West Bank

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

intrahealth — Wed, 19 Jun 2019 22:50:54 +0000

What Does It Take to Strengthen Health Systems in a Fragile State? intrahealth June 19, 2019

June 19, 2019

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

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.)

By Eva Canoutas

Senior Technical Manager, IntraHealth International

Palestinian Health Capacity Project Health Workforce & Systems West Bank

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Early Termination of West Bank Project Affects 120,000+ Clients and 100,000+ Health Workers

mnathe — Fri, 08 Feb 2019 13:49:33 +0000

Early Termination of West Bank Project Affects 120,000+ Clients and 100,000+ Health Workers mnathe February 08, 2019 February 08, 2019

IntraHealth International’s Palestinian Health Capacity Project shut down its activities on January 31—eight months before the project was scheduled to end—due to a request by the US Agency for International Development (USAID) in response to the new Anti-Terrorism Clarification Act.

This early termination will affect more than 120,000 clients who seek specialized medical care outside the West Bank and thousands of West Bank health workers who had been benefiting from the project’s preservice and continuing education and digital health improvements.

Since 2013, IntraHealth led this five-year, USAID-funded project that strengthened the West Bank’s health system by reforming its patient medical referral system and better preparing its health workforce to meet the population’s diverse needs. But in December, USAID asked IntraHealth and other USAID-supported NGOs in the West Bank and Gaza to end projects by January 31, due to the new act.

The quality and availability of health care will suffer today for Palestinian patients.

The project was on track to meet its objectives, but without its final eight months to transition its interventions to the local health sector, the sustainability of the program’s results is at risk.

“The years the project has invested in creating more self-reliant and stronger health systems, supported by the American people, are at risk of being wasted,” says Pape Gaye, president and CEO of IntraHealth. “The quality and availability of health services will suffer today for more than a hundred thousand Palestinian patients. We will also lose the opportunity to learn from and document the unique experiences of strengthening health systems in an area prone to conflict—lessons that could inform some of the biggest development challenges we face around the world today.”

Improvements and cost-savings for client referrals will be jeopardized

The West Bank has very few tertiary-level hospitals that can provide advanced medical care and access to specialists is limited. When clients need specialized care that’s not available in the public health system, the Palestinian Ministry of Health refers them to local private- or NGO-managed hospitals or to hospitals abroad. Referrals drastically increased in recent years—from 8,000 in 2000 to 62,000 in 2013—and nearly half were directed to service providers outside the West Bank, mostly in Israel.

Referrals are also expensive—in 2014, the annual cost of referrals peaked at $100 million.

But the Palestinian Health Capacity Project helped reform the referral system, defining referral eligibility protocols, standardizing referral approvals and processing, and negotiating agreements with referral hospitals on better prices for certain medical services. The project developed an eReferral web-based application to track and regulate referrals and minimize delays in much-needed care. The project also helped set up customer service centers where clients could ask questions and process paperwork.

The improvements and yearly savings will be jeopardized or lost.

These efforts led to dramatic improvements in the overall appropriateness of referrals (referrals following new eligibility protocols rose from 41% to 88% in 2016) and helped reduce the total cost of referrals from West Bank health facilities to Israeli hospitals by 34%, or about $32.6 million annually. They also streamlined the process for both clients and hospital administrators.

Ceasing the project’s activities now—without a transition plan implemented—will affect 122,000 Palestinian clients who receive referrals for medical treatment outside the Palestinian public health care system. The improvements through referral reform and yearly savings of 120 million NIS ($30 million) will be jeopardized or lost.

Health worker education programs will halt

The Palestinian Health Capacity Project improved health worker preservice education, continuing professional development programs, and licensing and certification systems.

The project equipped Palestinian nursing educators and students to better care for clients with complex medical needs by introducing a new competency-based critical care nursing curriculum at all nursing colleges in the West Bank. And it integrated patient safety and service quality principles into undergraduate health sciences programs, revised residency program curricula to match international standards, and established guidelines for continuing professional development for health workers.

The critical care nursing curriculum will face difficulties in sustainability and compliance.

Terminating the integration of safety and quality principles into undergraduate health sciences programs alone will affect 1,500 undergraduate health professional students currently enrolled. Losing the improvements in residency curricula will affect 500 residents currently enrolled in the four residency programs. And the critical care nursing curriculum, without the oversight and monitoring the project provided, will face difficulties in sustainability and compliance by college administrations, affecting the 600 undergraduate nursing students who are currently using it.

Sustainability and benefits of digital health tools will be lost

The project also improved the governance and use of the national health information system (HIS) to expand access to health information and increase accountability and efficiency of health facilities and workers.

By working to integrate the HIS with other systems and build the capacity of stakeholders at the national and facility levels to lead HIS initiatives and use data to inform health-sector decisions, the project helped the Palestinian Ministry of Health save 427,000 NIS ($122,120) by independently implementing its HIS in Tubas Turkish Hospital.

