UN Millennium Development Goals and Oman

“And I say that life is indeed darkness save when there is urge, and all urge is blind save when there is knowledge, and all knowledge is vain save when there is work...”

Khalil Gibran (1883–1931)

The year 2000 was a special milestone for the global agenda to improve quality of life and especially important for developing countries. In that year, 192 nations of the world met at the United Nations (UN) and signed the “Millennium Declaration”. In the Declaration, 8 Millennium Development Goals (MDGs) were identified to be achieved by 2015.1 The hope is that they will reduce poverty, hunger and disease in developing nations, and provide universal access to health care and education, with emphasis on gender equality in both areas and access to political representation. The 8 Goals (G1-G8) are accompanied by 18 Targets and 62 Indicators. As Oman is marking 40 years of its ‘Renaissance’, it is relevant to reflect how the country has fared in relation to the MDG benchmarks. This Editorial focuses on those MDGs that are germane to health issues.

Help from affluent industrialised countries should be a pivotal incentive for developing countries to accomplish the MDGs by the deadline. An essential prerequisite is that affluent countries provide more aid to developing nations. Although generous amounts were pledged, unfortunately most of the 10 year aid targets have not been reached. To compound the problem, the efforts of many developing countries can hardly be described as stellar. However, the UN has not given up on the MDGs. It organised a summit in September 2010, attended by most world leaders, to celebrate the 10^th anniversary of the Declaration and to check on the progress of developed and developing nations towards the 8 Goals.

Among the nations with success stories is Oman.2,3 Sayyid Badr bin Hamed Al Busaidy, Secretary-General of the Oman Foreign Ministry,4 spoke to the world leaders of Oman’s many successes in the last 10 years. He also drew attention to the negative impact of natural disasters, epidemics and civil unrest on progress in several developing countries. Oman’s development and progress towards the MDGs is a matter of rejoicing as we celebrate the 40^th Anniversary of His Majesty, Sultan Qaboos bin Said Al Said’s enlightened leadership since 1970. Our development in the last 40 years has exceeded all expectations as will become apparent in the following paragraphs.

With respect to the first goal (G1), “Eradicate extreme poverty and hunger”, Oman has reduced extreme poverty to beyond the target set by the UN. This goal has 2 targets, halving both the number of people living in extreme poverty and those who suffer from hunger by 2015. While it is clear that Oman is winning the war against extreme poverty and hunger, some challenges still persist. The number of underweight children below 5 years is still unacceptably high in Oman at 17.9%;3,5 this is a matter of concern given our other positive achievements. However, there is some evidence from health centre patients, that it may have declined to 16.5% or even 10.8%,5 but these figures cannot perhaps be generalised as they refer only to clinic registered patients. Nonetheless, the mortality rate among children under 5 has fallen by 29% since 1990.6 Thus many G1 targets have been met and we still have 5 more years for complete achievement.

With respect to G2, “Achieve universal primary education”, Oman, with universal free education up to and including tertiary level, has been paying particular attention to the quality of education from early childhood onwards. Indeed, Ministry of Education efforts have boosted primary school enrolment to almost 100% in Oman; however, there is a gradual drop-out during primary and secondary school and in tertiary education. This hinders the fulfillment of one Target of this Goal which is for children to complete a full course of primary schooling. Another indicator in this target is the illiteracy rate among the 15–24 year-olds. A barrier to achieving this in Oman, considering the number of high school graduates, is that more opportunities for higher education are still needed. This is despite the fact that the country has instituted major initiatives in developing higher education aiming to increasing vocational skills as well as academic learning. This is an increasing need given Oman’s young population.

As for G3, “Promote gender equality and empower women”, the Target is to eliminate gender disparity in primary and secondary school. The Indicators are the ratio of girls to boys in primary, secondary and tertiary education, and ratio of literate women to men. There may still be some way to go in addressing the gender gap in primary and secondary education, but the Target should be fully achieved before 2015. On the contrary, in the tertiary education, female enrolment is about to exceed that of males and women also play a significant role in the public and private sector workforces. Another Indicator is the portion of seats held by women in national parliaments. Women, in Oman, have taken over many leadership positions with the continued encouragement, support and care of His Majesty, Sultan Qaboos bin Said. For example, we currently have three female government ministers in Oman, and 14 (19.4%) of the 72 seats in our Senate are held by women.7

