Trauma care in Oman: A call for action

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Trauma care in Oman: A call for action Amber Mehmood, MBBS, FCPS,a Katharine A. Allen, PhD,a Abdullah Al-Maniri, PhD,b Ammar Al-Kashmiri, MD,c Mohamed Al-Yazidi, MD,c and Adnan A. Hyder, PhD,a Baltimore, MD, and Muscat, Oman

Many Arab countries have undergone the epidemiologic transition of diseases with increasing economic development and a proportionately decreasing prevalence of communicable diseases. With this transition, injuries have emerged as a major cause of mortality and morbidity in the Gulf Cooperation Council countries in addition to diseases of affluence. Injuries are the number one cause of years of life lost and disability-adjusted life-years in the Sultanate of Oman. The burden of injuries, which affects mostly young Omani males, has a unique geographic distribution that is in contrast to the trauma care capabilities of the country. The concentration of health care resources in the northern part of the country makes it difficult for the majority of Omanis who live elsewhere to access high-quality and time-sensitive care. A broader multisectorial national injury prevention strategy should be evidence based and must strengthen human resources, service delivery, and information systems to improve care of the injured and loss of life. This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies. (Surgery 2017;j:j-j.) From the Johns Hopkins International Injury Research Unit,a Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; the Research Council of Oman,b Muscat, Oman; and the Ministry of Health,c Sultanate of Oman, Muscat, Oman

BETWEEN 1990 AND 2010, the Arab world demonstrated increased gains in health with a 33.8% decline in disability-adjusted life-years (DALYs) due to communicable diseases.1 Injuries, however, especially road traffic injuries (RTIs) are still ranked the sixth leading cause of death in Arab countries and the leading cause of DALYs for men in the region’s Gulf Cooperation Council (GCC) countries, which include the Sultanate of Oman.2 Oman remains representative of other GCC countries in the Arabian Gulf, which are characterized as being high-income, oil-exporting countries with a high burden of injuries and trauma (Table I).4 Supported by The Research Council of Oman. AM, KA, KS, and AH are partly supported through grant #TRC/SRG/RS/13/ 003. The content is solely the responsibility of the authors and does not necessarily represent the official view of The Research Council. Accepted for publication January 20, 2017. Reprint requests: Amber Mehmood, MBBS, FCPS, Health Systems Division, International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Ste E8644, Baltimore, MD 21205. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2017.01.028

The discovery of oil combined with better economic opportunities was accompanied by a rapidly expanding road network and vehicle-topopulation ratio.5,6 As the use of motor vehicles has increased in GCC countries in the past 3 decades, road injuries have taken an increasing toll on population health, becoming the number one cause of DALYs in this region since 1990. Some of this increase might be due to inadequate road safety and driving behaviors, which has resulted in a growing burden on the health care system.7,8 This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies. Lessons learned from Oman and its existing trauma system can be expanded to other GCC countries in the region. The Sultanate of Oman is located in the southeast coast of the Arabian Peninsula and is one of the member states of the GCC, which also includes Saudi Arabia, Kuwait, the United Arab Emirates, Qatar, and Bahrain. The population of Oman is 3.85 million people, of whom 1.68 million are non-nationals.9,10 Over two-thirds of all residents are concentrated in urban parts of the country and about half of the population lives in the Muscat governorate and the Batinah coastal plain northwest of the capital. The United Nations’ Human Development Report 2014 indicates that the SURGERY 1

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Table I. Health expenditure and injury mortality among GCC countries versus the United States

Bahrain Kuwait Oman Qatar Saudi Arabia United Arab Emirates United States

GDP per capita in current USD*

Per capita health expenditure in USD*

Age standardized mortality due to injuriesy

Years of life lost due to injuriesy

24,113 48,463 20,205 94,574 24,646 42,987 52,750

1,142 1,253 563 2,068 1,052 1,151 8,988

34 25 53 41 41 32 44

1,329 1,199 2,443 1,690 1,577 1,546 2,159

*The World Bank 2013 statistics (http://data.worldbank.org/indicator/NY.GDP.PCAP.CD).3 yWorld Health Statistics Report 2015: numbers expressed per 100,000 population.4

