In Oman, no security for the migrant health workers fighting the pandemic
Oman, like other Gulf states, has used migrant workers to achieve its development goals but has consistently failed to give back.
On the 50th anniversary of Sultan Qabus coming to power in a palace coup d’etat - an event often seen as the founding of the modern Omani state - we consider the impact of the coronavirus pandemic on Oman from the perspective of ‘human security’ for Omani citizens and first and second generation foreign migrants.
The broadening of the agenda of security studies in the 1990s moved beyond an almost exclusive state-centred concern to encompass the concept of ‘human security’. In this conceptualization the referent object of security - what or who is being threatened - was widened from the state to embrace human communities and their security from threat, including threats to health - a prime one being a pandemic disease. Following Sultan Qaboos’ death in January 2020, Oman’s response under Sultan Haitham to the current challenges of COVID-19 and associated low oil prices is placed in context as we critically assess the development of Oman’s health system since 1970 and important related issues of education, migration and citizenship.
Oil for health
When Sultan Qaboos took power on 23 July 1970 removing his father, Sultan Sa’id bin Taimur, in a British-supported palace coup d’etat at the height of the Dhofar War, the so-called Nahda (Renaissance) started in the country. Pursuing a very cautious budgetary policy, Sa’id bin Taimur had little concern for the welfare of the Omani populace who often had to migrate to the other Gulf states to find work, and health services were limited. Emerging from Britain’s informal empire in the Gulf, over the next fifty years Oman under Qaboos pursued important achievements in economic and social development and sought to adapt the local Islamic religious discourse (Ibadism) and its value-system to a modernization process.
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This modernization process has taken place embedded in the Omani version of the ‘rentier’ state in which the state, through its accrual of large revenues from the hydrocarbons sold on the world market can exact political quiescence from the population by offering ample subsidies and public sector jobs and yet not need to extract revenue from the population in taxation.
The health sector, financed through the burgeoning oil and gas revenues, was developed in a rapid and impressive way
Drawing on revenues from oil exports which had started in 1967, far-reaching plans for socio-economic development were implemented, and delicate balances were pursued between the various components of the Sultanate and the powerful tribes of the interior. Continuity and innovation apparently merged, affecting the welfare and health sectors as well. The latter, financed through the burgeoning oil and gas revenues, was developed in a rapid and impressive way.
In July 1970, when life expectancy was 49 years, there were only two hospitals, run by an American Mission, and ten clinics and dispensaries in the whole country. Three years later there were already nine fully operative hospitals at Ruwi, Salalah, Tan‘am, Matrah, Muscat, Nizwa, Rostaq, Sohar and Sumail, and rising numbers of health centres and dispensaries in each region.
The Ministry of Health developed the system in three main stages. Between 1976 and 1990 the focus was mainly on health infrastructure building, then between 1991 and 2005 new strategies were adopted to establish a system of decentralised health centres, widely spread in eleven health administrative divisions throughout a country divided in seven administrative regions. In such a way, the right to free primary health services could rapidly be guaranteed to Omani citizens almost everywhere, from urban areas to the most isolated rural and Bedouin’s areas, from the mountains to the desert and the coasts.
Between 2006 and 2010 more comprehensive plans were conceived to involve both central health institutions and local structures in the various divisions, in order to better address the new challenges. Health initiatives based on prevention became a top priority: while malaria and other infectious diseases had been eradicated in a few years, non-communicable diseases had started increasing with modernisation.
The relevance of a community-based approach comes to the fore: in 2000 Oman reached the World Health Organisation’s top ranking for the ability to invest efficiently in health improvements, apparently without disparities. Such an approach seems to be quite consistent with the Ibadi ethos, which contributed throughout the centuries to “weld together Omani society into a unity that was relatively little divided by social barriers”.
The social principles of “justice, equality, and equal opportunities between Omanis” are also clearly expressed in article 12 of the Basic Statute of the State, declaring the state’s responsibility “for public health and the means of prevention and treatment of diseases and epidemics”, and adding that “the State endeavours to provide healthcare for every citizen and encourages the establishment of private hospitals, polyclinics and medical institutions.” The latest available data, related to the quality of health developed during Sultan Qaboos’ reign, place Oman in line with the other GCC member States and in the group of countries with the highest human development (see figure 1).
However, although there have been significant investments in health care infrastructure, the quality of health care in Oman, does not necessarily meet modern standards. According to a survey, 43% of Omanis would prefer to get treatment abroad. That is particularly evident when it comes to some non-communicable diseases, in which treatment is also influenced by the quality of research. At the same time a recent study notes that Oman together with the other GCC states, is “currently experiencing an increased demand for health care services due to an immense population growth, increasing life expectancy and higher incidence of non-communicable diseases”. To meet these expanding needs the role of migrant workers in the health sector, as in other parts of the economy, has been critical.
Migrants on the health frontlines
Immigrants are crucial to several sectors of Omani economy due to a labor shortage of native populations in various public and private economic sectors such as education, health, manufacturing, finance, and business. In fact, the whole healthcare sector depends heavily on expatriates. This is true for all GCC states: For example, expatriate staff make up 78% of health care professionals in Saudi Arabia and 85% in UAE.
