2000 Oman Health Transition Rec 347399

unicef
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The Mortality and Health Transitions in Oman: Patterns and Processes
Editors Allan G.Hill Adaline Z. Muyeed Jawad 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). The Mortality and Health Transitions in Oman: Patterns and Processes. WHO Regional Office for the Eastern Mediterranean and UNICEF, Oman. Muscat 2000.
Page
PREFACE----------- 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 2.1
B. Estimation Methods C Results TronHc _ -.______ I 2. Age Patterns of Mortality Change 3. Sex Differentials 4. Geographical Differentials in Childhood Mortality 5. Differentials by Age of Mother, Parity and Birth Interval 6. Social Class Differentials 7. International Comparisons D. Changing Patterns of Cause of Death
I I d IVJO -.-...-
2.4 2.5
2 5 fc.w
2.11 2.12 2.12 2.14 2.14 2.15 2.15 2.21 2.21

2.26
//. ADUL T SURVIVAL 2.19 A. Adult In-patient Deaths 2.20
B. Maternal mortality C. Fertility and its Effects on Mothers and Children

///. MORBIDITY -------
A. Decline of Infectious Diseases B. Seasonal Morbidity C. Persistence of First Generation Illnesses D. Non-communicable Diseases 1. Malnutrition 2. Diseases of the Circulatory System 3. Diabetes Mellitus 4 Cancer 5. Accidents 6. New and Unanticipated Threats: HIV/AIDS
IV. CONCLUSIONS
2.26 2.30 2.31 2.33 2.33 2.37 2.38 2.39 2.40 2.40
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 1. Organisation and Management 2. Strategies 3. Facilities and Infrastructure 4. Human Resources for Health
3.5 3.5 3.5 3.6 3.8
B. Utilization of Health Services 3.10 C. Financing and the Private Sector --- 3.12 1. Financing 3.12 _ _ _ _ _ r i ivciic wwoivji _ ^. I^ 2 . Private ^pirtnr _ __ ___________ 114.
III. DEVELOPMENT AND STATUS OF HEALTH PROGRAMMES - 3.15
A. Disease Control-- 3.15 1. Expanded Programme on Immunisation 3.15 2. Control of Diarrhoea! Diseases and Acute Respiratory
3. Malaria Control 4. Tuberculosis Prevention 5. Trachoma and other Eye Health Care B. Maternal and Child Health 1. Maternal and Child Health Programme 2. The Birth Spacing Programme 3. Child Nutrition 4. Breast-feeding: the Baby-Friendly Hospital Initiative 5. School Health C. Emergence of Chronic Diseases
1. i
.
3.19 3.23 3.25 3.26 3.26 3.27 3.28 3.29 3.30 3.32
1 7O O.Ofc
o .wO oo O
niahptAQ Lyiauwiwo
panrpr _ \JQ\ lOwl
2 3. Heart Disease - 4. Accidents ---
__ __ __ _ _ _ _ _ __ _______ -.__.. _ _ _ _ _ _ --.
3.34 3.35
IV. SUMMARY AND CONCLUSIONS 3.35 CHAPTER 4: THE CONTRIBUTION OF RISING NATIONAL INCOME AND PERSONAL WEALTH TO HEALTH AND WELFARE ____/. GROWTH OF THE ECONOMY: OIL PRODUCTION AND REVENUES //. GOVERNMENT EXPENDITURES IN THE SOCIAL SECTOR -A. Employment
4.1
4.2 4.3
B. Social Houses, Low Cost Housing Loans and. Grants C. Government Grants for Social Welfare, Individual and General Disasters 4.3 D. Services & Interest Free Loans & Grants Aimed at Increasing Family Income 4.3 E. Incentives for Business 4.3
///. CHANGES IN PERSONAL INCOME IV. CONCLUSION 4.9 4.13
4.4 4.5
CHAPTER 5: SOCIAL AND ENVIRONMENTAL DEVELOPMENT ---------- 5.1 /. EDUCATION: ENROLMENT AND LITERACY 5.1
A. The Expansion of Schools and Education B. Primary Completion Rates and Transition to Secondary Education C. Gender Disparities in School Enrolment and Educational Status-D. Adult Literacy
//. WOMEN'S ACCESS TO HEALTH, GENDER DIFFERENTIALS IN HEALTH AND USE OF HEALTH SERVICES A. Access to and Use of Health Services
5.2
5.4
5.4 5.5
5.6 5.7
B. Health and Nutritional Status C. Morbidity and Mortality of Females ///. WATER AND SANITATION: EFFECTS ON DIARRHOEAL DISEASE AT THE LOCAL LEVEL BY MUNICIPALITY Environmental Health in Oman 1. The Early Years 2. Environmental Health in the 80's 3. The Situation in the 90's
5.8 5.9
5.10 5.10 5.10 5.10 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 ANC API ASR ARI BCG BFHI CDC CDD CHP CRS CVD DHI&I DHS DPT3 ECWA EPI E(x) GCC GNP GDP GP IDD HbsAg HBV HFA HIV IGT IUGR IVF IMR KAP MCH MOH MR MR-2 NCHS NOS NWCCP OCHS OFHS OPV3 ORT PAPCHILD PBT
Acquired Immune Deficiency Syndrome Ante Natal Care Annual Parasitic Incidence Annual Statistical Report Acute Respiratory Infections Bacille Calmette-Guerin Baby Friendly Hospital Initiative Centre for Disease Control & Prevention Control of Diarrhoeal Diseases Child Health Program Congenital Rubella Syndrome Cardiovascular Diseases Department of Health information and Statistics Demographic Health Surveys Diphtheria, Pertussis and Tetanus vaccination, third dose. Economic Commission for Western Asia Expanded Programme on Immunization Life Expectancy Gulf Cooperation Council Gross National Product Gross Domestic Product General Practitioner Iodine Deficiency Disorder Hepatitis B surface Antigen Hepatitis B Virus Health For All Human Immunodeficiency Virus Impaired Glucose Tolerance Intra Uterine Growth Retardation Intravenous Fluids Infant Mortality Rate Knowledge, attitude and practice Maternal and Child Health Ministry of Health Measles and Rubella Medical Record- 2 National Child Health Survey Not Otherwise Specified National Women and Child Care Plan Oman Child Health Survey 1988-89 Oman Family Health Survey 1995 Oral Polio Vaccine, third dose Oral Rehydration Therapy Pan-Arab Child Health Survey Preceding Birth Technique
IV
PEM PHC RO SPR SOP STD TB TFR TF Tl TS TV UAE

UNDP UNICEF VAD
Protein and energy malnutrition Primary Health Care Rials Omani Slide Positivity Rate Standard Operating Procedure Sexually Transmitted Disease Tuberculosis Total Fertility Rate Trachoma Follicular Trachoma Intense Trachoma Scarring Television United Arab Emirates
United Nations Development Programme United Nations Children's Fund Vitamin A Deficiency World Health Organization
WHO
PREFACE
he Sultanate of Oman, under the wise leadership of His Majesty Sultan Qaboos Bin Said, has accomplished astounding achievements in the health of its population over a short period of time. These achievements have been widely recognized and acclaimed by various international organizations, including the World Health Organization (WHO), the United Nations Children's Fund (UNICEF) and the United Nations Development Programme (UNDP). Health indicators such as infant, under five and maternal mortality rates continued to show progressive and consistent reduction in the Sultanate over the past three decades. Several diseases have been eliminated and life expectancy at birth has reached levels comparable to those in developed countries. An extensive network of modern health facilities providing full range services is made available and easily accessible to the entire Omani population. One recent witness to the international recognition of Oman's glaring health successes came in WHO World Health Report 2000, which was devoted to measuring performance of health systems worldwide. Oman's health system was rated the first among more than 190 national health systems in its attainment 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 and breath catching achievements in health development. It describes the health status of the Omani people in the pre-Renaissance era (before 1970), and the subsequent changes in different health parameters, which took place since then. It also attempts to establish attribution and furnish understanding for the roles of direct health interventions and indirect social and economic factors on the advent of the observed health transition. Although various sources have previously documented different aspects of the Omani experience in health development, however, this Report is the first comprehensive documentation of the entire experience. It is also unique in the wealth of data and information, which was complied in it from various sources and also by the depth of its analysis.
The findings of the Report clearly demonstrate that sustainable development in the
Omani health sector would not have occurred in isolation of the overall social development and the accelerated infrastructure building. The Report also confirms the even distribution of health gains over the different geographic locations and among different social groups in the Sultanate. This latter fact highlights the strong commitment to equity, which guided Oman's steps on the road to development.
The Manuscript also explored and highlighted the remaining and emerging health challenges facing the country. High among these was shown to be the lingering problem of malnutrition among children and the "shift" of the burden of diseases from communicable to chronic non-communicable and lifestyle related diseases such as diabetes, cardiovascular diseases and injuries associated with road traffic accidents. 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 these emerging challenges. With the completion of this valuable work, we would like to take the opportunity to commend the intense and dedicated effort, which was, invested it. Our appreciation
goes to the editors of the manuscript for their patient and meticulous efforts, which is well reflected in the quality of the work they produced. Our thanks are also extended
to the task force from both Harvard University and Ministry of Health Oman, who
contributed valuable inputs to the work as well as the collaborators from other
sectors of the Government of Oman in providing the complementary relevant information. Finally, this work would not have been conceived or materialized without the continuous guidance and support which it received from H. E. Dr Ali bin Mohammed
bin Moosa, Minister of Health whose leadership and insight were instrumental in shaping Oman's leaps in health development.
(A/^
Naheed Aziz UNICEF Representative, Oman. Dr Ibrahim Abdul-Raheem WHO Representative, Oman
VII
ACKNOWLEDGEMENTS AND AUTHORSHIP
his volume is the result of a collaborative effort between several agencies and institutions. The original idea stemmed from some discussions between the Shahnaz Kianian Firouzgar, former UNICEF Representative in Oman, Dr. Jamil Khan, former WHO Representative in the Sultanate and several senior figures in the Government of Oman. Prominent amongst this group were: Dr. Ali Jaffer Mohamed, 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 of international Relations, Ministry of Health. In addition to this talented group, the
project enjoyed full support at the highest levels from H. E. Dr. Ali bin Mohammed bin Moosa, Minister of Health; H. E. Dr. Ahmed A. K. al-Ghassany, Undersecretary for Health Affairs; and H. E. Mohammed bin Hassan bin Ali, Under-Secretary for Planning Affairs in the Ministry of Health.
Clearly, this group was well qualified to produce an excellent study of Oman's health transition on their own but the decision was made to invite international participation in the project both to add a comparative dimension to the study but also to guarantee that the conclusions would not be dismissed by outsiders as a propaganda exercise but would be treated as serious scientific attempt to analyse the essential factors responsible for what has emerged as one of the fastest health and mortality transitions on record. As a result, the group from Harvard School of Public Health was invited to join the national team and an initial visit was made by Professors Lincoln Chen, Allan Hill and Ms. Adaline Muyeed in November 1994.
The study progressed in the following manner: first, a small steering committee met to agree on the contents of two reports. One was to be a short brochure, intended for the twenty-fifth anniversary of the accession to power of H. M. Sultan Qaboos bin Said in November 1995. The other was a longer report with full documentation of the transition. Ms. Muyeed remained in Oman to gather materials and to work with the person identified as the co-ordinator of the study, Dr. Jawad Ahmad al-Lawati. In a second phase, Ms. Muyeed and Dr. Jawad continued their joint work in the Boston area in the winter of 1995-96, producing draft sections of the report under the overall supervision of Chen and Hill. More material was forthcoming from the larger team engaged in generating the basic information for the study (see the complete list of contributors at the end of this section). Much re-writing and production of tables and graphs continued in the Harvard Center for Population and Development Studies throughout 1996 and 1997. The editors and organisers certainly under-estimated the magnitude of the task of synthesising the mass of materials available on Oman and the 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 and approved 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 the contents and then Adaline Muyeed with Jawad al-Ahmad worked with Omani colleagues 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 by qualified individuals including:
Chapter 3 was written in sections. Section I on the history of policy development and section II on the health services were initially written by Adaline Muyeed and then re-written by Allan Hill. Section III was produced in draft by Drs. Jawad Ahmad alLawati, Ferdosi Mehta, Pradeep Malankar, A Colaco, Asya al-Riyami, Mohammad Ali Khalifa, Allan G. Hill, Leila Jassim, Mr. Abdullah bin Rashid AI-Mandhry, and Ms Dina al-Asfoor.
Chapter 4 on the contribution of rising national income and personal wealth to health and welfare as drafted by Adaline Muyeed and Allan Hill. Chapter 5 on social and environmental development was initially written by Jawad al-Lawati, Adaline Muyeed, Abdullah bin Rashid al-Mandhry and Said Darwish al-Alawi. Chapter 6, Comparisons and Conclusions, was written by Allan G. Hill. Very Helpful general comments 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 the final product. Much of the praise must go to the small team who conceived the original idea for such an ambitious and wide-ranging study. Much of the very hard task of synthesising the materials provided fell on the shoulders of Dr. Al-Lawati and Ms. Muyeed. The list of individuals who took time off from their usual jobs to write sections on particular diseases, programmes or special activities is very long. The editors are to blame if the original form and content of the volume does not meet the aspirations of the numerous contributors.
IX
INTRODUCTION
espite many years of attention by scholars and health professionals, there is still considerable uncertainty about the true causes of the secular improvements in mortality and health which began in earnest at the turn of the century in rich countries and at later dates elsewhere. There are broad similarities in the patterns of change in the early part of the health transition, including the decline of mortality from infectious disease particularly in small children. Later in the transition, we see considerable differences in the paths from high mortality and poor health to low mortality and improved health. In the circumstances, there is a strong case for more detailed case studies of the transitions experienced by different countries. This desire to document and publicise the experience of one country was the initial impetus behind the Health and Mortality Transition Study in Oman.
There are, however, more challenging questions to be addressed. One such question involves an attempt to portion out the contribution of different sets of factors to the improvements in health and mortality. This is a much more difficult task.
In 1993, the World Bank chose health as the subject of its World Development Report. In this influential volume, the factors responsible for improving health were subsumed into three broad categories:
Medical technology (including better treatment systems as well as new drugs and vaccines); public health measures (the urban infrastructure, water, primary health care facilities as well as rising levels of education); and income growth (incorporating improvements in housing, improved nutrition and greater use of health care).
Source: (World Bank, 1993: 34-6).
These are broad categories but they have the merit of being both comprehensive and capable of empirical evaluation. Indeed, the World Development Report contains some rough estimates of the contribution of each of these clusters of variables 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 in Ivory Coast, whereas in Egypt half of the improvement is attributed to increase in per capita income. For Oman, we are able to document the principal changes which have taken place in health since the transition only began in earnest with the assumption of power by H. M. Sultan Qaboos al-Said in 1970. Given the radical nature and breadth of the reforms touching all aspects of public life introduced by the Sultan, it is well nigh impossible to link the improvements in health with any single factor. From the point of 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 and international agencies are interested in finding short-cuts to speed up the transition to better health and if Oman has found a magic formula, then the rest of the world is interested in sharing this success.
The project thus began with a very general theoretical framework defining how health improves- no more specific than the well-known diagram of Mosley and Chen which isolates the main sets of biological factors responsible for improved child survival. Rather than attempt the impossible task of trying to calculate the contribution of single factors to the health transition in Oman, this volume tries to sort out the contributions from the three major clusters of variables chosen by the World Bank for the 1993 World Development Report (see above). The volume begins 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 second cluster of factors discussed concerns the contribution of public health measures. Finally, the contribution of wealth and social development is considered. The conclusions include some discussion of the relevant importance of these three sets of major factors but do not include any magic formula or easy short-cut on the road to good health. If there is a single lesson it is that doing a few simple things well in the health sector pays rich dividends.
XI
CHAPTER 1
OMAN- EARLY DEVELOPMENT AND SPECIAL FEATURES
CHAPTER 1
OMAN - EARLY DEVELOPMENT AND SPECIAL FEATURES
wenty-five years after the accession to power of its ruler, Sultan Qaboos bin Said 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 more obvious. Planned housing developments and new towns preserve some semblance of the older tradition of stone housing with crenelated walls. All the services of a modern 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 other in style and modernism but inside, Omanis in traditional dress conduct the business of state by telephone, fax and computer. It all seems well established and calmly efficient, as is the welcome by the no-nonsense immigration service at the international airport.
It is difficult to accept that almost all the modern physical infrastructure has been built 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 the Gulf region in the discovery and export of oil and gas. This book does not have to recount the many vicissitudes of Omani history in .any details since other authors cover very well the long periods of economic decline and international isolation until oil exports began in 1967. It is important to remember some features of Oman's past when writing about the contemporary scene, however, since traces of this history shape the current policies and explain some of the special features of Oman's post1970 development. /
I. OMAN'S SPECIAL HISTORY1
A distinguishing feature of Oman compared to<the other states of the Arabian

Peninsula 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 distance commerce by sea to supplement the limited natural resources of their dry and mountainous homeland. From the time of the arrival of the first Portuguese fleet off Ras al-Hadd in 1507, Oman has capitalised on its location on several major seaways and corridor of international trade. It was following the expulsion of the Portuguese in 1650 that Imam Sultan continued his exploration of the coast of western India and East Africa, embarking under the flag of a jihad or holy war. The wealth which flowed in produced the great fort at Nizwa and many other forts and large houses. Although Oman's navy remained a formidable force abroad throughout 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, which delayed 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, especially Zanzibar. Emigration to Zanzibar and return remittances laid the basis for a more prosperous period in Muscat. As compensation for the loss of the Zanzibar in a treaty negotiation with the British, an annual subsidy of 40,000 Maria Theresa dollars was paid to the Omani exchequer. Zanzibar defaulted on the payment, so from 1881 until 1947, the British government paid the sum from Bombay, and from then until 1956, by the Foreign Office in London. Thus, although poor compensation for loss of an empire, the annual subsidy provide one small but steady source of income during a period when other revenues were very uncertain.
Tribal war between the interior and coast continued intermittently throughout the nineteenth and then early twentieth centuries until the Treaty of Sib in 1920. This prepared the way for the reign of Sultan Sa'id bin Taimur (1932-1970), the father of the present Sultan. A succession of external events all thrust Oman and the Sultan to the forefront of regional and international affairs. The result was an increase in tension at home and the outbreak of civil war in 1956. Peace was not re-established until 1959 by which time the Sultan's control over the interior had been clearly established.
Oil was discovered in 1964 and exports began in 1967. From his time on, the oil trade dominated economic and political developments. Sultan Sa'id bin Taimur had difficulty coping with the pressures to modernise his country and with the externally supported armed revolt which broke out in Dhofar in 1965. Sultan Qaboos bin Said thus assumed power from his ailing father in July 1970. External support from the People's Democratic Republic of Yemen and other radical Arab countries made the Dhofar rebellion a running sore until the general amnesty and cease-fire agreed by
Sultan Qaboos in March 1976. In the early 1970s, the rebellion meant that 46% of
the 1973 budget, 40% of the 1974 budget and 43% of the 1975 budget was spent on defence. Thus, expenditures on development were relatively modest until peace had been established throughout the Sultanate in 1976 by the general amnesty and cease-fire agreed by Sultan Qaboos. This sketchy history of Oman serves to bring out three key features of the modern development. One is that the modern state is a very recent creation, dating from the accession of Sultan Qaboos in 1970 and the end of the Dhofar rebellion in 1976. As a huge country, it has taken modern communications to bring the capital into regular contact 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 some of its old significance. Revenues come mainly to the state and so the course of development thus depends 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 oil revenues in a productive and equitable manner. Thirdly, Oman's oil reserves are modest in comparison to those of Saudi Arabia, Kuwait or Iran. The implications of this limited wealth are several. It has meant that expenditures have had to be more carefully monitored than in other very much richer oil exporting countries. More important, it means that Omanis have had to cope with most of their own development. By attracting Omani return migrants from the Gulf, other Arab countries and East Africa, the domestic labour force has provided the bulk of the labour force needed for the expansion of the modern state. Omanis remain a large majority (73% of the total population, according to the 1993 census) in their own country unlike the Gulf States (except Bahrain) which are dominated by foreign workers.
//. OMAN'S POPULATION
Oman's 1993 census revealed that the Sultanate contained just over 2 million people, of whom 26% were non-Omanis (Table 1.1 and 1.2)
Table 1.1 The Population of Oman, 1993. Males Females Total Omanis 755,110 728,116 1,483,226 Non-Omanis 422,895 111,953 534,848 Total 1,178,005 840,069 2,018,074 Source: Population Census. 1993, table 3.5.
As is the case for most immigrant populations in the Gulf and Saudi Arabia, the majority of the foreigners are men. 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 an odd age and sex structure. Whilst 51% of the Omanis are under age 15, the majority of the non-Omanis are working age men.
The most densely settled areas are the alBatinah and Muscat regions which contain 28% and 27% of the 19 93 population respectively with a density of 157 per sq. km. (Census, table 2.1). Over half the population lives in the relatively densely settled coastal strip (Muscat and alBatinah), so that the remainder of the population is spread out over a huge area totalling some 309,000 square kilometres. Providing services to the half of the population outside the capital and the al-Batinah regions is a constant challenge.
LJ
Table 1.2 Distribution of the Omani Population by Region and Nationality, 1993. % of all Region Total Population % Omani non-Omanis 47.4 Muscat 549,150 54.0 al-Batinah 564,677 84.0 17.3 28,727 78.0 Musandam 1.2 181,224 75.0 A'Dhahirah 8.6 87.0 5.7 A'Dakhliyah 229,791 258,344 85.0 7.3 A'Sharqiyah 17,067 80.0 0.6 al-Wusta 189,094 66.0 Dhofar 11.9 2,018,074 73.5 26.5 Total Source: Population Census, 1993, table 3.1.2.

The age composition of the Omani population is very young, with a median age of just 13.4 years, compared to 20.2 years for the Omani and non-Omani populations in combination (Census, pp. 42). This young age composition of the national population is clearly the result of very high fertility and rapidly declining childhood mortality. As the analysts of the 1993 census point out, this age distribution even with the offsetting effects of the immigration of men and women in the economically active 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 both current and future economic and social development. In addition to the high proportion of the Omani population under age 15, we note a common feature of many oil-exporting economies, which is the low rate of economic activity amongst many Omani adults. Whilst 91% of the non-Omanis over age 15 are 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 - only 7% were in the labour force in 1993. This will undoubtedly change with rising levels of female education (see Chapter 5) but for the near future, the dependence on imported 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 nonOmanis, by contrast, work in the construction (24%) and wholesale and retail trade sectors (18%) (Census, pp. 59). The very small proportion of the labour force directly employed in the oil sector is a feature seen in many Gulf states.
Another distinguishing feature of the Omani population, which has a bearing on health, is the large size of most Omani families. In part the result of high fertility but also a legacy of the past preference for extended family living, we find in the census that 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 Majesty Sultan 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 political commitment to develop a modern welfare state, including the promotion of the health of the Omani people. Through judicious use of income generated by Oman's oil wealth, discovered in 1964 and commercially exploited in 1967, the Government was able to build from scratch a modern national health system that offers all Omani citizens universally accessible health services free of charge. The dramatic health advances enjoyed by the Omani people are documented by three principal national data sources. A Child Health Survey in 1988-89, executed as part of the Gulf Child Health Survey Programme, the first national population census in 1993, and the Oman Family Health Survey of 1995 provide the first comprehensive estimates of infant and child mortality. In addition, health service statistics of the Ministry of Health offer detailed information on infrastructure, service
1 4

utilisation, and outbreaks of epidemic diseases. These national data sets are supplemented by many special studies on specific health problems and programmes.
In 1976, Oman devoted 9 million Omani Rials (RO) (US$ 23.4 million) to the health sector. By 1994, the health budget had grown to RO 111.5 million (US$ 289.9 million). The proportion of total government expenditure (recurrent and development) spent on health in 1994 was 5.5%, similar to other countries with approximately the same income levels. Spending on health by the government in Oman amounted to just US$ 138 per person/ per year. This is considered low by comparison with the high income countries of western Europe and North America referred to by the World Bank as "established market economies" where spending per head was US$ 1860 in 1990 (World Bank, 1993, table A.9). By comparison with other Arab countries, Oman's per capita spending on health is less than half the level in Saudi Arabia; about the same as in Algeria; twice the Jordanian level and eight 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 gross domestic product spent on health are exceptional given the country's income level. It thus appears that Oman's investments in health have been both effective and efficient. How was this achieved? Health became a primary concern soon after H. M. Sultan Qaboos assumed power in 1970. The health sector strategy was initially articulated in the First Five-Year Plan in 1976. The plans gave pride of place to the construction of a basic health infrastructure that would be universally accessible to the whole population. Importantly, the facilities were equitably distributed to all regions of the country and expensive tertiary facilities were kept to a minimum. Lacking trained people, Oman imported health workers from neighbouring countries of the Middle East and South Asia. From only a few doctors working in two hospitals with 12 beds in 1970, Oman by 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 region and 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-toHospital Country 1000 1000 doctor beds per population population ratio 1000 population 2.4 Oman (1994) 1.3 2.3 3.1 2.7 1.5 2.2 1.5 Saudi Arabia (1988-92)
Jordan (1988-92) Tunisia (1988-92) UK (1988-92)
1.5 0.5 1.4
0.4 1.3 2.8
0.3 2.7 2.0
1.9 2.0 6.3
Source: World Bank 1993 World Development Report, table A. 8 and Oman, Health Facts. 1994.
1.5

