2000 oman health transition rec 347399

unicef VT^*

The Mortality and Health Transitions inOman: Patterns and Processes

EditorsAllan G.Hill

Adaline Z. MuyeedJawad A. al-Lawati

A Study Commissoned by the Government of Oman,UNICEF Oman Office

the WHO Regional Office for the Eastern Mediterranean

December 2000

SUGGESTED CITATION: Hill AG, Muyeed AZ, al-Lawati JA, (editors). TheMortality and Health Transitions in Oman: Patterns and Processes. WHORegional Office for the Eastern Mediterranean and UNICEF, Oman. Muscat 2000.

PagePREFACE————————————-—————---—---————----——————— VI

ACKNOWLEDGEMENTS AND AUTHORSHIP————-———---———-—---------- VIM

INTRODUCTION————————————————————————————— X

CHAPTER 1: OMAN - EARLY DEVELOPMENT AND SPECIAL FEATURES —— 1.1/. OMAN'S SPECIAL HISTORY —————————————————— 1.1//. OMAN'S POPULA TVOA/———————————————————— 1.3/// OMAN'S DEVELOPMENT——————————————————— 1 -4

CHAPTER 2: CHANGES IN MORTALITY AND HEALTH STATUS —-—————- 2.1/. CHILD SURVIVAL —————————————————————— 2.1

A. Sources of information————————————————————— 2.1B. Estimation Methods ——————————————————— 2.4C Results —————————————————————————— 2.5

I TronHc ————_ -.„„______ 2 5I I d IVJO ——————-.——-.—•..»——————-———————————————————————————»— fc.w

2. Age Patterns of Mortality Change ——————————— 2.113. Sex Differentials——————————————————— 2.124. Geographical Differentials in Childhood Mortality—————— 2.125. Differentials by Age of Mother, Parity and Birth Interval —— 2.146. Social Class Differentials———————————————— 2.147. International Comparisons—————————————————— 2.15

D. Changing Patterns of Cause of Death ———————————— 2.15//. ADUL T SURVIVAL ————————————————————————— 2.19

A. Adult In-patient Deaths ———————————————————— 2.20B. Maternal mortality ——————————————————— 2.21C. Fertility and its Effects on Mothers and Children ——————— 2.21

///. MORBIDITY -------——————————————————————— 2.26A. Decline of Infectious Diseases ——————————————— 2.26B. Seasonal Morbidity ———————————————————— 2.30C. Persistence of First Generation Illnesses ——————————— 2.31D. Non-communicable Diseases —————————————— 2.33

1. Malnutrition ——————————————————————————— 2.332. Diseases of the Circulatory System ————————————— 2.373. Diabetes Mellitus ——————————————————— 2.384 Cancer ————————————————————————— 2.395. Accidents ———————————————————————————— 2.406. New and Unanticipated Threats: HIV/AIDS ————————— 2.40

IV. CONCLUSIONS ——————————————————— 2.41

CHAPTER 3: EVOLUTION OF THE HEALTH SERVICES ——————————— 3.1/. HISTORY OF POLICY DEVELOPMENT ——————————— 3.1//. HEALTH SYSTEM ——————————————————— 3.5

A. Provision of Health Services ————————————————— 3.51. Organisation and Management ———————————————— 3.52. Strategies ——————————————————————————— 3.53. Facilities and Infrastructure ————————————————— 3.64. Human Resources for Health ———————————————— 3.8

B. Utilization of Health Services————————————————— 3.10C. Financing and the Private Sector ——————————-——--— 3.12

1. Financing ——————————————————————————— 3.122 Private ^pirtnr _ _ _ _ _ _ __ ___________ 114.. r i ivciic wwoivji ——————————————— ———— ——— _—— —— —— .̂ I^

III. DEVELOPMENT AND STATUS OF HEALTH PROGRAMMES -—— 3.15A. Disease Control———--—————————————————— 3.15

1. Expanded Programme on Immunisation—————————— 3.152. Control of Diarrhoea! Diseases and Acute Respiratory

3. Malaria Control ———————————————————— 3.194. Tuberculosis Prevention ——————————————————— 3.235. Trachoma and other Eye Health Care ——————————— 3.25

B. Maternal and Child Health ————————————————— 3.261. Maternal and Child Health Programme——————————— 3.262. The Birth Spacing Programme ———————————————— 3.273. Child Nutrition ———————————————————— 3.284. Breast-feeding: the Baby-Friendly Hospital Initiative ———— 3.295. School Health ——————————————————————— 3.30

C. Emergence of Chronic Diseases ——————————————— 3.321 niahptAQ __ __ __ _ _ _ _ _ __ _______ 1 7Oi . Lyiauwiwo — — — — — — — — — ————————«-.—————_——————————_—.•. ——— —— O.Ofc

2 panrpr _ _ _ _ _ _ _ o oo. \JQ\ lOwl — — —————••-—————————————-—«.—————»———— ———- O.wO

3. Heart Disease ——————-————————————————— 3.344. Accidents ———————————-—-——————————-—— 3.35

IV. SUMMARY AND CONCLUSIONS ———————————————— 3.35

CHAPTER 4: THE CONTRIBUTION OF RISING NATIONAL INCOME ANDPERSONAL WEALTH TO HEALTH AND WELFARE ____——————————- 4.1

/. GROWTH OF THE ECONOMY: OIL PRODUCTION ANDREVENUES————————————————————————— 4.2

//. GOVERNMENT EXPENDITURES IN THE SOCIAL SECTOR ——-- 4.3A. Employment —————————————————————————— 4.4B. Social Houses, Low Cost Housing Loans and. Grants —————— 4.5C. Government Grants for Social Welfare, Individual and General

Disasters ————————————————————————— 4.3D. Services & Interest Free Loans & Grants Aimed at Increasing

Family Income ——————————————————————— 4.3E. Incentives for Business ——————————————————— 4.3

///. CHANGES IN PERSONAL INCOME —————————————— 4.9IV. CONCLUSION ———————————————————————— 4.13

CHAPTER 5: SOCIAL AND ENVIRONMENTAL DEVELOPMENT --—--—----—-- 5.1/. EDUCATION: ENROLMENT AND LITERACY————————— 5.1

A. The Expansion of Schools and Education ———————————— 5.2B. Primary Completion Rates and Transition to Secondary

Education ——————————————————————— 5.4C. Gender Disparities in School Enrolment and Educational

Status———————————————————————-———- 5.4D. Adult Literacy ————————————————————— 5.5

//. WOMEN'S ACCESS TO HEALTH, GENDER DIFFERENTIALS INHEALTH AND USE OF HEALTH SERVICES —————————— 5.6A. Access to and Use of Health Services ——————————— 5.7B. Health and Nutritional Status ——————————————— 5.8C. Morbidity and Mortality of Females ———————————— 5.9

///. WATER AND SANITATION: EFFECTS ON DIARRHOEALDISEASE AT THE LOCAL LEVEL BY MUNICIPALITY—————— 5.10

Environmental Health in Oman ————————————— 5.101. The Early Years ——————————————————— 5.102. Environmental Health in the 80's ——————————— 5.103. The Situation in the 90's ——————————————— 5.11

CHAPTER 6: COMPARISONS AND CONCLUSIONS -__-______—————- 6.1/. LESSONS LEARNED ———————————————————— 6.4//. THE FUTURE OF HEALTH IN OMAN ——————————————— 6.7

References—————————————————————————————————————— R.1

LIST OF ACRONYMS

AIDS Acquired Immune Deficiency SyndromeANC Ante Natal CareAPI Annual Parasitic IncidenceASR Annual Statistical ReportARI Acute Respiratory InfectionsBCG Bacille Calmette-GuerinBFHI Baby Friendly Hospital InitiativeCDC Centre for Disease Control & PreventionCDD Control of Diarrhoeal DiseasesCHP Child Health ProgramCRS Congenital Rubella SyndromeCVD Cardiovascular DiseasesDHI&I Department of Health information and StatisticsDHS Demographic Health SurveysDPT3 Diphtheria, Pertussis and Tetanus vaccination, third dose.ECWA Economic Commission for Western AsiaEPI Expanded Programme on ImmunizationE(x) Life ExpectancyGCC Gulf Cooperation CouncilGNP Gross National ProductGDP Gross Domestic ProductGP General PractitionerIDD Iodine Deficiency DisorderHbsAg Hepatitis B surface AntigenHBV Hepatitis B VirusHFA Health For AllHIV Human Immunodeficiency VirusIGT Impaired Glucose ToleranceIUGR Intra Uterine Growth RetardationIVF Intravenous FluidsIMR Infant Mortality RateKAP Knowledge, attitude and practiceMCH Maternal and Child HealthMOH Ministry of HealthMR Measles and RubellaMR-2 Medical Record- 2NCHS National Child Health SurveyNOS Not Otherwise SpecifiedNWCCP National Women and Child Care PlanOCHS Oman Child Health Survey 1988-89OFHS Oman Family Health Survey 1995OPV3 Oral Polio Vaccine, third doseORT Oral Rehydration TherapyPAPCHILD Pan-Arab Child Health SurveyPBT Preceding Birth Technique

IV

PEM Protein and energy malnutritionPHC Primary Health CareRO Rials OmaniSPR Slide Positivity RateSOP Standard Operating ProcedureSTD Sexually Transmitted DiseaseTB TuberculosisTFR Total Fertility RateTF Trachoma FollicularTl Trachoma IntenseTS Trachoma ScarringTV TelevisionUAE United Arab EmiratesUNDP United Nations Development ProgrammeUNICEF United Nations Children's FundVAD Vitamin A DeficiencyWHO World Health Organization

V

PREFACE

The Sultanate of Oman, under the wise leadership of His Majesty SultanQaboos Bin Said, has accomplished astounding achievements in the health ofits population over a short period of time. These achievements have been

widely recognized and acclaimed by various international organizations, includingthe World Health Organization (WHO), the United Nations Children's Fund(UNICEF) and the United Nations Development Programme (UNDP). Healthindicators such as infant, under five and maternal mortality rates continued to showprogressive and consistent reduction in the Sultanate over the past three decades.Several diseases have been eliminated and life expectancy at birth has reachedlevels comparable to those in developed countries. An extensive network of modernhealth facilities providing full range services is made available and easily accessibleto the entire Omani population. One recent witness to the international recognitionof Oman's glaring health successes came in WHO World Health Report 2000, whichwas devoted to measuring performance of health systems worldwide. Oman's healthsystem was rated the first among more than 190 national health systems in itsattainment of higher health goals over a short period of time and at reasonable cost.

This Report is an attempt to analyze and document Oman's remarkable stride andbreath catching achievements in health development. It describes the health statusof the Omani people in the pre-Renaissance era (before 1970), and the subsequentchanges in different health parameters, which took place since then. It also attemptsto establish attribution and furnish understanding for the roles of direct healthinterventions and indirect social and economic factors on the advent of the observedhealth transition.

Although various sources have previously documented different aspects of theOmani experience in health development, however, this Report is the firstcomprehensive documentation of the entire experience. It is also unique in thewealth of data and information, which was complied in it from various sources andalso by the depth of its analysis.

The findings of the Report clearly demonstrate that sustainable development in theOmani health sector would not have occurred in isolation of the overall socialdevelopment and the accelerated infrastructure building. The Report also confirmsthe even distribution of health gains over the different geographic locations andamong different social groups in the Sultanate. This latter fact highlights the strongcommitment to equity, which guided Oman's steps on the road to development.

The Manuscript also explored and highlighted the remaining and emerging healthchallenges facing the country. High among these was shown to be the lingeringproblem of malnutrition among children and the "shift" of the burden of diseasesfrom communicable to chronic non-communicable and lifestyle related diseasessuch as diabetes, cardiovascular diseases and injuries associated with road trafficaccidents. To this extent the report underlined the need to develop long term

VI

strategies, tailored to the local culture and realities of Omani life to combat theseemerging challenges.

With the completion of this valuable work, we would like to take the opportunity tocommend the intense and dedicated effort, which was, invested it. Our appreciationgoes to the editors of the manuscript for their patient and meticulous efforts, which iswell reflected in the quality of the work they produced. Our thanks are also extendedto the task force from both Harvard University and Ministry of Health Oman, whocontributed valuable inputs to the work as well as the collaborators from othersectors of the Government of Oman in providing the complementary relevantinformation.

Finally, this work would not have been conceived or materialized without thecontinuous guidance and support which it received from H. E. Dr Ali bin Mohammedbin Moosa, Minister of Health whose leadership and insight were instrumental inshaping Oman's leaps in health development.

(£A/^Naheed Aziz Dr Ibrahim Abdul-RaheemUNICEF Representative, WHO Representative,Oman. Oman

VII

ACKNOWLEDGEMENTS AND AUTHORSHIP

This volume is the result of a collaborative effort between several agencies andinstitutions. The original idea stemmed from some discussions between theShahnaz Kianian Firouzgar, former UNICEF Representative in Oman, Dr.

Jamil Khan, former WHO Representative in the Sultanate and several senior figuresin the Government of Oman. Prominent amongst this group were: Dr. Ali JafferMohamed, Director-General of Health Affairs; the late Professor Musallam el-Bualy,Head of Child Health at the Royal Hospital; and Mrs. Fatima al-Ghazali, Director ofinternational Relations, Ministry of Health. In addition to this talented group, theproject enjoyed full support at the highest levels from H. E. Dr. Ali bin Mohammedbin Moosa, Minister of Health; H. E. Dr. Ahmed A. K. al-Ghassany, Undersecretaryfor Health Affairs; and H. E. Mohammed bin Hassan bin Ali, Under-Secretary forPlanning Affairs in the Ministry of Health.

Clearly, this group was well qualified to produce an excellent study of Oman's healthtransition on their own but the decision was made to invite international participationin the project both to add a comparative dimension to the study but also toguarantee that the conclusions would not be dismissed by outsiders as apropaganda exercise but would be treated as serious scientific attempt to analysethe essential factors responsible for what has emerged as one of the fastest healthand mortality transitions on record. As a result, the group from Harvard School ofPublic Health was invited to join the national team and an initial visit was made byProfessors Lincoln Chen, Allan Hill and Ms. Adaline Muyeed in November 1994.

The study progressed in the following manner: first, a small steering committee metto agree on the contents of two reports. One was to be a short brochure, intendedfor the twenty-fifth anniversary of the accession to power of H. M. Sultan Qaboos binSaid in November 1995. The other was a longer report with full documentation of thetransition. Ms. Muyeed remained in Oman to gather materials and to work with theperson identified as the co-ordinator of the study, Dr. Jawad Ahmad al-Lawati. In asecond phase, Ms. Muyeed and Dr. Jawad continued their joint work in the Bostonarea in the winter of 1995-96, producing draft sections of the report under the overallsupervision of Chen and Hill. More material was forthcoming from the larger teamengaged in generating the basic information for the study (see the complete list ofcontributors at the end of this section). Much re-writing and production of tables andgraphs continued in the Harvard Center for Population and Development Studiesthroughout 1996 and 1997. The editors and organisers certainly under-estimated themagnitude of the task of synthesising the mass of materials available on Oman andthe volume of work out-grew the resources to manage the project. After further work,a draft was submitted to the wider group of actors engaged in the project andapproved for publication.

The three editors jointly produce the Introduction and Chapter 1 of the study.Chapter 2 was a truly collaborative effort. The editors' fist sketched an outline of thecontents and then Adaline Muyeed with Jawad al-Ahmad worked with Omanicolleagues to obtain first drafts of the different sections. The sections were inevitable

VIII

too long and had to be heavily edited. They were then carefully reviewed byqualified individuals including:

Chapter 3 was written in sections. Section I on the history of policy development andsection II on the health services were initially written by Adaline Muyeed and thenre-written by Allan Hill. Section III was produced in draft by Drs. Jawad Ahmad al-Lawati, Ferdosi Mehta, Pradeep Malankar, A Colaco, Asya al-Riyami, MohammadAli Khalifa, Allan G. Hill, Leila Jassim, Mr. Abdullah bin Rashid AI-Mandhry, and MsDina al-Asfoor.

Chapter 4 on the contribution of rising national income and personal wealth to healthand welfare as drafted by Adaline Muyeed and Allan Hill. Chapter 5 on social andenvironmental development was initially written by Jawad al-Lawati, AdalineMuyeed, Abdullah bin Rashid al-Mandhry and Said Darwish al-Alawi. Chapter 6,Comparisons and Conclusions, was written by Allan G. Hill. Very Helpful generalcomments and advice was received from Drs. Carol Watson and Yasmin Jaffer.

Thus, in such a collaborative work, it is very hard to allocate responsibilities for thefinal product. Much of the praise must go to the small team who conceived theoriginal idea for such an ambitious and wide-ranging study. Much of the very hardtask of synthesising the materials provided fell on the shoulders of Dr. Al-Lawati andMs. Muyeed. The list of individuals who took time off from their usual jobs to writesections on particular diseases, programmes or special activities is very long. Theeditors are to blame if the original form and content of the volume does not meet theaspirations of the numerous contributors.

IX

INTRODUCTION

Despite many years of attention by scholars and health professionals, there isstill considerable uncertainty about the true causes of the secularimprovements in mortality and health which began in earnest at the turn of

the century in rich countries and at later dates elsewhere. There are broadsimilarities in the patterns of change in the early part of the health transition,including the decline of mortality from infectious disease particularly in smallchildren. Later in the transition, we see considerable differences in the paths fromhigh mortality and poor health to low mortality and improved health. In thecircumstances, there is a strong case for more detailed case studies of thetransitions experienced by different countries. This desire to document and publicisethe experience of one country was the initial impetus behind the Health and MortalityTransition Study in Oman.

There are, however, more challenging questions to be addressed. One suchquestion involves an attempt to portion out the contribution of different sets offactors to the improvements in health and mortality. This is a much more difficulttask.

In 1993, the World Bank chose health as the subject of its World DevelopmentReport. In this influential volume, the factors responsible for improving health weresubsumed into three broad categories:

Medical technology (including better treatment systems as well as new drugs andvaccines); public health measures (the urban infrastructure, water, primary healthcare facilities as well as rising levels of education); and income growth(incorporating improvements in housing, improved nutrition and greater use ofhealth care).

Source: (World Bank, 1993: 34-6).

These are broad categories but they have the merit of being both comprehensiveand capable of empirical evaluation. Indeed, the World Development Reportcontains some rough estimates of the contribution of each of these clusters ofvariables to mortality decline in Costa Rica, Egypt, Ivory Coast and Japan (pp. 39).The surprising conclusion is that their proportional contributions are very different -two-thirds of the improvements from 1960-87 being attributed to rising education inIvory Coast, whereas in Egypt half of the improvement is attributed to increase inper capita income.

For Oman, we are able to document the principal changes which have taken placein health since the transition only began in earnest with the assumption of power byH. M. Sultan Qaboos al-Said in 1970. Given the radical nature and breadth of thereforms touching all aspects of public life introduced by the Sultan, it is well nighimpossible to link the improvements in health with any single factor. From the pointof view of outsiders, however, it is important to have some idea of the contribution of

the health sector itself to the improvements in health compared with other factors -such as income growth an its associated changes. As always, other countries andinternational agencies are interested in finding short-cuts to speed up the transitionto better health and if Oman has found a magic formula, then the rest of the world isinterested in sharing this success.

The project thus began with a very general theoretical framework defining howhealth improves- no more specific than the well-known diagram of Mosley and Chenwhich isolates the main sets of biological factors responsible for improved childsurvival. Rather than attempt the impossible task of trying to calculate thecontribution of single factors to the health transition in Oman, this volume tries tosort out the contributions from the three major clusters of variables chosen by theWorld Bank for the 1993 World Development Report (see above). The volumebegins with a review of the changes, which we can document from existing data,and then considers the role of the health services in the transition. The secondcluster of factors discussed concerns the contribution of public health measures.Finally, the contribution of wealth and social development is considered. Theconclusions include some discussion of the relevant importance of these three setsof major factors but do not include any magic formula or easy short-cut on the roadto good health. If there is a single lesson it is that doing a few simple things well inthe health sector pays rich dividends.

XI

CHAPTER 1

OMAN- EARLY DEVELOPMENTAND SPECIAL FEATURES

CHAPTER 1

OMAN - EARLY DEVELOPMENT AND SPECIAL FEATURES

Twenty-five years after the accession to power of its ruler, Sultan Qaboos binSaid in 1970, Oman presents to the visitor an image of bustling prosperity.New four-lane highways link cities and suburbs in a web of tarmac and bright

lights, more startling at night when the extent of the built-up area becomes moreobvious. Planned housing developments and new towns preserve some semblanceof the older tradition of stone housing with crenelated walls. All the services of amodern state - water, electricity, telephone, television, shopping malls, schools,hospitals, clinics, even a university - appear established and in good working order.Government offices in the al-Khuwair district of the capital areas vie with each otherin style and modernism but inside, Omanis in traditional dress conduct the businessof state by telephone, fax and computer. It all seems well established and calmlyefficient, as is the welcome by the no-nonsense immigration service at theinternational airport.

It is difficult to accept that almost all the modern physical infrastructure has beenbuilt since 1970 and that the system of ministerial government is even more recent.For Oman was a relative latecomer amongst the countries of eastern Arabia and theGulf region in the discovery and export of oil and gas. This book does not have torecount the many vicissitudes of Omani history in .any details since other authorscover very well the long periods of economic decline and international isolation untiloil exports began in 1967. It is important to remember some features of Oman's pastwhen writing about the contemporary scene, however, since traces of this historyshape the current policies and explain some of the special features of Oman's post-1970 development. /

I. OMAN'S SPECIAL HISTORY1

A distinguishing feature of Oman compared to<the other states of the ArabianPeninsula is its long involvement with East Africa and the Indian sub-continent.Omanis at an early stage in their history were forced to turn to long distancecommerce by sea to supplement the limited natural resources of their dry andmountainous homeland. From the time of the arrival of the first Portuguese fleet offRas al-Hadd in 1507, Oman has capitalised on its location on several majorseaways and corridor of international trade. It was following the expulsion of thePortuguese in 1650 that Imam Sultan continued his exploration of the coast ofwestern India and East Africa, embarking under the flag of a jihad or holy war. Thewealth which flowed in produced the great fort at Nizwa and many other forts andlarge houses. Although Oman's navy remained a formidable force abroadthroughout the eighteenth century, civil war at home produced instability and

1 See Townsend (1977) for a fuller account of this period.

Chapter 1: Oman - Early Development and Special Features

economic decline. Tribal rivalries left lasting divisions in traditional society, whichdelayed the consolidation of Muscat (the coastal area), with Oman, the interior.

Sayyid Sa'id in the 1820s took Oman into a new phase of foreign expansion,acquiring a base in Dhofar and expanding the east African territories, especiallyZanzibar. Emigration to Zanzibar and return remittances laid the basis for a moreprosperous period in Muscat. As compensation for the loss of the Zanzibar in atreaty negotiation with the British, an annual subsidy of 40,000 Maria Theresadollars was paid to the Omani exchequer. Zanzibar defaulted on the payment, sofrom 1881 until 1947, the British government paid the sum from Bombay, and fromthen until 1956, by the Foreign Office in London. Thus, although poor compensationfor loss of an empire, the annual subsidy provide one small but steady source ofincome during a period when other revenues were very uncertain.

Tribal war between the interior and coast continued intermittently throughout thenineteenth and then early twentieth centuries until the Treaty of Sib in 1920. Thisprepared the way for the reign of Sultan Sa'id bin Taimur (1932-1970), the father ofthe present Sultan. A succession of external events all thrust Oman and the Sultanto the forefront of regional and international affairs. The result was an increase intension at home and the outbreak of civil war in 1956. Peace was not re-establisheduntil 1959 by which time the Sultan's control over the interior had been clearlyestablished.

Oil was discovered in 1964 and exports began in 1967. From his time on, the oiltrade dominated economic and political developments. Sultan Sa'id bin Taimur haddifficulty coping with the pressures to modernise his country and with the externallysupported armed revolt which broke out in Dhofar in 1965. Sultan Qaboos bin Saidthus assumed power from his ailing father in July 1970. External support from thePeople's Democratic Republic of Yemen and other radical Arab countries made theDhofar rebellion a running sore until the general amnesty and cease-fire agreed bySultan Qaboos in March 1976. In the early 1970s, the rebellion meant that 46% ofthe 1973 budget, 40% of the 1974 budget and 43% of the 1975 budget was spenton defence. Thus, expenditures on development were relatively modest until peacehad been established throughout the Sultanate in 1976 by the general amnesty andcease-fire agreed by Sultan Qaboos.

This sketchy history of Oman serves to bring out three key features of the moderndevelopment. One is that the modern state is a very recent creation, dating from theaccession of Sultan Qaboos in 1970 and the end of the Dhofar rebellion in 1976. Asa huge country, it has taken modern communications to bring the capital into regularcontact with the interior, the remote northern tip of Musandam and with Dhofar.Secondly, Oman's modern development is fuelled very largely by oil exports.Agriculture and herding have dwindled in importance although fishing retains someof its old significance.

Revenues come mainly to the state and so the course of development thusdepends heavily on the ruler and a small group of advisors. As later chapters


illustrate, much of the early strategy was about how best to distribute the oilrevenues in a productive and equitable manner. Thirdly, Oman's oil reserves aremodest in comparison to those of Saudi Arabia, Kuwait or Iran. The implications ofthis limited wealth are several. It has meant that expenditures have had to be morecarefully monitored than in other very much richer oil exporting countries. Moreimportant, it means that Omanis have had to cope with most of their owndevelopment. By attracting Omani return migrants from the Gulf, other Arabcountries and East Africa, the domestic labour force has provided the bulk of thelabour force needed for the expansion of the modern state. Omanis remain a largemajority (73% of the total population, according to the 1993 census) in their owncountry unlike the Gulf States (except Bahrain) which are dominated by foreignworkers.

//. OMAN'S POPULATIONOman's 1993 census revealed that the Sultanate contained just over 2 millionpeople, of whom 26% were non-Omanis (Table 1.1 and 1.2)

Table 1.1 The Population of Oman, 1993.Males Females Total

OmanisNon-Omanis

755,110422,895

728,116111,953

1,483,226534,848

Total 1,178,005 840,069 2,018,074

As is the case for mostimmigrant populations in theGulf and Saudi Arabia, themajority of the foreigners aremen. Amongst the non-Omanis,there were 3.8 men for every

woman in the 1993 census. Overall, this gives the de facto population of Oman anodd age and sex structure. Whilst 51% of the Omanis are under age 15, the majorityof the non-Omanis are working age men.

Source: Population Census. 1993, table 3.5.

Table 1.2 Distribution of the Omani Population byRegion and Nationality, 1993.Region Total Population

Muscatal-BatinahMusandamA'DhahirahA'DakhliyahA'Sharqiyahal-WustaDhofarTotal

549,150564,67728,727181,224229,791258,34417,067

189,0942,018,074

% Omani

54.084.078.075.087.085.080.066.073.5

% of allnon-Omanis

47.417.31.28.65.77.30.611.926.5

Source: Population Census, 1993, table 3.1.2.

The most denselysettled areas are the al-Batinah and Muscatregions which contain28% and 27% of the 1993 p o p u l a t i o nrespectively with adensity of 157 per sq.km. (Census, table 2.1).Over half the populationlives in the relativelydensely settled coastalstrip (Muscat and al-

Batinah), so that the remainder of the population is spread out over a huge areatotalling some 309,000 square kilometres. Providing services to the half of thepopulation outside the capital and the al-Batinah regions is a constant challenge.

LJ


The age composition of the Omani population is very young, with a median age ofjust 13.4 years, compared to 20.2 years for the Omani and non-Omani populationsin combination (Census, pp. 42). This young age composition of the nationalpopulation is clearly the result of very high fertility and rapidly declining childhoodmortality. As the analysts of the 1993 census point out, this age distribution evenwith the offsetting effects of the immigration of men and women in the economicallyactive age groups, creates a large dependency ratio (0-14 year olds + 65 and over /population 15-64) equal to 120. This is very high and has major implications for bothcurrent and future economic and social development.

In addition to the high proportion of the Omani population under age 15, we note acommon feature of many oil-exporting economies, which is the low rate of economicactivity amongst many Omani adults. Whilst 91% of the non-Omanis over age 15are economically active, only 38% of Omanis in this age group are at work (Census,pp. 54). Part of the explanation is the low participation rate of Omani females - only7% were in the labour force in 1993. This will undoubtedly change with rising levelsof female education (see Chapter 5) but for the near future, the dependence onimported labour will continue.

Most of the Omani jobs are in the public administration and defence sector (56%)with a more even spread across all industries for the non-Omanis. Most of the non-Omanis, by contrast, work in the construction (24%) and wholesale and retail tradesectors (18%) (Census, pp. 59). The very small proportion of the labour forcedirectly employed in the oil sector is a feature seen in many Gulf states.

Another distinguishing feature of the Omani population, which has a bearing onhealth, is the large size of most Omani families. In part the result of high fertility butalso a legacy of the past preference for extended family living, we find in the censusthat 35% of Omani families consist of 10 or more family members and a further 41%of families consist of 5-9 members (Census, pp. 63).

/// OMAN'S DEVELOPMENT

Oman began its sustained programme of national development when His MajestySultan Qaboos bin Said al-Said succeeded his father as Head of State in July 1970.Among the earliest decisions made by the new government was a strong politicalcommitment to develop a modern welfare state, including the promotion of thehealth of the Omani people. Through judicious use of income generated by Oman'soil wealth, discovered in 1964 and commercially exploited in 1967, the Governmentwas able to build from scratch a modern national health system that offers all Omanicitizens universally accessible health services free of charge.The dramatic health advances enjoyed by the Omani people are documented bythree principal national data sources. A Child Health Survey in 1988-89, executed aspart of the Gulf Child Health Survey Programme, the first national population censusin 1993, and the Oman Family Health Survey of 1995 provide the firstcomprehensive estimates of infant and child mortality. In addition, health servicestatistics of the Ministry of Health offer detailed information on infrastructure, service

1 4


utilisation, and outbreaks of epidemic diseases. These national data sets aresupplemented by many special studies on specific health problems andprogrammes.

In 1976, Oman devoted 9 million Omani Rials (RO) (US$ 23.4 million) to the healthsector. By 1994, the health budget had grown to RO 111.5 million (US$ 289.9million). The proportion of total government expenditure (recurrent anddevelopment) spent on health in 1994 was 5.5%, similar to other countries withapproximately the same income levels. Spending on health by the government inOman amounted to just US$ 138 per person/ per year. This is considered low bycomparison with the high income countries of western Europe and North Americareferred to by the World Bank as "established market economies" where spendingper head was US$ 1860 in 1990 (World Bank, 1993, table A.9). By comparison withother Arab countries, Oman's per capita spending on health is less than half thelevel in Saudi Arabia; about the same as in Algeria; twice the Jordanian level andeight times the level in Egypt. Oman's heath sector is thus relatively well supported,but neither the absolute amounts expended on health nor the proportion of the grossdomestic product spent on health are exceptional given the country's income level. Itthus appears that Oman's investments in health have been both effective andefficient. How was this achieved?

Health became a primary concern soon after H. M. Sultan Qaboos assumed powerin 1970. The health sector strategy was initially articulated in the First Five-YearPlan in 1976. The plans gave pride of place to the construction of a basic healthinfrastructure that would be universally accessible to the whole population.Importantly, the facilities were equitably distributed to all regions of the country andexpensive tertiary facilities were kept to a minimum. Lacking trained people, Omanimported health workers from neighbouring countries of the Middle East and SouthAsia. From only a few doctors working in two hospitals with 12 beds in 1970, Omanby 1994 had 2629 doctors and 6224 nurses in the country. The ratios of 1.3 doctors,3 nurses, and 2.3 beds per 10,000 population are among the highest in the regionand are not far from the figures for some developed countries (see Table 1.3).

Table 1.3 Health Services in Oman Compared with Selected Countries.____Doctors per Nurses per Nurse-to- Hospital

Country 1000 1000 doctor beds perpopulation population ratio 1000

populationOman (1994)Saudi Arabia (1988-92)Jordan (1988-92)Tunisia (1988-92)UK (1988-92)

1.31.51.50.51.4

3.12.20.41.32.8

2.41.50.32.72.0

2.32.71.92.06.3

Source: World Bank 1993 World Development Report, table A. 8 and Oman, HealthFacts. 1994.

1.5


Oman remains heavily dependent on expatriate doctors and nurses with 92% ofdoctors and 89% of nurses coming from other countries. The Medical School andthe Nursing Institutes will gradually help to reduce this dependence on expatriates.

In 1983, the basic health infrastructure was brought into focus through a nationalthree-tier primary health care strategy. The basic building blocks of the primary caresystem are the health centres and local hospitals in the Wilayah, backed by referraland technically more sophisticated regional hospitals and central facilities in Muscat.This policy of dispersal of the health facilities has brought services close to most ofthe population. To heighten the impact of primary care, the Ministry of Healthlaunched a series of vertical programmes targeted at the most prevalent healthproblems among the most vulnerable people. Such programmes included theexpanded programme on immunisation, prevention and case management ofdiarrhoea and respiratory tract infections, the control of malaria and tuberculosis,maternal-child health programmes, breast-feeding promotion, and school healthprogrammes. The rapid rise in vaccine coverage and maintenance of this coverage(see details in Chapters 2 and 3) illustrates the success of Oman's primary healthcare strategy.

In the early 1990s, the Ministry of Health began to integrate these verticalprogrammes into stable primary systems at the Wilayah level. Decentralisation ofdecision-making and responsibility is underway from headquarters to the WilayahHealth Management Teams whose responsibilities include planning andadministration; supervision of all health staff; management of out-patient servicesand where there is a hospital, responsibility for in-patient services too. This Wilayah-based approach provides an integrated system of care to people in the regions andmeans that vertical programmes such as immunisation against infectious diseasescan be made more effective locally. Overall, the aim is to provide an integrated setof primary health care services, which the Ministry considers essential to reach"Health for All" by the year 2000.

