WHO-AIMS REPORT ON

MENTAL HEALTH SYSTEM

IN OMAN

MINISTRY OF HEALTH
SULTANATE OF OMAN
 WHO-AIMS REPORT ON

MENTAL HEALTH SYSTEM

IN OMAN

A report of the assessment of the mental health system in Oman

using the World Health Organization - Assessment Instrument for
Mental Health Systems (WHO-AIMS)

Muscat, Oman

2008

Ministry of Health
Oman

WHO, Oman
WHO, Regional Office for the Mediterranean
WHO Department of Mental Health and Substance Abuse (MSD)
This publication has been produced by the WHO, Oman in collaboration with WHO,
Regional Office for Eastern Mediterranean and WHO, Headquarters. At WHO
Headquarters this work has been supported by the Evidence and Research Team of the
Department of Mental Health and Substance Abuse, Cluster of Noncommunicable
Diseases and Mental Health.

For further information and feedback, please contact:

1) Asad Saeed Abod, In charge of Mental Health of Oman, asadsky@yahoo.com

1) Jawad Ahmed Al-Lawati, Director of non-communicable dept., jallawat@yahoo.com
2) Jihane Tawilah, the representative of WHO Oman, tawilahj@oma.emro.who.int
3) Shekhar Saxena, WHO Headquarters, saxenas@who.int

3
Acknowledgement

The World Health Organization Assessment Instrument for Mental Health Systems
(WHO-AIMS) was used to collect information on the mental health system of Oman.

The project in Oman was implemented by Asad Saeed Abod, Psychiatrist, in charge of
Mental Health and Drug abuse section, Department of Non-Communicable Diseases
Surveillance and Control, and Coordinator of National Mental Health Committee,
Ministry of Health (MOH), together with Jawad Ahmed Jawad Al-Lawati,
Epidemiologist, Director of the Department of Non-Communicable Diseases
Surveillance and Control, Ministry of Health, Yusuf Mirza, Psychiatrist, Head of the
Mental Health Department at Ibn Sina Hospital and Mahmood Alabri, Psychiatrist,
Head of the Alcohol and Drug Addiction Department at Ibn Sina Hospital. The project
was supported by Jihane Tawilah, representative of WHO Country Office in Oman.

The project was also supported by the Mohammad Taghi Yasamy, WHO, Regional
Office for the Eastern Mediterranean.

We are grateful for the technical support to Dr. Hala Sakr (Technical Officer) at WHO
Regional Office for the Eastern Mediterranean, Dr. Jihane Tawilah (WHO
Representative, Oman) and to Mrs. Ruth Mabry (Technical Officer) at Office of the
WHO Representative, Oman.

The preparation of this study would not have been possible without the collaboration of
the Ministry of Health, Royal Oman Police and Sultan Qaboos University.

The World Health Organization Assessment Instrument for Mental health Systems
(WHO-AIMS) has been conceptualized and developed by the Mental Health Evidence
and Research team (MER) of the Department of Mental Health and Substance Abuse
(MSD), World Health Organization (WHO), Geneva, in collaboration with colleagues
inside and outside of WHO.

Please refer to WHO-AIMS (WHO, 2005) for full information on the development of
WHO-AIMS at the following website.
http://www.who.int/mental_health/evidence/WHO-AIMS/en/index.html

The project received financial assistance and/or seconded personnel from: The National
Institute of Mental Health (NIMH) (under the National Institutes of Health) and the
Center for Mental Health Services (under the Substance Abuse and Mental Health
Services Administration [SAMHSA]) of the United States; The Health Authority of
Regione Lombardia, Italy; The Ministry of Public Health of Belgium and The Institute
of Neurosciences Mental Health and Addiction, Canadian Institutes of Health Research.

The WHO-AIMS team at WHO Headquarters includes: Benedetto Saraceno, Shekhar

Saxena, Tom Barrett, Antonio Lora, Mark van Ommeren, Jodi Morris, Anna Maria
Berrino and Grazia Motturi. Additional assistance had been provided by Sachiko
Kuwabara and Patricia Esparza.

The WHO-AIMS project is coordinated by Shekhar Saxena.

4
Executive Summary
The World Health Organization Assessment Instrument for Mental Health Systems
(WHO-AIMS) was used to collect information on the mental health system in Oman.
The goal of collecting this information is to improve the mental health system and to
provide a baseline for monitoring the change. This will enable Oman to develop
information-based mental health plans with clear base-line information and targets. It
will also be useful to monitor progress in implementing reform policies, providing
community services, and involving users, families and other stakeholders in mental
health promotion, prevention, care and rehabilitation .

A mental health policy and plan exist in Oman. The last revision of the mental health
plan was in 2005. It includes the following components: 1) reforming the mental
hospital to provide more comprehensive care, 2) developing a mental health component
in primary health care (PHC), 3) developing human resources in mental health related
disciplines, 4) advocacy and promotion, 5) human rights protection of users 6)
financing, 7) quality improvement, and 8) monitoring systems. Essential medicines and
an essential drug list are available. Currently the Ministry of Health (MOH) is drafting
comprehensive mental health legislation and final draft of public health law has been
submitted for approval.

