SQU Med J, April 2010, Vol. 10, Iss. 1, pp. 12-22, Epub. 17th Apr 10 Submitted 27th Jan 10 Revision Req. 22nd Feb 10, Revision Recd. 24th Feb 10 Accepted 24th Feb The contemporary history of health care in Oman dates back to 1970 when the reign of His Majesty Sultan Qaboos commenced. In just about 40 years, the Omani Renaissance has brought prosperity, social and economic progress to all the people of Oman with health being a primary concern.1 Health care up to 1970 was scarce and limited. Before 1958, Oman had two hospitals; one was opened in 1935 by the American Arabian Mission and was named the Knox Memorial Hospital while the other was established in 1948. The latter received partial financing from the Sultan at the time and was staffed and administered by the British Consulate.2 People had to travel up to four days just to reach a hospital, where hundreds of patients would already be waiting in line to see one of the few (expatriate) doctors.3 At that time, only 13 physicians served the entire nation, implying a physician-population ratio of 1 per 50,000. Morbidity and mortality rates were very high. One out of every eight infants born alive died before reaching their first birthday, and one out of every five died before reaching the age of 5 years. Out of every three people in the population, one had an episode of malaria, and out of every thousand persons, thirty were reported to be infected with trachoma, eight with pulmonary tuberculosis and six with hepatitis. The average life expectancy was only 49.3 years in 1970.4 In the early 1970s, there were no laws or regulatory systems to define how institutions should function, their principles and goals, or the rights and duties of employees. Actually, the codification of government began only in the mid-1970.5 A royal decree was issued on 22nd of August 1970 to establish the Ministry of Health (MOH) in Oman.6 Directorate General of Planning, Ministry of Health, Muscat, Oman E-mail: drmoness@gmail.com أربعة عقود من التقدم تطور النظام الصحي يف سلطنة ُعمان م�ؤن�س م�شطفى ال�ش�شتاوي يف البالد جناح كبري حد اإىل حتقيقه على �شاعد والذي ال�شحة، يف ومهما �رسيعا تقدما ت�شهد ُعمان و�شلطنة عام 1970م، منذ امللخ�ص: ت�شييد بنية حتتية حديثة لتقدمي الرعاية ال�شحية. تعر�س هذه املقالة جتربة �شلطنة ُعمان يف جمال التنمية ال�شحية، وحُتلل النظام برمته، وُت�شلط ال�ش�ء على نقاط الق�ة فيه، كما حتدد الع�امل التي ميكن اأن ُيعزى اإليها جناح ُعمان يف هذا املجال. عالوة على ذلك، تناق�س املقالة اخلدمات وج�دة ال�شحية، الرعاية تقدمي ونظام ال�شحي، املجال يف العاملة والق�ى ، ُعمان يف ال�شحية الرعاية نفقات مت�يل بالتف�شيل ال�شحية وغريها من الق�شايا. كما تتناول املقالة اأي�شا هيكلية النظام ال�شحي، وال�شيا�شة ال�شحية والتخطيط يف �شلطنة ُعمان. ميكن ا�شتخدام هذا التحليل كم�شدر للمعل�مات للدرا�شات امل�شتقبلية وعملية تط�ير النظام ال�شحي يف �شلطنة ُعمان. مفتاح الكلمات: نظام �شحي، تخطيط �شحي، نتائج �شحية، ُعمان. abstract: Since 1970, Oman has witnessed rapid and significant improvements in health made possible largely because of the country’s success in building a state-of-the-art health care infrastructure. This paper presents Oman’s experience in health development, analyses the whole system, highlights its strengths and delineates the factors to which Oman’s success could be attributed. Furthermore, health care financing and expenditures, health care workforce, the delivery system, quality and other issues are discussed in detail. The paper intends also to study thoroughly the organisation of Oman’s health system and discuss health policy, and planning in Oman. This analysis could serve as a source of information for future investigation and development of the health system in Oman. Keywords: Health system; Health planning; Health outcomes; Oman. special contribution Four Decades of Progress Evolution of the health system in Oman Moeness M Alshishtawy Moeness M Alshishtawy Special Contribution | 13 The ministry was responsible for the organisation and development of the national health service, and spent 534,282 Omani Rials (USD 1,387,620) on health service development projects.3 In July 1975, the Royal Decree #26/75 introduced laws to regulate the administration. It set out the Council of Ministers and other government bodies with powers and responsibilities, in tandem with the first Civil Service Law in the Royal Decree #27/75, which outlined civil servants’ rights and duties.5 Since then, the MOH has been able to build from scratch a modern national system that offers all Omani citisens universally accessible health services free of charge. Such developments were only possible through proper health planning.6 Health Planning in Oman Since its establishment in 1971, the MOH faced great challenges to build the national health system and improve the health of the people of Oman. Therefore, the MOH developed Five-Year Health Development Plans to achieve its goals, the first of which started in 1976.7 Since then, seven Five-Year Health Development Plans have been implemented. Health planning in Oman has passed through three phases. The first phase stretched from 1976 to 1990. During this period, three five-year plans were implemented. They were mainly investment plans that aimed at building health infrastructure. The second