With respect to G4, “Reduce child mortality”, Oman has successfully reduced child mortality rates, both for under 5 year-olds and infant mortality. The former dropped a staggering 94% from 181 per 1,000 live births in 1972 to 11 in 2008.6,7 This more than meets the MDG target to reduce the under-5 mortality rate by two-thirds by 2015, but globally, Murray Christopher et al. concluded, “we are not doing a better job of reducing child mortality now compared with three decades ago.”8 The other Target is the proportion of one year-olds immunized against measles. Our immunization rate in Oman is at 99%, well above the MDG indicators.6

There have been significant advances in G5, “Improve maternal health.” in Oman. The MDG Target is to reduce maternal mortality ratio (MMR) by 75% by 2015. Indicators are the MMR and the proportion of births attended by skilled health personnel. The proportion of births attended by skilled medical staff in Oman is close to 99%. In addition, Oman currently has almost 100% coverage for antenatal care,6 reflecting an outstanding development of child and maternal health care infrastructure in the last 40 years.

Oman has made efforts to tackle HIV/AIDS to meet G6 “Combat HIV/AIDS, malaria and other diseases”. The Target is to halt the disease by 2015 and begin reversing the spread of HIV/AIDS. The number of reported HIV/AIDS cases in Oman fell to 116 in 2009 from 145 in 1990.3 Another Target is the percent of population with comprehensive and correct knowledge of HIV and AIDS. Oman has also gone out of its way to educate young people about HIV/AIDS with the help of UNICEF officials.3,4 Malaria has been almost completely eliminated in Oman with only 965 cases in 2008 compared to 32,720 in 1990,6 and most of those likely to have contracted malaria outside Oman.

In ensuring the fulfillment of G7, “Ensure environmental sustainability”, Oman is playing its role by trying to green the country and reduce carbon dioxide emissions by ensuring no old cars are on the road. The Ministry of Environment is setting high standards for all new factories. One Indicator is carbon dioxide emissions and consumption of ozone-depleting cholorofluorocarbons (CFCs). There is now only limited consumption of substances such as CFCs in Oman, with a drop from 452 tons in 1992 to 29 tons in 1997.9 The other Targets of this goal are to halve by 2015 the proportion of people without sustainable access to safe drinking water and sanitation; and to significantly improve the lives of at least a 100 million slum-dwellers. Oman has not fully achieved sustainable access to safe drinking water and sanitation in all regions, but the authorities are working diligently on this issue and winning ground.

As for G8, “Develop a global partnership for development”, Oman cooperates with the private sector to make available new information and communications technologies, exactly one of the G8 Targets. Another Target includes commitment to good governance, development and poverty reduction. Oman is on track for all 4 targets of G8 “through national and international measures”, under the visionary direction of the Sultan.

Where does the rest of the world stand in achieving the goals of the United Nations? According to Laila Gad, the UNICEF Representative in Oman,3,9 several countries have achieved success in combating extreme poverty and hunger, improving school enrolments, children’s health, expanding access to clean water, controlling diseases, and treating HIV. Thus, the MDGs can be achieved with the appropriate policies, investment and international support. Oman is an “exemplary success story”. Gad pointed out that the government of Oman has already adopted programmes to combat the problem of underweight children under 5 years old, and that Oman has achieved many successes towards the goals, but she also pointed out that progress has been uneven and the focus on equality is the biggest challenge to advancement. The rural-urban and gender gaps need to be addressed (in Oman) in order to avoid uneven development and this applies to many nations. There is also concern about mortality rates among young pregnant women, like in many other countries. Fortunately, our policy-makers are targeting interventions for this.

In Oman, there are other relatively major problems such as road accidents and non-communicable diseases such as diabetes. Road accidents and non-communicable diseases remain the two greatest challenges for Oman as the Country continues to strive to meet the Millennium Development Goals.2,10,11 We need to take a hard look into these problems as they cause 15% and 60% (respectively) of premature deaths around the world.4 In Oman, significant efforts are being made to improve road safety including public education and research support;10 a new National Diabetes Centre will aid in our struggle with non-communicable diseases.