The percentage of expenditures on mental health is unknown. In Oman the financing

system in MOH does not separate the mental health budget from other health sectors
budget (as there is no program budget). All medical services including access to the
mental health services and to essential psychotropic medicines, are 100% free to all
Omani population.

There are 26 outpatient mental health facilities available in the country, of which 2 are
for children and adolescents. In 2006, these facilities treated 386 users per 100,000
general population. Female users make up over 40% of the population in all mental
health facilities in the country. The proportion of female users is highest in inpatient
and outpatient facilities in general hospitals and lowest in the mental hospital.

The majority of beds in the country are provided by the mental hospital followed by
inpatient units in general hospitals. The majority of users are treated in outpatient
facilities and in the mental hospital. The percentage of children and adolescents is
generally low in all mental health facilities. The distribution of diagnoses varies across
facilities: in outpatient facilities neurotic and mood disorders are most common
whereas in inpatient facilities and in the mental hospital schizophrenia has the highest
prevalence. Psychotropic drugs are most widely available in the mental hospital,
followed by outpatient units, and then inpatient mental health facilities. Most of mental
health facilities are present in or near large cities. In order to promote equity of access
to mental health services, Oman is encouraging the development of community-based
psychiatric units and outpatient facilities in each catchment's area throughout the
country.

The majority of beds in mental health facilities in the country are provided by the
mental hospital (2.88 beds per 100,000 population), followed by community-based

5
inpatient psychiatric units (1.01 beds per 100,000 population) and forensic units (0.19
beds per 100,000 population). There has been an increase by 23% in the number of the
mental hospital beds in the last 5 years.

Nine percent of the training for medical doctors is devoted to mental health, in
comparison to seven percent for nurses. Six percent of primary care doctors and three
percent of nurses received at least 2 days of refresher training in mental health in 2006.
Only doctors can prescribe psychotropic medications in primary care settings.

The total number of human resources working in mental health facilities or private
practice per 100,000 population is 14.18. In terms of staffing in mental health facilities,
there are 0.27 psychiatrists per bed in community-based psychiatric inpatient units, in
comparison to 0.34 psychiatrists per bed in the mental hospital. As for nurses, there are
0.69 nurses per bed in community-based psychiatric inpatient units, in comparison to
1.84 per bed in the mental hospital. The density of psychiatrists in or around the largest
city (Muscat) is 2.42 times greater than the density of psychiatrists in the entire country.
There are only 67 psychiatrists, 11 assistant psychiatrists, 183 nurses, 12 psychologists
and 8 social workers working in or for mental health facilities in Oman. In 2006, 85
general medical doctors, 493 nurses, 1 psychiatrist and 21 nurses specialized in mental
health care, and 1 occupational therapist with at least 1 year training in mental health
care graduated from various institutions in or outside Oman.

In Oman government agencies, non-governmental organizations (NGOs), professional

associations, and international agencies have promoted public education and awareness
campaigns in the last five years. Fifty seven percent of primary and secondary schools
have either a part-time or a full-time health professional. Regarding mental health
activities in criminal justice system, there is a permanent psychiatrist working at this
facility. All prisoners are briefly reviewed by the psychiatrist at least once per month.

A defined list of individual data is collected by the directorate general of planning

(information and statistical department) of the Ministry of Health. All the facilities had
transmitted their data to this department during the last year. Of all health related
research, 4% is conducted on mental health.

6
Table of contents
ACKNOWLEDGEMENT----------------------------------------------------------------------------------------------------4

EXECUTIVE SUMMARY---------------------------------------------------------------------------------------------------5

WHO-AIMS COUNTRY REPORT FOR OMAN--------------------------------------------------------7

Introduction------------------------------------------------------------------------------------------------------------------------------8

Domain 1: Policy and Legislative Framework----------------------------------------------------------------9

Policy, plans, and legislation--------------------------------------------------------------------------------------------------9
Financing of mental health services--------------------------------------------------------------------------------------9
Human rights policies. ------------------------------------------------------------------------------------------------------------10

Domain 2: Mental Health Service ------------------------------------------------------------------------------------10

Organization of mental health services-------------------------------------------------------------------------------10
Mental health outpatient facilities----------------------------------------------------------------------------------------10
Day treatment facilities ----------------------------------------------------------------------------------------------------------10
Community-based psychiatric inpatient units--------------------------------------------------------------------11
Community residential facilities-------------------------------------------------------------------------------------------11
The Mental hospital-----------------------------------------------------------------------------------------------------------------11
Forensic and other residential facilities------------------------------------------------------------------------------11
Human rights and equity--------------------------------------------------------------------------------------------------------12
Summary Charts----------------------------------------------------------------------------------------------------------------------12

Domain3: Mental Health in Primary Health Care------------------------------------------------------16

Training in mental health care for primary care staff------------------------------------------------------16
Mental health in primary health care----------------------------------------------------------------------------------16
Prescription in primary health care-------------------------------------------------------------------------------------17