phase covered 1991 until the end of 2005. During this period, the Fourth, Fifth and Sixth Five-Year Plans for Health Development were implemented. At the beginning of this period, a planning agency was established and health services were decentralised by establishing 10 health regions. Local health administrations were set up at the wilayat (district) level. That period of development showed an increase in the numbers of health centres and hospitals. It also witnessed the start of a number of preventive programmes, each one of them addressing a priority health or health- related problem(s).8, 9,10 With the beginning of the Seventh 5-Year Plan that started in 2006, the new phase of strategic planning started in the country.11 In the Seventh Five-Year Health Development Plan, and in the light of the identified objectives and strategic directions for health development in Oman (2006–2010), a number of priorities in different fields were defined. Following the prioritisation of important issues and problems, a framework for the Seventh Five-Year Plan for Health Development (2006–2010) was developed, through a consultative process, including ten proposed visions and the goals arising from these visions. The current Seventh Five-Year Health Development Plan (2006–2010) was developed at various levels and is monitored by outcome and performance indicators.11 The seventh plan (2006–2010) has targeted the further development of the health services infrastructure, primary care and early prevention of diseases, and community involvement through health education promotion. This focus is an effort to face the challenges of the demographic, economic and social changes that have brought with them new epidemiological trends.6 National Health Policy Oman’s health policy is committed explicitly to the global Health For All (HFA) strategy, and accordingly, has laid down in broad terms the national strategy to achieve HFA based on Primary Health Care (PHC).12 In this context, national health policy rests on several basic principles, which govern health development in Oman:13 1. Provision of comprehensive health services based on primary health care with its four components (curative, preventive, promotive and rehabilitative). 2. Equity in the distribution of health services among different population groups according to their health needs (with due consideration of the special needs of marginal and poor people, isolated villages, women, children, elderly and accessibility to health facilities). 3. Community involvement in planning and implementation of its health care aimed at developing community self-reliance for sustainable health development. 4. Inter-sectoral cooperation with other health- related sectors to ensure a positive impact on community health.11 In order to ensure accelerated health development the government adopted several well thought out strategies to implement its health policy. First, the government declared health not only as a Four Decades of Progress Evolution of the health system in Oman 14 | SQU Medical Journal, April 2010, Volume 10, Issue 1 fundamental right of the citizen, but also committed itself to the provision of public health services for free.14 The government viewed this investment not only in the context of its contribution to provide financial protection against the cost of ill-health, but also because of the pivotal role of health development in economic and social development.15 Second, priority was given to the construction of a basic health infrastructure that would be universally accessible to the whole population. Today government local health services reach 100% of urban families and 90% of rural families.16 Health services are also provided, through mobile teams, to people living in very isolated areas. Third, with insufficient manpower, the MOH worked on a two- pronged human resource policy: importing health professionals from neighbouring countries of the Middle East and South Asia to meet the immediate need of the health system and, at the same time, developing its own indigenous human resources to achieve self-reliance in the long term.17 Fourth, from the early seventies, the MOH launched a series of vertical programmes targeted at the priority health problems based on their magnitude, prevalence and intensity as well as their associated burden of diseases.18 As an example, the rapid decline of malaria from 32,000 cases in 1990 to a few hundred per annum today (and these mostly imported)19 illustrates the success of Oman’s health care strategy. Health Financing in Oman Oman finances its health system largely through the Government budget, very limited cost- sharing, limited private payments for private sector expatriates through an “employer mandate”, and very small contributions from automobile accident insurance and social security taxes on private sector employees to cover work-related injuries. Oman spends just 2.4% of gross domestic product (GDP) on health [Table 1].19 Governmental spending on health accounts for about 82.5% of total health expenditure. The government provides 93% of hospitals and about 97.3% of hospital beds. Public health services employ 77.2% of the doctors in the Sultanate, 