A key feature of the preventive health programmes is the extraordinary diseasesurveillance system, which was instigated initially to assess progress with childhoodimmunisation aod< now .covers many other conditions. The utility and effectiveness ofthis system was illustrated in 1988 when a small outbreak of poliomyelitis occurred.In a textbook illustration of the correct response to such an outbreak, Oman wasable to quickly identify the communities in which cases were occurring and tovaccinate widely in both the affected and the surrounding population. As a result ofthis capacity to find cases quickly, diseases like polio and measles are increasinglyrare, as Chapter 2 will illustrate.

Due in part to the ease of geographic access to these decentralised and freeservices, Oman has one of the highest health care utilisation patterns in the world.Between 1975 and 1994, outpatient clinic attendance more than tripled to nearly 12million visits per year. An average Omani pays 4.6 visits to a hospital annually, 3.2visits to the primary health care centre and an average of 6.4 antenatal visits perpregnancy. The intensive pattern of health service utilisation can also be attributed

I .6


to the demand of the Omani people, reflecting earlier deprivation, the influence ofreturning expatriate Omanis, and the credibility and performance of theGovernment's health system. Such intensive facility utilisation also translates into aheavy outlay by the government and is one of the strategic issues, which thegovernment must face in the immediate future.

In this report, we begin by documenting the changes, which have occurred in Omanand then move to the principal sets of factors, which have wrought the Oman healthand mortality transitions. At the end, we return to the issue of the causes of the rapidchanges, which have swept Oman, trying to parcel out the credit so that other maylearn from the Omani experience.

1.7

CHAPTER 2

CHANGES IN MORTALITYAND HEALTH STATUS

CHAPTER 2

CHANGES IN MORTALITY AND HEALTH STATUS

Our first task is to describe as accurately as possible the extent and pattern ofthe changes in health and mortality which have swept Oman over the lasttwenty-five years. We have to present the details on the speed and pattern of

the health transition before moving on to the search for the principal driving forcesbehind the changes. Are the improvements in life expectancy and health in Omansince 1970 quite exceptional or are there parallels elsewhere? How does the patternof change in Oman compare with experience in other countries especially those inthe same region? Are the improvements in health very broadly distributed by ageand sex as well as by social class and region? Are there still sub-groups whosehealth remains a problem? How fast are new patterns of disease makingthemselves felt as living standards rise and life styles evolve? These are thequestions we address in this chapter, before proceeding to a more detailed analysisof the possible causes of the transition.

/. CHILD SURVIVALA. Sources of informationChildhood mortality measures, particularly the infant mortality and under fivemortality rates, are amongst the most commonly used indicators of the health statusof populations world-wide (UNICEF has popularised both the infant mortality rateand the under five mortality rate as international indicators of child health - see theannual State of the World's Children for illustration). The accurate determination ofinfant and childhood mortality levels, trends and differentials usually requires acomplete system of birth and death registration. Jn most developing countries, thesesystems are often lacking or incomplete so othef ways have to be found to measurechild survival. Amongst the methods commonly used are special questions includedin national population censuses, population-based demographic surveys, andprospective community surveys or sample registration systems.

Oman has not attempted to institute a compulsory vital registration system althoughthe coverage of the health information system is increasingly complete and has thepotential to be used to monitor changes in mortality, morbidity and fertility. For theperiod before 1970, we have very few sources of information on child mortality apartfrom reports from mission hospitals and travellers, which testify to the generally poorhealth, and poverty of the Omani population. In 1971, Boustead, (DevelopmentSecretary 1958-61) reported, for example, that after twenty years in the Middle East,his staff "had never seen a people so poverty-stricken or so debilitated with diseasecapable of treatment and cure" (quoted in Townsend, 1977: 65).

Some sample surveys were conducted in the 1970s but it was 1988 before the firstnationally representative study of health and welfare was conducted. The 1988-89

Chapter 2: Changes in Mortality and Health Status

Oman Child Health Survey (OCHS) thus fills a major gap in our knowledge of childsurvival in the 1980s. The first national population census conducted in 1993 alsocollected information suitable for the estimation of childhood mortality for Omanis.Since then, the Oman Family Health Survey (OFHS) was conducted in 1995 andthere have been an assortment of smaller more specialised studies which aregradually providing more and more information on the evolution of Oman's healthand mortality profile. The statistics generated by the various Directorates of theMinistry of Health conveniently synthesised in the Annual Statistical Reports and thequarterly Community Health and Disease Surveillance Newsletter provide a hugeamount of additional information on health and mortality to these survey data andthe census. The only reservation in using the rich array of information from thehealth services is of course uncertainties about the coverage of these services andthe characteristics of the population not represented in these data.

The information required for the assessment of childhood mortality was collected indifferent ways in different studies so that in some cases, the results from thesedifferent sources are not consistent with each other. These differences arise bothbecause of variations in estimation methods (see below) and because of data errorsand sampling biases. For Oman, the most important sources of information onchildhood mortality are shown in table 2.1

The two urban surveys in 1975 and in 1977-79 were conducted in conjunction withthe UN Economic Commission for Western Asia (ECWA). They were samplehousehold surveys in which ever-married women were asked about the number ofchildren ever-borne and surviving. They did not include a full birth history but didinclude some questions on recent deaths in the household. A full analysis of thedata from either study was never formally published. The clinic-based childhoodmortality survey in 1986 consisted of asking questions on the survival of the twopreceding born children to all mothers giving birth in public hospitals and clinics. Themortality estimates were then derived using the Preceding Birth Technique (Hill andMacrae, 1985; Hill and Aguirre, 1991). The 1988-89 Oman Child Health Survey(OCHS) was the first to collect a full birth history from ever-married Oman! women.In addition the aggregate questions on children ever-born and surviving were askedof all ever-married women, Omanis and non-Omanis, so that mortality estimates forthe whole population can be derived by indirect estimation methods (Indirecttechniques are model-based methods developed by demographers to estimate vitalrates when civil registration is lacking (See UN 1983 and section B below fordetails.). The 1993 census was a fully comprehensive enumeration of the entire defacto resident population. Note that only Omani ever-married women were asked thequestions on children ever-born and surviving so that the census does not provide abasis for the estimation of the mortality and fertility of the non-Omanis. The finalresults from the 1995 Oman Family Health Survey (OFHS) are not yet available butthis study included a full birth history as well as a set of questions on maternal andchild health as well as some questions on chronic and acute illness in adults.

1.2


In addition to the surveys, as was mentioned above, Oman's health informationsystem is very comprehensive and could easily be exploited to capture year to yeartrends and regional differentials in child survival. The antenatal registers trackwomen from pregnancy to delivery and the MR2 Child Health Register followschildren until fully immunised. Defaulters are traced and systematically followed sothat the survival of the new-borns is known very accurately. At present, the systemis used principally to mange the provision of health services but it could readily beadapted to form the basis of a comprehensive vital registration system.

Table 2.1 Sources of Information on Childhood Mortality in Oman.________Source Date Coverage Size & notesSocio-demographicSurvey in 5 Towns

Socio-demographicSurvey in 11Towns

Clinic-basedChildhood MortalitySurvey

Oman Child HealthSurvey(OCHS)

1975

1977-79

March/May1986

Nov. 1988/Feb. 1989

General Census ofPopulation,Housing andEstablishments

Oman FamilyHealth Survey(OFHS)

1-10December1993

1995

5 towns: Muscat,Mutrah, Sohar, Nizwaand Sur

11 towns

All 37 public hospitalsand MCH centres

Representative nationalsample.i. Household data for allresidentsii. Full birth history etc.for Omanis only

Everyone resident inOman on census night.Children ever-born &surviving questions forOmani ever-marriedwomen.

Representative sampleof Omani households

3829 households;21,119 population;5268 ever-marriedwomen; 92% Omani

13,923 households;4262 -ever-marriedwomen aged 15-49.

2585 last live births

24,321 individuals;3617 ever-marriedwomen under 50;health data for 6,886children born in 1982and after.

2,018,074 totalpopulation. 264,055ever-married Omaniwomen aged 15 andover.

6103 households;51,562 persons,6405 ever-marriedwomen interviewedfor the reproductivehealth survey.___

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B. Estimation MethodsA variety of different approaches are used internationally to measure levels andtrends in childhood mortality when full registration of births and deaths is inaccurateor incomplete. We can distinguish two different approaches. On the one hand, wecan ask women about the dates of all their live births and about the dates of death ofthose who have died by the time of the survey. These data, usually arranged in theform of a chronological table, are then used to calculate directly the probabilities ofdying for different generations of children or for different time periods before thesurvey. A life table approach is usually used to deal with the problem of the varyingexposure times of the different children to the risk of dying. This is the "direct"approach to the estimation of childhood mortality, so called because it uses the dataas reported by mothers without reference to any models or the inclusion ofadditional assumptions. This way of collecting the dates of birth and dates of deathfor children who die is a laborious and difficult task so the approach is only suitablefor use in sample surveys such as the 1988-89 OCHS and the 1995 OFHS. Oncethe data have been collected, however, and they prove to be of reasonably goodquality, there are many possibilities for detailed analysis. The so-called birth historyapproach, for example, is the only method that allows us to examine the age patternof mortality in childhood. It is the sole method that permits the analysis of relatedfactors such as birth interval length and the part played by the demographic andsocio-economic characteristics of individual mothers in determining child survival.

For larger enquiries such as the 1993 census, much simpler questions have to beused to measure child survival. In general, the so-called "Brass" questions (Brass etal, 1968), on the total number of live born children and the total number alive at thetime of the enquiry, have been in use in censuses around the world since the early1900s. The proportions dead of children ever-born tabulated by the mother's age ormarriage duration is the key information needed to reconstruct levels and trends inchildhood mortality in the twenty or so years before the census or survey. Togenerate mortality measures, which are comparable with those from vitalregistration, data or the direct methods applied to birth histories mentioned above, anumber of assumptions and some demographic models are required. The suite ofmethods developed for this purpose are known as "indirect" techniques since theywork with the proportions of children dead rather than with .the direct reports onbirths and deaths recorded by date of occurrence (UN, 1983). The result of theapplication of these methods is a series of life table measures of childhood mortality,which provide an estimate of the time trend of childhood mortality for periods of timebefore the study. Model life tables are required to provide a consistent series ofinfant or under 5 mortality rates. Thus, the indirect approach makes the datacollection simpler and less prone to error but depends on demographic models andassumptions to produce the final estimates of the trends and differentials in childsurvival.

A more recent addition to this collection of indirect methods is the Preceding BirthTechnique developed to make fuller use of information on the survival of previous

2.4


born children when mothers deliver again (Hill and Aguirre 1991). The method worksbest when most mothers deliver in clinics where records are kept. It is mentionedhere since one of the earliest estimates we have for childhood mortality in Omanstems from a trial of the method in 1986 in all public hospitals and health centres.

To produce the mortality estimates from these diverse sources, model life tablesmust be employed. For the sake of consistency, we have followed the principle inthe Oman Child Health Survey, which meant using the South version of thePrinceton model life tables for the early childhood mortality estimates, switching tothe West pattern from the mid-1980s onwards. This choice is justified on thegrounds that mortality of the 1-4 year-olds was relatively high compared to themortality of infants at the outset but later on, as immunisation and other child healthmeasures became more widespread, the excess mortality of the 1-4 year olds isthen reduced.

Assembling a composite picture of childhood and adult mortality in Oman is thusrelatively complex due to differences in the coverage of the different studies and inthe nature of the questions used to measure recent mortality. In addition, there aredifferent estimation methods, direct and indirect, which can be applied to the samedata so that the results can vary according to the estimation method selected.

C. Results1. TrendsThe earliest statistical information we have on mortality in Oman stems from thesurvey of 5 towns conducted in April-May 1975 with the technical support of ECWA.This study interviewed about a quarter of the households in Muscat, Mutrah, Sohar,Sur and Nizwa. This survey covered 3829 households containing 21,119 people, ofwhom 19,376 (92%) were Omanis (Directorate General of National Statistics, 1976:table 8). The data thus refer to a population of just under 100,000, the estimatedresident population of the 5 cities - table 31 in the report -- not the whole populationof Oman, and probably covering a population with better than average health andmortality.

All ever-married women were asked about their total number of live births and thenumbers surviving. It is these data on parity and on the proportions dead, whichallow us to estimate childhood mortality from the survey (Table 2.2).

As we shall see from later comparisons, this first attempt at collecting reliable fertilityand mortality data in Oman was an important pioneering study but was probably notvery successful at enumerating all the births and child deaths experienced byOman's female population, especially older women. We see in the average parities,for example, a decline in the reported children ever-born above age 40 - a sure signof some omissions of births. This is not surprising given the poor educational levelsof the population at this time and the difficulties which must have surrounded the

2.5


asking of relatively personal questions in the home for the first time. Most of theenumerators were female teachers who would have been very largely non-Omani atthis time so there may have been some communication problems. In addition, thetraining period for the enumerators was only 6-8 days for each team. Generally, thedata seem internally consistent and reliable enough particularly for the period nearthe date of the survey.

Table 2.2 Children Ever-born and Surviving and Under 5 Mortality Estimatesfrom the 1975 Survey of 5 Towns.

Age ofwomen

15-1920-2425-2930-3435-3940-4445-49

Averageparity

0.5551.9713.5874.8945.0975.4495.321

% childrendead

10.911.411.715.921.622.730.5

Referencedate

Aug 1973Mar 1972Apr 1970Mar 1968Jan 1966May 1963May 1960

q(1): infantmortality per

1000788989108131130155

q(5): under 5mortality per

1000104124123162210208260

Notes: Mortality estimates calculated by indirect methods using the SouthPrinceton model life tables. See text for justification.Source: Directorate General of National Statistics (1976): tables 7, 25, andAppendix tables 14 and 31.

The data in Table 2.2 suggest that fertility was relatively modest at this time (anestimated total fertility rate of just 5.4 births) and that infant mortality was below 100per 1000. Both these numbers seem surprisingly low. Comparison with thesubsequent 11 towns survey (which excluded the 5 larger towns surveyed in 1975)but using the same methodology suggests some under-enumeration of both birthsand deaths since the differentials between the 5 towns and the 11 smaller townsseem very large (Figure 2.1). Although the absolute levels in the first survey may betoo low, the trend in child survival may be a useful guide to the improvement ofmortality conditions in the 1960s and 1970s. As we see on Figure 2.1, theimprovements in childhood mortality which become better documented in the laterperiod appear to have begun in the early 1960s and to have continued to thepresent day.

The next statistical source we have for childhood mortality stems from the survey ofeleven smaller towns conducted in 1977-79. This was similar in structure and designto the 1975 study of 5 towns but with a much wider coverage. In addition, we expectboth the surveyors and the respondents to have grown in competence andexperience following the 1975 study. The studies were spread out over a longer timeperiod that should have contributed to an improvement in data quality.

The results obtained by applying indirect estimation methods to the data on children

2.6


ever-born and surviving from the 1977-79 surveys are shown in Table 2.3.

These results clearly only apply to the eleven towns and exclude the five townssurveyed in 1975 as well as the rest of the rural population. It is difficult to say howrepresentative the figures are of the national situation at that time. Most of thepopulation was thought to live in the rural areas and small towns at the time of thesurvey and so they may be a better guide than the 1975 survey to mortality levels ingeneral. In any case, the figures give us some idea of the high levels of childhoodmortality in the 1960s in some of the more remote parts of Oman. In the 11 towns,about a third of all children then were dying before their fifth birthday. The decline inthe 1970s was precipitous so that by September 1976, infant mortality had fallen tobelow 150/1000 and about one-fifth of children were dying before their fifth birthday.

Table 2.3 Infant and Under 5 Mortality Estimated from the Proportions Deadof Children Ever-borne as Reported in the 1977-79 Survey of 11 Towns.(Probabilities of dying per 1000)Mortality measure

Infant mortalityUnder 5 mortality

Feb.1964227337

Oct.1966222330

Mar.1969184274

Apr. 1971

150225

June1973152227

Apr.1975129191

Sep.197684119

Source: Indirect estimates using Princeton South model life tables from data from th<11 towns surveys reported in ESCWA (1981), table 9.3.

The OCHS provides us with the first estimates of childhood mortality both for thetotal population, Omanis and non-Omanis included (Table 2.4).

Table 2.4 Infant and Under 5 Mortality Estimated from the Proportions Deadof Children Ever-born as Reported in the OCHS (Omanis and Non-OmanisCombined). (Probabilities of dying per 1000)Mortality measure

Infant mortalityUnder 5 mortality

Feb.1972117171

Jan.197599143

Feb.197873101

Apr.19815776

Feb.19844557

June19863645

Feb.1988(64)(87)

Source: Indirect estimates using Princeton West model life tables: OCHS(1988-89), table 4.4.

The fall in both, infant and early childhood mortality, indicated by these data is verydramatic from the early-1970s to the late-1980s. From the more detailed data basedon the birth histories collected as part of the OCHS, we can discover much moreabout the pattern of change in the child mortality of the Omanis. The directestimates of childhood mortality for Omanis from the 1988-89 OCHS are shown inTable 2.5.

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Figure 2.1: Trends in Under 5 Mortality from Various Sources-OFHS 1995-OCHS 1988-S9 birth histories-OCHS-indirect

-PBT1985-5 Towns Survey 1975

- 1977-79 11 Towns survey1993 Census

40% r

35%

1975 1980

Reference date1985

Figure 2.2: Trends in Infant Mortality from Various Sources

25%

1975 1980

Reference date1995

-5 Towns Survey 1975-OCHS 1988-89 Birth Histories- OFHS 1995 Birth Histories-1993 Census

- 11 Towns Survey 1977-79-PBT 1985-Vital Statistics-OCHS-indirect

These calculations, based on the answers provided directly by Omani women to thefemale interviewers, are obviously dependent on the quality of the reporting and onthe completeness of the reporting of births and especially the child deaths. Giventhat deaths are more likely to be omitted than living children are, we can againregard the estimates above as minimum estimates of childhood mortality in Oman.The message from Table 2.5 is very clear. For Omani children born 1969-73, infant

2.8


mortality fell from 140/1000 to less than a fifth of this value (26/1000) by 1984-88.The proportion of Omani children dying by their fifth birthday fell from 22% in 1969-73 to under 4% by 1984-88. This is a startling drop with few parallels elsewhere inthe world, as we shall see later.

Table 2.5 Probabilities of Dying per 1,000 Omani Children for 5-year Periodsbefore the Survey: Direct Estimates from Birth Histories.Mortality measureInfant mortality qoEarly childhood mortality 4qiUnder 5 mortality sqo

1969-7314098

225

1974-789750142

1979-83471965

1984-88261137

Source: Oman Child Heath Survey OCHS (1988-89), table 4.5.

Turning to the census data, which provide us with proportions of children dead bythe age and marriage duration of Omani mothers (non-Omanis were not asked thefertility and child mortality questions), we can calculate the equivalent probabilities ofdying for periods before the census. The results are shown in Table 2.6.

Table 2.6 Indirect Estimates, of Childhood Mortality for Omani Children fromthe 1993 Population Census. (Probabilities of dying per 1000)____________Measure__________1979 1982 1985 1988 1990 1992Infant mortality 127 101 71 55 43 39Under 5 mortality_____187 146 99____73____55 49Source: Calculated from 1993 census data by indirect methods, West model lifetables.

Again, the picture is very striking and shows a very dramatic improvement inchildhood mortality over the 20 or so years before the census. With the indirectmethods of estimation, we are unable to say anything about the rate of change ofinfant mortality compared to the mortality of children aged 1-4.

The most recent 1995 Oman Family Health Survey collected full birth histories fromever-married women as in the 1988 Oman Child Health Survey. The mortality ratesshown in Table 2.7 are taken directly from the preliminary report and are derived bylife table calculations from the birth histories. This survey confirms the continuingand extremely rapid improvement in child survival into the 1990s.

The broad picture of the improvement of mortality of infants and the under 5 year-olds can be more readily appreciated on a graph. On Figure 2.1, all the points fromdifferent sources, including the 1986 clinic-based survey, have been plotted forcomparison. By asking mothers seen at the time of a subsequent delivery about thesurvival of their preceding birth, this study was able to come up with an estimate forthe probability of dying between birth and the second birthday of 44 per 1000. Thisfigure (using model life tables for extrapolation) is associated with an infant mortalityrate in the 1980s of 40 per 1000 and a probability of dying before age 5 of 49 per

2.9


1000 for mid-1984.

Table 2.7 Infant and Childhood Mortality from the Birth Histories in the 1995Oman Family Health Survey._____________________________Approx. Date of Infant mortality 1-4 mortality per Under 5 mortalitymortality estimate____per 1000: q(1)____1000:4q1____per 1000: q(5)March 1993June 1987March 1983March 1978

14.326.646.994.6

5.76.715.028.1

20.033.161.2120.0

Source: Oman Family Health Survey 1995, Preliminary Report, table 12.1.

All these data from different sources and analysed in different ways provide solidevidence of a very rapid improvement in the mortality both of infants and of childrenaged 1-4 since the late 1960s. Although the 1993 census data describe a slightlyhigher pattern of mortality than in the earlier surveys, the slope of the trend lines aresimilar. It is hard to explain why the census data produce higher mortality estimatesthan the 1988-89 or the 1995 surveys -- it seems unlikely that Omanis would over-report the number of dead children in the census and the evidence is that thechildren ever-born were not under-reported in any major way. It seems best toaccept the general trend indicated by a combination of the 11 towns survey of 1977-79, the direct and indirect estimates from the 1988-89 Oman Child Health Survey,and the direct estimates from the 1995 Oman Family Health Survey, as representingthe best estimates of the pace and timing of childhood mortality improvements fromthe mid-1960s onwards.

Although registration of births and deaths is not compulsory, 89% of births in thethree years before the 1995 OFHS took place in health facilities (OFHS, 1995, table10.1). It is believed that most of the infant deaths are also known to the healthfacilities because of the efficient system of follow-up and defaulter-tracing afterdelivery. The infant mortality rates from the health service data are thus areasonable comprehensive indicator of infant mortality trends. These data areshown on Table 2.8 and have been added to Figure 2.1 where the correspondinginfant mortality rates from all the sources used for the under 5 mortality rates havealso been plotted.

One notable feature of Figures 2.1 and 2.2 (showing trends in infant and under 5mortality) is that the decline in infant and childhood mortality seems to have beeninitiated before the major development efforts of the 1970s. One question to whichwe will return is the possibility that small increases in prosperity and the beginningsof social change were under way as oil exploration began and oil exports started in1967. Before going further, we need to establish in greater details the characteristicsof this transition. Usually, the distribution of deaths by age and sex, by region and bysocial class, by cause and place of occurrence are all valuable clues to the factorsdriving the mortality transition. In the sections, which follow, we describe some of

2.10


these patterns for childhood mortality, returning to the issue of causes of theimprovements in later chapters.

Table 2.8 Infant Mortality Rate Calculatedfrom Health Service StatisticsYear Infant Mortality Year Infant Mortality The conclusion from this

_______Rate___________Rate___ section is very clear. Oman1980 64JO 1989 3 T O h a s achieved one of the1981 59.0 1990 29.0 fastest declines in child1982 55.0 1991 27.0 mortality ever recorded. In the1983 51.0 1992 25.0 1960s, about 35% of Omani1984 48.0 1993 23.0 children were dying before1985 45.0 1994 23.0 their fifth birthday. In the mid-1986 42.0 1995 20.0 1990s, less than 2% were1987 38.0 1996 18.3 dying by age 5. For infants,1988____43.0____1997____18.0____ the story is similar; aSource: Statistical Yearbook 1995, table 2.18 and reduction from an infantAnnual Statistical Report, 1995 & 1997, table 3.1 mortality rate of about 200 per

1000 live births in the mid-1960s to rate of about 20 per 1000 in the mid-1990s. As Table 2.9 and Figures 2.1and 2.2 all show, this implies an annual improvement of over 7% in infant mortalityand of over 9% for under 5 mortality over the 30 year period 1965-1995. This trulyremarkable achievement requires detailed analysis.

Table 2.9 Direct Estimates of Infant and Childhood Mortality for Omani Children1969-1995. (Rates per 1000)Rates

NeonatalPost-neonatalInfantChildhood (1-4)Under 5

1969-73568414098225

1974-7838599750141

1979-832225471965

1984-881115261137

1986-91151127733

1991- Annual change958614620

8.5%1 1 .4%10.0%12.1%10.5%

Source: OCHS (1992): table 4.5 and OFHS (1996), table 12.1

2. Age Patterns of Mortality ChangeDetailed analysis of the birth histories reveals some special features of the Omanitransition in childhood mortality. Assuming the data from the 1988-89 and the 1995surveys are equally reliable, it seems that neonatal mortality, post-neonatal mortalityand the mortality of 1-4 year olds all decreased at about the same rate over theperiod 1969-73 to 1991-95 (see Table 2.9 and Figure 2.3).

In most high mortality countries, we usually see major mortality reductions in the 1-4age group but less change in the neonatal and post-neonatal categories. The

2.11


reasons are related to the nature of the interventions and the age pattern of deathby cause. Initially, most countries begin with an immunisation programme affectingfor the most part the mortality of 1-2 year olds. Only much later do we see aneffective set of clinical and other community-based interventions introduced to dealwith the problem of neonatal and perinatal mortality. Oman, it seems, managed toreduce both the under 1 and the 1-4 mortality at the same time. As Table 2.9 andFigures 2.1 and 2.2 show, there have been huge improvements in the survival ofyoung children over the 1969-95 period with 1-4 and infant mortality rates improvingat approximately the same pace.

Perinatal and early neo-natal mortality were relatively high in the 1980s although theabsolute levels are extremely low. The estimate based on data from the majordistrict hospitals in 1987-88 was 21 per 1,000 births (Perinatal, neonatal and infantmortality, no date). By 1994, this rate had not changed greatly (it was estimated tobe 17/1000 in 1994) with asphyxia the leading cause of death. About 8% of births in1995 were low birth weight (<2500 grams) and about two-thirds of the low birthweight babies are small for gestational age (Annual Statistical Report, 1997: table 9-4). The still birth rate was about 12/1000 births for 1995. Dealing with theseconditions requires both more involvement of mothers and the community and moretimely clinical intervention for mothers at risk.

3. Sex DifferentialsIn many male-dominated societies, the survival of girls is worse than that of boys.Direct estimates calculated from the OCHS and indirect estimates from the 1993census reveal that sex differences in the mortality of boys and girls are insignificantfor the recent period. The OCHS survey shows, for example, that for the 10-yearperiod before the survey, the infant mortality rate and the under five mortality rate forboys-was slightly higher than that for girls (OCHS, 1992: table 4.7). The moststriking trend since the 1970s has been the fast decline in the neonatal mortalityrates for both boys and girls. This improvement is probably due to the rising fractionof deliveries taking place in health facilities. Thus, we have no evidence in the sex-specific mortality rates to suggest any discrimination against girls.

4. Geographical Differentials in Childhood MortalityThe 1988-89 OCHS was a sample survey and so it is difficult to produce figures onchanging levels and patterns of child mortality for small areas or sub-populations.One feature is notable in the rates calculated for the 10-year period before thesurvey. This is the narrowness of the gaps between the infant and under fivemortality of the rural areas and the urban or semi-urban areas. The under 5 mortalityfor the urban areas averaged 38/1000 for the period 1979-88 but the rates for thesemi-urban (52/1000) and rural (54/1000) were not far behind (OCHS, 1992: table4.6). The narrow spread of these figures suggests that health improvements werequite widespread in the Omani population. The regional differences are a little wider.Note, however, that the numbers in the OCHS (1992), table 4.6, are small for some

2.12


Figure 2.3: Trends in Age Patterns of Childhood Mortality from the1988-89 OCHS and the 1995 OHFS

£ 150 i^ I

•Neonatal -»-Post-neonatal -*-Infant -#-Childhood (1-4) -»-Under5

Table 2.10 Regional Differentials inChildhood Mortality around 1988.(Probabilities of dying per 1000)Governorate

al-WustaDhofarA1 DakhliyahA' Sharqiyahal-BatinahMusandamA' DhahirahMuscatAll

InfantMortalityrate: q(1)

735147474444353143

Under 5mortalityrate: q(5)

1016861615757443956

Source: Calculated from the proportionsdead of children ever-born to Omani womenmarried 10-14 years in the 1993 censususing Princeton West model life tables.

advantage. In 1990-95, for example, the infantper 1000, 37% higher than in urban areas where

The 1993 census which asked thequestions on children ever-bornand surviving of all Omani womenprovides a stronger basis for thestudy of regional differentials thanthe sample surveys. Using indirectmethods and focusing on womenmarried 10-15 years, we canderive the following estimates forthe about mid-1988 (Table 2.10).

These figures suggest that as themortal i ty t rans i t ion wasproceeding, mortality differentialswidened. Preliminary data from the1995 survey suggest thatdifferentials in child survival haveclosed in absolute terms althoughthe children born to urban, literatemothers still have a considerablemortality rate in rural areas was 17was 13 per 1000 (OFHS, 1995).

2.13


5. Differentials by Age of Mother, Parity and Birth Interval.The biological effects of age, parity and birth interval length are well known andquite systematic in most human populations. The 1988-89 OCHS drew attention tosome of the special risks faced by children born to teenage mothers and to highparity older mothers. The effects of age and parity are confounded. The very lowage at first marriage in Oman in the past (over half of all women aged 30 and over in1988 had married by age 15) meant that a substantial amount of fertility took placein the younger age groups. As the parities by age bring out in the 1988 survey, ever-married women aged 20-24 had borne on average 2.5 live births, rising to 4.1 livebirths for the 25-29 age group. This is high fertility especially in the youngest agegroups. We find, therefore, that the infant mortality rate of children born to 15-19year olds in 1979-88 was over 1.5 times as high as the rate for children of womenaged 20-29 (OCHS, 1992, table 4.7). The effects at the older end of the reproductivelife span are less severe but nonetheless significant. The infant mortality rate ofbirths to women 40-49 at survey was nearly one-fifth higher than that for womenaged 20-29.

Whilst the mean age at marriage is rising quickly - and with it the mean age at firstbirth - the major demographic factor which will affect child mortality in the future willbe a decline in fertility. This decline has already begun with the 1993-5 period totalfertility rate estimated to be 7.1 births, down from 7.8 in 1987-88 (OFHS, 1995: table7.2 and OCHS, 1992, table 11.11). Further steep falls in fertility are evident from thevital registration data. These figures produce a crude birth rate of 29/1000 for 1997,down from 45/1000 in 1990 (Annual Statistical Report, 1997: table 3.1). Still, withrelatively high fertility, child-bearing extends into ages and parities where the risks ofan adverse pregnancy outcome and a premature death of the infant are both morelikely. For children born less than two years after a preceding birth, the infantmortality rate is 2.6 times higher than for children born 2-3 years apart (OCHS,1992: table 4.7). Clearly, it would be beneficial for mothers and children if there werefewer and better spaced births and if fertility could be concentrated in the 20-35 agerange, thus avoiding the age ranges where excess risks appear. These are the aimsof the birth spacing programme whose organisation and effects are discussed laterin this chapter.

6. Social Class DifferentialsSome of the differences in child mortality by social class are related to differences infertility patterns and to ecological effects linked to place of residence. Oneremarkable feature of the Omani situation is the small range of the child mortalityrates for mothers with different levels of education. In the 1988-89 OCHS survey, forexample, we find that the infant mortality of children born to illiterate mothers was37/1000 whereas for mothers with at least a primary school education, the rate was30/1000 (OCHS, 1992: table 4.6). Even for the under 5 mortality rates, where theeducation of the mother might be expected to play a large role in child care and childsurvival, we find that the rates are similarly close (52/1000 for children of illiterate

2.14


mothers; 45/1000 for mothers with at least a primary school education).

Part of the explanation must be the very comprehensive nature of the healthservices - we see small differences in the use of ante-natal services, place ofdelivery or in up-take of immunisations by the mothers education (OCHS, 1992:chapter 9). Certainly, very few mothers who had delivered at home said that thereason for doing so was difficulty of gaining access to a health facility (OCHS, 1992:table 9.15). It may also be that improvements in living standards have also beenquite generalised. These questions about the reasons for this pattern of change willcome up again later.

7. International ComparisonsOne of the clearest indications of the rapid progress Oman has made in childsurvival in recent years is the changing position of Oman with reference to otherArab countries. Using the under five mortality as the best single indicator of childsurvival, we see from Figures 2.4a and 2.4b the remarkable improvement in Oman'sranking from 1960 to 1992. Moving from a position amongst the countries with thehighest child mortality in 1960, (and it has to be said that 300/1000 is probably anunder estimate of under five mortality in Oman around 1960, as we have seen fromthe data in the 11 towns survey, table 2.3), Oman is now amongst the bestperformers in the Arab region.

Another perspective on the pace of recent improvements can be gained from anexamination of the under 5 mortality trends in Oman in comparison with the otherstates of the Arabian Peninsula. For this comparison, we have the series of childhealth surveys and the PAPCHILD surveys, all of which were conducted on a similarbasis. The results (using the indirect estimates to ensure comparability) are shownin Figure 2.5. Yemen still suffers from exceptionally high mortality. The consistencyof Oman's performance is remarkable - the graph shows that starting from a muchhigher level than all other countries except Yemen, Oman has caught up oncountries like Bahrain and Kuwait, which had a much earlier start in oil production,and in the subsequent process of economic and social development.

Another comparison is to compare the time difference countries took to move from ahigh level of infant and child mortality to some lower level. As Table 2.11 shows,Oman's mortality transition ranks as one of the fastest ever.

D. Changing Patterns of Cause of DeathWithout a system of full vital registration and medically certified death certificates,our knowledge of the causes of death in young children is necessarily incomplete. InOman, we have quite comprehensive statistics from health facilities, which cover alarge fraction of the total population. About one-fifth of all infant deaths occur inhospitals so we can use these data as an indicator of the leading causes of death inyoung children although there may be some selection factors at work which will

2.15


produce biases in the data. As indicated above, the use of the health services isvery widespread and we see only small differences in usage by social class. As the1988-89 survey bears out, some 88% of all mothers had at least one ante-natal visit(OCHS, 1992: table 9.2); and this figure was 83% for the rural areas, 85% amongstilliterate mothers and 73% for the remote southern region (OCHS, 1992: table 9.5).Only 13% of births in the 10 years before the survey occurred at home and a doctoror a nurse attended 87% of all deliveries. Post-natal care for mothers was relativelylow (38%) but 97% of all children has received some immunisation and 99% hadreceived the BCG immunisation. Thus, there are sure to be biases in the hospitaldeath statistics but they are probably less important than in other countries wherelevels of contact with the health services are much lower.