Domain 4: Human Resources---------------------------------------------------------------------------------------------17

Number of human resources in mental health care-----------------------------------------------------------17
Training professionals in mental health------------------------------------------------------------------------------19
Consumer and family associations---------------------------------------------------------------------------------------20

Domain 5: Public Education and links with other Sectors----------------------------------------20

Public education and awareness campaigns on mental health---------------------------------------20
Legislative and financial provisions for persons with mental disorders-----------------------21
Links with other sectors-----------------------------------------------------------------------------------------------------------21

Domain 6: Monitoring and Research-------------------------------------------------------------------------------22

Strengths and Weaknesses of the Mental Health System in Oman----------------------23

Next Steps for strengthening the Mental Health System in Oman -----------------------24

7
Introduction
Background

Sultanate of Oman is located in the south eastern corner of the Arabian Peninsula. It is
with an approximate geographical area of 309,500 square kilometres and a population
of 2.577 million people (Ministry of Health, 2006). The main language used in the
country is Arabic. The largest ethnic group is Arab, and the other ethnic groups are
Baluchi, South Asian and African. The largest religious group is Muslim. The country
is an upper middle income group country based on World Bank 2006 criteria.

Roughly thirty seven percent of the population is under the age of 15 years and 3.6 %
of the population is above the age of 60 (MOH, 2006). The literacy rate is 81.4% for
adults (older than 15 years) and 97.3% for youth (15-24 years) (UN Human
Development Report 2006). Twenty-eight percent of the population is rural (UN
Human Development Report 2006). The life expectancy at birth is 73.18 years for
males and 75.43 years for females (MOH, 2006). The healthy life expectancy at birth is
63 years for males and 65 years for females (WHO, 2004).
The proportion of health budget to GDP is 4.7% (MOH, 2006). The total per capita
expenditure on health is $ 295 USD and the per capita government expenditure on
health is $ 240 USD (WHO (2007).

Health System Infrastructure

The Health services in the Sultanate of Oman have developed tremendously over the
past years. During early 1970, there were only 2 hospitals with 12 beds and 10 clinics
and by 2006, the Ministry of Health (MOH) was running 49 hospitals. The total
number of health centers is 150; of which 67 are equipped with beds (a total of 144
beds). In addition there are 19 extended health centers run by the Ministry of Health.

Oman is witnessing a shift in its main health problems from communicable

diseases to health problems related to changes in life style and changes in population
structure manifested in non-communicable diseases. Thus, in its five-year health
development plan, the Ministry of Health has therefore emphasized the development of
secondary and tertiary care in order to meet the future needs of the management of such
health problems. There are currently a total of 4,549 hospital beds; 194 hospital beds
per 100,000 general population and 1.16 general practitioners per 100,000 general
population. Roughly three percent of all hospital beds are in the private sector.

The MOH provides health services to all the people of Oman through its health
institutions and has attempted to strengthen health services outside Muscat
Governorate. Therefore an umbrella of health services was established to cover
the entire Sultanate. There is a “Regional Hospital” in each health region that provides
secondary care (tertiary in some) for the people in its catchment area. This is in addition
to “wilayat hospitals,” “local hospitals,” and health centers in each health region.

Ministry of Health is the main health care provider in the Sultanate. In addition the
Ministry of Defense, Royal Oman Police (ROP), Petroleum Development Oman (PDO)
and Sultan Qaboos University (SQU) also provide health care mainly for their

8
employees and dependents. The University Hospital also provides both secondary and
tertiary care for the general population.

In terms of primary care, there are 567 physician-based primary health care (PHC)
clinics in the country (194 in the public sector and 373 in the private) while non-
physician based primary health care clinics are not applicable in Oman.

Data was collected in 2007 and is based on the year 2006.

Domain One: Policy and Legislative Framework

Policy, plans, and legislation

Oman's mental health policy was last revised in 1992 and includes the following
components: 1) developing community mental health services, 2) developing a mental
health component in primary health care, 3) human resources, 4) involvement of users
and families, 5) advocacy and promotion, 6) human rights protection of users, 7) equity
of access to mental health services across different groups, 8) financing, 9) quality
improvement and 10) monitoring system.

In addition, all the essential psychotropic medicines, which are listed by WHO, are
available in Oman. These medicines include antipsychotic, antidepressants, anxiolytics,
mood stabilizer and antiepileptic drugs.

The last revision of the mental health plan was in 2005. This plan contains the
following components: reforming the mental hospital to provide more comprehensive
care; developing a mental health component in primary care; human resources; human
rights protection of users, mental health advocacy and promotion; equity of access to
mental health services across different groups; financing; quality improvement and
monitoring system. In addition, a budget, timeframe, and specific goals are identified.

Currently the MOH is drafting comprehensive mental health legislation and the final
draft of public health legislation has been submitted for approval. The latter law will
provide for and cover certain basic and minimum standards related to mental health
issues. Until 2007, there was no emergency/disaster preparedness plan for mental health
in Oman.