91.6% of nurses [Table 2] and 85% of other paramedics.20 However, the private sector contribution in the health field has increased fairly rapidly over the last few decades as evidenced by the increasing numbers of private hospitals, clinics and pharmacies.4 The MOH is the main provider of health services in the country; currently MOH expenditure comprise 3.8% of total government expenditure.4 The MOH’s spending amounts to 80% of public sector spending, 47% of which is spent on inpatient care. The Ministry provides comprehensive coverage to all Omani citizens and expatriates working for the public sector and requires the annual purchase of a “health card” (for 1 Omani riyal = US$ 2.6) and a small co-payment for each facility visit (0.2 Omani riyals = US$ 0.50). The other public sector providers offer similar treatment benefits with very limited cost-sharing by those eligible to receive benefits. The MOH does provide coverage for treatment abroad, and funds treatment for around 350-400 individuals a year.21 Private spending is almost evenly split between employer-provided and out-of-pocket spending at 9% and 9.6% of total spending respectively. Types of services offered by the private sector vary: 2% for the most expensive services which are inpatients services, 59% for dental services, 51% for drugs and 19% for outpatient services.20 Table 1: Health expenditure indicators in Oman Indicators (reference year 2007) - Gross domestic product (GDP) per capita in US$ 15,229 - Total expenditure on health per capita in US$ 373 - Government expenditure on health per capita in US$ 308 - Total expenditure on health as % of GDP 2.4 - General government expenditure on health (GGHE) as % of total health expenditure (THE) 82.5 - Out-of-pocket expenditure as % of THE 10.2 - General government expenditure on health as % of total government expenditure 5.2 - Ministry of Health budget as % of government budget 4.6 Source: World Health Organization. Oman Country Profile.19 Moeness M Alshishtawy Special Contribution | 15 Health System in Oman The Sultanate of Oman has entrusted the MOH with the responsibility of stewardship and coordination of the health sector, apart from being the principal health care provider. The MOH develops health policies, strategies and health programmes and plans for the sector and also bears the preventive, curative, and rehabilitative care workload.14 Services provided by the MOH are supplemented by other government hospitals/clinics including the Armed Forces Medical Services (AFMS), Royal Oman Police Medical Services (ROPMS), Petroleum Development Oman Medical Services (PDOMS) and the Sultan Qaboos University Hospital (SQUH). While the SQU Hospital serves mainly as a teaching hospital and provides tertiary care, the other public care providers cater mainly to their own employees and their families. The private hospitals and clinics, licensed by MOH through its Directorate of Private Health Establishments, and supervised by the respective regional directorates, play an increasingly important role in providing health care in Oman.4 Thus, policies decided by government are necessarily implemented to the full since there is no real alternative to the state health care system. The MOH owns alone 49 hospitals (84.5% of the total), with 84.1% of hospital bed capacity in Oman. Four of these hospitals act as national referral hospitals, and 10 are regional hospitals providing tertiary plus secondary health care services (the last are also provided through 5 wilayat hospitals). In addition, MOH operates a network of 30 local hospitals and 167 health centers that provide PHC services.4 Table 2 presents the currently available information on the existing health infrastructure and human resources by provider. The Government has laid special emphasis on the role of private sector in the field of health care industry. It views the involvement of this sector as a contribution towards alleviating the increasing burden on the public health system, and creates an atmosphere of competition between public and private health sectors, thus improving the quality of health care provided in the country. Thus, the government has formulated a number of strategies to encourage the private sector to invest in health. The government gives financial support to the private health care sector through a law that treats them on an equal basis with those who invest in industry. They are given the same advantages and the same grants. In addition, the MOH provides the private sector with all the technical support they need to start their hospitals or clinics. Moreover, the MOH has privatised most of its support services in hospitals and health institutions, thus enabling the private sector to play an important role even for the Table 2: Health infrastructure and human resources in Oman (2008) Provider Hospitals Hospital beds Health Centers & Extended Health Centers Clinics Physicians Nurses Ministry of Health 49 4,605 167 0 3,620 9,277 Sultan Qaboos University Hospital 1 410* 1 0 329 833* royal omani Police 1 50 0 3 34 101 Medical Services of Diwan of royal Court 0 0 0 1 18 46 Ministry of Defense** 3 260 0 31 - - Petroleum Development of oman 0 0 0 9 11 36 