Ensuring universal access to primary health care in Oman

By: Leila Ben Halim, Fatma Alajmi, and Said Al Lamki

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Background and context

Situated at the base of the Arabian Peninsula, flanked by Yemen, Saudi Arabia, and the UAE, Oman is a high-income country with a population of over 4.8 million. 1 The Omani population is young, with over 56% of the country below the age of 25 in 2017, but with a rapidly aging generation as well. 2 Additionally, around 45% of the Omani population is comprised of expatriates. While nearly the entirety of the expat population, and the majority of the Omani population, is concentrated in urban centers of Muscat, the coastline, and the area around the nearby northern Al Hajar Mountains, the remainder of the population remains scattered throughout the country, in sparsely populated towns, villages, and hamlets.2

In 1970, His Majesty Sultan Qaboos ascended to the throne and soon spearheaded a series of developmental policies with healthcare as a focal aspect of his agenda. Within a few years of the new government’s establishment, Sultan Qaboos announced his vision of a universal health care system with free primary health care (PHC) for all Omanis as the backbone. During the past four decades, there have been huge developments in health services and health institutions across Oman. The focus on PHC as the fundamental tool to advance the health of the Omani population has been credited with the considerable advances in health outcomes—many of which are now comparable to other high-income countries—since 1970. This case study focuses primarily on how Oman used various strategies to improve access and population health management to improve their PHC system and contribute to universal health care.

Early development of the PHC system

Before 1970, Oman’s PHC infrastructure was nascent and minimally functional. In 1958, only two hospitals were operational; one administered by the British consulate and the second by the American Arabian Mission. Thirteen expatriate physicians served the entire nation—one for every 50,000 people—and patients regularly traveled for up to four days to reach a physician for consultation. 345 In order to efficiently construct the PHC system from the ground-up, the Omani government first enshrined the importance of universal health care in Oman's Basic Law which “commits to investing in health care as a means of ensuring citizens' well-being.” 4 The prominence which the government accorded the goal of universal health care has enabled them to direct resources towards health initiatives; this re-evaluation and re-building of Oman’s healthcare system were funded primarily by Omani oil and gas revenue.(6) Notably, Oman’s reliance on oil and gas revenue means that much of the government portfolio, including Oman’s publicly funded healthcare system, is vulnerable to fluctuating global commodity prices.

In Oman, health service delivery is divided into three levels: primary, secondary, and tertiary. The primary level corresponds to regional health centers and local hospitals, secondary level to regional and district hospitals, and tertiary level to the four national hospitals. 7 Within this system, the Ministry of Health (MoH) acts as a steward to both coordinate sectors within healthcare and to effectively serve the community as the principal health provider. 8 PHC is considered as the first point of contact between the citizen and the healthcare system in Oman, acting as a liaison between the community and the specialized levels of health care.

Emphasis on access 

The Omani MoH – established in 1971 – has operationalized the idea of Universal Health Care as a fundamental right by placing significant emphasis on ensuring population access to primary health care services and on financing such efforts through natural resources. As a result, the population currently has nearly universal geographic and financial access to health care. 2

Geographic access

To ensure geographic access, the MoH has focused on minimizing physical barriers to patients accessing care. Oman is composed of a range of mountains which form a belt between the desert and the sea, expanses of distance between isolated towns, and desert areas which act as barriers between regions of the country. 7 To ensure access even in the face of such challenging topography, the MoH constructed a dense network of PHC facilities throughout the country. PHC institutions in Oman are generally classified into health centers, extended health centers (with delivery facility), polyclinics, and local hospitals. In general, the target across Oman is to have one health center per 10,000 population. However, in order to provide access to basic healthcare even in the remotest regions for Oman’s citizens, additional rural health centers have been built to serve as few as 500-1000 population.

In addition to increasing facility infrastructure, Oman has focused on building a PHC workforce capable of delivering preventative, curative, promotive, and rehabilitative care services. Typically, PHC facilities are staffed by general practitioners, nurses, dentists, lab technicians, pharmacists, and paramedical staff.

In 2015, 238 local, district, and regional primary health facilities managed by the MoH existed, spread across all 11 governorates and 61 wilayats  (districts) and the density of physicians increased to 21.7 per 10,000, as compared to 16.7 in 2005. 4 A similar trend was observed for nurse density, which increased from 37 to 47 per 10,000 over this time period. As a result of these targeted efforts, over 95% of the population now lives within five kilometers of a primary health care center. 6

Financial access

Oman has also prioritized financial access to primary health care. The MoH offers free universal health care to all Omani nationals and for expatriates working in the government sector, including access to mental health services and associated medicines. 9 The expatriate workforce in the private sector is mostly covered by employer-provided insurance. Oman is able to support this because their health system is structured within a welfare state system, meaning that the state claims responsibility in its Basic Law for ‘providing aid for citizens in case of emergencies, sickness and aging’.(10) As of 2014, Oman’s total expenditure on health consisted of 3.5% of its GDP. 11 This allows universal health coverage without significant financial investment by patients. Nominal fees for doctor visits have been recently instated, but patients generally have to pay very little out of pocket for health services. 4 This commitment to achieving financially accessible PHC has been thus far largely funded by Omani natural resources. 8

In an effort to ensure the financial sustainability of PHC, the government has recently instated a mandatory health insurance system. In Health Vision 2050, the MoH emphasized that government regulatory services would maintain involvement in the insurance system in order to uphold the quality of health delivery services. The insurance system was designed to target the expatriate population, who were not universally covered by UHC.(2) However, the system is now in the process of being scaled to the entire population in order to lower government healthcare spending and therefore ensure universal health care in practice, and to guarantee sustainability through a private-public partnership between the government and private insurance companies. 2 Additionally, the insurance system creates incentives for Omanis to maintain healthy lifestyles and act preventatively in their lifestyle, to avoid lifestyle-induced health disorders. 4

Timely access

In order to ensure timely access to care, Oman has recently instated a system which allows patients to “walk-in” for PHC services without an appointment needed. Referral to secondary or tertiary care is through appointments, and Oman has recently launched a time-based appointment system to reduce waiting times. After a trial period, this timeliness initiative began in early 2019 at the Royal Hospital, based in Muscat. 12 This system is particularly tailored to serve patients coming from remote areas by promoting close WhatsApp communication between medical professionals and patients to help the patients efficiently plan their journey without needing to stay overnight or drive through the night. 12 This system is intended to be scaled throughout the Omani health services.