country has a human development index of 0.783, which classifies it as highly developed.11 Between 1980 and 2013, Oman’s gross national income per capita increased by about 119.8%, while life expectancy at birth increased by 16.8 years. The country has undergone a rapid epidemiologic transition since 1970, and a major focus on primary health care has resulted in substantial gains in child and maternal mortality (Table II) and fewer deaths due to communicable diseases.12 Recent reports also indicate that rapid motorization due to increased economic growth has resulted in increasing numbers of road injuries, but at the same time, emergency and trauma care services have lagged behind in providing timely care to patients.13 There is considerable variation in health expenditure among the GCC countries (Table I). With relatively modest per capita health expenditure, Oman’s age-standardized mortality and years of life lost due to injuries are high compared with other GCC countries. Much attention has been paid to the road safety programs and infrastructure development in these high-income developing countries; however, little emphasis has been placed on the access and delivery of trauma care services across the region.8 BURDEN OF INJURIES IN OMAN With more than 56% of the total population under 25 years of age, injuries are the leading cause of years of life lost and DALYs in Oman.14 Injuries pose a considerable burden to the health care system, and in 2013, injuries were recorded at a rate of 877 per 10,000 population across all Ministry of Health (MOH) institutions. The inpatient rate of injury admission was 40 per 10,000 population during the same year, and injuries were also the top cause of hospital-based mortality among those aged 1 to 44 years.9 Among injuries, falls are the most common cause of inpatient

(27.9%) and outpatient (33%) visits, followed by road traffic injuries and exposure to mechanical forces.9 A review of data from the Royal Oman Police collected over the past decade reveals that the rate of road traffic crashes and injuries has been declining (Fig 1). The latest global status report on road safety indicates that the majority of road injuries involve car occupants (64%) and pedestrians (23%).17 Fifty-nine percent of all deaths recorded nationwide were the result of road injuries, and over half of all prehospital deaths were also secondary to transport injuries.9 Most of the fatal road crashes were reported from Muscat, North Al Batinah, and Al Dakhliya, which are industrial areas located on the northern coastal and central part on the country connected with large highways.15 According to the National Center for Statistics and Information, 80% of road injuries and 71% of road fatalities were among Omani nationals in 2010, and despite a 64% recorded decline in road injuries and an 18% decline in road deaths in 2015, this ratio of Omani and expatriate victims has remained consistent.16,18 Although road injuries are also considered to be an important contributor to disabilities in Oman, the estimates are dated and there is little information on the size of the disabled population secondary to injuries.19 Some studies suggest that Oman had 7.2 years lived with disability/100 persons due to disabilities in 2004, but the details and context of these disabilities are unknown.20 This highlights the lack of data on injured patients after they leave the hospital and reflect, in part, an underdeveloped rehabilitation scheme in the country. OMANI HEALTH SYSTEM Prior to 1970, Oman lacked a formally defined national health care system.21 A few missionary hospitals existed in the capital, Muscat.22 Since

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Table II. Health indicators of Oman Population (*000) total Omani Expatriates Health indicators Life expectancy at birth Crude birth rate/1,000 population Crude death rate/1,000 population Infant mortality rate/1,000 live births Under 5 mortality rate/1,000 live births Maternal mortality rate/100,000 live births

1995

2000

2013

2,091 1,552 539

2,401 1,777 623

3,855 2,172 1,683

67.4 34 6.1 20 27 22

73.38 32.58 3.65 16.7 21.7 16.1

76.6 33.8 2.9 9.8 11.8 12.3

Source: Annual Health Report, Oman Ministry of Health.

Oman road injury trends: 2002-2014 2500 2019.58

2000 1500

1797.93

1625.37

1108.12

1000

941.39 757.98 569.31

500 291.39 0

21.37 2002

228.57 21.9 2004

243.3 21.9 2006

(A) Injuries

318.81

339.18

375.96

28.7 2008

27.63 2010

36.85 2012

(B) Deaths

118.48 25.96 2014

(C) Crash rate

Fig 1. Trend over time in (A) Injuries. (B) Deaths. (C) Road traffic crashes. *Injury and fatality rate expressed per 100,000 population.15 Crash rate per 100,000 registered vehicles. Source: Royal Oman Police Annual Statistics; National Center for Statistics and Information, Annual report.16

the ascension of Sultan Al-Qaboos bin Said in 1970, heath care administration has become centralized and is delivered through the MOH. The Directorate General of Health Affairs at the MOH is responsible for the planning and implementation of effective health policies and programs with the input and cooperation of governorate-level health authorities (Fig 2). The country is divided into 11 regions or governorates. Those along the northern coastal line are heavily populated and urbanized. The government provides free health care to all citizens, and MOH is the major payer for health care in Oman, with out-of-pocket payments estimated to be only 12% of the total health expenditure.22,23 Expatriates seek medical care for injuries through emergency departments, which is free of cost, and in some instances are provided with medical insurance by their employer for nonemergency conditions.24 The health care system in Oman is

