Oman embraces digitisation, develops local resources and promotes private education

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In the four decades after Sultan Qaboos bin Said Al Said assumed leadership in 1970, Oman made such strides in health care provision that the UN, in its “Human Development Report 2010”, declared it the most-improved nation out of 135 countries. The sultanate is now looking to breathe fresh momentum into the coming decades under its current long-term development plan, Health Vision 2050.

Published in May 2014, just one month before the price of oil began to fall, the document laid out a roadmap for modernisation on a never-before-seen scale in the country, from building new specialised hospitals to digitising information systems. Perhaps most striking was its call for a major increase in the role of the private sector, which by then made up one-tenth of total health care provision.

FINANCIAL BACKDROP: From mid-2014 the price of oil halved in just 18 months, which took its toll on an economy whose oil rents comprised 35% or more of GDP since 2010, according to the World Bank. The steepest budget cuts came in 2016, as authorities decreased overall spending to help reign in a deficit that had reached 21% of GDP. Yet through 2017 Oman’s health sector continued to make steady advances, as it was largely spared from cuts to uphold the social compact enshrined in Oman’s Basic Law, which commits to investing in health care as a means of ensuring citizens’ well being.

Total government expenditure turned positive again in the 2018 budget, with health spending rising by 7% to OR654m ($1.7bn), compared to 3% for defence and security, and 3% for oil activities.

ACTIVITY SNAPSHOT: A raft of contracts were announced in November 2017 to build new hospitals in Salalah, Sohar, Khasab and Suwaiq, and expand others in Muscat, Sohar and Nizwa. Furthermore, an e-Health initiative has now linked nearly every government health facility to a centralised portal, allowing more efficient management of data, operational processes and patient records. Authorities have also pressed forward with research and public awareness campaigns with the help of the World Health Organisation (WHO) to tackle the rise of lifestyle-related diseases (see analysis).

To drive operational and financial effectiveness, the government plans to privatise a host of state-owned enterprises and health services. Efforts in this regard are increasingly data-driven, with countless cost analyses and state-commissioned studies to guide decision making – suggesting considerable opportunities for investors who keep an eye on the authorities’ moves in 2018. “The implementation plan for Health Vision 2050 is dynamic,” Ahmet Al Qasmi, director of planning and studies at the Ministry of Health (MoH), told OBG. “This means we have left flexibility to adjust areas of financing as conditions change and results come in from the evaluations we are continuously conducting.”

HISTORY: In 1970, the year Oman’s modernisation drive began, the sultanate had just two hospitals and 13 physicians – or one for every 50,000 people. At that time, 20% of children died before the age of five, and there were no regulatory systems in place to define institutions’ roles or development. Today the sector has 74 modern hospitals, and 1371 health centres and private clinics spread across all governorates. Under-five mortality is extremely rare, and communicable diseases are all but eradicated. The strong state of current statistics has been made possible by four decades of investment and planning.

Founded in 1971, the MoH has since issued consistent five-year development plans to carry out its mandates for social and economic development as stipulated in royal decrees, as well as the Vision 2020 and Vision 2040 strategy documents. The sector’s history can be divided broadly into three phases, each covering three five-year plans. The first period, 1976-90, focused on building up health infrastructure, mostly from scratch. The second, spanning 1991-2005, emphasised qualitative development and geographical expansion – a period that saw a planning agency established, preventive programmes formulated and health services decentralised under 10 health regions administered at the wilaya (province) level. By 2005 there was a public hospital in every governorate providing specialised secondary as well as some tertiary care. The third phase, covering 2006-20, has seen an ongoing rise in service quality, with a new emphasis on primary care, early prevention of diseases and the promotion of health education. Plans during this period have been developed at a national level under an evidence-based management model that pursues targeted expansions via governorate-level sub-plans, backed by monitoring and evaluation of key performance indicators and a fixed timetable.

As a result, life expectancy in Oman has risen from just 49.3 years in 1970 to 76.6 years as of 2015, on a par with developed countries and well above averages for the region (68.8 years) and the world (71.4 years), according to the latest WHO data.

