low medical density that needs to send patients abroad, at least in the short term, until adequate treatment is provided locally. In Oman, and in a number of other countries, the travelling patient can seek reimbursement if the treatment is not available locally. This sponsoring is very costly, however, and not all countries can afford such schemes. In addition, in many developing countries, medical travel remains driven by a lack of confidence in local health care providers, and remains perceived a luxury rather than a necessity.

In countries, mainly in the North, where treatment is more expensive than in competing health services provider countries, imports under mode 2 could ease some tensions on health insurance systems and make them sustainable. According to Mattoo and Rathindran (2005), the healthcare system of the US would save USD 1.4 billion annually if only one in ten patients were to go abroad for a limited set of 15 highly tradable, low risk treatments.

# **Case study n°1: Remedying Health Shortages Through Trade under Modes 4 and 2 – The Case of Oman**

Oman is an upper-middle income, resource-rich, and labor-importing country. The health sector is no exception, and Oman is a net importer of health workforce. In 2003, the Ministry of Health employed 18,558 professionals, of whom almost 40 percent were foreigners – up to 76 percent of the physicians. Most health administrators are Omani nationals. The same year, there were 2,838 health professionals employed in the private sector, and 95 percent were foreigners (mostly from India, Egypt, Pakistan, Philippines, Sudan, and Iraq).

# **Foreign Professionals Working in the Public Health Sector in Oman**

<!-- Start of picture text --> 100<br>90<br>34<br>80 39<br>51<br>70 64 65<br>60 76<br>50<br>40<br>66<br>30 61<br>49<br>20 36 35<br>10 24<br>0<br>Physicians Dentists Pharmacists Nurses Assistant Total<br>pharmacists workforce in<br>MOH<br>Omani Foreigners<br>Source: WHO<br>Percentage workforce<br><!-- End of picture text --> Despite these significant imports, the Omani health sector still falls below international benchmarks with a density of 12.6 doctors, 31.6 nurses, 0.7 pharmacists, and 0.7 dentists per 10,000 inhabitants (MOH, 2006). Therefore, Oman has to supplement these imports under mode 4 with imports under mode 2, i.e. send some of its patients for treatment abroad. Accordingly, there is an official policy to sponsor Omanis for treatment abroad if not available locally. The average annual cost was USD 3 million for 2001-2003. The number of patients treated abroad has dropped from 418 in 1990 to 237 in 2006 due to public investments in the sector. In 2006, 44 Omani patients were treated for neoplasm abroad (compared to 180 in 2000), 58 for orthopedic diseases, 39 for cardiac diseases, and 31 for ophthalmologic diseases. Targeted public investment can help significantly reduce the cost of these healthcare imports. For example, government-funded medical travel for oncology fell by 92 percent from 2004 to 2005 after an oncology center opened.

At the margin of healthcare services, Oman also imports medical education services under Mode 2: in 2003/2004, 1,341 medical students received foreign training – 52 percent were government sponsored, and 48 percent selfsponsored.

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