Table 2.11 Years Taken to Reduce Infant Mortalityfrom 100 to 30 per 1000 Live Births in SelectedCountries. ________________________

Information on cause ofinfant deaths occurring inhospitals and healthcentres is available from1988 onwards. The totalnumber of deathsregistered this way issmall (just 2164 in total in1995) so that the scopefor detailed analysis bycause and age group isquite limited. The reportscome f rom theunpublished annual in-patient morbidity andmortality statistical reportsthat c lassi fy eachrecorded death by cause

using ICD categories and by broad age groups. Despite the small numbers in somecells, we can still discern some trends in the causes for specific age groups.

Taking neonates (those dying within 28 days of birth) first of all, we see thatconditions originating in the perinatal period and congenital anomalies haveremained by far the most important causes of death for this age group (AnnualStatistical Report, 1995, table 10-15). For children dying between 28 days and oneyear, diseases of the respiratory system and congenital anomalies dominate.Considering all infant deaths together, we see some small change over the 1988-95period. The leading causes of death among infants in 1988 were (in descendingorder); slow foetal growth and malnutrition; conditions originating in the perinatalperiod; congenital anomalies, and pneumonia. By 1995, when infant mortality had

Country

United Arab EmiratesRepublic of KoreaBarbadosOmanChileTunisiaKuwaitSyriaMauritiusJordanEngland and Wales

Periodcovered

1965-771960-731956-691975-901964-801975-921955-801966-921954-801960-921915-51

Years to reduceInfant mortalityfrom 100 to 30

per 1 0001213131516172526263236

Source: Mitchell (1976 and 1988); Hill and Yazbeck(1994).

2.16


fallen to low levels, the causes related to conditions around the time of birth hadbecome slightly more important as the management and prevention of the infectiousdiseases (such as pneumonia) improved. Improved perinatal care had also resulted

350

« 300

I| 250j

I 200

I| 150

O100

50

0 —

^

Figure 2.4a: Comparison of Under 5 Mortality amongSelected Arab Countries, 1960.

/ // / / /// + */s s */ //Country

Figure 2.4b: Comparison of Under 5 Mortality amongSelected Arab Countries, 1992

X X s/ f// ' /// ss '/ +//&

Country

in a decline in the proportions of the deaths attributed to causes in this period. Theremarkable new feature in the 1990s is the small number of deaths due to infectious

2.17


disease. Data from 1988 to 1995 show that only 1% of inpatient infant deaths areattributable to infectious diseases. The low rates can only be attributed topreventative activities such as immunisation and good clinical care of cases. Deathsfrom acute gastro-enteritis and diarrhoea that still persist have also declined causing4% of all deaths in 1988 and no deaths in 1995.

Figure 2.5: Indirect Estimations of Under 5 Mortality in the Gulf Region and Yemen

—#— Oman —t— Yemen » Kuwait —^-Qatar —»—Saudi Arabia -^-Bahrain

1974 1976

The main causes of in-patient deaths for children aged 1 to 14 are shown in Table2.12. The two principal specific causes (septicaemia and intracranial injuries) remainthe same over the whole 1988-95 period. Over half the deaths are attributed a largenumber of different causes too numerous to be the subject of detailed analysis.Again, there are some signs in the data in Table 2.12 that the non-infectious causes(leukaemia, neoplasms and so on) are growing in importance as the infectiousdiseases and the more complex conditions associated with child birth are beingmanaged more effectively by the health system. Mortality from septicaemia hasbeen high through the years from 1988 to 1995. Small outbreaks of such diseasesoccur from time to time. In 1995, septicaemia caused 10.1% of the deaths in thisage category. Meningitis and burns have both been on the decline since 1988.Pneumonia deaths are declining slowly, as Table 2.12 illustrates.

Based on the cause of death data of the two age groups, we see that deaths fromslow foetal growth/malnutrition, congenital anomalies and septicaemia remain aproblem among infants whereas deaths from acute gastro-enteritis and infectiousdiseases are rare. Among the older age group of children (age 1-14) there has beena rise in deaths due to pneumonia, fractures and neoplasms while those frominfectious diseases have shown considerable fluctuations over the period. Deathsfrom septicaemia and interacranial injuries have remained high, contributing 25% of

2.18


all deaths in 1995. Overall, we see the co-existence of older diseases and newerhealth problems in the statistics on in-patient deaths among infants and children ofOman.

Table 2.12 Percentage Distribution of Causes of Death in Children Aged 1 to14 for 1988-1995.____________________________________Cause____1988 1989 1990 1991 1992 1993 1994 1995 AverageSepticaemia 13.7 To3 rLO1^8 8~ !61^4 1O8 1CL1 vTiIntracranial 13.0 11.6 7.7 8.2 17.3 6.7 9.3 13.5 10.9

InjuriesMeningitis 3.1 5.8 3.8 1.2 1.6 0.0 5.4 0.7 2.7Pneumonia 4.3 5.1 6.6 5.6 6.2 2.2 6.2 5.4 5.2Leukaemia 1.9 2.6 4.4 1.9 5.5 1.5 2.3 1.4 2.7Neoplasms 3.7 3.9 6.6 6.9 6.2 3.7 5.4 6.8 5.4Burns 4.4 3.2 3.3 1.2 0.8 1.5 4.7 2.7 2.7Infectious 1.8 5.1 2.7 1.9 5.5 6.9 6.2 2.7 4.1

diseasesFractures 1.2 1.9 1.1 1.2 0.8 2.2 8.5 6.8 3.0Other_____52.9 50.5 52.8 58.1 47.5 58.9 41.1 50.0 51.5Total_____100 100 100 100 100 100 100 100 100Source: In-patient health statistics. Unpublished data provided by the Departmentof Information and Statistics, Ministry of Health.

II. ADULT SURVIVAL

Neither of the two surveys, the OCHS and the OFHS, nor the 1993 census includedthe questions that would have helped to measure the levels and trends in adultmortality. Our best guess of adult mortality levels is to extrapolate from theestimates of childhood mortality, checking for consistency with the data from thehealth services largely based on hospital deaths. This is rather unsatisfactory sincechildren have been the special focus of the health services (see above) and in asituation where mortality is changing rapidly, there may be divergent trends amongstadults and children. Nevertheless, adopting this procedure since we have nopractical alternative, we discern that the expectancy of life at birth for Omanis in1992 was probably around 77 years, based on the data on child survival andextrapolation in model life tables. For adults, this implies that 92% of those reachingage 15 will survive to their 60th. birthday - a very high level of survival indeed. Atage 60, the average expectancy of life will be over 23 years. The implications ofthese very low mortality rates for the future are significant - growth rates for theelderly will be very rapid. As fertility falls, Oman will then see an increasingproportion of its population in the older age groups, with important implications forhealth services and the patterns of cause of death.

Apart from these extrapolations, the only clue to the pattern of adult mortality inOman is from adult inpatient deaths by cause and sex. Again, there are biases in

2.19


these data but about a quarter of all deaths occur in health facilities.

A. A dult In-pa tien t Dea ths.The leading causes of death of adult in-patients between the years of 1989-1995 areshown in Table 2.13. Circulatory diseases account for about 47% of all adult deaths,most amongst adults 45 years and over. Some of the main diseases in this categoryare ischaemic heart disease, cardiac dysrhythmias, acute myocardial infarctions,diseases of the pulmonary circulation and heart, and cerebrovascular diseases.

CauseCirculatory diseasesNeoplasmsInjuries and poisoningInfectious diseasesIll-defined causesRespiratory diseasesDigestive diseasesGenitourinary diseasesBlood, endocrine and immune systemNervous systemTotal (%)Total deaths 1989-95

Male45.811.411.46.85.85.65.13.02.52.6

100.06,302

Female49.513.35.46.36.96.03.73.13.42.4

100.03,815

Total47.212.19.26.66.25.84.63.12.82.4

100.010,117

Source: Data from in-patient statistics, Annual Statistical Year Books 1989-1995Ministry of Health.

Neoplasms constitute 12% of all deaths, again mainly in the people aged 45 yearsand over. Data from the Oman National Cancer Registry show stomach cancer asthe most common cancers among Omani males, while breast cancer is the mostcommon among Omani females. Other sites of malignancy are lung, trachea andbronchus, prostate and lymphatic and hemopoietic tissue.

Lung cancer, a leading cancer world-wide among males,, is still trailing second.However, with changes in live styles and increasing prevalence of smoking (23% inmales, 1.5% in females, National Diabetes Study 1991, unpublished date), lungcancer may soon overtake stomach cancer in ranking among males.

Injuries and poisoning constitute 9.2% of all deaths. These cases are clearly morecommon in males between the ages of 15 and 44 years. The main injury in all agegroups, especially among the males, appears to be intracranial and internal injuriesincluding the spinal cord. These injuries are likely to be from road traffic accidents.Other significant causes of death for the 1989-1995 period included (by descendingorder): infectious diseases, signs of ill-defined conditions, respiratory diseases,

2.20


digestive system diseases, genitourinary, blood and endocrine system and thenervous system.

In summary, we see in these data the beginning of a pattern of death morecommonly seen in low mortality countries. Oman's health transition for adults is wellunderway.

Maternal mortalityInformation on maternal health for the community was not available until recentlydespite the wealth of information on the MCH cards and other records. For maternalmortality in particular, a new notification system was established in 1991 to reportmaternal deaths. The number of reported maternal deaths is very small and so therate fluctuates widely from year to year (Table 2.14).

Year Pregnancy- Recordedrelated maternal births

deaths19911992199319941995Total

13134136

49

45,67047,78547,38246,29944,670231,806

ratio* per100,000births

28278

2722

21.14*Maternal deaths due to direct and indirect causesabstracted from Community Health and DiseaseSurveillance Newsletter 1996 5(1): 4 and 19976(1): 4-5. Statistical Yearbook 1995, table 10-18.1994-96 figures based on a projection of all birthsAnnual Statistical Report (1996, 1997: 3.5).

Figures for 1991-96 showthat 13% of maternal deathswere to women under 20 and18% to women over age 35(Community Health andDisease Survei l lanceNewsletter, 1996:5(1): 5).Over 44% of the maternaldeaths were to women withparities of 7 and above.The most recent figuressuggest a very low maternalmortality ratio largely due tothe expansion of the ante-natal services and to thehigh proportion of births

occurring in health facilities. The high level of fertility still puts women at risk veryfrequently but the birth spacing programme initiated in 1994 aims to have over halfof all births spaced 3 or more years apart by the year 2000 (Community Health andDisease Surveillance News Letter, 1997, 6(2): 1-2). More details of this programmeare given below. In addition, counselling in the ante-natal clinics is encouragingmore and more Omani mothers to give birth in health facilities (Community Healthand Disease Surveillance News Letter, 1992 1(3): 4).

C. Fertility and its Effects on Mothers and Children.It is very clear from the 1988-89 OCHS, the 1993 population Census and the 1995OFHS that the fertility of Omani couples was and remains extremely high. On

2.21


average, older women reported close to 8 live births in the OCHS and of course,many couples had much larger families. Fertility rates in the Gulf states in generalare high but the figures for Oman were amongst the highest in the late 1980s andearly 1990s (Table 2.15).

From the older surveys in the 1970s, it seems that fertility was lower in the pastalthough we must recognise that the 5 Towns Survey of 1975 and the 11 TownsSurvey of 1977-79 probably under-estimated the true level of fertility in the Omanipopulation (Table 2.16). The OFHS, for example, reports estimated total fertilityrates for the late 1970s of nearly 10 births per woman, almost double the levelindicated by the 11 Towns Survey of 1977-79 (OFHS, 1995: table 31). Table 2.16summarises the available data on the parities of Omani women by age.

From the parities in Table 2.16 and in the birth histories in the 1988-89 OCHSsurveys, there is evidence of a rise in fertility from 1975 to 1993 with more recentfalls for younger women after 1993. A more sensitive measure of fertility change isthe pattern of the age-specific rates. These rates are calculated from theretrospective birth histories, which form the core of the OCHS and the OFHS. In allsuch retrospective surveys, there are always questions about data quality and theability of mothers to recall events, which took place many years before the interview.The graph of the rates (Figure 2.6) is very encouraging on this point, since there is agood match between the rates reported in the 1988-89 and the 1995 surveys bysuccessive cohorts for approximately the same calendar period. The rise in fertilitybefore 1980 cannot be confirmed from the 1995 survey. Indeed, the analysts of the1988-89 survey believed that some of the rise was due to reporting errors (OCHS,1992: 218-9). Taken with the parity data from the 1975 and the 1977-79 surveys, itseems clear that the fertility of Omani women did rise significantly in the 1960s and1970s. Some of the factors responsible were probably biological and many werebehavioural. Some are related to the changing patterns of breast-feeding describedin the 1988-89 OCHS: table 11.13. As in Yemen, the initial forces of modernisationled Omani women to alter their traditional patterns of breast-feeding withconsequent effects on the duration of post-partum amenorrhoea. The mean durationof breast-feeding (full and partial) in the 1988-89 survey was 16 months, 19 monthsin the 1995 OFHS. In the 1988-89 survey, younger women were introducing solidsinto their children's diet at about 6 months. The OCHS reported that in the first threedays of life, 7% of mothers provided food other than breast milk for their children.The pattern of infant feeding described in the 1995 survey seems to correspond tomany of the international recommendations on breast-feeding practice and weaning.

Thus, from the child's point of view, Omani mothers are taking better and better careof their offspring. The survey data document this change by showing the differencesbetween the practices of the younger, better educated mothers and their olderpeers. Amongst older women, breast-feeding continued for longer andsupplementation with solids occurred as late as 10 months or older. Data from the1988-89 OCHS reveal that an average birth interval of 26.5 months for all mothers

2.22


with 20.8 months among younger mothers (15-19) year old and 29.7 months amongmothers aged 45-49 years.

•c 300

i

150

100

50

Figure 2.6: Changes in Age-Specific Fertility Rates for DifferentCohorts of Oman! Women: OCHS and OFHS Compared

- 25-29 » 30-34 -

1975 1980

Reference date1995 2000

Table 2.15 Total Fertility Rates for the 12 Monthsbefore each Survey for Selected Arab Countries.Country Total Date of Date of

fertility survey reportrate

OmanYemenKuwaitSaudi ArabiaUnited Arab EmiratesQatarBahrainEgypt

7.847.706.516.465.914.494.194.10

1988-891990198719871987198719891991

19921991199119911991199119921991

Source: National Child Health Surveys (PAPCHILD, theGulf Child Health Surveys & OCHS)

Thus, the forces ofmodernisation havechanged the pattern ofinfant feeding in a waywhich initially drove upthe fertility of marriedwomen before thecountervailing effectsof later marriage andmore widespread useof contraception havemade their presencefelt. In the transitionalphase, fertility was

very high and birth intervals short. With more recent campaigns to promote breast-feeding and "baby-friendly" hospitals, some of the changes have now beenreversed. Other factors responsible for the fertility rise must include the return ofOmani men from overseas after the export of oil began and to changes infecundability related to general improvements in health and nutrition.

In addition to changes in fertility linked to later marriage, we also see signs of

2.23


change in the fertility of married women. We know from surveys and from the routinestatistics from the birth spacing programme that contraception is of growingimportance. Only 9% of married women were using contraception at the time of the1988-89 survey, mostly the better-educated married women. This had risen to 24%of currently married women in 1995, 18% of them using modern methods (OFHS,table 8.3).

The new (1994) birth spacing programme will undoubtedly have an effect on birthinterval length and final family size for younger Omani couples. Already changes areunder way. A survey in April 1994 (702 women and 479 men in 9 regions) revealedthat awareness of contraceptive methods is high. About 43% of the womenperceived contraception to be good. Among non-pregnant women, 23% were usingcontraception and 41% reported as having used contraception in the past.

The most recent data from the 1995 OFHS for the year before the survey showsome of the effects of this new programme. The data indicate a period total fertilityrate of 6.1 births with signs of falls in fertility amongst older women (Figure 2.7 andTable 2.16).

Service statistics from the birth spacing programme show that the demand formodern contraception is high. In 1995 alone, 13,399 new clients accepted a modernmethod and 94% of these clients were Omani (Annual Statistical Report, 1995: table9-5). A surprising 63% of the clients were under age 30 and 42% had fewer than 5children. Pills and the injectable contraceptive were by far the most popular methods(Annual Statistical Report, 1995: table 9-5). These statistics signal the beginning ofa major decline in marital fertility independent of the earlier declines attributable to alater age at first marriage. It is likely that fertility in Oman will fall quickly as it hasdone in the Gulf states following the improvement in the educational status ofwomen and the provision of safe and effective family planning services as part ofmaternal and child health care. Not only will such changes reduce the annualnumber of births but also they will contribute to the further reduction in maternalmortality and morbidity and to the reduction of peri-natal and childhood mortality.

Although there is a high level of attendance of pregnant women for ante-natal care,late registration of pregnant women is still a problem. Initiation of prenatal care iscurrently being encouraged to begin in the first trimester of pregnancy to allow timeto recognise risk factors and educate the mothers. More information on the health ofpregnant mothers will be available in the near future with the pregnancy riskevaluation process. This classifies pregnant women into risk categories based onparity, stature, past or present pregnancy complications, medical diseases, previousbirth history, haemoglobin levels, history of infertility or abortions, surgery orcaesarean sections and detailed examinations during pregnancy for conditions suchas anaemia, malpresentation, severe growth retardation, cervical incompetence etc.

The 1993 data show that a substantial number of women are being reported with

2.24


some risk factors (Table 2.17). Some 90% of the women registered were deemed

Table 2.16 Distribution of Women Registered for Ante-natal Care by Risk Category in 1992 (Percentages).

Region Total on Grade A Grade B Grade C Totalregister Low risk at risk High risk

MuscatDhofarN. BatinahS. BatinahA'DakhliyahA'DhahirahN. SharqiyahMusandamal-WustaS. SharqiyahOman

100134240113956827779041444999732165

350453809

36.435.553.849.136.441.339.944.043.050.543.4

38.354.541.846.154.552.154.851.252.145.546.9

0.81.51.61.20.81.70.90.51.81.51.2

75.591.597.296.491.795.195.695.897.097.591.5

to be "at risk"(Grades A + B) butless than 2% of thetotal women in allregions were in the"high risk" category.There appear to beno major regionaldifferences in thed is t r ibut ion ofwomen acrossd i f fe ren t r iskcategories.

Any abnormalityfound is treated if

possible.Immunisations for children, ante-natal services and the significant shift from home-based to hospital-based delivery have contributed to the improvement in morbidityand mortality. Efforts to promote breast feeding through the Baby Friendly HospitalInitiative (1992) and the birth spacing programme (1994) will further improve thehealth of mothers and children. The policy change in the timing of the ante-natalcare program is meant to address problems before it is too late to intervene. Finally,the reporting of maternal deaths and especially efforts at identifying pregnantwomen at risk will contribute to improving the health and maternal mortality ofwomen in Oman.

Table 2.17 Average Numbers of Children Ever-born to Omani Women fromDifferent Sources.

Source: Musaiger, 1992

Age ofWomen

15-1920-2425-2930-3435-3940-4445-49

5 Townssurvey1975

0.55521.97133.58654.89405.09715.44875.3207

11 Townssurvey

1977-790.57871.99533.64154.43765.24865.63585.4755

OCHS1988-89

0.03710.99202.52303.40316.58916.94917.1224

Census1993

0.17981 .78454.27176.55187.88917.76757.5516

OFHS1995

0.14001.34003.80006.36007.89008.26008.5200

OCHS, Oman Child Health Survey; OFHS, Oman Family Health Survey.

2.25


Figure 2.7: Average Number of Children Born to OmaniWomen from Different Sources

-5 Towns survey 1975- 11 Towns survey 1977-79- 1988-89 OCHS-1993 census-1995OFHS

£ 5cttff 4

25 30 35

Age of women at interview

///. MORBIDITY

Oman has seen a decline in mortality from communicable diseases due to recentrapid socio-economic development, improvement in sanitation and health services.With the development of its economy and the growth of personal wealth, there havebeen changes in the life style of the population. Recent modernisation has led tochanging nutritional habits and a decrease in habitual physical exercise. Non-communicable diseases have emerged as a dominant factor contributing towards illhealth.

In this section we will illustrate aspects of health change that are distinctive. We willsee that although an epidemiological transition has occurred with the emergence ofnon-communicable diseases, there is a persistence of some communicablediseases. Currently, one can see simultaneously the co-existence of diseasescharacteristic of several stages of the health transition.

A. Decline of Infectious Diseases (Particularly Vaccine PreventableDiseases)The importance of the control of infectious and parasitic diseases in all ageswarrants some special attention. Morbidity from communicable diseases as well asmortality have both declined and especially for the vaccine-preventable diseases.This section describes the trends in morbidity in the vaccine preventable diseasesfrom the 1970s onwards.

The Expanded Programme on Immunisation was launched in 1981. Since 1985, the

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Ministry of Health has established a rigorous policy with the following basicobjectives: (UNICEF, 1979: 79)• To screen and vaccinate all under 2 children at any point of contact with the

Ministry of Health institutions;• To screen and give tetanus toxoid vaccination to all women in the 12-49 age

group;• To register all children in the child health register in Ministry of Health institutions

nearest their home;• To trace defaulters and immunise them.

The coverage of the programme rose rapidly in the 1980s and reached 94% in 1992for all of the vaccine preventable diseases: pertussis, polio, measles, hepatitis-B,diphtheria, tetanus and tuberculosis. In the 1995 OFHS, all children aged 12-23months at interview had received BCG immunisation and 98% has receivedmeasles vaccination. In Figure 2.8, we see the dramatic decline in measles cases,the smaller but important decline in tuberculosis (especially in the recent period) andpertussis. The fluctuations in the number of measles cases are to be expected in apopulation in which there are important movements of poorly immunised peoplefrom other countries and periodic accumulation of susceptible individuals. Figure 2.9displays the trend in cases of the acute respiratory infections and diarrhoealdiseases. Again, the trend is downwards with annual fluctuations discussed below.Note that throughout this period, the system for the notification of cases wasconstantly being improved so that the trend lines are probably an under-estimate ofthe true decline in the number of cases of infectious disease.

There are nonetheless periodic outbreaks of certain diseases. Taking pertussis asan example, we find that pertussis cases numbered 13,057 in 1975 compared to2,745 in 1982 (Table 2.18). The increase in the number of cases after 1992 was dueto an outbreak in a specific region such as the Dhofar region's Maqinat ShahanWilayah. Subsequently, the cases spread to other Wilayahs and to other regions.Between 1992 and 1993, the number of cases grew. The immunisation status of the239 cases in 1993 revealed that 51.5% were below one year. In this group, 19.2%were below 3 months and thus were not eligible for immunisation, 19.7% werepartially immunised - had not yet completed the full schedule (Community Healthand Disease Surveillance Newsletter, 1994(2): 3). The rest of the cases were mainlybetween the ages of 1 and 6 (40.2%) and a smaller number 6 years and above(8.4%). Among the 1 to 2 year old cases, the majority had been immunised (87.2%).Among the 2 to 6 year old cases, a lower percentage (61.2%) had been immunised.Among the 6 years and over cases, the immunisation status of all was not indicated.

The present schedule of DPT given at 3, 5 and 7 months has not protected childrenin early infancy as 38.9% of cases were in the age group below 7 months. Controlmeasures were initiated immediately the outbreak was discovered. Severaldifficulties remain in the way of controlling diseases like pertussis. They include lowspecificity of diagnosis, low compliance to 14 days of chemoprophylaxis and

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efficiency of the vaccine is 70-90% and outbreaks even in well vaccinatedpopulations are known to occur.

Figure 2.8: Reported Cases of the Vaccine Preventable DiseasesCovered by the EPI Programme 1975-1995

-TB ALL FORMS ——DIPTHERIA —— PERTUSIS TETANUS NEONATAL —— POLIO MEASLES ——RUBELLA ——— HEPATITIS E

12 1993 1994 1995

Figure 2.9: Monthly Attendances for Acute Respiratory Infectionsand for Communicable Diarrhoeal Diseases 1989-1993

—•— ARI -•— Diarrhoeal Diseases

A similar example is provided by poliomyelitis. From 1975 onwards, cases ofpoliomyelitis declined steadily until 1987. In 1988, an outbreak occurred and 118

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children contracted the disease. As a result of this outbreak, the immunisationschedule for polio was modified and surveillance system to detect Acute FlaccidParalysis (AFP) was established. The eradication campaign and the intensifiedsurveillance of reported cases of acute flaccid paralysis with the conduct of nationalimmunisation days (NID's) have greatly contributed to the decline. Maintenance of apolio free status is difficult due to the ever-present risk of fresh infections beingimported by migrants from the Indian sub-continent in particular.

Table 2.18 Reported Cases of Selected Infectious Diseases (Vaccine-preventable) 1975-97.Year19751982198319841985198619871988198919901991199219931994199519961997

TB*616212748239481229700616477478482442348275294259288292

Diphtheria43191396400002100000

Pertussis13057274526058307652075162549264523916810873694

Tetanus^---.111181001000100

Polio1898141303396118504020000

Measles16679166459151965236752001380460524255126227618343108181682412

Rubella----1017717554278

211125310946107

Hepatitis t49 n

---

2118222318261688139011761066146513221969263121671943

* Includes all forms of TB; - Indicates missing data; ^Tetanus Neonatorum ;t Totalhepatitis cases reported including Australia antigen positive, negative andunspecified. Source: Annual Statistical Report (1995, table 10-21 & 1997, table 10-9).

Among the vaccine preventable diseases, measles and rubella continue to causethe highest morbidity among children. Although the number of measles cases hasdeclined significantly over time from 16,679 notified cases in 1975 to only 68 in1995, small numbers of cases continue to occur. There was also evidence of asignificant rise from 1834 in 1992 to 3,108 cases in 1993. Measles continues to be apreventable cause of death and acute and chronic ill health. Looking at one timeperiod between December 1991 and March 1992, a total of 309 cases had beenreported in most of the Wilayahs (Community Health and Disease SurveillanceNews Letter 1(2): 3). The age distribution of the cases reveals that children mostaffected were aged between 5 and 15 indicating an accumulation of non-immunechildren in this age group. The low number of deaths among the children aged 1 to 4points out to the effectiveness of the vaccine that was used prior to 1994.

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Rubella vaccine was not part of the expanded programme of immunisationschedule. As can be seen from Table 2.18, there was an outbreak in 1992 of 211cases, and the number of cases rose to a much higher number of 1253 by 1993. In1992, the notification system was modified to individual notification within 24 hours.Prior to this, pregnant mothers with rubella were notified within a week and othercases were reported on a monthly basis. The outbreak that occurred in 1993 wasvery wide-spread and covered all regions excepting the more sparsely populatedMusandam region. The age distribution of the 1993 cases revealed that 25% of thecases were in the 2 to 6 year age group and 44.8% were in the 6 to 14 year agegroup. A blanket mass immunisation operation to cover all children was carried outin March- April 1994. The younger age group of 6 and below was covered inpaediatric outpatient departments in hospitals and health centres. The 6 to 18 year-olds were immunised in schools. Due to the high morbidity seen in the country, themeasles-rubella vaccine has been integrated into the expanded programme onimmunisation schedule and is given at 15 months. The effect of these measures hasbeen to reduce the number of cases significantly to 46 in 1995.

Cases of diphtheria and neonatal tetanus are now extremely rare. All forms oftuberculosis have declined - from 1975 (6,962 notified cases) to 1995 (259 cases).The BCG vaccination coverage of children was 95% in 1993 (Community Healthand Disease Surveillance News Letter 2(4):4. The government's policy is tovaccinate all new-borns within the first year, in order to reduce the chances ofcontracting severe forms of childhood tuberculosis such as miliary tuberculosis andtuberculosis meningitis. Efforts have been undertaken to evaluate the presence ofBCG scars by institution and determination of the proficiency of the nursesadministering the BCG vaccine in 1993.

A number of viral hepatitis cases occur, although the numbers have declined from4971 cases in 1975 to 2631 in 1995. The hepatitis-B vaccine was introduced into theexpanded programme on immunisation schedule in 1990. Prior to the introduction ofthe HBV vaccine, between 1300 and 2200 cases were reported from 1985 to 1989.In 1991, the number of cases appears to have reached the minimum number of1066 and since then has been a little higher. The attack rate is highest inA'Dakhliyah (1.9 per 1,000) and lowest in Muscat (0.2 per 1,000).

B. Seasonal MorbidityA good illustration of the continuing exposure of even well vaccinated children toenvironmental risks is provided by the case of seasonal morbidity. Looking at themorbidity of acute respiratory infections and diarrhoeal disease in Oman between1989-1993 (Figure 2.9), we see that both diseases show a pattern of strongseasonal variation. The first peak for respiratory infections occurs in March and thesecond in October each year. This is mainly due to changes in the weather- thetransition between the hot and the cool seasons. Communicable diarrhoeal diseasesalso follow a similar pattern.This seasonal pattern seems to persist for several reasons. One is the number of

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repeat visits made for the same case. A survey conducted in 1994 showed that 56%of the patients re-visited the health institution with the same condition. Another isthat physicians at different health institutions may classify similar health problemssuch as pharyngitis, otitis media, bronchial asthma or other uncertain conditions asan acute respiratory infection.

C. Persistence of First Generation IllnessesIn the previous section we have seen the decline in infectious diseases in the lasttwo decades, especially the vaccine preventable diseases such as diphtheria,neonatal tetanus, pertussis, poliomyelitis, measles and tuberculosis (Table 2.18 andFigures 2.8 and 2.9). Some outbreaks still occur (such as polio, pertussis, measlesand rubella) and Oman continues its efforts to totally eradicate measles and polio.The outbreaks have stimulated new approaches to disease control. For instance,the number of cases of measles and rubella has accelerated the inclusion of themeasles-rubella vaccine in the expanded programme of immunisation schedule. Theapparent success of this programme can be seen in the dramatic reduction of casesof each disease to less than 100 by 1995. The success with the vaccine preventablediseases has greatly reduced mortality and morbidity from infectious diseasesespecially among children.

Despite the decline in morbidity in communicable diseases due to widespreadimmunisation coverage and treatment, two main sources of morbidity remain. Basedon in-patient discharge statistics, first are diseases of the respiratory tract (the 8709cases of acute upper respiratory infection cases are a quarter of the total) andsecond, infectious and parasitic diseases, mostly acute gastro-enteritis anddiarrhoea cases (9841 cases together). Treatment with antibiotics and oralrehydration solution therapy has greatly reduced the mortality caused by thesediseases. Morbidity has remained steady, however, with few changes in the numberof cases of acute gastro-enteritis and diarrhoea (Table 2.19). The persistence ofdiarrhoea is related to environmental problems that will require time to reverse.Some problems may be the quality and availability of clean water, hygiene, andearly supplementation of the diets of infants. Acute respiratory infections are alsorelated to living conditions. Crowding may be responsible for the persistence ofthese problems.

The number of cases of acute upper respiratory tract infections were the highest inA'Sharqiyah, A'Dakhliyah and Musandam with rates of 1.6, 1.6 and 1.2 episodes per100 population respectively. All of these are northern regions. The lowestpercentage of the population affected was in Muscat. Acute Respiratory Infectionsamongst the under 5 year age children remain an important health issue. Althoughmortality due to ARI was low, the number of episodes per 1000 children under age 5was 2,531 in 1995 with 20% of the cases classified as "moderate" or "severe"(Annual Statistical Report, 1995; table 9-11). Other diseases of the respiratorysystem among outpatients are chronic bronchitis, emphysema and asthma,pneumonia, acute bronchitis and acute tonsillitis among others.

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T a b l e 2 .19Numbers ofEpisodes ofGastroenteritisand DiarrhoeaReported to theDiseaseSurveillanceSystem, 1987-95.Year Episodes198719881989199019911992199319941995

276,047291,050280,211273,920227,127193,709198,975196,761178,823

Source: DHI&S,Ministry of Health.

The distribution of inpatient discharges of acute gastro-enteritis and diarrhoea was highest in A'Sharqiyah andMusandam (1.7% and 1.03%) and the lowest in Muscat(0.10%). This differential is expected due to the establishedwater supply networks within the capital Muscat (97% ofhouses) compare to water wells (over 60%) as the mainsource of water in most other regions. The number ofepisodes of this disease reported in Dhofar and A'Dhahirahregions approximate 0.6% of the population in these regions.The total number of cases notified to have suffered from acutegastroenteritis and diarrhoea was 178,823 in the year 1995.

Malaria was a major public health problem in most regions ofOman. It is endemic in Oman with the exception of theSouthern region where transmission is sporadic. There were16,787 cases of malaria in 1993 (Annual Statistical Report,1995: table 9-19). By 1995 the number of cases declined to1,801. The attack rate was 8.6 per 10,000, the fourth highestof the notified communicable diseases. The largest numbersof positive cases were identified in A'Dhahirah, A'Dakhliyah,Muscat and North Batinah regions.

Transmission of malaria is dependent on the availability of suitable environmentalconditions for the breeding of mosquitoes. Sustainability of the eradication programis especially important as a large number of the country's expatriate populationcome from highly endemic areas and therefore the risk of new cases of malariaarriving from overseas is always there. Poor environmental conditions and lowpublic awareness also greatly contributes to malaria infection. A sustainederadication program in Muscat and Dhofar has successfully kept the levels at 0.18%and 0.01% of the populations respectively. An eradication effort since 1991 in Northand South Sharqiyah has reduced the number from 3,161 in 1991 to below 500cases in later years. Due to the success in this region, the eradication programmehas been extended to the other endemic regions beginning with the North and SouthBatinah region in 1993 and to Muscat Wilayah and the Nizwa Wilayah ofA'Dakhliyah region. Despite heavy rain in 1995, the number of cases was held to1,801. In North and South Sharqiyah, no transmission took place from 1994onwards and in A'Dhahirah and eradication was completed in 1997. Arrivals fromEast Africa are now routinely screened for malaria at main entry points. By 1997, itwas estimated that 87% of the population were protected from malaria by house tohouse spraying. In the 5th five-year Plan, the aim was to reach an annual parasiteincidence (API) rate of 1/10,000. The API rate was held to 0.45 in 1997 with 1026positive cases, of which only 129 were usual residents (Annual Statistical report,1995: tables 9-23 & 9-43).