Given sufficient resources and political will, the MDGs are thus achievable in Oman and elsewhere. If achieved, they would lead to a world with less poverty, hunger and disease and more people with access to better health care and education. Apart from the shortfall of the target in the second goal, namely, the “underweight children under 5 years”, Oman has been very successful and ahead of many nations in attaining the 1^st, 3^rd and 4^th goals, as well as the 5^th and 6^th goals, and there is clear visible progress in environmental sustainability and developing global partnership for development, which are the 7^th and 8^th goals. With the impressive way the Sultanate has progressed, it is clear that we will achieve the UN targets by 2015.12,13

Where do we go from here? The problem is to get the developed nations to stick to their commitments. The UN Goal for each of the developed nations is to contribute 0.7% of their gross national income (GNI) towards helping developing countries achieve these goals by the year 2015. Unfortunately, several countries in Europe, except for the UK, are very far behind this goal.14 “We have no right to do less than what we have decided to do,” French President, Nicolas Sarkozy, told the assembled leaders. The United Nations Secretary-General, Ban Ki-Moon, stressed that the world has to raise US$ 20 billion for humanitarian aid this year if we are to meet the MDGs by 2015.

The BBC News analysed global progress towards achieving the MDGs.15 They pointed out that the 7^th Target has not been achieved. We have not improved the lives of 100 million slum-dwellers neither have the donor nations reached the target of donating 0.56% of their gross national income by the year 2010, and it is unlikely, they will reach the 0.7% target by 2015. While it is true that the richest countries have failed to reach their targets, there is hope for reversal of this as of this year.

US President Obama, following his speech to the UN, announced that US is adopting a new foreign policy to help developing countries.16 He announced initiatives on global climate change, global food security, and global health when he signed a Presidential Policy Directive on Global Development. This is the first time an American administration has ever made such a commitment. US Leadership and international development had taken a hit in recent years and, hopefully, this effort can begin to reverse that trend. Sarkozy, also made an impassioned plea to developed countries to join France in raising their contributions to meeting the MDGs, and said that France would increase its contribution by 20% over the next three years.14

The developing countries must, however, play their role adequately. The African Development Bank Group17 points out that African countries can achieve the MDGs if they re-dedicate and re-commit themselves to them and implement the 7-point Agenda for Action which is intended to strengthen cooperation, both in the private sector and at national level. Statistics from Arab nations are not much better18 although Oman is doing very well compared to many neighbours and other Arab countries. In fact, Oman topped all the Arab nations in the 2003 literacy statistics for G2.18

The UN reports that the world has more than one billion under-nourished people this year. It is estimated that 10.5 million children aged under 5 years die every year from largely preventable conditions.8 About 40% of these deaths occur within the first month of life, thus Oman is not alone in facing the problem of undernourished children. About half a million women die each year as a result of pregnancy. These statistics are stark, but improved economic conditions are expected to reduce the number of hungry people to just over 900 million from the one billion.

The question is what can we do as a medical community? What should be our role in all of this? Unfortunately, the medical community in Oman, in general, has left the responsibility of “health advocacy” to the Ministry of Health. No question, the Ministry of Health has the prime responsibility for the health of Oman, but we, as physicians, can and must play a direct role by educating the public in the better nourishment of their young. We also need to play a more active role in educating the public regarding sanitation, good nutrition and disease prevention. Indeed, we are privileged as university faculty and staff, and it is our social and moral obligation to take positive and definitive steps to improve the health of our fellow citizens and in particular our young ones.

The 2009 Oman National Nutrition Report,5 which alerted us to the 17.9% of our children under 5 years who are under-nourished, should be a wakeup call to all medical personnel, physicians and nurses alike, to play their role in health advocacy in Oman. Indeed, the country will have to tighten its belt in other areas since Oman currently spends far too little on health care, the health care share of gross domestic product (GDP) being only 2% in 2009.6,19 This is only 4% of total government expenditure.19 The Ministry of Health has to be congratulated on what it has achieved on this limited budget, but more needs to be spent to catch up with Gulf neighbours and other developed countries and cope with emerging health care challenges. Almost all the developed western countries spend 7–10% of GDP on health care, except USA, which spends about 16%.20 We are now trying to teach our young physicians at the Oman Medical Specialty Board (OMSB) that “Health Advocacy” is one of the Seven Basic Competencies that they are expected to have upon graduation in their specialisation. We have to teach by example.

To achieve the UN MDGs, all parents in Oman should enrol their sons and daughters in school and ensure they remain in education to secondary and tertiary levels. While Oman vaccinates 99% of the new generation, we have still not quite fully reached the maternal care targets. Let us celebrate the success story of Oman, but not be complacent. Let us be determined to exceed the MDGs under the wise and visionary leadership of His Majesty Sultan Qaboos Bin Said on this 40^th year of the Renaissance of Oman.