REGULATION & OVERSIGHT: Oman’s health care sector is overseen by the MoH, led by the minister of health, Dr Ahmed Mohammed Obaid Al Saidi, who directs policy planning through a Health Council, assisted by several advisors and consultants. Working beneath him are three undersecretaries focused on provision, planning and administration; hence the resulting organisational chart has three main branches. The Directorate General of Health Affairs recruits health professionals and oversees a host of directorates charged with implementing policy in coordination with the governorates, including for family and community health, disease surveillance and control, environmental health, health education, school health, public health research, blood bank services, hospital affairs, primary health care, nutrition and pharmaceutical affairs.

The Directorate General of Planning Affairs oversees directorates for health information and statistics; research and studies; planning, monitoring and evaluation; education and training; and IT systems. In addition, the Directorate General for Financial Affairs is in charge of directorates for contracts and purchases, revenue and spending, budget and accounts, personnel services, medical supply and engineering. All bodies are guided by Health Vision 2050, which lays out the sector’s long-term goals.

PROVISION & PERFORMANCE: Oman offers health services to all nationals free of charge at public hospitals and health centres spread among its 11 governorates. If Omanis elect to visit private hospitals – in order to avoid wait times, for example – the state usually reimburses hospitals.

Additionally, the state reimburses patients that seek medical treatment abroad when it is not available domestically. “The majority of nationals and people from other GCC countries prefer to fly out of the country to seek specialised medical care, especially for high-end surgeries and complicated ailments. The preferred destination for treatment is India, but many people also go to Thailand, the US or Europe,” K O Devassy, chief marketing officer at Badr Al Samaa hospital group, told OBG.

Expatriates, who comprise around 45% of Oman’s total population of 4.6m, take treatment from private medical establishments and can also receive care at public facilities on referrals. Most of their medical treatment is typically paid for by third-party insurers through their employer.

In a country with per capita GDP of around $15,000 as of 2016, according to the World Bank – and likely much higher among nationals whose average incomes are typically well above many low-skilled expatriates – many Omanis also pay out of pocket for additional, elective care.

DEMOGRAPHICS: Oman’s population is relatively young: roughly one in seven persons is under five years of age, one in three is under 15 and over half are under 30. Conversely, just one in 17 persons is over the age of 60, according to the National Centre for Statistics and Information. This profile suggests a large demographic dividend is on the horizon for the sector, with profound implications for the future of the sultanate’s health system.

The population is split nearly evenly between male and female residents, save for a male tilt among expatriates in their 20s, 30s and 40s, who largely come from the Indian subcontinent to work in the sultanate and remit part of their salary back to their home country. The majority of residents are concentrated along coastal areas in the governorates of Muscat (33%), Al Batinah North and South (26%), and Dhofar (10%). Between 2010 and 2016 the crude birth rate rose from 29.2 to 33.7 per 1000 people, yielding a fertility rate of four children per woman aged 15-49. This is up from 3.3 in 2010, although down from six in 1995, according to the MoH. The average family size in Oman is 7.8 persons.

KEY INDICATORS: On most measures, Oman’s health indicators resemble those of developed countries. Infant and maternal mortality ratios were 5.2 and 17 per 100,000 live births, respectively, as of 2015. Some 99% of births were attended to by skilled health personnel and vaccination rates were high, at 99% for both diptheria-tetanus-pertussis and Hepatitis B, according to the WHO report titled “World Health Statistics 2017: Monitoring Health for the Sustainable Development Goals”. Under-five mortality, meanwhile, dropped from 21.7 to 11.6 per 1000 live births between 2000 and 2015, partly because an immunisation programme that began in 1981 has helped eliminate several serious childhood diseases, including poliomyelitis, diphtheria and tetanus, and helped bring others under control, such as measles, rubella, mumps and pertussis.

Communicable diseases are nearly non-existent in Oman: in 2015 there were zero new cases of malaria, neglected tropical diseases (a WHO designation) or HIV infection among adults aged 15-49, and just 8.4 cases of tuberculosis and 99 of Hepatitis B per 100,000 people. Deaths from poor sanitation or unsafe water were negligible, at 0.4 per 100,000 people in 2012. In 2016 the WHO ranked Oman fifth-highest in the Eastern Mediterranean region for implementation of international health regulations based on 13 core capacities, with an average score of 95 out of 100.