Oman remains heavily dependent on expatriate doctors and nurses with 92% of doctors and 89% of nurses coming from other countries. The Medical School and the Nursing Institutes will gradually help to reduce this dependence on expatriates. In 1983, the basic health infrastructure was brought into focus through a national three-tier primary health care strategy. The basic building blocks of the primary care system are the health centres and local hospitals in the Wilayah, backed by referral and technically more sophisticated regional hospitals and central facilities in Muscat. This policy of dispersal of the health facilities has brought services close to most of the population. To heighten the impact of primary care, the Ministry of Health launched a series of vertical programmes targeted at the most prevalent health problems among the most vulnerable people. Such programmes included the expanded programme on immunisation, prevention and case management of diarrhoea and respiratory tract infections, the control of malaria and tuberculosis, maternal-child health programmes, breast-feeding promotion, and school health programmes. 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 health care strategy. In the early 1990s, the Ministry of Health began to integrate these vertical programmes into stable primary systems at the Wilayah level. Decentralisation of decision-making and responsibility is underway from headquarters to the Wilayah Health Management Teams whose responsibilities include planning and administration; supervision of all health staff; management of out-patient services and where there is a hospital, responsibility for in-patient services too. This Wilayahbased approach provides an integrated system of care to people in the regions and means that vertical programmes such as immunisation against infectious diseases can be made more effective locally. Overall, the aim is to provide an integrated set of 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 disease surveillance system, which was instigated initially to assess progress with childhood immunisation aod< now .covers many other conditions. The utility and effectiveness of this 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 was able to quickly identify the communities in which cases were occurring and to vaccinate widely in both the affected and the surrounding population. As a result of this capacity to find cases quickly, diseases like polio and measles are increasingly rare, as Chapter 2 will illustrate.
Due in part to the ease of geographic access to these decentralised and free services, 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 12 million visits per year. An average Omani pays 4.6 visits to a hospital annually, 3.2 visits to the primary health care centre and an average of 6.4 antenatal visits per pregnancy. 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 of returning expatriate Omanis, and the credibility and performance of the Government's health system. Such intensive facility utilisation also translates into a heavy outlay by the government and is one of the strategic issues, which the government must face in the immediate future.
In this report, we begin by documenting the changes, which have occurred in Oman
and then move to the principal sets of factors, which have wrought the Oman health
and mortality transitions. At the end, we return to the issue of the causes of the rapid changes, which have swept Oman, trying to parcel out the credit so that other may learn from the Omani experience.
1.7
CHAPTER 2
CHANGES IN MORTALITY AND HEALTH STATUS
CHAPTER 2
CHANGES IN MORTALITY AND HEALTH STATUS
ur first task is to describe as accurately as possible the extent and pattern of the changes in health and mortality which have swept Oman over the last twenty-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 forces behind the changes. Are the improvements in life expectancy and health in Oman since 1970 quite exceptional or are there parallels elsewhere? How does the pattern of change in Oman compare with experience in other countries especially those in the same region? Are the improvements in health very broadly distributed by age and sex as well as by social class and region? Are there still sub-groups whose health remains a problem? How fast are new patterns of disease making themselves felt as living standards rise and life styles evolve? These are the questions we address in this chapter, before proceeding to a more detailed analysis of the possible causes of the transition.
/. CHILD SURVIVAL
A.
Sources of information
Childhood mortality measures, particularly the infant mortality and under five mortality rates, are amongst the most commonly used indicators of the health status of populations world-wide (UNICEF has popularised both the infant mortality rate and the under five mortality rate as international indicators of child health - see the annual State of the World's Children for illustration). The accurate determination of infant and childhood mortality levels, trends and differentials usually requires a complete system of birth and death registration. Jn most developing countries, these systems are often lacking or incomplete so othef ways have to be found to measure child survival. Amongst the methods commonly used are special questions included in national population censuses, population-based demographic surveys, and prospective community surveys or sample registration systems. Oman has not attempted to institute a compulsory vital registration system although the coverage of the health information system is increasingly complete and has the potential to be used to monitor changes in mortality, morbidity and fertility. For the period before 1970, we have very few sources of information on child mortality apart from reports from mission hospitals and travellers, which testify to the generally poor health, and poverty of the Omani population. In 1971, Boustead, (Development Secretary 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 disease capable of treatment and cure" (quoted in Townsend, 1977: 65). Some sample surveys were conducted in the 1970s but it was 1988 before the first nationally 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 child survival in the 1980s. The first national population census conducted in 1993 also collected information suitable for the estimation of childhood mortality for Omanis. Since then, the Oman Family Health Survey (OFHS) was conducted in 1995 and there have been an assortment of smaller more specialised studies which are gradually providing more and more information on the evolution of Oman's health and mortality profile. The statistics generated by the various Directorates of the Ministry of Health conveniently synthesised in the Annual Statistical Reports and the quarterly Community Health and Disease Surveillance Newsletter provide a huge amount of additional information on health and mortality to these survey data and the census. The only reservation in using the rich array of information from the health services is of course uncertainties about the coverage of these services and the characteristics of the population not represented in these data.
The information required for the assessment of childhood mortality was collected in different ways in different studies so that in some cases, the results from these different sources are not consistent with each other. These differences arise both because of variations in estimation methods (see below) and because of data errors and sampling biases. For Oman, the most important sources of information on childhood mortality are shown in table 2.1
The two urban surveys in 1975 and in 1977-79 were conducted in conjunction with the UN Economic Commission for Western Asia (ECWA). They were sample household surveys in which ever-married women were asked about the number of children ever-borne and surviving. They did not include a full birth history but did include some questions on recent deaths in the household. A full analysis of the data from either study was never formally published. The clinic-based childhood mortality survey in 1986 consisted of asking questions on the survival of the two preceding born children to all mothers giving birth in public hospitals and clinics. The mortality estimates were then derived using the Preceding Birth Technique (Hill and Macrae, 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 asked of all ever-married women, Omanis and non-Omanis, so that mortality estimates for the whole population can be derived by indirect estimation methods (Indirect techniques are model-based methods developed by demographers to estimate vital rates when civil registration is lacking (See UN 1983 and section B below for details.). The 1993 census was a fully comprehensive enumeration of the entire de facto resident population. Note that only Omani ever-married women were asked the questions on children ever-born and surviving so that the census does not provide a basis for the estimation of the mortality and fertility of the non-Omanis. The final results from the 1995 Oman Family Health Survey (OFHS) are not yet available but this study included a full birth history as well as a set of questions on maternal and child health as well as some questions on chronic and acute illness in adults.
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In addition to the surveys, as was mentioned above, Oman's health information system is very comprehensive and could easily be exploited to capture year to year trends and regional differentials in child survival. The antenatal registers track women from pregnancy to delivery and the MR2 Child Health Register follows children until fully immunised. Defaulters are traced and systematically followed so
that the survival of the new-borns is known very accurately. At present, the system is used principally to mange the provision of health services but it could readily be adapted to form the basis of a comprehensive vital registration system.
Table 2.1 Sources of Information Source Date Socio-demographic 1975 Survey in 5 Towns on Childhood Mortality in Oman.________ Coverage Size & notes 5 towns: Muscat, 3829 households; 21,119 population; Mutrah, Sohar, Nizwa 5268 ever-married and Sur women; 92% Omani 11 towns
13,923 households; 4262 -ever-married women aged 15-49.
2585 last live births
Socio-demographic Survey in 11 Towns Clinic-based Childhood Mortality Survey Oman Child Health Survey (OCHS)
1977-79
March/May 1986
All 37 public hospitals and MCH centres
Nov. 1988/ Feb. 1989
Representative national sample. i. Household data for all residents ii. Full birth history etc. for Omanis only Everyone resident in Oman on census night. Children ever-born & surviving questions for Omani ever-married women.
Representative sample of Omani households
24,321 individuals; 3617 ever-married women under 50; health data for 6,886 children born in 1982 and after.
2,018,074 total population. 264,055 ever-married Omani women aged 15 and over.
General Census of Population, Housing and Establishments
1-10
December
1993
Oman Family Health Survey (OFHS)
1995
6103 households; 51,562 persons, 6405 ever-married women interviewed for the reproductive
health survey.___
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B. Estimation Methods
A variety of different approaches are used internationally to measure levels and trends in childhood mortality when full registration of births and deaths is inaccurate or incomplete. We can distinguish two different approaches. On the one hand, we can ask women about the dates of all their live births and about the dates of death of those who have died by the time of the survey. These data, usually arranged in the form of a chronological table, are then used to calculate directly the probabilities of dying for different generations of children or for different time periods before the survey. A life table approach is usually used to deal with the problem of the varying exposure 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 data as reported by mothers without reference to any models or the inclusion of additional assumptions. This way of collecting the dates of birth and dates of death for children who die is a laborious and difficult task so the approach is only suitable for use in sample surveys such as the 1988-89 OCHS and the 1995 OFHS. Once the data have been collected, however, and they prove to be of reasonably good quality, there are many possibilities for detailed analysis. The so-called birth history approach, for example, is the only method that allows us to examine the age pattern of mortality in childhood. It is the sole method that permits the analysis of related factors such as birth interval length and the part played by the demographic and socio-economic characteristics of individual mothers in determining child survival.
For larger enquiries such as the 1993 census, much simpler questions have to be used to measure child survival. In general, the so-called "Brass" questions (Brass et al, 1968), on the total number of live born children and the total number alive at the time of the enquiry, have been in use in censuses around the world since the early 1900s. The proportions dead of children ever-born tabulated by the mother's age or marriage duration is the key information needed to reconstruct levels and trends in childhood mortality in the twenty or so years before the census or survey. To generate mortality measures, which are comparable with those from vital registration, data or the direct methods applied to birth histories mentioned above, a number of assumptions and some demographic models are required. The suite of methods developed for this purpose are known as "indirect" techniques since they work with the proportions of children dead rather than with .the direct reports on births and deaths recorded by date of occurrence (UN, 1983). The result of the application 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 time before the study. Model life tables are required to provide a consistent series of infant or under 5 mortality rates. Thus, the indirect approach makes the data collection simpler and less prone to error but depends on demographic models and assumptions to produce the final estimates of the trends and differentials in child survival. A more recent addition to this collection of indirect methods is the Preceding Birth Technique 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 works best when most mothers deliver in clinics where records are kept. It is mentioned here since one of the earliest estimates we have for childhood mortality in Oman stems 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 tables must be employed. For the sake of consistency, we have followed the principle in the Oman Child Health Survey, which meant using the South version of the Princeton model life tables for the early childhood mortality estimates, switching to the West pattern from the mid-1980s onwards. This choice is justified on the grounds that mortality of the 1-4 year-olds was relatively high compared to the mortality of infants at the outset but later on, as immunisation and other child health measures became more widespread, the excess mortality of the 1-4 year olds is then reduced.
Assembling a composite picture of childhood and adult mortality in Oman is thus relatively complex due to differences in the coverage of the different studies and in the nature of the questions used to measure recent mortality. In addition, there are different estimation methods, direct and indirect, which can be applied to the same data so that the results can vary according to the estimation method selected.
C. Results
1.
Trends
The earliest statistical information we have on mortality in Oman stems from the survey 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, of whom 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 estimated
resident population of the 5 cities - table 31 in the report -- not the whole population
of Oman, and probably covering a population with better than average health and mortality.
All ever-married women were asked about their total number of live births and the numbers surviving. It is these data on parity and on the proportions dead, which allow us to estimate childhood mortality from the survey (Table 2.2).
As we shall see from later comparisons, this first attempt at collecting reliable fertility and mortality data in Oman was an important pioneering study but was probably not very successful at enumerating all the births and child deaths experienced by Oman'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 sign of some omissions of births. This is not surprising given the poor educational levels of 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 the enumerators were female teachers who would have been very largely non-Omani at this time so there may have been some communication problems. In addition, the training period for the enumerators was only 6-8 days for each team. Generally, the data seem internally consistent and reliable enough particularly for the period near the date of the survey. Table 2.2 Children Ever-born and Surviving and Under 5 Mortality Estimates from the 1975 Survey of 5 Towns. Age of Average % children q(1): infant q(5): under 5 Reference women parity dead mortality per date mortality per 1000 1000 15-19 0.555 104 10.9 Aug 1973 78 20-24 1.971 11.4 124 Mar 1972 89 25-29 3.587 11.7 Apr 1970 89 123 30-34 4.894 15.9 Mar 1968 162 108 35-39 5.097 21.6 Jan 1966 131 210 40-44 5.449 22.7 May 1963 130 208 45-49 5.321 30.5 260 May 1960 155 Notes: Mortality estimates calculated by indirect methods using the South Princeton model life tables. See text for justification. Source: Directorate General of National Statistics (1976): tables 7, 25, and Appendix tables 14 and 31. The data in Table 2.2 suggest that fertility was relatively modest at this time (an estimated total fertility rate of just 5.4 births) and that infant mortality was below 100 per 1000. Both these numbers seem surprisingly low. Comparison with the subsequent 11 towns survey (which excluded the 5 larger towns surveyed in 1975) but using the same methodology suggests some under-enumeration of both births
and deaths since the differentials between the 5 towns and the 11 smaller towns
seem very large (Figure 2.1). Although the absolute levels in the first survey may be too low, the trend in child survival may be a useful guide to the improvement of mortality conditions in the 1960s and 1970s. As we see on Figure 2.1, the improvements in childhood mortality which become better documented in the later period appear to have begun in the early 1960s and to have continued to the present day. The next statistical source we have for childhood mortality stems from the survey of eleven smaller towns conducted in 1977-79. This was similar in structure and design to the 1975 study of 5 towns but with a much wider coverage. In addition, we expect both the surveyors and the respondents to have grown in competence and experience following the 1975 study. The studies were spread out over a longer time period 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 towns surveyed in 1975 as well as the rest of the rural population. It is difficult to say how representative the figures are of the national situation at that time. Most of the population was thought to live in the rural areas and small towns at the time of the survey and so they may be a better guide than the 1975 survey to mortality levels in general. In any case, the figures give us some idea of the high levels of childhood mortality 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 in the 1970s was precipitous so that by September 1976, infant mortality had fallen to below 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 Dead of Children Ever-borne as Reported in the 1977-79 Survey of 11 Towns. (Probabilities of dying per 1000) Feb. Mar. Apr. 1971 June Apr. Sep. Oct. Mortality measure 1964 1976 1966 1969 1973 1975 227 Infant mortality 222 184 152 129 84 150 337 274 227 191 119 Under 5 mortality 330 225 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 the total population, Omanis and non-Omanis included (Table 2.4).
Table 2.4 Infant and Under 5 Mortality Estimated from the Proportions Dead of Children Ever-born as Reported in the OCHS (Omanis and Non-Omanis Combined). (Probabilities of dying per 1000) Mortality measure Feb. Jan. Apr. Feb. June Feb. Feb. 1972 1984 1986 1988 1975 1978 1981 (64) Infant mortality 117 73 57 45 36 99 57 (87) 171 101 76 45 Under 5 mortality 143 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 very dramatic from the early-1970s to the late-1980s. From the more detailed data based on the birth histories collected as part of the OCHS, we can discover much more about the pattern of change in the child mortality of the Omanis. The direct estimates of childhood mortality for Omanis from the 1988-89 OCHS are shown in Table 2.5.
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Figure 2.1: Trends in Under 5 Mortality from Various Sources

-OFHS 1995 -PBT1985
-OCHS 1988-S9 birth histories -OCHS-indirect
-5 Towns Survey 1975
- 1977-79 11 Towns survey 1993 Census
40% r
35%
1975
1980
1985
Reference date
Figure 2.2: Trends in Infant Mortality from Various Sources

25%
1975
1980
1995
Reference date
-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 the female interviewers, are obviously dependent on the quality of the reporting and on the completeness of the reporting of births and especially the child deaths. Given that deaths are more likely to be omitted than living children are, we can again regard 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
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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 196973 to under 4% by 1984-88. This is a startling drop with few parallels elsewhere in the world, as we shall see later.
Table 2.5 Probabilities of Dying per 1,000 Omani Children for 5-year Periods before the Survey: Direct Estimates from Birth Histories. 1984-88 Mortality measure 1979-83 1969-73 1974-78 26 97 47 Infant mortality qo 140 11 50 19 Early childhood mortality 4qi 98 37 142 65 Under 5 mortality sqo 225 Source: Oman Child Heath Survey OCHS (1988-89), table 4.5.
Turning to the census data, which provide us with proportions of children dead by the age and marriage duration of Omani mothers (non-Omanis were not asked the fertility and child mortality questions), we can calculate the equivalent probabilities of dying for periods before the census. The results are shown in Table 2.6. Table 2.6 Indirect Estimates, of Childhood Mortality for Omani Children from the 1993 Population Census. (Probabilities of dying per 1000)____________ Measure__________1979 1982 1985 1988 1990 1992 Infant mortality 127 101 71 55 43 39 Under 5 mortality_____187 146 99____73____55 49 Source: Calculated from 1993 census data by indirect methods, West model life tables. Again, the picture is very striking and shows a very dramatic improvement in childhood mortality over the 20 or so years before the census. With the indirect methods of estimation, we are unable to say anything about the rate of change of infant mortality compared to the mortality of children aged 1-4. The most recent 1995 Oman Family Health Survey collected full birth histories from ever-married women as in the 1988 Oman Child Health Survey. The mortality rates shown in Table 2.7 are taken directly from the preliminary report and are derived by life table calculations from the birth histories. This survey confirms the continuing and extremely rapid improvement in child survival into the 1990s.
The broad picture of the improvement of mortality of infants and the under 5 yearolds can be more readily appreciated on a graph. On Figure 2.1, all the points from different sources, including the 1986 clinic-based survey, have been plotted for comparison. By asking mothers seen at the time of a subsequent delivery about the survival of their preceding birth, this study was able to come up with an estimate for the probability of dying between birth and the second birthday of 44 per 1000. This
figure (using model life tables for extrapolation) is associated with an infant mortality rate in the 1980s of 40 per 1000 and a probability of dying before age 5 of 49 per
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1000 for mid-1984.
Table 2.7 Infant and Childhood Mortality from the Birth Histories in the 1995 Oman Family Health Survey._____________________________ Approx. Date of Infant mortality 1-4 mortality per Under 5 mortality mortality estimate____per 1000: q(1)____1000:4q1____per 1000: q(5) March 1993 20.0 5.7 14.3 June 1987 6.7 33.1 26.6 March 1983 61.2 46.9 15.0 March 1978 28.1 120.0 94.6 Source: Oman Family Health Survey 1995, Preliminary Report, table 12.1.
All these data from different sources and analysed in different ways provide solid evidence of a very rapid improvement in the mortality both of infants and of children aged 1-4 since the late 1960s. Although the 1993 census data describe a slightly higher pattern of mortality than in the earlier surveys, the slope of the trend lines are similar. It is hard to explain why the census data produce higher mortality estimates than the 1988-89 or the 1995 surveys -- it seems unlikely that Omanis would overreport the number of dead children in the census and the evidence is that the children ever-born were not under-reported in any major way. It seems best to accept the general trend indicated by a combination of the 11 towns survey of 197779, 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 representing the best estimates of the pace and timing of childhood mortality improvements from the mid-1960s onwards.
Although registration of births and deaths is not compulsory, 89% of births in the three years before the 1995 OFHS took place in health facilities (OFHS, 1995, table 10.1). It is believed that most of the infant deaths are also known to the health facilities because of the efficient system of follow-up and defaulter-tracing after delivery. The infant mortality rates from the health service data are thus a reasonable comprehensive indicator of infant mortality trends. These data are shown on Table 2.8 and have been added to Figure 2.1 where the corresponding infant mortality rates from all the sources used for the under 5 mortality rates have also been plotted.
One notable feature of Figures 2.1 and 2.2 (showing trends in infant and under 5 mortality) is that the decline in infant and childhood mortality seems to have been initiated before the major development efforts of the 1970s. One question to which we will return is the possibility that small increases in prosperity and the beginnings of social change were under way as oil exploration began and oil exports started in 1967. Before going further, we need to establish in greater details the characteristics of this transition. Usually, the distribution of deaths by age and sex, by region and by
social class, by cause and place of occurrence are all valuable clues to the factors driving 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 the improvements in later chapters.
Table 2.8 Infant Mortality Rate Calculated from Health Service Statistics Year Infant Mortality Year Infant Mortality The conclusion from this _______Rate___________Rate___ section is very clear. Oman 1980 64JO 1989 3 T O h a s achieved one of the 1981 59.0 1990 29.0 fastest declines in child 1982 55.0 1991 27.0 mortality ever recorded 1983 51.0 1992 25.0 1960s, about 35% of Omani 1984 48.0 1993 23.0 children were dying before 1985 45.0 1994 23.0 their fifth birthday. In the mid1986 42.0 1995 20.0 1990s, less than 2% were 1987 38.0 1996 18.3 dying by age 5. For infants, 1988____43.0____1997____18.0____ the story is similar; a Source: Statistical Yearbook 1995, table 2.18 and reduction from an infant Annual Statistical Report, 1995 & 1997, table 3.1 mortality rate of about 200 per 1000 live births in the mid1960s to rate of about 20 per 1000 in the mid-1990s. As Table 2.9 and Figures 2.1 and 2.2 all show, this implies an annual improvement of over 7% in infant mortality and of over 9% for under 5 mortality over the 30 year period 1965-1995. This truly remarkable achievement requires detailed analysis. Table 2.9 Direct Estimates of Infant and Childhood Mortality for Omani Children 1969-1995. (Rates per 1000)
Rates
Neonatal Post-neonatal Infant Childhood (1-4) Under 5
2.
196973 56 84 140 98 225
197478 38 59 97 50 141
1979- 1984- 1986- 1991- Annual change 83 95 88 91 22 11 15 8.5% 8 1 1. % 4 25 15 11 6 10.0% 47 27 14 26 19 11 12.1% 7 6 65 37 33 20 10.5%
Source: OCHS (1992): table 4.5 and OFHS (1996), table 12.1
Age Patterns of Mortality Change
Detailed analysis of the birth histories reveals some special features of the Omani transition in childhood mortality. Assuming the data from the 1988-89 and the 1995 surveys are equally reliable, it seems that neonatal mortality, post-neonatal mortality and the mortality of 1-4 year olds all decreased at about the same rate over the
period 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 1-4 age 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 death by cause. Initially, most countries begin with an immunisation programme affecting for the most part the mortality of 1-2 year olds. Only much later do we see an effective set of clinical and other community-based interventions introduced to deal with the problem of neonatal and perinatal mortality. Oman, it seems, managed to reduce both the under 1 and the 1-4 mortality at the same time. As Table 2.9 and Figures 2.1 and 2.2 show, there have been huge improvements in the survival of young children over the 1969-95 period with 1-4 and infant mortality rates improving at approximately the same pace. Perinatal and early neo-natal mortality were relatively high in the 1980s although the absolute levels are extremely low. The estimate based on data from the major district hospitals in 1987-88 was 21 per 1,000 births (Perinatal, neonatal and infant mortality, no date). By 1994, this rate had not changed greatly (it was estimated to be 17/1000 in 1994) with asphyxia the leading cause of death. About 8% of births in 1995 were low birth weight (<2500 grams) and about two-thirds of the low birth weight babies are small for gestational age (Annual Statistical Report, 1997: table 94). The still birth rate was about 12/1000 births for 1995. Dealing with these conditions requires both more involvement of mothers and the community and more timely clinical intervention for mothers at risk. 3. Sex Differentials
In 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 1993 census reveal that sex differences in the mortality of boys and girls are insignificant for the recent period. The OCHS survey shows, for example, that for the 10-year period before the survey, the infant mortality rate and the under five mortality rate for boys-was slightly higher than that for girls (OCHS, 1992: table 4.7). The most striking trend since the 1970s has been the fast decline in the neonatal mortality rates for both boys and girls. This improvement is probably due to the rising fraction of deliveries taking place in health facilities. Thus, we have no evidence in the sexspecific mortality rates to suggest any discrimination against girls.
4. Geographical Differentials in Childhood Mortality
The 1988-89 OCHS was a sample survey and so it is difficult to produce figures on changing 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 the survey. This is the narrowness of the gaps between the infant and under five mortality of the rural areas and the urban or semi-urban areas. The under 5 mortality for the urban areas averaged 38/1000 for the period 1979-88 but the rates for the semi-urban (52/1000) and rural (54/1000) were not far behind (OCHS, 1992: table 4.6). The narrow spread of these figures suggests that health improvements were quite 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 the

