Introduction
General Practice – once the mainstay of Oman’s thriving private healthcare sector – was dominated by expatriate physicians from India. Then came state-led reform, which paved the way for private hospital chains – primarily from India — to barrel their way into the sector. All but crowded out of the market, GPs were left with little option but to join the big players or simply shut shop – a process hastened by onerous minimum standards imposed by local authorities on holdouts. The final devastating blow to the dwindling GP community came during the recent pandemic when protracted lockdowns all but shuttered businesses. The Check-Up speaks to Dr. Sanjay Dalal, one of Muscat’s best-known GPs who, over his illustrious 40-year career as an expat family physician, has witnessed up-close the demise of GP services in the Sultanate of Oman.
When Dr Sanjay Dalal and his wife Dr Sateja first set foot in Oman back in 1983, the healthcare sector was at best rudimentary – and understandably so! After all, this Gulf state had barely 13 years earlier declared its rebirth as a modern nation in 1970, after spending decades in almost self-imposed isolation and shunning any of the institutional and infrastructural trappings necessary for growth and modernization.
“Healthcare was a priority for Oman’s modernizing ruler, the late Sultan Qaboos, but it can be built virtually from scratch,” Dr Dalal recalls. “Up until 1970, there were only two small hospitals staffed by expatriate physicians. It was not uncommon for people to travel – often on foot – for four days and then await their turn amid crowds to be seen by the doctors. In fact, at the time, there were barely 13 physicians covering the entire population, implying a physician-to-population ratio of 1 per 50,000.”
Within weeks of his accession, Qaboos established by Royal Decree the Ministry of Health in one of his first actions as the new ruler. At the same time, the fledgling private sector opened up to General Practitioners, mostly from India. Candidates who cleared written and oral assessments administered by a small department at the Ministry received licenses to set up clinics in the capital city among other far-flung parts of the expansive desert nation. They represented a godsend to Oman’s suffering population, according to Dr Dalal.
“The GPs were the backbone of the healthcare system then. They were sought-after for the treatment of all kinds of common health problems, ranging from ENT, eye and skincare sicknesses to paediatrics, chest and abdomen ailments and to orthopaedic problems too. A few GPs were also allowed to perform minor operations like circumcision, abscess draining, ear piercing, suturing of wounds, and so on. Likewise, a handful of clinics were permitted to perform deliveries. GPs were authorized to stock up on basic medicines and dispense them too. Some operated rudimentary labs to conduct basic tests. They were also tapped to support immunization programmes per guidelines of the Health Ministry. All in all, GPs were one-stop providers of healthcare services at the time.”
GP-owned private clinics proliferated across the sultanate over the ensuing decades supplementing primary healthcare services provided by the Ministry of Health. Expatriates patronized private GPs, but so did sizable numbers of the local population who built personalized relationships with individual physicians spanning multiple decades. Indian doctors accounted for the large majority of GPs, many of them operating in remote parts of the country. Many of them had to leave their families behind in India in order to work in isolated towns that lacked suitable international schooling facilities for their young children.
By around the year 2000, GPs saw their numbers balloon to around 600 plus. Together with an expanding private healthcare network, they helped drive up the doctor/population ratio to 3/10,000 by 2000. A handful of private hospitals with inpatient care were in operation during this period, catering primarily to customers at the high-end of the market.
The new millennium ushered in significant changes in healthcare services landscape in Oman. Private polyclinics staffed by specialists with lab facilities to boot, began mushrooming in the capital region. Over time, they expanded their operations to include in-patient and specialist treatment services, according to Dr Dalal.
To all intents, however, state-funded public healthcare institutions remained the dominant provider of services to the general public, most notably local Omanis. Regional hospitals and super-specialty centres proliferated across the country on the back of relatively generous budgetary outlays for the healthcare sector every year.
The advent of health insurance sparked a new wave of investment in private healthcare services. Although not mandatory at the time, many corporates offered health coverage to their expatriate staff and family dependents, eventually extending to their Omani employees as well. Health insurance has since remained one of the fastest growing segments of the insurance industry in Oman, unlocking new revenue streams for the increasingly competitive private healthcare industry.
To its misfortune, the entire GP community found itself locked out of the health insurance ecosystem as insurers preferred to deal directly with hospital chains that offered the most competitive terms and volumes. Customers with health coverage had little choice but to turn their backs on their trusty GPs and opt for private hospitals ‘approved’ by their insurers.
To compound matters for the GPs, the health authorities began mandating a new set of guidelines, effectively making it cumbersome and costly for individual GPs to run their clinics and yet turn a profit, if not cover their operational costs.
“While the underlying objective behind these new measures, espousing international-class quality and standards, was welcomed by all, the new guidelines imposed a significant cost-burden on small private clinics,” said Dr Dalal. “For many well-established GPs, who had served the local community for decades, the new costs no longer made their businesses viable.”
Delivering a body blow to the GP community was the pandemic, which witnessed the departure of an estimated half a million expatriates, who represent the lifeblood of the private healthcare sector in Oman. Joining the exodus were several leading lights of the GP community from different nationalities, but primarily from India.
Barely a handful of GP-run clinics from the pre-pandemic fraternity exist today. The suburbs of the capital do reveal evidence of new GPs setting up shop, but they’re unlikely to survive in this GP-averse commercial market, he warns.
While General Practice is on its last legs in Oman – if not already vanquished – it can be revived if the authorities appreciate the important contribution that GPs make to the healthcare sector, Dr Dalal says.
“With sectoral reform that recognizes and safeguards the interests of GP-run clinics, a revival of this key segment is possible. Many Omanis have tended to stay on with their family GPs for years, having earned the confidence and trust of their physicians – a relationship they can never hope to have with individuals at a corporate hospital. GPs will also ease the current burden on public healthcare services, as is evident from the huge crowds at hospitals and lengthy waiting lists for certain key procedures.”
Dr Sanjay Dalal
Dr Sanjay D Dalal is a Muscat-based Medical Doctor & Consultant with over 40 years of practice as a Family Physician in the private sector in the Sultanate of Oman. More recent opportunities have included stints as Marketing & Business Development at a number of leading private hospital brands in Oman, and for a time as a Consultant for the development of airport clinics on behalf of Oman Airports. Felicitated by the Omani Ministry of Health for his contribution to healthcare, Dr Dalal is also Founder and Coordinator of Muscat Family Physicians – a grouping that continues to support CME initiatives.
As narrated to Conrad Prabhu