HEALTH RISKS: As in much of the developed world, lifestyle changes in Oman have led to a rise in the incidence of non-communicable diseases (NCDs). Illnesses in this category led to the deaths of 6000 people in 2015 and currently cause 68% of all deaths in the country, according to the WHO. Contributing to this, and a possible portent of future health issues, a UN interagency task force concluded in April 2016 that a large majority of Omani adults do not eat enough fruits and vegetables, 40% do not exercise and 14% smoke. As a result, 40% of Omanis have hypertension and 12% have diabetes.

The probability at birth of dying prematurely from one of the four main lifestyle diseases – diabetes, cancer, cardiovascular disease and chronic respiratory disease – between the ages of 30 and 70 was 17.8% in Oman in 2015. This was the eighth-lowest of 21 countries in the Eastern Mediterranean, but is still above the figures for developed countries like the UK (11%) and Canada (9.8%). The sultanate is taking calculated measures to combat these diseases and the habits that cause them.

On the one hand, tobacco use among those over 15 years of age is around 15%, according to a 2015 study by the WHO, which also projected this would rise markedly in the coming years, to 19% in 2020 and 23% in 2025. Alcoholism, on the other hand, is not a priority concern: per capita consumption of pure alcohol was just half a litre in 2016, most likely a reflection of religious practices in the region.

Irresponsible driving, however, is cause for concern: road traffic injuries were among the region’s highest, causing 25.4 deaths per 100,000 people as of the latest WHO data, from 2013; only four countries in the Eastern Mediterranean reported a larger ratio on this measure. Furthermore, deaths from pollution totalled 14.5 per 100,000 population, according to 2012 data.

FACILITIES: As of the end of 2016 the MoH reported that the sultanate had 74 hospitals with a total of 6589 beds – or 14.9 per 10,000 people – as well as 266 governmental health centres, clinics and dispensaries, and 1105 private clinics. The public system accounted for 49 hospitals and 4659 beds, while the private sector provided 15 with 637 beds. The rest were operated by the Royal Armed Forces, the Royal Oman Police and Sultan Qaboos University.

WORKFORCE: In 2015 the country had 48.9 health workers per 10,000 people, ranking 7th out of the 21 countries in the Eastern Mediterranean, according to the WHO. More recent and inclusive data from the MoH show the number of doctors in the country in 2016 totalled 8622, or 19.5 per 10,000 people, while nurses numbered 19,760, or 44.8 per every 10,000 residents. In addition, there were 1234 dentists and 2420 pharmacists, equating to 2.8 and 5.5 per 100,000 people, respectively.

Other personnel included 2351 lab technicians (5.3 per 10,000), 2193 assistant pharmacists (5 per 10,000), 1087 radiographers (2.5 per 10,000) and 524 physiotherapists (1.2 per 10,000). Add in paramedical, technical, orderlies and other support staff, and the entire medical workforce in 2016 totalled some 55,200 people, split between 71% employed at MoH facilities, 21% in the private sector and 8% at non-MoH government facilities. The proportion of Omanis employed in the sector overall was 55%, although this masked a large disparity between the three systems: nationals accounted for 69%, 7% and 59% of the workforce in the MoH, private and non-MoH segments, respectively.

SPENDING TRENDS: Total health spending was estimated to be $2.6bn in 2016, split between $1.6bn for outpatient and $1bn for inpatient care, according to research by the US Department of Commerce in mid-2017. According to the MoH’s 2016 annual report, the latest available at the time of press, the government accounted for nearly 77% of this sum, with total recurrent spending of OR758m ($2bn) for the year, down from OR793m ($2.1bn) in 2015. This represented the first decrease in years: sector spending grew by 240% between 2010 and 2015. Outlay for development activities in 2016 was reduced to OR35m ($91m) from OR99m ($257m) the previous year, but expenditure in the category of supplies, equipment and medicines dropped by just 5.1% to OR114m ($295.8m). While a review of MoH spending for 2017 was not available in early 2018, public health expenditure was cut again to OR613m ($1.6) in the 2017 budget. However, the 2018 budget shows a 6.6% increase to OR654m ($1.7bn).