The role of migrant workers in the health sector, as in other parts of the economy, has been critical
Oman in general “is a major recipient of South Asian labor immigrants, and correspondingly, the demographic statistics reveal that the non-Omani populations primarily are constituted of the Asians”. The four largest immigrant groups constitute immigrants from India, Bangladesh, Pakistan and Sri Lanka. While the majority of immigrants are low-skilled, Mansour “highlights significant clusters of Indian and Pakistani high-skilled immigrants in urban residential communities within the Muscat governorate”. Despite the fact that a remarkable increase took place in the number of health care workers there is still a huge shortage. This is also due to migration and citizenship policies in the Gulf which neither favour naturalisation of immigrants nor their integration on a social and cultural level.
Kafala (Arabic for sponsorship), the work-permit sponsorship system in operation throughout the GCC, enshrines mechanisms of exclusion and the definition of migrants’ work condition and power relations between migrants and employers. It has been characterised as a form of modern day slavery. The kafala assigns a status of temporariness to migrant populations while a distinction is being made between blue and white collar immigrants and the recruitment of high-skilled workers for example to the health sector has been stressed. These professional expats or immigrants with a specific expertise, contribute to build the countries “knowledge economy”.
Kafala (Arabic for sponsorship), the work-permit sponsorship system in operation throughout the GCC, enshrines mechanisms of exclusion
Besides the fact that all expats working in the health care sector in Oman are based on kafala, there are several challenges with this reliance on expats in general: while this system might have some cost-efficiencies, no continuity of professional care is guaranteed as there is a huge turnover of personnel, as professionals tend to move back to their home countries or to other countries.
Moreover, due to the dependency on foreign health care professionals there is a substantial variation in clinician competence as professionals are being hired from around the globe with different training backgrounds. According to official reports “health services in GCC are provided free of cost to all residents and health insurance is available for both the expatriates and nationals”. The application of this rule to non-nationals, especially blue-collar workers, however, is questionable. Indian workers, as they are working on the front line, were heavily affected by the pandemic diseases. In fact, it was mostly expats who were in need of intensive care. In the course of the outbreak of COVID-19, the Minister of Health, Dr Ahmed al Saeedi, announced free treatment and testing for expats.
A perfect storm
While Omanis were still coming to terms with the death of Sultan Qaboos on 10 January 2020, another massive challenge emerged: the coronavirus pandemic emanating out of Wuhan province in China which inexorably spread around the world forcing governments to impose lockdown measures on their population leading to economic shutdown. Reacting to the grounding of nearly all flights and collapse in demand, the global oil price fell to new lows.
Like most governments the Omani government took drastic steps to curtail the exponential spread of the virus. Sultan Haitham formed a Supreme Committee which imposed progressively severe restrictions. Firstly, barring entry to travellers from China and Iran, then limiting entry to allow only Omani citizens and legal residents, followed by the shutting down of all commercial flights on 29 March (except for to and from Musandam Governorate).
There is little interest in extending citizenship to the migrant populations that make up the majority of the population in most GCC states
In the middle of March, the Supreme Committee announced all government offices would operate on 30 percent staffing and closed all schools and most shops along with other steps. Lockdowns were implemented in Muscat, Dhofar and Duqm; Muscat’s restrictions wre gradually released from April but lockdown was extended in Dhofar to 17 July. Oman’s measures initially were seemingly effective in containing the virus and minimizing the number of deaths but at the end of June the Omani Health Minister announced there had been a disturbing surge in COVID-19 infections and urged adherence to the public health guidelines. By 22 July there had been over 70,000 cases and over 330 deaths and the curve of the infection rate was climbing upwards. However, some Omani analysts believe that it has actually been the collapse of the oil price associated with the shutdown of the global economy which is the greater problem for Oman, compounding long-standing issues and challenges facing its rentier state and economy.
The government of Oman has used the pandemic to accelerate its Omanization programme and the number of migrant workers in the Sultanate fell from 2.1 million in June 2017 to 1.9 million in June 2020. While it has extended free testing and treatment to expats during the pandemic it is clear that the Omani government has not adopted any notion of security of residency as far as migrant workers are concerned who, as in the rest of the Gulf, are regarded as a disposable workforce. Furthermore, the Omani government, like the other GCC states, privileges conceptions of citizenship based around the nation-state. Due to the economic benefits associated with GCC citizenship and national identity projects there is little interest in extending citizenship to the migrant populations that make up the majority of the population in most GCC states and notions of transnational citizenship are restricted.
As part of the history of modern Oman the health sector has without doubt undergone huge reforms in recent decades, yet a long road lies ahead. Our analysis, drawing on our experience as professors and researchers in Oman, nevertheless suggest that the significant and difficult challenge for a successful development of the health sector is rooted also in the development of the country’s educational sector: this includes the raising of educational opportunities for all members of society, including in rural areas and across genders, and above all the quality of educational institutions. It is this quality that can contribute to enhance the role of in-house research in the health field, which was largely neglected in the last fifty years.
Change must come from within, and enlightened change comes from the development of a knowledge-based society holding on to the past with one hand and stretching out to the future with the other. Arguably, another aspect of that enlightenment would be an understanding that immigrant groups have contributed substantially to the socioeconomic development of Oman and that a path to citizenship for these migrants needs to be laid out according to international norms.
Oman, like other Gulf states, have used migrant workers to achieve its development goals and have consistently fallen short of international labour standards let alone considered an inclusive approach to the acquisition of citizenship and associated civil, political and social rights. For this reason, long standing immigrant groups will continue to feel great insecurity and their experience during this pandemic confirms this enduring pattern in the Omani rentier state.
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