1988-89 OCHS and the 1995 OHFS
150 i ^ I
Neonatal --Post-neonatal -*-Infant -#-Childhood (1-4) --Under5
These figures suggest that as the mortality transition was proceeding, mortality differentials widened. Preliminary data from the 1995 survey suggest that differentials in child survival have closed in absolute terms although the children born to urban, literate mothers still have a considerable advantage. In 1990-95, for example, the infant mortality rate in rural areas was 17 per 1000, 37% higher than in urban areas where was 13 per 1000 (OFHS, 1995).
Table 2.10 Regional Differentials in Childhood Mortality around 1988. (Probabilities of dying per 1000) Governorate Infant Under 5 Mortality mortality rate: q(1) rate: q(5) al-Wusta 73 101 Dhofar 51 68 1 A Dakhliyah 47 61 A' Sharqiyah 47 61 al-Batinah 44 57 Musandam 44 57 A' Dhahirah 35 44 Muscat 31 39 All 43 56 Source: Calculated from the proportions dead of children ever-born to Omani women married 10-14 years in the 1993 census using Princeton West model life tables.
The 1993 census which asked the questions on children ever-born and surviving of all Omani women provides a stronger basis for the study of regional differentials than the sample surveys. Using indirect methods and focusing on women married 10-15 years, we can derive the following estimates for
the about mid-1988 (Table 2.10).
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5. Differentials by Age of Mother, Parity and Birth Interval.
The biological effects of age, parity and birth interval length are well known and quite systematic in most human populations. The 1988-89 OCHS drew attention to some of the special risks faced by children born to teenage mothers and to high parity older mothers. The effects of age and parity are confounded. The very low age at first marriage in Oman in the past (over half of all women aged 30 and over in 1988 had married by age 15) meant that a substantial amount of fertility took place in the younger age groups. As the parities by age bring out in the 1988 survey, evermarried women aged 20-24 had borne on average 2.5 live births, rising to 4.1 live births for the 25-29 age group. This is high fertility especially in the youngest age groups. We find, therefore, that the infant mortality rate of children born to 15-19 year olds in 1979-88 was over 1.5 times as high as the rate for children of women aged 20-29 (OCHS, 1992, table 4.7). The effects at the older end of the reproductive life span are less severe but nonetheless significant. The infant mortality rate of births to women 40-49 at survey was nearly one-fifth higher than that for women aged 20-29. Whilst the mean age at marriage is rising quickly - and with it the mean age at first birth - the major demographic factor which will affect child mortality in the future will be a decline in fertility. This decline has already begun with the 1993-5 period total fertility rate estimated to be 7.1 births, down from 7.8 in 1987-88 (OFHS, 1995: table 7.2 and OCHS, 1992, table 11.11). Further steep falls in fertility are evident from the vital 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, with relatively high fertility, child-bearing extends into ages and parities where the risks of an adverse pregnancy outcome and a premature death of the infant are both more likely. For children born less than two years after a preceding birth, the infant mortality 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 were fewer and better spaced births and if fertility could be concentrated in the 20-35 age
range, thus avoiding the age ranges where excess risks appear. These are the aims of the birth spacing programme whose organisation and effects are discussed later in this chapter.
6.
Social Class Differentials
Some of the differences in child mortality by social class are related to differences in fertility patterns and to ecological effects linked to place of residence. One remarkable feature of the Omani situation is the small range of the child mortality rates for mothers with different levels of education. In the 1988-89 OCHS survey, for example, we find that the infant mortality of children born to illiterate mothers was 37/1000 whereas for mothers with at least a primary school education, the rate was 30/1000 (OCHS, 1992: table 4.6). Even for the under 5 mortality rates, where the education of the mother might be expected to play a large role in child care and child survival, we find that the rates are similarly close (52/1000 for children of illiterate
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mothers; 45/1000 for mothers with at least a primary school education).
Part of the explanation must be the very comprehensive nature of the health services - we see small differences in the use of ante-natal services, place of delivery 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 the reason 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 been quite generalised. These questions about the reasons for this pattern of change will come up again later.
7. International Comparisons
One of the clearest indications of the rapid progress Oman has made in child survival in recent years is the changing position of Oman with reference to other Arab countries. Using the under five mortality as the best single indicator of child survival, we see from Figures 2.4a and 2.4b the remarkable improvement in Oman's ranking from 1960 to 1992. Moving from a position amongst the countries with the highest child mortality in 1960, (and it has to be said that 300/1000 is probably an under estimate of under five mortality in Oman around 1960, as we have seen from the data in the 11 towns survey, table 2.3), Oman is now amongst the best performers in the Arab region. Another perspective on the pace of recent improvements can be gained from an examination of the under 5 mortality trends in Oman in comparison with the other states of the Arabian Peninsula. For this comparison, we have the series of child health surveys and the PAPCHILD surveys, all of which were conducted on a similar basis. The results (using the indirect estimates to ensure comparability) are shown in Figure 2.5. Yemen still suffers from exceptionally high mortality. The consistency of Oman's performance is remarkable - the graph shows that starting from a much higher level than all other countries except Yemen, Oman has caught up on
countries 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 a high 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 Death
Without a system of full vital registration and medically certified death certificates, our knowledge of the causes of death in young children is necessarily incomplete. In Oman, we have quite comprehensive statistics from health facilities, which cover a large fraction of the total population. About one-fifth of all infant deaths occur in hospitals so we can use these data as an indicator of the leading causes of death in young children although there may be some selection factors at work which will
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produce biases in the data. As indicated above, the use of the health services is very widespread and we see only small differences in usage by social class. As the 1988-89 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% amongst illiterate 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 doctor or a nurse attended 87% of all deliveries. Post-natal care for mothers was relatively low (38%) but 97% of all children has received some immunisation and 99% had received the BCG immunisation. Thus, there are sure to be biases in the hospital death statistics but they are probably less important than in other countries where levels of contact with the health services are much lower.
Table 2.11 Years Taken to Reduce Infant Mortality from 100 to 30 per 1000 Live Births in Selected Countries. ________________________ Country Period Years to reduce Infant mortality covered from 100 to 30 per 1 000 United Arab Emirates 1965-77 12 Republic of Korea 1960-73 13 Barbados 1956-69 13 Oman 1975-90 15 Chile 1964-80 16 Tunisia 17 1975-92 Kuwait 1955-80 25 Syria 1966-92 26 Mauritius 26 1954-80 Jordan 1960-92 32 England and Wales 36 1915-51 Source: Mitchell (1976 and 1988); Hill and Yazbeck (1994).
Information on cause of infant deaths occurring in hospitals and health centres is available from 1988 onwards. The total number of deaths registered this way is small (just 2164 in total in 1995) so that the scope for detailed analysis by cause and age group is quite limited. The reports come from the unpublished annual inpatient morbidity and mortality statistical reports that classify each recorded death by cause using ICD categories and by broad age groups. Despite the small numbers in some cells, 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 that conditions originating in the perinatal period and congenital anomalies have remained by far the most important causes of death for this age group (Annual Statistical Report, 1995, table 10-15). For children dying between 28 days and one year, diseases of the respiratory system and congenital anomalies dominate. Considering all infant deaths together, we see some small change over the 1988-95 period. The leading causes of death among infants in 1988 were (in descending order); slow foetal growth and malnutrition; conditions originating in the perinatal period; congenital anomalies, and pneumonia. By 1995, when infant mortality had
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fallen to low levels, the causes related to conditions around the time of birth had become slightly more important as the management and prevention of the infectious diseases (such as pneumonia) improved. Improved perinatal care had also resulted
Figure 2.4a: Comparison of Under 5 Mortality among Selected Arab Countries, 1960.
350
I
I
300
| 250 j I 200
| 150
100
50
0 ^
/ // / / ///
Figure 2.4b:
+ */s s */ //
Country
Comparison of Under 5 Mortality among Selected Arab Countries, 1992
X X s/ f//
' ///
&
Country
ss '/ +//
in a decline in the proportions of the deaths attributed to causes in this period. The remarkable new feature in the 1990s is the small number of deaths due to infectious
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disease. Data from 1988 to 1995 show that only 1% of inpatient infant deaths are
attributable to infectious diseases. The low rates can only be attributed to preventative activities such as immunisation and good clinical care of cases. Deaths from acute gastro-enteritis and diarrhoea that still persist have also declined causing 4% 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 Table 2.12. The two principal specific causes (septicaemia and intracranial injuries) remain the same over the whole 1988-95 period. Over half the deaths are attributed a large number 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 infectious diseases and the more complex conditions associated with child birth are being managed more effectively by the health system. Mortality from septicaemia has been high through the years from 1988 to 1995. Small outbreaks of such diseases occur from time to time. In 1995, septicaemia caused 10.1% of the deaths in this age 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 from slow foetal growth/malnutrition, congenital anomalies and septicaemia remain a problem among infants whereas deaths from acute gastro-enteritis and infectious diseases are rare. Among the older age group of children (age 1-14) there has been a rise in deaths due to pneumonia, fractures and neoplasms while those from infectious diseases have shown considerable fluctuations over the period. Deaths from septicaemia and interacranial injuries have remained high, contributing 25% of
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all deaths in 1995. Overall, we see the co-existence of older diseases and newer health problems in the statistics on in-patient deaths among infants and children of Oman.
Table 2.12 Percentage Distribution of Causes of Death in Children Aged 1 to 14 for 1988-1995.____________________________________ Cause____1988 1989 1990 1991 1992 1993 1994 1995 Average Septicaemia 13.7 To3 r L O 1 ^ 8 8 ~ ! 6 1 ^ 4 1O8 1CL1 vTi Intracranial 13.0 11.6 7.7 8.2 17.3 6.7 9.3 13.5 10.9 Injuries Meningitis 3.1 5.8 3.8 1.2 1.6 0.0 5.4 0.7 2.7 Pneumonia 4.3 5.1 6.6 5.6 6.2 2.2 6.2 5.4 5.2 Leukaemia 1.9 2.6 4.4 1.9 5.5 1.5 2.3 1.4 2.7 Neoplasms 3.7 3.9 6.6 6.9 6.2 3.7 5.4 6.8 5.4 Burns 4.4 3.2 3.3 1.2 0.8 1.5 4.7 2.7 2.7 Infectious 1.8 5.1 2.7 1.9 5.5 6.9 6.2 2.7 4.1 diseases Fractures 1.2 1.9 1.1 1.2 0.8 2.2 8.5 6.8 3.0 Other_____52.9 50.5 52.8 58.1 47.5 58.9 41.1 50.0 51.5 Total_____100 100 100 100 100 100 100 100 100 Source: In-patient health statistics. Unpublished data provided by the Department of Information and Statistics, Ministry of Health.
II. ADULT SURVIVAL
Neither of the two surveys, the OCHS and the OFHS, nor the 1993 census included the questions that would have helped to measure the levels and trends in adult mortality. Our best guess of adult mortality levels is to extrapolate from the estimates of childhood mortality, checking for consistency with the data from the health services largely based on hospital deaths. This is rather unsatisfactory since children have been the special focus of the health services (see above) and in a situation where mortality is changing rapidly, there may be divergent trends amongst adults and children. Nevertheless, adopting this procedure since we have no practical alternative, we discern that the expectancy of life at birth for Omanis in 1992 was probably around 77 years, based on the data on child survival and extrapolation in model life tables. For adults, this implies that 92% of those reaching age 15 will survive to their 60th. birthday - a very high level of survival indeed. At age 60, the average expectancy of life will be over 23 years. The implications of these very low mortality rates for the future are significant - growth rates for the elderly will be very rapid. As fertility falls, Oman will then see an increasing proportion of its population in the older age groups, with important implications for health services and the patterns of cause of death. Apart from these extrapolations, the only clue to the pattern of adult mortality in Oman is from adult inpatient deaths by cause and sex. Again, there are biases in
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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 are shown 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 category are ischaemic heart disease, cardiac dysrhythmias, acute myocardial infarctions, diseases of the pulmonary circulation and heart, and cerebrovascular diseases.
Cause Circulatory diseases Neoplasms Injuries and poisoning Infectious diseases Ill-defined causes Respiratory diseases Digestive diseases Genitourinary diseases Blood, endocrine and immune system
Female Total Male 49.5 47.2 45.8 11.4 13.3 12.1 5.4 9.2 11.4 6.3 6.6 6.8 6.2 5.8 6.9 6.0 5.8 5.6 3.7 4.6 5.1 3.1 3.1 3.0 3.4 2.5 2.8 Nervous system 2.4 2.4 2.6 Total (%) 100.0 100.0 100.0 10,117 Total deaths 1989-95 6,302 3,815 Source: Data from in-patient statistics, Annual Statistical Year Books 1989-1995 Ministry of Health.
Neoplasms constitute 12% of all deaths, again mainly in the people aged 45 years and over. Data from the Oman National Cancer Registry show stomach cancer as the most common cancers among Omani males, while breast cancer is the most common among Omani females. Other sites of malignancy are lung, trachea and bronchus, 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% in males, 1.5% in females, National Diabetes Study 1991, unpublished date), lung cancer may soon overtake stomach cancer in ranking among males.
Injuries and poisoning constitute 9.2% of all deaths. These cases are clearly more common in males between the ages of 15 and 44 years. The main injury in all age groups, especially among the males, appears to be intracranial and internal injuries including 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 descending
order): infectious diseases, signs of ill-defined conditions, respiratory diseases,
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digestive system diseases, genitourinary, blood and endocrine system and the nervous system.
In summary, we see in these data the beginning of a pattern of death more commonly seen in low mortality countries. Oman's health transition for adults is well underway.
Maternal mortality
Information on maternal health for the community was not available until recently despite the wealth of information on the MCH cards and other records. For maternal mortality in particular, a new notification system was established in 1991 to report maternal deaths. The number of reported maternal deaths is very small and so the rate fluctuates widely from year to year (Table 2.14).
Year
suggest a very low maternal mortality ratio largely due to the expansion of the antenatal services and to the high proportion of births occurring in health facilities. The high level of fertility still puts women at risk very frequently but the birth spacing programme initiated in 1994 aims to have over half of all births spaced 3 or more years apart by the year 2000 (Community Health and
Disease Surveillance News Letter, 1997, 6(2): 1-2). More details of this programme are given below. In addition, counselling in the ante-natal clinics is encouraging more and more Omani mothers to give birth in health facilities (Community Health and Disease Surveillance News Letter, 1992 1(3): 4).
PregnancyRecorded ratio* per 100,000 related maternal births deaths births 1991 13 45,670 28 1992 13 47,785 27 4 47,382 1993 8 1994 13 46,299 27 1995 6 44,670 22 21.14 Total 49 231,806 *Maternal deaths due to direct and indirect causes abstracted from Community Health and Disease Surveillance Newsletter 1996 5(1): 4 and 1997 6(1): 4-5. Statistical Yearbook 1995, table 10-18. 1994-96 figures based on a projection of all births Annual Statistical Report (1996, 1997: 3.5).
Figures for 1991-96 show that 13% of maternal deaths were to women under 20 and 18% to women over age 35 (Community Health and Disease Surveillance Newsletter, 1996:5(1): 5). Over 44% of the maternal deaths were to women with parities of 7 and above. The most recent figures
C.
Fertility and its Effects on Mothers and Children.
It is very clear from the 1988-89 OCHS, the 1993 population Census and the 1995 OFHS that the fertility of Omani couples was and remains extremely high. On
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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 general are high but the figures for Oman were amongst the highest in the late 1980s and early 1990s (Table 2.15). From the older surveys in the 1970s, it seems that fertility was lower in the past although we must recognise that the 5 Towns Survey of 1975 and the 11 Towns Survey of 1977-79 probably under-estimated the true level of fertility in the Omani population (Table 2.16). The OFHS, for example, reports estimated total fertility rates for the late 1970s of nearly 10 births per woman, almost double the level indicated by the 11 Towns Survey of 1977-79 (OFHS, 1995: table 31). Table 2.16 summarises 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 OCHS surveys, there is evidence of a rise in fertility from 1975 to 1993 with more recent falls for younger women after 1993. A more sensitive measure of fertility change is the pattern of the age-specific rates. These rates are calculated from the retrospective birth histories, which form the core of the OCHS and the OFHS. In all such retrospective surveys, there are always questions about data quality and the ability 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 a good match between the rates reported in the 1988-89 and the 1995 surveys by successive cohorts for approximately the same calendar period. The rise in fertility before 1980 cannot be confirmed from the 1995 survey. Indeed, the analysts of the 1988-89 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, it seems clear that the fertility of Omani women did rise significantly in the 1960s and 1970s. Some of the factors responsible were probably biological and many were behavioural. Some are related to the changing patterns of breast-feeding described in the 1988-89 OCHS: table 11.13. As in Yemen, the initial forces of modernisation
led Omani women to alter their traditional patterns of breast-feeding with
consequent effects on the duration of post-partum amenorrhoea. The mean duration of breast-feeding (full and partial) in the 1988-89 survey was 16 months, 19 months in the 1995 OFHS. In the 1988-89 survey, younger women were introducing solids into their children's diet at about 6 months. The OCHS reported that in the first three days 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 to many 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 care of their offspring. The survey data document this change by showing the differences between the practices of the younger, better educated mothers and their older peers. Amongst older women, breast-feeding continued for longer and supplementation with solids occurred as late as 10 months or older. Data from the 1988-89 OCHS reveal that an average birth interval of 26.5 months for all mothers
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with 20.8 months among younger mothers (15-19) year old and 29.7 months among mothers aged 45-49 years.
Figure 2.6: Changes in Age-Specific Fertility Rates for Different Cohorts of Oman! Women: OCHS and OFHS Compared
- 25-29 30-34 -
c 300
150 100 50
1975
1980
1995
2000
Reference date
countervailing effects of later marriage and more widespread use of contraception have made their presence felt. In the transitional phase, fertility was very high and birth intervals short. With more recent campaigns to promote breastfeeding and "baby-friendly" hospitals, some of the changes have now been reversed. Other factors responsible for the fertility rise must include the return of Omani men from overseas after the export of oil began and to changes in fecundability related to general improvements in health and nutrition.
Table 2.15 Total Fertility Rates for the 12 Months before each Survey for Selected Arab Countries. Country Total Date of Date of fertility survey report rate 1992 Oman 7.84 1988-89 1991 Yemen 7.70 1990 1987 1991 Kuwait 6.51 1991 Saudi Arabia 6.46 1987 1987 1991 United Arab Emirates 5.91 1987 1991 Qatar 4.49 1992 1989 Bahrain 4.19 1991 4.10 1991 Egypt Source: National Child Health Surveys (PAPCHILD, the Gulf Child Health Surveys & OCHS)
Thus, the forces of modernisation have changed the pattern of infant feeding in a way which initially drove up the fertility of married
women before the
In addition to changes in fertility linked to later marriage, we also see signs of
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change in the fertility of married women. We know from surveys and from the routine statistics from the birth spacing programme that contraception is of growing importance. Only 9% of married women were using contraception at the time of the 1988-89 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 birth interval length and final family size for younger Omani couples. Already changes are under way. A survey in April 1994 (702 women and 479 men in 9 regions) revealed that awareness of contraceptive methods is high. About 43% of the women perceived contraception to be good. Among non-pregnant women, 23% were using contraception and 41% reported as having used contraception in the past.
The most recent data from the 1995 OFHS for the year before the survey show some of the effects of this new programme. The data indicate a period total fertility rate of 6.1 births with signs of falls in fertility amongst older women (Figure 2.7 and Table 2.16). Service statistics from the birth spacing programme show that the demand for modern contraception is high. In 1995 alone, 13,399 new clients accepted a modern method and 94% of these clients were Omani (Annual Statistical Report, 1995: table 9-5). A surprising 63% of the clients were under age 30 and 42% had fewer than 5 children. Pills and the injectable contraceptive were by far the most popular methods (Annual Statistical Report, 1995: table 9-5). These statistics signal the beginning of a major decline in marital fertility independent of the earlier declines attributable to a later age at first marriage. It is likely that fertility in Oman will fall quickly as it has done in the Gulf states following the improvement in the educational status of women and the provision of safe and effective family planning services as part of maternal and child health care. Not only will such changes reduce the annual number of births but also they will contribute to the further reduction in maternal mortality 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 is currently being encouraged to begin in the first trimester of pregnancy to allow time to recognise risk factors and educate the mothers. More information on the health of pregnant mothers will be available in the near future with the pregnancy risk evaluation process. This classifies pregnant women into risk categories based on parity, stature, past or present pregnancy complications, medical diseases, previous birth history, haemoglobin levels, history of infertility or abortions, surgery or caesarean sections and detailed examinations during pregnancy for conditions such as anaemia, malpresentation, severe growth retardation, cervical incompetence etc. The 1993 data show that a substantial number of women are being reported with
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some risk factors (Table 2.17). Some 90% of the women registered were deemed
Table 2.16 Distribution of Women Registered for Antenatal Care by Risk Category in 1992 (Percentages). Region Total on Grade A Grade B Grade C Total register Low risk at risk High risk Muscat 10013 36.4 38.3 0.8 75.5 Dhofar 4240 54.5 1.5 91.5 35.5 N. Batinah 41.8 97.2 11395 53.8 1.6 S. Batinah 6827 96.4 49.1 46.1 1.2 A'Dakhliyah 7790 36.4 54.5 0.8 91.7 A'Dhahirah 4144 52.1 1.7 41.3 95.1 N. Sharqiyah 4999 54.8 0.9 95.6 39.9 Musandam 732 51.2 0.5 95.8 44.0 al-Wusta 52.1 165 43.0 1.8 97.0 S. Sharqiyah 3504 50.5 45.5 1.5 97.5 Oman 53809 43.4 46.9 1.2 91.5 Source: Musaiger, 1992
to be "at risk" (Grades A + B) but less than 2% of the total women in all regions were in the "high risk" category. There appear to be no major regional differences in the distribution of women across different risk categories.
Any abnormality found is treated if possible. Immunisations for children, ante-natal services and the significant shift from homebased to hospital-based delivery have contributed to the improvement in morbidity and mortality. Efforts to promote breast feeding through the Baby Friendly Hospital Initiative (1992) and the birth spacing programme (1994) will further improve the health of mothers and children. The policy change in the timing of the ante-natal care program is meant to address problems before it is too late to intervene. Finally, the reporting of maternal deaths and especially efforts at identifying pregnant women at risk will contribute to improving the health and maternal mortality of women in Oman.
Table 2.17 Average Numbers of Children Ever-born to Omani Women from Different Sources. OFHS Age of 11 Towns OCHS Census 5 Towns 1995 Women survey 1988-89 1993 survey 1977-79 1975 0.1400 0.5787 0.0371 0.1798 15-19 0.5552 1.3400 1 .7845 20-24 1.9953 0.9920 1.9713 3.8000 4.2717 3.6415 2.5230 25-29 3.5865 6.3600 6.5518 30-34 4.4376 3.4031 4.8940 7.8900 6.5891 7.8891 5.0971 5.2486 35-39 8.2600 6.9491 7.7675 5.4487 5.6358 40-44 8.5200 7.1224 7.5516 5.3207 5.4755 45-49
OCHS, Oman Child Health Survey; OFHS, Oman Family Health Survey.
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Figure 2.7: Average Number of Children Born to Omani Women from Different Sources
-5 Towns survey 1975
- 11 Towns survey 1977-79

