The Pharmaceutical Journal
Vol 268 No 7187 p302-303
2 March 2002

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In February 1999 I turned to the back pages of my Pharmaceutical Journal (as many do) and found an advertisement for a job that could have been written especially for me. It was for a post with the Ministry of Health in the Sultanate of Oman. They were seeking a clinical pharmacist with a number of years of experience and a background involving pharmaceutical work in at least one developing country. I scrutinised their list of requirements point by point and, in the main, I seemed to have what was required.

I graduated in 1970 from Heriot-Watt University in Edinburgh and was awarded a PhD from the same institution in 1973. Most of my pharmaceutical career has been spent overseas in the United States, Canada, Malawi and also in Brunei on the island of Borneo. My background has been in teaching, research and hospital pharmacy, and since 1989 I have worked in the field of rational drug use.

My first post in a developing country was in Malawi — the "Warm Heart of Africa" (formerly Nyassaland) from 1989 to 1995. During the period 1993 to 1995 I worked with the World Health Organization Essential Drugs Programme in Malawi. It was during this time I became aware of the huge international efforts underway to control diminishing drug budgets, and met many colleagues working in this field.

I was interviewed for the position in the Sultanate of Oman, in Muscat, in the summer of 1999 and was offered the post of senior clinical pharmacist officer/advisor to start work in May 2000. My job was with the newly created Directorate of Rational Drug Use within the Ministry of Health.

About Oman

The population of Oman is 2.33m (1999) in a country of about 312,000km². Administratively, it is split into 10 regions with the most populous being Muscat Region around the capital city.

Oman is a fascinating country geologically and culturally. It is a complex mixture of the ultra modern and ancient Arabic cultures and its ancient maritime ties with Zanzibar in East Africa are much in evidence. It contains some spectacular scenery ranging from desert with vast sand dunes, to rocky mountains, dry river beds, lush pools and oases of date palms. It has many miles of coastline and palm-lined, beautiful beaches including a nature reserve where hundreds of giant greenback turtles make an annual pilgrimage to lay their eggs. The land is dotted with ancient fortresses perched precariously on rocky outcrops. It also has a scaled down, but no less spectacular, version of the Grand Canyon in Arizona and one of the highest peaks on the Arabian Peninsula. Oman is also one of the hottest places on Earth with summer temperatures in the high 40s and often reaching more than 50C in the interior. In contrast, winter temperatures are like warm summer days in the United Kingdom.

The health system in Oman

The Sultanate has a very progressive health system which has grown dramatically over the past 30 years. In fact, Oman recently achieved the distinction of being voted number one by WHO for the most improved performance in its health system efficiency and good utilisation of financial resources.¹ Medicines in the public sector are free with patients paying only a minimum fee of 1 Rial (= 1000 baisa, about £1.80 or $2.59) for annual registration with a health facility and 200 baisa (36p /52 cents) for each subsequent visit.

Directorate of Rational Drug Use

Oman, like many countries, is concerned about the escalating costs of drug therapies and is keeping a prepared eye on the future. Policy makers firmly believed that action had to be taken immediately to maximise the use of available health resources and minimise waste. The Sultanate of Oman took a bold, new initiative by establishing a Directorate of Rational Drug Use. Thus, on 15 April 2000, the directorate came into being as a result of Ministerial Decree 31/2000.

Organisationally, the directorate comes under, and reports directly to, the Office of His Excellency the Undersecretary for Health Affairs. Thus, the directorate has been given the prime responsibility to research and follow up on all aspects of irrational prescribing, dispensing and drug use. The directorate is staffed full-time by an Omani director, a senior medical officer, a senior clinical pharmacist officer, a chartered accountant /auditor and a secretary. A senior clinical pharmacologist has recently joined the directorate.

Working in Oman

My work in Oman initially involved gathering information on prescribing, dispensing and the use of drugs by patients. The work requires a lot of in-country travel and often to remote and sparsely populated areas. By the end of 2002 I should have visited most of the regions in the Sultanate.

In each region a team of RDU personnel visits the main district hospital and some randomly selected health centres, and studies a sample of prescriptions from each. The prescriptions are examined for a variety of parameters including the WHO prescribing and dispensing indicators which are internationally recognised and comparable.² Additionally, each of the sample prescriptions are studied for clinical content, and access to patients records is sought where appropriate. A financial auditor is part of the team and examines budgets, inventories, costs per prescription and overall consumption. By these methods the directorate is building a large database of information about prescribing and dispensing in the country. Depending on the outcome of our baseline studies we will design interventions to control any problems found. In fact we are now operating on many fronts and already taking a variety of intervention steps.

In order to establish a continuous monitoring system of drug use, the directorate is aiming to recruit assistant pharmacists in the field as researchers. More and more of the health units are becoming fully computerised and this is an amazing achievement in itself. The computerisation of health units has introduced some advantages for us by giving rapid access to certain data. However, there are also some problems with data presentation and storage which we will have to resolve.

Oman is still not self-sufficient in the supply of health care workers and many are recruited from overseas. As a result they come to the country with a variety of backgrounds and experiences. The directorate has established an induction course for all newly appointed general practitioners to the Ministry of Health. This course is an intense immersion into the principles of rational prescribing and drug use and is a mixture of theory, problem tackling and role play. The first workshop was labelled a great success. Follow-up research is planned with the participants from these workshops. The RDU directorate also submits questions on RDU principles and pharmacotherapy to the monthly interview examinations for all new physicians, and plays an active role in subsequent oral examinations.

Oman has its own fully equipped medical school and teaching hospital as part of the Sultan Qaboos University. The campus is located about 50km from the capital city and has state-of-the-art facilities for medical teaching and learning. The directorate has established many collaborative projects with the medical school and is currently involved with teaching part of the therapeutics course. A new course in rational drug use has been established for medical interns on rotation and a similar course for undergraduates is in preparation. I am actively involved with the teaching of these courses.

Public misconceptions and cultural beliefs have a high impact on the rational use of drugs and therefore our work involves interaction with the public in health education and collaboration with specialist units within the Ministry of Health. One of my colleagues has been actively involved with a knowledge, attitudes and practice study (KAP) of the general public in Muscat. This work will be expanded to include other regions. These studies should give an indication of the types of problems encountered and which key messages to focus on for public education.

On other fronts, the team investigates sporadic changes in drug consumption and analyses figures from the medical stores. Additionally, we receive reports on sudden changes in patterns of drug use in different regions from the regional pharmacists. We are often informed of irrational practices or unusual uses for drugs in an area and we are asked to follow these up. Other work in the department has been in facilitating and reactivating Pharmacy and Therapeutics Committees in the district and generally listening to the problems of health workers in the field. We are fortunate that Oman has an excellent infrastructure in place. This makes our tasks much more achievable.

The Ministry of Health has been proactive and visionary in the establishment of the Directorate of Rational Drug Use. By giving the responsibility to a single body it should be easier to study problems of irrational drug use and to make interventions as quickly as possible. It is now up to the directorate to produce results. Many countries will be interested to learn the outcomes of the work carried out here.

I would say that this position has been one of the most interesting and personally fulfilling jobs I have ever had. In the UK it seems that most pharmaceutical eyes are permanently turned westwards. There are many facets of pharmaceutical knowledge; experience gained from countries in all stages of development can prove to be invaluable. So look east, too!

Dr Gunn is Senior clinical pharmacist officer/adviser, Directorate of Rational Drug Use, Ministry of Health, Sultanate of Oman