| 4. In which ways is the initiative creative and innovative?
The program went through different stages until it reached the final step of implementation and application on the ground.
- In 2002 the first step was initiated through a comprehensive situational analysis and need assessment.
- In August 2003 a small pilot phase was initiated in two governorates (Aldakhliya and Muscat governorate). The small pilot included a small sample of the elderly/disabled population.
- In 2004, a research study followed, covering the same governorates with the objective of exploring the profile and needs for the elderly/disabled population. In the same year, the Department of Nursing and Midwifery at the MoH conducted a need analysis for developing a training program to strengthen community nursing practices. As a result, a 16-weeks on Job Training program for community health nurses was initiated in the Muscat Governorate ‘Wilayat Al Amerat’ as a pilot study. Six months later, the program was approved and extended to three other Governorates, namely North Sharqiya, North Batinah and Dhakliya.
- In 2005, a wider service pilot phase was implemented after developing the processes for all PHC institutions in the same governorates.
- In 2007, a cost analysis exercise was carried out, demonstrating that community health care services are both cost effective and viable in comparison to the costs incurred by tertiary and secondary levels of service. For example, the cost for one patient’s spending a day in a tertiary level hospital was around $130-195 (50-75 RO), compared to less than $10 (4 OR) for one patient being visited by a community health nurse.
- In March 2010, the program was implemented on the national level in four phases.
- In 2012, as part of future planning to strengthen the initiative with the trained nurses, the MoH signed a Memorandum of Understanding with Cardiff University for a partnership in developing and delivering a BSc (Hons) Community Health Nursing Practice Program.
- In 2013, the first group of 20 nurses graduated successfully from the same program and 24 were admitted into the second cohort.
- In 2014, all the governorates in Oman started calling for Community Health Nursing service. So far, however, the service has only been actively implemented in two out of eleven health regions. As the first step to initiating the program, the other nine regions recently started to work on the awareness about the service.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative went through different phases, each bringing in more and more sectors, which have both a direct and indirect impact of the services provided in this initiative.
The Management Set Up
The first task in establishing this program was to decide on who was best suited to manage the program, and ensuring that management backup was in place.
Two levels of management was required for achieving this:
The leadership level (as a management backup).
The program management (steering) level.
The leadership level:
The leadership level is represented by an advisory committee, including policy makers, and higher health and social administration.
The main task of the committee is to take decisions that deal with policies, legislation, finance and inputs. Initially, the committee met four times until the action plan was approved. Nowadays it is scheduled to meet regularly every six months.
1. - the Undersecretary of Health Affairs for the Ministry of Health (MoH)
2. - the Undersecretary of the Ministry of Social Development (MoSD)
3. - the Director of the Department of Primary Health Care (PHC)
4. - the Director of the Department of Special Care in the MoSD
5. - the Elderly Care Section head in the Department of PHC
6. - A technical advisor (a doctor working in Elderly Care Section
7. - Two social workers from the governorates
8. - Royal Hospital administration
9. - Khoula Hospital administration
10. - Al Nahdha Hospital Administration
11. - Quraiyat Hospital Administration
12. - Al Rahma Hospital Administration
The following members were involved in relevant activities:
1. The Director of Nursing in MoH
2. Two community leaders
3. Two representatives of NGOs
| 6. How was the strategy implemented and what resources were mobilized?
Taking a holistic view of dealing with this issue required substantial resources. In terms of human resources, the recruitment process was started at early stages, as it was recognised difficult and time consuming or even crippling to the program management. As a matter of fact, this program is an integrated service and supposed to be run with the available human resources as much as possible. This, however, subjected to the situation analysis outcome. The elderly/disabled services require some paramedical staff which is not usually available in the PHC like the physiotherapists and social workers. The staff categories that needed to be recruited are as follows:
Doctors – general practitioners
Nutritionists and/or dieticians
Other paramedics may be naturally available in the PHC institutions.
MATERIALS AND LOGESTICS.
Types of materials:
The lists of the materials are enumerated below. The most important list to work on is the physiotherapy mobile unit’s equipment as the indenting procedures may be subjected to financial and administrative routines. The supply from the dealer may also take some time.