- 1988-89 OCHS
-1993 census -1995OFHS
c
tt
ff
25
30
35
Age of women at interview
///.
MORBIDITY
Oman has seen a decline in mortality from communicable diseases due to recent rapid socio-economic development, improvement in sanitation and health services. With the development of its economy and the growth of personal wealth, there have been changes in the life style of the population. Recent modernisation has led to changing nutritional habits and a decrease in habitual physical exercise. Noncommunicable diseases have emerged as a dominant factor contributing towards ill health.
In this section we will illustrate aspects of health change that are distinctive. We will see that although an epidemiological transition has occurred with the emergence of non-communicable diseases, there is a persistence of some communicable diseases. Currently, one can see simultaneously the co-existence of diseases characteristic of several stages of the health transition.
A. Decline of Infectious Diseases (Particularly Vaccine Preventable Diseases)
The importance of the control of infectious and parasitic diseases in all ages warrants some special attention. Morbidity from communicable diseases as well as mortality have both declined and especially for the vaccine-preventable diseases. This section describes the trends in morbidity in the vaccine preventable diseases from 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 basic
objectives: (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 1992 for all of the vaccine preventable diseases: pertussis, polio, measles, hepatitis-B, diphtheria, tetanus and tuberculosis. In the 1995 OFHS, all children aged 12-23 months at interview had received BCG immunisation and 98% has received measles 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) and pertussis. The fluctuations in the number of measles cases are to be expected in a population in which there are important movements of poorly immunised people from other countries and periodic accumulation of susceptible individuals. Figure 2.9 displays the trend in cases of the acute respiratory infections and diarrhoeal diseases. Again, the trend is downwards with annual fluctuations discussed below. Note that throughout this period, the system for the notification of cases was constantly being improved so that the trend lines are probably an under-estimate of the true decline in the number of cases of infectious disease.
There are nonetheless periodic outbreaks of certain diseases. Taking pertussis as an example, we find that pertussis cases numbered 13,057 in 1975 compared to 2,745 in 1982 (Table 2.18). The increase in the number of cases after 1992 was due to an outbreak in a specific region such as the Dhofar region's Maqinat Shahan Wilayah. Subsequently, the cases spread to other Wilayahs and to other regions. Between 1992 and 1993, the number of cases grew. The immunisation status of the 239 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% were partially immunised - had not yet completed the full schedule (Community Health and Disease Surveillance Newsletter, 1994(2): 3). The rest of the cases were mainly between 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 children in early infancy as 38.9% of cases were in the age group below 7 months. Control measures were initiated immediately the outbreak was discovered. Several difficulties remain in the way of controlling diseases like pertussis. They include low specificity of diagnosis, low compliance to 14 days of chemoprophylaxis and
2.27
efficiency of the vaccine is 70-90% and outbreaks even in well vaccinated populations are known to occur.
Figure 2.8: Reported Cases of the Vaccine Preventable Diseases Covered by the EPI Programme 1975-1995
- T B ALL FORMS DIPTHERIA PERTUSIS TETANUS NEONATAL POLIO MEASLES RUBELLA HEPATITIS E
12
1993 1994 1995
Figure 2.9: Monthly Attendances for Acute Respiratory Infections and for Communicable Diarrhoeal Diseases 1989-1993
ARI - Diarrhoeal Diseases
A similar example is provided by poliomyelitis. From 1975 onwards, cases of poliomyelitis 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 immunisation schedule for polio was modified and surveillance system to detect Acute Flaccid Paralysis (AFP) was established. The eradication campaign and the intensified surveillance of reported cases of acute flaccid paralysis with the conduct of national immunisation days (NID's) have greatly contributed to the decline. Maintenance of a polio free status is difficult due to the ever-present risk of fresh infections being imported by migrants from the Indian sub-continent in particular.
Table 2.18 Reported Cases of Selected Infectious Diseases (Vaccinepreventable) 1975-97.
Year 1975 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
TB* Diphtheria Pertussis Tetanus^ Polio Measles Rubella Hepatitis t 6162 13057 189 16679 43 49 n 1274 19 2745 81 16645 823 41 13 2605 9151 . 948 9 830 30 9652 11 2118 1229 6 765 33 3675 10 700 1 4 207 11 9 2223 2001 616 77 1826 0 5 8 6 3804 477 1 16 118 6052 175 1688 0 478 5 54 1390 0 25 0 4255 482 0 27 1176 0 49 0 1262 1 4 1066 442 2 26 8 276 1 1465 348 0 1834 211 45 0 1322 275 2 1253 0 239 0 3108 1969 294 0 0 109 0 168 181 259 1 2631 0 108 0 68 46 2167 288 0 0 24 10 0 73 1943 694 0 12 7 292 0 0
* Includes all forms of TB; - Indicates missing data; ^Tetanus Neonatorum ;t Total hepatitis cases reported including Australia antigen positive, negative and
unspecified. Source: Annual Statistical Report (1995, table 10-21 & 1997, table 10-
9).
Among the vaccine preventable diseases, measles and rubella continue to cause the highest morbidity among children. Although the number of measles cases has declined significantly over time from 16,679 notified cases in 1975 to only 68 in 1995, small numbers of cases continue to occur. There was also evidence of a significant rise from 1834 in 1992 to 3,108 cases in 1993. Measles continues to be a preventable cause of death and acute and chronic ill health. Looking at one time period between December 1991 and March 1992, a total of 309 cases had been reported in most of the Wilayahs (Community Health and Disease Surveillance News Letter 1(2): 3). The age distribution of the cases reveals that children most affected were aged between 5 and 15 indicating an accumulation of non-immune children in this age group. The low number of deaths among the children aged 1 to 4 points 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 immunisation schedule. As can be seen from Table 2.18, there was an outbreak in 1992 of 211 cases, and the number of cases rose to a much higher number of 1253 by 1993. In 1992, the notification system was modified to individual notification within 24 hours. Prior to this, pregnant mothers with rubella were notified within a week and other cases were reported on a monthly basis. The outbreak that occurred in 1993 was very wide-spread and covered all regions excepting the more sparsely populated Musandam region. The age distribution of the 1993 cases revealed that 25% of the cases were in the 2 to 6 year age group and 44.8% were in the 6 to 14 year age group. A blanket mass immunisation operation to cover all children was carried out in March- April 1994. The younger age group of 6 and below was covered in paediatric outpatient departments in hospitals and health centres. The 6 to 18 yearolds were immunised in schools. Due to the high morbidity seen in the country, the measles-rubella vaccine has been integrated into the expanded programme on immunisation schedule and is given at 15 months. The effect of these measures has been to reduce the number of cases significantly to 46 in 1995.
Cases of diphtheria and neonatal tetanus are now extremely rare. All forms of tuberculosis have declined - from 1975 (6,962 notified cases) to 1995 (259 cases). The BCG vaccination coverage of children was 95% in 1993 (Community Health and Disease Surveillance News Letter 2(4):4. The government's policy is to vaccinate all new-borns within the first year, in order to reduce the chances of contracting severe forms of childhood tuberculosis such as miliary tuberculosis and tuberculosis meningitis. Efforts have been undertaken to evaluate the presence of BCG scars by institution and determination of the proficiency of the nurses administering the BCG vaccine in 1993.
A number of viral hepatitis cases occur, although the numbers have declined from 4971 cases in 1975 to 2631 in 1995. The hepatitis-B vaccine was introduced into the expanded programme on immunisation schedule in 1990. Prior to the introduction of the 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 of 1066 and since then has been a little higher. The attack rate is highest in A'Dakhliyah (1.9 per 1,000) and lowest in Muscat (0.2 per 1,000).
B. Seasonal Morbidity
A good illustration of the continuing exposure of even well vaccinated children to environmental risks is provided by the case of seasonal morbidity. Looking at the morbidity of acute respiratory infections and diarrhoeal disease in Oman between 1989-1993 (Figure 2.9), we see that both diseases show a pattern of strong seasonal variation. The first peak for respiratory infections occurs in March and the second in October each year. This is mainly due to changes in the weather- the transition between the hot and the cool seasons. Communicable diarrhoeal diseases also 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 is that physicians at different health institutions may classify similar health problems such as pharyngitis, otitis media, bronchial asthma or other uncertain conditions as an acute respiratory infection.
C. Persistence of First Generation Illnesses
In the previous section we have seen the decline in infectious diseases in the last two decades, especially the vaccine preventable diseases such as diphtheria, neonatal tetanus, pertussis, poliomyelitis, measles and tuberculosis (Table 2.18 and Figures 2.8 and 2.9). Some outbreaks still occur (such as polio, pertussis, measles and 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 the measles-rubella vaccine in the expanded programme of immunisation schedule. The apparent success of this programme can be seen in the dramatic reduction of cases of each disease to less than 100 by 1995. The success with the vaccine preventable diseases has greatly reduced mortality and morbidity from infectious diseases especially among children.
Despite the decline in morbidity in communicable diseases due to widespread immunisation coverage and treatment, two main sources of morbidity remain. Based on in-patient discharge statistics, first are diseases of the respiratory tract (the 8709 cases of acute upper respiratory infection cases are a quarter of the total) and second, infectious and parasitic diseases, mostly acute gastro-enteritis and diarrhoea cases (9841 cases together). Treatment with antibiotics and oral rehydration solution therapy has greatly reduced the mortality caused by these diseases. Morbidity has remained steady, however, with few changes in the number of cases of acute gastro-enteritis and diarrhoea (Table 2.19). The persistence of diarrhoea is related to environmental problems that will require time to reverse.
Some problems may be the quality and availability of clean water, hygiene, and
early supplementation of the diets of infants. Acute respiratory infections are also related to living conditions. Crowding may be responsible for the persistence of these problems. The number of cases of acute upper respiratory tract infections were the highest in A'Sharqiyah, A'Dakhliyah and Musandam with rates of 1.6, 1.6 and 1.2 episodes per 100 population respectively. All of these are northern regions. The lowest percentage of the population affected was in Muscat. Acute Respiratory Infections amongst the under 5 year age children remain an important health issue. Although mortality due to ARI was low, the number of episodes per 1000 children under age 5 was 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 respiratory system among outpatients are chronic bronchitis, emphysema and asthma, pneumonia, acute bronchitis and acute tonsillitis among others.
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Table 2 . 1 The distribution of inpatient discharges of acute gastro9
Numbers of Episodes of Gastroenteritis and Diarrhoea Reported to the Disease Surveillance System, 1987-95. Year Episodes
enteritis and diarrhoea was highest in A'Sharqiyah and Musandam (1.7% and 1.03%) and the lowest in Muscat (0.10%). This differential is expected due to the established water supply networks within the capital Muscat (97% of houses) compare to water wells (over 60%) as the main source of water in most other regions. The number of episodes of this disease reported in Dhofar and A'Dhahirah
regions approximate 0.6% of the population in these regions. The total number of cases notified to have suffered from acute gastroenteritis and diarrhoea was 178,823 in the year 1995.
1987 1988 1989 1990 1991 1992 1993 1994 1995
276,047 291,050 280,211 273,920 227,127 193,709 198,975 196,761 178,823
Source: DHI&S, Ministry of Health.
Malaria was a major public health problem in most regions of Oman. It is endemic in Oman with the exception of the Southern region where transmission is sporadic. There were 16,787 cases of malaria in 1993 (Annual Statistical Report, 1995: table 9-19). By 1995 the number of cases declined to 1,801. The attack rate was 8.6 per 10,000, the fourth highest of the notified communicable diseases. The largest numbers of positive cases were identified in A'Dhahirah, A'Dakhliyah, Muscat and North Batinah regions.
Transmission of malaria is dependent on the availability of suitable environmental conditions for the breeding of mosquitoes. Sustainability of the eradication program is especially important as a large number of the country's expatriate population come from highly endemic areas and therefore the risk of new cases of malaria arriving from overseas is always there. Poor environmental conditions and low public awareness also greatly contributes to malaria infection. A sustained eradication 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 North and South Sharqiyah has reduced the number from 3,161 in 1991 to below 500 cases in later years. Due to the success in this region, the eradication programme has been extended to the other endemic regions beginning with the North and South Batinah region in 1993 and to Muscat Wilayah and the Nizwa Wilayah of A'Dakhliyah region. Despite heavy rain in 1995, the number of cases was held to 1,801. In North and South Sharqiyah, no transmission took place from 1994 onwards and in A'Dhahirah and eradication was completed in 1997. Arrivals from East Africa are now routinely screened for malaria at main entry points. By 1997, it was estimated that 87% of the population were protected from malaria by house to house spraying. In the 5th five-year Plan, the aim was to reach an annual parasite incidence (API) rate of 1/10,000. The API rate was held to 0.45 in 1997 with 1026 positive 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 the northern regions and hookworm infections in the south. Compared to other regions, there appears to be a high prevalence of brucellosis (from drinking unpasteurised milk), in the region of Dhofar. There were 260 cases in 1985 and 348 in 1995, 322 cases in southern region of Dhofar alone. There is a potential for the spread of the disease to other parts of the country. In 1995, the disease surveillance had identified three cases in each of A'Dakhliyah and North Batinah. The other communicable diseases not mentioned earlier with high attack rates are influenza, chicken pox and mumps (Table 2.20).
D.
1.
Non-communicable Diseases
Malnutrition
Although the nutritional status of infants and children has improved from a decade ago, 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 of nutrition. Susceptibility to diarrhoea and infectious diseases is associated with nutritional status and general health. Episodes of diarrhoea make children highly susceptible to malnutrition by increasing fluid loss and decreasing fluid retention of nutrients and reducing absorption through the intestinal brush border. The prevalence of intestinal parasitic diseases was highest among under 6 year-old children, decreased for 6-14 year old children and remained the same for adults over 15 years (Musaiger, 1991). Personal hygiene and re-infection from migrants from endemic regions are believed to be the causes of the persistence of intestinal parasitic diseases. The disparities in access to safe drinking water in the home or within 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 or close to it (97-98% of houses in urban areas such as Muscat have their own toilets compared 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 the distribution of intestinal parasitic infections such as hookworm (A/. Americanus). A study in Dhofar showed that a 23% of the study population were infected from hookworm (Untitled Source, WHO Consultant, 1992-94). The results also showed that males and females were affected with equal frequency. There was a difference in infection by age. The 6-13 year olds showed the highest prevalence and the 2-5 year 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 2500 grams. The proportion of children entering primary school with weight-for-age corresponding to the minimum median reference values fallen to 64%. The results of a 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 reveal distinctive regional disparities ranging from 2% with PEM in infants in Muscat to 50% in Rustaq amongst 3-4 year olds.
Musaiger (1991) showed that malnutrition among children coincides with the weaning period. Although almost all mothers initiate breast feeding, supplementation starts early and weaning can occur very abruptly. This survey also showed that 93% of the mothers breast fed their children in 1991 compared to 75% of the mothers 3 years earlier. This indicates that more mothers are becoming more aware of the benefits of breast feeding. Although the mean duration of breast-feeding was 9.7 months in a study carried out in 1991, the survey revealed that 73% of the infants 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%) or water 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% for 4-6 weeks and 13% for 7-9 weeks.
Table 2.20 Reported Cases of Selected Communicable Diseases Notified in 1995 and Attack Rates per 10,000 Population. Attack rate Disease Number per of cases 10,000 population Acute gastro-enteritis and diarrhoea 178,823 855.0 Influenza 300.4 62,818 Mumps 69.7 14,574 Chicken pox 67.8 14,185 Trachoma 8,426 40.3 Amoebiasis 3,512 16.8 Viral hepatitis - total 2,631 12.6 Shigellosis 2,449 11.7 Malaria (confirmed cases) 1,801 8.6 Food poisoning 596 2.8 Syphilis 379 1.8 Brucellosis 348 1.7 Gonococcal infection 310 1.5 Tuberculosis 1.2 276 Typhoid fever 1.1 213 Meningitis - all 171 <1 Whooping cough <1 108 Measles <1 68 Rubella <1 46 Leprosy <1 38 Source: Annual Statistical Report, 1995, table 10-5, DHI&S, Ministry of Health.
The main reasons given for stopping breast-feeding were the occurrence of a new pregnancy (45%); child refuses to feed (17%), lack of milk secretion (16%); illness of the 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 well water, 9% used falaj (canal) water and 33% used bottled water to prepare weaning foods.
A rapid assessment survey carried out in 1991/92 also showed that 60% of the families in Bawsher district eat together from the same dish including children of age three and older. Younger children may not eat as much as they need to. Snacks with a low nutritious value are also popular with school children, reducing their intake of nutritious food. In this study, 22% of children under five were mild to moderately malnourished and 16% of children 5-12 were also, mild to moderately malnourished. In low and middle-income families, feeding large families three times a day with a nutritious diet is understandably difficult.
The Musaiger (1991) study also indicates the persistence of numbers of underweight (low weight for height) and stunted (low height-for-age) children. The proportions of children under weight between 1 and 10 years of age ranges between 13% and 35.3%. The range was from 13% to 35.3% amongst boys to 13.5% to 26.4% amongst girls (Musaiger, 1991:75). Stunting is also higher among most males, especially those aged 6 and older. The prevalence of stunting among boys ranges 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). Approximately 11.5% of the girls were overweight, with a range of 22.3% (in Salalah) and 3.9% (in Samail). (P.65 UNICEF State of the World's Children) Only 25% of the women had a normal weight. A 1992 study (Musaiger, 1992) found that based on body mass index, 13% of the mothers were underweight, 33% were normal, 27% were overweight and 28% were obese. It is clear that the proportion of underweight women has declined substantially. The problems of overweight and obesity have
become significant (55% of the Omani mothers). Obesity increases the prevalence of non-communicable diseases such as hypertension, diabetes, arthritis, asthma
and back pain. The study showed that heart diseases were higher among overweight 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 category at 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 were anaemic. Currently, the awareness of adolescent girls of nutritious foods during pregnancy is adequate, as indicated in 1991 Musaiger study. Women, however, still suffer from iron-deficient anaemia. The same study showed that 60% of adult women suffer from low haemoglobin levels. Although the causes specific to Omani women have not been studies, the most common reasons for this condition are menorrhagia and repeated pregnancies. It is suggested that low incomes, limited
access 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 are identified as having a problem cannot read their health cards and cannot communicate effectively with the health staff, many of whom speak little Arabic. The traditional dietary habits of mothers are changing and consumption of foods rich in fat has increased. Consumption of commercial over processed foods also lack in nutritional value. A high level of tea drinking (87% of mothers) can also contribute to iron deficiency among women (Musaiger 1991). In 1995 the most comprehensive nutrition survey to date in Oman reviled a high prevalence of underweight (2 or more standard deviations below the NCHS/CDC/WHO reference median weight-for-age standards) among under-five year old children (23.3%) (OFHS, 1995, table 13.1). Another 23.1% were stunted and 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 adversely affect the health of women and children. They include:
Reduction in food intake during pregnancy to produce a smaller baby for easier delivery. This practice may lead to nutrient deficiency and insufficient weight gain associated 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. Other foods recommended during this period are tea with brown sugar, dates with wheat flour and black pepper, ginger tea, coffee with brown sugar and avoidance of fish for 40 days after birth. Most of these foods are high in calories and low in protein 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 of anaemia (Musaiger 1996b) The results showed that anaemia (haemoglobin levels below 12.0 g) was common in over half of the population, moderate (6-8.9 g) among 8% of the population and severe (less than 6 g) in 0.8% of the population. Adults were not affected by severe anaemia. Of the 11 cases of severe anaemia, 9 cases were among children of 2 to 5 and 2 cases among children between 6 and 13 of age. All age groups were affected by moderate level of anaemia, especially the 2-5 year old group (41.5%) and the adults, although to a lesser extent (20.8%). Mild anaemia, which constitutes almost 50% of the population, was mostly prevalent among adults (25%) and 6-9 year olds (24%) and to a lesser extent among 2-5 year olds (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 significantly more affected than males. The results also show that within Dhofar the prevalence of anaemia by Wilayah varied greatly (Musaiger 1996b). The study also showed that infection with hookworm did not make a significant difference in the prevalence of anaemia. Vitamin A is an important element of child survival strategy. Its deficiency increases mortality of children under 6 years of age. The deficiency increases the severity of measles and other infectious diseases such as diarrhoea and pneumonia. Vitamin A also prevents night blindness, xerophthalmia and blindness. All these factors are relevant to the health status of Omani children. Severe vitamin A deficiency does not seem to be prevalent in Oman in the 6 months to 7 years age group. However it is suggested that sub-clinical, mild to moderate deficiency in pre-school children may exist 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 school children: vitamin B, vitamin A, iron, calcium and fluorosis. Vitamin B and C deficiency, calcium and fluorosis was higher among older children (13 to 18 year olds) and young adults (19-24 year olds) than the 6 to 12 year olds. Iron deficiency was higher among the 13 to 18 year old groups and the same among the 6 to 12 and the 19-24 year old groups. A national study on the prevalence of iodine deficiency indicates that half of the country may have a mild deficiency. The results showed that 49.8% of the children in 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 results in physical and mental damage. It is suggested that even mild Iodine Deficiency Disorder (IDD) indicates that there is inadequate iodine availability for normal development of the brain in-utero for some parts of the population. Universal salt iodisation (USI) has therefore been made compulsory by law since 1995 (Ministerial
Decree 92/95, Ministry of Commerce & Industry), and monitoring will continue with
the aim of achieving USI by the year 2000. 2. Diseases of the Circulatory System
Various types of non-communicable diseases are emerging. Of particular concern are diseases of cardiovascular origin. The 1995 In-patient Morbidity Statistical Report indicates that diseases of the circulatory system account for 7.6% of all discharges (Annual Statistical Report, 1995: table 10-2). The rate of discharge was higher in males (8.5%) than in females (4.6%). Between 1990 and 1995, the average increase was about 8% per year. Hypertensive diseases constituted about 24% of the diseases of the circulatory system in 1995, ischaemic heart diseases constituted 40% and diseases of the pulmonary circulation and heart constitute about 19% (Annual Statistical Report, 1995: table 10-15). Cardiovascular diseases caused 36.7% of all adult deaths in 1993.
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A rheumatic heart disease survey among school children showed that the prevalence is 8 per 10,000 Omani schoolchildren, a level close to that for developed countries (Hassab, 1997). Follow-up of the sample for a further three months gave an annual incidence rate of 4 per 10,000 schoolchildren. Data also show higher congenital heart diseases among females (30.9 per 10,000 females as compared to 6.8 per 10,000 males).
3. Diabetes Mellitus
Data from the annual national statistics indicate that hospital discharges for diabetes mellitus have risen steadily - from 1528 cases in 1986 to 3340 cases in 1995. The proportions of patients diagnosed with diabetes are significant as seen in a survey carried 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 that about 9% of all adult hospital admissions and 12% of adult hospital bed occupancy were related to diabetes. Outpatient clinics in district hospitals showed proportions as high as 20-30% with diabetes (Asfour, 1995). Using the WHO methodology, the prevalence of diabetes and IGT (impaired glucose tolerance) among Omani adults aged 30-64 years, was 14% and 11% in males and 14% and 17% in females respectively (King, 1993). An epidemiological survey carried out by the Ministry of Health in collaboration with WHO in 1991 showed that the prevalence of diabetes was 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 in both sexes throughout their lifetime to 20% in males and 25% in females for diabetes and to a maximum of 30% for IGT.
Recognising the importance of diabetes as a significant public health problem, the Ministry of Health in the Sultanate of Oman established a National Programme for Diabetes Control and Prevention in 1991. A National Committee was formed to steer the program activities. At the tertiary level a National Diabetes Centre was established at the Royal Hospital and was designated as the first WHO collaborative centres in the Eastern Mediterranean Region. Furthermore, the 5th five-year Health Development Plan, 1996 - 2000 has identified diabetes as a major priority. With the exception of Musandam and al-Wusta regions, a specialist in diabetes in all other regions was appointed in line with the policy of decentralisation. The main objective was 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 into the local primary health care services. National management guidelines were developed and annual workshops are organised to train PHC physicians, nurses, health educators and dieticians, on the various aspects of management of diabetes in primary health care settings. All basic drugs and insulin required for the treatment of 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 a surveillance system has been designed (National Diabetes Registry). This system organises 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. Cancer
The data on inpatient discharges indicates that there where 2,220 cases of malignant neoplasm discharged in 1995 (1.0% of total discharges). The highest percentage were in Muscat, Dhofar and A'Dakhliyah regions. The high percentage in Muscat 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 average annual increase in the discharge rates for cancer was 15.5%. The cause of this rise in cancer discharges may be attributed to more organised referral services between secondary and tertiary centres. To monitor future trends for cancer, a cancer registry was developed in 1985 in A'Nahdah Hospital. Later it was shifted to the noncommunicable diseases control section to function as a population-based registry. The notification system will be discussed in Chapter 3. Table 2.21 Frequency and Incidence of Cancer per 100,000 among Omanis, by Gender, 1993-1997. Year Males Total Females Cases CR ASR Cases Cases CR ASR 1993 432 57.3 796 107.3 364 50.0 94.0 1994 408 52.9 760 94.5 352 47.3 85.5 1995 475 50.2 833 109.8 358 47.0 81.5 1996 457 56.2 897 109.6 350 44.7 84.6 1997 510 61.1 895 121.8 385 47.8 93.6 Total 2282 108.4 57.8 4091 1809 47.0 87.0 Source: al-Lawati, et a/., (2000) Between 1993-1997 4091 cases of cancer (2282 males and 1809 females) were reported to the Oman National Cancer Registry giving the average crude annual incidence rate of 57.8 per 100,000 for males and 44.9 per 100,000 for females (table 2.21). The corresponding age-adjusted rates were 108.4 and 87 per 100,000 population respectively. The male to female ratio ranging from 118 to 132 males per 100 females. Stomach cancer was the leading cancer among males in Oman (11.1%), followed by non-Hodgkin's lymphoma (9.6%), prostate (7.6%), leukaemia (6.7%) lung and bronchus (6.4%), primary liver cancer (4.9%), bladder cancer (4.5%), brain and nervous 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 is followed by cervical cancer (8.8%), non-Hodgkin's lymphoma (7.6%), stomach cancer (6.9%), thyroid cancer (6.4%), Leukaemia's (5.4%), ovarian cancer (3.8%),
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bronchus and lung (2.9%), primary liver cancer (2.5%) and connective tissue cancers (2.2%). (Table 2.23).
Table 2.22 The Ten Most Common Cancers among Omani Males, 19931997. Topography Frequency % Stomach 254 11.1 NHL* 220 9.6 174 Prostate 7.6 Leukaemia 153 6.7 147 Lung & Bronchus 6.4 Primary Liver 111 4.9 Bladder 102 4.5 77 Brain and Nervous 3.4 Hodgkin's Disease 68 3.0 Colon 63 2.8 Total 1369 60 *NHL, Non-Hodgkin's Lymphoma Source: al-Lawati, et a/., (2000) Table 2.23 The Ten Most Common Cancers among Omani Females, 1993-1997. Frequency % Topography 13.7 248 Breast 8.8 159 Cervix Uteri 7.6 NHL* 138 6.9 Stomach 125 6.4 116 Thyroid 5.4 98 Leukaemia's 3.8 Ovarian 68 2.9 52 Lung & Bronchus 2.5 Primary liver 46 2.2 Connective tissue 40 60.2 1090 Total
*NHL, Non-Hodgkin's Lymphoma Source: al-Lawati, et a/., (2000)
A study (al-Lamki, 1994) of malignant tumours in children indicated that among those 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 cases were mostly among the 2-year-olds.
5.
Accidents
The number of accidents and especially the severity of road traffic accidents have risen dramatically with road building and the rapid extension of vehicle ownership. A road traffic accident survey in 1993 indicated an incidence rate of 6 per 1000 population. The death rate from road traffic accidents was 23 per 100,000 population. Forty percent of the accidents occurred in adults within the age of 26-50 and 27.5% within the young adult age of 16 and 25 years. More than 80% of cases were males. Hospital discharges from injuries and poisoning in general have been on the rise by 64% between the years of 1986 and 1993. Injuries and poisoning constitute 8% of all discharges. The rising trend of these problems is of great concern. 6. New and Unanticipated Threats: HIV/AIDS
In 1984 the first HIV case was reported in Oman. By 1994, a total of 134 HIV cases and 10 new AIDS cases were reported in total. In 1995, the corresponding numbers were 113 and 14 respectively. Thus, the HIV/AIDS prevalence in Oman is very low and concentrated in males aged 20 to 40 years old. Most (39%) of the transmission
is sexual with HIV prevalence being highest amongst those with a history of other
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sexually transmitted diseases and intravenous drug abuse. The HIV prevalence rate among patients with STD's seen in Ministry of Health institutions was 6 per 1000 STD cases. The HIV prevalence rate amongst TB patients fell slightly between 1992
to 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 for the prevention and control of HIV infection. This was followed by the establishment of a national technical Committee on AIDS in May 1997 with representatives from the Ministry of Health, the Royal Oman Police, the armed forces and from Sultan Qaboos University.
Oman has instituted a strong surveillance system to identify cases with HIV or AIDS since 1990. All HIV/AIDS cases are part of mandatory disease reporting system. In addition, a special report is completed for all AIDS cases and the Medical Officer in charge is responsible for notification. A counselling service is provided for those who are diagnosed with HIV/AIDS. There are 24 counsellors nationally. The counsellors are also responsible for identifying families of cases for screening and follow-up of cases. HIV/AIDS awareness in Oman is not high but all Omanis leaving through the airport are provided with information on HIV/AIDS.
IV. CONCLUSIONS
This chapter has shown that there is extensive evidence to prove that Oman is well launched on its mortality and health transitions. The childhood mortality data describe one of the fastest drops in infant and under 5 mortality on record, certainly much faster than the rates recorded for the major countries of Europe and North America earlier this century. A particular characteristic of the mortality transition in Oman was the way in which differentials between rural and urban, educated and less educated sections of the population have been kept to a minimum. The coincidence of the mortality falls and the implementation of major health programmes suggest a strong connection between the two. One curiosity is the evidence from some of the earlier demographic surveys that childhood mortality was falling even before 1970 and the subsequent health measures were implemented. The data on deaths by cause demonstrate the major role played by the immunisation programme in controlling diseases such as measles in particular. Further evidence of the impact of the public health measures comes from the data on morbidity - both new cases reported and in-patient discharge data. These sources portray a complex pattern of improvement with declines in the diseases, which are controllable by vaccination and other public health measures, but persistence of the diseases, which require more personal actions, such as diarrhoea and gastro-enteritis. Non-communicable diseases, on the other hand, are fast emerging 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 living standards and improvements in education? These are the central concerns of the subsequent chapters.
2.42
CHAPTER 3
EVOLUTION OF THE HEALTH SERVICES
*/
CHAPTER 3
EVOLUTION OF THE HEALTH SERVICES
n this chapter, we examine the contribution of the health sector to the improvement of health and mortality in Oman up to 1995. The expansion and development 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 the early commitment to Primary Health Care (PHC), to the integration of the different parts of the health services, and to the decentralisation of services and responsibilities following the World Health Assembly on PHC in 1977. Oman has been consistent in its policies since the mid-1980s. Indeed, many of the policies being implemented in the 1990s have their origins in the Strategy for Health for All by the Year 2000 published by the Ministry of Health in 1989. In addition to the provision of fully comprehensive, free and widely accessible health services, Oman embarked on major programmes of health promotion and preventive measures with community involvement in the planning and provision of these services. Although the 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 Ministry supplied good quality services throughout the country but the population has made use of these services in a remarkable way. The establishment of good quality and free health services certainly generated huge demands for health care, signalling a growing consciousness of health issues in the Omani population.
This account begins with a brief outline of the development of national policy but the main part of the chapter discusses the content of the health services, considers some particular health programmes and then looks at how the health services are dealing with some new and emerging conditions. There is a danger that the reader will be lost in the detail but it is by documenting the detail that we can appreciate the
amount of planning and thought which has gone into the development f the Omani
national health system.

/. HISTORY OF POLICY DEVELOPMENT
One of the first Royal Decrees issued by Sultan Qaboos was one establishing the Ministry of Health in 1970. From almost nothing, the Ministry has built up a free and comprehensive health system through concerted efforts set out in a series of FiveYear Plans. The first of these was initiated in 1976 and was largely concerned with the rationalisation of existing services and the mobilisation of the resources needs to expand the health services. The second and Third Five-Year Plans focused on expanding the coverage of the health services and on increasing the quality of care provided (Annual Statistical Report, 1995: 2-1). Naturally, these plans led to a huge expansion in the number of health facilities in the country and to a major increase in health personnel, Omani and non-Omani. Throughout, the strategy followed has been 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 with the exception of the mission hospital in Muscat. There were only 10 Omani doctors and 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 1970 was to create the Ministry of Health headed by Dr. Asim al-Jamali who had been working along the coast in the present UAE before his appointment (Oman 1994: pp 177). Very soon, the beginnings of modern health service began to take place. The growth of the health facilities and the human resources for health is described in later sections. Here we focus initially on the emergence of the policies that were later to shape the current health system.
The end of the Dhofar war in 1975 allowed the new administration to devote extra resources to social and economic development. To indicate the government's commitment to improving living conditions for all Omanis throughout the country, the construction of health facilities and schools was begun in all major population centres under the terms of the First Five-Year Plan. This plan was largely concerned with 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 that region into the nation, the rural health service was begun using mobile teams and health posts to bring health care to those previously receiving none (Graz, 1982: 157). The experience gained and the positive response from the population prepared the way for the development of a primary health care system that was to reach all parts of the country. By 1980, following the Alma Ata conference on Health for All and the agreement that primary health care was the principal means to achieve this goal, Oman formally incorporated this strategy into the first declaration on Health for All by the Year 2000 in 1980. In the Third Five-Year Plan (1986-90), the PHC strategy became the central component in the development of the health sector. Later policy documents on
evaluation (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 to
have convinced senior policy makers in the Ministry of Health and in the government that the decentralised approach providing basic health services was the preferred model.
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 1987 but 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 the publication of the Strategy for Health for All by the Year 2000 in 1989. This report was 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
140 120
100
6000
"5
I
1980
Year
1985
development of the health services in the 1980s. Although based on the Alma Ata principles, the health services had nonetheless grown up in a rather fragmented way as a result of the rapid growth of preventive and curative care in parallel but separate tracks. The key phrase in this report appears on page 37:
"Thus, there is a complete cleavage between the preventive and curative aspects of
primary health care, both structurally and functionally."
This, and other major organisational problems, then became the major agenda for the Ministry in the 1990s. Once the basic principle of integration was accepted, then the other policies that became the hallmark of the Omani health services were also
put in place. These included the commitment to regionalisation, the governorate
(Wilayah) basis of organisation of the health services, the referral system introduced initially only for the Royal Hospital, and then the development of the nationally conceived but regionally implemented health programmes. The content of the Primary Health Care package has been greatly extended and now covers thirteen activities (Table 3.1).
Driving the whole system was a remarkable commitment to the development of a health information system that provided a factual basis for the setting of many numerical targets. The list of objectives and targets in the 1989 Annual Statistical Report (pp. 32-34) is extraordinary. Few countries can match the information available on specific "problems" (such as diarrhoea! disease, malaria, tetanus, acute respiratory infections and so on) and even fewer can produce numbers from the routine health information system to demonstrate how far the country has gone with
the control or elimination of such problems. The targets included not only problems related 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 education 2. Promotion of proper nutrition for mothers, pregnant women and children 3. Environmental health - food safety, sanitation and vector control 4. Maternal health - ante-natal care, deliveries & post-natal care 5. Child health - growth monitoring, control of diarrhoeal, acute respiratory and helmenthic disease 6. School health 7. Immunisation against childhood diseases 8. Prevention and control of endemic diseases 9. Mental health 10. Eye health 11. Oral health 12. Treatment of common diseases and injuries 13^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 to deal with Oman's health problems. First, it helped that Oman's economy was expanding rapidly in the 1980s (see Chapter 4 for details), providing the resources for the changes proposed. These new resources meant that Oman could afford not only the development of a network of centres providing primary care nation-wide but also had the resources to build a medical school and the Royal Hospital as well as other tertiary-level hospitals. In addition to the funds needed for buildings and equipment, Oman also was able to recruit trained health workers from all around the world but mostly from the Indian sub-continent and Asia. Secondly, the health sector was and remains completely dominated by the Ministry of Health, an almost exclusive provider of health care services to the nation. The services provided by the Ministry of Defence and the Royal Oman Police are important but they follow the government's lead in health policy. The services provided by Petroleum Development Oman (PDO) company are also provided in close consultation with government. The private sector was and remains small. Thus, policies decided by government are necessarily implemented to the full since there is no real alternative to the state health care system. Thirdly, Oman has been open to ideas from outside from the beginning (as Chapter 1 explained) and has been careful to keep up with new ideas and concepts as they develop. The international agencies in the form of resident representatives of WHO and of UNICEF, for example, have been useful to Oman 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 benefit from the experience of others and to move directly to programmes, which have been tried and tested elsewhere. Let us turn now to the details of the development of the health services, their use and additional health measures introduced by the Ministry of Health.
3.4

