Family Care Unit
Mininstry of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Delivering efficient and cost effective elderly care services for present and future generations is a challenge faced by most nations. Oman is in no way exempted from this fact. From the 1970s and onwards is considered the birth of modernity in Oman. The modern period has witnessed rapid growth in population density, and an increase in longevity and life expectancy as a result of changes in the socioeconomic status of the people. With modernization, new societal challenges emerged, including, for instance, the growth of life-style related chronic diseases. To tackle these challenges, it has been necessary to revamp and modernize the delivery of health services. As families lacked the skills and the resources to provide the minimum care these groups required, they had to regularly physically attend the health institute to receive the necessary care. Lack of mobility for the elderly and disabled presented tremendous challenges in this respect, especially for the large fraction of the population living in rural areas, having to travel long distances without availability of public transport. Consequently, there has been an increasing demand to focus on community health services, especially in rural areas by moving care closer and deeper into the community. Despite the fact that the elderly population is a small fraction of the population, only 2.5 per cent in 2010, it is expected to grow exponentially as life quality continuous to improve, reaching 20% or above in 2035, thus changing the current population pyramid. This is also exemplified by the fact that Oman’s life expectancy at birth increased from 59.8 to 76.6 between 1980 and 2013. Among the elderly population today, 60% are active, 35% suffer from ailments and need medical support, and the other 5% are bedridden, forming an important group of attendants to the primary, secondary and tertiary care. In secondary and tertiary, a key health problem has been associated with long stays of the elderly in the health institutions, causing bed blocking and long waiting lines for those seeking care. What made this worse was the fact that elders were frequently abandoned there by their families, who lacked the means to provide for them. At one point, the Ministry of Health (MoH) noticed 126 abandoned elders in hospitals across secondary and tertiary care hospitals in Oman. As a response, it initiated the first attempt to handle elderly care in August 2003 (Nizwa Elderly Home Care Pilot Project). Following this, the current initiative was created based on the elderly and disabled needs for home and family services. This high quality service is easily accessible as a walk-in for elders free of charge.

B. Strategic Approach

 2. What was the solution?
Steps towards this initiative began at the request of the Ministry of Health (MoH) in 2003. Based on the well-established solutions from the primary health care, it incorporated key principles for the raising family based community care. This included participation by the community, partnership between the community and health professionals, protection from and prevention of illness and disease, and the promotion of health education. The Vision was ‘providing PHC services for the elders and disabled people in Oman based on their actual and specific needs with the aim of improving their quality of life through a structured program that is based on integration of services in PHC institutions and empowering the staff working in these institutions’. More specifically, the main objective was to provide all the elderly and disabled population with excellent care in the community in their place of living by strengthening and supporting the families abilities to take care of them. The initiative aimed to provide those in need of particular types of care. a. The medical home service: This is provided by a team composed of a doctor, nurse, and medical orderly. After assessment of the actual needs, a physiotherapist and/or social worker can also be requested to join the team. b. The nursing home service: This is delivered by a team consisting of a nurse and a medical orderly. A physiotherapist and/ or a social worker can also join the team upon request, depending on the actual needs. The initiative aims to increase the percentage of elderly people who cannot reach public health centers and receive home care from the 3.2 per cent to 70 per cent by 2015. Moreover, the percentage of healthcare institutions that provide healthcare services to the elderly/disabled was raised from 6.6 to 60%. The initiative managed to help families to take care of their elder, and thereby reduced the number having to go to the health institution by more than 60%.

 3. How did the initiative solve the problem and improve people’s lives?
The ‘Comprehensive Assessment’ is the assessment tool used in the program, which is not only designed to provide the service provider with clinical diagnosis, but also assesses the state of the elder/disabled physical, mental and social state. This holistic approach is targeted towards finding the best possible intervention in the areas that can improve life quality the most. The clinical diagnosis for the elder/disabled may be known prior to the assessment, as many of them may have visited the PHC or other higher levels of health care many times before. Instead what is most urgently needed to be made clear is the state of the quality of life in areas such as: • the state of mobility • assessing the social support networks, contacts and caregivers who are taking care of the elder/disabled • mental status with special concern for dementia and depression • nutrition and hygiene • assessing how the elder/disabled performs the activities in daily life • assessment of polypharmacy.

C. Execution and Implementation

 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. Membership: 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  Nurses  Physiotherapists  Social workers  Health educators  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  Easy maintenance  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 DAILY 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 MONITORING: 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. - Training 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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The initiative changed the concept of health in Oman. More precisely, it changed how people viewed their own role in the health care system. Today, with the help of outreaching teams from the elderly care initiative and community service program, people have a sense of responsibility in supporting disabled and elderly people. This initiative opened the door for creating much needed community resources. The initiative was an eye opener for the health leaders to understand the needs of the community, in so doing creating a health system focusing on the current and future needs of communities. Additionally, this initiative is the first to involve NGO’s in the planning and deliverance of services in the health sector. The positive outcomes from this collaboration has resulted in increased involvement of NGO’s this arena.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative is sustained trough the behavioral change of people, who now understand how they can reap the benefits from this type of services. The initiative was integrated in the primary health care as a specific program with its own budget, human resources, and full support from MoH. The ministry has currently a full suction under primary health care for community care. Before the initiative there was no formal screening program in the country for D.M and hypertension. As the initiative provide a screening for those diseases, it provides a base for national screening programs in relation to health issues like diabetes, hypertension and depression through the care assessment form. As previously mentioned, the initiative was initially started in two governorates, thereafter disseminated, replicated in other governorate, and eventually scaled-up to be a national program for everyone in the country. In March 2010, the program was implemented in the national level in four phases of implementation that will cover all elders in Oman by the end of 2014.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This vital experience provided an opportunity to learn how to deliver home based services to the elderly and disabled segments of the population. For the first time, NGO sectors were participating in designing and planning a health related program. It represented an opportunity to target programs for different levels of physical abilities, as well as offering programs for groups as well as individuals. Moreover, it increased the reach of people to access services, while at the same time bringing health programs to peoples home. By involving people in developing and evaluating the programs, it was possible to create a sense of ownership for the program. The initiative has also indirectly fostered stronger family relations and rebuilt some families into a functioning part of the community once again. One of the key lessons is how to make the programs culture-specific by connecting with existing social networks such as community groups and NGOs. Involving community groups and NGOs made it possible to address some of the challenges and barriers in providing such a service to the community. One of the barriers faced initially was how to make people willing to allow health workers into their houses, as well as providing the required service to the any person in the family who needs care. The community groups and NGOs prepared the community to accept this by speaking to the people in a way that resonated with their situation. The initiative was kept affordable by dedicating a portion from the total budget of the ministry for the program. Currently, the program has all the human resources it requires to optimally function for the long-term. Finally, it now has the support of all stakeholders in the country to run the program as an integral part of the health system. By involving all stakeholders from the beginning has ensured the continuity and learning of the program.

Contact Information

Institution Name:   Mininstry of Health
Institution Type:   Government Agency  
Contact Person:   Khalsa Al Battashi
Title:   Ms.  
Telephone/ Fax:  
Institution's / Project's Website:  
Postal Code:  
City:   Muscat

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