Financing of mental health services

The percentage of expenditures on mental health, and consequently the percentage for
the mental hospital is unknown. In Oman the financing system in MOH does not
separate the mental health budget from other health sectors budget (as there is no
program budget). Since the mental hospital is part of MOH, its operational annual
budget is known to be USD $ 5550000 in 2006. This budget has not included
medications (which are supplied centrally).
In terms of affordability of mental health services, all medical services including access
to the mental health services and to essential psychotropic medicines, are 100% free to
all Omani population.

9
Human rights policies
A national human rights review body does not exist. However, the mental hospital in
Oman has had at least one day review/inspection of human rights protection of patients
in the last two years, and 1 of the 2 psychiatric inpatient units had such a review. In
terms of training, all of the mental hospital staff and 50% of psychiatric inpatient units
staff have had at least one day training, meeting, or other type of working session on
human rights in the year of assessment.

Domain 2: Mental Health Services

Organization of mental health services

The Mental Health and Drug Abuse Section within the Non-Communicable Diseases
Department acts as a national mental health authority which provides advice to the
government on mental health policies and legislation. This authority is also involved in
(a) service planning, (b) service management and co-ordination, and (c) monitoring and
quality assessment of mental health services. Mental health services are organized in
terms of catchment areas. There are no mental health facilities in some areas. However,
residents in those areas have access to services in adjoining regions.

Mental health outpatient facilities

There are 26 outpatient mental health facilities available in the country, of which 2 are
for children and adolescents only. In 2006, these facilities treated 9,901 users (386
users per 100,000 general population). Of all users treated in mental health outpatient
facilities, 45% are female and 8% are children or adolescents. The users treated in
outpatient facilities are primarily diagnosed with neurotic, stress-related and
somatoform disorders (28%) and mood (affective) disorders (24%).

The average number of contacts per user is 5.95. No outpatient facility provides
follow-up care in the community, and there are no mental health mobile teams. In terms
of available interventions, a few (1-20%) users received one or more psychosocial
interventions in 2006. All mental health outpatient facilities had at last one
psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood
stabilizer, anxiolytics, and antiepileptic medicines) available in the facility or in a near-
by pharmacy all year round.

Day treatment facilities

There are no day treatment facilities available in the country. The need for such facility
is felt and it is hoped that this activity will be addressed in the next five year MOH
health plan.

10
Community-based psychiatric inpatient units
There are two community-based psychiatric inpatient units available in the country for
a total of 1.01 beds per 100,000 population. None of these beds are reserved for
children and adolescents only. A total of 48% of admissions to community-based
psychiatric inpatient units are female and 15% of admissions are children/adolescents.
The diagnoses of admissions to community-based psychiatric inpatient units were
primarily from the following two diagnostic groups: schizophrenia (35%) and mood
(affective) disorders (20%). On average patients spend 9 days per discharge. Some
patients (21-50%) in community-based psychiatric inpatient units received one or more
psychosocial interventions in the last year. All community-based psychiatric inpatient
units had at least one psychotropic medicine of each therapeutic class (anti-psychotic,
antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the
facility.

Community residential facilities

There are no community residential facilities for patients with mental disorders in
Oman. Possible reasons for this include stigma related to mental illness, lack of trained
working personnel and lack of funding.

The Mental hospital

There is only one mental hospital in Oman (Ibn Sina Hospital) which is located in the
capital Muscat, with a total of 2.88 beds per 100,000 population. This facility is
organizationally integrated with mental health outpatient facilities. None of the beds in
the mental hospital are reserved for children and adolescents only. The number of beds
has increased by 23% in the last five years. The patients admitted to the mental hospital
belong primarily to the following two diagnostic groups: schizophrenia, schizotypal and
delusional disorders (50%) and mood (affective) disorders (20%). In 2006, 837 (32.61
per 100,000 population) patients were admitted in the mental hospital, of which 32% of
users were female The average length of stay was 27.24 days in the mental hospital.
Nearly eighty percent of patients spend less than one year, 5% of patients spend 1-4
years, 3% of patients spend 5-10 years, and 14% of patients spend more than 10 years
in the mental hospital. Some patients (21-50%) in the mental hospital received one or
more psychosocial interventions in 2006. The mental hospital had at least one
psychotropic medicines of each therapeutic class (anti-psychotic, antidepressant, mood
stabilizer, anxiolytics, and antiepileptic medicines) available in the facility.

Forensic and other residential facilities

In addition to beds in mental health facilities, there are also 5 beds for persons with
mental disorders in forensic inpatient. There is no forensic inpatient unit available in
the country, but there are 5 beds (3 beds in the mental hospital and 2 beds in the prison)
for forensic patients (0.19 beds per 100,000 population). Eleven percent of patients
spend less than one year, fourteen percent of patients spend 1-4 years, 42% of patients
spend 5-10 years, and 25% of patients spend more than 10 years.