The project’s early end jeopardizes about 2.1 million client records in the HIS. It also inhibits the development of a continuing professional development electronic system intended for use by all health professional associations in the West Bank—this affects 100,000 health professionals. Once fully implemented, the system would have provided access to information and online courses, and would have allowed providers, for the first time, to track health education, enhancing the capacity to plan for health professional development and providing a mechanism for licensing and relicensing for health workers.

This forced early closure blocks to the road to self-reliance in the West Bank.

The project invested more than $2.2 million in developing digital health information systems and tools for referrals and continuing professional development, as well as a business intelligence tool, all of which have enhanced the quality of health care and increased timely access to information for decision-making and planning. While many aspects of the system have been installed, the full cycle of its work has not been tested yet, and the project’s closure will negatively affect its successful administration and sustainability.

“IntraHealth is proud to have worked on locally tailored and innovative solutions to address the largest barriers to sustainable access to essential health services in the West Bank, including addressing the high number of patients who must seek services in Israel or in private Palestinian or NGO-managed facilities,” says Salwa Bitar, IntraHealth’s chief of party for the project. “The forced early closure on such short notice prevents the effective transition of these solutions and blocks the road to self-reliance in the West Bank.”

West Bank Technology Policy & Advocacy Health Financing Health Workforce & Systems Health in ConflictA surgeon at work in the West Bank, where USAID-supported NGOs have been forced to cease their activities. Photo courtesy of IntraHealth International.Palestinian Health Capacity Project

Palestinian Ministry of Health Saves Money, Improves Quality of Care through Its Health Information System

intrahealth — Wed, 07 Feb 2018 19:10:15 +0000

Palestinian Ministry of Health Saves Money, Improves Quality of Care through Its Health Information System 2018 intrahealth February 07, 2018

The Palestinian Health Capacity Project (PHCP), led by IntraHealth International with funding from the US Agency for International Development (USAID), is helping the ministry implement and expand its health information system in four governmental hospitals throughout the West Bank. The Tubas implementation was the first to be conducted solely by the ministry—a key achievement toward sustainability of the system. This success story describes the process and impact of the implementation.

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Countries West Bank

Projects Palestinian Health Capacity Project

Topics Digital Health

Publisher IntraHealth International

Picture It: Now, Customer Service Centers

intrahealth — Wed, 08 Nov 2017 20:42:06 +0000

Picture It: Now, Customer Service Centers

intrahealth November 08, 2017

Picture It: West Bank Health Workers Use New Online Resource Centers to Prepare for Ebola and Other Health Care Challenges

intrahealth — Tue, 10 Oct 2017 19:10:51 +0000

Picture It: West Bank Health Workers Use New Online Resource Centers to Prepare for Ebola and Other Health Care Challenges

intrahealth October 10, 2017

Stronger Health Systems Can Provide Palestinians with Better Health Care

intrahealth — Mon, 18 Sep 2017 21:15:33 +0000

Stronger Health Systems Can Provide Palestinians with Better Health Care intrahealth September 18, 2017

September 18, 2017

Improvements can help Palestinians access better health care today—and prepare for the unknowns of tomorrow.

Outside the Palestinian Medical Complex in Ramallah, I saw a woman emerge from the crowd. She looked frantic with worry and purpose as she approached.

She needed the doctor who was accompanying me, or rather his signature on a referral form—a formality that stood between her and the specialized health care she, or perhaps a loved one, needed.

I was there last month to visit our Palestinian Health Capacity Project, which is doing crucial and challenging work to help the Palestinian Ministry of Health rationalize its patient referral system, improve continuing professional development for its health workforce, and strengthen its health information system.

This woman was the perfect illustration of the purpose of our project. My colleague stopped to review and sign the form, and told me it happens all the time.

It is not easy for Palestinians to access the health care they need.

Lives depend on forms like the one that woman was carrying.

Primary care is available in the West Bank and Gaza, but quality is an issue. Clinicians deal with extraordinary caseloads and do not have systematic opportunities to routinely update their skills and knowledge. Underlying these problems is a severe shortage of health workers.

I visited a beautiful, new, 10-bed pediatric ward at the Palestinian Medical Complex. Only two beds were functional. There weren’t enough human resources to run the ward even close to its capacity.

In fact, the public health system is not equipped with the staff or facilities to provide most tertiary (or specialized) care. If you need such care—like dialysis or treatment for cancer—you must get a referral to a private hospital in the West Bank, East Jerusalem, or abroad.

Lives depend on forms like the one that woman was carrying.

The Cost of Referrals

Referring so many of its clients to hospitals outside of its own system is not ideal for the ministry. But at this point in time, it’s necessary—and very costly.