Oman spent approximately 2.6% of GDP on health care in 2013, according to a 2016 report by regional investment bank Alpen Capital titled “GCC Health-care Industry”. This was below the averages for the GCC (3.1%) and the world (10%), and equalled roughly $680 per capita – the lowest in the Gulf countries that year. However, the World Bank shows the figure jumped to 3.6% of GDP in 2014, in part due to oil prices falling in the second half of the year. Meanwhile, the government’s share of health spending in 2014 grew to 90%, up from around 80% during the previous two decades, World Bank data shows – partly because state budget commitments remained unchanged while private out-of-pocket spending pulled back. As a proportion of public expenditure, Oman devoted 6.8% of its budget to health services (including education and social protection) in 2014, according to the latest WHO data available. This was less than Saudi Arabia (8.2%) and the UAE (8.7%), but more than Iraq (6.5%) and Morocco (6%).

STRATEGY: A strategy shift at the MoH in 1990 following a comprehensive review of the sector led to the formulation of five main goals that the ministry continues to pursue today: decentralise decision making to the governorates regarding technical and administrative matters; expand and emphasise sector-wide planning; develop education and training programmes; conduct constant research and monitoring of health systems; and improve coordination between the governorates, state agencies and foreign bodies.

In May 2014 the MoH published the over-arching Health Vision 2050 development document that projects the sector’s needs over the next 35 years – based on 2012 data – and outlines plans accordingly. The main findings were that Oman’s population would nearly double to 7m by 2050, while the share of residents over the age of 60 would rise from 6.1% in 2012 to 13.1%. This would occur alongside a shift in the nation’s epidemiological profile towards NCDs – phenomena necessitating large investments and careful planning over the coming decades. To address this, among other things, the plan calls for the expansion of specialist services; measures to reduce costs and incentivise quality, results-based project funding; further decentralisation of management; a patient-centred approach to provision; and more transparency and collaboration among providers. “Since oil prices fell, the main idea under the plan is to rationalise services,” the MoH’s Al Qasmi told OBG. “As we continue to make investments and finance development, our guiding principle is how to make optimal use of resources with a reasonable amount of funding, while not sacrificing quality.”

NEW FACILITIES: To meet projected demand for services, the authorities are carrying out major expansions of public health infrastructure. In November 2017 the MoH announced it had signed contracts to build three new hospitals in Salalah, Khasab and Suwaiq, worth a combined OR270m ($701.1m). The first of these is a new Sultan Qaboos Hospital with 620 beds to be built on a 200,000-sq-metre plot in the southern Dhofar Governorate. That same month, the MoH awarded the OR121.6m ($315.8m) design-and-build contract to Carilion Alawi, a joint venture between the UK-based contractor Carillion and Zawawi Group, a local conglomerate. Its seven storeys will include 16 wards for inpatient care, as well as outpatient clinics and units for emergencies, renal medicine, burns, radiology, intensive care, rehabilitation, operations, maternity and chemotherapy. Local press reported that phase one, related to design and mobilisation, would begin immediately, while construction under phase 2 would begin in 2018 after funding was finalised.

The second project is a 150-bed hospital to be built on a 100,000-sq-metre plot in Khasab, with three storeys providing both specialised care and outpatient services. Three days after the Salalah hospital award was announced, local media reported that Carillion had signed a contract to build the Khasab facility “on similar terms” with Zawawi Group, at a value of OR60.8m ($157.9m).

The third project, the 260-bed Al Suwaiq Hospital, will be a three-storey facility on a 200,000-sq-metre plot to include outpatient clinics and units for nephrology, day care, intensive care, cardiology, burns, surgery, rehabilitation, internal medicine, and paediatrics. In November 2017 the project was awarded to International Hospitals Group, although as of late 2017 the value of the contract and other details had not yet been announced.

In the private sector, Badr Al Samaa group broke ground in June 2017 on a new 100-bed hospital in Sohar. In addition to core services, the facility will host specialised units ranging from cardiac care and neurosurgery to nephrology and comprehensive internal medicine. Delivery is expected by June 2019.

While new hospitals are being planned, existing ones are expanding. In November 2017 the MoH announced OR40m ($103.9m) worth of upgrade projects to add a combined 553 beds at three referral hospitals. Of these, 56 will be added to The Royal Hospital in Muscat, spread among the paediatric ward, neonatal intensive care unit (ICU), radiology and operations; 268 at Sohar Hospital on the north coast for the coronary and post-coronary care units, ICU, day care, haemodialysis and cardiac surgery; and 229 at Nizwa Hospital – 140 km inland from Muscat – for the ICU, and the paediatrics, obstetric surgery and emergency care units.