population based, and health facilities are provided throughout the country in a tiered fashion. The system operates hospitals and health centers at national, regional, and local levels that act as a continuum of care (see Table III).21 Primary and extended health care centers are distributed to cater to widely dispersed villages and local communities (Table III). Secondary care hospitals are located in large towns, called wilayat. Tertiary care and referral hospitals are mainly located in the capital, Muscat.25 In addition to the MOH institutions, these services are supplemented by other government hospitals, such as those run by the Ministry of Defense, Royal Oman Police, the Sultan Qaboos University, and the Petroleum Development Authority of Oman. Numbers from 2014 indicate 19.9 physicians and 45.7 nurses/10,000 population as compared to 9.0 doctors and 26.0 nurses per 10,000 population in 1990.9,23 Approximately 71% of doctors are employed by the MOH, whereas the rest work in the private sector or the above governmental nonMOH entities. Until 2013, there were 12 hospitals and over 1,200 private clinics registered in Oman, with 1,685 doctors and 2,432 nurses employed by the private sector exclusively.9 Prehospital care. The Public Authority for Civil Defense and Ambulance, launched in 2004, is primarily responsible for the delivery of prehospital care in Oman utilizing qualified advanced emergency medical technicians (EMTs). The ambulance service was initially designed to target road traffic injuries in the Muscat Governorate but is now responsible for all general medical emergencies and trauma in the capital, as well as other parts of the country.26 The Public Authority for Civil Defense and Ambulance has a goal response time of 20 minutes for rural areas and 10 minutes for urban areas.26-28 Over two-thirds of total calls attended are for trauma victims in the Muscat

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Fig 2. Organization chart: Ministry of Health Oman. Source: Annual Health Report, Ministry of Health, 2016.9

Table III. Geographical Distribution of MOH Health Institutions as on December 31, 2015 Health centers (HC)

Hospitals

Governorates

Total health institutions

Total

With bed

Without bed

Extended HC

Total

Local

Wilayat

Governorate

Muscat Dhofar Musandam Al Burayami Ad Dakhliyah North Al Batinah South Al Batinah South Ash Sharqiyah North Ash Sharqiyah Adh Dhahriyah Al Wusta Total

38 40 7 9 31 30 22 24 22 18 13 254

32 33 4 7 25 25 17 20 16 16 10 205

1 21 3 3 3 4 6 6 3 7 8 65

27 12 0 3 18 16 8 12 11 8 2 117

4 0 1 1 4 5 3 2 2 1 0 23

6 7 3 2 6 5 5 4 6 2 3 49

2 6 2 1 3 3 4 2 4 1 2 30

0 0 0 0 2 1 0 1 1 0 0 5

4 1 1 1 1 1 1 1 1 1 1 14

Source: Oman Ministry of Health.

and Al-Batinah regions. Air ambulance facilities are limited to the Dhofar region during the annual “Khareef” festival. Funding for emergency medical services (EMS) comes exclusively from the government, and EMS services are provided free of charge for all patients regardless of their insurance status.26 The EMS system is still in its infancy, as demonstrated by the limited number of nationwide emergency calls and thin volume of services provided in the central parts of the

country (Fig 3). For instance, in 2012, the total number of calls responded to by the EMS was 9,230.28 It is reported that 25% to 50% of seriously injured road traffic crash victims are still not transported via ambulance, and field triage is limited or compromised due to the lack of a tiered system of designated trauma care facilities.25,29,30 EMTs provide care in the field and are trained in basic and advanced life support; however, the EMS does not offer dispatchassisted medical care.28

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6000

5000

4000

3000

2000

1000

0 Muscat No. of cases 5535

North South North South Ad Al Al Al Al Al Musan Al Al Dakhli Dhofar Buraim dam Wusta Dahira Sharqi Sharqi Batina Batina yah i h h ya ya 1572 572 521 317 70 197 60 115 195 76

Fig 3. Distribution of cases across governorates attended to by EMS. Source: Public Authority of Civil Defence and Ambulance, Oman, 2012.28