Promoting population health management through a community focus

Oman’s approach to population health management incorporates engaging communities and community leaders to identify local health priorities as core components of policymaking. This has been enabled by a process of decentralization, which began in 1991 when the MoH divided Oman into eleven health governorates and 61 wilayats. The goals of decentralization were to aid the identification of more specific and nuanced needs and to improve the management of local resources. Since implemented, decentralization has supported the development of local initiatives, community planning, and resource management due to increased local accountability and awareness. 7 The Omani MoH financially and programmatically supports community-based initiatives within each wilayat. These initiatives strive to engage community members in the analysis, decision making, and implementation of local programs. 13

For example, in 1995 the MoH implemented a community engagement initiative called the ‘Wilayat Health Team’. This enabled local teams, in collaboration with the MoH, to develop health development plans for their wilayat. Members of the teams are trained in health management processes including strategic planning and monitoring. The teams then solicit community participation in the planning, implementation, and monitoring of health services. 13

Similarly, in 1992, local ‘Community Support Groups’ were developed to train female volunteers to provide health education and promotion related to reproductive and child health, including nutrition and breastfeeding. Currently around 3075 Community Support Group volunteers operate throughout the country. 14 During the early stages of implementation, many volunteers faced resistance because the groups predominantly consist of young women; however, due to their clear impact, the groups became recognized as a central component of the primary health care network. 14 Experience assessments conducted among the Omani female volunteers demonstrated high levels of enthusiasm and satisfaction with their work and contributions. 14

Continued and future challenges

Oman’s Health Vision 2050, published by the MoH in 2014, outlines a vision for the future of Oman and analyzes how the intersection of politics, economics, and social and technological advances will impact health system structures in the coming years. Along with Oman’s significant and continued success in PHC, the report addresses how the country continues to contend with a number of challenges. Firstly, the demographic and epidemiological transition has presented difficulties as the MoH tries to shift from a curative model into focusing on preventative treatment and non-communicable disease awareness. 7

Additionally, while Oman is currently in a politically and economically stable situation—the Prime Minister and Council of Ministers have the task of implementing the vision of His Majesty Sultan Qaboos and local elections determine governance at the district level—Oman’s relatively high dependence on natural resources may raise doubts about the future funding and sustainability of robust PHC. Oman also continues to grapple with the challenges of a rapidly expanding expatriate population which is projected to reach one third of the population by 2050. This challenge impacts both the patient population and efforts to ensure financial access to non-Omani citizens as well as the workforce. For example, in 2012, only 29% of Oman’s doctors were Omani nationals. 4 In order to ensure the sustainability of the healthcare systems, the government remains committed to undertaking a process referred to as ‘Omanisation’. 2 This process of ‘Omanisation’ is a set of labor laws which mandate that government ministries and Omani companies hire Omani nationals in the place of foreign workers and replace expatriates with trained Omanis to the maximum extent possible. 15 By 2017, Omanisation had resulted in the proportion of Omani doctors rising to 35%, while throughout the health sector, 68% of workers were Omani nationals by 2015. 4  These successes are critical to the MoH’s goals of sustaining progress and ensuring the sustainability of the health system by institutionalizing knowledge and formalizing primary health care as a long-lasting priority.

Moving forward

Oman’s targeted and sustained focus on strengthening primary health care has led to tremendous gains in health outcomes since the 1970s. For example, life expectancy at birth has risen from 49 to 76.9. 16 The total fertility rate is four and the maternal mortality ratio has dropped to 20.7 deaths per 100,000 live births. Nearly three-quarters (73.3%) of pregnant women register at a PHC facility during their first trimester and over 95% are screened for HIV. Child health indicators have also improved dramatically. Infant and under-five mortality have dropped in recent decades, with infant mortality dropping to 9.5 per 1000 live births and under-five mortality dropping from a high of 149 per 1000 in 1975 to 11.6 in 2017. 4 Exclusive breastfeeding at six months is 23%, childhood immunization rates are 99%, and protein energy malnutrition for children is 1.5%.

Nevertheless, constantly changing societal and community dynamics have given rise to the need for PHC to evolve as well in order to ensure that no one is left behind. Key priority areas for Oman currently to keep pace with changing needs and ensure a constant revitalization of PHC for the current times include working to create a culture among health care workers that PHC is a core foundation of universal health care; educating and building a workforce including community health workers and social workers; capacitating primary health centers to handle emergencies; and working towards the care of aging population and supportive palliative care.

Oman’s Health Vision 2050 addresses long-term health investment and implementation plans and outlines the development of a primarily preventative care model to combat increasing rates of non-communicable diseases. Public healthcare spending is predicted to increase in 2019 and 2020 due to steady economic growth, and the introduction of mandatory healthcare insurance for expatriates. Oman has made impressive steps in building a sturdy health infrastructure, mobilizing the community, and promoting greater access in health care delivery to ensure the universal human right to health.


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