II. HEALTH SYSTEM
A.
Provision of Health Services
1.
Organisation and Management
The current organisation and management of the Ministry of Health reflects a considerable period of evolution. As the organisation chart in the 1995 Annual Statistical Report clearly shows, the Under-secretary for Health Affairs is the focal point for all matters dealing with health. In most of the regions, there is a DirectorGeneral of Health Services who reports on all aspects of the region's health directly to the Under-secretary. This is the result of the implementation of the conclusions reached 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 neither sufficiently integrated nor adequate decentralised primary health care services. Service elements were being delivered in a fragmented manner, compromising efficiency, quality, and cost-effectiveness. The Ministry of Health, therefore, delivers a comprehensive package of services. This has led to the current policy of combining curative and preventive care, decentralising and regionalising all services. The current structure was laid out in the Fourth Five-Year Plan (1992). The two Directorates-General, Curative and Preventative Medicine, were integrated into one Directorate-General of Health Affairs and the public health units in the regions were amalgamated with the nearby hospitals and health centres where they were located. An example of the new policy is the creation of the Extended Health Centres. These are primary health care centres, which support specialised (secondary) care at outpatient (ambulatory care) level. 2. Strategies
A Royal Decree in 1985 provided the legislative basis for the administrative reforms later incorporated in the 1989 document. This decree also established an InterMinisterial Health Committee to permit fuller collaboration on health matters with other ministries and departments. The National Child Care Plan that was set up in 1985 was expanded into the National Woman and Child Care Plan (NWCCP) in 1989. NWCCP is a body that assists collaborating government agencies to implement specific projects for women and children. This body has been instrumental in accelerating EPI, spreading awareness of nutrition and breastfeeding, especially the Baby-Friendly Hospital Initiative, and recently the promotion of birth spacing. The NWCCP organises workshops, provides training, develops informational materials such as booklets, posters, videos, and uses the mass media. All these actions aim to improve knowledge and practices within the home and to increase the participation of the community.
Within the Ministry of Health, the need to integrate curative and preventive services was recognised as far back as 1975 when the Minister of Health, Dr. Mubarak alKhaduri stated:
"The Ministry's national health programme is based on the fact that health is a nondivisible 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 the comparative neglect of preventive activities. In the 1990s, these two functions were integrated administratively in the Ministry of Health. The ongoing decentralisation
and regionalisation processes have facilitated integration of services, especially at the local levels.
Decentralisation and regionalisation of decision-making have been underway for several years. More and more, financial and administrative decisions are being devolved to the regional level. There are ten health regions, and there are plans to further decentralise to the district level when and where feasible. In the decentralisation plan, each of the 59 W/7aya/?-level health systems will be led by a local health management team responsible for five main work areas including: planning, community participation, and inter-sectoral co-ordination; administration and management of community health programs; supervision and in-service training of health staff; out-patient services; and in-patient services in hospitals. Regionalisation has also meant the decentralisation of monitoring and evaluation of health services. In 1992, a health information system was decentralised to nine regions. Regional health information officers were appointed for collection of monthly data from health units and for entering the information in regional computers. Reports are provided via computer diskettes to the health unit manager and 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 data collected in health units countrywide and to establish reliable documentation and comparability of information across regions.
There are signs that regionalisation and decentralisation of decision-making have improved the efficiency of staff time use, the monitoring of local health problems, the effectiveness of management, and local participation. It is hoped that widespread service access and improvement of service quality in regions outside the capital region will improve national health equity as well as prevent excessive utilisation of tertiary facilities and wasteful migration into the cities for health services.
3. Facilities and Infrastructure
The Health Services in Oman have developed tremendously over the past twentyfive years (Table 3.2). In 1970, Oman had only two hospitals with 12 beds but by 1995, the Ministry of Health was operating 47 hospitals and 40 health centres providing 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 of health centres 120. This represents an increase in the number of health centres of 28% when compared to the end of 1990 showing an average annual growth rate of
5% 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 in the MOH health services becomes very clear.
The MOH provides free health services to all the people of Oman through its health institutions and it has attempted to provide a good geographical spread of health centres and hospitals. Table 3.3 illustrates the distribution Extended Health Centres 0 5 of these services among the Health Centres with Beds 0 49 health regions and it is clear Health Centres without Beds 19 66 that the hospitals and health Total Health Centres 19 120 Source: Annual Statistical Report, 1995: table 4-1. centres are widely dispersed throughout the country. While there is considerable variation in the number of beds available in the regions (52 in al-Wusta compared to 291 in North A'Sharqiyah for example), when this is compared to the population of each region, the distribution per head is remarkably equable (341 people per bed in al-Wusta and 402 in North A'Sharqiyah).
Table 3.2 Development of The Ministry of Health Services and Institutions. 1970 1995 Number of Hospitals 2 47 Number of Hospital Beds 12 3,958 Population per Hospital Bed 54,811 528
Table 3.3 Geographical Distribution of Health Institutions on December 31st 1995. Governorate/ Number of Number of Number of Population Total number Region health hospitals hospital per hospital of health centres beds bed institutions Muscat 1,394 19 13 6 405 42 Dhofar 37 5 376 520 A'Dakhliyah 10 394 607 16 6 N. Sharqiyah 7 12 5 291 402 S. Sharqiyah 12 466 17 5 326 N. Batinah 11 5 304 1,226 16 S. Batinah 8 5 294 730 13 A'Dhahirah 13 5 435 432 18 Musandam 3 3 92 324 6 al-Wusta 2 52 8 6 341
Source: Annual Statistical Report, 1995, table 4-2.
There is a "regional hospital" in each health region that provides secondary (and sometimes tertiary) care for the people in its catchment area. This is usually built in the centre of the region and is considered as a referral hospital for critical cases from other hospitals and health centres of the health region. The regional hospitals for the Muscat region act as national referral hospitals for critical cases from other regional hospitals. The capital region therefore has a proportionally larger number of beds available than the other regions (Table 3.3). The Wilayah hospitals and the local 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 geographically well distributed health institutions, steps have also been taken to provide services via mobile health teams to populations living in very secluded areas. Despite these extensive efforts, however, it is estimated that approximately 5% of the population of Oman is still not easily reached by the modern health services (Annual Statistical Report, 1995: table 2.3).
4.
Human Resources for Health
Since 1975 the number of health personnel employed by the Ministry of Health has increased 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, and nurses in 1975, 1985 and 1995. The number of doctors increased from 147 to 2,477; 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, whereas 54% of the dentists and 18% of the pharmacists are working for the Ministry of Health. Over the past decade, the ratios of dentists, and pharmacists to the population have remained relatively stable. The ratios of nurses and doctors to population, however, have both almost doubled during the same period: nurses from 15.6 per ten thousand to 28.9 per ten thousand and doctors from 6.9 per ten thousand to 11.8 per ten thousand.
Table 3. 4 Health Manpower in Oman 1975 -1995. Three key questions arise Positions 1975 1985 1995 with regard to human resource development in 2,477 147 Doctors 958 Oman. The first relates to 143 Dentists 6 53 the geographic distribution 356 Pharmacists 8 193 Nurses 450 2,156 6,036 of manpower, the second to the balance or blend of personnel with different 11.8 Doctors/10,000 population 6.9 1.8 skills, and the third to the 28.9 Nurses/10,000 population 5.6 15.6 heavy dependence on nonSource: Annual Statistical Report, 1995, table 5-1. Omani workers.
The geographic distribution of health manpower shows both extensive coverage as well as some variability across Oman's regions. Whereas the population per doctor is 787 and 794 in Musandam and Muscat respectively, the ratio in North Batinah is more than double at 2,631 (Annual Statistical Report, 1995: Table 5.5). A similar pattern can be observed with the regional distribution of nurses. This can partially be explained and justified on geographical and policy grounds. Muscat is the capital where all the national referral hospitals were located and it is therefore reasonable that 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 system provided, 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 expensive primary care. In planning for the future, one of the key personnel issues that will require attention is the role that non-physicians can play in primary, preventive, and emergency services. Table 3. 5 Ministry of Health Personnel in 1995. Number personnel % Omani 93 102 Health Administrators 13 1,800 Doctors 17 77 Dentists 13 63 Pharmacists 15 5,128 Nurses Source: Annual Statistical Report, 1995, table 5.
In spite of a steady increase in Omani medical personnel in the last decade, Oman's health system remains heavily dependent upon
expatriate
doctors
and
nurses (Table 3.5). NonOmanis constitute the overwhelming proportion of the doctors (87%) and nurses (85%) in the national health care system. There exists also a great dependence on foreign dentists and pharmacists. It is encouraging to see, however, the large number of Omani assistant nurses (89%), which must reflect the focus on training put forward by the Ministry of Health. But the heavy reliance upon expatriates generates several types of problems such as language and cultural barriers between service providers and users, high costs, and the long-term sustainability of the system.
The Ministry of Health is well aware of these human resource challenges and it has systematically attempted to accelerate the production of Omani health personnel. Male Female Total Year The Faculty of Medicine at the Sultan 24 1984 6 18 Qaboos University Medical School 27 9 18 1985 (established in 1987) is now graduating an 6 9 3 1986 average of 50 doctors per year. Although 9 10 19 1987 all of these graduates have followed a 5 6 11 1988 community-oriented curriculum shaped to 2 15 1989 13 rural health needs, it remains to be seen 2 8 1990 6 how many of these graduates will be 16 13 29 1991 prepared to serve in smaller health centres 44 59* 15 1992 in remote parts of the country. The Institute 31 85 116 1993 of Health Sciences, established in 1982, is 32 161 193 1994 training nurses, assistant nurses, medical 221 52 169 1995 laboratory technicians, radiographers, and Notes: Graduates as Medical physiotherapists (Table 3.6). This table Laboratory Technicians, illustrates the remarkable increase in radiographers and physiotherapists nursing graduates particularly over the last not included. * Includes 14 Assistant five years, from 29 in 1991 to 221 in 1995. Nurses upgraded to General More recently, the Institute has started Nursing. Source: Annual Statistical courses in dental surgery (1993), maternity Report, 1995, table 6-3. care (1995) and electro-cardiograph (1995). Consequently, the number of Omani physiotherapists has grown from only 1
Table 3.6 Graduates in General Nursing from the Institute of Health Sciences 1984-1995.

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 were each producing between 35 and 40 general nursing students annually. Omani nursing staff forms almost 15% of the total nursing staff in the country in 1995. In 1995, the total number of students undertaking training in the Ministry of Health Training Institutes was 1353. Over time, these educational institutions should be able to produce a cadre of Omani professionals to staff the national health care system. Overall, the distribution of the existing doctors and nurses by region is relatively even (Table 3.7) already.
Table 3.7 Doctors and Nurses by Region, December 1995. Region Doctors/ Nurses/ 10,000 10,000 Populatio Populatio n n Muscat 12.6 40.2 Dhofar 7.4 21.3 A'Dakhliyah 6.2 16.0 N. A'Sharqiyah 7.4 22.6 S. A'Sharqiyah 7.8 19.2 N. Batinah 3.8 10.3 S. Batinah 6.6 18.3 A'Dhahirah 12.0 28.5 Musandam 12.7 33.5 al-Wusta 6.2 22.6 National Total 8.6 24.5 Source: Annual Statistical Report, 1995, table 5-6.
B. Utilisation of Health Services
The numbers, skill levels, assignments, and appropriateness of these personnel will need to be carefully planned for matching to what is likely to be a rapidly evolving health care system. The Ministry of Health is very conscious of the need to keep medical personnel abreast of recent developments in their particular fields. For advanced clinical, planning, and public health skills, Omani graduates are being sent abroad to regional and international institutions to study for post graduate degrees. At a local level, the Directorate of Education and Training launched in 1995 a continuing education movement in nursing aimed at enhancing clinical practice.
Several factors have influenced the people's demand for and the utilisation of health services. Obviously, the rapid development of free and high quality government services have stimulated utilisation. Less well appreciated is the role of broad-based education in promoting health awareness and positive health-seeking behaviour among the Omani people.
The Ministry of Health compiles utilisation statistics. From 1975 to 1995, the number of outpatient visits to Ministry of Health facilities (hospitals and health centres together) has increased almost nine-fold from 1.4 million to 12.2 million annually and the number of inpatients discharged has increased from 46,738 to 220,846 (Figure 3.2). This explosion in the utilisation of the health services can also be expressed in
the mean number of visits per person each year. This has increased from 1.7 visits
per person per year in 1975 to 5.8 per year in 1995. Regional differences in the mean 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 visits being 4.0. Ante-natal visits have increased steadily and pregnant women pay almost monthly visits to health centres (Figure 3.3). The number of out-patient visits per year to hospitals is very high (Figure 3.4) and should decline as the referral system becomes more accepted.
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
7000
6000
150 |
X
3000
o 100 ~
2000
1994
0 1996
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.
O 250
I
I/I '
l/> >
200
"5
3 SI
>
<u
Z
2 C S 1
1978
1980
1 8 1 8 1 8 1 8 1990 1 9 1 9 1996 9 2 9 4 9 6 9 8 9 2 9 4
Year
The reasons for this heavy utilisation of health facilities are various. They include the 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 negative dimension of the utilisation pattern is the low primary health care centre attendance in comparison to hospital attendance (Figure 3.4), excepting al-Wusta and South Batinah. Primary health care attendance varied enormously from one Wilayah to another within a region. For instance in Muscat and A'Seeb Wilayah, attendance was 1.1 visits per person in 1995 whereas in Quriyat Wilayah it was 6.5. In another region such as Dhofar, the highest visit rate was 10.5 in Sadah Wilayah in 1995 compared to 1.3 visits in Muqshin Wilayah. Such variable attendance rates point to local factors that influence utilisation (staff performance, geographic barriers, etc.) making it very difficult to generalise about the reasons behind variable health service utilisation.
Figure 3,4: Outpatient Utilization by Region in 1995

D Hospital Health Centre D Extended Health Centre
i:
>
i*O 5
VA
Region
Imbalances also exist with regard to the heavy inpatient utilisation of hospital services. 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 833). These utilisation patterns differ between facilities. There is overcrowding in some major urban hospitals and under-utilisation in some regional hospitals and some health centres.
C. 1. Financing and the Private Sector 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 governmental expenditures more than doubled between 1980 to 1995 and in 1995 the Ministry of Health 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 of government budget expended for health - and also other social sectors - has steadily expanded from about 3% to 5.7%. In part, the capacity to invest more in health, welfare, and social security has come from a significant reduction of defence spending 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 in 1980, reached a peak of RO 64 (US$ 166) in 1985 and stabilised at around RO 5759 (US$ 148-153) in 1992 to 1995 (Figure 3.5).
Figure 3.5: Government Expenditure on Health
1500
The Ministry of Health budget is divided into recurring and development categories in a ratio of about 85% and 15%, respectively. In 1995, the recurring budget was RO 103.5 million (US$ 269.1 million) in comparison to development expenditures of RO 18.1 million (US$ 47.1 million). Salaries alone consume about 63% of the recurring budget. Development expenditures were for new facilities as well as for new programmes. As all services are provided free of charge, the Omani health budget is based on a total cost system, basing eacn year's budget on the previous year's, but adjusted for increases, new programmes, and other changes. Few studies have been undertaken to examine the efficiency of Oman's health expenditure pattern, nor on the sustainability of such high health expenditures. Rapid shifts in governmental revenues and ultimately the decline of petroleum revenues are fiscal factors that will determine the affordability of the current health system. These key issues of fiscal efficiency and sustainability are discussed in the conclusion of this chapter.
Jnffli
I Ministry of Health Total Expenditure - Ministry of Health Expenditure per capita
1970 1975 1980 1985 1990 1991 1992
- 70
1993
1 9 1995 9 4
Year
3.13

2.
Private Sector
There is a small private health sector in Oman, mainly providing services to expatriates (who were not covered by the public system) and Omani workers in
private companies. In 1995, there were 471 clinics and 254 pharmacies operated by
private companies and individual sponsors, mostly situated in Muscat and North Batinah. Although for-profit private medicine has not played a major historical role in Oman, the number and types of clinics and especially pharmacies have shown a significant rise. Private pharmacies primarily sell drugs, and private clinics mostly provide curative services. Table 3. 8 Government Expenditures on Health 1980-1995. Year Total Ministry of Government Ministry of (million Health spending Health spending RO) expenditure (% of total) (million RO) per capita (RO) 1980 924.7 28.3 3.1 28.0 1985 1909.6 63.7 86.6 4.5 1990 1851.7 52.2 92.9 5.0 1991 1851.5 85.4 4.6 47.4 1992 2209.4 108.3 57.1 4.9 1993 2199.4 117.3 5.3 59.0 1994 2232.9 122.3 5.5 59.7 1995 2124.9 121.7 5.7 58.2 Source: Annual Statistical Yearbooks, 1990-95, various tables. To convert from Omani Rials to US$ multiply by 2.6. Another systems of health services are those provided by other government agencies. Two hospitals with a total of 351 beds are operated by the Armed Forces Medical Services, the Royal Oman Police, Petroleum Development Oman and the Sultan Qaboos University
Hospital
(Annual
Statistical Report, 1995,
table 11-1). There is also
a small private hospital in Salalah with 6 beds. Employees and dependants of these governmental units are serviced by these institutions (seeTable 3.9).
As very little information is available on the private health sector, it is difficult to evaluate the quality and the demand for these services. In 1995, there were 471 private clinics 1 Dispensaries & 3 9 13 and 254 private PHC Centres pharmacies operating in Beds 12 37 0 49 Oman (Annual Statistical f ROP, Royal Oman Police; PDO, Petroleum Report, 1995: table 11-4). Development Oman; SQUH, Sultan Qaboos With just over 500 University Hospital. Source: Annual Statistical physicians and 302 nurses Report, 1995, table 11.1. working in the private sector, it is clear that the Ministry of Health dominates the health sector (Annual Table 3.9 Health Services Provided By Other Agencies 1995.____________________ Indicator ROPf PDOf SQUHf Total 1 1 0 2 Hospitals Beds 59 0 292 351
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Statistical Report, 1995: table 11-4). More attention to the private health sector may be necessary in the near future. Commercially driven private health activities can attract those able to pay primarily for curative services. For-profit systems, however, will not promote preventive activities, nor will they venture into poor and inaccessible regions. Private sector involvement, however, may absorb some public costs, lessen public sector overloads, and improve efficiency by increasing competition. A policy to shape an appropriate public-private mix in Oman's health development is an extremely important planning task for the future.
///. DEVELOPMENT AND STATUS OF HEALTH PROGRAMMES
A. 1.
Disease Control Expanded Programme on Immunisation
In 1981, the Ministry of Health launched the national Expanded Programme on Immunisation (EPI) to protect the population against six vaccine-preventable diseases: tuberculosis, diphtheria, pertussis, polio, tetanus, and measles. Within a decade, extraordinarily high coverage was attained, thus contributing significantly to the reduction of disease incidence, child morbidity, and child mortality in Oman.
Vaccinations were initially delivered only at fixed centres, and coverage in the early years was as low as 20%. In 1985, the EPI gained momentum when it was integrated and delivered as part of the child health programme. Coverage increased sharply in the second half of the 1980s. In 1985, it was just above 60% and by 1995
the 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 & Measles for 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 Year
1995

Oman's EPI strategy is aimed at universal coverage shaped to the unique circumstances of a dispersed population. Many strategic factors have contributed to its success, among which were the following:
Pro-Active Retrieval. All children are reached through existing institutions and programmes near where the child is born or resides. Children are followed up from 0-5 years (and recently 0-6 years) by these institutions, which assume immunisation responsibility. Defaulters are retrieved in passive and pro-active ways - passive retrieval by telephone or sending a verbal or letter messages and active retrieval through 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 time is used as an opportunity to check the child's immunisation status. If due or overdue for any vaccine dose, the child is not allowed to leave the institution without receiving the appropriate vaccine. This can happen at any institute that belongs to the Ministry of Health or any other sister organisation. This policy acted as a filter to catch defaulters.
24-Hour Availability. Immunisation services are offered 24 hours a day throughout the year.
Vaccine Practices. A minimum number of children is not necessary to open a multidose 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 be extremely cost-effective.
Mass Education. Launching of the EPI was accompanied by a well-designed and intensive mass media educational campaign. Outreach was achieved through every means available (radio, TV, English and Arabic newspapers). This increased
awareness among the genera! public, especially sensitising mothers to the importance of immunisation.
Community Mobilisation. As part of the decentralisation of health services, the Ministry of Health has appointed Wilayah health superintendents who act as bridges between the health and non-health development activities in the Wilayah. Superintendents also help in mobilising the community, mass campaigns, and correcting problems of non-compliance.
The achievements of this programme can be seen in Table 3.10, which shows the dramatic reductions of reported disease incidence for childhood infections. Tuberculosis cases declined from 16,162 in 1975 to only 276 cases in 1995, a major reduction. The impact of the BCG vaccine is also suggested by the lack of cases of TB meningitis and miliary TB. Pertussis cases have been reduced from 13,075 in
1975 to only 5 cases in 1987. The number of pertussis cases fluctuated disturbingly showing an increasing trend. In 1993, there was an outbreak mainly in the southern region 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 either disease have been recorded in the whole of Oman since 1993. Only one case of neonatal tetanus was reported in 1991, no cases in 1992, 1993 and 1994 and just one case in 1995. Since 1993, no cases of poliomyelitis have been reported in Oman. Table 3.10 Number of Cases of Notifiable Infectious Disease in the EPI Programme.
Year 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
TBt 122 700 616 477 478 482 442 367 289 300 276
Diphtheria 6 4 0 0 0 0 2 1 0 0 0
Pertussis 64 207 5 16 25 49 26 45 239 168 108
Polio 33 9 6 118 5 0 4 0 2 0 0
Tetanus 64 24 10 11 11 10 8 10 7 7 7
Rubella 10 1 77 175 54 27 8 211 1253 109 46
Measles 3657 2001 3804 6052 4255 1262 276 1834 3108 181 68
fTB, Tuberculosis. Source: Annual Statistical Report, 1995, table 10-5.
The EPI programme has also confronted two types of second-generation challenges. The first are episodic outbreaks of vaccine-prevent diseases in incompletely immunised populations, and the second is the incorporation of new antigens to the basic immunisation package. In 1988, an outbreak of poliomyelitis (118 cases) occurred in six of eight regions in
Oman. This was despite 88% immunisation coverage for OPV3 in all regions. A
case-control study conducted by the Ministry of Health and the US Centre for Diseases Control (Sutter, 1993) showed that 87% of cohorts had received at least the first dose of polio vaccine and 50% had received three doses. The genomic sequencing of the outbreak virus showed it to be Type I suggesting that it had been imported from South Asia since it was distinguishable from isolates indigenous to the Middle East. As a result of this outbreak, the immunisation schedule was modified to include a dose of oral polio vaccine at birth and at 6 weeks. Surveillance of acute flaccid paralysis was also instituted, and the system of outbreak control was strengthened. The southern Oman pertussis outbreak in 1993 occurred despite precautions taken by the Ministry of Health. Outbreaks of pertussis are known to occur periodically in populations even with high coverage since the immunity conferred by the vaccine is 70-90%. Besides, 40% of the outbreak cases were either below 3 month or 3-7 months of age and hence could not be protected by the present schedule of DPT at 3,5 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 reported cases. Despite measures taken to contain this epidemic, the outbreak continued through 1993 to reach a total of 3,108 new cases (giving an attack rate of 154 per 100,000). 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 that could vastly reduce the number of measles susceptible individuals in Oman. Since then, the routine immunisation schedule includes two doses of measles vaccine - at 9 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 on these diseases. Since enhancement of the rubella surveillance system in 1992 (by placing it into category A diseases - i.e. reportable within 24 hours of detection), an increased number of rubella cases were reported in 1993 followed by a dramatic decline in 1994 and 1995 (Table 3.10). In 1992 a rubella outbreak was reported in Muscat that soon spread to other parts of the country bringing the total number of cases to 211. The epidemic continued throughout 1993 when the total number of reported cases peaked at 1,253. Because of the threat of Congenital Rubella Syndrome (CRS), a blanket operation with MR (measles-rubella) vaccine was conducted nationally in the age group 15 months to 18 years in March/April 1994. In only 4 weeks, 705,000 persons were immunised, achieving 94% coverage. The MR vaccine was also integrated permanently at 15 months into the EPI schedule as of January 1994.
2. Control of Diarrhoeal Diseases and Acute Respiratory Infections
The diarrhoeal diseases were among the major causes of childhood morbidity in Oman (138,178 cases in 1995) (Annual Statistical Report 1995: table 9-12). As a consequence, in 1985 the Control of Diarrhoeal Diseases (CDD) Programme was introduced to reduce diarrhoeal mortality and morbidity among Omani children. It began by standardising procedures in the clinical management of diarrhoea and dehydration, banning the use of anti-diarrhoeal mixtures and drugs, and rationalising the use of antibiotics and intravenous fluids. The CDD also endeavoured through health education and promotional activities at all health facilities to increase the awareness and knowledge in the use of oral rehydration therapy (ORT) in the management of diarrhoea/ dehydration. In addition, the programme promoted the importance of good nutrition (exclusive breast feeding in the first four months of life, good complementary feeding practices), safe water, personal and environmental hygiene, immunisation and other related issues in the prevention of diarrhoea. The programme was implemented throughout Oman's national network of health care system
Field data on diarrhoeal incidence are sparsely available in Oman, as is the case in most countries. A KAP survey conducted as part of the OFHS in 1995 showed that 88% of the children who had diarrhoea were treated with increased fluids and continued feed and 83% had recovered ORT solution. Based upon hospital data on diarrhoea cases among children from 1984 to 1995, there were suggestions of

causes like inadequate personal hygiene practices, inadequate environmental hygiene, lack of clean water, and lack of understanding in communities. Eradication of trachoma and its complications by the year 2000 is an optimistic goal, which can be achieved by addressing these underlying causes.
B. Maternal and Child Health
1.
Maternal and Child Health Programme
Although the Ministry of Health provided MCH services prior to the establishment of the MCH programme, the services were neither uniform nor standardised, nor they were monitored appropriately. Target setting, regular monitoring, management information systems, and other MCH programme strategies were deficient. Since its inception in 1987, the MCH Programme has focused on the standardisation of procedures for maternal and child health services all over the country. One year later in 1988, the programme received added impetus from the launching of the NWCCP.
Over a period of seven years, the quality of ante-natal, perinatal, and post-natal care have improved tremendously. Antenatal service coverage has increased, antenatal registration has moved progressively toward the first trimester; more and more births were taking place in hospitals and other health facilities; post-natal services were increasingly being utilised (Figure 3.3).
A few selective programme statistics demonstrate these performance improvements. In 1994, the percentage of eligible mothers contacted for ante-natal services rose to nearly 95%. In 1995, on average, women paid 7 visits per pregnancy to health facilities for ante-natal care (Figure 3.3) (Annual Statistical Report, 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 to
antenatal clinics compared with 8.1 visits in Dhofar and A'Dhahirah. In 1993, 94% of the ante-natal cases were registered in the second trimester. Late registration in the
third trimester has come down from 10% in 1991 to 7% in 1994. The percentage of births 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 of transportation facilities.
There has been a remarkable rise in the number of visits for post-natal checks over the period 1988-95, rising from 29% to 83% of eligible mothers. In 1995, the ratio of post-natal to ante-natal visits was 1.2 for the country as whole (Annual Statistical Report, 1995: table 9-3). This has made possible by raising the awareness of pregnant woman during the ANC period. Some of results of these programmes can be 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 Care
The 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 survey concluded that active trachoma was highly prevalent in the population. The prevalence of acute trachoma amongst schoolchildren ranged between 94% in Nizwa and 26% in Muscat. In the community, the rate ranged between 12% and 25%. The prevalence of trachoma has declined in the 1980's. Comparison of the results of three surveys in Nizwa showed that active trachoma in that region had declined from 93% to 26% and in school children from 94% to 3%. During the 1970s, trachoma was treated mainly through a curative approach at health institutions of the Ministry of Health and in a limited manner through the Trachoma Control Unit and Community Development Programme. As the concept of a national control programme was not implemented, it is believed that the main reason for the dramatic decrease in active trachoma was the wide-spread socioeconomic changes. The 1981 survey not only showed a decline in trachoma prevalence 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 Health established a Prevention of Blindness Programme that had a two- pronged outreach strategy: (1) school screening by school health visitors and (2) community screening by field teams working in the endemic areas. This Programme working in seven selected regions continued up to 1991.
The programmatic strategy was guided in part by field research. In 1988, Graz conducted an attitude survey on trachoma (Graz, 1988). The study finding delineated 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. The prolonged 'time lag' between the initial infection, complications (Trichiasis/ Entropion), and eventual blindness 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 reorganised as the Eye Health Care Programme. The Programme is being broadened to cover most of the regions of the country. Stress is being laid on integration with other programmes like school health, primary health care and the Wilayah health system; standardisation of policies/procedures of management of common eye diseases especially trachoma; standardisation in methodologies of training/monitoring/evaluation; and increased stress on community involvement/ health education.
In conclusion, the prevalence of active trachoma in Oman has been dramatically reduced mainly due to socio-economic changes and only partially due to the interventions 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 all regions were involved and children at different ages were examined for BCG scarring. The results showed very high levels of BCG scarring, with 97% having a scar at 3 months and 90% by 19 months. It was recommended that BCG scar checks be undertaken of all children at 3 months of age to determine whether revaccination is indicated and that children entering school at 6-7 years of age should be 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 nonrandomly selected cluster of villages around the country. Out of 5,746 people surveyed, 115 symptomatics (2%) were identified from whom sputa were taken for examination. Only one sputum was found to be positive for tuberculosis, giving a prevalence rate of 17 per 100,000 through active case finding. A symptomatic survey was also undertaken among 12,480 people. With 309 symptomatics (2%), the survey suggested that about 2% of people will have sputum-positive examinations in the general population. The Programme is planned, monitored and evaluated by the Tuberculosis Control Section of the Department of Disease Surveillance and Disease Control with two supervisory staff at headquarters. The Programme has achieved good nation-wide coverage, efficient defaulter-retrieval system, contact tracing and screening, central cross-indexing system, efficient monitoring and supervision and a standard regimen of anti-tubercular treatment. In 1995 there were 276 new cases of tuberculosis in Oman (135 sputum positive cases, 59 radiologically suggestive cases, and 82 extra pulmonary 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
n E
z
5 3
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 of malaria. Indeed, the problem of malaria was worsening and could be expected to deteriorate because of the emergence of the multi-drug resistant strains of malaria parasites plus rapidly rising insecticide resistance. These conditions propelled Oman towards a new, experimental strategy of eradication. Preliminary field results of the A'Sharqiyah pilot project suggest that eradication may be feasible. Success will depend upon political commitment and leadership; a well trained and experienced staff; public awareness; and appropriate international technical exchange. The goal of 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 to malaria, available information does not permit an accurate assessment of the significance of infectious tuberculosis in various communities or an accurate assessment of its prevalence in the country. In the 1970s, there were many cases of advanced sputum-positive pulmonary tuberculosis throughout the country but many other cases that were not confirmed bacteriologically. In limited tuberculin skin surveys carried out in the country, only about 5% of school entrants showed a positive reaction of 10 mm or more to 2 Tuberculin Unit Mantoux test. These results among others suggest that the risk of tuberculosis infection in pre-school years is not as high as commonly believed nor in comparison with that reported in many developing countries. In 1981, a national Tuberculosis Control Programme was launched. One year earlier, a WHO Consultant, had recommended BCG vaccination of all new-born and school entrants (EMI/TB/140, March 1975). Five district hospitals were reporting tuberculosis 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 drug sensitivity tests were established. However, It was also obvious that a large proportion of known infectious cases were not cured largely because of the high default 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 of how each institution was dealing with tuberculosis cases. With this background information, a Control Programme was evolved based on the two well known measures- case-finding and institutional treatment and BCG vaccination. The Programme was launched with both preventive and curative services involved, and subsequently integrated into primary health care. In the development of the Programme, priority was given to extending BCG vaccination and to improving the organisation 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 main anti-vector weapon, some supplementary measures were deployed- e.g. selective residual house spraying, mechanical control measures, ULV spraying (imagociding), and providing impregnated mosquito bed nets in remote areas. Together, the actions were called "integrated control". The aim is to bring the Anopheles vectors below the critical density to ensure the complete interruption of malaria transmission. The effect of these actions can be seen in the declining number of positive 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 - ...
o
O Q.
20
15
Simultaneously, case detection goes on through different activities: - passive case detection, active case detection, malariometric school surveys (including parasitological surveys and spleen surveys), epidemiological contract surveys, and sometimes mass blood surveys. In addition a plan was prepared in 1995 to involve the private sector as well in case detection. Simultaneously, national guidelines for the treatment of malaria and its complications were developed to ensure the malaria cases were treated radically and thus eliminating the reservoir of infection. Health education has been a very important component of the programme. Different seminars were arranged not only for the public but also for the medical and paramedical staff to spread awareness. TV spots programmes and interviews were also organised. An ideal national malaria eradication programme attempts to reduce the API (annual parasitic incidence) to 0.01% in approximately 6-7 years. In A'Sharqiyah, this low level has been achieved within three years, which is extremely promising. The Slide Positivity 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 imported cases). 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 country were simply acting as fire brigades moving in non-organised patterns without clearly defined targets. Action occurred only after outbreaks or epidemics instead of working towards prevention. The situation was clearly ineffective and also
unsustainable. Therefore, the Ministry of Health realised that that policy could not be maintained successfully, especially since the problem of malaria has recently worsened all over the world due to two factors. These were the increasing
emergence of chloroquine-resistant strains of falciparum malaria. These species
used to constitute 94% of malaria in Oman before the dramatic change of the parasitic formula with the establishment of the successful eradication programme,
followed by the emergence of multi-drug resistant strains (Fansidar, quinine and
even mefloquine resistant. The Second reason is the increasing emergence of insecticide resistance by the anopheles vector.
Based on the above, the Ministry of Health decided that Oman would adopted a new strategy to move from control to eradication - from a reduction of the incidence of malaria cases to the cessation of malaria transmission and the elimination of the reservoir of infected cases. Although the Ministry of Health recognises that eradication is extremely difficult if not impossible to accomplish, it hopes that an intensive campaign over limited time could interrupt transmission completely.
To achieve this objective, a malaria eradication section has been established in each of the high risk regions, headed by a medical officer with an experience in malarialogy and backed by four wings - epidemiological, entomological, operational and administrative. Each headquarters supervises a malaria unit in every Wilayah in the 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 and
geographical reconnaissance was done to ensure that all the potential breeding
places for the vector are located and marked to be covered by larviciding on a
weekly basis. Strict vigilance is maintained through well organised and stratified
supervision in a special set up of malaria staff. At least in the attack and
consolidation 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 each Wilayah, there is a general map and this Wilayah is divided both on the map and by
clear numerated demarcations in the field into sectors, so called daraks, each of which is about 4-5 km. Each darak has its own map and is again divided both on the map and by clear numerated demarcations in the field into 5 sections representing
the 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 days
by 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).
Figure 3.7: Confirmed Cases of Malaria, Oman (1988 -1995)
1988
1989
1990
1991
1992
1993
1994
1995
Year
Figure 3.8: Seasonal Variations in Malaria Cases in 1995
re O
D
</>
0)
250
1
200
BH
3tl
. .5jT
i i
i i
Jan Feb Mar
:
Apr
m
May Jun Jul Aug Sep Oct Nov Dec
In 1975, the Ministry of Health started a malaria control programme based on four well-known principles of control: (1) Early diagnosis and prompt treatment; (2) Selective application of sustainable preventive measures (in Oman, mainly larviciding with Temephos); (3) Immediate, vigorous, and wide-scale response to epidemics; and (4) development of reliable surveillance and information.
; ~>r,

modest declines in incidence, but the longer-term trend is not clear. Among hospital cases of diarrhoea, however, the case-fatality ratio appears to have steadily declined with only 4 deaths among children below 5 years of age due to diarrhoeal diseases 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) (Annual Statistical Report 1995: pp 9-21). Reducing diarrhoeal morbidity will require addressing underlying causes such as the lack of clean drinking water, poor environmental and personal hygiene, and inadequate nutrition during and after diarrhoea. These underlying conditions must be addressed through vigorous
community-based initiatives rather than reliance on hospital-based activities.