Acute care hospitals and rehabilitation. Fourteen regional hospitals provide secondary and tertiary care for a governorate’s population and are generally located in the governorate’s main cities. These hospitals have emergency departments usually staffed by general practitioners with some experience in emergency medicine. Trauma care capabilities are limited and mostly located in the northern coastal urban tertiary care centers of the Muscat, Al Batinah, and Ad-Dakhliya regions, though a significant number of road traffic crashes (>30%) occur in other parts of Oman. Four Muscat hospitals---Royal (oncology, cardiology, and child health), Al-Nahda (ophthalmology and otolaryngology), Khoula (trauma and surgical), and Al- Masarra (Psychiatric hospital) ---serve as national referral centers. Among the tertiary care referral centers, Khoula Hospital is the only national trauma referral hospital. This center was developed as a predominantly surgical treatment center and acquired the function of trauma center over time. Trauma surgery as a separate specialty, however, is still not well developed, and most of the trauma care provided in Khoula is through general surgery and orthopedics specialists. According to national estimates, Khoula Hospital alone provides inpatient care to up to a quarter of all injured patients of the country and is specialized in burn and neurosurgical care.9,30 In contrast, Sultan Qaboos University Hospital, which operates outside of the MOH structure, has a dedicated trauma service

led by qualified trauma surgeons (trained in Canada) and advanced facilities (eg, angioembolization) but caters to far fewer numbers of trauma patients because most are referred to the Khoula Hospital by default.31 In terms of rehabilitation programs, this field remains underdeveloped with a paucity of resources in the Sultanate.19,32-34 Over 100,000 patients use outpatient physiotherapy each year, but current capabilities are below the level of demand, and long-term, community-based, and team-based multidisciplinary rehabilitation services are currently inadequate.24 As of 2015, there are only 1.25 physiotherapists per 10,000 population in Oman.16 Data from the neighboring Kingdom of Saudi Arabia (KSA) reveal a comparable situation: of all the patients referred for physical rehabilitation due to lower limb amputations, injuries are the underlying cause in 44% of cases. The availability of rehabilitation services, however, are scarce; there are 0.56 physiotherapists or physiotherapy technicians per 10,000 population.35 In contrast, high-income countries, such as Australia, New Zealand, and the United States, have 5 to 6 physiotherapists per 10,000 population; Nordic countries, known to have a large aging population have set the standard even higher with 12 to 21 physiotherapists and occupational therapists per 10,000 population.20 In Oman, Sultan Qaboos University and Khoula Hospitals are the only centers in the country that offer outpatient neurorehabilitation treatment for traumatic brain injury patients.33,36

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There are no training programs for rehabilitation physicians or therapists; hence, as of 2012, there were only 15 occupational therapists in all of Oman.32 Private sector hospitals are few and their role in trauma care and rehabilitation is not well established. It is also important to mention that while quality control and performance improvement programs are at early stages in government sector hospitals, these programs do not exist in the private sector. Moreover, there is no official hospital accreditation system in Oman, and some reports suggest that sometimes unqualified managers are running health care facilities, including hospitals and health centers, which could be a result of undefined standards of governance, management, and service delivery.21 Only 2 private hospitals have acquired international accreditation through the Joint Commission International, whereas no government-run institution is internationally accredited. Human resources. Due to the government’s continuous efforts, over the years there have been considerable gains in health manpower.10 The expertise and number of health care providers, from physicians to rehabilitation specialists and auxiliary services, have improved over time. Like many of its neighbors, Oman has a large population of expatriate workers, and the health care sector is also heavily dependent on this expatriate workforce. This is evidenced by the fact that approximately 75% of qualified, trained, and professional health care staff were non-Omani in 2002.21 Over the past several decades, the national government has reduced this dependence through “Omanization,” encouraging both the public and private sectors to hire Omani citizens rather than expatriates. In the health sector, Omanization among doctors, dentists, pharmacists, and nurses collectively working for the MOH has reached almost 55.1% in 2013; this is in contrast to health administrators who are 97% Omanis. Development of human resources in the health sector has been facilitated by 2 government initiatives: first, fully sponsored programs for Omani students to obtain overseas education and specialization, and second, establishment of educational and training institutions in Oman. To create incentives for Omani workers to take in-country jobs, policies have been enacted to provide Omanis with strong employment protections and higher positions.37 As a result, since 1990, the health sector has seen significant (40%–50%) increases in the number of locally trained Omani nurses (62%), radiographers (63%), and laboratory technicians (60%).9 Despite these efforts, capability in certain specialties is still limited. According to 2014 statistics,