11
In addition, under the Ministry of Social Affairs, there are 2 residential facilities with a
total of 84 beds for people with multiple physical and mental disabilities; one of which
is specifically for children aged 14 years and younger (24 beds). There is no residential
facility specifically for people with mental retardation, but there is a school for
mentally retarded children under the Ministry of Education. It consists of 30 classrooms,
with a capacity of 200 students

Human rights and equity

There were no involuntary admissions to community-based inpatient psychiatric units.
However, 50% of admissions to the mental hospital in 2006 were involuntary. Between
2-5 percent of patients were restrained or secluded at least once within 2006 in the
mental hospital while the number of patients who were restrained or secluded within
2006 in community-based psychiatric inpatient units was unknown. The majority of
psychiatric beds in the country are located in or near the largest city (Muscat). The
density of psychiatric beds in or around Muscat is 3.57 times greater than the density of
beds in the entire country. Such a distribution of beds prevents access for rural users in
the rest of regions. Inequity of access to mental health services for other minority users
(e.g., linguistic, ethnic, religious minorities) is not an issue in the country as access to
the medical care is universal in the country.

Summary Charts

Graph 2.1 - Beds in mental health facilities and other

residential facilities

Forensic beds
5%
Psychiatric
Inpatient Units
25%

Mental Hospital
70%

The majority of beds in the country are provided by the mental hospital, followed by
community based inpatient units. However, other residential facilities that formally are
not mental health facilities but where, nevertheless, the majority of the people residing
in the facilities have diagnosable mental retardation provide 84 (3.27 per 100,000
general population) additional beds.

12
 Graph 2.2 - Patients treated in mental health facilities (rate per
100,000 population)

Forensic beds 0.19

Mental hospital 32

Inpatient units 24

Outpatient facilities 385

0 100 200 300 400 500

The majority of the users are treated in outpatient facilities and in the mental hospital,
while the rate of users treated in inpatient units and forensic units is lower.

Graph 2.3 - Percentages of female users treated in mental health

facilities

Mental hospital 32%

Inpatient units 48%

Outpatient facilities 45%

0% 10% 20% 30% 40% 50% 60%

On average, female users make up over 40% of the population in all mental health
facilities in the country. The proportion of female users is highest in inpatient units and
outpatient facilities and lowest in the mental hospital facilities.

13
 Graph 2.4 - Percentage of children & adolescents treated in
mental health facilities among all users

Inpatient units 15%

Outpatient
8%
facilities

0% 2% 4% 6% 8% 10% 12% 14% 16%

The percentage of users that are children and/or adolescents varies substantially from
facility to facility. The proportion of children users is highest in mental health inpatient
facilities and lowest in outpatient facilities.

Graph 2.5 - Patients treated in mental health facilities by diagnosis

100%

80%

60%

40%

20%

0%
Outpatient facilities Inpatient Ibn Sina Hospital
Mood disorders 24% 20% 20%
Others 18% 16% 10%
Personality disorders 3% 4% 1%
Neurotic disorders 28% 18% 1%
Schizophrenia 20% 35% 50%
Substance abuse 7% 6% 18%

The distribution of diagnoses varies across facilities: in outpatients facilities neurotic

disorders and affective disorders are most prevalent, while in both in-inpatient units and
in the mental hospital schizophrenia and affective disorders diagnoses are most
frequent.

14
 Graph 2.6 - Length of stay in inpatient facilities (days per year)

30 27

25

20

15

9
10

0
Inpatient units Mental hospital

The longest length of stay for users is in the mental hospitals and then in community-
based psychiatric inpatient units.

Graph 2.7 - Inpatient care versus outpatient care

70,000
58,907
60,000

50,000

40,000
28176
30,000

20,000

10,000

0
Outpatient care Inpatient care

The ratio between outpatient contacts and days spent in all the inpatient facilities (The
mental hospital, residential facilities and general hospital units) is an indicator of extent
of community care: in this country the ratio is 2:1.

15
Domain 3: Mental Health in Primary Health Care

Training in mental health care for primary care staff

Nine percent of the training for medical doctors is devoted to mental health, in
comparison to 7% for nurses. There is no estimate for non-doctor/non-nurse primary
health care worker training. In terms of refresher training, 6% of primary health care
doctors have received at least two days of refresher training in mental health, while 3%
of nurses and 2% of non-doctor/non-nurse primary health care workers have received
such training.

Graph 3.1 - Percentage of primary care professional with at least

2 days of referesher training in mental health in the last year

7%
6%
6%

5%

4%
3%
3%
2%
2%

1%

0%
PHC doctors PHC nurses PHC others

Mental health in primary health care

All primary health care (PHC) clinics are physicians based and all or almost all (81-
100%) of physician-based PHC clinics have assessment and treatment protocols
available for key mental health conditions. Some (21-50%) physician-based PHC
clinics make an average of at least one referral to a mental health professional per
month. As for professional interaction between PHC staff and other care providers,
some (21-50%) primary care doctors have interacted with a mental health professional
at least once in the last year. None of the PHC facilities (physician-based and non-
physician-based) or mental health facilities have had interactions with complimentary/
alternative/ traditional practitioners.

