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What Does It Take to Strengthen Health Systems in a Fragile State?


Salwa Bitar answers 6 questions about improving health care on the ground in West Bank.


Eva Canoutas
By Eva Canoutas
Senior Technical Manager, IntraHealth International

Salwa Bitar is a medical doctor with over 30 years of experience in global health and working in fragile states. As chief of party for the IntraHealth International-led Palestinian Health Capacity Project, she led a health systems strengthening initiative in West Bank that focused on medical referral reform, digital health solutions, and human resources for health. She joined us today to share her experience.

Dr. Salwa, what element of your team’s work in West Bank are you most proud of? 

There are many things I am proud of, but I will share two: building the capacity of our local IntraHealth team and of our Palestinian Ministry of Health (PMOH) counterparts.

Our team learned a lot about strategic thinking, planning, rolling out interventions successfully,  quality-improvement techniques, and developing digital health solutions. Most importantly, we used a shared learning approach—team members of every level worked together to come up with solutions and action plans. Adults like this better than classroom training approaches.

On the government side, the ministry IT teams are now capable of expanding and monitoring the health information system at new hospitals. And the Palestinian Medical Council, for the first time, can now revise the curricula of residency programs. They now have electronic logbooks and systems to monitor residency programs in person and virtually. We also reformed the electronic medical referral system—all 12 public hospitals and the Service Purchase Unit (SPU) are using guidelines for electronic referrals.

Development work is not easy. It means lots of patience, long-term vision, long-term planning, but also acting quickly and immediately. You need to find a balance between the two. 

What was your biggest programmatic challenge and how did you and your team find a solution?  

My, our challenges were enormous.

As it relates to development, there were very few staff at the ministry and Palestinian Medical Council, which were our main government partners. There were issues of motivation and resistance to change. But we succeeded in advocating at the highest level of the ministry to increase the number of PMOH staff. The Service Purchase Unit, for example, is the heart of the referrals system, and the PMOH eventually added a couple of staff there, covered by their funds.

Regarding motivation, our best approach was the shared learning workshops, where teams came from different facilities and presented their work in front of each other and high-level stakeholders. It created a positive competition platform.  

We experienced political challenges throughout the project, many beyond our control. West Bank is in an occupied area of Israel—there are checkpoints everywhere and they often restrict movement. Many of our workshops and activities were affected by those checkpoints.

There was also continuous political tension between the US and Palestinian governments—this affected donor visibility and made funding tenuous. At one point, we had to freeze our program for six months.

Improved quality of care is a priority for Palestinians.

Unfortunately, the project ended prematurely in January. How does this affect health care for Palestinians?

Due to the Anti-Terrorism Clarification Act, USAID stopped all projects, including ours. This situation will certainly affect health care for Palestinians.

There was a big program in Gaza for primary health care funded by USAID, which stopped. Gaza has poor primary health care services in general, almost nonexistent tertiary services. The referral system relied on IntraHealth’s technical assistance—and although we achieved many of our milestones, we could have used another year to institutionalize some of the health systems gains from USAID’s investment.

If Palestinian aid resumes in the future, or if other donors expand support to the region, what should they focus on?  

Improved quality of care is a priority for Palestinians.

We have primary and secondary health care, some tertiary health care, but at higher levels, the quality drops drastically. Highly specialized doctors may not be available or they are overwhelmed, and quality as a result is poor.

Health systems are weak—human resources, supplies, equipment, referral systems, drugs are all lacking.

Palestinian people have a public national insurance system that includes around 20 different types of insurance schemes, such as military, poverty, unemployment insurance, while all Jerusalem and Gaza citizens are 100% insured for essential services. This is a generous package. However, the package is not well defined, and patients receive referrals for expensive services outside the essential package that are fully covered by the ministry. This is a huge burden on the ministry, which has no source of funding except donors.

Take baby steps on each element of the health system together instead of working on each piece in isolation.

Your leadership experience in global health is extensive. What key lesson did you learn along the way? What do you still struggle with? 

Development work is not easy. It means lots of patience, long-term vision, long-term planning, but also acting quickly and immediately. You need to find a balance between the two. You need to focus on the quick fixes that can be done now. When we work on capacity building, we need to tailor it to the absorptive capacity of the host country. Let’s not introduce solutions that don’t work in that specific country.

Another thing I learned is that if you try to fix one part of the health system at a time, it doesn’t work. You need to improve the whole system together.

For example, you can’t fix referrals when human resources are not available or capable. All health systems are interlinked. Take baby steps on each element of the health system together instead of working on each piece in isolation.

I struggle with working in fragile states. It always feels like patching. Patch one gap, then three other gaps appear. Setting your priorities is hard in a fragile site.

What advice do you have for the next generation of global health leaders, particularly those working in complex environments?   

My advice is to be ambitious, but don’t let failure discourage you.

You might feel all the right intentions, plans, and strategies are in place, but when working in complex environments, you will no doubt experience failure. Learn from that failure, rebound quickly, and regain your courage—but be sure to change your approach quickly. If you keep doing the same thing, you will get the same results. 

(Interview edited for brevity and clarity.)