PRIVATE SECTOR ROLE: In light of budget constraints, government officials are increasingly looking to the private sector to fill gaps in demand. “We need more specialised hospitals to cater to growing needs,” Al Qasmi told OBG. “For this we are encouraging the private sector to invest in priority services, especially those where people commonly go abroad for treatment, including rehabilitation, children’s health, gynaecology, obstetrics and oncology.”

Another means of cutting state cost is to privatise certain facilities and services where it makes commercial sense. “The government is studying the costs and benefits closely, and finding that there are many services they can hand over to the private sector,” Haitham Abu Hashim, director at Muscat Private Hospital, told OBG. “One model is where private firms build, equip and operate new greenfield facilities, but another is simply to reallocate the services the government already pays for to places where it is done more efficiently, compensating facilities on a per-patient basis.”

INSURANCE: In terms of paying for treatment, Omanis have had little need for health insurance in recent decades, since services are free of charge, while expatriates typically have health coverage through employers. Some 4-5% of Omanis, 15% of expatriates and around 500,000 people overall are medically insured, Badr Al Samaa’s Devassy told OBG.

In late 2017 Al Qasmi confirmed to OBG that the MoH was considering introducing mandatory health insurance for private sector workers. Phase one would require all expatriates to be covered starting in January 2018, while phase two would require this of all Omanis working in the private sector, following a review of the outcomes of phase one. “Private sector investment is slower than it might otherwise be, partly because there is insufficient demand for services to justify it. In turn, demand for services is lower than it might otherwise be, partly because insurance is not required,” Al Qasmi said. “The new mandate is meant to help solve this.”

EDUCATION & TRAINING: To help meet future demand for health care services and increase the proportion of nationals employed in the industry, the MoH supports human resource development for Omani nationals, all the way from pre-baccalaureate training to undergraduate and post-graduate studies, fully funded both at home and abroad. As a precursor to advanced degrees, it runs educational health institutes (EHIs) that offer pre-baccalaureate training to build capacity in the disciplines of nursing and allied science, including a general nursing programme offered in every governorate. In the 2016/17 academic year, the number of students studying at EHIs reached 579; those enrolled in bachelor of science nursing programmes, 258; and those in post-graduate diploma programmes, 37.

A second MoH-supported initiative provides scholarships for ministry faculty to earn medical degrees at overseas universities. This scheme counted 114 undergraduate students in 2016, while 152 were in engaged in post-graduate studies. Beyond the tertiary level, the MoH also sponsored 154 doctors through a local residency programme under the Oman Medical Specialty Board, and another 154 abroad who were engaged in specialist studies. Of those, 49 returned to Oman to practice.

ADMINISTRATIVE REFORMS: Furthermore, the MoH is enacting a host of changes to improve its administration of medical training. Officials are currently working to refine education bylaws to merge all EHIs into a single entity to promote better integration of the public health workforce training system. All EHIs have recently installed the MoH’s Health Academic Management System, a data storage and retrieval programme that was being tested in 2017, with the potential to enhance decision making on a ministry-wide level. Meanwhile, the MoH’s training arm, the Centre for Continuing Professional Development (CCPD), directly conducted 14 workshops and seminars with 113 participants in 2016, including 12 courses on life support given to 72 trainees. The CCPD, whose remit includes collecting data on training across the public system, calculated that MoH institutions provided training to nearly 21,000 participants over the course of the year through 2645 activities, ranging from workshops and conferences to seminars and short training programmes – all of which were accredited by the Oman Council for Medical Specialties.

In May 2015 the ministry also launched an e-library system – billed as the largest such collection in the Middle East – granting its employees access to a trove of health care information through a web portal maintained by the ministry, including medical texts, point-of-care databases and electronic books.

TECHNOLOGY: Changes are also afoot in soft infrastructure capable of enhancing efficiency and cutting costs in the sector. As part of broader e-government efforts to digitise administration activity across state institutions, in January 2017 the MoH began implementing a cashless transaction system at its facilities, allowing digital payments at its hospitals and health care centres. In November 2017 it announced that cash would no longer be accepted at government hospitals as of January 1, 2018. All payments must now be made with a debit or credit card, which should streamline payments and cut processing times.