Patients, especially from rural areas, often go to traditional and religious healers before
or after seeking medical advice from the health system. This trend is difficult to study
especially with regards to patients who use the health system in parallel with traditional
ways.

16
Prescription in primary health care

Nurses and non-doctor/non-nurse primary care workers are not allowed to prescribe
psychotropic medications in any circumstance. Primary health care doctors are allowed
to prescribe psychotropic medications but with restrictions. The primary health care
doctors are only allowed to prescribe tricyclic antidepressants (amitryptyline),
chlorpromazine and carbamazepine As for availability of psychotropic medicines, a
majority (51-80%) of physician-based PHC clinics have at least one psychotropic
medicines of each therapeutic category (anti-psychotic, antidepressant, mood stabilizer,
anxiolytic, and antiepileptic) in comparison to none of the non-physician based PHC
clinics.

Domain 4: Human Resources

Number of human resources in mental health care
The total number of human resources working in mental health facilities or private
practice per 100,000 population is 14.18. The breakdown according to profession is as
follows: 67 psychiatrists (2.61 per 100,000 general population), 11 other medical
doctors (not specialized in psychiatry) (0.43 per 100,000 general population), 183
nurses (7.13 per 100,000 general population), 12 psychologists (0.47 per 100,000
general population), 8 social workers (0.31 per 100,000 general population), 5
occupational therapists (0.19 per 100,000 general population) and 79 other health or
mental health workers (including auxiliary staff, non-doctor/non-physician primary
health care workers, health assistants, medical assistants, professional and
paraprofessional psychosocial counselors) (3.08 per 100,000 general population). See
graph 4.1.

Graph 4.1- Human resources in mental health

(rate per 100,000 population)
8
7.13
7
6
5
4
3.08
3 2.61

2
1 0.43 0.47 0.31 0.19
0
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17
The majority of psychiatrists (87%) work only for government administered mental
health facilities, 3% work for private practice, while 10% work for both the sectors.
Ninety-eight percent of psychologists, social workers, nurses and occupational
therapists work only for government administered mental health facilities, 2% work
only for private practice, and no psychologists, social workers, nurses or occupational
therapists working for both the sectors.

Regarding the workplace, 35 psychiatrists work in outpatient facilities, 7 work in

community-based psychiatric inpatient units and 25 in the mental hospital. Eleven other
medical doctors, not specialized in mental health, work in both inpatient facilities and
in the mental hospital. As for nurses, 29 work in outpatient facilities, 18 in community-
based psychiatric inpatient units, and 136 work in the mental hospital. Fourteen
psychosocial staff (psychologists, social workers and occupational therapists) work in
outpatient facilities, 4 in community-based psychiatric inpatient units and 7 in the
mental hospital. As regards to other health or mental health workers 9 work in
outpatient facilities, 1 in community-based psychiatric inpatient units and 69 work in
the mental hospital.

Graph 4.2 - Staff working in mental health facilities

(percentage in the graph, number in the table)

100%

80%

60%

40%

20%

0%
Psychiatrist Other Psychosoci Other M.H.
Nurses
s doctors al staff w orkers

Mental Hospital 25 6 136 7 69

Inpatient units 7 5 18 4 1
Outpatient facilities 35 0 29 14 9

In terms of staffing in mental health facilities, there are 0.27 psychiatrists per bed in
community-based psychiatric inpatient units, in comparison to 0.34 psychiatrists per
bed in the mental hospital. As for nurses, there are 0.69 nurses per bed in community-
based psychiatric inpatient units, in comparison to 1.84 per bed in the mental hospital.
Finally, for other mental health care staff (e.g., psychologists, social workers,
occupational therapists, other health or mental health workers), there are 0.19 per bed
for community-based psychiatric inpatient units, and 1.02 per bed in the mental
hospital.

18
The distribution of human resources between urban and rural areas is disproportionate.
The density of psychiatrists in or around the largest city is 2.42 times greater than the
density of psychiatrists in the entire country. The density of nurses is 3.42 times greater
in the largest city (Muscat) than in the entire country.

Graph 4.3 - Average number of staff per bed

2 1.84
1.8
1.6
Psychiatrists
1.4
1.2 Nurses
1
0.69 Psychosocial
0.8
staff
0.6
0.34
0.4 0.27
0.15 0.09
0.2
0
Inpatient units Mental Hospital

Training professionals in mental health

The number of professionals who graduated last year from academic and educational
institutions is as follows: 1 psychiatrist (0.04 per 100,000), 85 other medical doctors
(3.31 per 100,000), 493 general nurses (not specialized in psychiatry) (19.21 per
100,000), 21 specialised nurses with at least 1 year training in mental health care (0.82
per 100,000), and 1 occupational therapist with at least 1 year training in mental
healthcare (0.04 per 100,000). See graph 4.4. None of the psychiatrists have emigrated
to other countries within 5 years after completion of their training.
Graph 4.4 Professionals graduated in mental health
(rate per 100,000 population)
25

19.21
20

15

10

5 3.31
0.04 0.82 0.04
0
ts rs s s is t
ris cto r se rse ap
ia t o nu nu he
r
ch rd ral ed l t
sy he ne is na
P Ot Ge i al o
ec ati
Sp c up
Oc

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Graph 4.5 shows the percentage of mental health care staff with at least two days of
refresher training in the rational use of drugs, psychosocial interventions, and
child/adolescent mental health issues.

