the Ministry of Sports and head of the Physical Inactivity Team, the campaign “targets all community members, both male and female, in which the mass media as well as the social media will be used to send out clear messages”, he said at the campaign’s launch.

LOCALISED CARE: The authors of Health Vision 2050 have pointed to the need to move the treatment of non-communicable diseases and health care out of the hospitals and closer to the patients’ communities and homes, as both a means of better serving patients and reducing the burden on hospitals themselves. “Future health policies should consider providing more specialist services in community settings, developing primary care services to include diagnostics and services for people with long-term conditions, and developing community support for patients with chronic diseases,” the Health Vision 2050 report said.

Health Vision 2050 also points to the growing need for geriatric care facilities, with the number of elderly people living in Oman expected to increase five-fold through to 2050. Those over the age of 60 are expected to increase from 6.1% of the population to 13.1% over that period. “Geriatric health care clinics should be made available in primary health care facilities,” the report said. “Home care should also be considered for geriatric patients who find it difficult to attend health facilities. Home care should also be extended to the terminally ill or those with chronic long term conditions.” This change in demographics represents a significant opportunity for those looking to get involved in the sector.

PAYING FOR ACCESS: Per capita visits to health care centres in Oman are considered high, largely due to the fact that the public health care system is free of charge, which can easily clog up the system and increase costs. Out-of-pocket health care expenditure in Oman comprises just 5.8% of total health expenditure, according to the Business Times.

Some industry actors believe instituting a small, nominal fee for doctor appointments would help to reduce visit numbers. “It would be better if people paid a small fee for medical services,” Ingrid Andersson, CEO of Harub Medical Centre, told OBG. “Having a system that is completely free of charge is not sustainable, it makes people careless with their appointments and leads to long waiting times.

MAKING IT EFFICIENT: Andersson also explained that many companies operating in Oman find themselves negatively affected, because they do not know if their employees will be away for one hour or the whole day when they visit a medical centre or hospital. The system would be more efficient if people pay one or two riyals when they see the doctor, which many would be willing to do. When health care is completely free, it won’t be valued as highly and efficiency will suffer,” Andersson told OBG.

Private health insurance is available, but Andersson believes that a nationalised insurance scheme could help improve general health in the country and also help to rein in health care spending. “To have a national health insurance would be very useful,” Andersson, told OBG. “Then you can cautiously frame incentives. What we see in Oman today is that a lot of health disorders are lifestyle-induced. By having a national health insurance system in place, you would be able to incentivise people to be proactive and take preventive actions themselves, which would save money and make people happier and better off in the long run.”

A national insurance scheme would also allow for the outsourcing of specialised care to private facilities, which would enable more private clinics to be established and would stop residents of Oman from needing to go abroad to receive specialised treatment that is not currently available in the sultanate.

PRIVATE SECTOR: At present, the government in Oman owns and operates around 83.1% of hospitals in the sultanate, according to estimates, accounting for roughly 92.5% of all available hospital beds. However, with the rising cost of funding the health care sector, the Omani government has shown itself keen to increase the role of the private sector in the industry, and many believe there are strong opportunities for collaboration. “There is a great opportunity for major international joint ventures in health care in Oman, not just in the private sector, but in the public sector as well,” Christopher Evans, CEO of Burjeel Hospital, a recently opened private hospital in the sultanate, said in an interview with Muscat Daily in June 2016.“Allowing a regulated private health care sector to function alongside the public sector can significantly contribute to addressing the health care needs of both the local and expatriate population,” he added.

Most health care facilities in Oman are currently owned and operated by the government, but as increasing numbers of Omanis and expats seek private treatment to bypass long waiting lists, the number of private facilities operating in the sultanate is on the rise. Currently there are more than a dozen private hospitals in Oman, including multi-specialty facilities like Starcare Hospital in Muscat, owned and operated by the UK-based Starcare Health Systems, and United Medical’s Muscat Private Hospital.

The Badr Al Samaa chain of private hospitals includes facilities in Al Khoud, Al Khuwair, Al Tarif Sohar, Barka, Nizwa, Ruwi, Salalah and Sur, while Burjeel Hospital recently began operations in the commercial centre of Al Khuwayr in Muscat.

In April 2016 the MoH upgraded private health care provider Apollo Medical Centre to a hospital, renamed Apollo Hospital Muscat, which subsequently allowed the facility to expand its operations into new specialties, including urology, a thalassemia clinic for children, gastroenterology, and orthopaedic and bariatric surgeries. In December 2016 Apollo Hospital Muscat became the first hospital in Oman to be certified by the Infection Control Accreditation Programme.