Also in 2017 the MoH’s IT directorate launched an e-Health initiative aimed at digitising all medical paperwork and processes. Known as Al Shifa, a new health care information system links digital patient records to other electronic modules to make referrals and receive notifications, and connects them to a central laboratory and research units. Besides streamlining administration – a MoH presentation from 2015 says the initiative could save medical personnel 60% of time – the aim is to give health care workers a more comprehensive view of a patient’s history to assist in decision making and improve the quality of care. It will also create resources to help authorities understand the system’s strengths and weaknesses as they plan additional development phases under Health Vision 2050.

MEDICINES & SUPPLIES: The expense of disposable items has been steadily rising for over a decade. For drugs alone, the MoH spent some OR67.1m ($174.2m) – or 8.8% of its recurrent spending – in 2016, up from OR44.8m ($116.3m), or 6.2%, two years earlier, and just OR15m ($39m) in 2005. Spending on medical supplies rose at a similar pace, nearly quadrupling from OR5.3m ($17.8m) in 2005 to OR20.9m ($54.3m) in 2014 and reaching OR35m ($90.9m) in 2016, according to ministry reports.

To help curb these expenses, officials are turning to the private sector to produce such items domestically, especially pharmaceuticals – 93% of which are currently imported, according to the MoH. “Developing local pharmaceutical production capacity is essential to meeting the sultanate’s long-term goals for the health sector and broader diversification,” M V Suresh, CEO of National Pharmaceutical Industries, told OBG. “Replacing imports of pharmaceutical products with locally produced generics will help make it more feasible to increase spending on health care.”

Such investments could pay themselves off handily, according to Hashim of Muscat Private Hospital. “Making drugs in Oman is eminently commercially viable,” he told OBG. “For outpatient visits, they contribute 18-20% of the cost for clinics and 25% for hospitals; nearly all are expensive, branded imports. If we made the same medicines locally, such costs would decrease by 5-7% at a minimum.”

MEGA-PROJECTS: Large-scale infrastructure projects are another area of focus, although they may take some time to get off the ground. The biggest of these is Sultan Qaboos Medical City, a hospital complex being planned in Barka at a cost of $1.5bn as part of the sultanate’s ninth five-year plan for 2016-20. To sit on a plot of 5m sq metres, the complex will supply 1250 beds, split among a specialty hospital and a paediatric hospital, with separate centres for trauma, rehabilitation, neurology, diagnostic radiology, medical laboratories, a centre for research and training, and a college for health sciences. In addition, certain plots will be allocated for private sector investment in hospitals, clinics, shopping centres, hotels, residential compounds and recreation centres. In February 2016 a memorandum of understanding to develop the medical city was signed by the MoH and the Supreme Council for Planning, although the project has been in the works since 2013. However, the city was on hold in late 2017 as officials adjust blueprints and the timeframe alongside recent cost constraints.

Another planned mega-project is the $1bn International Medical City, an 866,000-sq-metre complex in Salalah that aims to make Oman a centre for medical tourism. Being developed by Apex Medical Group, a subsidiary of Saudi Arabia’s Al Joaib Holding, in coordination with the ministries of health and tourism, and in partnership with US-based firms GE and Methodist International, the project will comprise three clusters: a provision centre, a health resort and a centre for medical education. The first phase is to be a 250-bed tertiary care hospital, while the second and third phases would bring the capacity to 530 beds, and construct a host of hotels, serviced apartments, wellness centres and a convention space. The project’s engineering design was completed in 2014, but delays in the start of construction have pushed back the original building timeframe of 2013-16. As of late 2017, the project was on hold pending bid evaluations and a budget review.

MID-SIZED PROJECTS: A third longer term project is a new Royal Oman Police Hospital to be built in Muscat at an estimated cost of $826m. Built according to the “hospitals within a hospital” model that stacks smaller specialised units on top of each other, the five-storey facility – designated exclusively for members of the royal police and their families – will have 400 beds split among the cancer, trauma, paediatrics, maternity, cardiology and surgery units. The project management contract was awarded to Kuwaiti firm Option One in 2012, although further progress had not been announced as of late 2017.