Graph 4.5 - Percentage of mental health with two days of

refresher training in the past year
80%
70%
60%
50%
40%
30%
20%
10%
0%
Psycho-
Psych. MD Nurses Other
social

Rational use of drugs 19% 73% 18% NA 6%

Psychosocial interventions 28% 73% 67% 64% 15%
Child m ental health issues 6% 0% 10% 8% 0%

Psych = psychiatrists; MD =other medical doctors not specialized in psychiatry; psychosocial = psychologists, social
workers, and occupational therapists. Others = other health and mental health

Consumer and family associations

There is very limited information about consumer and family associations in Oman.
While there is no interaction between mental health facilities and consumer associations,
a few (less than 20%) mental health facilities have had interaction with family
associations in the last year. There are five family associations involved in community
and individual assistance activities. It is unknown if there are any consumer or other
NGOs in the country involved in individual assistance activities

Domain 5: Public Education and links with other Sectors

Public education and awareness campaigns on mental health

The Ministry of Health acts as a coordinating body that oversees public education and
awareness campaigns in mental health and mental disorders. However, other
government ministries and NGOs have also promoted public education and awareness
campaigns. These campaigns have targeted the following groups: the general
population, children, adolescents, and women. In addition, there have been public
education and awareness campaigns targeting professional groups including health care
providers, teachers, and social services staff.

20
Legislative and financial provisions for persons with mental disorders
At the present time, there is no legislative or financial support for the following: legal
obligations for employers to hire a certain proportion of employees that are disabled;
protection from discrimination (dismissal, lower wages) solely on account of mental
disorder; or protection from discrimination in allocation of housing for people with
severe mental disorders. However, there are legislative or financial provisions
concerning priority in state housing and in subsidized housing schemes for people with
severe mental disorders. Further, based on certain criteria, financial support is provided
for physically handicapped and mentally retarded people with associated physical
disability through the ministry of social development.

Links with other sectors

There are formal collaborations with the health agencies/departments responsible for:
1) primary healthcare, 2) family and community health, 3) HIV/AIDS, 4) reproductive
health, 5) child and adolescent health, 6) substance abuse, 7) education, 8) welfare, and
9) criminal justice system.

In terms of support for child and adolescent health, a psychosocial care system in
schools has been established. Fifty seven percent of the primary and secondary schools
have either a part-time or full-time mental health professional (social adviser), and all
or almost all of primary and secondary schools have school-based activities to promote
mental health and prevent mental disorders. The existence of psychosocial care is one
of the criteria for assessment of schools by the Ministry of Education.

Regarding mental health activities in the criminal justice system, there is a permanent
psychiatrist working at this facility. The percentage of prisoners with psychosis is about
2-5%, while the corresponding percentage for mental retardation is less than 2%. All
prisoners are briefly reviewed by the psychiatrist, inside the prison, at least once per
month.

As for training, a few police officers (1-20%) and few judges and lawyers (1-20%) have
participated in educational activities on mental health in the last 5 years.

In terms of financial support for users, none of the mental health facilities provide paid
employment opportunities outside their institutions. Finally, 31% of people who receive
social welfare benefits from the Ministry of Social Development do so for a mental
disability (mental retardation with apparent severe physical disability).

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Domain 6: Monitoring and Research

A formally defined list of individual data items that ought to be collected by all mental
health facilities exists. As shown in table 6.1, the extent of data collection is consistent
among mental health facilities: 100% in the mental hospital, 100% in community based
inpatient units and 100% in outpatient facilities.

The Directorate General of Planning (Information and Statistical Department) of the

Ministry of Health has received data, on monthly basis, from all mental health facilities.
However, no report on mental health was published on the transmitted data.

In terms of research, there were 256 health publications written about Oman in the last
five years (2001-2006) - indexed on PubMed. Among these only 14 publications (5%)
were on the subject of mental health.

In the last five years, mental health research in Oman has focused on the following
topics: 1) epidemiological studies in community and clinical samples, 2) non
epidemiological clinical/questionnaires assessments of mental disorders, 3) biology and
genetics, 4) services research, 5) policy, 6) programmes, 7) financing/economics, 8)
psychosocial interventions/ psychotherapeutic interventions, and 9) pharmacological,
surgical, and electroconvulsive interventions.

