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Reduce Childhood Mortality Rate: Infants and Children under 5 years of Age
Ministry of Health
Oman

The Problem

Oman is a fast developing nation with a young population. With a healthy birth rate of 31 per 1000 population, Oman has been successful in reducing the maternal mortality rate in childbirth from 22 (per 100,000 live births) in 1995 to 13.4 in 2009 and Infant Mortality Rate of 20 (per 1000 live births) in 1995 to 9.6 in 2009. This was attributed to comprehensive healthcare services for mother and child and with an IT-based Mother and Child system, the progress of pregnant mothers and children development under the age of 5 is carefully monitored to ensure full survival.
Before the automation; pre-natal check-up, services, and follow-up for mother and child health were done manually. For the pre-natal check-up, a manual record was stored in the green card. The green card check-up and follow-up activities were strictly kept with the doctors and health institutions, the follow-up on each category where several investigations and activities must be done were not closely monitored. As a result, pregnant mothers’ health was affected. In addition, pregnant women were made to provide all their personal data for every pregnancy in the green card. Every pregnancy was treated separately and there was no continuity in personal and medical information. Since, medical check-up was scheduled manually with no appointment system, very often the women had to wait a long time at the medical center or clinic for their check-up. There was no standardize manner in which the pregnant women were educated on the medical check-ups and investigation required during the course of their pregnancy.
Similarly, once the women had given birth, the child medical record would be created manually. Oman in achieving the Millennium Development Goals objective, adopted the WHO checklist for screening and immunization programme for children between 0-5 years old (Integrated Management of Childhood Illnesses- IMCI). However, before 1999, the health system was targeting the age group (0-5) through vertical programmes which were disease oriented, for example, communicable diseases, acute respiratory illness, and protein energy malnutrition; where each of these programmes was managed by a different department and they did not communicate with each other. As the disease oriented programmes were running independently of each other, information about the child was not shared across the programmes and therefore it was not possible to link health conditions and treat them together. Through manual monitoring of the child via the healthcare card, information could not be shared with the main healthcare system and patient records were not updated. There was no follow-up action for those who did not attend the required check-ups. Infant mortality rate was 29 per 1000 live births in 1990 and under 5 Mortality rate was 35 per 1000 live births in 1990.
Clearly a holistic programme to enhance the quality of mother and child healthcare system is critical for the benefits of the whole nation.