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Intestinal parasitic diseases that are locally important include amoebiasis in thenorthern regions and hookworm infections in the south. Compared to other regions,there appears to be a high prevalence of brucellosis (from drinking unpasteurisedmilk), in the region of Dhofar. There were 260 cases in 1985 and 348 in 1995, 322cases in southern region of Dhofar alone. There is a potential for the spread of thedisease to other parts of the country. In 1995, the disease surveillance had identifiedthree cases in each of A'Dakhliyah and North Batinah.

The other communicable diseases not mentioned earlier with high attack rates areinfluenza, chicken pox and mumps (Table 2.20).

D. Non-communicable Diseases1. Malnutrition

Although the nutritional status of infants and children has improved from a decadeago, malnutrition and obesity, especially among adolescent girls and women,persist. The causes of malnutrition are various and include socio-economic status,food habits (traditional and modern), and availability of food and public awareness ofnutrition. Susceptibility to diarrhoea and infectious diseases is associated withnutritional status and general health. Episodes of diarrhoea make children highlysusceptible to malnutrition by increasing fluid loss and decreasing fluid retention ofnutrients and reducing absorption through the intestinal brush border.

The prevalence of intestinal parasitic diseases was highest among under 6 year-oldchildren, decreased for 6-14 year old children and remained the same for adultsover 15 years (Musaiger, 1991). Personal hygiene and re-infection from migrantsfrom endemic regions are believed to be the causes of the persistence of intestinalparasitic diseases. The disparities in access to safe drinking water in the home orwithin 15 minutes walking distance (97-98% in urban areas - Muscat - and 44-56%in rural areas) and inadequate facilities for excreta disposal available in the house orclose to it (97-98% of houses in urban areas such as Muscat have their own toiletscompared to 68-72% in rural areas). Faecal contamination in certain environments,such as wet areas (Dhofar in the summer time for instance) is conducive to thedistribution of intestinal parasitic infections such as hookworm (A/. Americanus). Astudy in Dhofar showed that a 23% of the study population were infected fromhookworm (Untitled Source, WHO Consultant, 1992-94). The results also showedthat males and females were affected with equal frequency. There was a differencein infection by age. The 6-13 year olds showed the highest prevalence and the 2-5year olds showed the lowest. In the north, where the climate is hotter and more arid,the population suffers from giardia, entamoeba and hymenolepis infection.

The 1992 hospital deliveries show that 91% of new-borns weighed at least 2500grams. The proportion of children entering primary school with weight-for-agecorresponding to the minimum median reference values fallen to 64%. The results ofa 1992 nutritional survey found 17% of infants were under weight and among

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children between 3 and 10, the figure varied from 25% to 35%. The data also revealdistinctive regional disparities ranging from 2% with PEM in infants in Muscat to 50%in Rustaq amongst 3-4 year olds.

Table 2.20 Reported Cases of Selected CommunicableDiseases Notified in 1995 and Attack Rates per 10,000Population.

Disease

Acute gastro-enteritis and diarrhoeaInfluenzaMumpsChicken poxTrachomaAmoebiasisViral hepatitis - totalShigellosisMalaria (confirmed cases)Food poisoningSyphilisBrucellosisGonococcal infectionTuberculosisTyphoid feverMeningitis - allWhooping coughMeaslesRubellaLeprosy

Numberof cases

178,82362,81814,57414,1858,4263,5122,6312,4491,801596379348310276213171108684638

Attack rateper

10,000population855.0300.469.767.840.316.812.611.78.62.81.81.71.51.21.1<1<1<1<1<1

Source: Annual Statistical Report, 1995, table 10-5, DHI&S,Ministry of Health.

Musaiger (1991)showed that

malnutritionamong childrencoincides with theweaning period.Although almostall mothers initiatebreast feeding,

supplementationstarts early andweaning canoccur veryabruptly. Thissurvey alsoshowed that 93%of the mothersbreast fed theirchildren in 1991compared to 75%of the mothers 3years earlier. Thisindicates thatmore mothers arebecoming moreaware of thebenefits of breastfeeding. Althoughthe mean durationof breast-feeding

was 9.7 months in a study carried out in 1991, the survey revealed that 73% of theinfants received food or liquid other than breast milk during the first three days of life(Musaiger 1991). The most common supplementary foods were water (79%) orwater and sugar (12%), bottle feeding (4%) and other foods/liquids (5%) (UNICEF,1990, 68). Only 30% of the mothers breastfed predominantly for 1-3 weeks, 18% for4-6 weeks and 13% for 7-9 weeks.

The main reasons given for stopping breast-feeding were the occurrence of a newpregnancy (45%); child refuses to feed (17%), lack of milk secretion (16%); illness ofthe mother (4%); child reached weaning age (3.5%) and other reasons (14%).Among young women, the occurrence of a new pregnancy is the main factor.

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Another issue is that the infant formula is not always mixed in the correct proportion.It is also important to know that 37% of the women used tap water, 21% used wellwater, 9% used falaj (canal) water and 33% used bottled water to prepare weaningfoods.

A rapid assessment survey carried out in 1991/92 also showed that 60% of thefamilies in Bawsher district eat together from the same dish including children of agethree and older. Younger children may not eat as much as they need to. Snackswith a low nutritious value are also popular with school children, reducing theirintake of nutritious food. In this study, 22% of children under five were mild tomoderately malnourished and 16% of children 5-12 were also, mild to moderatelymalnourished. In low and middle-income families, feeding large families three timesa day with a nutritious diet is understandably difficult.

The Musaiger (1991) study also indicates the persistence of numbers ofunderweight (low weight for height) and stunted (low height-for-age) children. Theproportions of children under weight between 1 and 10 years of age ranges between13% and 35.3%. The range was from 13% to 35.3% amongst boys to 13.5% to26.4% amongst girls (Musaiger, 1991:75). Stunting is also higher among mostmales, especially those aged 6 and older. The prevalence of stunting among boysranges from 9.2% to 26.8% and among girls from 11.9% to 29.4%.

The prevalence of underweight girls was 63% amongst 11-19 year old girls(Musaiger 1989), ranging from 52% (in Muscat) to 82% (in Samail). Approximately11.5% of the girls were overweight, with a range of 22.3% (in Salalah) and 3.9% (inSamail). (P.65 UNICEF State of the World's Children) Only 25% of the women had anormal weight. A 1992 study (Musaiger, 1992) found that based on body massindex, 13% of the mothers were underweight, 33% were normal, 27% wereoverweight and 28% were obese. It is clear that the proportion of underweightwomen has declined substantially. The problems of overweight and obesity havebecome significant (55% of the Omani mothers). Obesity increases the prevalenceof non-communicable diseases such as hypertension, diabetes, arthritis, asthmaand back pain. The study showed that heart diseases were higher amongoverweight and obese women in comparison to normal and underweight women.

A WHO study in 1988 by Kazimi showed that the mothers in the high-risk categoryat pre-natal examination had a low weight and inadequate maternal weight gain.They also had a history of closely spaced births and multiple pregnancies and wereanaemic. Currently, the awareness of adolescent girls of nutritious foods duringpregnancy is adequate, as indicated in 1991 Musaiger study. Women, however, stillsuffer from iron-deficient anaemia. The same study showed that 60% of adultwomen suffer from low haemoglobin levels. Although the causes specific to Omaniwomen have not been studies, the most common reasons for this condition aremenorrhagia and repeated pregnancies. It is suggested that low incomes, limitedaccess to a balanced selection of foods and lack of knowledge about nutritious

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foods are the main reasons. Another problem is that some the women who areidentified as having a problem cannot read their health cards and cannotcommunicate effectively with the health staff, many of whom speak little Arabic. Thetraditional dietary habits of mothers are changing and consumption of foods rich infat has increased. Consumption of commercial over processed foods also lack innutritional value. A high level of tea drinking (87% of mothers) can also contribute toiron deficiency among women (Musaiger 1991).

In 1995 the most comprehensive nutrition survey to date in Oman reviled a highprevalence of underweight (2 or more standard deviations below theNCHS/CDC/WHO reference median weight-for-age standards) among under-fiveyear old children (23.3%) (OFHS, 1995, table 13.1). Another 23.1% were stuntedand 12.8 wasted. There was no evidence in the data on any disparities against girls.Indeed, girls were faring a little better than the boys.

Based on discussion with programme managers, some traditional habits adverselyaffect the health of women and children. They include:

• Reduction in food intake during pregnancy to produce a smaller baby for easierdelivery. This practice may lead to nutrient deficiency and insufficient weight gainassociated with low birth weight babies who are at risk for neo-natal death,disabilities and birth defects;

• Avoidance of spicy foods, tea and citrus fruits;• The preferred diet during pregnancy is assida (wheat flour, ghee or fried butter

and honey), meat cooked with ghee and ghee mixed with milk and honey. Otherfoods recommended during this period are tea with brown sugar, dates withwheat flour and black pepper, ginger tea, coffee with brown sugar and avoidanceof fish for 40 days after birth. Most of these foods are high in calories and low inprotein and iron. Avoidance offish leads to reducing intake of protein.

• Infants are given ghee from the first day to fatten them up.• Sudden stopping of breast-feeding by putting bitter mixes and mixes with hair to

deter the child. More gradual weaning is healthier for mother and infant.

A haemoglobin survey carried out in Dhofar showed the severity and extent ofanaemia (Musaiger 1996b) The results showed that anaemia (haemoglobin levelsbelow 12.0 g) was common in over half of the population, moderate (6-8.9 g) among8% of the population and severe (less than 6 g) in 0.8% of the population. Adultswere not affected by severe anaemia. Of the 11 cases of severe anaemia, 9 caseswere among children of 2 to 5 and 2 cases among children between 6 and 13 ofage. All age groups were affected by moderate level of anaemia, especially the 2-5year old group (41.5%) and the adults, although to a lesser extent (20.8%). Mildanaemia, which constitutes almost 50% of the population, was mostly prevalentamong adults (25%) and 6-9 year olds (24%) and to a lesser extent among 2-5 yearolds (21%) and 10-13 year olds (22%) and lowest among the 14-17 year old group.Thus, the problem exists among most age groups. Looking at prevalence by sex

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shows us that at all levels of anaemia the percentage of females are significantlymore affected than males. The results also show that within Dhofar the prevalenceof anaemia by Wilayah varied greatly (Musaiger 1996b). The study also showed thatinfection with hookworm did not make a significant difference in the prevalence ofanaemia.Vitamin A is an important element of child survival strategy. Its deficiency increasesmortality of children under 6 years of age. The deficiency increases the severity ofmeasles and other infectious diseases such as diarrhoea and pneumonia. Vitamin Aalso prevents night blindness, xerophthalmia and blindness. All these factors arerelevant to the health status of Omani children. Severe vitamin A deficiency does notseem to be prevalent in Oman in the 6 months to 7 years age group. However it issuggested that sub-clinical, mild to moderate deficiency in pre-school children mayexist as poor sanitation, hygienic practice and prevalence of malnutrition still exists.A study was initiated in October 1994.

A study carried out in 1979 found several nutritional deficiencies among schoolchildren: vitamin B, vitamin A, iron, calcium and fluorosis. Vitamin B and Cdeficiency, calcium and fluorosis was higher among older children (13 to 18 yearolds) and young adults (19-24 year olds) than the 6 to 12 year olds. Iron deficiencywas higher among the 13 to 18 year old groups and the same among the 6 to 12and the 19-24 year old groups.

A national study on the prevalence of iodine deficiency indicates that half of thecountry may have a mild deficiency. The results showed that 49.8% of the childrenin the ten regions under study had median urinary iodine values less than 10 mcg/dl(National Study on Iodine Deficiency Disorder). Even mild iodine deficiency resultsin physical and mental damage. It is suggested that even mild Iodine DeficiencyDisorder (IDD) indicates that there is inadequate iodine availability for normaldevelopment of the brain in-utero for some parts of the population. Universal saltiodisation (USI) has therefore been made compulsory by law since 1995 (MinisterialDecree 92/95, Ministry of Commerce & Industry), and monitoring will continue withthe aim of achieving USI by the year 2000.

2. Diseases of the Circulatory SystemVarious types of non-communicable diseases are emerging. Of particular concernare diseases of cardiovascular origin. The 1995 In-patient Morbidity StatisticalReport indicates that diseases of the circulatory system account for 7.6% of alldischarges (Annual Statistical Report, 1995: table 10-2). The rate of discharge washigher in males (8.5%) than in females (4.6%). Between 1990 and 1995, theaverage increase was about 8% per year. Hypertensive diseases constituted about24% of the diseases of the circulatory system in 1995, ischaemic heart diseasesconstituted 40% and diseases of the pulmonary circulation and heart constituteabout 19% (Annual Statistical Report, 1995: table 10-15). Cardiovascular diseasescaused 36.7% of all adult deaths in 1993.

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A rheumatic heart disease survey among school children showed that theprevalence is 8 per 10,000 Omani schoolchildren, a level close to that for developedcountries (Hassab, 1997). Follow-up of the sample for a further three months gavean annual incidence rate of 4 per 10,000 schoolchildren. Data also show highercongenital heart diseases among females (30.9 per 10,000 females as compared to6.8 per 10,000 males).

3. Diabetes MellitusData from the annual national statistics indicate that hospital discharges for diabetesmellitus have risen steadily - from 1528 cases in 1986 to 3340 cases in 1995. Theproportions of patients diagnosed with diabetes are significant as seen in a surveycarried out in 1990 in four hospitals in Oman. (Asfour, 1991) Between 7% and 13%of the total number of patients in these hospitals were diabetic. It was estimated thatabout 9% of all adult hospital admissions and 12% of adult hospital bed occupancywere related to diabetes. Outpatient clinics in district hospitals showed proportionsas high as 20-30% with diabetes (Asfour, 1995). Using the WHO methodology, theprevalence of diabetes and IGT (impaired glucose tolerance) among Omani adultsaged 30-64 years, was 14% and 11% in males and 14% and 17% in femalesrespectively (King, 1993). An epidemiological survey carried out by the Ministry ofHealth in collaboration with WHO in 1991 showed that the prevalence of diabeteswas 10% among both sexes and IGT was prevalent more in females (13%)compared to males (8%), (Asfour, 1995). Both of the conditions rose with age inboth sexes throughout their lifetime to 20% in males and 25% in females fordiabetes and to a maximum of 30% for IGT.

Recognising the importance of diabetes as a significant public health problem, theMinistry of Health in the Sultanate of Oman established a National Programme forDiabetes Control and Prevention in 1991. A National Committee was formed to steerthe program activities. At the tertiary level a National Diabetes Centre wasestablished at the Royal Hospital and was designated as the first WHO collaborativecentres in the Eastern Mediterranean Region. Furthermore, the 5th five-year HealthDevelopment Plan, 1996 - 2000 has identified diabetes as a major priority. With theexception of Musandam and al-Wusta regions, a specialist in diabetes in all otherregions was appointed in line with the policy of decentralisation. The main objectivewas to provide high standards of care to all patients with diabetes through Oman.In recent years the Ministry's policy has been to integrate the diabetes program intothe local primary health care services. National management guidelines weredeveloped and annual workshops are organised to train PHC physicians, nurses,health educators and dieticians, on the various aspects of management of diabetesin primary health care settings. All basic drugs and insulin required for the treatmentof diabetes in PHC have been made available to all PHC centres throughout Oman.

To monitor the profile of the people with diabetes and associated complications asurveillance system has been designed (National Diabetes Registry). This systemorganises the referral of patients between different health care levels and follows up

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______Chapter 2: Changes in Mortality and Health Status______

patients for five years.

4. CancerThe data on inpatient discharges indicates that there where 2,220 cases ofmalignant neoplasm discharged in 1995 (1.0% of total discharges). The highestpercentage were in Muscat, Dhofar and A'Dakhliyah regions. The high percentage inMuscat is partly due to referrals from other regions (Annual Statistical Report, 1995,table 10-2). Cancer is the second leading cause of death among hospital in-patients,accounting for 10% of all deaths in 1995. For the period 1986-95, the averageannual increase in the discharge rates for cancer was 15.5%. The cause of this risein cancer discharges may be attributed to more organised referral services betweensecondary and tertiary centres. To monitor future trends for cancer, a cancer registrywas developed in 1985 in A'Nahdah Hospital. Later it was shifted to thenoncommunicable diseases control section to function as a population-basedregistry. The notification system will be discussed in Chapter 3.

Table 2.21 Frequency and Incidence of Cancer per 100,000 among Omanis, byGender, 1993-1997.Year

19931994199519961997Total

Cases432408475457510

2282

MalesCR

57.352.950.256.261.157.8

FemalesASR107.394.5109.8109.6121.8108.4

Cases364352358350385

1809

CR50.047.347.044.747.847.0

ASR94.085.581.584.693.687.0

TotalCases

796760833897895

4091Source: al-Lawati, et a/., (2000)

Between 1993-1997 4091 cases of cancer (2282 males and 1809 females) werereported to the Oman National Cancer Registry giving the average crude annualincidence rate of 57.8 per 100,000 for males and 44.9 per 100,000 for females (table2.21). The corresponding age-adjusted rates were 108.4 and 87 per 100,000population respectively. The male to female ratio ranging from 118 to 132 males per100 females.

Stomach cancer was the leading cancer among males in Oman (11.1%), followedby non-Hodgkin's lymphoma (9.6%), prostate (7.6%), leukaemia (6.7%) lung andbronchus (6.4%), primary liver cancer (4.9%), bladder cancer (4.5%), brain andnervous system cancers (3.4%), Hodgkin's disease (3%) and carcinoma of the colon(2.8%) (table 2.22).

Breast cancer is the leading cause of cancer among females (13.7%). This isfollowed by cervical cancer (8.8%), non-Hodgkin's lymphoma (7.6%), stomachcancer (6.9%), thyroid cancer (6.4%), Leukaemia's (5.4%), ovarian cancer (3.8%),

2.39


bronchus and lung (2.9%), primary liver cancer (2.5%) and connective tissuecancers (2.2%). (Table 2.23).

Table 2.22 The Ten Most CommonCancers among Omani Males, 1993-1997.

Table 2.23 The Ten Most CommonCancers among Omani Females,1993-1997.

TopographyStomachNHL*ProstateLeukaemiaLung & BronchusPrimary LiverBladderBrain and NervousHodgkin's DiseaseColonTotal

Frequency254220174153147111102776863

1369

%11.19.67.66.76.44.94.53.43.02.860

TopographyBreastCervix UteriNHL*StomachThyroidLeukaemia'sOvarianLung & BronchusPrimary liverConnective tissueTotal

Frequency2481591381251169868524640

1090

%13.78.87.66.96.45.43.82.92.52.2

60.2*NHL, Non-Hodgkin's LymphomaSource: al-Lawati, et a/., (2000)

*NHL, Non-Hodgkin's LymphomaSource: al-Lawati, et a/., (2000)

A study (al-Lamki, 1994) of malignant tumours in children indicated that amongthose studied the most common was leukaemia (32.3%), followed by lymphomas(29%) and by brain tumours (11.2%). The male to female ratio was 1.3:1 and caseswere mostly among the 2-year-olds.

5. AccidentsThe number of accidents and especially the severity of road traffic accidents haverisen dramatically with road building and the rapid extension of vehicle ownership. Aroad traffic accident survey in 1993 indicated an incidence rate of 6 per 1000population. The death rate from road traffic accidents was 23 per 100,000population. Forty percent of the accidents occurred in adults within the age of 26-50and 27.5% within the young adult age of 16 and 25 years. More than 80% of caseswere males. Hospital discharges from injuries and poisoning in general have beenon the rise by 64% between the years of 1986 and 1993. Injuries and poisoningconstitute 8% of all discharges. The rising trend of these problems is of greatconcern.

6. New and Unanticipated Threats: HIV/AIDSIn 1984 the first HIV case was reported in Oman. By 1994, a total of 134 HIV casesand 10 new AIDS cases were reported in total. In 1995, the corresponding numberswere 113 and 14 respectively. Thus, the HIV/AIDS prevalence in Oman is very lowand concentrated in males aged 20 to 40 years old. Most (39%) of the transmissionis sexual with HIV prevalence being highest amongst those with a history of other

2.40


sexually transmitted diseases and intravenous drug abuse. The HIV prevalence rateamong patients with STD's seen in Ministry of Health institutions was 6 per 1000STD cases. The HIV prevalence rate amongst TB patients fell slightly between 1992to 1994 - from 1.6% to 1.4%.

The prevalence of HIV among blood donors ranges from 0.02% (in 1994) to 0.04%(in 1995). The Sultanate of Oman began a blood-screening programme in 1986 forthe prevention and control of HIV infection. This was followed by the establishmentof a national technical Committee on AIDS in May 1997 with representatives fromthe Ministry of Health, the Royal Oman Police, the armed forces and from SultanQaboos University.

Oman has instituted a strong surveillance system to identify cases with HIV or AIDSsince 1990. All HIV/AIDS cases are part of mandatory disease reporting system. Inaddition, a special report is completed for all AIDS cases and the Medical Officer incharge is responsible for notification. A counselling service is provided for those whoare diagnosed with HIV/AIDS. There are 24 counsellors nationally. The counsellorsare also responsible for identifying families of cases for screening and follow-up ofcases. HIV/AIDS awareness in Oman is not high but all Omanis leaving through theairport are provided with information on HIV/AIDS.

IV. CONCLUSIONSThis chapter has shown that there is extensive evidence to prove that Oman is welllaunched on its mortality and health transitions. The childhood mortality datadescribe one of the fastest drops in infant and under 5 mortality on record, certainlymuch faster than the rates recorded for the major countries of Europe and NorthAmerica earlier this century. A particular characteristic of the mortality transition inOman was the way in which differentials between rural and urban, educated andless educated sections of the population have been kept to a minimum. Thecoincidence of the mortality falls and the implementation of major healthprogrammes suggest a strong connection between the two. One curiosity is theevidence from some of the earlier demographic surveys that childhood mortality wasfalling even before 1970 and the subsequent health measures were implemented.The data on deaths by cause demonstrate the major role played by theimmunisation programme in controlling diseases such as measles in particular.Further evidence of the impact of the public health measures comes from the dataon morbidity - both new cases reported and in-patient discharge data. Thesesources portray a complex pattern of improvement with declines in the diseases,which are controllable by vaccination and other public health measures, butpersistence of the diseases, which require more personal actions, such as diarrhoeaand gastro-enteritis. Non-communicable diseases, on the other hand, are fastemerging as a dominant feature of ill-health in Oman.

The role of the health services in the transitions was key but can we be more

2.41


precise about their contribution? What have been the contributions of rising livingstandards and improvements in education? These are the central concerns of thesubsequent chapters.

2.42

CHAPTER 3

EVOLUTION OF THE HEALTH SERVICES

*/

CHAPTER 3

EVOLUTION OF THE HEALTH SERVICES

In this chapter, we examine the contribution of the health sector to theimprovement of health and mortality in Oman up to 1995. The expansion anddevelopment of the Omani health services is a remarkable story in itself but there

are several other major points that this chapter aims to convey. First, we have theearly commitment to Primary Health Care (PHC), to the integration of the differentparts of the health services, and to the decentralisation of services andresponsibilities following the World Health Assembly on PHC in 1977. Oman hasbeen consistent in its policies since the mid-1980s. Indeed, many of the policiesbeing implemented in the 1990s have their origins in the Strategy for Health for Allby the Year 2000 published by the Ministry of Health in 1989. In addition to theprovision of fully comprehensive, free and widely accessible health services, Omanembarked on major programmes of health promotion and preventive measures withcommunity involvement in the planning and provision of these services. Althoughthe inventory of services provided is long and comprehensive, as we shall see later,we also have to take into account the intensive use of these services. The Ministrysupplied good quality services throughout the country but the population has madeuse of these services in a remarkable way. The establishment of good quality andfree health services certainly generated huge demands for health care, signalling agrowing consciousness of health issues in the Omani population.

This account begins with a brief outline of the development of national policy but themain part of the chapter discusses the content of the health services, considerssome particular health programmes and then looks at how the health services aredealing with some new and emerging conditions. There is a danger that the readerwill be lost in the detail but it is by documenting the detail that we can appreciate theamount of planning and thought which has gone into the development ©f the Omaninational health system.

/. HISTORY OF POLICY DEVELOPMENT

One of the first Royal Decrees issued by Sultan Qaboos was one establishing theMinistry of Health in 1970. From almost nothing, the Ministry has built up a free andcomprehensive health system through concerted efforts set out in a series of Five-Year Plans. The first of these was initiated in 1976 and was largely concerned withthe rationalisation of existing services and the mobilisation of the resources needs toexpand the health services. The second and Third Five-Year Plans focused onexpanding the coverage of the health services and on increasing the quality of careprovided (Annual Statistical Report, 1995: 2-1). Naturally, these plans led to a hugeexpansion in the number of health facilities in the country and to a major increase inhealth personnel, Omani and non-Omani. Throughout, the strategy followed hasbeen remarkably consistent since the early years.

Chapter 3: Evolution Of The Health Services

We know that in 1970, there were almost no modern health facilities in Oman withthe exception of the mission hospital in Muscat. There were only 10 Omani doctorsand all these were working abroad (Graz, 1982: 157). We know too from travellers'reports that health conditions were very poor (for example Phillips, 1966, chapter 4;Smith, 1988; and Graz, 1982). One of the first decrees of the new Sultan in 1970was to create the Ministry of Health headed by Dr. Asim al-Jamali who had beenworking along the coast in the present UAE before his appointment (Oman 1994: pp177). Very soon, the beginnings of modern health service began to take place. Thegrowth of the health facilities and the human resources for health is described inlater sections. Here we focus initially on the emergence of the policies that werelater to shape the current health system.

The end of the Dhofar war in 1975 allowed the new administration to devote extraresources to social and economic development. To indicate the government'scommitment to improving living conditions for all Omanis throughout the country, theconstruction of health facilities and schools was begun in all major populationcentres under the terms of the First Five-Year Plan. This plan was largely concernedwith building up the infrastructure of a modern welfare state. In Dhofar in particular,where there was a special interest in the closer integration of the population of thatregion into the nation, the rural health service was begun using mobile teams andhealth posts to bring health care to those previously receiving none (Graz, 1982:157). The experience gained and the positive response from the populationprepared the way for the development of a primary health care system that was toreach all parts of the country.

By 1980, following the Alma Ata conference on Health for All and the agreement thatprimary health care was the principal means to achieve this goal, Oman formallyincorporated this strategy into the first declaration on Health for All by the Year 2000in 1980. In the Third Five-Year Plan (1986-90), the PHC strategy became the centralcomponent in the development of the health sector. Later policy documents onevaluation (MOH, 1985) and on a revised strategy on health for all (MOH, 1989)confirmed this commitment to the provision of primary care in all settled districts.Thus, the coincidence of a new Minister with a vision of health services for all,combined with international support for the primary health care approach, seems tohave convinced senior policy makers in the Ministry of Health and in the governmentthat the decentralised approach providing basic health services was the preferredmodel.

This did not conflict with the development of hospitals in larger centres. Before 1980,there were already 28 such institutions (Annual Statistical Report, 1995: table 4.1),but the total number of beds in Ministry of Health hospitals was only 1784 in 1980(Annual Statistical Report, 1995: table 4.1). This number doubled to 3450 by 1987but thereafter, the growth in hospital beds was more gradual (Figure 3.1).

The real watershed for the re-organisation of the Omani health services was thepublication of the Strategy for Health for All by the Year 2000 in 1989. This reportwas the encapsulation of much of the diffuse thinking that had been driving the

3.2


Figure 3.1: Development of the Health Services in Oman 1970-1995

-»- Doctors -*- Nurses -•- Hospital Beds -»- Health Centres

7000

6000

1980 1985Year

140

120

100

I"5I

development of the health services in the 1980s. Although based on the Alma Ataprinciples, the health services had nonetheless grown up in a rather fragmented wayas a result of the rapid growth of preventive and curative care in parallel butseparate tracks. The key phrase in this report appears on page 37:

"Thus, there is a complete cleavage between the preventive and curative aspects ofprimary health care, both structurally and functionally."

This, and other major organisational problems, then became the major agenda forthe Ministry in the 1990s. Once the basic principle of integration was accepted, thenthe other policies that became the hallmark of the Omani health services were alsoput in place. These included the commitment to regionalisation, the governorate(Wilayah) basis of organisation of the health services, the referral system introducedinitially only for the Royal Hospital, and then the development of the nationallyconceived but regionally implemented health programmes. The content of thePrimary Health Care package has been greatly extended and now covers thirteenactivities (Table 3.1).

Driving the whole system was a remarkable commitment to the development of ahealth information system that provided a factual basis for the setting of manynumerical targets. The list of objectives and targets in the 1989 Annual StatisticalReport (pp. 32-34) is extraordinary. Few countries can match the informationavailable on specific "problems" (such as diarrhoea! disease, malaria, tetanus, acuterespiratory infections and so on) and even fewer can produce numbers from theroutine health information system to demonstrate how far the country has gone withthe control or elimination of such problems. The targets included not only problemsrelated to specific diseases or conditions but also immunisation, PHC coverage, and

3.3


water and sanitation goals.

Table 3.1 Primary Health Care Activities in 1995.1. Health education2. Promotion of proper nutrition for mothers, pregnant women and children3. Environmental health - food safety, sanitation and vector control4. Maternal health - ante-natal care, deliveries & post-natal care5. Child health - growth monitoring, control of diarrhoeal, acute respiratory andhelmenthic disease6. School health7. Immunisation against childhood diseases8. Prevention and control of endemic diseases9. Mental health10. Eye health11. Oral health12. Treatment of common diseases and injuries13^Adequate supply and rational use of essential drugs_____________Source: Annual Statistical Report, 1995: table 2-1.

Several factors were responsible for this enlightened view of the policies needed todeal with Oman's health problems. First, it helped that Oman's economy wasexpanding rapidly in the 1980s (see Chapter 4 for details), providing the resourcesfor the changes proposed. These new resources meant that Oman could afford notonly the development of a network of centres providing primary care nation-wide butalso had the resources to build a medical school and the Royal Hospital as well asother tertiary-level hospitals. In addition to the funds needed for buildings andequipment, Oman also was able to recruit trained health workers from all around theworld but mostly from the Indian sub-continent and Asia. Secondly, the health sectorwas and remains completely dominated by the Ministry of Health, an almostexclusive provider of health care services to the nation. The services provided bythe Ministry of Defence and the Royal Oman Police are important but they follow thegovernment's lead in health policy. The services provided by PetroleumDevelopment Oman (PDO) company are also provided in close consultation withgovernment. The private sector was and remains small. Thus, policies decided bygovernment are necessarily implemented to the full since there is no real alternativeto the state health care system. Thirdly, Oman has been open to ideas from outsidefrom the beginning (as Chapter 1 explained) and has been careful to keep up withnew ideas and concepts as they develop. The international agencies in the form ofresident representatives of WHO and of UNICEF, for example, have been useful toOman in providing a window on experiences in the rest of the world. This knowledge(and Oman's later development) has meant that the country has been able to benefitfrom the experience of others and to move directly to programmes, which have beentried and tested elsewhere.

Let us turn now to the details of the development of the health services, their useand additional health measures introduced by the Ministry of Health.

3.4


II. HEALTH SYSTEM

A. Provision of Health Services1. Organisation and ManagementThe current organisation and management of the Ministry of Health reflects aconsiderable period of evolution. As the organisation chart in the 1995 AnnualStatistical Report clearly shows, the Under-secretary for Health Affairs is the focalpoint for all matters dealing with health. In most of the regions, there is a Director-General of Health Services who reports on all aspects of the region's health directlyto the Under-secretary. This is the result of the implementation of the conclusionsreached in the 1989 report on Health for All by the Year 2000 referred to above.There, it was recognised that the health care delivery system was providing neithersufficiently integrated nor adequate decentralised primary health care services.Service elements were being delivered in a fragmented manner, compromisingefficiency, quality, and cost-effectiveness. The Ministry of Health, therefore, deliversa comprehensive package of services. This has led to the current policy ofcombining curative and preventive care, decentralising and regionalising allservices. The current structure was laid out in the Fourth Five-Year Plan (1992). Thetwo Directorates-General, Curative and Preventative Medicine, were integrated intoone Directorate-General of Health Affairs and the public health units in the regionswere amalgamated with the nearby hospitals and health centres where they werelocated. An example of the new policy is the creation of the Extended HealthCentres. These are primary health care centres, which support specialised(secondary) care at outpatient (ambulatory care) level.

2. StrategiesA Royal Decree in 1985 provided the legislative basis for the administrative reformslater incorporated in the 1989 document. This decree also established an Inter-Ministerial Health Committee to permit fuller collaboration on health matters withother ministries and departments. The National Child Care Plan that was set up in1985 was expanded into the National Woman and Child Care Plan (NWCCP) in1989. NWCCP is a body that assists collaborating government agencies toimplement specific projects for women and children. This body has beeninstrumental in accelerating EPI, spreading awareness of nutrition and breast-feeding, especially the Baby-Friendly Hospital Initiative, and recently the promotionof birth spacing. The NWCCP organises workshops, provides training, developsinformational materials such as booklets, posters, videos, and uses the mass media.All these actions aim to improve knowledge and practices within the home and toincrease the participation of the community.

Within the Ministry of Health, the need to integrate curative and preventive serviceswas recognised as far back as 1975 when the Minister of Health, Dr. Mubarak al-Khaduri stated:

"The Ministry's national health programme is based on the fact that health is a non-divisible entity and, while at the moment preventive and curative services are not yet

3.5


converging, the Ministry's health policy aims at an integrated service."

Despite this recognition, the system had concentrated on curative services to thecomparative neglect of preventive activities. In the 1990s, these two functions wereintegrated administratively in the Ministry of Health. The ongoing decentralisationand regionalisation processes have facilitated integration of services, especially atthe local levels.