Table 6.1 - Percentage of mental health facilities collecting and compiling data
by type of information

Mental Inpatient Outpatient

Hospital Units Facilities
N° of beds 100% 100% ---------------

N° inpatient admissions/ users 100% 100% 100%

treated in outpatient facilities
N° of days spent/user contacts 100% 100% 100%
in outpatient facilities.
N° of involuntary admissions UN UN ---------------
N° of users restrained UN UN ---------------

Diagnoses 100% 100% 100%

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Strengths and Weaknesses of the Mental Health System in Oman
Based on the assessment we can summarize the strengths of the mental health
system in Oman as following:

• Mental health services are provided through primary, secondary and tertiary health
care institutes.
• All mental health services at 3 different health care levels are free to all Omani
people.
• Majority (51-80%) of physician-based PHC clinics have at least one of the essential
psychotropic medicines (anti-psychotic, antidepressant, mood stabilizer, anxiolytic,
and antiepileptic).
• A national mental health policy, programme and plan are present and the mental
health plan is updated every 5 years.
• Efforts have been made towards integrating mental health services into primary
health care, which helps to reduce stigma and improve access to mental health
services
• The mental health program had a very good inter-sectoral collaboration with other
relevant authorities (e.g. Ministry of Education, Ministry of Social Development,
Sultan Qaboos University, criminal justice, etc).
• A mental health information database is currently being developed for all mental
health facilities.

Substance abuse was not addressed in the assessment. However, an additional strength
of the mental health system in Oman is:
• The national authority has given high concern to the issue of drug abuse. A
narcotics and psychotropics control law has been present since 1999 and a
national plan for narcotics and psychotropic substances control exists and is
updated. There is also, the National Committee for Narcotics and Psychotropic
Substances Affairs. This committee has an executive office, which is the technical
and administrative body for the implementation of the resolutions of the national
committee. It is also the center for the analysis of drug abuse data through its
national drug abuse registry that collects data by notification processes from all
mental health institutions.

The weaknesses revealed by the assessment include the following:

• The national mental health policy was formulated in 1992 and it has not been
updated.
• There was no national consultative committee until 2007.
• There is no national mental health legislation to protect human rights of patients. At
present time, legislation is in progress and it is expected to be enforced in 2008-
2009.
• There is a limited amount of training provided to primary care staff. Only 6% of
PHC doctors and 3% of PHC nurses receive at least two days of refresher training
in mental health, and in particular, on the rationale use of drugs.
• The mental health system has no day treatment facilities. Such facilities are needed
in Oman and will hopefully be addressed in the next five-year health plan put
forward by the Ministry of Health.

23
• Although the current information health system has provided some useful
indicators, its scope could be widened to include socio-demographic aspects of the
users of mental health services.
• Psychosocial interventions were provided only for a few patients in outpatient
mental health facilities in 2006.

Next Steps for strengthening the Mental Health System in Oman

Domain 1: Policy and Legislative Framework.
• Update the national mental health policy.
• Establish comprehensive mental health legislation that protects and
promotes the human rights of people with mental disorders.
• Develop a disaster mental health programme.

Domain 2: Mental Health Services

• Create and strengthen the community mental health facilities.
• Create a rehabilitation center for alcohol and drug addicts.
• Establish forensic facilities and services.

Domain 3: Mental Health in Primary Health Care

• Increase and continue training on essential mental health care issues for
primary care staff.
• Encourage the integration of mental health services into primary health care.
• Provide all types of essential psychotropic medicines to all primary health
care clinics.

Domain 4: Human Resources

• Increase the number of human resources and psychosocial staff (e.g., social
workers, psychologists, etc.).
• Establish an appropriate refresher training scheme for mental health
professionals with regards to different mental health issues.
• Encourage the formation of consumer and family associations.

Domain 5: Public Education and links with other Sectors

• Increase linkages between the mental health system and other key sectors
which support and promote mental health (e.g. Ministry of Social
Development, Ministry of Education and the sector responsible for HIV,
etc).
• Encourage the contribution of NGO's in promoting mental health issues and
developing prevention programmes.

Domain 6: Monitoring and Research

• Improve the mental heath information system.
• Encourage/support research in the field of mental health.

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The World Health Organization Assessment Instrument for
Mental Health Systems (WHO-AIMS) was used to collect
information on the mental health system in Oman. The goal of
collecting this information is to improve the mental health
system and to provide a baseline for monitoring the change.

The results of the assessment illustrate positive areas of the

mental health system as well as gaps that need to be studied
and addressed.

The mental health plan of Oman was last revised in 2005 in

which both a budget and timeframe are identified and the plan
has been significantly implemented. All medical services
including access to the mental health services and to essential
psychotropic medicines, are 100% free to all Omani population.

The network of mental health facilities in Oman consists of one

mental hospital, 26 mental health outpatient clinics and 2
community-based inpatient units. Most resources for mental
health are concentrated in the capital city of Muscat. These
facilities offer free access to services and free essential
psychotropic medications to almost 100% of the Omani
population.

The total number of human resources working in mental health

facilities or private practice per 100,000 populations is 14.18. The
breakdown according to profession is as follows: 67
psychiatrist, 11 other medical doctors (not specialized in
psychiatry), 183 nurses, 12 psychologists, 8 social workers, 5
occupational therapists and 79 other health or mental health
workers

The report also includes recommendations on how to improve

the mental health system in Oman.

25