In 2014, referrals to Israeli hospitals cost the Palestinian authority a mindboggling $100 million.

IntraHealth International has been working with the ministry of health since then to standardize the system and bring down costs. There are now agreed-upon prices for services with referral hospitals and processes in place to ensure each referral is medically necessary.

In 2015 and 2016, the costs dropped by 30% compared to 2014.

While I was visiting, the ministry launched an eReferral system to further streamline the mostly paper-based process and opened the first of several planned customer service centers where health care clients can ask questions or get information, rather than having to track down their doctors on the hospital steps.

We’ve also helped the ministry develop a national strategy for continuing professional development and to strengthen its health information system, which will provide powerful data to inform decisions.

Systems in Distress

When I spoke with health workers and officials in West Bank, most of them said our contributions are helping them get organized—helping establish processes and collect data to increase efficiency, reduce costs, and provide information the health sector can use to improve care.

They are right. This is part of what we call systems strengthening.

As I prepared for my trip, someone asked me why IntraHealth is engaged in strengthening a health system that is operating in chronic distress. After all, everything is patchwork. How can a thriving health system ever exist when there is no end in sight to the occupation and the threat of violence is part of everyday life? Isn’t it a losing battle?

My answer is no.

Palestinians don’t just need health care someday down the road. They need it today.

Of course this type of work is not business as usual, and the immediate goal cannot be a state-of-the-art, high-functioning health system that offers every level of impeccable care. But because there is a semifunctioning system in place, we can help the ministry lay stronger groundwork for when things improve, and at the same time make the health system more efficient and resilient right now.

Simply put, we can help the government provide the best possible care to its people, even in these difficult circumstances.

To do that, the typical linear approach—assessing and updating policies, developing and rolling out standards and protocols, and so on—won’t work. Instead, we must be prepared to deal with emergencies as they come (and they will come) while also establishing improvements that can survive the emergencies.

At the same time, saving money—such as through referral reform—puts the ministry in a much better position to continue improving systems for better health care. And by addressing critical issues of access and quality, the ministry can help the Palestinian population achieve better health and better lives.

Good health is just the first step. West Bank is ready for multisector approaches. Despite the ongoing conflict, Palestinians are seeing new economic opportunities, particularly in the technology sector. Health and economic development can come together and improve not only health, but also engagement in civil society, governance, and the economy.

We simply cannot and should not wait for the conflict to end before strengthening these health systems. Palestinians don’t just need health care someday down the road. They need it today.

This post originally appeared in HuffPost. The Palestinian Health Capacity Project is funded by the US Agency for International Development.

Banner photo of Palestinian nurse by Marie-Claire Boyle (CC BY-NC-SA 2.0)

By Pape Amadou Gaye

Founder & President, Baobab Institute

Palestinian Health Capacity Project Health Workforce & Systems West Bank

I get a demonstration of the health information system during a visit with health workers in the Pediatric Emergency Department at the Palestinian Medical Complex. Photo by Jihad Mashal for IntraHealth International.

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Health Systems Innovations Help the Palestinian Ministry of Health Save Money and Improve Access to Specialty Care

cbales — Fri, 15 Sep 2017 17:24:42 +0000

Health Systems Innovations Help the Palestinian Ministry of Health Save Money and Improve Access to Specialty Care cbales September 15, 2017 September 15, 2017

Last month, the Palestinian Ministry of Health launched a new electronic medical referral system and opened its first Customer Service Centers. These efforts will help the ministry streamline referral processes, improve client experience, and ultimately increase access to specialty care for Palestinians. The Palestinian Health Capacity Project, led by IntraHealth International and funded by USAID, helped the ministry design and roll out these innovations.

The ministry serves approximately 4.6 million people living in the West Bank and Gaza. When clients need specialized care that is not available within the Palestinian health sector, the ministry refers them to private or NGO-managed facilities in the West Bank and East Jerusalem, or abroad—mostly in Israel.

Over the last 15 years the number of medical referrals skyrocketed from 8,000 to 62,000 per year, and became a challenge for the ministry to manage and finance. In 2014, the annual cost of referrals peaked at $100 million.

Since 2014, IntraHealth has been helping the ministry reform its referral system, including establishing an official communication pathway with referral hospitals, defining referral eligibility protocols, standardizing referral approvals and processing, and negotiating agreements with referral hospitals on better prices for certain medical services, admissions processes, and invoicing.

So far these efforts have led to dramatic improvements in the overall appropriateness of referrals (those that follow the newly defined eligibility protocol rose from 41% to 88% in 2016) and a 30% decrease in overall referral costs in 2015 and 2016 (compared to 2014).

eReferral system

To further streamline the cumbersome paper-based process and minimize delays in accessing much-needed care, the project helped the ministry develop and pilot an electronic medical referral system. In mid-August, the ministry began to scale up its "eReferral” web application—it went live at 12 ministry hospitals and will soon be made available at more than 40 referral facilities in the West Bank and Israel.