Private Sector 4 148 0 766 1,182 941 Total 58 5,473 168 810 5,194 11,233 * Data updated from: Ministry of National Economy, Statistical Year Book 2009, Issue 37, 2009 * *Complete information currently unavailable. Note: There are in addition 364 private pharmacies. Source: Ministry of Health Statistics.4 Four Decades of Progress Evolution of the health system in Oman 16 | SQU Medical Journal, April 2010, Volume 10, Issue 1 market segment of Omani nationals, government- employed staff, and their families who are generally eligible for free health care to the extent that this is feasible. The pharmaceutical sector and a large part of the dentistry services are almost exclusively left for the private sector to cover. The government provides soft loans (and free or subsidised sites in some cases) to private entrepreneurs desirous of setting up clinics/hospitals. Ministry of Health also extends other technical support to private establishments in numerous ways.21,22 Organisation and Management Oman has a relatively small population of 2.9 million inhabitants4 who are scattered over large areas of sparsely populated settlements, many with 1,000 or fewer inhabitants.23 The MOH has made every effort to make health services easily accessible. More than 98% of the population19 now has access to primary health care services and the remaining 2% is served through mobile teams.6 The institutional organisation of the MOH is relatively centralised with three under-secretaries responsible for administrative/financial affairs, health services and planning reporting directly to the Minister.24 The MOH has, however, pursued a decentralisation process since 1990. A Directorate General of Health Services was established in each of the ten health regions (now eleven). Delegation of responsibilities, financial and administrative as well as decision-making was gradually devolved to health regions. Decentralisation has also been in effect at the wilayat (district) level since 1993.7 This approach to decentralisation has allowed the MOH to delegate necessary authorities and responsibilities to regional and wilayat levels. This has encouraged local initiatives and enabled local planning, and budget control.18 Furthermore, the wilayat health level, matching as it does the administrative level of local government, has a pivotal role in addressing determinants of health. It provides the ideal platform for inter-sectoral collaboration on a broader health agenda where the determinants of health need to be addressed by a multiplicity of agencies and the wider community. The Wilayat Health Committees, established in 1999 in all wilayats and chaired by the Wali (local governor) provide, in principle, the main forum for supporting the multi-sectoral and community-based activities of the MOH and inducting community support group volunteers, whose main orientation is towards health education Table 3: Coverage and primary health care service indicators in Oman Indicators % Reference Year + Population with access to local health services, total 98 2008 + Population with access to local health services, urban 100 2008 + Population with access to local health services, rural 95 2008 + Antenatal care coverage 99 2007 + Births attended by skilled health personnel 99 2007 + Population with sustainable access to improved water source 75 2003 + Population with access to improved sanitation 89 2003 - One year-old immunised in 2008 with + BCG anti tuberculosis vaccine 99.9 2008* + DPT3 diphtheria, pertussis (whooping cough) and tetanus vaccine 99.2 2008* + OPV3 polio vaccine 99.9 2008* + Measles/MMR1 (MCV1) measles mumps and rubella vaccine 99.9 2008* + HBV3 hepatitis vaccine 99.2 2008* Legend: * = Data updated from MOH statistics4 Source: World Health Organization. Oman Country Profile.19 Moeness M Alshishtawy Special Contribution | 17 in the community.25 Several community-based initiatives such as the Healthy Wilayat Project, Healthy Lifestyle Project, Healthy City and Healthy Village projects were recently implemented in order to help increase the awareness of the respective communities about environmental and health problems, and thus create active community involvement and ownership for health actions.11 Recently, a number of regional referral hospitals and major wilayat hospitals were made autonomous and now are run, administratively and financially, by hospital management boards with a reasonable degree of decision-making authority.7 Plans to monitor performance of the autonomous hospitals are being developed. It is expected that the hospital autonomy initiative will ensure better and more cost- effective services in the future than ever before. Health Workforce In the early years of the Omani Renaissance, Oman imported its health workforce from other countries in large numbers, as its educational infrastructure was inadequate. It adopted that policy in order to accelerate health services development and fulfill the aspirations of the people of Oman. His Majesty Sultan Qaboos has advocated Omanisation as a national strategy for self-reliance, in order to sustain the social and economic development achieved in the country. The government attaches significant importance to