Acute respiratory infections (ARI) were also extremely common causes of illness among 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 the outpatient 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 Standard guidelines for the management of ARI in children were initiated in 1987. These involve improved case management, judicious use of drugs, and increased awareness for early detection and treatment. Gradually, programme activities have been extended to achieve nation-wide coverage. A major component of the ARI/CDD programme is training. The strategy is to train regional master-trainers, who in turn would train all concerned health staff. Training courses consist of modules, lectures, role-plays, and group discussions and also emphasise 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 of 630 new health staff was trained in 1995.
3. Malaria Control
Malaria has been and remains one of the most important health problems endemic to Oman. In 1977, 340,322 cases were clinically diagnosed as malaria, 6.5% of all the hospital attendees were malaria positive, and case-fatality among malaria inpatients 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 been
reduced to just 1,801 cases. The persistence of malaria is shown in Figure 3.7 that plots 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 but the southern region. Thus, all the ecological factors that play a role in the transmission of malaria are present in Oman. Malaria transmission is highly regional, common in Muscat, A'Sharqiyah, A'Dakhliyah , A'Dhahirah, and al-Batinah but virtually absent in the Dhofar southern area It is also highly seasonal with the
in

At this stage of MCH development in Oman, it can be considered that the strategy for effective ante-natal, obstetrical, and post-natal services is in place. Future strategies will need to advance maternal-child health through risk reduction (maternal nutrition, birth spacing, etc.) as well as disease prevention. 2. The Birth Spacing Programme
As we have seen in Chapter 2, section II.C, fertility amongst Omani women was
extremely high in the 1980s. It appears from an analysis of the parities from older
surveys (Table 2.16) and from the trends in the age-specific fertility rates from the
OCHS and the OFHS that fertility probably rose as a result of the changes in health
and living conditions which began in the 1970s. Recognising that high fertility, including an early start to child-bearing, short birth intervals and deliveries to grand multi-parae, exposes women and children to numerous health risks, the government began a new programme to encourage birth spacing amongst couples of reproductive age. The programme was launched in October 1994 after careful preparation and training, including a small knowledge, attitudes and practice survey to assess the needs of Omani couples more accurately (Annual Statistical Report, 1995: 9-11). Information and services were provided through the network of Ministry of Health facilities. Attempts have also been made to involve others in sister institutions and the private sector in the programme.
The results of this innovation are very striking. The fertility effects have already been mentioned but it worth repeating that the parities for Omani women aged 45-49 were as high as 8.5 children in the 1995 survey (OFHS, 1995, table 7.1). The same high fertility 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 indicate that total fertility rates (a measure of final family size when fertility is experienced at the measured rates) have fallen to 7.0 births overall, 6.6 in urban areas and 7.9 in rural areas (OFHS: 28, table 7.2). Figure 3.11 shows quite clearly that most of the changes in fertility were amongst younger women. Older women, as judged by the
panties (OFHS: 31, table 7.4) have continued to have large families.
These fertility changes closely reflect the pattern of contraceptive use stimulated very 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 parities under 5 and 63% were less than 30 years old (Annual Statistical Report, 1995: table 9.6) Most prefer the temporary methods (34% adopted the pill; 31% the injectable; and 14% the condom). The connection between the birth spacing programme and current use is very clear -- 64% of clients said they had obtained their information about family planning through the Ministry of Health (Annual Statistical Report, 1995: 9-11). Most women seem to have been satisfied with the new services since 60% of the re-visits were for re-supply and another 19% for follow-up according to the protocol of the birth spacing programme. Only 19% attend either for method problems or requests for method changes (Annual Statistical Report, 1995: table 9.7). In the 1995 OFHS, a remarkable 97% of Omani women knew of at least one contraceptive 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 in 1988-89, only 8.6% of respondents were using a contraceptive method at the time of
survey (OFHS, 1996: table 8.1 and pp. 33).
Figure 3.11: Age -specific Fertility Rate, Oman 1993-1995.
1993 1994 1995 400 350 300
c 0)
I 250 o o o 7 200
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 primarily responsible for these major changes in reproductive patterns, we note that the differentials in use by region and education were every small (OFHS, 1995, table 8.2). This is probably a reflection of the way the programme has been implemented throughout the country using the extensive network of health facilities run by the Ministry. There is still an attachment to large families however, since in the 1995 survey, the mean ideal final family size was still 6.4 children (the modal number was 4) 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 that the rising generation of younger women who were already delaying their marriages and postponing the age at which they have their first births will also want to restrict their fertility within marriage. All in all, the Oman case is an extraordinary example of a rapid change in reproduction driven by an enlightened and non-coercive birth spacing programme.
3. Child Nutrition
Despite enormous health progress, the prevalence of child malnutrition continues to be a major public health problem in Oman. High prevalence of wasting, stunting, low birth weight babies and anaemia among both children and mothers reflect child malnutrition. Malnutrition is the result of several inter-related economic, educational, agricultural, and health factors. As such, it is a multi-sectoral problem, not simply a medical problem of the Ministry of Health.
3.28

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 child anthropometry (Musaiger, 1992). About a quarter to half of children ages 1-4 years were either stunted or wasted in comparison to international standards. Interestingly, growth retardation among boys may be worse than among girls. Six studies also demonstrate a high level of anaemia among Omani women and children. Significant nutritional anaemia can be found among half of pregnant women (Musaiger, 1991).
What were the causes of these nutritional deficiencies and why has progress been so 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 a result of parasitic infestation. Malaria can no longer be implicated due to the effective control programme. Frequent and repeated pregnancies, lack of breastfeeding and other behavioural problems were other possible factors in the genesis of 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 complementary and synergistic measures will be critical in determining the future nutritional health of Omani children.
4.
Breast-feeding: the Baby-Friendly Hospital Initiative
Breast-feeding was a customary practice, normal for all infants in traditional Omani society. The advent of modernisation brought along changes in the infant care practices, many favourable but with the clear exception of bottle feeding. Like many other societies, bottle-feeding in Oman gained enormous popularity during the 1970s and 1980s as confirmed by the National Child Health Survey of 1988 and
also in a study by Musaiger (UNICEF 1988). Easy access and availability of breast milk substitutes along with the vigorous sales campaigns lured many Omani mothers to resort to alternative feeding methods.
Studies on breast-feeding in Oman describe the evolution of these practices and demonstrate what is possible through concerted government action backed by international agencies. The first breast-feeding study was carried out in 1972-1973 in two areas of Oman jointly sponsored by UNICEF and the Ministry of Health. Prelacteal (foods other than breast milk like honey, ghee, molasses, saffron and dates) were commonly offered to new-born infants because colostrum was considered harmful. Breast-feeding was started 3-7 days after delivery, and breast-feeding was continued on demand. The duration of breast-feeding varied generally discontinued after two years or until the next pregnancy. The practice of adding complementary foods while breast-feeding was practised by 45-70% of the mothers. Rice mixed with samel (animal fat) and Parley's rusks were the most popular foods used for complementary 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 OCHS showed that breast-feeding was started immediately after delivery for 89% of infants. Twenty percent of babies under 2 months were getting supplementation with powdered milk. About 40 % of infants started solids on a regular basis at 4 or 5 months and another 20% at six or seven months. To deal with the crisis in breast-feeding, Oman launched the Baby Friendly Hospital Initiative (BFHI) in 1992 in the wake of the 1990 World Summit for Children. BFHI embodies ten steps to successful breast-feeding, designed to provide clear and consistent practices for all health care workers in every maternity health facility. A national committee was formed in 1992 consisting of members from the Ministry of Health, Ministry of Social Affairs and Labour, the national organisation for Scouts and Guides, and the Omani Women Association. The committee worked to make all hospitals baby friendly and adopted strategies which included capacity building, supporting women on breast-feeding, and empowering the beneficiaries. As part of the capacity-building trainers were developed from health and social sectors to improve the knowledge and skills of the health staff and the support groups. Communities were empowered by generating a network of mother support groups throughout the country.
Oman was one of the first countries in the world to embrace this global initiative and to implement it with complete commitment in a systematic manner. On December 17, 1994, Oman declared all of its 52 hospitals as baby friendly, being the first country in the world to achieve this status
5. School Health
Oman has accorded a very high priority to universal education and the growth of the national educational system has been one of the outstanding features of Oman's modern development (see Chapter 5). Between 1970 and 1995, the number of schools has increased from 3 to 969. The total number of pupils over this same time period has increased from 909 to 494,684, so that almost a quarter of Oman's total population are school children (Figure 3.12).
The School Health Programme began in 1972, initially covering only schools in the Muscat region but has expanded rapidly to cover most schools in all 10 regions of the Sultanate by the 1990s. In 1994/1995, there were 102 school doctors and 163 nurses, both full and part-time. School health doctors are mainly general practitioners. Their job is to carry out the routine medical screening of pupils according to a fixed schedule and to provide consultation services to individual
pupils, pupils referred by the school nurse, teachers and parents, and secondary schools teenagers who personally and confidentially ask for an appointment. They also provide health education to pupils, parents, school personnel, and the community. The doctor/pupils ratio is 1:4,850. School nurses contribute to the
3.30

control of the communicable diseases through immunisation and surveillance, early detection, and reporting of pupils with contagious diseases. The nurse inspects cleanliness of the pupil, manages simple health problems and measures height and weight of schoolchildren. The school health nurse pupils ratio is 1/3,035.
Figure 3.12: Growth in the Number of Schools and Pupils 1973-1995

300 1200
250
I Schools -Boys -Girls
1000
200
150
'a.
a.
3
100
50
1982
1985
School Year Beginning
The Programme's activities include medical screening of all pupils in the first year of primary, 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 chronic illnesses or developmental weaknesses and subsequently, referred to specialists. Of the different health problems detected by screening, the most frequently encountered were underweight (13%) and hair infestation (5%). Other detected conditions were short stature (5%), upper respiratory tract infections (6%), skeletal disorders (2%), cardiovascular disorders (1%), skin infestations (2%), nervous system disorders (0.6%) and disorders of the external genitalia (0.6%).
The Programme aims to change the beliefs and practices of school children by providing them with knowledge of healthy habits through health education. The health education is designed in collaboration with the Ministry of Education. Oman is also currently examining standards for a healthy school environment. The examination currently concentrates on physical aspects, which include water and sanitation, canteen and food hygiene, building cleanliness and safety, insect and rodent control During the past three years, the School Health Programme has been strengthened in Oman and significant resources have been invested. Plans are underway to train
~ "> i O.J 1

one teacher in each school in the country to deal with simple health problems and to operate as a link between the school health workers and the schoolteachers especially for follow up of cases that need more attention.
C. Emergence of Chronic Diseases
In the last few decades, an increasing awareness of the importance of the noncommunicable diseases has grown in Oman. Many chronic conditions, previously considered to be peculiar to the temperate climate and more developed countries, have been gradually emerging in Oman. Inpatient morbidity for diagnosis related to non-communicable diseases- especially cardiovascular disease, cancer, endocrine including diabetes, Nervous system and sense organs and injuries and poisoningwere growing and becoming a significant share of Oman's burden of disease (Table 3.11). The rapid economic developments of the 1970s and 1980s have contributed to major changes in life style, including a reduction of physical activity, and the introduction of westernised food habits, and exposure to new risks like accidents and smoking. Changing risk factors translate into changing disease patterns, especially the emergence of non-communicable diseases. 1. Diabetes
The general impression among many Omani physicians is that diabetes has become a major non-communicable disease problem. In 1991, a National Diabetes Survey 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 prevalence of diabetes and impaired glucose tolerance (IGT) varies among different regions of the 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 among males (8%); both diabetes and IGT increased steadily with age. The same survey showed that overweight and obesity (BMI>30 kg/m2) are highly prevalent, affecting about 19% of the total sample surveyed (10.5% among males and 27% among females). 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 the highest reported in the Arab region. Similar surveys were conducted in the other Arab countries in the Eastern Mediterranean Region with countries reporting much lower 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 noncommunicable public health threat in Oman. As diabetes and its complications were expected to grow in the coming years, the Ministry of Health has established a National Diabetes Centre at the Royal Hospital and a consultative committee to launch a National Programme for the Prevention and Control of Diabetes.

Table 3.11 Percentages of Inpatient communicable Diseases, 1992-1999. CO OJ "3Ol CD CD Disease Group CD CD CD
CVD 6.5 5.6 Cancer 1.2 1.0 Nervous system & sense 2.9 2.5 organs Endocrine, Metabolic & 2.6 2.2 Immunity Injuries & poisoning________9.1 8.4 Source: Annual Statistical Reports 1998-1999, 6.0 0.8 2.5
Morbidity
in
CD
CD CD
for
h~
Selected
00
CD
NonCD CD CD
CD CD
cn
CD
CD
6.2 1.0 2.8
6.3 1.1 3.1
6.4 1.6 3.5
6.7 1.5 3.6
6.7 1.6 3.7
2.2
2.2
2.3
2.0
2.4
2.3
8.4 9.0 9.7 8.7 9.3 8.5 tables 10-4 pp 10-11 & 9-6 pp 13-9.
2.
Cancer
Hospital 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 cancer discharges have doubled over the period 1986 to 1993, averaging 15% yearly. In 1995 the discharge rate of the neoplasms was 11.0 per 10 000 population.
At present, there is no evidence of excessive exposure to occupational carcinogens in the country, but newly adapted westernised dietary patterns along with lack of proper physical activity might be significant risk factors. Tobacco use among male adults (20 years and above) estimated to be 20.3% (National Diabetes Survey, unpublished data). A more recent survey estimated the prevalence of any type of tobacco use to be 15.5% among males and 1.5% among females (OFHS: 21, table 5.1). However in this second survey information on smoking for were collected from the household head who asked questions about smoking habits and behaviours of member households. This proxy information in likely to underestimate the actual prevalence and may partially explain the discrepancy in figures between the two surveys.
In 1985, a Cancer Registry was started in A'Nahdah Hospital. Later it was transferred to the Royal Hospital and finally to Noncommunicable Disease Control Section in the Ministry of Health head quarters. Initially only histopathologically diagnosed cases were registered, including cancer deaths at peripheral hospitals. In 1993, 796 cases were registered among Omanis, 54% among males and 46% among females. In 1995, 833 cases were registered, of which 57% were males (see table 2.21 chapter 2). Stomach cancer was the leading cancer among males in Oman (11.1%), followed by non-Hodgkin's lymphoma (9.6%), prostate (7.6%), Leukaemia (6.7%) lung and bronchus (6.4%), primary liver cancer (4.9%), bladder cancer (4.5%), brain and nervous system cancers (3.4%), Hodgkin's disease (3%) and carcinoma of the colon (2.8%) (see table 2.22 chapter 2).
"i "ii
j.jj>
Figure 3.13: Ten Leading Causes of Death in Oman, 1989-1993.

CVD
Cancer
_____

^B
|
! i i
lnj+ Poison
Infections
Ill-defined
Resp
Digestive
GU
Blood, Endocrine
Nervous
5
0 500 1 000
.
1 500 2000 2500 3000 3500
I
4000
Deaths
Breast cancer is the leading cause of cancer among females (13.7%). This is followed by cervical cancer (8.8%), non-Hodgkin's lymphoma (7.6%), stomach cancer (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 tissue cancers (2.2%). (Table 2.23) .
Malignancy among Omani children was studied by al-Lamki et al, in 1994. Among the studied cases, leukaemia was most common (32%), followed by lymphomas (29%) and brain tumours (11%). The male to female ratio was 1:3 with the commonest presenting age being 2 years. The authors concluded that the pattern of childhood neoplasm is not very different from elsewhere.
3. Heart Disease
In 1992, the Rheumatic Heart Survey among school children found 8 cases of rheumatic heart disease out of 9,904 student examined, giving a rate of 8 per 10 000. The annual incident rate of rheumatic fever was 4 per 10,000. Survey data showed that the prevalence of congenital heart diseases was 2 per 1,000 school children, higher among females than males. About 6% of Omani school students had high blood pressure. The level of rheumatic heart disease was similar to that of the 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 to 1990. Ischaemic heart disease was the commonest, followed by hypertensive and pulmonary circulatory conditions (Annual Statistical Report, 1995: tables 10-1 and 10-2).
3.34

4. Accidents
Oman'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 to disability, injury and death. Injuries due to road traffic are now a major health problem in the Sultanate. The Road Traffic Accident Survey in 1993 reported that there were 11,754 accidents in that 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, mostly skeletal (41%) and neurological which required surgery (30%) followed by facial injuries (17%). Most of the road traffic injuries were among males (80%) and 40% of the injuries were in the age group 26-50 years, followed by the age group 16-25 years (36%). The Survey recorded 461 deaths out of 6,975 injuries giving a case fatality rate of 66 per 1,000 injuries. Recently the Shura Council has examined road safety. The Ministry of Health issued a ministerial Qararfor the establishment of an inter-sectoral National Committee for the Road Traffic Accidents Prevention. It also invited several international consultants to assist in an analysis of the problem and to prepare a plan of action for training, management, and data collection. The Royal Police collect a lot of sophisticated data, but unfortunately it does not contain information about morbidity and disability. The Ministry of Health data collection system, it is hoped, would assist in the management, priority setting, policy formulation, and programme planning and evaluation of prevention programmes.
IV. SUMMARY AND CONCLUSIONS
We can draw several conclusions form this review of the growth and effectiveness of Oman'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 Omani
population. In addition, barriers to the use of the public health services have been
broken down. Indeed, Omanis seems to be amongst the most avid consumers of
health services in the world. Although Oman was lucky enough to have had the
funds to build and staff both major tertiary hospitals as well as to construct an extensive primary health care system, the firm commitment to a consistent national health policy since 1970 has been important to the development of the health services in their 1995 form. Health services have reached every corner of the Sultanate and so we see far narrower differentials in health and mortality than in most other countries. Secondly, the interest in surveillance and in special studies has provided a much
stronger numerical basis for planning and assessment than seen elsewhere. The
rapid feedback provided to outlying centres, particularly in connection with the Expanded Programme on Immunisation (EPI), is widely appreciated and must be an important 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 the existence of a very complete and efficient surveillance system. Thirdly, Oman has constantly kept up to date with new technical developments and different approaches to health care provision. This commitment to learning from others has paid off in that new vaccine schedules, new drug treatments and new control strategies are quickly accepted throughout the health system. It helps when making such changes for the Ministry to have a near monopoly of health care provision. Fourthly, the commitment to Primary Health Care form the beginning has had several major consequences. We have already mentioned the decentralisation of services but in the section on manpower, we see a trend towards the greater reliance 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 the Indian sub-continent in the main but the point here is that the many of the programmes are run at a peripheral level with the minimum number of high-level medical personnel. There are of course many problems facing the health services that we will return to in the concluding chapter. Here we need only mention the need to assess more rigorously the system's effectiveness, efficiency, equity, and sustainability. Given our technical knowledge base, the effectiveness and efficiency (health impact for resources invested) can be expected to be high, but there are several reasons to believe that even greater effectiveness and efficiency can be attained. There is comparatively little research on whether certain policies or practices have desirable health outcomes. The very intensive utilisation of free services, direct approach to tertiary rather than primary facilities for initial complaints, the large number of special, vertically-organised programmes, and the absence of detailed allocative cost information all suggest that considerable scope exists to gain greater health impact from the current level of resource investments, let alone controlling the rapid escalation of costs. The equity of the system appears to be good because of policy decisions to provide universal coverage. However, perhaps 10% of the population have not been reached, and amongst some of them, the unit cost of outreach will be extraordinarily expensive (e.g. helicopters, mobile teams). The two biggest challenges facing the future of the health care system are the role of the private, for-profit commercial sector in the national health plans and the challenge of human, institutional, and fiscal sustainability. Private medicine has already begun to take roots in Oman; yet, few policies have been developed that seeks to level the playing field to achieve an effective public-private mix in the health sector. There are some potential positive benefits of private sector engagement more resources, fee-for-service among those able to pay competition, etc. Without clear guidelines and a regulatory environment, a private market in health can generate 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 urban concentration of providers, over-utilisation of expensive tertiary services, and the poor 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 still young Oman! health institutions in research and education, and free services paid for entirely by the government are certainly unsustainable. While every effort is underway to increase the number and quality of Omani health personnel, a manpower development policy is required to shape human resource production to the future needs of a changing health care system. Indigenous Omani research and educational capacity, backed by appropriate regional and international collaboration, is essential if Oman is to develop an internal capacity to manage health systems change. Given limited petroleum reserves, plans should be made to find means of developing sufficient self-financing capacity within the health care system to relieve its dependence upon government income. User fees could be considered, initially for rationalising wasteful utilisation behaviour (for example, charging for patients skipping directly to tertiary facilities without referral from primary health centres or charging for drug use so that consumption matches better with medical indications). Eventually, cost-recovery through user fees or risk-sharing insurance systems should be considered as important contributors to fiscal sustainability. Finally, it should be underscored here that both the Government of Oman and the relevant international agencies, especially WHO and UNICEF, deserve considerable recognition for their sensitive, artful, and technically-effective balance of indigenous Omani decision-making matched to appropriate international technical and financial assistance. While all of the policies considered here have Omani origins, international agencies obviously played important technical support roles that have benefited the growth and development of the national health care system.
.37
cJU
CHAPTER 4
THE CONTRIBUTION OF RISING NATIONAL INCOME AND PERSONAL WEALTH TO HEALTH AND WELFARE
CHAPTER 4
THE CONTRIBUTION OF RISING NATIONAL INCOME AND PERSONAL WEALTH TO HEALTH AND WELFARE
o far, we have examined the decline in mortality and morbidity in Chapter 2. There, we established that Oman's mortality and health transitions have been amongst the fastest on record. Our initial search for explanations for these precipitous improvements began with a study of the expansion of the health services in Chapter 3. It is clear that the direct contribution of the health services to Oman's mortality 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 try to identify the contribution of rising levels of national and personal income to several aspects of welfare including health. The, economic explanation is not fully satisfactory since everywhere the role of human development, education in particular, is widely cited as a reason for the surprisingly good level of health in several poor countries (Halstead, Walsh and Warren, 1985). This social development and the investment in living conditions will be covered in Chapter 5. Both Chapters 4 and 5 attempt to assess the importance of human development broadly defined as a source of some of the improvements in health. The basic explanatory framework we are working with remains that set out in Chapter 1. This is itself a borrowing from the 1993 World Development report which was the first global attempt to put the role of the health service's in the context of other economic and social development trends.
In dealing with the Omani economy and its contribution to human welfare, we have to remember that the economy of Oman, like many neighbouring states, is very heavily dependent on oil and gas exports for its revenues. Indeed, in 1995, 77% of total government revenues were from the proceeds from oil and gas (Statistical Year Book, 1995, table 2-15) and other revenues were indirectly associated with oil sector activities. This heavy reliance on production and exports from a single sector makes the government's task very difficult. First, such revenues can fluctuate according to world energy prices which are in turn a reflection of a mix of technological, political and economic factors, each prone to sudden change. Certainly, they are not fully within the control of Oman or any other single oil-exporting country. Secondly, this revenue from oil and gas production and sales is paid directly to a single source, the government exchequer. Full responsibility for the use of these revenues thus rests with a single body, which then has the complex task of spending these revenues wisely 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 diversified economy using oil revenues as the driving force. Many of the smaller oil exporting countries of the region have experimented with state capitalism and using the construction 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 longestablished 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 public buildings, enterprises and agricultural and manufacturing development projects. Every oil-exporting country wishes to avoid the simple distribution of funds to its citizens in the form of grants and pensions since this leads to the creation of dependency and a vulnerable economy. Generally, the solution, and one chosen by Oman, is to invest heavily in human development, building a welfare state which stops short of providing complete income support for all. At the same time, steps were taken to diversify the economy but avoiding, as far as possible, major new demands for expatriate labour. In Oman, the major investments in health described in Chapter 3 were matched by major expenditures by the Ministries of Education and 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 heavy dependence on outside sources of labour. Initially, the demands of the oil and gas companies are for relatively small numbers of highly skilled workers. As construction proceeds, the demands for unskilled and semi-skilled labour grow rapidly. Behind the immigration policies in force throughout the Gulf region was the hope that citizens would acquire the new skills very quickly, thus holding down demands for new immigrant workers. Thus, the human development of the population also has to be judged against the background of dependency for certain types of skills on outsiders. The population composition of the nationals as well as the cultural, educational and skill levels of the immigrants is every different from those of the immigrants. The foreign workers begin by assuming tasks that cannot be performed by the national population but often, despite rising skill levels amongst the nationals, we see dependency on foreign workers being perpetuated as certain manual and unpleasant tasks are shunned by the citizens. Thus, amongst the measures we must 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 participated in 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 very clearly the large contribution of petroleum activities to the GDP between 1980 and 1995. Oil was discovered in Oman in 1962 in Yibal and production began in 1967. High expenditures have been maintained for exploration and development to keep the discovery of oil ahead of depletion (McLachlan, p. 14). The total government revenues have increased dramatically from RO 50 million (US$ 130 million) in 1971 to 1851.6 million (US$ 4814.16 million) in 1995, largely due to increases in revenues from the energy sector. The growth in government income was quite slow in the early 1970s but expanded very quickly after the price increases associated with the boycott following the 1973 Arab-Israeli war. Production and exports grew quite slowly in the 1980s but the price increases for oil and gas meant that government revenues increased thirteen times between 1973 and 1980 and doubled again between 1980 and 1995 (Table 4.2).
4.2