While the MoH formally adopted the GCC Infection Prevention & Control Manual as the national reference guideline in 2010, the German qualification is considered to be of a higher standard. In 2015 the MoH recorded more than 6700 cases of communicable and infectious diseases in Oman. 

At the same time, a number of other foreign private health care providers have indicated plans to enter the Omani market or have already begun construction on new developments (see analysis), all pointing to significant growth in the private sector. “I think the private sector has a very  important role to play, and that this is a recognised fact now,” Pillai told OBG. “At least during my tenure in Oman over the last three years, I see a lot of stress by the ministry to develop private health care capabilities and infrastructure. This in my view would lead to private players evolving in scale and structure, and playing a larger role in catering to the growing health care needs of the country.”

There is also a hope that Oman could eventually bring in medical tourism; however, those involved in the sector feel that priorities lie elsewhere. “Medical tourism will typical follow, but first we need to cater to local needs. Once we start getting established of course there is a great opportunity to cater to outside patients,” Pillai added.

TERTIARY CARE: There is also a need to improve available tertiary care in the sultanate, as well as to extend its geographic reach. According to Al Saidi, analysis that took place as part of Health Vision 2050 showed the need for greater tertiary care, as well as its potential benefit for Oman and for those living in the sultanate. “This would not only have financial implications, but social implications. It would reduce health expenditure made by patients seeking care outside the country and would provide better care to patients near their homes and within their families,” he told Singaporean newspaper the Business Times in an interview in November 2016.

In November 2016 the Omani government announced plans to establish an investment fund to support the construction of an advanced tertiary health care and medical education centre at Barka, near SQMC, building on the same public-private partnership (PPP) model SQMC was developed with.

One tertiary care facility already under development in the sultanate is a 225-bed centre that is part of the OR72m ($187m) integrated health care complex in Al Hail. The facility will focus on family medicine, paediatrics, obstetrics, gynaecology, internal medicine, orthopaedics, endocrinology, neurology and physiotherapy, among other areas. The $1bn IMC in Salalah is also set to include a 530-bed tertiary specialty care hospital.

DOCTORS NEEDED: Medical training in Oman officially began in 1986, with the establishment of the College of Medicine & Health Sciences at SQU. Prior to the opening of the College of Medicine & Health Sciences, Omani students needed to travel abroad in order to pursue medical degrees and specialisation. This left the sultanate almost fully reliant on overseas expertise and medical training. Although today this balance has been significantly redressed, the country still has many doctors, nurses and other medical personnel coming from overseas to work.

With the growth in the population in recent years and the resulting expansion of the health care infrastructure, there has been a considerable increase in medical personnel. Between 2005 and 2015 the number of physicians in Oman increased from 16.7 per 10,000 people to 21.4, while the number of nurses grew from 37 per 10,000 to 46.3. Prior to 1970 there were just 13 physicians working in Oman, each serving more than 50,000 people on average. Still, with further growth needed in the health care sector, Oman continues to require a steady stream of new doctors and health workers, whether from Oman or abroad. The government has identified this issue in the past and worked to address it.

LOOKING CLOSER TO HOME: The MoH has placed a strong emphasis on greater Omanisation among health professionals working in the public and private sectors, with the last five-year plan, which ran from between 2011 and 2015, identifying the shortage of Omani health care workers as the most significant challenge facing the MoH. In 2012 only 29% of the country’s doctors were Omani nationals. However, the rate has since risen to 35%, according to the MoH. This represents steady progress, however, it is clear that more needs to be done.

With Oman estimated to need an additional 7000 doctors by 2050, there is an opportunity to progressively increase the number of native-born physicians. The ministry has made good progress in the Omanisation of other sectors of the public health care industry: between 2010 and 2015 the total number of health care workers employed by the MoH rose by 10% a year to reach 41,000, an increase of 53% from 26,000 in 2010. Across the health care sector the Omanisation rate reached 68% by the end of 2015; Omanis also filled 84% of all pharmacist jobs in the sultanate, according to Al Saidi.

When it comes to specialised areas of medicine, however, Oman will have to continue to rely on foreign doctors and expertise for the near future at least. Nonetheless, greater attention is being paid to educating Omani medical staff in advanced specialties so they can be prepared to eventually take over. “Foreign expats with the right qualification and experience in the medical field are welcome and needed in Oman. Omanisation in the field of health is necessary but needs to be taken with the proper training and education,” Al Saidi told OBG.