Decentralisation and regionalisation of decision-making have been underway forseveral years. More and more, financial and administrative decisions are beingdevolved to the regional level. There are ten health regions, and there are plans tofurther decentralise to the district level when and where feasible. In thedecentralisation plan, each of the 59 W/7aya/?-level health systems will be led by alocal health management team responsible for five main work areas including:planning, community participation, and inter-sectoral co-ordination; administrationand management of community health programs; supervision and in-service trainingof health staff; out-patient services; and in-patient services in hospitals.

Regionalisation has also meant the decentralisation of monitoring and evaluation ofhealth services. In 1992, a health information system was decentralised to nineregions. Regional health information officers were appointed for collection ofmonthly data from health units and for entering the information in regionalcomputers. Reports are provided via computer diskettes to the health unit managerand subsequently to the national health information section of the Ministry of Health.This system was put in place to provide feedback to managers on routine datacollected in health units countrywide and to establish reliable documentation andcomparability of information across regions.

There are signs that regionalisation and decentralisation of decision-making haveimproved the efficiency of staff time use, the monitoring of local health problems, theeffectiveness of management, and local participation. It is hoped that widespreadservice access and improvement of service quality in regions outside the capitalregion will improve national health equity as well as prevent excessive utilisation oftertiary facilities and wasteful migration into the cities for health services.

3. Facilities and InfrastructureThe Health Services in Oman have developed tremendously over the past twenty-five years (Table 3.2). In 1970, Oman had only two hospitals with 12 beds but by1995, the Ministry of Health was operating 47 hospitals and 40 health centresproviding a total of 3,958 beds (1995 Annual Statistical Report, table 4.1).

During 1995, the MOH opened one new hospital (the Ibri Hospital in A'Dhahirah)and five new health centres providing primary care, making the total number ofhealth centres 120. This represents an increase in the number of health centres of28% when compared to the end of 1990 showing an average annual growth rate of5% during the fourth Five -Year Plan. If this is compared to the average annual

3.6


natural increase of the population, which is 3.7%, the scale of the improvements inthe MOH health services becomes very clear.

Table 3.2 Development of The Ministry ofHealth Services and Institutions.

Number of HospitalsNumber of Hospital BedsPopulation per Hospital Bed

1970212

54,811

199547

3,958528

Extended Health CentresHealth Centres with BedsHealth Centres without BedsTotal Health Centres

001919

54966120

Source: Annual Statistical Report, 1995: table 4-1.

The MOH provides freehealth services to all thepeople of Oman through itshealth institutions and it hasattempted to provide a goodgeographical spread of healthcentres and hospitals. Table3.3 illustrates the distributionof these services among thehealth regions and it is clearthat the hospitals and healthcentres are widely dispersedthroughout the country. While

there is considerable variation in the number of beds available in the regions (52 inal-Wusta compared to 291 in North A'Sharqiyah for example), when this iscompared to the population of each region, the distribution per head is remarkablyequable (341 people per bed in al-Wusta and 402 in North A'Sharqiyah).

Table 3.3 Geographical Distribution1995.

of Health Institutions on December 31st

Governorate/ Number ofRegion health

centresMuscatDhofarA'DakhliyahN. SharqiyahS. SharqiyahN. BatinahS. BatinahA'DhahirahMusandamal-Wusta

1337107121181336

Number of Number ofhospitals hospital

beds6565555532

1,3943763942913263042944359252

Populationper hospital

bed405520607402466

1,226730432324341

Total numberof health

institutions194216121716131868

Source: Annual Statistical Report, 1995, table 4-2.

There is a "regional hospital" in each health region that provides secondary (andsometimes tertiary) care for the people in its catchment area. This is usually built inthe centre of the region and is considered as a referral hospital for critical casesfrom other hospitals and health centres of the health region. The regional hospitalsfor the Muscat region act as national referral hospitals for critical cases from otherregional hospitals. The capital region therefore has a proportionally larger number ofbeds available than the other regions (Table 3.3). The Wilayah hospitals and thelocal hospitals provide primary and secondary health care to the inhabitants of the

3.7


local area.

As well as the efforts that have been directed towards constructing geographicallywell distributed health institutions, steps have also been taken to provide servicesvia mobile health teams to populations living in very secluded areas. Despite theseextensive efforts, however, it is estimated that approximately 5% of the population ofOman is still not easily reached by the modern health services (Annual StatisticalReport, 1995: table 2.3).

4. Human Resources for HealthSince 1975 the number of health personnel employed by the Ministry of Health hasincreased dramatically from 2,488 to 15,451 in 1995 (Annual Statistical Report,1995: Table 5.2). Table 3.4 shows the number of doctors, dentists, pharmacists, andnurses in 1975, 1985 and 1995. The number of doctors increased from 147 to2,477; dentists from 6 to 143; pharmacists from 8 to 356; nurses from 450 to 6036.Of the doctors and nurses, the Ministry of Health employed 85% of each, whereas54% of the dentists and 18% of the pharmacists are working for the Ministry ofHealth. Over the past decade, the ratios of dentists, and pharmacists to thepopulation have remained relatively stable. The ratios of nurses and doctors topopulation, however, have both almost doubled during the same period: nurses from15.6 per ten thousand to 28.9 per ten thousand and doctors from 6.9 per tenthousand to 11.8 per ten thousand.

Table 3. 4 Health Manpower in Oman 1975 -1995.Positions 1975 1985 1995DoctorsDentistsPharmacistsNurses

Doctors/10,000 populationNurses/10,000 population

14768

450

1.85.6

95853193

2,156

6.915.6

2,477143356

6,036

11.828.9

Source: Annual Statistical Report, 1995, table 5-1.

Three key questions arisewith regard to humanresource development inOman. The first relates tothe geographic distributionof manpower, the secondto the balance or blend ofpersonnel with differentskills, and the third to theheavy dependence on non-Omani workers.

The geographic distribution of health manpower shows both extensive coverage aswell as some variability across Oman's regions. Whereas the population per doctoris 787 and 794 in Musandam and Muscat respectively, the ratio in North Batinah ismore than double at 2,631 (Annual Statistical Report, 1995: Table 5.5). A similarpattern can be observed with the regional distribution of nurses. This can partially beexplained and justified on geographical and policy grounds. Muscat is the capitalwhere all the national referral hospitals were located and it is therefore reasonablethat this is where one should find the greatest concentration of doctor and nurses.

The composition and blend of personnel obviously reflects the mix of health systemprovided, planned and actual. The high ratio of doctors to other health personnel

3.8


suggests a bias towards more costly curative services rather than less expensiveprimary care. In planning for the future, one of the key personnel issues that willrequire attention is the role that non-physicians can play in primary, preventive, andemergency services.

Table 3. 5 Ministry of Health Personnel in 1995.Number personnel % Omani

Health AdministratorsDoctorsDentistsPharmacistsNurses

1021,800

7763

5,128

9313171315

Source: Annual Statistical Report, 1995, table 5.

In spite of a steadyincrease in Omanimedical personnel in thelast decade, Oman'shealth system remainsheavily dependent uponexpatriate doctors andnurses (Table 3.5). Non-Omanis constitute the

overwhelming proportion of the doctors (87%) and nurses (85%) in the nationalhealth care system. There exists also a great dependence on foreign dentists andpharmacists. It is encouraging to see, however, the large number of Omani assistantnurses (89%), which must reflect the focus on training put forward by the Ministry ofHealth. But the heavy reliance upon expatriates generates several types ofproblems such as language and cultural barriers between service providers andusers, high costs, and the long-term sustainability of the system.

Table 3.6 Graduates in GeneralNursing from the Institute ofHealth Sciences 1984-1995.

The Ministry of Health is well aware ofthese human resource challenges and ithas systematically attempted to acceleratethe production of Omani health personnel.The Faculty of Medicine at the SultanQaboos University Medical School(established in 1987) is now graduating anaverage of 50 doctors per year. Althoughall of these graduates have followed acommunity-oriented curriculum shaped torural health needs, it remains to be seenhow many of these graduates will beprepared to serve in smaller health centresin remote parts of the country. The Instituteof Health Sciences, established in 1982, istraining nurses, assistant nurses, medicallaboratory technicians, radiographers, andphysiotherapists (Table 3.6). This tableillustrates the remarkable increase innursing graduates particularly over the lastfive years, from 29 in 1991 to 221 in 1995.More recently, the Institute has startedcourses in dental surgery (1993), maternitycare (1995) and electro-cardiograph

(1995). Consequently, the number of Omani physiotherapists has grown from only 1

Year198419851986198719881989199019911992199319941995

Male693951361615313252

Female1818610622134485161169

Total2427919111582959*116193221

Notes: Graduates as MedicalLaboratory Technicians,radiographers and physiotherapistsnot included. * Includes 14 AssistantNurses upgraded to GeneralNursing. Source: Annual StatisticalReport, 1995, table 6-3.


in 1984 to 35 in 1995 and the number of radiographers from 9 in 1984 to 52 in 1995.

Regional nursing institutes in Nizwa, Sur, Sohar, Ibri, Salalah, Ibra and Rustaq wereeach producing between 35 and 40 general nursing students annually. Omaninursing staff forms almost 15% of the total nursing staff in the country in 1995. In1995, the total number of students undertaking training in the Ministry of HealthTraining Institutes was 1353. Over time, these educational institutions should beable to produce a cadre of Omani professionals to staff the national health caresystem. Overall, the distribution of the existing doctors and nurses by region isrelatively even (Table 3.7) already.

Table 3.7 Doctors and Nurses byRegion, December 1995.Region

MuscatDhofarA'DakhliyahN. A'SharqiyahS. A'SharqiyahN. BatinahS. BatinahA'DhahirahMusandamal-WustaNational Total

Doctors/10,000

Population

12.67.46.27.47.83.86.612.012.76.28.6

Nurses/10,000

Population

40.221.316.022.619.210.318.328.533.522.624.5

Source: Annual Statistical Report,1995, table 5-6.

The numbers, skill levels, assignments,and appropriateness of these personnelwill need to be carefully planned formatching to what is likely to be a rapidlyevolving health care system. TheMinistry of Health is very conscious ofthe need to keep medical personnelabreast of recent developments in theirparticular fields. For advanced clinical,planning, and public health skills, Omanigraduates are being sent abroad toregional and international institutions tostudy for post graduate degrees. At alocal level, the Directorate of Educationand Training launched in 1995 acontinuing education movement innursing aimed at enhancing clinicalpractice.

B. Utilisation of Health ServicesSeveral factors have influenced the people's demand for and the utilisation of healthservices. Obviously, the rapid development of free and high quality governmentservices have stimulated utilisation. Less well appreciated is the role of broad-basededucation in promoting health awareness and positive health-seeking behaviouramong the Omani people.

The Ministry of Health compiles utilisation statistics. From 1975 to 1995, the numberof outpatient visits to Ministry of Health facilities (hospitals and health centrestogether) has increased almost nine-fold from 1.4 million to 12.2 million annually andthe number of inpatients discharged has increased from 46,738 to 220,846 (Figure3.2). This explosion in the utilisation of the health services can also be expressed inthe mean number of visits per person each year. This has increased from 1.7 visitsper person per year in 1975 to 5.8 per year in 1995. Regional differences in themean number of visits per year range from the highest in North Sharqiyah with 8.5

3.10


visits per person per year tc the lowest in Muscat with the mean number of visitsbeing 4.0. Ante-natal visits have increased steadily and pregnant women pay almostmonthly visits to health centres (Figure 3.3). The number of out-patient visits peryear to hospitals is very high (Figure 3.4) and should decline as the referral systembecomes more accepted.

7000

6000

» 3000

2000

Figure 3.2: Number of Out-patient Visits and In-patient Discharges 1980-1995

- Outpatient visits to Hospitals -•— Oupatient visits to Health Centres —*— Number of discharges from Hospitals

——————————————————————————————————————————————————————————————————————————— 250

1994

150 |

X

o100 ~

—— 01996

O 250

l/> 200>

n

Figure 3.3: Number of Ante-natal Visits and Mean Number of Visits per Pregnancy

—•— Number of Ante-natal Visits —•- Mean Number of Visits per Pregnancy

a.5 I

I/I

'«4 >

"5<u

3 SI

3Z

2 CS

1

1978 1980 1982 1984 1986 1988 1990 1992 1994Year

1996

The reasons for this heavy utilisation of health facilities are various. They includethe free service, the high rates of referral, good quality care, procedures requiring

3.11


frequent treatments, and a low level of family education and awareness. A negativedimension of the utilisation pattern is the low primary health care centre attendancein comparison to hospital attendance (Figure 3.4), excepting al-Wusta and SouthBatinah. Primary health care attendance varied enormously from one Wilayah toanother within a region. For instance in Muscat and A'Seeb Wilayah, attendancewas 1.1 visits per person in 1995 whereas in Quriyat Wilayah it was 6.5. In anotherregion such as Dhofar, the highest visit rate was 10.5 in Sadah Wilayah in 1995compared to 1.3 visits in Muqshin Wilayah. Such variable attendance rates point tolocal factors that influence utilisation (staff performance, geographic barriers, etc.)making it very difficult to generalise about the reasons behind variable health serviceutilisation.

Figure 3,4: Outpatient Utilization by Region in 1995

D Hospital • Health Centre D Extended Health Centre

i :>i*- 5O

i1 V ARegion

Imbalances also exist with regard to the heavy inpatient utilisation of hospitalservices. The average duration of hospital stay was 4.4 days per person in 1995,and hospital bed occupancy cveraged 69% (Annual Statistical Report, 1995: table 8-33). These utilisation patterns differ between facilities. There is overcrowding insome major urban hospitals and under-utilisation in some regional hospitals andsome health centres.

C. Financing and the Private Sector

1. Financing

In 1991, Oman's per capita GDP was US $ 5,800 (Annual Statistical Report 1995,table 3-2). Since most of the national income comes from petroleum resources,much of the income is accessible to the government. Total governmentalexpenditures more than doubled between 1980 to 1995 and in 1995 the Ministry ofHealth was allocated RO 121.7 million (US$ 316.4 million), which constituted 5.7%

3.12

p.̂Chapter 3: Evolution Of The Health Service

of the total national budget (Table 3.8). Between 1980 and 1995, the percent ofgovernment budget expended for health - and also other social sectors - hassteadily expanded from about 3% to 5.7%. In part, the capacity to invest more inhealth, welfare, and social security has come from a significant reduction of defencespending from about half to one-third of government expenditure in 1980 and 1990,respectively. The Ministry of Health expenditure was RO 28 (US$ 73) per capita in1980, reached a peak of RO 64 (US$ 166) in 1985 and stabilised at around RO 57-59 (US$ 148-153) in 1992 to 1995 (Figure 3.5).

Figure 3.5: Government Expenditure on Health

I Ministry of Health Total Expenditure —•- Ministry of Health Expenditure per capita

——————— - 70

O 1500Jnffli1970 1975 1980 1985 1990 1991 1992 1993 1994 1995

Year

The Ministry of Health budget is divided into recurring and development categoriesin a ratio of about 85% and 15%, respectively. In 1995, the recurring budget was RO103.5 million (US$ 269.1 million) in comparison to development expenditures of RO18.1 million (US$ 47.1 million). Salaries alone consume about 63% of the recurringbudget. Development expenditures were for new facilities as well as for newprogrammes.

As all services are provided free of charge, the Omani health budget is based on atotal cost system, basing eacn year's budget on the previous year's, but adjusted forincreases, new programmes, and other changes. Few studies have beenundertaken to examine the efficiency of Oman's health expenditure pattern, nor onthe sustainability of such high health expenditures. Rapid shifts in governmentalrevenues and ultimately the decline of petroleum revenues are fiscal factors that willdetermine the affordability of the current health system. These key issues of fiscalefficiency and sustainability are discussed in the conclusion of this chapter.

3.13


2. Private Sector

There is a small private health sector in Oman, mainly providing services toexpatriates (who were not covered by the public system) and Omani workers inprivate companies. In 1995, there were 471 clinics and 254 pharmacies operated byprivate companies and individual sponsors, mostly situated in Muscat and NorthBatinah. Although for-profit private medicine has not played a major historical role inOman, the number and types of clinics and especially pharmacies have shown asignificant rise. Private pharmacies primarily sell drugs, and private clinics mostlyprovide curative services.

Table 3. 8 Government Expenditures on Health1980-1995.Year

19801985199019911992199319941995

Total Ministry of(million Health

RO) expenditure(million RO)

924.71909.61851.71851.52209.42199.42232.92124.9

28.386.692.985.4108.3117.3122.3121.7

Governmentspending

(% of total)

3.14.55.04.64.95.35.55.7

Ministry ofHealth

spendingper capita

(RO)28.063.752.247.457.159.059.758.2

Source: Annual Statistical Yearbooks, 1990-95, varioustables. To convert from Omani Rials to US$ multiply by2.6.

governmental units are serviced by these institutions (see

Another systems ofhealth services are thoseprovided by othergovernment agencies.Two hospitals with a totalof 351 beds are operatedby the Armed ForcesMedical Services, theRoyal Oman Police,Petroleum DevelopmentOman and the SultanQaboos UniversityHospital (AnnualStatistical Report, 1995,table 11-1). There is alsoa small private hospitalin Salalah with 6 beds.Employees anddependants of these

Table 3.9).

Table 3.9 Health Services Provided By Other As very little information isAgencies 1995.____________________ available on the private

health sector, it is difficultto evaluate the quality andthe demand for theseservices. In 1995, therewere 471 private clinicsand 254 privatepharmacies operating inOman (Annual StatisticalReport, 1995: table 11-4).With just over 500physicians and 302 nursesworking in the private

sector, it is clear that the Ministry of Health dominates the health sector (Annual

IndicatorHospitalsBeds

Dispensaries &PHC CentresBeds

ROPf1

59

3

12

PDOf00

9

37

SQUHf1

292

1

0

Total2

351

13

49f ROP, Royal Oman Police; PDO, PetroleumDevelopment Oman; SQUH, Sultan QaboosUniversity Hospital. Source: Annual StatisticalReport, 1995, table 11.1.

3.14


Statistical Report, 1995: table 11-4). More attention to the private health sector maybe necessary in the near future. Commercially driven private health activities canattract those able to pay primarily for curative services. For-profit systems, however,will not promote preventive activities, nor will they venture into poor and inaccessibleregions. Private sector involvement, however, may absorb some public costs, lessenpublic sector overloads, and improve efficiency by increasing competition. A policyto shape an appropriate public-private mix in Oman's health development is anextremely important planning task for the future.

///. DEVELOPMENT AND STATUS OF HEALTH PROGRAMMES

A. Disease Control1. Expanded Programme on ImmunisationIn 1981, the Ministry of Health launched the national Expanded Programme onImmunisation (EPI) to protect the population against six vaccine-preventablediseases: tuberculosis, diphtheria, pertussis, polio, tetanus, and measles. Within adecade, extraordinarily high coverage was attained, thus contributing significantly tothe reduction of disease incidence, child morbidity, and child mortality in Oman.

Vaccinations were initially delivered only at fixed centres, and coverage in the earlyyears was as low as 20%. In 1985, the EPI gained momentum when it wasintegrated and delivered as part of the child health programme. Coverage increasedsharply in the second half of the 1980s. In 1985, it was just above 60% and by 1995the percentage of children immunised against the six antigens was more than 97%.Figure 3.6 shows the remarkable achievement of accelerated coverage of DPT,polio, and measles vaccinations.

Figure 3.6: Immunization Coverage with DPT/P3 & Measlesfor Children Under 1 Year, Oman (1981-1995)

3? "I

a£

- DPT/P3 —- MEASLES

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995Year


Oman's EPI strategy is aimed at universal coverage shaped to the uniquecircumstances of a dispersed population. Many strategic factors have contributed toits success, among which were the following:

Pro-Active Retrieval. All children are reached through existing institutions andprogrammes near where the child is born or resides. Children are followed up from0-5 years (and recently 0-6 years) by these institutions, which assume immunisationresponsibility. Defaulters are retrieved in passive and pro-active ways - passiveretrieval by telephone or sending a verbal or letter messages and active retrievalthrough outreach teams of health visitors who visit the family of the defaulter child.

Opportunistic Contacts. Every contact of a child with any health service at any timeis used as an opportunity to check the child's immunisation status. If due or overduefor any vaccine dose, the child is not allowed to leave the institution withoutreceiving the appropriate vaccine. This can happen at any institute that belongs tothe Ministry of Health or any other sister organisation. This policy acted as a filter tocatch defaulters.

24-Hour Availability. Immunisation services are offered 24 hours a day throughoutthe year.

Vaccine Practices. A minimum number of children is not necessary to open a multi-dose vial of vaccine. Though this may increase vaccine costs, it improves coverage,and given the very high cost of retrieving missed children, the practice may beextremely cost-effective.

Mass Education. Launching of the EPI was accompanied by a well-designed andintensive mass media educational campaign. Outreach was achieved through everymeans available (radio, TV, English and Arabic newspapers). This increasedawareness among the genera! public, especially sensitising mothers to theimportance of immunisation.

Community Mobilisation. As part of the decentralisation of health services, theMinistry of Health has appointed Wilayah health superintendents who act as bridgesbetween the health and non-health development activities in the Wilayah.Superintendents also help in mobilising the community, mass campaigns, andcorrecting problems of non-compliance.

The achievements of this programme can be seen in Table 3.10, which shows thedramatic reductions of reported disease incidence for childhood infections.Tuberculosis cases declined from 16,162 in 1975 to only 276 cases in 1995, a majorreduction. The impact of the BCG vaccine is also suggested by the lack of cases ofTB meningitis and miliary TB. Pertussis cases have been reduced from 13,075 in1975 to only 5 cases in 1987. The number of pertussis cases fluctuated disturbinglyshowing an increasing trend. In 1993, there was an outbreak mainly in the southernregion of Oman, which is discussed later. Measles reduction has been remarkable.In 1975, 16,679 cases were reported but by 1995, had been reduced to only 68.


Diphtheria and neonatal tetanus have declined markedly, so that no cases of eitherdisease have been recorded in the whole of Oman since 1993. Only one case ofneonatal tetanus was reported in 1991, no cases in 1992, 1993 and 1994 and justone case in 1995. Since 1993, no cases of poliomyelitis have been reported inOman.

Table 3.10 Number of Cases of Notifiable Infectious Disease in the EPIProgramme.Year19851986198719881989199019911992199319941995

TBt122700616477478482442367289300276

Diphtheria64000021000

Pertussis6420751625492645239168108

Polio33961185040200

Tetanus642410111110810777

Rubella1017717554278

211125310946

Measles3657200138046052425512622761834310818168

fTB, Tuberculosis.Source: Annual Statistical Report, 1995, table 10-5.

The EPI programme has also confronted two types of second-generationchallenges. The first are episodic outbreaks of vaccine-prevent diseases inincompletely immunised populations, and the second is the incorporation of newantigens to the basic immunisation package.

In 1988, an outbreak of poliomyelitis (118 cases) occurred in six of eight regions inOman. This was despite 88% immunisation coverage for OPV3 in all regions. Acase-control study conducted by the Ministry of Health and the US Centre forDiseases Control (Sutter, 1993) showed that 87% of cohorts had received at leastthe first dose of polio vaccine and 50% had received three doses. The genomicsequencing of the outbreak virus showed it to be Type I suggesting that it had beenimported from South Asia since it was distinguishable from isolates indigenous tothe Middle East. As a result of this outbreak, the immunisation schedule wasmodified to include a dose of oral polio vaccine at birth and at 6 weeks. Surveillanceof acute flaccid paralysis was also instituted, and the system of outbreak control wasstrengthened.

The southern Oman pertussis outbreak in 1993 occurred despite precautions takenby the Ministry of Health. Outbreaks of pertussis are known to occur periodically inpopulations even with high coverage since the immunity conferred by the vaccine is70-90%. Besides, 40% of the outbreak cases were either below 3 month or 3-7months of age and hence could not be protected by the present schedule of DPT at3,5 and 7 months, respectively.In 1992, a large measles outbreak occurred mainly in the region of Dhofar, although


other regions of Oman like Muscat, A'Dakhliyah, and North Sharqiyah also reportedcases. Despite measures taken to contain this epidemic, the outbreak continuedthrough 1993 to reach a total of 3,108 new cases (giving an attack rate of 154 per100,000). In 1994, the Ministry of Health conducted a combined measles/ rubella(MR) vaccine campaign for all people aged 15 months to 18 years, a measure thatcould vastly reduce the number of measles susceptible individuals in Oman. Sincethen, the routine immunisation schedule includes two doses of measles vaccine - at9 and 15 months in combination with rubella vaccine.

Hepatitis B and rubella vaccines were added to the EPI schedule in 1990 and 1994,respectively. It is, of course, too early to measure the impact of immunisation onthese diseases. Since enhancement of the rubella surveillance system in 1992 (byplacing it into category A diseases - i.e. reportable within 24 hours of detection), anincreased number of rubella cases were reported in 1993 followed by a dramaticdecline in 1994 and 1995 (Table 3.10). In 1992 a rubella outbreak was reported inMuscat that soon spread to other parts of the country bringing the total number ofcases to 211. The epidemic continued throughout 1993 when the total number ofreported cases peaked at 1,253. Because of the threat of Congenital RubellaSyndrome (CRS), a blanket operation with MR (measles-rubella) vaccine wasconducted nationally in the age group 15 months to 18 years in March/April 1994. Inonly 4 weeks, 705,000 persons were immunised, achieving 94% coverage. The MRvaccine was also integrated permanently at 15 months into the EPI schedule as ofJanuary 1994.

2. Control of Diarrhoeal Diseases and Acute Respiratory InfectionsThe diarrhoeal diseases were among the major causes of childhood morbidity inOman (138,178 cases in 1995) (Annual Statistical Report 1995: table 9-12). As aconsequence, in 1985 the Control of Diarrhoeal Diseases (CDD) Programme wasintroduced to reduce diarrhoeal mortality and morbidity among Omani children. Itbegan by standardising procedures in the clinical management of diarrhoea anddehydration, banning the use of anti-diarrhoeal mixtures and drugs, and rationalisingthe use of antibiotics and intravenous fluids. The CDD also endeavoured throughhealth education and promotional activities at all health facilities to increase theawareness and knowledge in the use of oral rehydration therapy (ORT) in themanagement of diarrhoea/ dehydration. In addition, the programme promoted theimportance of good nutrition (exclusive breast feeding in the first four months of life,good complementary feeding practices), safe water, personal and environmentalhygiene, immunisation and other related issues in the prevention of diarrhoea. Theprogramme was implemented throughout Oman's national network of health caresystem

Field data on diarrhoeal incidence are sparsely available in Oman, as is the case inmost countries. A KAP survey conducted as part of the OFHS in 1995 showed that88% of the children who had diarrhoea were treated with increased fluids andcontinued feed and 83% had recovered ORT solution. Based upon hospital data ondiarrhoea cases among children from 1984 to 1995, there were suggestions of


causes like inadequate personal hygiene practices, inadequate environmentalhygiene, lack of clean water, and lack of understanding in communities. Eradicationof trachoma and its complications by the year 2000 is an optimistic goal, which canbe achieved by addressing these underlying causes.

B. Maternal and Child Health

1. Maternal and Child Health ProgrammeAlthough the Ministry of Health provided MCH services prior to the establishment ofthe MCH programme, the services were neither uniform nor standardised, nor theywere monitored appropriately. Target setting, regular monitoring, managementinformation systems, and other MCH programme strategies were deficient. Since itsinception in 1987, the MCH Programme has focused on the standardisation ofprocedures for maternal and child health services all over the country. One yearlater in 1988, the programme received added impetus from the launching of theNWCCP.

Over a period of seven years, the quality of ante-natal, perinatal, and post-natal carehave improved tremendously. Antenatal service coverage has increased, antenatalregistration has moved progressively toward the first trimester; more and more birthswere taking place in hospitals and other health facilities; post-natal services wereincreasingly being utilised (Figure 3.3).

A few selective programme statistics demonstrate these performanceimprovements. In 1994, the percentage of eligible mothers contacted for ante-natalservices rose to nearly 95%. In 1995, on average, women paid 7 visits perpregnancy to health facilities for ante-natal care (Figure 3.3) (Annual StatisticalReport, 1995: table 9-1). Only small regional differences in service utilisation persist.For example, women in South Batinah were paying 5.6 visits per pregnancy toantenatal clinics compared with 8.1 visits in Dhofar and A'Dhahirah. In 1993, 94% ofthe ante-natal cases were registered in the second trimester. Late registration in thethird trimester has come down from 10% in 1991 to 7% in 1994. The percentage ofbirths in hospitals has steadily risen, now approaching 90%. The remaining 10%constitute the hardest to reach due to inaccessibility, a nomadic life-style or lack oftransportation facilities.

There has been a remarkable rise in the number of visits for post-natal checks overthe period 1988-95, rising from 29% to 83% of eligible mothers. In 1995, the ratio ofpost-natal to ante-natal visits was 1.2 for the country as whole (Annual StatisticalReport, 1995: table 9-3). This has made possible by raising the awareness ofpregnant woman during the ANC period. Some of results of these programmes canbe detected in the falling proportion of low birth weight deliveries and stillbirths(7.5% low birth weights i.e. less than 2500 grams), and a stillbirth rate of only 1.2%in 1995 compared to 8.6 and 1.3 in 1991 respectively) (Annual Statistical Report,1995: table 3-1).

3.26


5. Trachoma and other Eye Health CareThe first epidemiological survey on trachoma in Oman was carried out in 1976,followed by a second and a third survey in 1978 and 1981. The 1976 surveyconcluded that active trachoma was highly prevalent in the population. Theprevalence of acute trachoma amongst schoolchildren ranged between 94% inNizwa and 26% in Muscat. In the community, the rate ranged between 12% and25%. The prevalence of trachoma has declined in the 1980's. Comparison of theresults of three surveys in Nizwa showed that active trachoma in that region haddeclined from 93% to 26% and in school children from 94% to 3%.

During the 1970s, trachoma was treated mainly through a curative approach athealth institutions of the Ministry of Health and in a limited manner through theTrachoma Control Unit and Community Development Programme. As the concept ofa national control programme was not implemented, it is believed that the mainreason for the dramatic decrease in active trachoma was the wide-spread socio-economic changes. The 1981 survey not only showed a decline in trachomaprevalence but also other causes of blindness. These causes included cataracts(15%), glaucoma (15%), suppurative corneal ulcers (20%), and other keratopathies(10%). Recognising these diverse causes of blindness, the Ministry of Healthestablished a Prevention of Blindness Programme that had a two- pronged out-reach strategy: (1) school screening by school health visitors and (2) communityscreening by field teams working in the endemic areas. This Programme working inseven selected regions continued up to 1991.

The programmatic strategy was guided in part by field research. In 1988, Grazconducted an attitude survey on trachoma (Graz, 1988). The study findingdelineated some of the community attitudes toward trachoma:

"Trachoma is not painful and therefore people do not feel the necessity to seek immediate treatment.Public perception of trachoma as a cause of blindness is not well understood by the community. Theprolonged 'time lag' between the initial infection, complications (Trichiasis/ Entropion), and eventualblindness disguises the severity of the disease. Blindness is generally considered unpreventable.Communities do not realise that trachoma blindness is avoidable."

Based on these recommendations, the Prevention of Blindness Programme was re-organised as the Eye Health Care Programme. The Programme is being broadenedto cover most of the regions of the country. Stress is being laid on integration withother programmes like school health, primary health care and the Wilayah healthsystem; standardisation of policies/procedures of management of common eyediseases especially trachoma; standardisation in methodologies oftraining/monitoring/evaluation; and increased stress on community involvement/health education.

In conclusion, the prevalence of active trachoma in Oman has been dramaticallyreduced mainly due to socio-economic changes and only partially due to theinterventions introduced by the Ministry of Health. Trachoma complications,however, still persist as a public health problem, worsened by certain underlying

3.25


had developed BCG scar following vaccination at birth. Nine major institutions in allregions were involved and children at different ages were examined for BCGscarring. The results showed very high levels of BCG scarring, with 97% having ascar at 3 months and 90% by 19 months. It was recommended that BCG scarchecks be undertaken of all children at 3 months of age to determine whether re-vaccination is indicated and that children entering school at 6-7 years of age shouldbe checked for a BCG scar and the child should be re-vaccinated if scar is absent.

In 1985, an active case finding and sputum survey was conducted in a non-randomly selected cluster of villages around the country. Out of 5,746 peoplesurveyed, 115 symptomatics (2%) were identified from whom sputa were taken forexamination. Only one sputum was found to be positive for tuberculosis, giving aprevalence rate of 17 per 100,000 through active case finding. A symptomaticsurvey was also undertaken among 12,480 people. With 309 symptomatics (2%),the survey suggested that about 2% of people will have sputum-positiveexaminations in the general population.

The Programme is planned, monitored and evaluated by the Tuberculosis ControlSection of the Department of Disease Surveillance and Disease Control with twosupervisory staff at headquarters. The Programme has achieved good nation-widecoverage, efficient defaulter-retrieval system, contact tracing and screening, centralcross-indexing system, efficient monitoring and supervision and a standard regimenof anti-tubercular treatment. In 1995 there were 276 new cases of tuberculosis inOman (135 sputum positive cases, 59 radiologically suggestive cases, and 82 extrapulmonary cases) (see Figure 3.10).

Figure 3.10: Cases of Tuberculosis in Oman 1988-1995

- Total number of New Cases —•— Number of Old Cases Restarting Treatment -*— Number of Cases Cured

o5 3»°nEz

200

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

Year

3.24


applied in the rest of the regions.

The epidemiology of malaria in Oman in the 1970s and 1980s like elsewhere,showed that the control system applied had insufficient impact on the incidence ofmalaria. Indeed, the problem of malaria was worsening and could be expected todeteriorate because of the emergence of the multi-drug resistant strains of malariaparasites plus rapidly rising insecticide resistance. These conditions propelled Omantowards a new, experimental strategy of eradication. Preliminary field results of theA'Sharqiyah pilot project suggest that eradication may be feasible. Success willdepend upon political commitment and leadership; a well trained and experiencedstaff; public awareness; and appropriate international technical exchange. The goalof the programme is for Oman to be free of malaria by the year 2000.