A more revealing way to view the growth of the economy allowing for price inflation is 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 a healthy rate. Table 4. 1 Growth of Gross Domestic Product Omanis have seen a rapidly in Million Omani Rials at Market Prices 1980- rising per capita income since 95. that time especially with the Year Petroleum Non-petroleum Total GDP steep rises in oil prices in 197374, followed by a decline in per activities activities capita income after the oil 1980 1322.7 878.2 2185.0 shocks 1980s. Between 1980 1981 1547.3 1117.9 2637.6 and 1990, the annual growth in 1982 1505.8 1297.3 2773.9 per capita income was 1983 1483.4 1477.3 2932.8 estimated to be 8.3% and for 1984 1566.9 1692.7 3232.1 the five year period 1990-95, 1985 1780.7 1832.3 3590.6 the growth was some 6% per 1986 1255.7 1921.9 3143.4 year (World Development 1987 1520.8 1840.2 3317.6 Report, 1997, 1). By 1995, the 1988 1266.9 2000.7 3224.5 per capita income in 1989 1551.5 2103.8 3603.6 Purchasing Power Parity dollars 1990 2144.4 2407.0 4493.0 was put at $8140 (World 1991 1825.1 2588.9 4360.8 Development Report, 1997, 1992 1952.0 2880.6 4787.8 table 1). 1993 1782.3 3071.0 4803.6
1994 1995
1814.8 2020.0
3220.0 3368.5
4967.3 5307.2
Oman's economic performance year. This has contributed to the development of the whole economy and to the non-oil sector in particular.
Adjusted for financial services and import taxes, t To convert to US$, Multiply by 2.6 Source: Statistical Year Book, 1997, tables 1-15 and 2-15 has, however, been quite steady over a number of
Although these income figures are high, they are not as high as some neighbouring oilexporting states (Table 4.4).
//.
GOVERNMENT EXPENDITURES IN THE SOCIAL SECTOR.
Direct spending in the social sector was one major way in which the government was able to significantly affect the welfare of the whole population of Oman and to encourage growth in private sector at the same time. Figure 4.1 shows very plainly the major increases in spending by the state since 1982. The graph shows the gradual decline in spending on development items as the infrastructure of the modern state took shape in the 1980s. Defence and public order remained major items, consuming 14.6% of the 1995 GDP, down from 20.7% in 1985 (World Development Report, 1997, table 19), equivalent to a third of total expenditure (Statistical Year Book, 1995, table 2.15). This is high by international standards, as the Human Development Report points out, equalling 205% of the spending in education and health. Fortunately, the economy has been growing fast enough to support 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
= S
1500
u.
1 1000
"--
-* ^ _^'
***
1965 1970 1 7 9 5
^~'
1985
1980
Year
Overall, expenditure on the social sector has been high in absolute terms although increasing only slowly in proportional terms (Table 4.5). Oman, like many other Gulf countries, spends a large proportion of central government funds on health and education.
Taking out defence expenditures, we see more clearly the size of the investments being made in education, followed by health and social affairs (Table 4.6) Spending on health (recurrent and development expenditures combined) rose
steeply in current prices during the 1980s and has been held at about 106 million RO (US$ 275.6 million) a year in the 1990s. The amounts spent on health have been approximately 4% of total government spending since the mid-1980s (Table 4.7). In the 1990s, this has amounted to about RO 50 (US$ 130) per head of population. Note that most per capita figures before the first census in 1993 are subject to some errors due to uncertainties in the earlier population estimates. A. Employment
Undoubtedly the largest contribution to personal income has been the wages and salaries paid to both Omanis and non-Omanis working in the civil service and in public corporations. The numbers employed in the civil service, the Diwan of Royal Courts 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 are Omanis, up from around 60% in the early and middle 1980s. The salaries and wages of these employees represent by far the largest transfer of resources from the 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 the police, the state also transfers a substantial part of its national income to individuals in 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 of
Oman! Rials.
Year
1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Revenue 50.1 53.0 68.6 303.2

387.7 488.0 520.0 502.3 692.2 923.7 1262.2 1175.4 1253.9 1340.7 1572.9 1186.9 1460.2 1204.8 1370.1 1876.3 1585.1 1680.2 1723.9 1757.4 1851.6
Recurrent 26.0 41.7 62.2 186.6

322.5 379.0 379.0 430.2 449.5 666.5 842.3 953.7 1100.1 1219.8 1333.7 1301.8 1225.5 1271.1 1361.1 1570.1 1463.0 1738.3 1727.6 1777.3 1859.5
Investment 20.0 30.0 46.2 162.6 187.0 195.0 145.0 129.8 200.9 258.2 332.0
411.7 388.2 480.3 550.9 544.2 338.4 280.2 270.3 285.8 391.7 471.1 477.6 458.9 456.9
Other Total expenditure 46.0 71.7 108.4 349.2 509.5 574.0 524.0 560.0 650.4 949.8 25.1 49.4 1223.7 47.5 1412.9 58.6 1546.9 60.2 1760.3 1928.4 43.8 1886.8 40.8 48.2 1609.1 15.9 1567.2 34.4 1665.8 1887.4 31.5 13.4 1868.1 49.3 2258.7 2242.4 37.2 16.7 2252.9 14.6 2331.0
Source: Statistical Year Book, 1997, tables 1-15 and 2-15 f To convert to US$ Multiply by 2.6
B. Social Houses, Low Cost Housing Loans and Grants
The social security and welfare system is geared towards improving the living conditions of the needy. The government decided that housing was a major component of living standards and began the distribution of low-cost housing units to the poor. The distribution of houses came to an end in 1993 and was replaced by a system of low-cost loans. In the housing sector, "social" houses as well as low cost housing loans and grants were provided on the basis of need. Eligibility for
4.5

subsidised housing is based on criteria first established in 1973. The beneficiaries had to be Omanis aged between 21 and 50 who has not received support from the state in another form (e.g. have received facilities or housing from any other government agency). There were other conditions such as not owning another house and being a resident of the same Wilayah where the subsidised houses were being distributed. The applicant had to have an annual income below RO 3,000 (US$ 7,800). Priority was also given to citizens whose land was taken by the government for public use and to those who were married with large families. The value of the house was to be paid off in monthly instalments, the price being set by the Minister of Housing. Those in hardship (a person in an accident or with a disability, those having difficulty paying who had already paid 75% of the cost of the house or the family of the deceased) were excused from further payments (Ministry of Housing, 1977).
Table 4. 4 Per Capita Income for Oman and Neighbouring Countries in 1995. Country PPP estimates of Annual GDP Annual Per Capita GNP growth (%) GDP growth GNP in current 1980-90 (%) international $ 1990-95 Bahrain 13,400 7,840 NA NA Kuwait 23,790 17,390 0.9 12.2 Oman 4,820 8,140 8.3 6.0 Qatar 11,600 17,690 NA NA Saudi Arabia 7,040 NA -1.2 1.7 16,470 -2.0 NA UAE 17,400 Notes: NA = not available. See original source for additional technical details. PPP$ - Purchasing Power Parity $. Source: World Development Report 1997, Table 4.3 Growth of Gross Domestic Product at 1988 Constant Prices. Year GDP Annual US$ growth (%) 1988 3,225 5.2 1989 3,321 3.0 1990 3,599 8.4 1991 3,816 6.0 1992 4,141 8.5 1993 4,395 6.1 To convert to Omani Rials, multiply by 0.386. Source: Statistical Year Book, 1997 tables 4-14, and 6-14.
tables 1, 1a and 11.

Figures for the total number of beneficiaries from this scheme are difficult to locate but over the 1990-92 period, it appears that the scheme was costing some RO 6 million (US$ 15.6 million) per year (unpublished figures, Development Council). After 1993, the scheme was replaced by a system of low-cost loans. These one-time loans were geared towards people with limited incomes for building houses, buying houses and building extensions to already built houses. In 1995, for example, 1607 loans 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 Muscat region, 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 198190 and 1990-95. Defence Other Health Social security Education & welfare 91Period SI91SI91-95 SI91SI9181-90 90 90 95 95 95 95 90 90 Oman Kuwait UAE
UK 3.99 6.7 6.8 13.6
5.1 4.5 7.1
8.92 11.9 11.4
10.2 8.8 16.2
2.22 10.6 3.1
3.1 13.7 3.4
37.82 33.91 14.5 36.8 43.3 37.5
47.0 47.73 56.3 36.1 35.. 5 35.8 9.2 40.7 42.2
14.0 2.7
4.2
30.0 30.5
13.0
Source: World Development Report. 1997, table A.3.

Table 4.6 Government Current Civil Expenditures by Broad Categories in 1995. % Type Million RO 212.9 24.2 Education & Sultan Qaboos University 37.8 4.3 Social affairs, labour and housing 101.2 11.5 Health 1 Subsidies to public authorities 8.1 59.0 518.1 Other administrative and government expenses Total 878.1 100 To convert to US$, multiply by 2.6. Source: Statistical Year Book, 1997, table 4-15 Table 4.7 Total and Per Capita Spending on Health 1980. MOH MOH expenditure MOH expenditure Year Total Government Expenditure Expenditure as % of total per capita in RO (Million RO) (Million RO) 1980 2.4 22.1 949.8 23.2 1985 1928.4 73.4 3.8 52.1 45.7 1990 1887.4 74.3 3.9
1991 1992 1993 1994 1995 1868.1 2258.7 2242.2 2252.9 2331.0 85.3 108.4 117.6 122.9 124.5 4.6 4.8 5.2 5.5 5.3 48.4 57.3 58.8 60.7 58.4
Note: To convert to US$ multiply by 2.6; Expenditures in the health sector include both 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 Disasters
The Ministry of Social Affairs was established in 1972 by Royal Decree to provide necessary care for the disabled through financial support. By 1977, the scope was expanded and government grants were made available as social security for disability, 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 RO 35 (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 of recipients of social welfare from 1732 in 1975 to 42,155 in 1995. The cost of this assistance has risen to RO 21.2 million (US$ 55.1 million) in 1995 (Statistical Year Book, 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 for emergencies faced by individuals (individual emergency grants) or groups (general emergency grant). Such assistance is small (RO 57.4 million (US$ 149.2 million) in 1995- Statistical Year Book, 1995, table 20-3) in comparison with the housing loans and social welfare benefits described above
D. Services and Interest Free Loans and Grants Aimed at Increasing Family Income
Additional programs managed by the Social Affairs and Labour sector involve
vocational training for women and income generating projects directed towards raising family income. The vocational centres for women teach sewing, knitting, embroidery and handicrafts. These centres are distributed in the capital, Nizwa and Sur. The number of women who completed training was about 130 in 1982. Family income-generating projects subsidise local industries and handicrafts which help low and middle income families generate income (UNICEF, 1984: 91) By 1982 the Ministry 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 Business
The Ministry of Commerce and Industry also administers capital grants to support small Omani industries with capital under RO 100,000 (US$ 260,000). This program
was started in 1991 and since that time RO 0.5 million (US$ 1.3 million) have been
granted. The grant can be invested in the Muscat Region but 60% is for remote areas.
The Oman Development Bank has lent over RO 63 million (US$ 16.4 million) for projects in various sectors. Most of the loans were to chemical, foodstuff and construction industries. Minor shares went towards financing agriculture and fisheries as well as other medium-sized manufacturing projects. Small businesses run 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 program reached over RO 23 million (US$ 59.8 million) over the period 1980 to 1992. The Bank is also providing loans for the promotion of exports, a scheme projected to cost 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 so on), the sta 9 has been very generous with its citizens in providing a variety of support mec' anisms to improve housing conditions and the level of family income, especially for the poor. Can we document some of these effects on household incomes in the Sultanate?
///. CHANGES IN PERSONAL INCOME
Oman had an estimated per capita income of US$ 6,309.5 in 1995 in current international dollars (World Development Report, 1997, table 1). The average annual growth rate was 9% between 1965 and 1980 dropping to 1.9% between 1980-91. It is clear that there has been a significant rise in the wealth of the country as a whole and it is clear that personal income has also risen at all levels (see below). Information on income and living conditions is difficult to find for the early years but living standards have been transformed since the 1970s. There are few poverty indicators, no information on income distribution over time and it is not possible to present the structural transformation in personal income over a long time period. The 1993 census and the OCHS 1988-89 and OFHS 1995 do provide reliable indirect information which can be used to gauge living standards at least in the late 1980s and early 1990s. The World Development Report of 1997 indicated that the GDP has risen from $256 in 1970 to $8,140 in Purchasing power parity (PPP) $ in 1995 (see Table 4.4). In addition to this information, we also know that the distribution of the GDP for private consumption has risen from 19.4% to 50.3% and in general, government
consumption rose from 12.8% to 26.4% from 1970 to 1991. Gross domestic savings
have been reduced from 67.8% to 23.3% in the same time period (World Development Report, pp 254, 1997 Year). Thus it is clear that consumption and purchasing power have both risen in the last two decades both in the government and private sectors. Unfortunately we do not have any information on trends in per capita consumption by region and for different population groups and therefore it is difficult 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 is impossible to show the rise in income by region or changes in the income distribution. 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 sector by region that can provide an indication of the distribution of income are available in the 1993 population census. The Development Council Statistical Yearbook of 1993 also 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 allow us to measure the change in salary with time. Finally, information on ownership of domestic durable goods across regions as well as some environmental factors which reflect standard of living by region is available from the 1988/89 Oman Child Health Survey, the 1993 population census and the 1995 Oman Family Health
Survey. According to the UNICEF, based on a small survey sample, one can see a wide range of incomes for the Omani population. As can be seen, the majority of the people interviewed reported an income of between RO 200 and RO 499 (US$ 5201297) per month (Table 4.8). Most of the families in the highest income bracket lived in Muscat and Dhofar. The regions with the highest percentage of population in the lower 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 1993 population census. Of the population 10 years of age and over, 46% were employed, 27% were students, 20% were homemakers, and only 2.5% were unemployed and seeking work for the first time. The highest number of women employees are also found in Muscat but women workers comprise only 5.1% of the economically active population. Table 4.8 Percentage Distribution of Family Income by Region and Income Category, Oman 1991.__________________________ Monthly Income in Omani Rials Region <200 200-499 500-999 1000+ Total Total Households North Batinah 38.2 50.9 110 10 0.9 100 South Batinah 27.2 48.9 20.7 3.3 92 100 A'Dakhliyah 60.5 124 33.1 4.8 1.6 100 A'Dhahirah 32.9 41.1 0 73 26 100 Dhofar 40.2 117 40.2 12.8 6.8 100 Musandam 37 56.5 4.3 2.2 100 46 Muscat 48.7 21.5 8.7 100 265 21.1 A'Sharqiyah 31.4 46.6 18.8 3.1 100 191 30.7 Total 48.8 16.2 4.3 100 1018 To 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 are firstly public administration, defence and social security with a total number of 165,646 people employed. The industry with the second highest number of employees is the wholesale and retail trade, repair of motor vehicles, motorcycles and personal and household goods (89,625 employees). Next is manufacturing with 60,446 followed by agriculture, hunting and forestry with 55,257 and 55,200 for agriculture, hunting and related activities. The industry of extraction of crude petroleum and natural gas, service activities incidental to oil and gas extraction excluding surveying employs only 13,334 people.
4.10

Unfortunately, information on salaries for the above forms of employment in the various industries is not available. The Statistical Yearbook of 1995 provides some information on average monthly salaries for foreigners in the private sector. It is not possible to infer the salaries for Omani workers in the same employment nor does it allow us to see the changes in salary with time.
Table 4.9 Average Monthly Salary in RO Paid to Non-Omani Workers in the Private Sector by Occupation Group, 1995. The data in Table 4.9 show that there is
Occupational group
Monthly Salary in RO
358 Professional Technical 187 Administrative & managerial 524 Clerical and related 182 'Sales 86 Service 46 Agriculture and fishing 40 Production workers 83 Transport 60 Labourers 51 All 89 To convert to US$, multiply by 2.6. Source: Statistical Year Book, 1995, table 5-7.
a large premium on skilled labour, such as professional and technical or administrative and managerial. Rates of pay for the unskilled are quite low. It is of course very difficult to assess these wage rates without having a clear idea of the cost of living in Oman. Other benefits in cash and kind (e.g. subsidised housing, air fares and paid leaves, for example) make it difficult to interpret these cash values. Estimation of the household income is beyond the scope of the present study but we can show some figures on possession of certain consumer goods and household items that will give some idea of the wealth of the Omani population in the 1990s.
interviewed in the main survey. The figures describe a well-housed population with good domestic services and ownership of many household consumer goods. Overall, the number of rooms per household was 4.2, with low densities per room (1.5 person per room on average: OCHS, table 3.5). Almost three-quarters of the households have flushing toilets, 44% had fitted carpets and 81% were using electricity from the public network. Only in the area of water supply were there some surprises. Only 26% of households had piped water from the public supply system and 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
4.11
Table 4.10 Percentage of Households Owning Specified Durable Goods in 1988-89. % of households Appliance or item owning Radio 81.8 74.2 Television Refrigerator 79.3 Telephone 25.9 Car 49.5 67.0 Air conditioning unit Scarce: OCHS, 1988-89, table 3.7.
In the 1988-89 Oman Child Health Survey, several questions were asked
of the household heads to describe the living conditions of the women

water and only 16% drew their water from wells (OFHS, 1995, p.11). The ownership of durable goods had reached even higher levels (Table 4.10) and in the 1995 survey, 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 or flats) and only small proportions of people were not living in a house of one kind or
another (Table 4.11). Table 4.11 Percentages of Households by Type of Housing in 1993. Villa Flat Arabic Village Hut Tent Collective Other Total
Region
The Sultanate Muscat al-Batinah Musandam A'Dhahirah A'Dakhliyah A'Sharqiyah al-Wusta Dhofar
16 25 11 10 14 15 7 3 18
15 33 4 3 6 6 3 0 39
House 44
29 58 70 49 50 61 3 11
House 11
2 14 11 15 19 13 3 19
House
7 5 8 2 5 5 10 53 5
1 0 0 0 0 1 1 33 3
1 1 0 1 1 0 0 2 2
5 5 4 3 11 5 6 3 3
100 100 100 100 100 100 100 100 100
Owner-occupancy had reached high levels by 1993 with nearly two-thirds of households owning their own homes (Table 4.12).
Table 4.12 Households by Housing Tenure in 1993.
Region The Sultanate Muscat AI-Batinah Musandam A'Dhahirah A'Dakhliyah A'Sharqiyah al-Wusta Dhofar
Owned Rented 62 22 38 33 75 13 74 16
Employment incentive 14 27 9 9
7 9 6 41 15
66 25 75 13 75 16 44 12 54 28 Source: Census of Population, 1993
Rent Free Others Total 2 1 100 1 1 100 1 100 2 1 100 0 2 0 100 1 100 2 1 100 2 3 0 100 2 0 100
The level of income can best be judged from the ownership of selected durable consumer goods (Table 4.13). Even for expensive items such as cars, levels of ownership are very high indeed. Figures over 100% indicate that many households own more than one of the items mentioned. Certainly, ownership of a car, a refrigerator 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 very
high disposable income for most of its citizens.
4.12
Table 4.13 Number of Appliances (by type) per 1000 of Population by Region._______________________________________ Region Private Tele- Washing Freezer Refrige- Cooker/ Video Tele-
car phone machine Muscat 79 55 87 AI-Batinah 75 23 115 41 78 Musandam 101 79 A'Dhahirah 51 62 41 A'Dakhliyah 80 70 A'Sharqiyah 105 0 4 al-Wusta 90 47 65 Dhofar 93 59 85 Sultanate 119 89 109 Source: Census of Population, 1993.
IV. CONCLUSION
rator
59 36 61
74 47 5 30 53 50
Oven
134 161 103 133 132 123 103 132 149
vision
32 51 37 29 34 4 62 56 110 128 148 122 114 112 6 134 136 174
107 156 104 105 99 10 100 119 160
This chapter has shown how growth in national income has also been translated into rapidly increasing living standards for most of the Omani population. The oil wealth, although initially concentrated almost exclusively in government hands, has been transferred to the general population by a series of polices designed to distribute the wealth and to keep differentials in living standards to the minimum. The tables above show that the outlying regions have benefited enormously from government investments in the social sector just as the capital area. The early commitment to the full re-integration of Dhofar into the nation probably helped in this respect. The investments in the social sector have been large and some have major implications for the future. First, there is the large civil service that is both costly and may be too large for efficient administration. Then there is the dependency on the state for a range of free or heavily subsidised services including health, education, housing and social welfare including old age pensions. In many ways, however, such
investments can be said to have paid off if the stock of human capital has been
permanently improved for future generations. A key part of this improvement is the increase in educational levels. This and the investment in environmental improvements is the subject of the next chapter.
4.13
CHAPTER 5
SOCIAL AND ENVIRONMENTAL DEVELOPMENT
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 on the 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 has been shown elsewhere (Preston and Haines, 1991, for example). An understanding of the biological basis for the disease processes can contribute to reduced morbidity and mortality. Literacy also confers on people a sense of personal efficacy in the face of adversity. In addition, the ability to communicate through the written word means individuals are better placed to deal with administrative systems (the modern health care system). Further, mothers with some education can also interact more effectively with health professionals. Indeed, the effect of being educated may also affect the attitude of the health professionals to the mothers. All in all, education has many direct and indirect effects on health and child survival in particular.
We also consider aspects of women's advancement in addition to becoming educated. Modernisation alters the public and private role of women both through structural changes in employment and also through changing attitudes and mores. These latter changes are more difficult to document but some attempt is made to capture some of the transitions that most visitors to Oman quickly notice.
Although changes in the environment in which Omanis live are of a different nature from education and changes in women's roles, some of these developments are treated here since they represent another way in which public investment has been used to improve the living conditions for all. Different from education but still a major contribution to improvements in living standards by the government, investments in
water and sanitation can be seen as another way in which private attitudes to hygiene 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 1970 has been truly dramatic. In the 1969/70 there were only three schools in the whole of Oman distributed in the capital and southern region. Additionally, Quranic schools taught basic skills in reading and writing. The lessons were often held in the open under trees. In 1995-6, Oman boasted 953 government schools, free and open to all; 24,271 teachers and 488,797 pupils (Statistical Year Book, 1995, table 2-19). In 1970, education was made universal and free to all Omanis. The public demand for education, even from the early 1970s was so great that at many levels, schools had to 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 1993 population census, the proportion of illiterates amongst the younger generations has fallen to very low levels. Both men and women have benefited from the expansion of schooling but there are still some gender differentials, especially at the higher educational levels. This differentials are discussed in greater detail below. The nonOmani population has much lower levels of illiteracy because of the selective effects of migration and the demands of the economy for skilled labour.
A. The Expansion of Schools and Education
In 1969/70, the total number of students was only 909, all of them boys. By the academic year 95-96, the total number of students enrolled in the Ministry of Education's institutions had reached nearly half a million. In 1995-6, there were 347 primary schools with 297,488 students; 458 preparatory schools with 122,457 students; 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 in
Oman every year. Primary education usually lasts for 6 years. The percentage of primary school children reaching grade 5 in 1990 was estimated to be 95%. Currently the gross enrolment rate (total number of children enrolled in a schooling level, expressed as the percentage of the total number of children in the relevant age group for that level) in the primary and preparatory stages has reached 94% and 84% respectively. The net enrolment rate (number of children enrolled in a schooling level who belong in the relevant age group, expressed as percentage of the total number in that age group) is 81% and 53% in the primary and preparatory stages respectively. This suggests that 19% of primary school age children never enrol in schools. The preparatory level follows the primary level of schooling between the ages of 12 and 14. Students are admitted to the secondary level after passing the preparatory exams. After completion of the secondary studies students are eligible to apply for university or other specialised training. As Figure 3.12 shows the rapid increase in the number of schools from three in two regions to 953 schools distributed over all regions. Despite this, 80% of classes are still being held in double shifts, which compromises the quality of education of these students. In addition most schools (primary more than preparatory) lack basic facilities such as libraries, workshops and laboratories. These are potential areas for future improvements.
To ensure greater diversity in the educational system, in 1980, 7 Islamic preparatory schools (linked to mosques) and one Islamic secondary Islamic school were established. These schools teach the same curriculum as the general schools but lay particular emphasis on Islamic studies. In addition, there are three schools for commerce, industry and agriculture; 9 vocational training secondary schools, 1 postsecondary vocational training institute, a Health Science Institute (under the Ministry of Health), an Institute of Public Services (under the Ministry of Civil Service), and one 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.
Figure 3.12: Growth in the Number of Schools and Pupils 1973-1995

300
1200
I Schools
-Boys
250
1000
-Girls
200 800
150
600
'5. 3
0.
100
400
50
200
1982
1985
School Year Beginning
The number of teachers has increased substantially from thirty in 1969/70 to over 22,000 <in 1995-6. More than 42% of the teachers are currently Omanis. To assess their impact, we need to know something about their training and about the studentto-teacher ratio. During 1970-77 there was a total lack of qualified and experienced Omani teachers. This gap was filled by recruiting large numbers of teachers mainly from Arab-speaking countries such as Egypt, Jordan and Sudan. The first national Teacher Training Institute started its courses in 1976/77 with 25 trainees. The institute was replaced by the Intermediate Colleges in 1984/85. Currently there are eight Intermediate Teacher Training Colleges, 5 for males with 1,684 students, and
3 for females with 1,445 (46%) students. These are distributed throughout the Sultanate. As a result, today there are 8,468 Omani teachers in the general education with 68% engaged in primary schools, 15% in the preparatory schools and 11% in the secondary schools. In addition, an institute has been established to train university graduates to become preparatory and secondary school teachers. Table 5.1 Student-to-teacher Ratios and The overall student-teacher ratios Number of Students by Educational appear to be good, with 22 Level, Oman 1995-96. students per teacher overall and an
Students per teacher

Overall Primary Preparatory
Secondary
22 27 19 16
Students per Class

33 34 32 30
average of 33 students per class, in academic year 1995-96, (Table 5.1). More information is needed on priorities (primary versus secondary education for example) and about
spending by sector of the educational system. The studentto-teacher ratios for primary education are higher (27 students per teacher) than for
5.3

preparatory (19) and secondary education (16). Teachers are widely distributed although class sizes and the student-to-teacher ratios are higher in the Muscat area due 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 in comparison to boys. This is due to several factors: failing two consecutive years; low-income families with the need to support all children needing assistance; and the early marriage of most secondary school girls. Boys, on the other hand, tend to have higher percentages repeating the same year. In 1990/91, 10-12% of boys and 8-14% of girls were repeaters in the primary cycle; 9-23% of boys and 6-11% girls were repeaters in the preparatory stages. The gap between the genders in the number of repeaters almost disappear in the secondary stage (3-10% of boys and 410% of girls are repeaters). Thus it is apparent that although drop out rates are quite low, there is a significant percentage of both boys and girls repeating at all educational levels.
To accommodate the need for the rapidly growing number of secondary school graduates seeking university qualification, a regular system for granting scholarships was established. The highest number of Omanis studying abroad (mostly in the USA, 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 in 1986/87. Today there are still 551 government sponsored, and 920 self-supported students abroad training in various disciplines. In addition, there are 331 Omanis abroad 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 enrolment