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only 414 specialist surgeons and 47 emergency medicine specialists are working in the MOH. Although Oman medical specialty board-certified emergency medicine graduates are becoming more common, currently there is no local specialty board for trauma surgery and critical care, which severely restricts the availability of dedicated, locally trained trauma surgeons in MOH hospitals.38,39 Moreover, of 13,059 nurses working in MOH hospitals throughout the country, there are only 716 emergency and 719 critical care nurses.9 Professional organizations under the Oman Medical Association have already established societies of public health, surgery, emergency medicine, orthopedics, and plastic surgery to enhance the professional and ethical practice of medicine, coordinate and collaborate with international academic institutions and associations, and help members find job opportunities.40,41 Little is known about the regular activities regading continuing medical education, skill development, and annual meetings offered through these professional organizations. Policies around injury prevention and research initiatives. Injury prevention and control has an important place in the health care agenda of the Omani government. Given that one of the leading causes of death and disability in Oman is RTIs, road safety is of particular concern.42 The Sultanate has a National Committee for Road Safety with the goal of a 25% reduction in RTI fatalities by 2020. The United Nations’ 2013 Global Road Safety Status Report highlights that enforcement of speed limits in Oman is less effective when compared to other high-income countries. Similarly, maximum speed limits in Oman are higher both on urban and rural roads in comparison to similarly developed countries.17 Similar observations are true for rear seatbelts and child restraints, which remain relatively underutilized. A summary of road safety initiatives is presented in Table IV. In addition to road injuries, the country has placed special emphasis on the reduction of fallrelated injuries, especially among very young children and older individuals. Reducing injuries involving unskilled laborers, poisoning, and assaults are also of priority.24 Other causes of injuries, such as household injuries, drowning, and environmental injuries such as heat stroke, have not been addressed as a priority in current policies. Despite having a good electronic health information system at all levels of health care services, use of such information is limited in decisionmaking and planning.21 Until recently, most trauma research was confined to hospital-based case series, cross-sectional studies, and review

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Table IV. Status of road safety in Oman Oman traffic policies and enforcement Lead agency National road safety strategy Fatality reduction target National speed limits Overall enforcement National drink-driving law National motorcycle helmet law Helmet standards National seatbelt law Seatbelt wearing rate National child restraint law National law on mobile phones while driving Universal access phone number Seriously injured transported by ambulance Emergency medicine training for doctors Emergency medicine training for nurses Policies for investment in public transport Policies to promote walking or cycling Policies to separate road users to protect vulnerable road users

National Committee for Road Safety Fully funded 25% by 2010 Yes, but urban and rural limits vary by terrain 9 out of 10 points Yes Yes No Yes 97% drivers. Other occupants not known No Yes 9999 11%–49% Yes Yes Yes Subnational Subnational

Source: WHO global status report on road safety 2015.

papers. Research around national priority issues is sparse and limits the evidence for informed policymaking and program planning. Various reasons for this discord have been cited, including poor communication between researchers and policymakers, ineffective dissemination of results, lack of technical capacity in policy processes, and difficulties in the uptake of scientific findings due to the lack of strong lobbying.43 Implementation of science and translational research is in its infancy in the Arab world, including Oman. Indeed, Oman’s research productivity has been the lowest among GCC countries when adjusted for country population.44,45 Recognizing the importance of research to understand priority issues and to provide effective interventions, the Research Council of Oman initiated a strategic program on road safety research in 2010. The program’s objectives were to encourage researchers from inside and outside of the Sultanate to submit research proposals, to increase research capacity in the field of road safety, and to provide scientific research results to relevant decision-makers.46 The themes of the program were accident analysis and prevention, behavioral and social issues, trauma care services, and legal and compliance issues. OPPORTUNITIES FOR SYSTEMS STRENGTHENING With high rates of injury and injury-related fatality, investment in both health system development and injury prevention policies in Oman is needed. Due to

a largely centralized health system and government financing for health care, most policy changes and interventions could be implemented more effectively and widely. Several opportunities for improvement of trauma care in Oman, from prevention to care, are discussed in the following section. (1) Strengthening service delivery for improved trauma care. Facility-based trauma care should be improved by upgrading existing health care facilities, increasing the number of trauma care facilities, or moving toward an inclusive trauma care system. Not only is more specialized care desirable, but a better distribution of these services in all regions of the country also is required. This also necessitates the expansion of existing EMS services, especially in the central parts of Oman. Introduction of field triage and dispatch-assisted medical care could shorten the transport time to trauma care facilities and simultaneously help improve prehospital care.47 Bringing private institutions under the auspices of the MOH, for integrated health care delivery and uniformity of services, could be useful in providing care to those who prefer private hospitals over public health facilities.48 An effective system of health care governance that focuses on accountability, quality improvement, and an appropriate accreditation system for trauma care will set the foundation for reducing death and disability by injuries at all levels of care. (2) Implementation of trauma registries and an injury surveillance system across MOH hospitals. Like other GCC countries, Oman has a good