human resources development as a strategy for achieving effective health services development.11 Nevertheless, the issue of human resources for health (HRH) is complex in Oman as health workforce development strategies are governed by a multiplicity of stakeholders from within the MOH itself, but also from outside the ministry. Health professional associations and councils have only recently started to form, though with limited influence so far on manpower planning, management and development.26 Of the 5,194 physicians now working in the health institutions, there are 1,323 Omanis representing a 25% Omanisation level.4 Physicians are trained by the Sultan Qaboos University College of Medicine and Health Sciences, the private sector Oman Medical College, and to a small extent by universities abroad. Sultan Qaboos University has increased its intake to the MD program to meet the increased need for graduate physicians and to promote the Omanisation of this category. In order to encourage medical education, the MOH permits the use of its Sohar Regional Hospital as a teaching hospital for the Oman Medical College. The MOH, in collaboration with Sultan Qaboos University, is sponsoring the Oman Medical Specialty Board to train physicians in a number of specialties.27 The availability of local training in nursing and other paramedical professions has significantly contributed to Omanisation levels. In 1975, there were only 450 nurses working in Oman, mostly expatriates. By the end of 2008, there were a total of 11,233 nurses, 56% of them were Omanis.4 By the same date, training institutes had also graduated a total of 9,031 health professionals from different specialties (including the basic diploma nursing); among these were 543 laboratory technicians, 376 radiographers, 133 physiotherapists and 622 assistant pharmacists. These graduates have contributed to Omanisation levels of 49% for laboratory technicians, and 56% for the last three categories.4 Table 4: Health status indicators in Oman Indicators (reference year 2008) - Total life expectancy at birth (years) 71.6 - Newborns with low birth weight (%) 9.2 - Perinatal mortality rate (per 1,000 total births)* 13.8 - Neonatal mortality rate (per 1,000 total births)** 6.4 - Infant mortality rate (per 1,000 live births) 9.0 - Under five mortality rate (per 1,000 live births) 11.7 - Maternal mortality ratio (per 10,000 live births) 16.7 * Calculated as the number of stillborn infants of 24 compeleted weeks or more plus the number of deaths occurring under 7 days of life divided by the number of stillborn infants of 24 weeks or more gestation plus all liveborn infants in the same year **Calculated as the number of children dying under 28 days of age divided by the number of live births that year. Source: Data updated from MOH statistics4 Four Decades of Progress Evolution of the health system in Oman 18 | SQU Medical Journal, April 2010, Volume 10, Issue 1 Health Care Delivery Generally, the organisation of health care delivery in Oman is based on a primary health care (PHC) approach, with clearly delineated referral pathways between 3 levels of care: primary, secondary and tertiary. The MOH is now operating 167 health centers of which 74 have maternity beds and 21 are extended health centres. These health centres provide preventive, curative and promotive primary health care to the community. In addition, the extended health centres were established to provide specialty care in certain disciplines.4 Local hospitals, also, provide PHC services.19 The PHC system is based on the wilayat, or district, the unit of local administration that is the closest to the community. The central role of community health work to a primary health care approach was placed firmly on the international health agenda by World Health Organization Member States in the Declaration of Alma-Ata in 1978.28 Secondary health care is provided through regional (mostly autonomous) and sub-regional (wilayat) hospitals. Tertiary care is provided through four national referral hospitals each specialising in a few fields. The MOH also extends the services of mobile medical teams to about 2% of the population living in remote mountainous areas.19 Over the years, there has been a growing trend in the utilization of health services (PHC in particular). During 2008, patient visits to outpatient clinics in MOH institutions were about 11 million with an average of 3.9 visits per individual per year.4 About 253 thousand patients were discharged from MOH hospitals, the average number of inpatients per day being 2,513. The average occupancy rate for all MOH hospitals is 54.9%, indicating significant excess capacity.4 Concerns for quality assurance and equity in health care availability, have dictated the Ministry’s health development plans and infrastructure development. Thus, the issue of quality moved high on the agenda of the MOH and was introduced in PHC in 2001, and then to hospitals as well. The Omani quality assurance and improvement programme aims to institutionalise quality in health care institutions with the ultimate goal of providing the highest quality standards of care and thus achieving user satisfaction.29 Health Outcomes