Solution and Key Benefits

 What is the initiative about? (the solution)
The initiative centers on providing a holistic primary care for pregnant mothers (pre-natal and post natal care) at all medical centers and towards birth at the tertiary hospital. Their records are made available throughout their pregnancy from primary healthcare center to the hospital through the Healthcare system. It records the birth history, prenatal care for mother and child special care and need and then transfer to the Primary care system which will then be extend to the child under the IMCI system.
At the same time, an electronic appointment system was also implemented in which appointment can be scheduled at appropriate time, reducing the waiting time to 30 minutes. Reminder is also sent within 48 hours before the appointment. With a pro-active approach to healthcare, the entire vaccination list and activities related to pre-natal and post natal care are incorporated to the patients’ record. The system will also verify if the vaccination is valid, medication history and ultrasound scan is also captured and stored in the patient record as well as the entire history of her pregnancies. These records are accessible at tertiary care medical institutions for patients referred for specialized treatment. Special care can be administered and recorded in the patients’ primary records should any complication is detected and special treatment is required. All information during pregnancy will be sent to the hospital for delivery, the tertiary care specialized. With a checklist embedded within the system, healthcare givers are able to provide better pre-natal and post natal care including advice on birth control or fertility programme if required.
Once the baby is born, the child record is created in the system and a holistic approach to treatment and management of child illnesses in the age group 0 to 5, IMCI is introduced. This programme targets the age group of 0-5 years of both genders, and also the mothers of these children, as it includes counseling services and educational services as well. IMCI (Integrated Management Childhood Illnesses) is a global strategy recommended by WHO and UNICEF, and was adopted and adapted by Oman. The main of the programme is to reduce childhood deaths, illnesses, and disabilities, and to contribute to the improved growth and development of children in Oman.
The system was developed in-house for use by the stakeholders in the health centers as a module in the Al Shifa System, easily accessible by all government hospitals and medical centers. From 2005 onwards, almost stem. If there were missing information, the doctor will be alerted on missing activities and follow-up actions will be taken. With a mandatory process along with a structured tests and immunization programme, the development of the child can be carefully monitored and assessed.
MoH have set the goal of reducing child mortality: infants and children less than five years of age. This goal was achieved as a result of many programmes developed for child care such as Immunization Programme (coverage has exceeded 99.9%), Integrated Management of Childhood illness (launched in 2001) and Baby Friendly Hospital Initiative. In addition to that, special programme designed for pregnant mother care (follow up, immunizations) and the specialized staffs were trained such as doctors, nurses, technicians, etc.
Oman has achieved the 4th MDG and managed to reduce Childhood mortality rate for under 5 years of age from 181 per 1000 live births in 1970 to 12 in 2009. Infants mortality rate reached 9.6 per 1000 live births in 2009 compared to 118 in 1970.
This project was recognized by UNICEF in the middle of 1990’s for continual reduction of child mortality.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The automation of the Mother and Child healthcare program was proposed and initiated by the national MCH (Mother and Child Health) and IMCI focal points at MoH in 2004. The implementation of the automated program was first implemented in Muscat region health care institutions and then propagated to other regions of the Sultanate, after it was reviewed and tested several times. The automation was carried out in collaboration with the Directorate General of Information Technology, the founder of Al-Shifa system (health information management system) that is implemented in the Sultanate. The program users (doctors, nurses, counselors, dieticians, etc.) and program managers were involved in the design, development and implementation process. This initiative involves other stakeholders, besides the users, the program managers, health directors at the headquarters, and health directors at the regions, and mainly, the children of Oman and their families.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objectives: the initiative consists of two main components; it covers integrated health care at the health facilities and family practices at home and in the community. The main objective is to provide a holistic and syndromic approach to management of women and children healthcare services. This include the reduction of maternal mortality rates and reduce the mortality and morbidity rates in the children age group (0-5), and improve the quality of care provided through aiming for the following:
- Strengthened health systems that use evidence based WHO and IMCI manuals.
- Well equipped institutions with the required medications as per the adopted evidence based guidelines.
- Involvement of the health care provider in the delivery of health care to the homes.
- Sustained and updated performance of medical staff (doctors, nurses, dieticians, counselors, etc.) through continuous training.

Strategies: first of all, the program was adopted and adapted in 1999, and implemented manually in Muscat region by 2000. Meanwhile, the production of the automated version was underway, which when completed was piloted in Muscat region again, and then finally scaled up and implemented at all regions of the Sultanate starting 2005.

The strategy of adapting, piloting, and then implementing across the country is a standard strategy that is followed by the ministry in general. The system is designed and implemented by the program managers and the IT development and implementation team at the ministry headquarters.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Before developing the automated version of the programme in the Al Shifa system, thorough meetings and discussions were held to study the flow of information and other requirements for capturing the necessary information. This involved reviewing the business process and standardizing the process for mother and child programme.

After development and testing, the first version was implemented in Muscat region and propagated to other regions. Soon after, a region wise workshop was conducted to receive feedback and comments on the system. After the modifications were done based on the feedback, the system was updated and allowed to run for 2 years, after which another review workshop was conducted in 2005. A third workshop was conducted in 2009 after which the latest version of the program is produced and implemented up to date. Yearly, brief reviews of the system are carried out 2 to 3 times a year to address any difficulties and concerns or changes that may occur in the main protocols that need to be applied electronically.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
1. High turnover of medical personnel due to doctors’ transfers, resignation, nurses’s rotation.
2. Difficulty to conduct training for medical staff, hence shorter training had to be done regularly so that all medical staff is able to use the system.
3. It is also a challenge to implement the standard protocols for mother and child programme as the doctors are over burdened with too many systems. However, with an easy user interface and ease of use, the doctors gradually move on to use the system. Furthermore, the doctors’ feedback on the system was also incorporated to make the system totally doctor friendly.
4. Change management had to be done tactfully and diplomatically as users were resistance to embrace the IT-based system. Nevertheless with support from top management and the Ministry officials, the system was fully implemented and users began to realize the benefits of the automated process when they received accolades from patients for their quality services. In addition, changes to the system were also done continuous as it was difficult to cover all the changes in a short period of time. Any changes required had to be propagated to other regions, in addition to the 180 institutions in Muscat region; the coordination is difficult because of the lack of specialized technical support in most regions and the dispersed geographical locations. Nevertheless, through a planned changed management approach, all changes were rolled out in good time to all medical institutions throughout the country.
5. Standardised protocol – The acceptance of the user to follow the standardize system was quite a challenge. Hence, involving the users in the development phase was essential so that they could accept the changes. Task forces with multi expertise to re-engineer the process and the system were also formed to obtain feedback, make the necessary changes and get feedback through pilot project until the final implementation.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The resources used for the initiative are, but not limited to, costs of conducting training and review workshops in each region, as well as at institution and national level. These included the manpower involved in conducting the training both theoretically and technically. Manpower was also assigned to the design and development of the automated system. The system was developed in-house based on an existing IT infrastructure by the Directorate General of Information Technology at the Ministry of Health.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The system is very sustainable because of the continuous review and supervision of the program focal point over the users, as well as the reliability of the technology in which the system was developed. In addition to the fact that is it part of a bigger comprehensive system that addresses the health care delivery at all levels and therefore, data is fed into and from the system seamlessly.