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health information system with electronic medical records. Lack of in-depth data on quality of trauma care and effectiveness of injury prevention initiatives, however, limits the ability of policymakers to direct funds toward focused interventions. Implementation of trauma registries can provide the in-depth data required for improved injury prevention efforts and better quality of trauma care.49,50 Neighboring countries, such as the United Arab Emirates and Qatar, have already embarked on such initiatives, which are providing important lessons for the region. Literature based on trauma registry data is charting pathways for identifying risk factors, vulnerable populations, and specific injury prevention strategies.51-54 (3) Investment in specialty-based human resource development. The American Association for the Surgery of Trauma convened an ad hoc committee in 2005 to define the future role of the trauma surgeon and recommended to include expertise in trauma surgery as well as acute care surgery and surgical critical care.55 The Omani government has already invested heavily in human resource development, particularly for those seeking higher education and specialty training, providing an opportunity to further develop the disciplines of trauma surgery and emergency medicine. The return of internationally trained specialists in Omani hospitals poses an opportunity coupled with a challenge. The opportunity lies in further advancement of the field of trauma care by harnessing their energy and drive to promote and enhance prevention, acute care, and rehabilitation. The challenge is to reduce the administrative work that is counterproductive and may lead to frustration; the way forward is to direct their ideas and enthusiasm toward new initiatives.41 Professional socities in collaboration with the MOH can play an important role in providing the right platform and fostering relationships with international counterparts to keep them up-todate and motivated. Before all hospitals can be equipped with qualified emergency physicians and trauma surgeons, unmet needs of basic trauma care knowledge and skills must be addressed. In the interim, steps should be taken to better prepare existing staff through mandatory advanced life support courses. Although internationally accredited courses, such as Advanced Trauma Life Support (ATLS), are preferred, locally developed workshops and courses taught by qualified clinicians could become an alternative and efficient way of bridging the knowledge gap for emergency staff. The relatively neglected fields of rehabilitation and occupational therapy can also be enhanced to

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support the injured and disabled population of Oman. Many young survivors of road crashes and other injuries can benefit from rehabilitation programs aimed toward making them socially and financially independent, thus reducing the burden on the family members caring for them on a longterm basis. (4) Health care financing. Health care systems around the world depend on a mix of funding sources, mainly derived from government taxation and social health insurance as well as private sources. Omani health expenditure is 88% based on government funding and therefore well utilized by Omani nationals. However, despite a large number of expatriate workers in almost all GCC countries, including Oman, it is reported that less than 30% of the migrant population are covered in pension plans and social insurance schemes.56 Thus, expanding health care financing through alternative sources such as fees-for-service, thirdparty insurance plans should be explored. Availability of employer-supported health plans, especially for injury and disability insurance among migrant workers, cannot be understated. Bringing the private sector on board to play a sustainable role in health service delivery is crucial. Medical saving accounts may be introduced to ensure financial risk protection for chronic illnesses or to prevent catastrophic health expenditure, for both nationals and the non-national population. (5) Injury prevention programs focused on vulnerable populations and high-risk environments. Focused efforts toward the reduction of vehicle speed, enforcement of seat belts and child restraints, creation of safer work environments for laborers, and home- and school-based interventions to reduce childhood injuries are vital aspects of any national injury prevention and control strategy. Utilizing the National Committee for Road Safety combined with a focused improvement of the trauma system in the Sultanate could potentially streamline the government’s efforts toward a comprehensive reduction in injury-related morbidity and mortality. Creating platforms where injury prevention experts and leading health care professionals can synergize their efforts to design preventive and curative strategies will open up a new avenue for concerted action in trauma care. There is a need to allocate more financial resources for injury prevention and safety promotion, not only for road traffic injuries, but also for safer communities, childhood injury prevention, and mitigation of occupational hazards. (6) Research around trauma and injury. Bridging the gap between health research and

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policymaking is a 2-way process and requires concerted efforts. To be well received by policymakers, research studies must take into account governmental vision, resource constraints, equity, and burden of disease measures. At the same time, platforms and forums must be created where policymakers can sit down and discuss studies or research findings with health researchers and understand relevant implications for planning or improving trauma care services. Examples of such research include trauma outcomes studies leading to trauma system development, emergency care benchmarks, and economic cost analyses. These studies would help health care providers, policymakers, and health system administrators to understand the gaps in quality of care, growing burden of disabilities, and evidence for resource allocation. The uptake of the findings will provide a foundation for performance improvement across the entire health system, but also advocacy for allocating resources for both prevention and curative care. In conclusion, it is imperative for Oman to work toward a safe and healthy environment for young people who are currently losing productive years of life to injuries. Although the health sector has a major role to play, other sectors, such as transportation safety, law enforcement, engineering, and public health, must also contribute and work toward combating the growing burden of injuries and trauma in Oman. Creating a sustainable and accountable health care system that creates an enabling environment for better trauma care across the country will not only help reduce morbidity and mortality from trauma but also ensure a more equitable distribution of resources for the entire population. Strong national leaders and injury prevention champions can drive focused efforts toward an inclusive national strategy. REFERENCES 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013;380:2095-128. 2. Mokdad AH, Jaber S, Aziz MI, AlBuhairan F, AlGhaithi A, AlHamad NM, et al. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet 2014;383:309-20. 3. Data Visualization by indicators. The World Bank, 2013. 4. World Health Statistics Geneva, Switzerland: World Health Organization, 2015. 5. Bener A, Crundall D. Road traffic accidents in the United Arab Emirates compared to Western countries. Advances in Transportation Studies;2005:Section A 6.