A fourth project in the works is the Al Madina International Hospital in Muscat. Announced in 2015 at a cost of OR72m ($187m), the health care complex is to be built by local developer Al Madina Real Estate in the capital city’s western Al Hail district. It will comprise a full-service, 225-bed tertiary care hospital; a 300-unit apartment block; a three-star hotel with 120 serviced apartments; a fitness centre; and retail space. Its initial completion date was scheduled for late 2018 or early 2019, with construction to begin in mid-2016, however, no updates have been announced as of late 2017.

SERVICE DISTRIBUTION: A look at geographical statistics from the MoH may serve as a useful indicator of where facility and service expansion are most required in the country. Using the ratio of population-to-hospital beds as a proxy for the capacity of health care provision, the region with the least need is Musandam Governorate – the part of the country that sits non-contiguously to the rest on a peninsula jutting into the Strait of Hormuz. Here, there was one hospital bed for every 278 people in 2016. The next-best ratio was found in Al Wusta, the middle of the country which is mostly desert, at one bed per 562 people. On the opposite end of the spectrum, however, were the two governorates of Al Batinah North and Al Batinah South. These areas were in the most need of additional facilities, with one bed per every 1602 and 1328 residents, respectively.

The data suggests there may be scope for new investment in Al Batinah North and South: a fertile region stretching along the coast west of Muscat that hosts the bulk of Oman’s agricultural land. Many of the sultanate’s most sought-after tourism sites are also in this area, such as Rustaq Castle and Jabal Shams, and its fifth-largest city, Sohar. While the probable implication is that many of Al Batinah’s 773,000 residents (as of 2010) drive to Muscat for treatment, to do so many of them face a one- to three-hour drive. This likely either acts as a deterrent to those seeking care, or further strains the resources in Muscat, which had the third-worst ratio of the 11 governorates, at one bed per 853 people.

UTILISATION: Where sufficient resources do exist, they see high levels of utilisation. In 2016 health facilities run by the MoH saw a total of 15.6m outpatient visits, equivalent to 3.5 visits per person that year. This figure does not account for provision at private and non-MoH government facilities, however, which had outpatient visits of 4m and 1.4m in 2016, respectively. All told, residents of Oman received outpatient care some 21m times in 2016, equal to 4.75 visits per person – above the average for the US (4) though still below that of OECD countries (6.9). It is worth noting that underlying the aggregate MoH data, the figure for Omani patients was much higher than that of expatriates, at 6.1 visits versus 0.4. In line with the health system’s emphasis on primary care as a first point of contact when treatment is sought, hospitals took just over one-quarter of MoH outpatient visits in 2016, with the rest handled by health centres and smaller “extended” health centres throughout the country.

Inpatient provision in the public system was similarly robust. While aggregate data of the private system for this category was unavailable, the total discharges tallied 343,000 at MoH facilities and 48,000 at non-MoH ones in 2016. In every service category, the public system saw utilisation come in measurably stronger than the previous year, recording around 71,200 deliveries, 111,000 surgeries, 26.4m lab procedures, 1.6m radiology procedures and 204,000 renal dialysis sessions. The only exception was dental visits, which fell by 1% to 283,000. Illustrating this, the total bed occupancy rate in 2016 rose to 63.3, up from 61.4 the previous year and 59 as recently as 2012. The average hospital stay was roughly even with the past five years, at 3.3 days.

OUTLOOK: Alpen Capital’s report projects that, as its population ages and NCDs become more prevalent, Oman’s health industry will achieve a compound annual growth rate (CAGR) of 12.9% over 2015-20, to reach $4.3bn. This, the firm said, implies demand for hospital beds will increase by a CAGR of 3.1% in that period, to around 7600, meaning investment will need to stay at least at recent levels to keep pace with market growth in the next two to three years.

However, since 2016 the public sector has been facing pressures to cut costs, an endeavour that competes with its mandate to provide health care to all, as well as its aspiration to raise quality and build up many specialised services at home that are currently sought abroad. To reconcile these goals, cost-optimisation efforts are expected to continue, driven by state-funded research and data culled from the e-Health initiative. Private sector investment will be critical over the coming years as the state looks to fund the next phase of expansion – an endeavour that could be sped up if authorities enact a detailed legal framework for public-private partnerships. While externally the biggest economic factors are regional stability and crude prices, to make the next 30 years a success will much depend on the authorities’ will to execute Health Vision 2050. “The mandate, roadmap and directives are all in place to bring about this transformation,” Al Qasmi told OBG. “Now we just have to go out and do it.”

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