Oman is one of the few countries worldwide that has achieved a dramatic transformation in its health status over a remarkably short span of time. Oman’s current health indicators compare well with those of many developed countries with a remarkable control of pregnancy related mortality and morbidities, preventable diseases of childhood and other communicable diseases of public health relevance.22 This is evident from the changes in the various health indicators. Currently, the country’s health status indices show an average life expectancy of 71.6 years for males and females at birth. This has been achieved despite a relatively high fertility rate and the consequent large proportion of the population under age 15 years (35.19%).4 On the other hand, four indices for population coverage with basic health services are among the highest in the world. These include over 99% coverage rate for major vaccines, 99.2% antenatal care coverage (at least one visit during pregnancy), 98.6% of all deliveries taking place in hospitals 4, and 98% of the population now have access to primary health care services [Table 3].19 Oman has also moved from a position amongst the countries in the region with the highest childhood mortality in 1970s, to be amongst the best performers and has even caught up with countries with a much earlier start in development and wealth [Table 4]. In less than 40 years, infant mortality rate has dropped to less than one tenth of its former level (9.0 per 1,000 live births in 2008, down from 118 in 1972), and the under-five mortality rate has dropped by a staggering 94% (11.7 per 1,000 live births in 2008, down from 181 in 1972).4 Such patterns reflects one of the fastest declines in under-five mortality ever recorded globally.30 This means that Oman has been successful in utilising all its available resources in order to achieve a satisfactory health status of the population. These dramatic declines in mortality indicators were mainly because of achievements in reducing communicable diseases. Childhood diseases were highly prevalent during the 1970s; 103 cases of acute poliomyelitis, 102 cases of tetanus, and 43 cases of diphtheria were reported in 1975. Today no single case of poliomyelitis has been reported since 1993. The last case of diphtheria was reported Moeness M Alshishtawy Special Contribution | 19 in 1992 and only one case of tetanus neonatorum has been reported since 1991. The number of cases of measles, mumps and pertussis reported was very high in 1975: more than 16,000 cases of measles, 14,000 cases of mumps and 13,000 cases of pertussis; these dropped in 2008 to 6, 995 and 58 respectively. Other communicable diseases have seen a similar reduction. There were 6,162 cases of pulmonary tuberculosis diagnosed clinically in 1975 compared to only 217 cases in 2007. About 5,000 cases of hepatitis and 24,000 of trachoma were reported in 1975 compared to only 772 and 72 cases respectively in 2008. Malaria, one of the most prevalent diseases in the past, is coming close to eradication. Only 965 cases of malaria were confirmed during 2008 compared to 32,720 during 1990. There were also 144 cases of leprosy and 39 cases of filariasis reported in 1975. Leprosy today is no longer a public health problem as the incidence is less than 1 per 100,000 of the population and no cases of filariasis have been reported.4 International Recognition Oman’s remarkable achievements in health developments during the recent past are well recognised and widely acclaimed both regionally and internationally. The country has been recognised for achieving record-breaking gains in population health status and health infrastructural development.31 In respect of its achievements, Oman has received the following international recognitions and appreciations in the last two decades: 1. According to the United Nations International Children’s Emergency Fund (UNICEF) Progress of Nations 1993 report, Oman’s 65% decline in its child mortality rate in the 1980s was the second highest in the world, and the highest in the Middle East and North Africa (MENA) region.32 2. In 1993, and according to the previous report, Oman’s 97% measles immunisation rate was the highest in the MENA region, and one of the best five in the world. Oman was among the 12 countries which achieved and exceeded the Decade Goal of vaccinating 90% of children against measles by the year 2000.32 3. The Progress of Nations report, issued in 1997 by UNICEF, acknowledged the Omani achievements in child health and ranked Oman among the leading countries in the Middle East, Africa and even the whole world in controlling childhood diseases such as poliomyelitis, diphtheria and tetanus neonatorurm.33 4. According to the Human Development Report 1997, Oman was the first in the world for its impressive achievements in under-5 mortality reduction and 99% immunisation coverage of infants, which led also to a marked reduction Table 5: Top 10 countries in the world according to health system performance Performance on health level (DALE) Overall performance rank Member States rank Member States 1 Oman 1 France 2 Malta 2 Italy 3 Italy 3 San Marino 4 France 4 Andorra 5 San Marino 5 Malta 6 Spain 6 