Schools in 1995-96 and Percentage have been in a continuous decline. In the Girls.__________________ year 1975/76, girls comprised 27% of Grade___Total pupils % girls primary students, 16% of preparatory Primary 297,488 48.3% students and 28% of secondary students. Preparatory 122,457 46.2% In the academic year 1995-6, these Secondary 68,852___52.4% figures have risen substantially (see Table Total_____488,797 48.3% 5.2). A rise in women's education will have Source: Statistical Year Book, 1995, desirable impacts on the health of women, tne r table 19-3. i children and families and on the community at large.
The 1993 population census provides a look at the overall women's educational attainment at various levels and allows us to assess the gap between male and female education as it exists in Oman today. Women comprise about 55% of all illiterates. It can also be seen that the gap rises as the level of education increases from 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 institute level, and rises again for university level studies through graduate and higher level studies. Thus, it is apparent that the overall education gaps between male and female are significant but the gap is closing for the younger cohorts of primary school children.
The number of women in higher education is on the rise. Sultan Qaboos University established in 1986, is the only university in Oman. It comprises seven faculties; Medicine, Engineering, Arts, Islamic Sciences, Agriculture, Commerce and Economy, and Education. In the academic year 1988/1989, the university enrolled 1,723 students with a slight male preponderance (57% males). By the year 1993/1994, 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 of Education. 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 men were either illiterate or had not completed primary education. To combat this
problem, 24 literacy centres and 47 adult education centres were opened in 1973/74 and 1975/76 respectively. Initially the literacy classes enrolled 2,429 students, 76%
males and 24% females, serving limited areas. Subsequently, the services became more widespread involving most towns and villages of Oman. In 1991, the literacy rate 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 illiterate population 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 number of parents enrol their children at either a private nursery or a kindergarten prior to admission to the government primary schools. This trend is borne out but the increasing number of private nurseries and kindergartens in Oman especially in the capital area. Figures show that the percentage of children in pre-school education was 4% of the total eligible children in 1995.
Besides the government financed schools, there were 90 private schools (including foreign community schools and kindergartens) with a total of 30,226 students and 1,644 teachers in 1995. These schools follow the same curriculum as those run by the Government with the same general preparatory and secondary school certificate examinations. Tuition fees must be approved by the Ministry of Education and they vary considerably depending on the facilities offered. In 1994, the annual charges
ranged 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 HEALTH AND USE OF HEALTH SERVICES
The Omani government through its development efforts has placed value in women's access to health and education. The general status of women including age at marriage, education, employment, fertility and social welfare directed towards women will be discussed to present an overall impression of the status of Omani women. The focus of the section remains access to and use of health services by women and the morbidity and mortality of women in general.
The age of Omani women at marriage is very low. The Oman Child Health Survey of 1988-89 showed that 39.7% of women aged 15-49 had married before reaching 15 years of age. About 26% were married between the ages of 15-17. Thus 65.7% of the women were married by age 17. Women marry much earlier than men. The singulate mean age of marriage of males is 25.6 years compared to 19.2 years for women. (OCHS, 1988-89). It is expected that in the near future with the rising educational status of women, age at marriage will rise, although this has not always been the case in other countries in the Middle East. As it was seen earlier, literacy levels are still low among older age women. Among younger girls however, primary education is universal. Information on trends in student enrolment in schools and gender differences in school enrolment 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 female education is persistent at all education levels. The percentage gap at the primary level is about 33% and rises to 41% and 47% at the preparatory and secondary levels respectively. At the level of higher education the gap reaches 64%. As mentioned in various sources, the rise of education among girls is in the process of creating a generational transformation in Oman. Undoubtedly, many more women will 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 to tradition, to the structure of the labour force and to the high fertility rates. Birth intervals are about 21 months among 15-19 year olds and 30 months among 45-49 year olds. The lack of spacing among young women particularly is very evident but this will change with the new Birth Spacing Programme (see Chapter 3). Regular sequences of births are valued socially. The "murabbiya" or the post-partum visiting period is extended several weeks whether the baby survives or not. This represents a social network system for women which establishes not only the status and prestige of the woman and her family in society but is also a valued means of communication in the community.
"... the degree to which many women are able to participate actively in the process 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 life styles in the long run. Women are more likely to find employment outside the home in urban areas and entire families may move away from their rural communities. The next 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. According to the 1993 population census, over 50% of all women in the economically active age range were homemakers and only 11% of the total were formally employed in 1993. The three leading occupations held by employed women were service and market sales workers (40%); professionals (40%); and clerks (about 8%). The majority of the women working as service and market sales workers and as professionals were between the ages of 20 and 39. The majority of the clerks were between 20 and 34. Those women working as skilled agricultural and fishery workers were evenly distributed between the ages of 15 and 50. Those working as plant and machine operators were mainly between the ages of 20 and 29. Among the economically active population as defined by the population census, less than 1% of the women were employers and only 4.3% were workers on their own account.
Legally, the civil code stresses equal treatment of women. In addition, they have the right to 60 days of paid maternity leave, an hour to breast-feed an infant before or after work, 1-2 years of unpaid leave to care for a child at home, and up to four years unpaid leave to go abroad with her husband. (UNICEF Situation Analysis of Women and Children, 1993). In 1994, the Sultan has given women the right to vote and 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 welfare are 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 families exposed to sudden disasters and low income. Government grants given by the Ministry of Social Welfare since 1972 have been expanded to include social security for disability, orphanhood, senility, widowhood and divorce (see Chapter 4). This type of government support for divorced women, for instance, establishes a support system 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 and amounts of social welfare are described in Chapter 4.
A. Access to and Use of Health Services
Records dating back to 1975 show that the access and use of the health services by females have been high. Information on the number of new cases, of re-attendance at hospitals, health centres and dispensaries all attest to this fact. Approximately 52% of the new cases seen in hospitals were women, 58% in health centres and 50% 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% in dispensaries. 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 have risen since then. The number of out-patients have risen from 3.3 million in 1975 to 7.2 million in 1993. The numbers of in-patients from about 56,000 to 226,000 respectively (see Chapter 3 for more details).
The high percentage of births in a health institution is also a measure of the high levels of use of health services by Omani women. Between 1988 and 1990, the percentage of births attended by health personnel was as high as 90% and rose to 98% in 1993. It is evident that the value society places on the safety and well-being of the delivery process outweighs the conservative tendency in many countries preventing women from using hospitals and health clinics. With extensive use of services, the important question remains the quality of services. In this regard the number of times a woman receives ante-natal care and whether she goes on to receive 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-natal services, there is still a significant number of late registrations. The number of pregnancy checks and the date of the first check are important factors in assessing the quality of maternal care. We saw in Chapter 3 that almost half of the women in their third to fifth month of pregnancy had only received one check. Furthermore, of the women in the later stages of pregnancy (7 months and higher) about one-third had 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 important issue 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 of risk factors. As discussed in earlier chapters, as a response to the lack of maternal health information, especially maternal mortality, a notification system was established in 1991 in the Maternal and Child Health reporting systems.
This system of reporting indicates that maternal mortality rates have been reduced
from 30 per 100,000 live births to 7 per 100,000 live births from 1991 to 1993. The
reporting system is very recent and the reliability of these figures are as yet uncertain. In general there is very scarce information of adult survival. Maternal morbidity is also an important factor that the Maternal and Child Health services have recently addressed. A pregnancy risk evaluation process has been developed which categorises women by level of risk in terms of several factors such as parity, stature of mother, past/present pregnancy complications, medical diseases, history of infertility/abortions, haemoglobin levels etc. This is a crucial step as a preventive measure to ensure that women at risk who are attending health institutions can be helped before more severe conditions result. Data show that about 35 to 55% of the registered women are either at "low risk" and "at risk" categories, although only 2%
are at "high risk". B. Health and Nutritional Status
Studies 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 time periods which will be used as a basis for this discussion. A 1991 study by Musaiger found that the proportions of children under-weight were higher among males than females (with the exception of girls aged 3 and 4). The prevalence underweight among 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. The prevalence of stunting among girls range from about 12 to 29%.
At older ages (between 11 and 19), an average of 63% percent of females are underweight in 1989 (Musaiger, 1996b). A women's nutrition survey based on body mass index showed that 13% of mothers were underweight, 33% were normal and 27% were overweight and 28% were obese (Musaiger, 1991). Only one in three mothers had a normal weight. The fact that 55% of the women are overweight or obese point towards the risk of chronic and degenerative diseases. The 1991 study showed that obese mothers suffer from higher prevalence of hypertension, diabetes, arthritis, asthma and back pain than others. The impacts of changing lifestyles and eating habits need to be assessed. A significant number of adult women (60%) also suffer from iron deficient anaemia. (Musaiger, 1991) The most common reasons for this condition in Oman are menorrhagia and pregnancy. Changing the traditional diet to one involving the consumption of processed foods with a low nutritional value is also a related factor.
C. Morbidity and Mortality of Females
As discussed in detail in earlier chapters, morbidity and mortality is based on inpatient data and therefore generalisation of to the community at large is not possible, especially for adult health data. Based on inpatient morbidity data from the 1993 statistical report, there are four areas of diseases where females have a higher number of discharges in comparison to men. They include diseases of the genitourinary 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 the digestive 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 to determine what percentage of men and women utilise health services in general.
Looking at the adult mortality information from in-patient mortality, it can be seen that males have higher levels of death at all ages in comparison to females. The most pronounced percentage gaps are about 56% for injuries and poisoning, 37% for digestive system diseases, 32% for nervous system diseases and 28% for infectious diseases (see Chapter 2 for details). Trends of inpatient adult deaths by sex and age between 1989 and 1993 indicate that among adults of ages 15 to 44 as well as ages 45 and above the number of deaths have been relatively steady in the past five years.
5.9

Universal primary education, gender equity in education, as well as social security for women are important complements to health sector and wealth in improving women'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 and women have experienced the benefits of the health interventions in the past 25 years. Social security entitlements to marginalised groups of women such as divorcees, widows, elderly and single women built within the legal/government system places women in a favourable status. It is important to note that previously existing and some emerging negative health problems of women need to be addressed. Prevalence of underweight and stunting among younger females as well as anaemia in the wider female population persist. The significant presence of pregnancy risk factors leading undoubtedly to pregnancy complications, which stands among the leading causes of inpatient morbidity in 1993 should be a focus for amelioration of women's health. New emerging problems related to changing nutritional habits and life style have increased obesity, smoking and chronic diseases among women.
///. WATER AND SANITATION: EFFECTS ON DIARRHOEAL DISEASE AT THE LOCAL LEVEL BY MUNICIPALITY.
A.
Environmental Health in Oman.
The effects of environmental factors are complex. In most developing nations, water and sanitation remain the key most environmental factors affecting the health of the people. The incidence and prevalence of diarrhoeal diseases are an excellent index
of progress in environmental improvements.
1. The Early Years.
Before 1970, diarrhoeal disease was common, contributing to the very high infant and under 5 mortality at that time. In 1975, the Ministry of Health established Environmental Health as a separate Section. The section quickly established a
strong link with the municipalities and began joint environmental health inspections. This was to provide technical support to the under-qualified municipality staffs and to make better use of limited resources. Much of the early work was "crisis management" and so little data collection took place.
2. Environmental Health in the 80's
In the 1980s, environmental health activities became more scientific and targetoriented. The WHO launched the Water and Sanitation Decade (1980-1990) which Oman readily adopted. In 1937, a national environmental health survey was carried out to determine the water and sanitation status of the country. The results showed that 60% of all falaj (traditional water canals or tunnels) were micro-biologically contaminated whilst over 40% of all wells and 34% of all water tankers were also contaminated. The survey did not include the capital area and the Dhofar region that were mainly connected by pipelin by the Government. The results gave for the first time baseline data for the planning of new goals for water and sanitation.
5.10

The National Environmental Health Survey results were used in several ways including the discrimination of different types of water by colour-coding the containers and vessels (drinking water; saline water; and sewage). The coding regulation was issued to help and ensure that contamination of drinking water supplied by water tankers was kept to a minimum. The achievements in the 1980's were commendable. Bacillary dysentery and Amoebiases cases dropped from 17,355 in 1983 to 6,507 in 1988; a 62.5% drop from the 1983 figure. Enteritis and other diarrhoeal diseases also dropped from 329,514 cases in 1984 to 227,127 cases in 1990; a drop of 31.1% from the 1984 figure. 3. The Situation in the 90's
Further improvements were achieved in the 1990s. In fact, it is in the 1990's that the major progress in water and sanitation were achieved. In 1990, the Environmental Health Section was developed into a full department. This resulted in a stronger coordination link with the municipalities and other developments including: a new regulation licensing all commercial wells; 170,161 wells and 1,880 falaj were registered by the Ministry of Water Resources; a Healthy Wilayah Project was begun by the Ministry of Health, and the WHO local office; and the Ministry of Health has computerised its water and sanitation database in order to address outstanding problems. The preliminary results of the efforts in the 90's are promising with the enteritis and other diarrhoeal diseases reduced from 273,920 cases in 1990 to 193,709 cases in 1992; a reduction in 29.3% from the 1990 figure and a reduction of 41% from the 1984 figure. Bacillary dysentery and amoebiasis reduced from 8,445 cases in 1989 to 4,446 cases in 1992; a reduction of 47.4% from the 1990 figure and a reduction of 74% from the 1983 figure.
In order to sustain any developmental achievement, the people's (community) active participation is required. With this in mind, the Ministry of Health, Environmental Health and Malaria Eradication Department is now emphasising several "healthy Wilayah" projects. This approach emphasises environmental health intervention and sound hygiene practices with the aim of improving the overall health status of the people of the Wilayah. It is a project involving the local community and all related governmental ministries and agencies to work together to achieving goals that cannot be feasibly achieved by any one party. Here again, the Ministry of Health is playing a co-ordinating role between governmental agencies and the communities in order to achieve the overall goals.
5.11
CHAPTER 6
COMPARISONS AND CONCLUSIONS
CHAPTER 6
COMPARISONS AND CONCLUSIONS
n this report, we have been able to document in a very detailed way the whole range of changes, which have swept Oman since H. M. Sultan Qaboos bin Said came 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 on record both for historical and contemporary populations (see Chapter 2). We know less about adult mortality changes but we assume that many of the factors, which contributed to the improvement of the survival of young children also, applied to adults. Certainly, we can document the decline in maternal mortality and the changing pattern of causes of death in adults, at least those who died in health facilities. In Figure 6.1, we present a synthetic graph showing our best estimates of under 5 mortality changes since the first surveys were conducted in 1975. We have plotted the probability of surviving to age 5, rather than the probability of dying by age 5, since we want to show how other social and economic indices have moved over the last 25 years on the same graph. This graph of the probability of surviving to age 5, l(5) in the life table, is an amalgam of all reliable sources. Some aberrant points have been dropped (i.e. the indirect estimates from teenage mothers) and the most recent section of the graph is derived from the infant mortality rates from the health services data. We have estimated l(5) from these infant mortality rates by using model life tables. Note the early start to tbe mortality decline - a decline that preceded the establishment of most of the modern health services.
Secondly, we can readily document the changing pattern of causes of death in young children. We have shown in Chapter 2 how the number of cases of the vaccine-preventable diseases declined as vaccine coverage rates climbed steadily in the 1980s. The disease surveillance system is good and was well established by the mid-1980s so we must accept the measured trends as truly representative changes of the disease patterns in Oman. The connection between the two must be more than coincidental or circumstantial.
Thirdly, we see the emergence of chronic conditions in the in-patient and the outpatient data from the health services in the late 1980s and the early 1990s. This emergence of new patterns is a sign of changing causes of death and signal that the epidemiological transition is well advanced in Oman. We also see the persistence of some 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 are readily documented. One is that the improvements in child survival were widespread and 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
05 1960 1965 1970 1975 1980
Year
Indeed, people in the peri-urban and rural areas have experienced a similar improvement 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 1972 and 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 mothers with little or no education improved more rapidly than those of literate mothers. These are signals that the public health measures introduced in Oman affected all classes of society and were not restricted to any particular sub-group. Such trends are evidence that differentials in childhood mortality narrowed rather than widened during the transition in child mortality. This is different from experiences elsewhere as Preston and Haines (1991) demonstrated for Europe and the USA. Other features of the mortality differentials are also important. One is the regional disparities. It is very clear that all regions of the Sultanate benefited from the improvements in child survival during the 1970s and 1980s. The capital area still has the lowest childhood mortality but not by much. Even in the peripheral regions, child survival has improved dramatically with rare exceptions. In addition, when we consider the differences in survival by sex for children aged 1-4, we note that girls have in the past experienced higher child mortality than boys. In most populations, physiological factors are responsible for higher early childhood mortality for boys and 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 to risk and treatment patterns generally play a larger role. In Oman, the excess mortality of girls relative to boys has been reduced in recent years but will require continued 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 health services. This figure suggests that the mortality improvements had begun before the
full establishment of the health services we know today. Undoubtedly, the health services contributed to the precipitous decline after 1970 but it is worth noting that some changes in Omani society, which had begun before 1970, were responsible
for an early improvement in child survival. Although Oman was relatively isolated from the modern world before that date, some of the changes in the surrounding countries must have affected Oman to some extent. The most obvious mechanism is 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 oil was discovered in Oman. There were almost 20,000 Omanis in Kuwait alone in 1965 (Kuwait, 1995 census, table 2). The effect of these emigrants, their income and their experiences overseas are all hard to quantify but they must have played a significant role in setting off some significant changes in personal wealth, attitudes and behaviour with relation to health.
Fig ire 6.2: Child Survival to age 5 Compared to some Health Indicators
l(5) * Coctois *Nurses* Beds
- 7000
i 6000
5000
j=
I/I O
{ 4000
t 3000
3 o
o
E'
1990
-L o
1995 2000
Figure 6.3 shows the link between national wealth (GDP per capita) and survival to the fifth birthday. Here we see a much closer connection between the growth of the economy and changing mortality. Even before the establishment of the modern welfare state, the rise in government revenues appears to have raised personal and national income with a consequent effect on child mortality. The connections are circumstantial 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 of spending on health rather than national income (Figure 6.4). Again, the strong suggestion is that some of the initial gains in child survival (and by extension, adult
survival) 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 transitions proceed.
Figure 6.3: Child Survival to age 5 from Diverse Sources
Compared to GDP per Capita

-|(S Per GaptaGCP (FO)
1
0. 95
oa
0. 85 0 .8 0. 75 0 .7 0. 65
0 B 0. 55
0 .5
1965 1970 1 9 7 5 1980
Year
1985
1990 1 9 9 5
Figure 6.4: Child Survival to Age 5 from Sources Compared to Mnistry of Health Expenditure
-|(5)
MOHExpendJure
1
0. 95
0 .9
o. as
0 .8 0. 75 0 7 0. 65
- 1 00
K 'c m
O
+ 8 0
o
3 -S
460
1^-
o
5
0 .6 0. 55
0 5
- o
1990
2000
/.
LESSONS LEARNED
There are a variety of dissenting views on the main reasons for the almost universal improvement in human survival and health in the twentieth century. This diversity exists because we are dealing with the views of medical and biological scientists as
6.4

well as those of social scientists. In the latter field, the prevailing thesis is the relatively minor importance of medical factors, at least in the historical period. In addition, it is clear now that the order of importance of the determinants of improved child survival in early twentieth century Europe is different from that in developing countries today. For example, vaccines make a huge contribution to preventing deaths from infectious disease today and were unimportant in the historical period. McKeown (1976 and 1983) was amongst the first to seriously question the previously dominant explanation - that medical science and medical services were responsible for the improvement in mortality in Europe at the beginning of the twentieth century. His thesis - that the changing virulence of harmful organisms, increasing human resistance due to improved nutrition and a more sanitary urban environment contributed more to mortality improvements than medicine - has been widely accepted in both medical and social science circles. Szreter (1988) stressed factors such as municipal ordinances on crowding, living conditions and of course the general improvement in urban water supplies and sewage disposal systems. Woods, Watterson and Woodward (1988 and 1989) provided a body of empirical evidence in support of the "healthy towns" hypothesis, adding to this the effect of 19th. century declines in fertility. These broader efforts to account for child survival improvements were complemented by more biological frameworks such as those produced by Mosley and Chen (1984). In these, the key proximate determinants are nutrition, environmental contamination, injury, maternal factors and personal illness control. With these overlapping explanations and a huge body of seemingly contradictory empirical and theoretical work on the topic, the definitive history of the reasons 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 its World Development Report. In this influential volume, the factors responsible for improving health were subsumed into three broad categories:
income growth (incorporating improvements in housing, improved nutrition and greater use of health care); medical technology (including better treatment systems as well as new drugs and vaccines); and public health measures (the urban infrastructure, water, primary health care facilities and rising levels of education)
How can we apportion the factors responsible for Oman's recent improvements in health and mortality? Taking the three categories of variables identified by the World Bank, we can use a number of specific indicators to examine Oman's performance internationally. 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 mortality rate is about what we would expect given its income level. It seems too that on nutrition, Oman's performance is on target. Certainly, in terms of use of health care services, the use rates cited above for Oman seem very high.
In the category of medical technology, we can list Oman's remarkable record in
6.5

controlling the infectious diseases of childhood and in creating baby-friendly hospitals. The Wilayah health care system is also a new administrative approach to providing decentralised and comprehensive primary health care.
It is in the category of public health improvements (urban infra-structure, provision of clean drinking water and raising educational levels) that Oman's achievements seem exceptional. These investments have produced dramatic changes in diseases such as bacillary dysentery and amoebiasis - down from over 17,000 cases in 1983 to just over 5000 in 1993. Enteritis and other diarrhoea! cases have fallen equally sharply. The one index on which Oman performs poorly is in the area of fertility but this is changing rapidly as educational levels improve and as the new birth spacing programme takes effect. The importance of the contribution of decline in fertility to improvements in maternal and child health is well illustrated in the work by Woods and Watterson (1988 and 1989) on the British mortality decline.
Several additional factors are specific to the Oman case. A strong and unwavering political commitment to public investment in health and education has meant that the social sectors have not suffered even when economic growth has slowed. The oil revenues provided a solid financial base for the development of the welfare state but without the commitment to health, education and social welfare, Oman could have been 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 but it is worth remembering that its real per capita income in purchasing power parity dollars is only half the levels in Qatar or the UAE. In addition, it is everywhere the case that increases in per capita income have less effect on life expectancy now than 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 had more than socialist ideals and a commitment to education to drive the health transition. The provision of a universally-accessible, high quality, modern health service free of charge to all citizens is a striking achievement but without the associated programmes of social development and the investment in the public health measures broadly defined, Oman's health transition would have been less dramatic and certainly slower. One difference with the past is that our knowledge of the mechanisms through which infections are spread is much superior today than at the turn of the century.
The demand and participation of the people are also critical elements of health progress. The pent-up demand of the people in the early 1970s combined with enthusiasm for the modern and the experience of the returning Omanis all contributed to an unleashing of demand-generated health forces that accounted for very rapid progress in the first decade of modernisation. Few barriers lay in the way of the establishment of a modern health system in conjunction with universal public education. 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
6.6

government. The adherence to a set of consistent policies centred around PHC has been important to the implementation of these policies. The polices seem to have been effectively implemented with a mix of Omani and non-Omani staff who appear to have been hard-working, committed and uncorrupted. Secondly, the stability of government and the support the government receives from the population at large has been important for the acceptance of new programmes and interventions. The interest in the full integration of Dhofar has reduced many of the regional differentials that might otherwise have emerged as result of very rapid growth in the capital area.
Although national health policy is decided upon by the state, Oman has worked harmoniously and tapped the resources of such international agencies as UNICEF, WHO and the World Bank. Oman's health strategy, therefore, is adapted to the conditions of the country and capitalises upon the most up-to-date international technical standards. The role of such international organisations as UNICEF and WHO has amounted to relatively modest financial support but more technical advice and provision of connections to experiences elsewhere.
//. THE FUTURE OF HEALTH IN OMAN
Oman 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 many first generation health problems have been tackled but not completely conquered while a second generation of chronic diseases is now beginning to emerge. Several features make the planning of the course of future health improvements especially difficult. One is the demographic situation. With over a quarter of the population from other countries, the constant flux of people makes the country vulnerable to imported 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 age distribution of the Omani population will alter dramatically. Care of the elderly and disabled will become a new problem in the very near future. In addition, the new cohorts emerging from schools and colleges will put pressure on the government, the country's largest employer, to create worthwhile jobs for them despite only modest 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 of the effectiveness of past interventions have been conducted. This makes decisions on which services to develop and which might be part of a partially privatised health sector very difficult. It is clear that the demand for health care is very strong but politically, it may be difficult to introduce charges for services that were previously provided free. Here is where international experience with fee for service schemes and social insurance schemes will be valuable. Despite its oil wealth, Oman will face the same problems as elsewhere - how is the use of health services to be rationed? One
solution is through manipulation of charges. Other less acceptable solutions adopted
6.7

by other countries with resources constraints have resulted on longer waiting times for less urgent care and some drop in the quality of services provided. Neither of these latter solutions is appealing to Oman. The problem with such changes is that there is no universal formula for making such reforms correctly - every case is different.
In order to make the existing services more effective and efficient, resources will have to be managed more closely with greater attention to the costs of alternative approaches than in the past. The role of the community is here critical since there needs to be a clearer understanding of what kinds of ailments and conditions require tertiary 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 an opportunity to involve the community more in the maintenance of its own health as Oman has embarked on a process of decentralisation of the responsibilities for health to the provincial (Wilayah) level. In these smaller units, it may be possible to encourage the population to gradually take more responsibility for its own health including public health measures such as water and sanitation. The dominance of the government sector has created a sense of dependence on government services and facilities which has to evolve into greater individual and community responsibility for health.
One additional feature of the decentralisation process is that collaboration between different government agencies may be more effective at this level. The necessarily hierarchical nature of government organisation is difficult to circumvent since financial responsibility resides in the separate ministries. At the provincial level, committees and other non-governmental groups may be able to express their demands more coherently to several ministries simultaneously, thus encouraging closer collaboration between the health and other welfare and educational services.
There is nonetheless a strong case for the government to continue to play a central role in the national effort to advance the health of the people of Oman. The state enjoys the confidence of the general population since it has provided stability, prosperity and a wealth of social and infra-structural developments unknown in Oman's previous history. With this leadership, more popular participation in decisions on health care provision, and good advice from agencies and countries with experience of the transition from a fully subsidised health care system, Oman should achieve as much health progress in the next quarter of a century as enjoyed in the first 25 years of Oman's "leap" to good health.
6.8
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unicef

The Mortality and Health Transitions in Oman: Patterns and Processes

Editors Allan G.Hill Adaline Z. Muyeed Jawad A. al-Lawati

2.11 2.12 2.12 2.14 2.14 2.15 2.15 2.21 2.21

//. ADUL T SURVIVAL 2.19 A. Adult In-patient Deaths 2.20

B. Maternal mortality C. Fertility and its Effects on Mothers and Children

3.5 3.5 3.5 3.6 3.8

2 3. Heart Disease - 4. Accidents ---

__ __ __ _ _ _ _ _ __ _______ -.__.. _ _ _ _ _ _ --.

PEM PHC RO SPR SOP STD TB TFR TF Tl TS TV UAE

ACKNOWLEDGEMENTS AND AUTHORSHIP

OMAN- EARLY DEVELOPMENT AND SPECIAL FEATURES

A distinguishing feature of Oman compared to<the other states of the Arabian

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

Chapter 1: Oman - Early Development and Special Features

Chapter 1: Oman - Early Development and Special Features

Chapter 1: Oman - Early Development and Special Features

Chapter 1: Oman - Early Development and Special Features

1.5 0.5 1.4

0.4 1.3 2.8

0.3 2.7 2.0

1.9 2.0 6.3

Chapter 1: Oman - Early Development and Special Features

Chapter 1: Oman - Early Development and Special Features

CHANGES IN MORTALITY AND HEALTH STATUS

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

All 37 public hospitals and MCH centres

Nov. 1988/ Feb. 1989

General Census of Population, Housing and Establishments

Oman Family Health Survey (OFHS)

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Figure 2.1: Trends in Under 5 Mortality from Various Sources

-OCHS 1988-S9 birth histories -OCHS-indirect

-5 Towns Survey 1975

- 1977-79 11 Towns survey 1993 Census

Figure 2.2: Trends in Infant Mortality from Various Sources

- 11 Towns Survey 1977-79

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

196973 56 84 140 98 225

Age Patterns of Mortality Change

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Figure 2.3: Trends in Age Patterns of Childhood Mortality from the

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

Chapter 2: Changes in Mortality and Health Status

Social Class Differentials

Chapter 2: Changes in Mortality and Health Status

and in the subsequent process of economic and social development.

Chapter 2: Changes in Mortality and Health Status

Chapter 2: Changes in Mortality and Health Status

Comparison of Under 5 Mortality among Selected Arab Countries, 1992

Chapter 2: Changes in Mortality and Health Status

__ _ _ _ _ _ ___ -... _ _ _ _ _ _ --.

Chapter 2: Changes in Mortality and Health Status