Also, training of the end users is continuously done. As the system is automated and is part of a bigger system, the system is easily implemented in other locations which allows for a standardized service across the country.
In the automation of the mother and child care system, Oman is the first and with plan with WHO to package the checklist to be used in other developing countries in the region. IMCI from WHO- EMRO representative is also looking at packaging the system to be adapted to other regions in Middle East North Africa region.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
1. Reduction in mortality rate for both mother and child
Reduced mortality rate in children under the age of 5 years from 35 per 1000 births in 1990 to 12 in 2009 and reduce the Infant Mortality rate from 29 per 1000 births in 1990 to 9.6 in 2009. Oman has also been successful in reducing the maternal mortality rate in childbirth from 22 (per 100,000 live births) in 1995 to 13.4 in 2009.

2. A holistic healthcare approach based on a pervasive health system that is well equipped with medication due to evidence based practice pre-natal and post-natal care and childhood illnesses care. All medical staff are up to date with the practices of childhood illnesses management and mothercare management. It promotes higher and sustained performance of the medical staff in this field and reduced human error as a result of the automated system
3. Elimination of manual patient files going missing and the information is retained throughout the lifespan of the patient. The automated system allows for a systematic examination of the patient because it applies enforcements and restrictions when entering certain fields, ensuring that mandatory data is entered and entered data is not modified after a certain time so that it does not loose authenticity. Patients are managed better because the system creates defaulter and automatically sends SMS reminders for immunization and examination appointments
4. The information is shared and linked with other health programs such as school health, nutrition, which previously were recorded vertically. This provides better monitoring of the child’s health because data is plotted on a digital growth chart. Mothers can now be assured of quality medical care right from pre-natal to post-natal treatment, thus reducing maternal mortality rate.


How the impact was measured: reference to the statistics available in the following links
- http://www.who.int/child_adolescent_health/en/
- http://gis.emro.who.int/HealthSystemObservatory/PDF/Oman/Health%20care%20financing%20and%20expenditure.pdf
- http://www.emro.who.int/cah/imci-adaptation.htm

In addition to the positive response from the users because of the increased demand for the system.
Who benefited: the families and communities, the doctors, nurses, and other health care providers, as well as the program managers and decision makers. The automated system saved time and lives. It also made it easier to allocate resources and services nationally through statistics extracted from the system.


The main factors that contributed to the success of this initiative lay in the fact that there is a strong collaboration between all the stakeholders and the support from high authorities in order to contribute to better health services delivery to the mothers and children in the country. In addition, adopting and adapting an internationally checklist such as IMCI is also great advantage.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Government Agency  
Contact Person:   Abdullah Al Raqadi
Title:   Mr.  
Telephone/ Fax:   0096824604770 / 0096824599839
Institution's / Project's Website:   www.moh.gov.om
E-mail:   roy-it-raqadi@moh.gov.om  
Address:   Ministry of Health, P.O. Box: 393
Postal Code:   113
City:   Muscat
State/Province:   Muscat
Country:   Oman

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