Some of those working in the health care sector point to a need to educate more doctors and nurses within Oman. These same voices have cautioned against the government prioritising filling positions with local Omani doctors and nurses at the expense of their gaining further education abroad. “Oman could put more interest in educating more health care professionals here in Oman, because it is very expensive to educated them abroad,” Andersson, told OBG. “Also, doctors that go abroad to get diplomas, as soon as they have earned their diploma they return very quickly. It would be better if they stayed and worked for a couple of years to gain experience, but everything is paid for by the government until you have your diploma, and after that you are supposed to return and start working.”

In addition to existing medical training infrastructure, Health Vision 2050 called for the establishment of a health school for postgraduate training for paramedical personnel, as well as postgraduate training in areas such as clinical pharmacy, occupational therapy and nutritional science, along with the establishment of a School of Public Health. These developments could spur growth in additional areas of the health care sector.

DOMESTIC MEDICAL SUPPLIES: The Omani government currently spends an estimated OR120m ($311.7m) a year on medicines, with more than 93% of medical supplies, including laboratory, surgical equipment and pharmaceuticals, needing to be imported from abroad. There is, however, an ongoing push to establish more pharmaceuticals operations in Oman. In fact, Health Vision 2050 stated that establishing local drug manufacturing, with the goal of supporting self-reliance in the coming years, was “a must and not an option”.

“The MoH is looking for companies to produce specialised products, ones that are very expensive to buy from outside Oman,” Shorab Khanduri, head of sales and marketing at National Pharmaceutical Industries, told OBG. “In the next 10 years imports will be in the range of 70-80%, but not less than that. Around 20-30% will be developed in Oman, which is a big reduction from the current situation. In Oman right now there are only two pharmaceuticals manufacturing plants.” However, Khanduri says that growing the industry will require investment in R&D. “There is a huge opportunity for developing in terms of local technical capability,” he said. Authorities in the country are also looking to local manufacturers to provide the health care system with 100% of its needs when it comes to more basic medical items, such as surgical gloves and gauze.

In recent years the MoH has cut the price of thousands of prescription drugs, with the hope that by lowering the cost of prescriptions fewer patients would opt out of completing their full treatment. In October 2014 the prices of 1400 drugs were reduced, followed by the prices of 1180 drugs in June 2015. The MoH announced plans for a further round of price cuts, comprising 4246 different drugs, in November 2015, but subsequently postponed implementation.

While drug prices in Oman are considered among the highest in the GCC region, there are concerns that these price reductions could negatively affect distributors, with some pharmacy owners welcoming the delay. One reason drug prices are high in Oman is that there are a limited number of drug manufacturing facilities, especially those producing generic drugs. This has impacted prices across the industry and helped to drive up prices for many prescription drugs in the country.

The cost of production in the sultanate is very high compared to outside countries,” Khanduri told OBG.” If you reduce prices, local manufacturers are hit, so you need to reduce the cost of production in Oman before lowering prices if you want to establish a pharmaceuticals industry.”

HEREDITARY CONCERNS: Among GCC countries it is traditional practice to marry within one’s tribal grouping, and often within one’s extended family as well, leading to higher risks of health problems related to consanguinity.

Statistics show that in Oman 24% of marriages take place between first cousins, with 12% between second cousins and roughly 20% involving couples that come from the same tribal groups. These couples have a higher risk of passing on hereditary genetic disorders, which could lead to health issues for their offspring and additional cost burdens for the health care system as a whole.

The Oman Centre for Community Genomic Studies, in partnership with SQU and two institutes based in London, has been involved in a series of studies on the issue, in part to raise public awareness. In November 2013 it was joined by the National Genetic Centre in Muscat, which offers free screening for common genetic disorders, targeted at higher-risk couples before they get married.

In 2015 the centre started a 16-month long genetic counselling course for medical professionals, focused on preventing genetic disorders and working with those affected to improve their lives.

OUTLOOK: While a number of serious challenges remain, notably when it comes to rising costs, Oman’s health care sector is built on solid foundations and continues to offer high-quality care to Omanis and expatriates alike. Oman still relies heavily on foreign medical expertise, as well as imported medicines and equipment, but serious efforts are under way to change this. Looking forward, the growing importance of the private sector, as well as steps taken towards preventive care, will lead to plenty of opportunities for private providers and foreign medical professionals. The development of the domestic pharmaceuticals industry, while challenging, could also offer a host of new opportunities.

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