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6. Bener A, Yousif A, Al-Malki M, El-Jack I, Bener M. Are road traffic fatalities affected by economic growth and urbanization development? Adv Transp Stud 2011:89-96. 7. Abbas AK, Hefny AF, Abu-Zidan FM. Seatbelt compliance and mortality in the Gulf Cooperation Council countries in comparison with other high-income countries. Ann Saudi Med 2011;31:347. 8. Bener A, Al Humoud SM, Price P, Azhar A, Khalid MK, Rysavy M, et al. The effect of seatbelt legislation on hospital admissions with road traffic injuries in an oil-rich, fast-developing country. Int J Inj Contr Saf Promot 2007;14:103-7. 9. Annual health report. In: Department of Health Information and Statistics MoH, ed. Muscat (Oman): Ministry of Health, Sultanate of Oman; 2016. 10. Statistical year book 2013. In: Information NCfSa, ed. Muscat (Oman): National Center for Statistics and Information, Sultanate of Oman; 2013. 11. Oman- HDI values and rank changes in the 2014 Human Development Report: United Nations Development Program, 2014. 12. Ganguly S, Al Shafaee M, Al Lawati JA, Dutta P, Duttagupta K. Epidemiological transition of some diseases in Oman: a situational analysis. East Mediterr Health J 2009;15. 13. Al-Reesi H, Ganguly SS, Al-Adawi S, Laflamme L, Hasselberg M, Al-Maniri A. Economic growth, motorization, and road traffic injuries in the sultanate of Oman, 1985– 2009. Traffic Inj Prev 2013;14:322-8. 14. Wang H, Dwyer-Lindgren L, Lofgren KT, Rajaratnam JK, Marcus JR, Levin-Rector A, et al. Age-specific and sexspecific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013;380:2071-94. 15. Oman Road Traffic Accident Statistics- Facts and figures. Oman: Royal Omani Police, 2015. 16. Statistical Year Book. National Center for Statistics and Information, Sultanate of Oman, 2016. 17. Global Status Report on Road Safety. Geneva, Switzerland: World Health Organization; 2015. 18. Statistical Year Book. National Center for Statistics and Information, Sultanate of Oman, 2011. 19. Al-Balushi T, Al-Badi AH, Ali S. Prevalence of disability in Oman: statistics and challenges. Can J Appl Sci 2011;1:81. 20. World Report on Disability. Geneva, Switzerland: World Health Organization; 2011. 21. Al Dhawi AA, West DJ Jr, Spinelli RJ, Gompf TA. The challenge of sustaining health care in Oman. Health Care Manag 2007;26:19-30. 22. Alshishtawy MM. Four decades of progress: Evolution of the health system in Oman. Sultan Qaboos Univ Med J 2010;10:12. 23. Framework for health information systems and core indicators for monitoring health situation and health system performance. Nasir City (Cairo): World Health Organization, Regional Office for the Eastern Mediterranean; 2014. 24. Country Cooperation Strategy for WHO and Oman 20102015. Cairo, Egypt: World Health Organization, 2010. 25. Al-Azri NH. Emergency medicine in Oman: current status and future challenges. Int J Emerg Med 2009;2:199-203. 26. Al-Shaqsi SZ. EMS in the Sultanate of Oman. Resuscitation 2009;80:740-2. 27. Al-Shaqsi S, Al-Kashmiri A, Al-Hajri H, Al-Harthy A. Emergency medical services versus private transport of trauma patients in the Sultanate of Oman: a retrospective audit at the Sultan Qaboos University Hospital. Emerg Med J 2014;31:754-7.