Singapore 7 Andorra 7 Spain 8 Jamaica 8 Oman 9 Japan 9 Austria 10 Saudi Arabia 10 Japan Source: WHO. World Health Report 2000: health systems: improving performance.31 Four Decades of Progress Evolution of the health system in Oman 20 | SQU Medical Journal, April 2010, Volume 10, Issue 1 in childhood morbidity. The report stated that Oman was a pioneer in the field of human development.18 5. In a study done by Harvard University and commissioned jointly by the Government of Oman, UNICEF and the WHO regional Office for the Eastern Mediterranean Region, health sector achievements in Oman were analysed and considered as a model to demonstrate health developments.1 6. In an analysis of health systems undertaken by the World Health Organization (WHO) in 2000, Oman’s health system ranked first among all WHO Member States (191 countries) for its health financing efficiency. It was also ranked 8th using a composite index measuring performance of the health system, attainment of health goals, responsiveness to users and the fairness of its financing [Table 5].31 7. The World Bank Report on the Sultanate of Oman in 2001, Cost Effectiveness Review of the Health Sector, praised the health system in Oman and stated that it spent less money in percent of gross domestic product (GDP) “public and private” compared with countries at a similar income level. Per capita total health expenditure was well below that found in countries with similar income levels.22 It thus appears that Oman’s investments in health have been both effective and efficient.22 8. The latest WHO report in 2008 acknowledged Oman’s performance in the last four decades and commended it exclusively as an example of success in investing consistently in a national health service and sustaining that investment over time.28 Conclusion Recent and ongoing efforts of the MOH guided by the national health policy have achieved impressive progress in the health status of Omani citizens as evidenced by high level health indicators that are comparable to those of developed countries. The attainment of what can be seen as a population health transition has taken place within a relatively short period of time and has been achieved at a comparatively modest cost.31 To learn from the experience, Oman’s success could be attributed to the following factors. It is believed that strong political commitment and national investment in the primary health care approach are the basis for the effective and efficient Omani health system. This was demonstrated not only in the assurance given by the government about free provision of health services to the people of Oman, but also in the keen interest that the Head of the Government, His Majesty Sultan Qaboos, has demonstrated towards health development. This is evidenced during His Majesty the Sultan’s annual tours in various regions of Oman during which he meets his people, and personally advocates for health even touching upon such sensitive issues as birth spacing. Historically, health transitions on a similar scale to that of Oman were widely attributed as much to the improvement of non-health conditions as to those related to the health system, for example, the level of income, education, transport, women’s empowerment and access to information. However, the role of the health sector and the health delivery system in speeding health transition has been significantly boosted by advances such as potent technologies (i.e. vaccines), effective medicines, and the feasibility of wider coverage of populations by these and other far-reaching public health interventions.12 It is interesting to note that with the possible exception of hospital delivery care, almost all of these interventions are provided as ambulatory deliverables at the PHC outlets in Oman.12 Furthermore, the effectiveness of PHC delivery was considerably consolidated by decentralisation and adoption of the wilayat PHC health system. The strategy brought the PHC system closer to the community and led to a number of community- based initiatives spearheaded and supported by Wilayat Health Committees and Community Support Groups.12 Oman laid great emphasis, right from the start, on sound planning supported by an efficient health information system. Proper planning at all levels fostered successful linkage between health goals and main functions of Oman’s national health system. The Omani health sector also benefited from others’ experiences by drawing on regional and international experiences in other countries, including the effective technical cooperation with international organisations such as UNICEF, WHO Moeness M Alshishtawy Special Contribution | 21 and the World Bank. Thus, the country was able to develop programmes, the designs of which had already been tested successfully elsewhere. In conclusion, Oman has achieved remarkable improvements in health indicators, including a rapid decline in communicable diseases during the past four decades. Increased expenditure on health has resulted in improved indicators of health services, health manpower development and health care. Planning has helped the government, policymakers, health care providers and all other stakeholders focus and work towards the set goals and objectives and work communally to achieve them. References 1. Hill GH, Muyeed AZ, Al-Lawati JA. The Mortality and Health Transition in Oman: Patterns and Processes: A study commissioned by the Government of Oman, UNICEF Oman Office, and the WHO Regional Office for the Eastern Mediterranean, December 2000. 