4. Tuberculosis Prevention.Although tuberculosis is a major health problem in Oman, perhaps second only tomalaria, available information does not permit an accurate assessment of thesignificance of infectious tuberculosis in various communities or an accurateassessment of its prevalence in the country. In the 1970s, there were many cases ofadvanced sputum-positive pulmonary tuberculosis throughout the country but manyother cases that were not confirmed bacteriologically. In limited tuberculin skinsurveys carried out in the country, only about 5% of school entrants showed apositive reaction of 10 mm or more to 2 Tuberculin Unit Mantoux test. These resultsamong others suggest that the risk of tuberculosis infection in pre-school years isnot as high as commonly believed nor in comparison with that reported in manydeveloping countries.

In 1981, a national Tuberculosis Control Programme was launched. One yearearlier, a WHO Consultant, had recommended BCG vaccination of all new-born andschool entrants (EMI/TB/140, March 1975). Five district hospitals were reportingtuberculosis cases, but most of the cases were without bacteriological confirmation.To strengthen the Programme, a standard drug regimen, recording and reporting,and a tuberculosis reference laboratory for culture and identification and drugsensitivity tests were established. However, It was also obvious that a largeproportion of known infectious cases were not cured largely because of the highdefault rate due to lack of health education and motivation of the patient.

All preventive and curative institutions in the country were surveyed to get an idea ofhow each institution was dealing with tuberculosis cases. With this backgroundinformation, a Control Programme was evolved based on the two well knownmeasures- case-finding and institutional treatment and BCG vaccination. TheProgramme was launched with both preventive and curative services involved, andsubsequently integrated into primary health care. In the development of theProgramme, priority was given to extending BCG vaccination and to improving theorganisation of ambulatory drug therapy.

In 1992, a pilot study was undertaken to determine the proportion of children who


insect collectors or superintendents of operations. Although larviciding is the mainanti-vector weapon, some supplementary measures were deployed- e.g. selectiveresidual house spraying, mechanical control measures, ULV spraying (imagociding),and providing impregnated mosquito bed nets in remote areas. Together, theactions were called "integrated control". The aim is to bring the Anopheles vectorsbelow the critical density to ensure the complete interruption of malariatransmission. The effect of these actions can be seen in the declining number ofpositive cases in recent years (Figure 3.9).

Figure 3.9: Confirmed Malaria Cases in Oman 1988-1995

^m Total Number of Positive Cases -•- % Slide Positivity Rate

35 ——————————- ——... ———

B 20o

« 15OQ.

£

Simultaneously, case detection goes on through different activities: - passive casedetection, active case detection, malariometric school surveys (includingparasitological surveys and spleen surveys), epidemiological contract surveys, andsometimes mass blood surveys. In addition a plan was prepared in 1995 to involvethe private sector as well in case detection. Simultaneously, national guidelines forthe treatment of malaria and its complications were developed to ensure the malariacases were treated radically and thus eliminating the reservoir of infection. Healtheducation has been a very important component of the programme. Differentseminars were arranged not only for the public but also for the medical andparamedical staff to spread awareness. TV spots programmes and interviews werealso organised.

An ideal national malaria eradication programme attempts to reduce the API (annualparasitic incidence) to 0.01% in approximately 6-7 years. In A'Sharqiyah, this lowlevel has been achieved within three years, which is extremely promising. The SlidePositivity Rate (SPR) in A'Sharqiyah region (north and south) in 1995 was 0.04 %and the API (annual parasitic incidence) was 0.003% (after discarding the importedcases). It is planned that gradually the eradication system will be extended and


In the early phase of the programme, most of the malaria units over the countrywere simply acting as fire brigades moving in non-organised patterns without clearlydefined targets. Action occurred only after outbreaks or epidemics instead ofworking towards prevention. The situation was clearly ineffective and alsounsustainable. Therefore, the Ministry of Health realised that that policy could not bemaintained successfully, especially since the problem of malaria has recentlyworsened all over the world due to two factors. These were the increasingemergence of chloroquine-resistant strains of falciparum malaria. These speciesused to constitute 94% of malaria in Oman before the dramatic change of theparasitic formula with the establishment of the successful eradication programme,followed by the emergence of multi-drug resistant strains (Fansidar, quinine andeven mefloquine resistant. The Second reason is the increasing emergence ofinsecticide resistance by the anopheles vector.

Based on the above, the Ministry of Health decided that Oman would adopted a newstrategy to move from control to eradication - from a reduction of the incidence ofmalaria cases to the cessation of malaria transmission and the elimination of thereservoir of infected cases. Although the Ministry of Health recognises thateradication is extremely difficult if not impossible to accomplish, it hopes that anintensive campaign over limited time could interrupt transmission completely.

To achieve this objective, a malaria eradication section has been established ineach of the high risk regions, headed by a medical officer with an experience inmalarialogy and backed by four wings - epidemiological, entomological, operationaland administrative. Each headquarters supervises a malaria unit in every Wilayah inthe region, although some of the larger Wilayahs may have more than one unit.Each malaria unit has a sanitary inspector, sanitary assistants, plus spray-men.

In August 1991, a Malaria Eradication Pilot Project was started in the A'Sharqiyah(Eastern) Region. Epidemiological and entomological surveys were conducted andgeographical reconnaissance was done to ensure that all the potential breedingplaces for the vector are located and marked to be covered by larviciding on aweekly basis. Strict vigilance is maintained through well organised and stratifiedsupervision in a special set up of malaria staff. At least in the attack andconsolidation phases of the project, it should be run as a vertical programme.

Geographical reconnaissance maps, an important tool in the eradication process,have been prepared to scale by a very well equipped draughtsman. For eachWilayah, there is a general map and this Wilayah is divided both on the map and byclear numerated demarcations in the field into sectors, so called daraks, each ofwhich is about 4-5 km. Each darak has its own map and is again divided both on themap and by clear numerated demarcations in the field into 5 sections representingthe work of 5 working days - from Saturday to Wednesday. A labourer (spray-man)is appointed from the same dark or the nearest village to cover this dark over 5 daysby larviciding - i.e. covering all the breeding places according to a fixed schedule.His work is cross-checked almost daily by sanitary assistants, sanitary inspectors,


peak of transmission occurring mostly between May and the end of December(Figure 3.8).

1988

Figure 3.7: Confirmed Cases of Malaria, Oman (1988 -1995)

1989 1990 1991 1992

Year1993 1994 1995

</>reO•D 2500)

£

200

1

Figure 3.8: Seasonal Variations in Malaria Cases in 1995

BH3tl. .5jT

ii«: miiJan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

In 1975, the Ministry of Health started a malaria control programme based on fourwell-known principles of control: (1) Early diagnosis and prompt treatment; (2)Selective application of sustainable preventive measures (in Oman, mainlylarviciding with Temephos); (3) Immediate, vigorous, and wide-scale response toepidemics; and (4) development of reliable surveillance and information.

•; ~>r,


modest declines in incidence, but the longer-term trend is not clear. Among hospitalcases of diarrhoea, however, the case-fatality ratio appears to have steadilydeclined with only 4 deaths among children below 5 years of age due to diarrhoealdiseases in 1995.

There is evidence that diarrhoea-related morbidity remains relatively high in Oman(more than 138,000 cases reported in 1995 and 156,000 cases in 1994) (AnnualStatistical Report 1995: pp 9-21). Reducing diarrhoeal morbidity will requireaddressing underlying causes such as the lack of clean drinking water, poorenvironmental and personal hygiene, and inadequate nutrition during and afterdiarrhoea. These underlying conditions must be addressed through vigorouscommunity-based initiatives rather than reliance on hospital-based activities.

Acute respiratory infections (ARI) were also extremely common causes of illnessamong children in Oman (704,079 cases in 1995) (Annual Statistical Report 1995:table 9-11). Available hospital data for the mid-1990s showed that 39% of theoutpatient attendance and 16% of hospital admissions in children were due to ARIs.

Oman:s ARI/CDD Programme was the first to be established in the region Standardguidelines for the management of ARI in children were initiated in 1987. Theseinvolve improved case management, judicious use of drugs, and increasedawareness for early detection and treatment. Gradually, programme activities havebeen extended to achieve nation-wide coverage.

A major component of the ARI/CDD programme is training. The strategy is to trainregional master-trainers, who in turn would train all concerned health staff. Trainingcourses consist of modules, lectures, role-plays, and group discussions and alsoemphasise clinical practice and communication skills. A total of 2,292 doctors,nurses, paramedics and others had been trained by the end of 1994 and a total of630 new health staff was trained in 1995.

3. Malaria ControlMalaria has been and remains one of the most important health problems endemicto Oman. In 1977, 340,322 cases were clinically diagnosed as malaria, 6.5% of allthe hospital attendees were malaria positive, and case-fatality among malaria in-patients was 2.5%. In 1988, there were still 21,580 confirmed cases of malaria(Annual Statistical Report, 1995: table 9-19) but by 1995; the figure had beenreduced to just 1,801 cases. The persistence of malaria is shown in Figure 3.7 thatplots the confirmed cases of malaria in the Sultanate between 1988 and 1995.

Oman is extremely diverse ecologically with mountainous areas, coastal areas,foothill areas and oases. The climate is varied and rainfall is low and erratic in ail butthe southern region. Thus, all the ecological factors that play a role in thetransmission of malaria are present in Oman. Malaria transmission is highlyregional, common in Muscat, A'Sharqiyah, A'Dakhliyah , A'Dhahirah, and al-Batinahbut virtually absent in the Dhofar southern area It is also highly seasonal with the

i n


At this stage of MCH development in Oman, it can be considered that the strategyfor effective ante-natal, obstetrical, and post-natal services is in place. Futurestrategies will need to advance maternal-child health through risk reduction(maternal nutrition, birth spacing, etc.) as well as disease prevention.

2. The Birth Spacing ProgrammeAs we have seen in Chapter 2, section II.C, fertility amongst Omani women wasextremely high in the 1980s. It appears from an analysis of the parities from oldersurveys (Table 2.16) and from the trends in the age-specific fertility rates from theOCHS and the OFHS that fertility probably rose as a result of the changes in healthand living conditions which began in the 1970s. Recognising that high fertility,including an early start to child-bearing, short birth intervals and deliveries to grandmulti-parae, exposes women and children to numerous health risks, the governmentbegan a new programme to encourage birth spacing amongst couples ofreproductive age. The programme was launched in October 1994 after carefulpreparation and training, including a small knowledge, attitudes and practice surveyto assess the needs of Omani couples more accurately (Annual Statistical Report,1995: 9-11). Information and services were provided through the network of Ministryof Health facilities. Attempts have also been made to involve others in sisterinstitutions and the private sector in the programme.

The results of this innovation are very striking. The fertility effects have already beenmentioned but it worth repeating that the parities for Omani women aged 45-49 wereas high as 8.5 children in the 1995 survey (OFHS, 1995, table 7.1). The same highfertility was experienced by urban (8.6 children) and rural couples (8.3 children)alike. For the period 1993-5, the data from the birth histories in the OFHS indicatethat total fertility rates (a measure of final family size when fertility is experienced atthe measured rates) have fallen to 7.0 births overall, 6.6 in urban areas and 7.9 inrural areas (OFHS: 28, table 7.2). Figure 3.11 shows quite clearly that most of thechanges in fertility were amongst younger women. Older women, as judged by thepanties (OFHS: 31, table 7.4) have continued to have large families.

These fertility changes closely reflect the pattern of contraceptive use stimulatedvery largely by the birth spacing programme. We note in the programme statistics,for example, that 42% of clients seen in the clinics for birth spacing have paritiesunder 5 and 63% were less than 30 years old (Annual Statistical Report, 1995: table9.6) Most prefer the temporary methods (34% adopted the pill; 31% the injectable;and 14% the condom). The connection between the birth spacing programme andcurrent use is very clear -- 64% of clients said they had obtained their informationabout family planning through the Ministry of Health (Annual Statistical Report,1995: 9-11). Most women seem to have been satisfied with the new services since60% of the re-visits were for re-supply and another 19% for follow-up according tothe protocol of the birth spacing programme. Only 19% attend either for methodproblems or requests for method changes (Annual Statistical Report, 1995: table9.7). In the 1995 OFHS, a remarkable 97% of Omani women knew of at least onecontraceptive method, 38% had ever-used a method and 24% were currently using

5.27


a contraceptive method. This last figure is especially notable since in the OCHS in1988-89, only 8.6% of respondents were using a contraceptive method at the time ofsurvey (OFHS, 1996: table 8.1 and pp. 33).

Figure 3.11: Age -specific Fertility Rate, Oman 1993-1995.

——1993 ——1994 ——1995

400

350

c 3000)

I 250ooo7 200

tiso

100

50

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Age group

In addition to this strong evidence that the birth spacing programme is primarilyresponsible for these major changes in reproductive patterns, we note that thedifferentials in use by region and education were every small (OFHS, 1995, table8.2). This is probably a reflection of the way the programme has been implementedthroughout the country using the extensive network of health facilities run by theMinistry. There is still an attachment to large families however, since in the 1995survey, the mean ideal final family size was still 6.4 children (the modal number was4) and most respondents wanted their daughters also to have large families (OFHS,1995, 38-39). These figures were very much affected by age and it is very likely thatthe rising generation of younger women who were already delaying their marriagesand postponing the age at which they have their first births will also want to restricttheir fertility within marriage. All in all, the Oman case is an extraordinary example ofa rapid change in reproduction driven by an enlightened and non-coercive birthspacing programme.

3. Child Nutrition

Despite enormous health progress, the prevalence of child malnutrition continues tobe a major public health problem in Oman. High prevalence of wasting, stunting, lowbirth weight babies and anaemia among both children and mothers reflect childmalnutrition. Malnutrition is the result of several inter-related economic, educational,agricultural, and health factors. As such, it is a multi-sectoral problem, not simply amedical problem of the Ministry of Health.

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The first epidemiological study of child nutrition was conducted in Oman in 1973(UNICEF 1973). A more recent study in 1992 found little improvement in childanthropometry (Musaiger, 1992). About a quarter to half of children ages 1-4 yearswere either stunted or wasted in comparison to international standards. Interestingly,growth retardation among boys may be worse than among girls. Six studies alsodemonstrate a high level of anaemia among Omani women and children. Significantnutritional anaemia can be found among half of pregnant women (Musaiger, 1991).

What were the causes of these nutritional deficiencies and why has progress beenso meagre? One hypothesis is that the population has low dietary intakes of protein,fat, carbohydrates and iron, but various dietary surveys do not support this(UNICEF, 1990a, 1990b). Another hypothesis is the malabsorption of nutrients as aresult of parasitic infestation. Malaria can no longer be implicated due to theeffective control programme. Frequent and repeated pregnancies, lack of breast-feeding and other behavioural problems were other possible factors in the genesisof childhood malnutrition.

Reducing childhood malnutrition in Oman will require a multi-sectoral effort,including the contribution of the Ministry of Health. Adequacy of nutrient intake,improved nutritional practices like breast-feeding, better spacing and fewer births,control of infectious diseases like diarrhoea and malaria, and many complementaryand synergistic measures will be critical in determining the future nutritional health ofOmani children.

4. Breast-feeding: the Baby-Friendly Hospital InitiativeBreast-feeding was a customary practice, normal for all infants in traditional Omanisociety. The advent of modernisation brought along changes in the infant carepractices, many favourable but with the clear exception of bottle feeding. Like manyother societies, bottle-feeding in Oman gained enormous popularity during the1970s and 1980s as confirmed by the National Child Health Survey of 1988 andalso in a study by Musaiger (UNICEF 1988). Easy access and availability of breastmilk substitutes along with the vigorous sales campaigns lured many Omanimothers to resort to alternative feeding methods.

Studies on breast-feeding in Oman describe the evolution of these practices anddemonstrate what is possible through concerted government action backed byinternational agencies. The first breast-feeding study was carried out in 1972-1973in two areas of Oman jointly sponsored by UNICEF and the Ministry of Health. Pre-lacteal (foods other than breast milk like honey, ghee, molasses, saffron and dates)were commonly offered to new-born infants because colostrum was consideredharmful. Breast-feeding was started 3-7 days after delivery, and breast-feeding wascontinued on demand. The duration of breast-feeding varied generally discontinuedafter two years or until the next pregnancy. The practice of adding complementaryfoods while breast-feeding was practised by 45-70% of the mothers. Rice mixed withsamel (animal fat) and Parley's rusks were the most popular foods used forcomplementary feedings. In 1988 Musaiger found that 50% of the babies were

3.29


breast fed, 24% bottle fed and 25% resorted to mixed feeding (Musaiger 1996,1996). Nearly half of the mothers abruptly weaned their babies before three months;an additional 20% weaned before the baby reached 6 months. The 1988-89 OCHSshowed that breast-feeding was started immediately after delivery for 89% ofinfants. Twenty percent of babies under 2 months were getting supplementation withpowdered milk. About 40 % of infants started solids on a regular basis at 4 or 5months and another 20% at six or seven months.

To deal with the crisis in breast-feeding, Oman launched the Baby Friendly HospitalInitiative (BFHI) in 1992 in the wake of the 1990 World Summit for Children. BFHIembodies ten steps to successful breast-feeding, designed to provide clear andconsistent practices for all health care workers in every maternity health facility.

A national committee was formed in 1992 consisting of members from the Ministryof Health, Ministry of Social Affairs and Labour, the national organisation for Scoutsand Guides, and the Omani Women Association. The committee worked to make allhospitals baby friendly and adopted strategies which included capacity building,supporting women on breast-feeding, and empowering the beneficiaries. As part ofthe capacity-building trainers were developed from health and social sectors toimprove the knowledge and skills of the health staff and the support groups.Communities were empowered by generating a network of mother support groupsthroughout the country.

Oman was one of the first countries in the world to embrace this global initiative andto implement it with complete commitment in a systematic manner. On December17, 1994, Oman declared all of its 52 hospitals as baby friendly, being the firstcountry in the world to achieve this status

5. School HealthOman has accorded a very high priority to universal education and the growth of thenational educational system has been one of the outstanding features of Oman'smodern development (see Chapter 5). Between 1970 and 1995, the number ofschools has increased from 3 to 969. The total number of pupils over this same timeperiod has increased from 909 to 494,684, so that almost a quarter of Oman's totalpopulation are school children (Figure 3.12).

The School Health Programme began in 1972, initially covering only schools in theMuscat region but has expanded rapidly to cover most schools in all 10 regions ofthe Sultanate by the 1990s. In 1994/1995, there were 102 school doctors and 163nurses, both full and part-time. School health doctors are mainly generalpractitioners. Their job is to carry out the routine medical screening of pupilsaccording to a fixed schedule and to provide consultation services to individualpupils, pupils referred by the school nurse, teachers and parents, and secondaryschools teenagers who personally and confidentially ask for an appointment. Theyalso provide health education to pupils, parents, school personnel, and thecommunity. The doctor/pupils ratio is 1:4,850. School nurses contribute to the

3.30


control of the communicable diseases through immunisation and surveillance, earlydetection, and reporting of pupils with contagious diseases. The nurse inspectscleanliness of the pupil, manages simple health problems and measures height andweight of schoolchildren. The school health nurse pupils ratio is 1/3,035.

300

250

200

« 150'a.3a.

100

50

Figure 3.12: Growth in the Number of Schools and Pupils 1973-1995

I Schools-Boys-Girls

X

1200

1000

1982 1985

School Year Beginning

The Programme's activities include medical screening of all pupils in the first year ofprimary, intermediate and secondary (at 6, 12 and 15 years of age respectively).The screening involves general medical screening, oral and dental examination,vision and trachoma screening, hearing test, and control of communicable diseases.

Through school screening, about 10% of children are usually identified with chronicillnesses or developmental weaknesses and subsequently, referred to specialists. Ofthe different health problems detected by screening, the most frequentlyencountered were underweight (13%) and hair infestation (5%). Other detectedconditions were short stature (5%), upper respiratory tract infections (6%), skeletaldisorders (2%), cardiovascular disorders (1%), skin infestations (2%), nervoussystem disorders (0.6%) and disorders of the external genitalia (0.6%).

The Programme aims to change the beliefs and practices of school children byproviding them with knowledge of healthy habits through health education. Thehealth education is designed in collaboration with the Ministry of Education. Oman isalso currently examining standards for a healthy school environment. Theexamination currently concentrates on physical aspects, which include water andsanitation, canteen and food hygiene, building cleanliness and safety, insect androdent controlDuring the past three years, the School Health Programme has been strengthenedin Oman and significant resources have been invested. Plans are underway to train

~» "> iO.J 1


one teacher in each school in the country to deal with simple health problems and tooperate as a link between the school health workers and the schoolteachersespecially for follow up of cases that need more attention.

C. Emergence of Chronic DiseasesIn the last few decades, an increasing awareness of the importance of the non-communicable diseases has grown in Oman. Many chronic conditions, previouslyconsidered to be peculiar to the temperate climate and more developed countries,have been gradually emerging in Oman. Inpatient morbidity for diagnosis related tonon-communicable diseasesespecially cardiovascular disease, cancer, endocrineincluding diabetes, Nervous system and sense organs and injuries and poisoning-were growing and becoming a significant share of Oman's burden of disease (Table3.11). The rapid economic developments of the 1970s and 1980s have contributedto major changes in life style, including a reduction of physical activity, and theintroduction of westernised food habits, and exposure to new risks like accidentsand smoking. Changing risk factors translate into changing disease patterns,especially the emergence of non-communicable diseases.

1. DiabetesThe general impression among many Omani physicians is that diabetes hasbecome a major non-communicable disease problem. In 1991, a National DiabetesSurvey found the prevalence of diabetes and impaired glucose tolerance to be 9.8%and 9.8%, respectively (Asfour 1995). The same survey showed that the prevalenceof diabetes and impaired glucose tolerance (IGT) varies among different regions ofthe Sultanate, ranging, for diabetes, from 7 to 13% and for IGT from 8 to 14%.Impaired glucose tolerance was more common among females (13%) than amongmales (8%); both diabetes and IGT increased steadily with age. The same surveyshowed that overweight and obesity (BMI>30 kg/m2) are highly prevalent, affectingabout 19% of the total sample surveyed (10.5% among males and 27% amongfemales). In addition 45% of the study subjects had elevated cholesterol (defined as>5.2 mmol/L) (unpublished data from the National Diabetes study).

The prevalence of diabetes and impaired glucose tolerance in the Sultanate was thehighest reported in the Arab region. Similar surveys were conducted in the otherArab countries in the Eastern Mediterranean Region with countries reporting muchlower levels of national prevalence - 4% in rural Egypt and 9% in Saudi Arabia(Alwan, 1992).

The National Diabetes Survey undoubtedly points to diabetes as a major non-communicable public health threat in Oman. As diabetes and its complications wereexpected to grow in the coming years, the Ministry of Health has established aNational Diabetes Centre at the Royal Hospital and a consultative committee tolaunch a National Programme for the Prevention and Control of Diabetes.


Table 3.11 Percentages of Inpatient Morbidity for Selected Non-communicable Diseases, 1992-1999.

Disease GroupOJOlCD

COCDCD

"3-CDCD

inCDCD

CDCDCD

h~cnCD

00CDCD

CDCDCD

CVD 6.5 5.6 6.0 6.2 6.3 6.4 6.7 6.7Cancer 1.2 1.0 0.8 1.0 1.1 1.6 1.5 1.6Nervous system & sense 2.9 2.5 2.5 2.8 3.1 3.5 3.6 3.7organsEndocrine, Metabolic & 2.6 2.2 2.2 2.2 2.3 2.0 2.4 2.3ImmunityInjuries & poisoning________9.1 8.4 8.4 9.0 9.7 8.7 9.3 8.5Source: Annual Statistical Reports 1998-1999, tables 10-4 pp 10-11 & 9-6 pp 13-9.

2. CancerHospital mortality data show cancer as the second leading cause of death in Oman(Figure 3.13) accounting for around 10.3% of all deaths. Data also show that cancerdischarges have doubled over the period 1986 to 1993, averaging 15% yearly. In1995 the discharge rate of the neoplasms was 11.0 per 10 000 population.

At present, there is no evidence of excessive exposure to occupational carcinogensin the country, but newly adapted westernised dietary patterns along with lack ofproper physical activity might be significant risk factors. Tobacco use among maleadults (20 years and above) estimated to be 20.3% (National Diabetes Survey,unpublished data). A more recent survey estimated the prevalence of any type oftobacco use to be 15.5% among males and 1.5% among females (OFHS: 21, table5.1). However in this second survey information on smoking for were collected fromthe household head who asked questions about smoking habits and behaviours ofmember households. This proxy information in likely to underestimate the actualprevalence and may partially explain the discrepancy in figures between the twosurveys.

In 1985, a Cancer Registry was started in A'Nahdah Hospital. Later it wastransferred to the Royal Hospital and finally to Noncommunicable Disease ControlSection in the Ministry of Health head quarters. Initially only histopathologicallydiagnosed cases were registered, including cancer deaths at peripheral hospitals. In1993, 796 cases were registered among Omanis, 54% among males and 46%among females. In 1995, 833 cases were registered, of which 57% were males (seetable 2.21 chapter 2).

Stomach cancer was the leading cancer among males in Oman (11.1%), followedby non-Hodgkin's lymphoma (9.6%), prostate (7.6%), Leukaemia (6.7%) lung andbronchus (6.4%), primary liver cancer (4.9%), bladder cancer (4.5%), brain andnervous system cancers (3.4%), Hodgkin's disease (3%) and carcinoma of the colon(2.8%) (see table 2.22 chapter 2).

"i "iij.jj>


CVD

Cancer

lnj+ Poison

Infections

Ill-defined

Resp

Digestive

GU

Blood, Endocrine

Nervous

Figure 3.13: Ten Leading Causes of Death in Oman, 1989-1993.

_____ |•••• !••••̂B

••• ii

M

5 . I0 500 1 000 1 500 2000 2500 3000 3500 4000

Deaths

Breast cancer is the leading cause of cancer among females (13.7%). This isfollowed by cervical cancer (8.8%), non-Hodgkin's lymphoma (7.6%), stomachcancer (6.9%), thyroid cancer (6.4%), Leukaemia's (5.4%), ovarian cancer (3.8%),bronchus and lung (2.9%), primary liver cancer (2.5%) and connective tissuecancers (2.2%). (Table 2.23) .

Malignancy among Omani children was studied by al-Lamki et al, in 1994. Amongthe studied cases, leukaemia was most common (32%), followed by lymphomas(29%) and brain tumours (11%). The male to female ratio was 1:3 with thecommonest presenting age being 2 years. The authors concluded that the pattern ofchildhood neoplasm is not very different from elsewhere.

3. Heart DiseaseIn 1992, the Rheumatic Heart Survey among school children found 8 cases ofrheumatic heart disease out of 9,904 student examined, giving a rate of 8 per 10000. The annual incident rate of rheumatic fever was 4 per 10,000. Survey datashowed that the prevalence of congenital heart diseases was 2 per 1,000 schoolchildren, higher among females than males. About 6% of Omani school studentshad high blood pressure. The level of rheumatic heart disease was similar to that ofthe developed countries.

Data from hospitals show that diseases of the circulatory system accounted for 6%of the total discharges in 1995, a 46% increase in the number of cases relative to1990. Ischaemic heart disease was the commonest, followed by hypertensive andpulmonary circulatory conditions (Annual Statistical Report, 1995: tables 10-1 and10-2).

3.34


4. AccidentsOman's rapid socio-economic development has led to rapid urbanisation,modernisation, and expansion of road networks throughout the country.Consequently, the magnitude and severity of accidents have increased, leading todisability, injury and death.

Injuries due to road traffic are now a major health problem in the Sultanate. TheRoad Traffic Accident Survey in 1993 reported that there were 11,754 accidents inthat year, giving an incidence of 5.8 per 1,000 population. For every 100 accidents,3.9 people were killed. Out of these accidents, 6,975 injuries were registered, mostlyskeletal (41%) and neurological which required surgery (30%) followed by facialinjuries (17%). Most of the road traffic injuries were among males (80%) and 40% ofthe injuries were in the age group 26-50 years, followed by the age group 16-25years (36%). The Survey recorded 461 deaths out of 6,975 injuries giving a casefatality rate of 66 per 1,000 injuries.

Recently the Shura Council has examined road safety. The Ministry of Health issueda ministerial Qararfor the establishment of an inter-sectoral National Committee forthe Road Traffic Accidents Prevention. It also invited several internationalconsultants to assist in an analysis of the problem and to prepare a plan of action fortraining, management, and data collection. The Royal Police collect a lot ofsophisticated data, but unfortunately it does not contain information about morbidityand disability. The Ministry of Health data collection system, it is hoped, would assistin the management, priority setting, policy formulation, and programme planning andevaluation of prevention programmes.

IV. SUMMARY AND CONCLUSIONSWe can draw several conclusions form this review of the growth and effectiveness ofOman's national health services. The first point is that the provision of good quality,widely dispersed and free health services has transformed the health of the Omanipopulation. In addition, barriers to the use of the public health services have beenbroken down. Indeed, Omanis seems to be amongst the most avid consumers ofhealth services in the world. Although Oman was lucky enough to have had thefunds to build and staff both major tertiary hospitals as well as to construct anextensive primary health care system, the firm commitment to a consistent nationalhealth policy since 1970 has been important to the development of the healthservices in their 1995 form. Health services have reached every corner of theSultanate and so we see far narrower differentials in health and mortality than inmost other countries.

Secondly, the interest in surveillance and in special studies has provided a muchstronger numerical basis for planning and assessment than seen elsewhere. Therapid feedback provided to outlying centres, particularly in connection with theExpanded Programme on Immunisation (EPI), is widely appreciated and must be animportant factor in keeping the performance of most centres up to high standards.


The textbook reaction to outbreaks of polio or pertussis was greatly facilitated by theexistence of a very complete and efficient surveillance system.

Thirdly, Oman has constantly kept up to date with new technical developments anddifferent approaches to health care provision. This commitment to learning fromothers has paid off in that new vaccine schedules, new drug treatments and newcontrol strategies are quickly accepted throughout the health system. It helps whenmaking such changes for the Ministry to have a near monopoly of health careprovision.

Fourthly, the commitment to Primary Health Care form the beginning has hadseveral major consequences. We have already mentioned the decentralisation ofservices but in the section on manpower, we see a trend towards the greaterreliance on nurses and some levelling off in the numbers of doctors. Fortunately,Oman has had access to a supply of dedicated and well-trained nurses from theIndian sub-continent in the main but the point here is that the many of theprogrammes are run at a peripheral level with the minimum number of high-levelmedical personnel.

There are of course many problems facing the health services that we will return toin the concluding chapter. Here we need only mention the need to assess morerigorously the system's effectiveness, efficiency, equity, and sustainability. Given ourtechnical knowledge base, the effectiveness and efficiency (health impact forresources invested) can be expected to be high, but there are several reasons tobelieve that even greater effectiveness and efficiency can be attained. There iscomparatively little research on whether certain policies or practices have desirablehealth outcomes. The very intensive utilisation of free services, direct approach totertiary rather than primary facilities for initial complaints, the large number ofspecial, vertically-organised programmes, and the absence of detailed allocativecost information all suggest that considerable scope exists to gain greater healthimpact from the current level of resource investments, let alone controlling the rapidescalation of costs.

The equity of the system appears to be good because of policy decisions to provideuniversal coverage. However, perhaps 10% of the population have not beenreached, and amongst some of them, the unit cost of outreach will be extraordinarilyexpensive (e.g. helicopters, mobile teams).

The two biggest challenges facing the future of the health care system are the roleof the private, for-profit commercial sector in the national health plans and thechallenge of human, institutional, and fiscal sustainability. Private medicine hasalready begun to take roots in Oman; yet, few policies have been developed thatseeks to level the playing field to achieve an effective public-private mix in the healthsector. There are some potential positive benefits of private sector engagement -more resources, fee-for-service among those able to pay competition, etc. Withoutclear guidelines and a regulatory environment, a private market in health cangenerate many problems, however. Experiences elsewhere have shown that health

3.36


equity can be worsened and costs escalate without commensurate health benefits.Problems can include the quality control of private practice, excessive urbanconcentration of providers, over-utilisation of expensive tertiary services, and thepoor quality of marketed pharmaceuticals all can grow.

It is the sustainability of Oman's health sector that confronts the greatest challenge.The heavy dependence on non-Omanis to staff the health care system, the stillyoung Oman! health institutions in research and education, and free services paidfor entirely by the government are certainly unsustainable. While every effort isunderway to increase the number and quality of Omani health personnel, amanpower development policy is required to shape human resource production tothe future needs of a changing health care system. Indigenous Omani research andeducational capacity, backed by appropriate regional and international collaboration,is essential if Oman is to develop an internal capacity to manage health systemschange. Given limited petroleum reserves, plans should be made to find means ofdeveloping sufficient self-financing capacity within the health care system to relieveits dependence upon government income. User fees could be considered, initiallyfor rationalising wasteful utilisation behaviour (for example, charging for patientsskipping directly to tertiary facilities without referral from primary health centres orcharging for drug use so that consumption matches better with medical indications).Eventually, cost-recovery through user fees or risk-sharing insurance systemsshould be considered as important contributors to fiscal sustainability.

Finally, it should be underscored here that both the Government of Oman and therelevant international agencies, especially WHO and UNICEF, deserve considerablerecognition for their sensitive, artful, and technically-effective balance of indigenousOmani decision-making matched to appropriate international technical and financialassistance. While all of the policies considered here have Omani origins,international agencies obviously played important technical support roles that havebenefited the growth and development of the national health care system.

.37

CHAPTER 4

THE CONTRIBUTION OF RISINGNATIONAL INCOME AND PERSONALWEALTH TO HEALTH AND WELFARE

CHAPTER 4

THE CONTRIBUTION OF RISING NATIONAL INCOME AND PERSONALWEALTH TO HEALTH AND WELFARE

So far, we have examined the decline in mortality and morbidity in Chapter 2.There, we established that Oman's mortality and health transitions have beenamongst the fastest on record. Our initial search for explanations for these

precipitous improvements began with a study of the expansion of the health servicesin Chapter 3. It is clear that the direct contribution of the health services to Oman'smortality and health transitions has been very substantial. It is important, however,not to ignore the role of social and economic development and in this chapter, we tryto identify the contribution of rising levels of national and personal income to severalaspects of welfare including health. The, economic explanation is not fullysatisfactory since everywhere the role of human development, education inparticular, is widely cited as a reason for the surprisingly good level of health inseveral poor countries (Halstead, Walsh and Warren, 1985). This socialdevelopment and the investment in living conditions will be covered in Chapter 5.Both Chapters 4 and 5 attempt to assess the importance of human developmentbroadly defined as a source of some of the improvements in health. The basicexplanatory framework we are working with remains that set out in Chapter 1. Thisis itself a borrowing from the 1993 World Development report which was the firstglobal attempt to put the role of the health service's in the context of other economicand social development trends.