The new eReferral system will ensure information about referral authorizations, medical procedures, follow up, and invoicing can be easily tracked, approved, or shared as needed by all stakeholders, including officials at the originating public hospitals, the ministry’s Service Purchase Unit, and referral facilities, as well as patients. The system will also produce regular reports to provide data to ministry decision-makers to inform future referral planning.

Customer Service Centers

On August 23, the Palestinian Ministry of Health opened its first Customer Service Centers in three government hospitals and at the ministry’s Service Purchase Unit, which oversees the referral process. The new centers will provide a comfortable atmosphere for clients to meet face-to-face with ministry staff to initiate new referral requests, check the status of existing referrals, and receive timely answers to questions. The Palestinian Health Capacity Project provided equipment and furniture for the center and created training materials, job descriptions, protocols, and procedures.

The Customer Service Centers will also provide clients with access to the eReferral system—they can log in themselves using their ID number. Clients can provide in-person feedback on the new system and the specialty services they receive.
“In opening these Customer Service Centers, we aim to not only improve patients’ access to health care,” said Palestinian Minister of Health Dr. Jawad Awwad, “but to raise awareness of medical treatments and patients’ rights and responsibilities regarding medical referrals.”

A history of strategic interventions

“We applaud the Palestinian Ministry of Health’s focus on customer service and digital health,” said IntraHealth’s President Pape Gaye at the grand opening of the center. “The centers and eReferral system align with IntraHealth’s mission to improve the performance of health workers worldwide and strengthen the systems in which they work.”

Prior to the ministry engaging with the project, no standardized criteria existed for issuing or approving medical referrals, and decisions largely depended on individual judgement. That meant the ministry had no way to predict or control costs, and the process, processing time, and quality of the referrals were inconsistent. Together the ministry and the project have increased the appropriateness and financial regulation of referrals. And now, with these two additional innovations, aim to increase patient knowledge about referrals and decrease the time it takes to process and approve them.

”The majority of these referrals are for complex tertiary care that cannot be treated within the Palestinian Ministry of Health sector,” said Dr. Amira Hindi, director of the Service Purchase Unit at the Palestinian Ministry of Health. “We are today referring more cases than before, at a lower cost and higher quality.”

West Bank Health Workforce & Systems Quality of CareIntraHealth International’s president Pape Gaye (third from left), Palestinian Minister of Health Dr. Jawad Awwad (fourth from left), USAID West Bank and Gaza Mission Director Monica Stein-Olson (fifth from left), IntraHealth's Chief of Party for the Palestinian Health Capacity Project Salwa Bitar (second from right), and others at the launch of the eReferral system in August. Photo by Jihad Mashal for IntraHealth International. Palestinian Health Capacity Project

Improvements to the Palestinian Medical Referral System Significantly Reduce Costs

intrahealth — Thu, 08 Jun 2017 20:27:30 +0000

Improvements to the Palestinian Medical Referral System Significantly Reduce Costs 2016 intrahealth June 08, 2017

This brief describes improvements made to the Palestinian Medical Referral System under the Palestinian Health Capacity Project.

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Countries West Bank

Projects Palestinian Health Capacity Project

Topics Health Financing

Publisher IntraHealth International

Updating Standards in Post-Graduate Surgical Education

intrahealth — Wed, 09 Nov 2016 17:41:09 +0000

Updating Standards in Post-Graduate Surgical Education 2016 intrahealth November 09, 2016

This success story describes how the Palestinian Health Capacity Project facilitated the first-ever revision of the Palestinian National General Surgery residency program curriculum.

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Countries West Bank

Projects Palestinian Health Capacity Project

Topics Education & Performance Surgeons

Publisher IntraHealth International

Rapid Assessment of Health Services Capacity in the West Bank

Anonymous — Thu, 06 Oct 2016 19:02:47 +0000

Rapid Assessment of Health Services Capacity in the West Bank 2014 Anonymous (not verified) October 06, 2016

Author: Stilwell, B, et al.

Description: This report presents an initial analysis of information collected to support the reform of the referral processes in West Bank/Gaza. The Palestinian Health Capacity Project has collected and analyzed data between January and February 2014 that relate to three aspects of referrals:

The cost and number of referrals being made from secondary to tertiary care across West Bank/Gaza.
Distortions in referrals that result in higher costs for referrals to Israeli hospitals.
The current capacity of referral hospitals in West Bank/Gaza to treat more of the cases that are currently referred to Israeli hospitals.

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Countries West Bank

Projects Palestinian Health Capacity Project

Topics Measurement and Evaluation

Publisher IntraHealth International

Series Technical Brief 1

By Barbara Stilwell