2. Allen CH, Rigsbee WL. Oman Under Qaboos: From Coup to Constitution 1970-1996. Portland, OR: Frank Cass, 2000. 3. Smith R. Oman: leaping across the centuries. BMJ 1988; 297: 540–4. 4. Ministry of Health. Annual Health Report 1975, 2008. Muscat: Ministry of Health, Oman, 1976, 2009. 5. United Nations International Children’s Fund (UNICEF) and Ministry of National Economy. Situation Analysis of Children and Women in Oman. Muscat: UNICEF, 2006. 6. Ministry of Health (Oman). Development of Health Services and Health Care. From http://www.moh. gov.om/nh_menu.php?fNm=reports/devofhelt.htm Accessed November 2009. 7. AI Bulushi HS, West Jr DJ. Health system reforms and community involvement in Oman. J Health Sci Manage Public Health, 2006; 7:16–28. 8. Gadalla F. Outlines of the Health Development Programmes of the Fourth Five-Year Plan (1991– 1995). Muscat: Ministry of Health, Oman, 1993. 9. Ministry of Health. The Fifth Five-Year Plan for Health Development (1996–2000). Muscat: Ministry of Health, Oman, 1996. 10. Ministry of Health. The Sixth Five-Year Plan for Health Development (2001–2005). Muscat: Ministry of Health, Oman, 2001. 11. Ministry of Health. The Seventh Five-Year Plan for Health Development (2006–2010). Muscat: Ministry of Health, Oman, 2006. From http://www.moh.gov. om/fiveyearPlan/English/Part%2001.pdf Accessed November 2009. 12. Abdel Rahim IM. Review of Primary Health Care Delivery in Oman and Strategic Directives for the Future. Unpublished report presented to the Ministry of Health, Oman, March 2003. 13. Ministry of Health, Oman. About the Ministry: Health Policy Statement. From http://www.moh. gov.om/nv_menu.php?fNm=p olic y/statement . php&SP=1 Accessed November 2009. 14. Ministry of Health, Oman. Ministry of Health Mission. From http://www.moh.gov.om/nv_menu. php?fNm=mission/mission.php&SP=1 Accessed November 2009. 15. World Health Organization. Macroeconomics and Health: Investing in Health for Economic Development: Report of the Commission on Macroeconomics and Health. Geneva: WHO, 2001. 16. World Health Organization. Demographic, Social and Health Indicators for Countries of the Eastern Mediterranean. Cairo: WHO, Regional Office for the Eastern Mediterranean, WHO-EM/HST/206/E, 2008. 17. Ministry of Health, Oman. Human Resources Development Review. From http://www.moh.gov. om/nv_menu.php?fNm=hr/HRDeview.htm &SP=1 Accessed November 2009. 18. Ministry of Health (Oman). Primary Health Care in the Sultanate of Oman. From http://www.moh. gov.om/nh_menu.php?fNm=reports/prihelt.htm Accessed November 2009. 19. World Health Organization. Oman Country Profile. From http://www.emro.who.int/emrinfo/index. asp?Ctry=oma Accessed November 2009. 20. Ministry of Health. Health Information System Review and Assessment, Directorate of Information and Statistics, Directorate General of Planning. Muscat: Ministry of Health, Oman, April 2008. 21. The World Bank. Sultanate of Oman: Enhancing Revenues for Health Services: Issues and Options. Washington: The World Bank, Human Development Sector, Middle East and North Africa Region, March 2006. 22. The World Bank. Sultanate of Oman: Cost Effectiveness Review of the Health Sector, Main Report. Washington: The World Bank, Human Development Sector, Middle East and North Africa Region, March 2001. 23. Ministry of National Economy. Results of Oman 2003 General Census. Muscat: Ministry of National Economy, Oman, 2004. 24. Ministry of Health (Oman). Organization of the Ministry of Health. From http://www.moh.gov. om/nh_menu.php?fNm=organisation/org_moh. php&SP=1.htm Accessed November 2009. 25. Alshishtawy MM. Health is a Right and Duty: The Experience of Health Committees in Oman. Muscat: Ministry of Health, Oman, 2002. Four Decades of Progress Evolution of the health system in Oman 22 | SQU Medical Journal, April 2010, Volume 10, Issue 1 26. Ministry of Health. Oman National HRH Observatory Lead Document: Human Resources for Health in the Sultanate of Oman. Muscat: Ministry of Health, Oman, 2008. 27. College of Medicine & Sultan Qaboos University Hospital. Annual Report 2007–2008. Muscat: Sultan Qaboos University, 2009. 28. World Health Organization. The World Health Report 2008: Primary Health Care: Now More Than Ever. Geneva: WHO, 2008. 29. Ministry of Health. The Comprehensive Manual of Quality Assurance Standards in Primary Health Care. Muscat: Ministry of Health, Oman, 2005. 30. Hill AG, Chen LC. Oman’s leap to good health: a summary of rapid health transition in the Sultanate of Oman. Muscat: World Health Organization, 1996. 31. World Health Organization. World Health Report 2000: health systems: improving performance. Geneva: WHO, 2000. 32. United Nations International Children’s Emergency Fund (UNICEF). Progress of Nations 1993. Muscat: UNICEF, 1993. 33. United Nations International Children’s Emergency Fund (UNICEF). Progress of Nations 1997. Muscat: UNICEF, 1997.