In dealing with the Omani economy and its contribution to human welfare, we haveto remember that the economy of Oman, like many neighbouring states, is veryheavily dependent on oil and gas exports for its revenues. Indeed, in 1995, 77% oftotal government revenues were from the proceeds from oil and gas (Statistical YearBook, 1995, table 2-15) and other revenues were indirectly associated with oil sectoractivities. This heavy reliance on production and exports from a single sector makesthe government's task very difficult. First, such revenues can fluctuate according toworld energy prices which are in turn a reflection of a mix of technological, politicaland economic factors, each prone to sudden change. Certainly, they are not fullywithin the control of Oman or any other single oil-exporting country. Secondly, thisrevenue from oil and gas production and sales is paid directly to a single source, thegovernment exchequer. Full responsibility for the use of these revenues thus restswith a single body, which then has the complex task of spending these revenueswisely and in ways, which will safeguard the interests of the state and its citizens.Different solutions have been found to the problem of developing a more diversifiedeconomy using oil revenues as the driving force. Many of the smaller oil exportingcountries of the region have experimented with state capitalism and using theconstruction industry to stimulate other sectors of the economy. Kuwait, for example,invested in a major reconstruction of the old city of Kuwait, buying land from long-established residents and thus spurring an economic boom throughout the

Chapter 4: Income and Wealth; Health and Welfare

economy, using the construction industry for the initial impetus (Ffrench and Hill,1971). There are other formulae, such as undertaking major investments in publicbuildings, enterprises and agricultural and manufacturing development projects.Every oil-exporting country wishes to avoid the simple distribution of funds to itscitizens in the form of grants and pensions since this leads to the creation ofdependency and a vulnerable economy. Generally, the solution, and one chosen byOman, is to invest heavily in human development, building a welfare state whichstops short of providing complete income support for all. At the same time, stepswere taken to diversify the economy but avoiding, as far as possible, major newdemands for expatriate labour. In Oman, the major investments in health describedin Chapter 3 were matched by major expenditures by the Ministries of Educationand of Social Affairs and Labour, as we shall see in Chapter 5.

One problem besetting all small oil-exporting countries at the outset is their heavydependence on outside sources of labour. Initially, the demands of the oil and gascompanies are for relatively small numbers of highly skilled workers. As constructionproceeds, the demands for unskilled and semi-skilled labour grow rapidly. Behindthe immigration policies in force throughout the Gulf region was the hope thatcitizens would acquire the new skills very quickly, thus holding down demands fornew immigrant workers. Thus, the human development of the population also has tobe judged against the background of dependency for certain types of skills onoutsiders. The population composition of the nationals as well as the cultural,educational and skill levels of the immigrants is every different from those of theimmigrants. The foreign workers begin by assuming tasks that cannot be performedby the national population but often, despite rising skill levels amongst the nationals,we see dependency on foreign workers being perpetuated as certain manual andunpleasant tasks are shunned by the citizens. Thus, amongst the measures wemust examine in human development is not just the advancement of the nationals,men and women alike, but also signs that the foreign workers have also participatedin the growth of the economy, receiving their fair share of benefits.

/. GROWTH OF THE ECONOMY: OIL PRODUCTION AND REVENUES

Oil and gas exports form the backbone of the economy. Table 4.1 shows veryclearly the large contribution of petroleum activities to the GDP between 1980 and1995. Oil was discovered in Oman in 1962 in Yibal and production began in 1967.High expenditures have been maintained for exploration and development to keepthe discovery of oil ahead of depletion (McLachlan, p. 14). The total governmentrevenues have increased dramatically from RO 50 million (US$ 130 million) in 1971to 1851.6 million (US$ 4814.16 million) in 1995, largely due to increases in revenuesfrom the energy sector. The growth in government income was quite slow in theearly 1970s but expanded very quickly after the price increases associated with theboycott following the 1973 Arab-Israeli war. Production and exports grew quiteslowly in the 1980s but the price increases for oil and gas meant that governmentrevenues increased thirteen times between 1973 and 1980 and doubled againbetween 1980 and 1995 (Table 4.2).

4.2


A more revealing way to view the growth of the economy allowing for price inflationis to consider the expansion of GDP at constant 1988 prices. As Table 4.3 shows,the economy has continued to grow throughout the late and early 1990s, 1980s at ahealthy rate.

Table 4. 1 Growth of Gross Domestic Productin Million Omani Rials at Market Prices 1980-95.Year Petroleum

activitiesNon-petroleum

activitiesTotal GDP§

1980198119821983198419851986198719881989199019911992199319941995

1322.71547.31505.81483.41566.91780.71255.71520.81266.91551.52144.41825.11952.01782.31814.82020.0

878.21117.91297.31477.31692.71832.31921.91840.22000.72103.82407.02588.92880.63071.03220.03368.5

2185.02637.62773.92932.83232.13590.63143.43317.63224.53603.64493.04360.84787.84803.64967.35307.2

§ Adjusted for financial services and importtaxes, t To convert to US$, Multiply by 2.6Source: Statistical Year Book, 1997, tables 1-15and 2-15

Omanis have seen a rapidlyrising per capita income sincethat time especially with thesteep rises in oil prices in 1973-74, followed by a decline in percapita income after the oilshocks 1980s. Between 1980and 1990, the annual growth inper capita income wasestimated to be 8.3% and forthe five year period 1990-95,the growth was some 6% peryear (World DevelopmentReport, 1997, 1). By 1995, theper capita income inPurchasing Power Parity dollarswas put at $8140 (WorldDevelopment Report, 1997,table 1).

Although these income figuresare high, they are not as highas some neighbouring oil-exporting states (Table 4.4).Oman's economic performance

has, however, been quite steady over a number of year. This has contributed to thedevelopment of the whole economy and to the non-oil sector in particular.

//. GOVERNMENT EXPENDITURES IN THE SOCIAL SECTOR.Direct spending in the social sector was one major way in which the governmentwas able to significantly affect the welfare of the whole population of Oman and toencourage growth in private sector at the same time. Figure 4.1 shows very plainlythe major increases in spending by the state since 1982. The graph shows thegradual decline in spending on development items as the infrastructure of themodern state took shape in the 1980s. Defence and public order remained majoritems, consuming 14.6% of the 1995 GDP, down from 20.7% in 1985 (WorldDevelopment Report, 1997, table 19), equivalent to a third of total expenditure(Statistical Year Book, 1995, table 2.15). This is high by international standards, asthe Human Development Report points out, equalling 205% of the spending ineducation and health. Fortunately, the economy has been growing fast enough tosupport both major expenditures on defence as well as heavy investments in the

4.3


social sector.

Figure 4.1: Government Total and Development Expenditure 1971-1995.

" "*"" Da/dopnent * Totd wpaiditLre

= 1500S

u.1 1000

***

• "•-•-••»-»* ̂ _^' ^~' * •• —

1965 1970 1975 1980 1985

Year

Overall, expenditure on the social sector has been high in absolute terms althoughincreasing only slowly in proportional terms (Table 4.5). Oman, like many other Gulfcountries, spends a large proportion of central government funds on health andeducation.

Taking out defence expenditures, we see more clearly the size of the investmentsbeing made in education, followed by health and social affairs (Table 4.6)

Spending on health (recurrent and development expenditures combined) rosesteeply in current prices during the 1980s and has been held at about 106 millionRO (US$ 275.6 million) a year in the 1990s. The amounts spent on health havebeen approximately 4% of total government spending since the mid-1980s (Table4.7). In the 1990s, this has amounted to about RO 50 (US$ 130) per head ofpopulation. Note that most per capita figures before the first census in 1993 aresubject to some errors due to uncertainties in the earlier population estimates.

A. EmploymentUndoubtedly the largest contribution to personal income has been the wages andsalaries paid to both Omanis and non-Omanis working in the civil service and inpublic corporations. The numbers employed in the civil service, the Diwan of RoyalCourts and in public corporations grew from 3,112 in 1971 to 110,444 in 1995(Statistical Year Book, 1995, table 4.2). Nearly 70% of these employees areOmanis, up from around 60% in the early and middle 1980s. The salaries andwages of these employees represent by far the largest transfer of resources fromthe state to individual families. In 1995, the total bill for wages and salaries in the

4.4


public sector was RO 523.9 million (US$ 1362.14 million) (Statistical Year Book,1995, table 15-5), excluding defence expenditures.

In addition to salaries and wages for government employees, the military and thepolice, the state also transfers a substantial part of its national income to individualsin a variety of different ways. We will review a few of these in the following sections.

Table 4.2 Government Revenue and Civil Expenditure 1971-95 in Millions ofOman! Rials.Year1971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995

Revenue50.153.068.6303.2387.7488.0520.0502.3692.2923.71262.21175.41253.91340.71572.91186.91460.21204.81370.11876.31585.11680.21723.91757.41851.6

Recurrent26.041.762.2186.6322.5379.0379.0430.2449.5666.5842.3953.71100.11219.81333.71301.81225.51271.11361.11570.11463.01738.31727.61777.31859.5

Investment20.030.046.2162.6187.0195.0145.0129.8200.9258.2332.0411.7388.2480.3550.9544.2338.4280.2270.3285.8391.7471.1477.6458.9456.9

Other---------

25.149.447.558.660.243.840.848.215.934.431.513.449.337.216.714.6

Total expenditure46.071.7108.4349.2509.5574.0524.0560.0650.4949.81223.71412.91546.91760.31928.41886.81609.11567.21665.81887.41868.12258.72242.42252.92331.0

Source: Statistical Year Book, 1997, tables 1-15 and 2-15f To convert to US$ Multiply by 2.6

B. Social Houses, Low Cost Housing Loans and GrantsThe social security and welfare system is geared towards improving the livingconditions of the needy. The government decided that housing was a majorcomponent of living standards and began the distribution of low-cost housing unitsto the poor. The distribution of houses came to an end in 1993 and was replaced bya system of low-cost loans. In the housing sector, "social" houses as well as lowcost housing loans and grants were provided on the basis of need. Eligibility for

4.5


Table 4.3 Growth of GrossDomestic Product at 1988Constant Prices.Year

198819891990199119921993

GDP AnnualUS$ growth (%)

3,2253,3213,5993,8164,1414,395

5.23.08.46.08.56.1

To convert to Omani Rials,multiply by 0.386. Source:Statistical Year Book, 1997tables 4-14, and 6-14.

person in an accident or withalready paid 75% of the costexcused from further payments

subsidised housing is based on criteria firstestablished in 1973. The beneficiaries had to beOmanis aged between 21 and 50 who has notreceived support from the state in another form(e.g. have received facilities or housing from anyother government agency). There were otherconditions — such as not owning another house andbeing a resident of the same Wilayah where thesubsidised houses were being distributed. Theapplicant had to have an annual income below RO3,000 (US$ 7,800). Priority was also given tocitizens whose land was taken by the governmentfor public use and to those who were married withlarge families. The value of the house was to bepaid off in monthly instalments, the price being setby the Minister of Housing. Those in hardship (a

a disability, those having difficulty paying who hadof the house or the family of the deceased) were(Ministry of Housing, 1977).

Table 4. 4 Per Capita Income for Oman and Neighbouring Countries in1995.Country

BahrainKuwaitOmanQatarSaudi ArabiaUAE

Per CapitaGNP

7,84017,3904,82011,6007,04017,400

PPP estimates ofGNP

in currentinternational $

13,40023,7908,14017,690

NA16,470

Annual GDPgrowth (%)

1980-90

NA0.98.3NA-1.2-2.0

AnnualGDP growth

(%)1990-95

NA12.26.0NA1.7NA

Notes: NA = not available. See original source for additional technical details.PPP$ - Purchasing Power Parity $. Source: World Development Report 1997,tables 1, 1a and 11.

Figures for the total number of beneficiaries from this scheme are difficult to locatebut over the 1990-92 period, it appears that the scheme was costing some RO 6million (US$ 15.6 million) per year (unpublished figures, Development Council). After1993, the scheme was replaced by a system of low-cost loans. These one-timeloans were geared towards people with limited incomes for building houses, buyinghouses and building extensions to already built houses. In 1995, for example, 1607loans were approved to the value of 22.1 million RO (Statistical Year Book, 1995,table 21-1). Whilst 40% of the low income homes had been distributed in the Muscatregion, all of the low-income loans were provided to residents of other regions(Statistical Year Book, 1995, table 20-2). Recipients had to be Omanis over 21 with

4.6


at least 3 years of citizenship and with an income of between RO 130 and RO 250(US$ 338- 650) per month. The maximum loan disbursed is RO 15,000 (US$39,000) which is interest free but monthly instalments have to be paid over 25 years.

Table 4.5 Percentage of Central Government Spending by Function in 1981-90 and 1990-95.

Health

Period

OmanKuwaitUAE

SI-90

3.996.76.8

91-95

5.14.57.1

Education

SI-90

8.9211.911.4

91-95

10.28.8

16.2

Social security& welfare

81-90

2.2210.63.1

91-95

3.113.73.4

Defence

SI-90

37.8214.543.3

91-95

33.9136.837.5

Other

SI-90

47.056.335.. 5

91-95

47.7336.135.8

UK 13.6 14.0 2.7 4.2 30.0 30.5 13.0 9.2 40.7 42.2Source: World Development Report. 1997, table A.3.

Table 4.6 Government Current Civil Expenditures by Broad Categories in 1995.TypeEducation & Sultan Qaboos UniversitySocial affairs, labour and housingHealthSubsidies to public authoritiesOther administrative and government expensesTotal

Million RO212.937.8101.28.1

518.1878.1

%24.24.311.5

159.0100

To convert to US$, multiply by 2.6.Source: Statistical Year Book, 1997, table 4-15

Table 4.7 Total and Per Capita Spending on Health 1980.Year Total Government

Expenditure(Million RO)

19801985199019911992199319941995

949.81928.41887.41868.12258.72242.22252.92331.0

MOH MOH expenditureExpenditure as % of total(Million RO)

23.273.474.385.3

108.4117.6122.9124.5

2.43.83.94.64.85.25.55.3

MOH expenditureper capita in RO

22.152.145.748.457.358.860.758.4

Note: To convert to US$ multiply by 2.6; Expenditures in the health sector includeboth development and recurrent spending.Sources: Statistical Year Book, 1997, table 15 - 4 and 15-6

4.7

______Chapter 4: Income and Wealth; Health and Welfare______

C. Government Grants for Social Welfare, Individual and General DisastersThe Ministry of Social Affairs was established in 1972 by Royal Decree to providenecessary care for the disabled through financial support. By 1977, the scope wasexpanded and government grants were made available as social security fordisability, orphanhood, widowhood, senility and divorce. Since the 1980s,beneficiaries have included families of prisoners, unmarried women and the elderly.Monthly grants ranged between a minimum of RO 10 (US$ 26) to a maximum of RO35 (US$ 91) in 1977. This range has been increased to between RO 30 to RO 80(US$ 78-208) in the 1990s. There has been a steady growth in the number ofrecipients of social welfare from 1732 in 1975 to 42,155 in 1995. The cost of thisassistance has risen to RO 21.2 million (US$ 55.1 million) in 1995 (Statistical YearBook, 1995, table 20-3). Almost half of the payments by value are for the elderly.Most of the recipients live in the al-Batinah and A'Sharqiyah regions.

The other two types of government grants besides social welfare include those foremergencies faced by individuals (individual emergency grants) or groups (generalemergency grant). Such assistance is small (RO 57.4 million (US$ 149.2 million) in1995- Statistical Year Book, 1995, table 20-3) in comparison with the housing loansand social welfare benefits described above

D. Services and Interest Free Loans and Grants Aimed at IncreasingFamily IncomeAdditional programs managed by the Social Affairs and Labour sector involvevocational training for women and income generating projects directed towardsraising family income. The vocational centres for women teach sewing, knitting,embroidery and handicrafts. These centres are distributed in the capital, Nizwa andSur. The number of women who completed training was about 130 in 1982. Familyincome-generating projects subsidise local industries and handicrafts which help lowand middle income families generate income (UNICEF, 1984: 91) By 1982 theMinistry had sponsored 64 family projects with a cost of RO 21,192 (US$ 55,099.2).More recent information is not available.

E. Incentives for BusinessThe Ministry of Commerce and Industry also administers capital grants to supportsmall Omani industries with capital under RO 100,000 (US$ 260,000). This programwas started in 1991 and since that time RO 0.5 million (US$ 1.3 million) have beengranted. The grant can be invested in the Muscat Region but 60% is for remoteareas.

The Oman Development Bank has lent over RO 63 million (US$ 16.4 million) forprojects in various sectors. Most of the loans were to chemical, foodstuff andconstruction industries. Minor shares went towards financing agriculture andfisheries as well as other medium-sized manufacturing projects. Small businessesrun by Omani graduates in particular with investments under RO 100,000 (US$260,000) have been provided with loans by the Bank. Interest charges range from

4.8


3% to 0%. The cumulative cost of the Bank's private sector capital subsidy programreached over RO 23 million (US$ 59.8 million) over the period 1980 to 1992. TheBank is also providing loans for the promotion of exports, a scheme projected tocost RO 7 million (US$ 18.2 million) by the end of the plan period in 1995.

From the above, it can be seen that in addition to the provision of health services,employment and the usual services of government (roads, public security, and soon), the sta 9 has been very generous with its citizens in providing a variety ofsupport mec' anisms to improve housing conditions and the level of family income,especially for the poor. Can we document some of these effects on householdincomes in the Sultanate?

///. CHANGES IN PERSONAL INCOMEOman had an estimated per capita income of US$ 6,309.5 in 1995 in currentinternational dollars (World Development Report, 1997, table 1). The averageannual growth rate was 9% between 1965 and 1980 dropping to 1.9% between1980-91. It is clear that there has been a significant rise in the wealth of the countryas a whole and it is clear that personal income has also risen at all levels (seebelow). Information on income and living conditions is difficult to find for the earlyyears but living standards have been transformed since the 1970s. There are fewpoverty indicators, no information on income distribution over time and it is notpossible to present the structural transformation in personal income over a long timeperiod. The 1993 census and the OCHS 1988-89 and OFHS 1995 do providereliable indirect information which can be used to gauge living standards at least inthe late 1980s and early 1990s.

The World Development Report of 1997 indicated that the GDP has risen from $256in 1970 to $8,140 in Purchasing power parity (PPP) $ in 1995 (see Table 4.4). Inaddition to this information, we also know that the distribution of the GDP for privateconsumption has risen from 19.4% to 50.3% and in general, governmentconsumption rose from 12.8% to 26.4% from 1970 to 1991. Gross domestic savingshave been reduced from 67.8% to 23.3% in the same time period (WorldDevelopment Report, pp 254, 1997 Year). Thus it is clear that consumption andpurchasing power have both risen in the last two decades both in the governmentand private sectors. Unfortunately we do not have any information on trends in percapita consumption by region and for different population groups and therefore it isdifficult to show that consumption and personal income have risen for everyone.

One household income and consumption survey has been carried out in Oman.Annual income surveys in the cities and rural areas are not yet routine and so it isimpossible to show the rise in income by region or changes in the incomedistribution. The one available study was done by UNICEF in 1991 (Musaiger 1992)(see table 4.8). The types of activity, employment status and the employment sectorby region that can provide an indication of the distribution of income are available inthe 1993 population census. The Development Council Statistical Yearbook of 1993also provides some information on labour cards issued to non-Omanis in the private

4.9


sector and the monthly basic salary for 1993. These figures, however, do not allowus to measure the change in salary with time. Finally, information on ownership ofdomestic durable goods across regions as well as some environmental factorswhich reflect standard of living by region is available from the 1988/89 Oman ChildHealth Survey, the 1993 population census and the 1995 Oman Family HealthSurvey.According to the UNICEF, based on a small survey sample, one can see a widerange of incomes for the Omani population. As can be seen, the majority of thepeople interviewed reported an income of between RO 200 and RO 499 (US$ 520-1297) per month (Table 4.8). Most of the families in the highest income bracket livedin Muscat and Dhofar. The regions with the highest percentage of population in thelower income bracket are Dhofar, North Batinah and Musandam.

Indicators of the distribution of income can be inferred by the types of activity,employment status and the industry of employment by region from the 1993population census. Of the population 10 years of age and over, 46% wereemployed, 27% were students, 20% were homemakers, and only 2.5% wereunemployed and seeking work for the first time. The highest number of womenemployees are also found in Muscat but women workers comprise only 5.1% of theeconomically active population.

Table 4.8 Percentage Distribution of Family Income by Region andIncome Category, Oman 1991.__________________________

Monthly Income in Omani RialsRegionNorth BatinahSouth BatinahA'DakhliyahA'DhahirahDhofarMusandamMuscatA'SharqiyahTotal

<20038.227.233.132.940.237

21.131.430.7

200-49950.948.960.541.140.256.548.746.648.8

500-99910

20.74.826

12.84.3

21.518.816.2

1000+0.93.31.60

6.82.28.73.14.3

Total100100100100100100100100100

Total Households110921247311746265191

1018To convert to US$, multiply by 2.6. Source: Musaiger 1992.

Looking at the type of industry by region, it is clear that the top five industries arefirstly public administration, defence and social security with a total number of165,646 people employed. The industry with the second highest number ofemployees is the wholesale and retail trade, repair of motor vehicles, motorcyclesand personal and household goods (89,625 employees). Next is manufacturing with60,446 followed by agriculture, hunting and forestry with 55,257 and 55,200 foragriculture, hunting and related activities. The industry of extraction of crudepetroleum and natural gas, service activities incidental to oil and gas extractionexcluding surveying employs only 13,334 people.

4.10


Unfortunately, information on salaries for the above forms of employment in thevarious industries is not available. The Statistical Yearbook of 1995 provides someinformation on average monthly salaries for foreigners in the private sector. It is notpossible to infer the salaries for Omani workers in the same employment nor does itallow us to see the changes in salary with time.

Table 4.9 Average Monthly Salary inRO Paid to Non-Omani Workers inthe Private Sector by OccupationGroup, 1995.Occupational group

ProfessionalTechnicalAdministrative & managerialClerical and related'SalesServiceAgriculture and fishingProduction workersTransportLabourersAll

MonthlySalary in

RO35818752418286464083605189

To convert to US$, multiply by 2.6.Source: Statistical Year Book, 1995,table 5-7.

The data in Table 4.9 show that there isa large premium on skilled labour, suchas professional and technical oradministrative and managerial. Rates ofpay for the unskilled are quite low. It isof course very difficult to assess thesewage rates without having a clear ideaof the cost of living in Oman. Otherbenefits in cash and kind (e.g.subsidised housing, air fares and paidleaves, for example) make it difficult tointerpret these cash values. Estimationof the household income is beyond thescope of the present study but we canshow some figures on possession ofcertain consumer goods and householditems that will give some idea of thewealth of the Omani population in the1990s.

Table 4.10 Percentage of HouseholdsOwning Specified Durable Goods in1988-89.Appliance or item % of households

owning

In the 1988-89 Oman Child HealthSurvey, several questions were askedof the household heads to describe theliving conditions of the womeninterviewed in the main survey. Thefigures describe a well-housedpopulation with good domestic servicesand ownership of many householdconsumer goods. Overall, the numberof rooms per household was 4.2, withlow densities per room (1.5 person perroom on average: OCHS, table 3.5).Almost three-quarters of the

households have flushing toilets, 44% had fitted carpets and 81% were usingelectricity from the public network. Only in the area of water supply were there somesurprises. Only 26% of households had piped water from the public supply systemand 58% still had to obtain their water from outside the dwelling, 28% from wells(OCHS, table 3.6). By 1995, however, 29% of households had access to piped

RadioTelevisionRefrigeratorTelephoneCarAir conditioning unit

81.874.279.325.949.567.0

Scarce: OCHS, 1988-89, table 3.7.

4.11


water and only 16% drew their water from wells (OFHS, 1995, p.11). The ownershipof durable goods had reached even higher levels (Table 4.10) and in the 1995survey, we note that 65% of households had private cars and 56% had telephones.

Particularly in the Muscat region, most households lived in modern housing (villas orflats) and only small proportions of people were not living in a house of one kind oranother (Table 4.11).

Table 4.11 Percentages of Households by Type of Housing in 1993.Region

The SultanateMuscatal-BatinahMusandamA'DhahirahA'DakhliyahA'Sharqiyahal-WustaDhofar

Villa

1625111014157318

Flat

153343663039

ArabicHouse

44295870495061311

VillageHouse

1121411151913319

Hut

75825510535

Tent Collective OtherHouse

1000011

333

110110022

5543115633

Total

100100100100100100100100100

Owner-occupancy had reached high levels by 1993 with nearly two-thirdshouseholds owning their own homes (Table 4.12).

of

Table 4.12 HouseholdsRegionThe SultanateMuscatAI-BatinahMusandamA'DhahirahA'DakhliyahA'Sharqiyahal-WustaDhofar

Owned623875746675754454

by Housing Tenure in 1993.Rented

223313162513161228

Employment incentive142799796

4115

Rent Free212122232

Others111001100

Total100100100100100100100100100

Source: Census of Population, 1993

The level of income can best be judged from the ownership of selected durableconsumer goods (Table 4.13). Even for expensive items such as cars, levels ofownership are very high indeed. Figures over 100% indicate that many householdsown more than one of the items mentioned. Certainly, ownership of a car, arefrigerator and an air conditioner can all have direct and indirect effects on health.But the figures are useful in indicating that Oman is now a population with a veryhigh disposable income for most of its citizens.

4.12


Table 4.13 Number of Appliances (by type) per 1000 of Population byRegion._______________________________________Region Private Tele- Washing Freezer Refrige- Cooker/ Video Tele-

car phone machine rator Oven visionMuscatAI-BatinahMusandamA'DhahirahA'DakhliyahA'Sharqiyahal-WustaDhofarSultanate

797510179801059093119

55234151410

475989

8711578627046585109

59366174475

305350

1071561041059910100119160

134161103133132123103132149

325137293446256110

1281481221141126

134136174

Source: Census of Population, 1993.

IV. CONCLUSION

This chapter has shown how growth in national income has also been translated intorapidly increasing living standards for most of the Omani population. The oil wealth,although initially concentrated almost exclusively in government hands, has beentransferred to the general population by a series of polices designed to distribute thewealth and to keep differentials in living standards to the minimum. The tablesabove show that the outlying regions have benefited enormously from governmentinvestments in the social sector just as the capital area. The early commitment tothe full re-integration of Dhofar into the nation probably helped in this respect. Theinvestments in the social sector have been large and some have major implicationsfor the future. First, there is the large civil service that is both costly and may be toolarge for efficient administration. Then there is the dependency on the state for arange of free or heavily subsidised services including health, education, housing andsocial welfare including old age pensions. In many ways, however, suchinvestments can be said to have paid off if the stock of human capital has beenpermanently improved for future generations. A key part of this improvement is theincrease in educational levels. This and the investment in environmentalimprovements is the subject of the next chapter.

4.13

CHAPTER 5

SOCIAL AND ENVIRONMENTALDEVELOPMENT

CHAPTER 5

SOCIAL AND ENVIRONMENTAL DEVELOPMENT

n this chapter, we turn to non-economic aspects of social development,concentrating on the rapid increase in educational levels with a special focus onthe education and changing public role of women. Interesting in their own right,

these topics are relevant to the understanding of the health transition since it hasbeen shown elsewhere (Preston and Haines, 1991, for example). An understandingof the biological basis for the disease processes can contribute to reduced morbidityand mortality. Literacy also confers on people a sense of personal efficacy in theface of adversity. In addition, the ability to communicate through the written wordmeans individuals are better placed to deal with administrative systems (the modernhealth care system). Further, mothers with some education can also interact moreeffectively with health professionals. Indeed, the effect of being educated may alsoaffect the attitude of the health professionals to the mothers. All in all, education hasmany direct and indirect effects on health and child survival in particular.

We also consider aspects of women's advancement in addition to becomingeducated. Modernisation alters the public and private role of women both throughstructural changes in employment and also through changing attitudes and mores.These latter changes are more difficult to document but some attempt is made tocapture some of the transitions that most visitors to Oman quickly notice.

Although changes in the environment in which Omanis live are of a different naturefrom education and changes in women's roles, some of these developments aretreated here since they represent another way in which public investment has beenused to improve the living conditions for all. Different from education but still a majorcontribution to improvements in living standards by the government, investments inwater and sanitation can be seen as another way in which private attitudes tohygiene and health have been altered by the several development plans.

1. EDUCATION: ENROLMENT AND LITERACY

The transformation of the educational status of the Omani population since 1970has been truly dramatic. In the 1969/70 there were only three schools in the wholeof Oman distributed in the capital and southern region. Additionally, Quranic schoolstaught basic skills in reading and writing. The lessons were often held in the openunder trees. In 1995-6, Oman boasted 953 government schools, free and open toall; 24,271 teachers and 488,797 pupils (Statistical Year Book, 1995, table 2-19). In1970, education was made universal and free to all Omanis. The public demand foreducation, even from the early 1970s was so great that at many levels, schools hadto be held in tents and classes run in morning and evening shifts.

One of the clearest ways to envisage the huge expansion in education and the

Chapter 5: Social and Environmental Development

consequent growth in literacy is to examine the data presented in the 1993population census, the proportion of illiterates amongst the younger generations hasfallen to very low levels. Both men and women have benefited from the expansion ofschooling but there are still some gender differentials, especially at the highereducational levels. This differentials are discussed in greater detail below. The non-Omani population has much lower levels of illiteracy because of the selective effectsof migration and the demands of the economy for skilled labour.

A. The Expansion of Schools and EducationIn 1969/70, the total number of students was only 909, all of them boys. By theacademic year 95-96, the total number of students enrolled in the Ministry ofEducation's institutions had reached nearly half a million. In 1995-6, there were 347primary schools with 297,488 students; 458 preparatory schools with 122,457students; and 148 secondary schools with 68,852 students (Statistical Year Book,1995, table 19-2). It is estimated that about 50,000 new students enter the system inOman every year.

Primary education usually lasts for 6 years. The percentage of primary schoolchildren reaching grade 5 in 1990 was estimated to be 95%. Currently the grossenrolment rate (total number of children enrolled in a schooling level, expressed asthe percentage of the total number of children in the relevant age group for thatlevel) in the primary and preparatory stages has reached 94% and 84%respectively. The net enrolment rate (number of children enrolled in a schoolinglevel who belong in the relevant age group, expressed as percentage of the totalnumber in that age group) is 81% and 53% in the primary and preparatory stagesrespectively. This suggests that 19% of primary school age children never enrol inschools. The preparatory level follows the primary level of schooling between theages of 12 and 14. Students are admitted to the secondary level after passing thepreparatory exams. After completion of the secondary studies students are eligibleto apply for university or other specialised training.

As Figure 3.12 shows the rapid increase in the number of schools from three in tworegions to 953 schools distributed over all regions. Despite this, 80% of classes arestill being held in double shifts, which compromises the quality of education of thesestudents. In addition most schools (primary more than preparatory) lack basicfacilities such as libraries, workshops and laboratories. These are potential areas forfuture improvements.

To ensure greater diversity in the educational system, in 1980, 7 Islamic preparatoryschools (linked to mosques) and one Islamic secondary Islamic school wereestablished. These schools teach the same curriculum as the general schools butlay particular emphasis on Islamic studies. In addition, there are three schools forcommerce, industry and agriculture; 9 vocational training secondary schools, 1 post-secondary vocational training institute, a Health Science Institute (under the Ministryof Health), an Institute of Public Services (under the Ministry of Civil Service), andone institute of Bankers (under the Central Bank of Oman). All together, these

5.2


institutions had an enrolment of about 11,000 students in the mid-1990s.

300

250

200

» 150'5.30.

100

50

Figure 3.12: Growth in the Number of Schools and Pupils 1973-1995

I Schools-Boys-Girls

X

1200

1000

800

600

400

200

1982 1985

School Year Beginning

The number of teachers has increased substantially from thirty in 1969/70 to over22,000 <in 1995-6. More than 42% of the teachers are currently Omanis. To assesstheir impact, we need to know something about their training and about the student-to-teacher ratio. During 1970-77 there was a total lack of qualified and experiencedOmani teachers. This gap was filled by recruiting large numbers of teachers mainlyfrom Arab-speaking countries such as Egypt, Jordan and Sudan. The first nationalTeacher Training Institute started its courses in 1976/77 with 25 trainees. Theinstitute was replaced by the Intermediate Colleges in 1984/85. Currently there areeight Intermediate Teacher Training Colleges, 5 for males with 1,684 students, and3 for females with 1,445 (46%) students. These are distributed throughout theSultanate. As a result, today there are 8,468 Omani teachers in the generaleducation with 68% engaged in primary schools, 15% in the preparatory schoolsand 11% in the secondary schools. In addition, an institute has been established totrain university graduates to become preparatory and secondary school teachers.

Table 5.1 Student-to-teacher Ratios and The overall student-teacher ratiosNumber of Students by EducationalLevel, Oman 1995-96.

Students perteacher

Students perClass

appear to be good, with 22students per teacher overall and anaverage of 33 students per class, inacademic year 1995-96, (Table5.1). More information is needed onpriorities (primary versus secondaryeducation for example) and aboutspending by sector of theeducational system. The student-

to-teacher ratios for primary education are higher (27 students per teacher) than for

OverallPrimaryPreparatorySecondary

22271916

33343230

5.3


preparatory (19) and secondary education (16). Teachers are widely distributedalthough class sizes and the student-to-teacher ratios are higher in the Muscat areadue to the large number of school-age children there.