ARTICLE IN PRESS 10 Mehmood et al

28. Annual Statistics. Muscat, Oman: Public Authority of Civil Defence and Ambulance; 2012. 29. Al-Shaqsi S. Models of international emergency medical service (EMS) systems. Oman Med J 2010;25:320. 30. Grant CS, Al-Kindy N. Surgery in Oman. Arch Surg 2005; 140:21-5. 31. Al-Harthy A, Al-Hinai A, Al-Wahaibi K, Al-Qadhi H. Blunt cerebrovascular injuries: a review of the literature. Sultan Qaboos Univ Med J 2011;11:448. 32. Al Busaidy NS, Borthwick A. Occupational therapy in Oman: the impact of cultural dissonance. Occup Ther Int 2012;19:154-64. 33. Al-Adawi S, Burke DT. Revamping neurorehabilitation in Oman. J Sci Res Med Sci 2001;3:61. 34. Al-Sinawi H, Al-Alawi M, Al-Lawati R, Al-Harrasi A, AlShafaee M, Al-Adawi S. Emerging burden of frail young and elderly persons in Oman: for whom the bell tolls? Sultan Qaboos Univ Med J 2012;12:169. 35. Health Statistical Annual Book 1433. Kingdom of Saudi Arabia: Ministry of Health, KSA, 2012. 36. Burke D, Shah M, Dorvlo A, Al-Adawi S. Rehabilitation outcomes of cardiac and non-cardiac anoxic brain injury: a single institution experience. Brain Inj 2005;19:675-80. 37. Al-Barwani T, Chapman DW, Ameen H. Strategic brain drain: implications for higher education in Oman. High Educ Policy 2009;22:415-32. 38. Alshishtawy M. Medical specialties in Oman: scaling up through national action. Oman Med J 2009;24:279. 39. Board OMS. Training programs. Oman: Oman Medical Specialty Board; 2014. 40. Declaration of Objectives, Oman Medical Association. Sultanate of Oman; 2001. 41. Reid JD. The emergence of surgical expertise in the care of the critically injured patient in the Arab gulf states. Sultan Qaboos Univ Med J 2009;9:113-5. 42. Al-Kharusi W. Update on road traffic crashes. Clin Orthop Relat Res 2008;466:2457-64. 43. Al-Riyami A. Health researchers and policy makers: a need to strengthen relationship. Oman Med J 2010;25:251. 44. Thomas V. “Think Research” in everyday clinical practice: fostering research culture in health care settings. Oman Med J 2011;26:75.

Surgery j 2017

45. Al-Maawali A, Al Busadi A, Al-Adawi S. Biomedical publications profile and trends in gulf cooperation council countries. Sultan Qaboos Univ Med J 2012;12:41. 46. Research Programs of the Research Council. The Research Council of Oman, 2017. Available at: https://home.trc.gov. om/tabid/65/language/en-US/Default.aspx. 47. Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep 2012;61: 1-20. 48. Holder Y, Organization WH. Injury surveillance guidelines. Geneva: World Health Organization Geneva; 2001. 49. Mehmood A, Razzak JA, Kabir S, MacKenzie EJ, Hyder AA. Development and pilot implementation of a locally developed trauma registry: lessons learnt in a low-income country. BMC Emerg Med 2013;13:4. 50. Stevens KA, Paruk F, Bachani AM, Wesson HH, Wekesa JM, Mburu J, et al. Establishing hospital-based trauma registry systems: lessons from Kenya. Injury 2013;44:S70-4. 51. Eid HO, Barss P, Adam SH, Torab FC, Lunsjo K, Grivna M, et al. Factors affecting anatomical region of injury, severity, and mortality for road trauma in a high-income developing country: lessons for prevention. Injury 2009;40: 703-7. 52. Osman OT, Abbas AK, Eid HO, Salem MO, Abu-Zidan FM. Alcohol-related road traffic injuries in Al-Ain City, United Arab Emirates. Traffic Inj Prev 2015;16:1-4. 53. Abdelrahman H, El-Menyar A, Al-Thani H, Consunji R, Zarour A, Peralta R, et al. Time-based trauma-related mortality patterns in a newly created trauma system. World J Surg 2014;38:2804-12. 54. Al-Thani H, El-Menyar A, Abdelrahman H, Zarour A, Consunji R, Peralta R, et al. Workplace-related traumatic injuries: insights from a rapidly developing Middle Eastern country. J Environ Public Health 2014;2014:430832. 55. Committee to Develop the Reorganized Specialty of Trauma SCC, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma 2005;58:614-6. 56. Batniji R, Khatib L, Cammett M, Sweet J, Basu S, Jamal A, et al. Governance and health in the Arab world. Lancet 2014;383:343-55.