(1) Physiotherapy mobile unit’s materials:
27 items of physiotherapy equipment. Usually 23 items are carried in a travelling bag with wheels for easy movement and 4 items are fixed in each PHC.
Each unit has a vehicle to tour the targeted health centres. Items were selected according to the following criteria:
Small in size and easy to carry and handle
Useful for the most common elderly musculoskeletal complaints
Heavy duty for long duration
Less running cost
These items were selected by a team of physiotherapists, engineers, biomedical engineers, physicians, and programme managers, Before final approval, the items were tested for three years. The total cost was estimated to be around $7,300,000 (2,8000,000 RO) funded exclusively by MoH. This is annual funding for the program which be revaluated in 3 years.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The following are the key outputs of the initiative:
a. Increased Coverage of Services – at least 60 – 75% of the targeted group covered by the elderly/disabled services from 2003 to mid-2014. It also managed to discharge around 90% of the cases that were abundant in the hospital, so the patient could receive care at home instead.
b. Community Awareness for Elderly/Disabled Care – an awareness campaign was started in the targeted governorates in 2003 before starting the pilot study. The aim was to provide education for public and health workers about the aims of the initiative, and how it will be implemented in the community. In 2010 a more comprehensive campaign was initiated for community participants in all governorates.
c. Developed Qualified National Staff for Elderly/Disabled Care Services – Numerous types of training sessions, usually joint sessions, for doctors and nurses. The training modules were developed by experts in the field from WHO and local experts.
d. Improving the Quality of Life for Elderly/Disabled People – as an example, the screening for some common NCD in the elderly population like DM, Hypertension and depression revealed about 10% of these cases were diagnosed through this initiative.
| 8. What were the most successful outputs and why was the initiative effective?
Monitoring occurs on daily and monthly routine, whereas evaluation is conducted every six months. Monitoring is the daily task of the coordinators in the institutional, regional and national levels. Evaluation is carried out in close collaboration between the coordinator and the focal point, which collect the consecutive six months reports, meticulously study the content, and thereafter prepare the six months report. To prepare the annual report, the same group study and analyse the two latest sixth month reports.
Evaluation is done through analysis of the output of the six month and one year. Mapping the obstacles and their solutions is an important part of the evaluation report. Any new inputs should be reported here and the value they add to performance must be evaluated. For each obstacle the suggested solution should be procedural rather than asking for new inputs.
TYPES OF MONITORING
This is a daily problem solving tool for follow-up activity done at the level of the region by calling the institutions one by one. In cases when the number of institutions in the region exceeds six, the regional coordinator divides them into two patches for being called in on different days. Upon calling the coordinator enquires about the following:
• How many elders/diasbled are registered?
• Any difficulties or issues encountered.
• Any queries that could not be solved locally.
The monitoring format is a checklist that must be completed for each institution visited. The document is subsequently used for follow-up visit to the same institution.
Monthly scheduled visits are organized to the relevant institutions at the regional and national level. The purpose of the visit is to evaluate the performance, problems and training needs, as well as discussing and evaluating local initiatives. The visit is useful for collecting information for the six months report. On top of this the program also has an annual monitoring and evaluation in place.
| 9. What were the main obstacles encountered and how were they overcome?
The challenges can be summarised in the following way:
- Manpower Recruitment
The recruitment process went through a number of stages, which were related to the directly to initiative, as well as to take in account the regulations of the country. Recruitment can be so difficult and time consuming or even crippling to the programme management. As a matter of fact, this programme is an integrated service and is thus supposed to be run with the available human resources as much as possible. This, however, is subjected to the situation analysis outcome.
A key challenge was how to train people for providing a new services to the community. Both local and international experts were engaged to train pre-chosen focal points to be master trainers. The master trainers subsequently became the trainers in the governorates.
- Community Awareness
Initially, the initiative lacked health educators, community support groups, and NGOs to support the community awareness campaigns. By offering to become partners in the project, they helped design and run the community awareness champions programme. Although communities were often aware of the available services, they were not always willing to participate due to the culture beliefs or local taboos.
To counter this, training sessions were run to create community awareness and grass root advocacy. The gradual acceptance and participation from the elders/disabled proved the effectiveness of this approach. As such, marketing efforts directly targeting the end users were also conducted in parallel with community awareness campaign.