B. Primary Completion Rates and Transition to Secondary Education

By 1990/91, the drop-out rates in all primary schools had decreased to 1%compared to 2% in the year 1986/87. Higher percentages of drop-outs are girls incomparison to boys. This is due to several factors: failing two consecutive years;low-income families with the need to support all children needing assistance; andthe early marriage of most secondary school girls. Boys, on the other hand, tend tohave higher percentages repeating the same year. In 1990/91, 10-12% of boys and8-14% of girls were repeaters in the primary cycle; 9-23% of boys and 6-11% girlswere repeaters in the preparatory stages. The gap between the genders in thenumber of repeaters almost disappear in the secondary stage (3-10% of boys and 4-10% of girls are repeaters). Thus it is apparent that although drop out rates are quitelow, there is a significant percentage of both boys and girls repeating at alleducational levels.

To accommodate the need for the rapidly growing number of secondary schoolgraduates seeking university qualification, a regular system for granting scholarshipswas established. The highest number of Omanis studying abroad (mostly in theUSA, UK, GCC states and other Arab countries) was 2,681 in the year 1985/86.This number has declined steadily since the opening of Sultan Qaboos University in1986/87. Today there are still 551 government sponsored, and 920 self-supportedstudents abroad training in various disciplines. In addition, there are 331 Omanisabroad studying for higher education such as masters and doctorates.

C. Gender Disparities in School Enrolment and Educational Status

Table 5.2 Pupils in Government Gender disparities in school enrolmentSchools in 1995-96 and Percentage have been in a continuous decline. In theGirls.__________________ year 1975/76, girls comprised 27% ofGrade___Total pupils % girls primary students, 16% of preparatoryPrimary 297,488 48.3% students and 28% of secondary students.Preparatory 122,457 46.2% In the academic year 1995-6, theseSecondary 68,852___52.4% figures have risen substantially (see TableTotal_____488,797 48.3% 5.2). A rise in women's education will haveSource: Statistical Year Book, 1995, desirable impacts on the health of women,table 19-3. tneir children and families and on the

community at large.

The 1993 population census provides a look at the overall women's educationalattainment at various levels and allows us to assess the gap between male andfemale education as it exists in Oman today. Women comprise about 55% of allilliterates. It can also be seen that the gap rises as the level of education increasesfrom being able to read and write to primary, preparatory and secondary studies.

5.4


This gender gap in education is reduced at the intermediate and technical institutelevel, and rises again for university level studies through graduate and higher levelstudies. Thus, it is apparent that the overall education gaps between male andfemale are significant but the gap is closing for the younger cohorts of primaryschool children.

The number of women in higher education is on the rise. Sultan Qaboos Universityestablished in 1986, is the only university in Oman. It comprises seven faculties;Medicine, Engineering, Arts, Islamic Sciences, Agriculture, Commerce andEconomy, and Education. In the academic year 1988/1989, the university enrolled1,723 students with a slight male preponderance (57% males). By the year1993/1994, this number had reached 3,858 students with females reaching 55% --the majority.

D. Adult Literacy

Adult Illiteracy eradication has been one of the major tasks of the Ministry ofEducation. In general, women were found to be more poorly educated than men.The 1988-9 Oman Child Health Survey showed that 82% of women and 63% of menwere either illiterate or had not completed primary education. To combat thisproblem, 24 literacy centres and 47 adult education centres were opened in 1973/74and 1975/76 respectively. Initially the literacy classes enrolled 2,429 students, 76%males and 24% females, serving limited areas. Subsequently, the services becamemore widespread involving most towns and villages of Oman. In 1991, the literacyrate of those above 15 years of age was 56% (65% for males and 47% for females).Illiteracy figures from the 1993 population census indicate that of the total illiteratepopulation the percentage of women is about 10.5%, higher than for men.

Although the official age of entry to primary school is 6 years, an increasing numberof parents enrol their children at either a private nursery or a kindergarten prior toadmission to the government primary schools. This trend is borne out but theincreasing number of private nurseries and kindergartens in Oman especially in thecapital area. Figures show that the percentage of children in pre-school educationwas 4% of the total eligible children in 1995.

Besides the government financed schools, there were 90 private schools (includingforeign community schools and kindergartens) with a total of 30,226 students and1,644 teachers in 1995. These schools follow the same curriculum as those run bythe Government with the same general preparatory and secondary school certificateexaminations. Tuition fees must be approved by the Ministry of Education and theyvary considerably depending on the facilities offered. In 1994, the annual chargesranged from RO 200-850 (US$ 520-2210) in Muscat to RO 150-350 (US$ 390-910)in other regions.

5.5


II. WOMEN'S ACCESS TO HEALTH, GENDER DIFFERENTIALS IN HEALTHAND USE OF HEALTH SERVICES

The Omani government through its development efforts has placed value inwomen's access to health and education. The general status of women includingage at marriage, education, employment, fertility and social welfare directed towardswomen will be discussed to present an overall impression of the status of Omaniwomen. The focus of the section remains access to and use of health services bywomen and the morbidity and mortality of women in general.

The age of Omani women at marriage is very low. The Oman Child Health Survey of1988-89 showed that 39.7% of women aged 15-49 had married before reaching 15years of age. About 26% were married between the ages of 15-17. Thus 65.7% ofthe women were married by age 17. Women marry much earlier than men. Thesingulate mean age of marriage of males is 25.6 years compared to 19.2 years forwomen. (OCHS, 1988-89).

It is expected that in the near future with the rising educational status of women, ageat marriage will rise, although this has not always been the case in other countries inthe Middle East. As it was seen earlier, literacy levels are still low among older agewomen. Among younger girls however, primary education is universal. Informationon trends in student enrolment in schools and gender differences in schoolenrolment show the steady closing of the male-female gap since the early eighties.Information from the population census of 1993 show that percent gap in femaleeducation is persistent at all education levels. The percentage gap at the primarylevel is about 33% and rises to 41% and 47% at the preparatory and secondarylevels respectively. At the level of higher education the gap reaches 64%. Asmentioned in various sources, the rise of education among girls is in the process ofcreating a generational transformation in Oman. Undoubtedly, many more womenwill soon be qualified to work in many areas that were not open to them previously.

Gender equity in education may not translate into new female employment due totradition, to the structure of the labour force and to the high fertility rates. Birthintervals are about 21 months among 15-19 year olds and 30 months among 45-49year olds. The lack of spacing among young women particularly is very evident butthis will change with the new Birth Spacing Programme (see Chapter 3). Regularsequences of births are valued socially. The "murabbiya" or the post-partum visitingperiod is extended several weeks whether the baby survives or not. This representsa social network system for women which establishes not only the status andprestige of the woman and her family in society but is also a valued means ofcommunication in the community.

"... the degree to which many women are able to participate actively in theprocess of social transformation remains tied to prolonging their period of fertility."

(Christine Eickelman, 1984)

5.6


It appears that modern trends in employment and education will affect traditional lifestyles in the long run. Women are more likely to find employment outside the homein urban areas and entire families may move away from their rural communities. Thenext generation of educated women will undoubtedly be facing a different reality.

In the early 1990s, women made up a low percentage of the work force. Accordingto the 1993 population census, over 50% of all women in the economically activeage range were homemakers and only 11% of the total were formally employed in1993. The three leading occupations held by employed women were service andmarket sales workers (40%); professionals (40%); and clerks (about 8%). Themajority of the women working as service and market sales workers and asprofessionals were between the ages of 20 and 39. The majority of the clerks werebetween 20 and 34. Those women working as skilled agricultural and fisheryworkers were evenly distributed between the ages of 15 and 50. Those working asplant and machine operators were mainly between the ages of 20 and 29. Amongthe economically active population as defined by the population census, less than1% of the women were employers and only 4.3% were workers on their ownaccount.

Legally, the civil code stresses equal treatment of women. In addition, they have theright to 60 days of paid maternity leave, an hour to breast-feed an infant before orafter work, 1-2 years of unpaid leave to care for a child at home, and up to fouryears unpaid leave to go abroad with her husband. (UNICEF Situation Analysis ofWomen and Children, 1993). In 1994, the Sultan has given women the right to voteand to be elected in the State Advisory Council (the Majlis al-Shura} in Muscat.

Safety net policies whether for low cost housing loans and grants or social welfareare being extended to groups of women such as widows, divorcees and the elderly.More precisely, widows and children have rights to land. Priority is given to familiesexposed to sudden disasters and low income. Government grants given by theMinistry of Social Welfare since 1972 have been expanded to include social securityfor disability, orphanhood, senility, widowhood and divorce (see Chapter 4). Thistype of government support for divorced women, for instance, establishes a supportsystem for women, even those who are exceptions to the social norm. Furthermore,from the 1980s onwards, the type of beneficiaries have included unmarried women,families of prisoners and the elderly. Detailed figures demonstrating the types andamounts of social welfare are described in Chapter 4.

A. Access to and Use of Health ServicesRecords dating back to 1975 show that the access and use of the health services byfemales have been high. Information on the number of new cases, of re-attendanceat hospitals, health centres and dispensaries all attest to this fact. Approximately52% of the new cases seen in hospitals were women, 58% in health centres and50% in dispensaries were also women. Women form the majority of out-patients -62% of re-attenders at hospitals were women, 63% in health centres and 58% indispensaries. Although female attendance at health institutions is not available over

5.7


the long run, we know that the total number of out-patients and in-patients haverisen since then. The number of out-patients have risen from 3.3 million in 1975 to7.2 million in 1993. The numbers of in-patients from about 56,000 to 226,000respectively (see Chapter 3 for more details).

The high percentage of births in a health institution is also a measure of the highlevels of use of health services by Omani women. Between 1988 and 1990, thepercentage of births attended by health personnel was as high as 90% and rose to98% in 1993. It is evident that the value society places on the safety and well-beingof the delivery process outweighs the conservative tendency in many countriespreventing women from using hospitals and health clinics. With extensive use ofservices, the important question remains the quality of services. In this regard thenumber of times a woman receives ante-natal care and whether she goes on toreceive post-natal care is important. As seen earlier chapter showed, (Chapter 2),although there is a high level of attendance of pregnant women for ante-natalservices, there is still a significant number of late registrations. The number ofpregnancy checks and the date of the first check are important factors in assessingthe quality of maternal care. We saw in Chapter 3 that almost half of the women intheir third to fifth month of pregnancy had only received one check. Furthermore, ofthe women in the later stages of pregnancy (7 months and higher) about one-thirdhad been seen once or twice (4 plus checks is a reflection of good maternal care).Use of post-natal care is lower (about 38%) but rising in recent years.

How the system is addressing maternal mortality and morbidity is also an importantissue in assessing the health system vis-a-vis the special needs of women.Evidence points to the fact that a large percentage of the women have a number ofrisk factors. As discussed in earlier chapters, as a response to the lack of maternalhealth information, especially maternal mortality, a notification system wasestablished in 1991 in the Maternal and Child Health reporting systems.

This system of reporting indicates that maternal mortality rates have been reducedfrom 30 per 100,000 live births to 7 per 100,000 live births from 1991 to 1993. Thereporting system is very recent and the reliability of these figures are as yetuncertain. In general there is very scarce information of adult survival. Maternalmorbidity is also an important factor that the Maternal and Child Health serviceshave recently addressed. A pregnancy risk evaluation process has been developedwhich categorises women by level of risk in terms of several factors such as parity,stature of mother, past/present pregnancy complications, medical diseases, historyof infertility/abortions, haemoglobin levels etc. This is a crucial step as a preventivemeasure to ensure that women at risk who are attending health institutions can behelped before more severe conditions result. Data show that about 35 to 55% of theregistered women are either at "low risk" and "at risk" categories, although only 2%are at "high risk".

B. Health and Nutritional StatusStudies on the health and nutritional status of younger as well as older population

5.8


are scarce. However, several surveys that have been carried out at different timeperiods which will be used as a basis for this discussion. A 1991 study by Musaigerfound that the proportions of children under-weight were higher among males thanfemales (with the exception of girls aged 3 and 4). The prevalence underweightamong females ranged from about 14 to 16% compared to 13 to 35% for boys.Stunting is also higher among boys particularly those aged 6 and higher. Theprevalence of stunting among girls range from about 12 to 29%.

At older ages (between 11 and 19), an average of 63% percent of females areunderweight in 1989 (Musaiger, 1996b). A women's nutrition survey based on bodymass index showed that 13% of mothers were underweight, 33% were normal and27% were overweight and 28% were obese (Musaiger, 1991). Only one in threemothers had a normal weight. The fact that 55% of the women are overweight orobese point towards the risk of chronic and degenerative diseases. The 1991 studyshowed that obese mothers suffer from higher prevalence of hypertension, diabetes,arthritis, asthma and back pain than others. The impacts of changing lifestyles andeating habits need to be assessed. A significant number of adult women (60%) alsosuffer from iron deficient anaemia. (Musaiger, 1991) The most common reasons forthis condition in Oman are menorrhagia and pregnancy. Changing the traditionaldiet to one involving the consumption of processed foods with a low nutritional valueis also a related factor.

C. Morbidity and Mortality of FemalesAs discussed in detail in earlier chapters, morbidity and mortality is based on in-patient data and therefore generalisation of to the community at large is notpossible, especially for adult health data. Based on inpatient morbidity data from the1993 statistical report, there are four areas of diseases where females have a highernumber of discharges in comparison to men. They include diseases of thegenitourinary system; endocrine, nutritional, metabolic and immunity disorders;neoplasms; and mental disorders.

Examining the five leading areas of inpatient morbidity (the respiratory system;infectious and parasitic; pregnancy complications; injuries and poisoning; and thedigestive system) it can be seen that with the exception of pregnancy complications,all of the other areas have higher male patient discharges. It is not possible todetermine what percentage of men and women utilise health services in general.

Looking at the adult mortality information from in-patient mortality, it can be seenthat males have higher levels of death at all ages in comparison to females. Themost pronounced percentage gaps are about 56% for injuries and poisoning, 37%for digestive system diseases, 32% for nervous system diseases and 28% forinfectious diseases (see Chapter 2 for details). Trends of inpatient adult deaths bysex and age between 1989 and 1993 indicate that among adults of ages 15 to 44 aswell as ages 45 and above the number of deaths have been relatively steady in thepast five years.

5.9


Universal primary education, gender equity in education, as well as social securityfor women are important complements to health sector and wealth in improvingwomen's status. Attendance and use of services have been encouraged for women,unlike other countries where women may not be allowed in public places. Girls andwomen have experienced the benefits of the health interventions in the past 25years. Social security entitlements to marginalised groups of women such asdivorcees, widows, elderly and single women built within the legal/governmentsystem places women in a favourable status. It is important to note that previouslyexisting and some emerging negative health problems of women need to beaddressed. Prevalence of underweight and stunting among younger females as wellas anaemia in the wider female population persist. The significant presence ofpregnancy risk factors leading undoubtedly to pregnancy complications, whichstands among the leading causes of inpatient morbidity in 1993 should be a focusfor amelioration of women's health. New emerging problems related to changingnutritional habits and life style have increased obesity, smoking and chronicdiseases among women.

///. WATER AND SANITATION: EFFECTS ON DIARRHOEAL DISEASE ATTHE LOCAL LEVEL BY MUNICIPALITY.

A. Environmental Health in Oman.The effects of environmental factors are complex. In most developing nations, waterand sanitation remain the key most environmental factors affecting the health of thepeople. The incidence and prevalence of diarrhoeal diseases are an excellent indexof progress in environmental improvements.

1. The Early Years.Before 1970, diarrhoeal disease was common, contributing to the very high infantand under 5 mortality at that time. In 1975, the Ministry of Health establishedEnvironmental Health as a separate Section. The section quickly established astrong link with the municipalities and began joint environmental health inspections.This was to provide technical support to the under-qualified municipality staffs and tomake better use of limited resources. Much of the early work was "crisismanagement" and so little data collection took place.

2. Environmental Health in the 80'sIn the 1980s, environmental health activities became more scientific and target-oriented. The WHO launched the Water and Sanitation Decade (1980-1990) whichOman readily adopted. In 1937, a national environmental health survey was carriedout to determine the water and sanitation status of the country. The results showedthat 60% of all falaj (traditional water canals or tunnels) were micro-biologicallycontaminated whilst over 40% of all wells and 34% of all water tankers were alsocontaminated. The survey did not include the capital area and the Dhofar region thatwere mainly connected by pipelin by the Government. The results gave for the firsttime baseline data for the planning of new goals for water and sanitation.

5.10


The National Environmental Health Survey results were used in several waysincluding the discrimination of different types of water by colour-coding thecontainers and vessels (drinking water; saline water; and sewage). The codingregulation was issued to help and ensure that contamination of drinking watersupplied by water tankers was kept to a minimum.

The achievements in the 1980's were commendable. Bacillary dysentery andAmoebiases cases dropped from 17,355 in 1983 to 6,507 in 1988; a 62.5% dropfrom the 1983 figure. Enteritis and other diarrhoeal diseases also dropped from329,514 cases in 1984 to 227,127 cases in 1990; a drop of 31.1% from the 1984figure.

3. The Situation in the 90'sFurther improvements were achieved in the 1990s. In fact, it is in the 1990's that themajor progress in water and sanitation were achieved. In 1990, the EnvironmentalHealth Section was developed into a full department. This resulted in a stronger co-ordination link with the municipalities and other developments including:

a new regulation licensing all commercial wells; 170,161 wells and 1,880 falaj wereregistered by the Ministry of Water Resources; a Healthy Wilayah Project wasbegun by the Ministry of Health, and the WHO local office; and the Ministry of Healthhas computerised its water and sanitation database in order to address outstandingproblems.

The preliminary results of the efforts in the 90's are promising with the enteritis andother diarrhoeal diseases reduced from 273,920 cases in 1990 to 193,709 cases in1992; a reduction in 29.3% from the 1990 figure and a reduction of 41% from the1984 figure. Bacillary dysentery and amoebiasis reduced from 8,445 cases in 1989to 4,446 cases in 1992; a reduction of 47.4% from the 1990 figure and a reduction of74% from the 1983 figure.

In order to sustain any developmental achievement, the people's (community) activeparticipation is required. With this in mind, the Ministry of Health, EnvironmentalHealth and Malaria Eradication Department is now emphasising several "healthyWilayah" projects. This approach emphasises environmental health intervention andsound hygiene practices with the aim of improving the overall health status of thepeople of the Wilayah. It is a project involving the local community and all relatedgovernmental ministries and agencies to work together to achieving goals thatcannot be feasibly achieved by any one party. Here again, the Ministry of Health isplaying a co-ordinating role between governmental agencies and the communities inorder to achieve the overall goals.

5.11

CHAPTER 6

COMPARISONS AND CONCLUSIONS

CHAPTER 6

COMPARISONS AND CONCLUSIONS

In this report, we have been able to document in a very detailed way the wholerange of changes, which have swept Oman since H. M. Sultan Qaboos bin Saidcame to power in 1970. The difficult task is to assign causes to some of the

effects we have described. Let us first review the conclusions reached so far.

First, it is plain that Oman's decline in childhood mortality is one of the fastest onrecord both for historical and contemporary populations (see Chapter 2). We knowless about adult mortality changes but we assume that many of the factors, whichcontributed to the improvement of the survival of young children also, applied toadults. Certainly, we can document the decline in maternal mortality and thechanging pattern of causes of death in adults, at least those who died in healthfacilities. In Figure 6.1, we present a synthetic graph showing our best estimates ofunder 5 mortality changes since the first surveys were conducted in 1975. We haveplotted the probability of surviving to age 5, rather than the probability of dying byage 5, since we want to show how other social and economic indices have movedover the last 25 years on the same graph. This graph of the probability of survivingto age 5, l(5) in the life table, is an amalgam of all reliable sources. Some aberrantpoints have been dropped (i.e. the indirect estimates from teenage mothers) and themost recent section of the graph is derived from the infant mortality rates from thehealth services data. We have estimated l(5) from these infant mortality rates byusing model life tables. Note the early start to tbe mortality decline - a decline thatpreceded the establishment of most of the modern health services.

Secondly, we can readily document the changing pattern of causes of death inyoung children. We have shown in Chapter 2 how the number of cases of thevaccine-preventable diseases declined as vaccine coverage rates climbed steadilyin the 1980s. The disease surveillance system is good and was well established bythe mid-1980s so we must accept the measured trends as truly representativechanges of the disease patterns in Oman. The connection between the two must bemore than coincidental or circumstantial.

Thirdly, we see the emergence of chronic conditions in the in-patient and theoutpatient data from the health services in the late 1980s and the early 1990s. Thisemergence of new patterns is a sign of changing causes of death and signal that theepidemiological transition is well advanced in Oman. We also see the persistence ofsome conditions for which we have no ready cure — acute respiratory infections,diarrhoea diseases and low birth weight are all good examples.

Several additional features of the transition are especially noteworthy and arereadily documented. One is that the improvements in child survival were widespreadand not restricted to the urban or the well-educated sections of the population.

Chapter 6: Comparisons and Conclusions

Figure 6.1: Child Survival to Age 5 from Diverse Sources

0. 95

0 3

0. 85

0 .8

£ 0.75

0 .7

0 .65

0 .6

0. 55

0 51960 1965 1970 1975 1980

Year

Indeed, people in the peri-urban and rural areas have experienced a similarimprovement in the survival of their children as those in urban areas. For example,in rural areas the under 5 mortality rate fell from 183 to 46 per 1000 between 1972and 1987 whilst the decline in urban areas was from 111 to 29 per 1000 (OCHS,1992: table 4.4). It seems too that the survival chances of children born to motherswith little or no education improved more rapidly than those of literate mothers.These are signals that the public health measures introduced in Oman affected allclasses of society and were not restricted to any particular sub-group. Such trendsare evidence that differentials in childhood mortality narrowed rather than widenedduring the transition in child mortality. This is different from experiences elsewhereas Preston and Haines (1991) demonstrated for Europe and the USA.

Other features of the mortality differentials are also important. One is the regionaldisparities. It is very clear that all regions of the Sultanate benefited from theimprovements in child survival during the 1970s and 1980s. The capital area still hasthe lowest childhood mortality but not by much. Even in the peripheral regions, childsurvival has improved dramatically with rare exceptions. In addition, when weconsider the differences in survival by sex for children aged 1-4, we note that girlshave in the past experienced higher child mortality than boys. In most populations,physiological factors are responsible for higher early childhood mortality for boysand Oman is no exception to this rule, as the infant mortality rates by sex bear out(Chapter 2). Beyond age one, social and environmental factors affecting exposure torisk and treatment patterns generally play a larger role. In Oman, the excessmortality of girls relative to boys has been reduced in recent years but will requirecontinued attention in future.

Turning to the interpretation of the results referred to above, we show on Figure 6.2

6.2


a graph of the under 5 mortality improvements and the expansion of the healthservices. This figure suggests that the mortality improvements had begun before thefull establishment of the health services we know today. Undoubtedly, the healthservices contributed to the precipitous decline after 1970 but it is worth noting thatsome changes in Omani society, which had begun before 1970, were responsiblefor an early improvement in child survival. Although Oman was relatively isolatedfrom the modern world before that date, some of the changes in the surroundingcountries must have affected Oman to some extent. The most obvious mechanismis through the remittances and the experiences of the many thousands of Omanis,almost all men, who worked in Kuwait and many of the other Gulf states before oilwas discovered in Oman. There were almost 20,000 Omanis in Kuwait alone in1965 (Kuwait, 1995 census, table 2). The effect of these emigrants, their incomeand their experiences overseas are all hard to quantify but they must have played asignificant role in setting off some significant changes in personal wealth, attitudesand behaviour with relation to health.

Fig ire 6.2: Child Survival to age 5 Compared to some HealthIndicators

• l(5) * Coctois *—Nurses—* Beds

- 7000

i 6000 -I

» 5000 j=

I/I O{ 4000 3 §

E'«t 3000 3 £

oo

— -L o1990 1995 2000

Figure 6.3 shows the link between national wealth (GDP per capita) and survival tothe fifth birthday. Here we see a much closer connection between the growth of theeconomy and changing mortality. Even before the establishment of the modernwelfare state, the rise in government revenues appears to have raised personal andnational income with a consequent effect on child mortality. The connections arecircumstantial rather than causal but the similarity of the trends is very striking.

Finally, we examine trends in the proportions surviving to age 5 and an indicator ofspending on health rather than national income (Figure 6.4). Again, the strongsuggestion is that some of the initial gains in child survival (and by extension, adultsurvival) took place ahead of the direct investments in health. Later, it seems that

6.3


the health services become more important as the mortality and health transitionsproceed.

10. 95

o a

0. 85

0 .8

£ 0. 75

0 .7

0. 65

0 B

0. 55

0 .5

Figure 6.3: Child Survival to age 5 from Diverse SourcesCompared to GDP per Capita

-|(S » Per GaptaGCP (FO)

1965 1970 1975 1980 1985 1990 1995

Year

1

0. 95

0 .9

o. as

0 .8

£ 0. 75

0 7

0. 65

0 .6

0. 55

0 5

Figure 6.4: Child Survival to Age 5 from SourcesCompared to Mnistry of Health Expenditure

-|(5) MOHExpendJure

1990

- 1 00 K'cm

+ 8 0 O —£ o3 -S

4 6 0 1^-

zo5

- o2000

/. LESSONS LEARNED

There are a variety of dissenting views on the main reasons for the almost universalimprovement in human survival and health in the twentieth century. This diversityexists because we are dealing with the views of medical and biological scientists as

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well as those of social scientists. In the latter field, the prevailing thesis is therelatively minor importance of medical factors, at least in the historical period. Inaddition, it is clear now that the order of importance of the determinants of improvedchild survival in early twentieth century Europe is different from that in developingcountries today. For example, vaccines make a huge contribution to preventingdeaths from infectious disease today and were unimportant in the historical period.

McKeown (1976 and 1983) was amongst the first to seriously question thepreviously dominant explanation - that medical science and medical services wereresponsible for the improvement in mortality in Europe at the beginning of thetwentieth century. His thesis - that the changing virulence of harmful organisms,increasing human resistance due to improved nutrition and a more sanitary urbanenvironment contributed more to mortality improvements than medicine - has beenwidely accepted in both medical and social science circles. Szreter (1988) stressedfactors such as municipal ordinances on crowding, living conditions and of coursethe general improvement in urban water supplies and sewage disposal systems.Woods, Watterson and Woodward (1988 and 1989) provided a body of empiricalevidence in support of the "healthy towns" hypothesis, adding to this the effect of19th. century declines in fertility. These broader efforts to account for child survivalimprovements were complemented by more biological frameworks such as thoseproduced by Mosley and Chen (1984). In these, the key proximate determinants arenutrition, environmental contamination, injury, maternal factors and personal illnesscontrol. With these overlapping explanations and a huge body of seeminglycontradictory empirical and theoretical work on the topic, the definitive history of thereasons for the rise in life expectancy still remains to be written.

In 1993, the World Bank (World Bank, 1993: 34-6), chose health as the subject of itsWorld Development Report. In this influential volume, the factors responsible forimproving health were subsumed into three broad categories:

income growth (incorporating improvements in housing, improved nutrition andgreater use of health care); medical technology (including better treatment systemsas well as new drugs and vaccines); and public health measures (the urbaninfrastructure, water, primary health care facilities and rising levels of education)

How can we apportion the factors responsible for Oman's recent improvements inhealth and mortality? Taking the three categories of variables identified by the WorldBank, we can use a number of specific indicators to examine Oman's performanceinternationally. Many of these data can be found in the annual UNICEF publication"Progress of Nations".

On income growth and related factors, we find that overall, Oman's under 5 mortalityrate is about what we would expect given its income level. It seems too that onnutrition, Oman's performance is on target. Certainly, in terms of use of health careservices, the use rates cited above for Oman seem very high.

In the category of medical technology, we can list Oman's remarkable record in

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controlling the infectious diseases of childhood and in creating baby-friendlyhospitals. The Wilayah health care system is also a new administrative approach toproviding decentralised and comprehensive primary health care.

It is in the category of public health improvements (urban infra-structure, provision ofclean drinking water and raising educational levels) that Oman's achievementsseem exceptional. These investments have produced dramatic changes in diseasessuch as bacillary dysentery and amoebiasis - down from over 17,000 cases in 1983to just over 5000 in 1993. Enteritis and other diarrhoea! cases have fallen equallysharply. The one index on which Oman performs poorly is in the area of fertility butthis is changing rapidly as educational levels improve and as the new birth spacingprogramme takes effect. The importance of the contribution of decline in fertility toimprovements in maternal and child health is well illustrated in the work by Woodsand Watterson (1988 and 1989) on the British mortality decline.

Several additional factors are specific to the Oman case. A strong and unwaveringpolitical commitment to public investment in health and education has meant that thesocial sectors have not suffered even when economic growth has slowed. The oilrevenues provided a solid financial base for the development of the welfare state butwithout the commitment to health, education and social welfare, Oman could havebeen wealthy but unhealthy - as the cases of some major oil exporters illustrates.Oman's health transition has benefited from the economic force of the oil exports butit is worth remembering that its real per capita income in purchasing power paritydollars is only half the levels in Qatar or the UAE. In addition, it is everywhere thecase that increases in per capita income have less effect on life expectancy nowthan in the past (Figure 1.9 in the 1993 World Development Report).

Compared with cases such as China, Kerala State or Sri Lanka, Oman has hadmore than socialist ideals and a commitment to education to drive the healthtransition. The provision of a universally-accessible, high quality, modern healthservice free of charge to all citizens is a striking achievement but without theassociated programmes of social development and the investment in the publichealth measures broadly defined, Oman's health transition would have been lessdramatic and certainly slower. One difference with the past is that our knowledge ofthe mechanisms through which infections are spread is much superior today than atthe turn of the century.

The demand and participation of the people are also critical elements of healthprogress. The pent-up demand of the people in the early 1970s combined withenthusiasm for the modern and the experience of the returning Omanis allcontributed to an unleashing of demand-generated health forces that accounted forvery rapid progress in the first decade of modernisation. Few barriers lay in the wayof the establishment of a modern health system in conjunction with universal publiceducation. The high level of demand for health and educational services is clear.

Several additional points are worth making about these links between income,welfare and health policies. First, Oman's health sector is dominated by the

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government. The adherence to a set of consistent policies centred around PHC hasbeen important to the implementation of these policies. The polices seem to havebeen effectively implemented with a mix of Omani and non-Omani staff who appearto have been hard-working, committed and uncorrupted. Secondly, the stability ofgovernment and the support the government receives from the population at largehas been important for the acceptance of new programmes and interventions. Theinterest in the full integration of Dhofar has reduced many of the regionaldifferentials that might otherwise have emerged as result of very rapid growth in thecapital area.

Although national health policy is decided upon by the state, Oman has workedharmoniously and tapped the resources of such international agencies as UNICEF,WHO and the World Bank. Oman's health strategy, therefore, is adapted to theconditions of the country and capitalises upon the most up-to-date internationaltechnical standards. The role of such international organisations as UNICEF andWHO has amounted to relatively modest financial support but more technical adviceand provision of connections to experiences elsewhere.

//. THE FUTURE OF HEALTH IN OMANOman has undergone a health revolution in the brief span of a quarter of a century.In health, the country is passing through an epidemiological transition wherein manyfirst generation health problems have been tackled but not completely conqueredwhile a second generation of chronic diseases is now beginning to emerge. Severalfeatures make the planning of the course of future health improvements especiallydifficult. One is the demographic situation. With over a quarter of the population fromother countries, the constant flux of people makes the country vulnerable toimported infections regardless of the level of health services in Oman. Secondly,with such a rapid fall in mortality and an imminent decline in fertility, the agedistribution of the Omani population will alter dramatically. Care of the elderly anddisabled will become a new problem in the very near future. In addition, the newcohorts emerging from schools and colleges will put pressure on the government,the country's largest employer, to create worthwhile jobs for them despite onlymodest economic growth.

In the health sector, more stress will need to be laid on the effectiveness, efficiency,and sustainability of Oman's national health system. Very few serious evaluations ofthe effectiveness of past interventions have been conducted. This makes decisionson which services to develop and which might be part of a partially privatised healthsector very difficult. It is clear that the demand for health care is very strong butpolitically, it may be difficult to introduce charges for services that were previouslyprovided free.

Here is where international experience with fee for service schemes and socialinsurance schemes will be valuable. Despite its oil wealth, Oman will face the sameproblems as elsewhere - how is the use of health services to be rationed? Onesolution is through manipulation of charges. Other less acceptable solutions adopted

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by other countries with resources constraints have resulted on longer waiting timesfor less urgent care and some drop in the quality of services provided. Neither ofthese latter solutions is appealing to Oman. The problem with such changes is thatthere is no universal formula for making such reforms correctly - every case isdifferent.

In order to make the existing services more effective and efficient, resources willhave to be managed more closely with greater attention to the costs of alternativeapproaches than in the past. The role of the community is here critical since thereneeds to be a clearer understanding of what kinds of ailments and conditions requiretertiary level care and which can be more effectively managed at the primary level.This understanding will come as education levels rise in the population. There is anopportunity to involve the community more in the maintenance of its own health asOman has embarked on a process of decentralisation of the responsibilities forhealth to the provincial (Wilayah) level. In these smaller units, it may be possible toencourage the population to gradually take more responsibility for its own healthincluding public health measures such as water and sanitation. The dominance ofthe government sector has created a sense of dependence on government servicesand facilities which has to evolve into greater individual and communityresponsibility for health.

One additional feature of the decentralisation process is that collaboration betweendifferent government agencies may be more effective at this level. The necessarilyhierarchical nature of government organisation is difficult to circumvent sincefinancial responsibility resides in the separate ministries. At the provincial level,committees and other non-governmental groups may be able to express theirdemands more coherently to several ministries simultaneously, thus encouragingcloser collaboration between the health and other welfare and educational services.

There is nonetheless a strong case for the government to continue to play a centralrole in the national effort to advance the health of the people of Oman. The stateenjoys the confidence of the general population since it has provided stability,prosperity and a wealth of social and infra-structural developments unknown inOman's previous history. With this leadership, more popular participation indecisions on health care provision, and good advice from agencies and countrieswith experience of the transition from a fully subsidised health care system, Omanshould achieve as much health progress in the next quarter of a century as enjoyedin the first 25 years of Oman's "leap" to good health.

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