Rebuilding from the Inside
A Conversation with Dr. Salaheddin Safadi, Syria’s Ministry of Health brought in a strategist with a mandate: reconstruct a broken sector and land it where it deserves to be.
When liberation came in late 2024 and Syria’s new government began staffing its ministries, Dr. Safadi moved. In April 2025 he joined the Ministry of Health as Head of Strategy, crossing back into the country he had spent years trying to serve from outside, now with a mandate to work on the system itself. The task he inherited was not simply one of reconstruction but one of reunification, because three parallel health architectures had emerged over fourteen years of war: the Damascus-centered government network, the NGO-sustained system in the northwest, and a third structure in the northeast, each with its own institutions, funding logic, and inherited habits. Bringing them under a single national framework, while simultaneously closing deep workforce gaps, rehabilitating damaged infrastructure, and reducing the out-of-pocket spending that crushes Syrian households, is the work Dr. Safadi is now leading.
We spoke with him in Damascus about what the past year has revealed, where the constraints bite hardest, and what it will take to reach the health system Syria deserves by 2031.
You spent years working on Syria’s health system from the outside. What did you find when you finally came inside, and what has been hardest to move?
The scale of the damage was not a surprise, I had been watching it from Gaziantep for years, trying to work around it. What I did not fully anticipate was how deeply the bureaucratic structure itself would become an obstacle to recovery, separate from the physical destruction, separate from the workforce gaps.
Syria’s public administration runs on paper, including forms, approvals, and physical signatures, and that system exists everywhere: inside the Ministry, across its affiliated bodies, at every level of implementation. When you are trying to move fast, and we must move fast, a paper-based bureaucracy is not merely inefficient but structurally incompatible with the pace of reform we need.
The workforce dimension compounds this considerably, because specialists emigrated during the war and did not return, which means you are working with reduced human capacity inside an apparatus that was already slow by design.
I contributed to a research note that framed Syria’s situation this way: the country entered the post-liberation period carrying three separate administrative health systems simultaneously, namely the Damascus-centered structure, the northwest, and the northeast, each of which had developed its own institutions, its own dependencies, and its own way of doing things. They did not dissolve when liberation came, and the task of unifying them is one of the defining challenges of this phase, one that cannot be done quickly or by decree alone.
How is that unification actually happening?
It is happening in three steps, each of which serves as a prerequisite for the next.
The first is mapping, because you cannot plan what you cannot count. We are documenting the human resources that exist across all regions, including where the cadres are, what specializations they hold, and what gaps exist, and that assessment is nearly complete.
The second is incorporation: the health infrastructure built in the northwest and northeast during the war, including the clinics, the referral networks, and the trained staff, needs to be formally brought inside the national service map. Much of it functions, but it has been operating outside the central system’s accounting, which means we have been planning with an incomplete picture of what Syria actually has.
The third is a rapid needs assessment for secondary and tertiary care, which is where the gap is most acute. The systems in the northwest and northeast were built almost entirely around primary care, which was the humanitarian priority and made sense at the time, but referral pathways for complex cases were improvised or nonexistent. As we draw the new national health map, we need to build proper corridors for populations in camps and remote areas who currently have no structured access to anything beyond basic care.
Private sector investment in post-conflict health systems is a fraught subject. Iraq is the cautionary example everyone cites: a two-tier system, high-quality private care in cities, degraded public care everywhere else. How does the Ministry manage that risk in Syria?
It is one of the things we are working on most seriously, because the governance framework that regulates the relationship between the state and the private sector was, before liberation, severely distorted and in many respects not functional at all. We are building it now, from close to nothing.
The core principle is uniform standards. Public and private facilities must operate under the same accreditation requirements, the same quality benchmarks. If that holds, the structural condition that produces a two-tier system, where private care operates under fundamentally different norms, is addressed at the root, not patched at the edges.
Syria is open to investment. The Ministry coordinates closely with the Investment Authority, the Ministry of Finance, and the Ministry of Economy to create real pathways for private capital in health. But I want to be honest about a term that circulates in these conversations: “organic development.” The idea that the private sector will grow naturally, following its own logic, and that the result will serve the national interest. I am not fond of that framing. The private sector does not grow organically. It grows where capital flows. Our role is to regulate and channel that flow, to ensure it serves the national system rather than pulling away from it. That requires active governance, not passive confidence.
On the urban-rural gap: that disparity already exists within the public sector, and we are not pretending otherwise. Closing it requires making peripheral postings genuinely attractive to health workers, not only through salary but through training access, professional development, regional workshops, and participation in the broader medical community, because people do not only follow money; they follow opportunity and recognition, and that is what we are trying to create.
Out-of-pocket spending in Syria is among the highest in the region. What brings it down?
It currently stands at around 45% of total health spending, and the target for 2030 is 40%, which may sound like a modest five-percentage-point reduction but is anything but.
The strategy to bring it down runs on four parallel tracks.
The first is government spending: we have a commitment from the Ministry of Finance to increase public health expenditure by 0.5 percentage points annually, from approximately 7.8% of the budget today to 10.3% by 2030, and every point that government spending rises, household exposure falls correspondingly.
The second is primary care reform. A strong primary care system, accessible, prevention-focused, free or nearly free at the point of use, reduces the number of people who reach secondary and tertiary care in the first place. We are designing an essential services package that every Syrian can access at no or minimal cost: both an equity intervention and a direct mechanism for reducing household health expenditure.
The third is health insurance. We are currently targeting 1.6 million employees and their families by the end of 2028. That is a starting point. Over time, coverage needs to extend to private sector workers and broader segments of the population, with public and private insurers alike operating within the national framework. The logic is straightforward: the more people in a risk pool, the lower the catastrophic exposure for any individual household.
The fourth track is the Ministry’s own financial independence. We are working to reduce dependence on NGO financing. That dependence is not neutral. It shapes priorities, creates parallel structures, and introduces distortions in how resources get allocated. A Ministry with stable domestic revenue streams is a Ministry that can actually plan. Reducing NGO dependence is both a governance objective and a financial one.
Sixty percent of Syria’s health facilities have structural problems. How do you decide where to start?
We could not answer that question with instinct alone, so we needed to build a framework.
We built a prioritization matrix around a set of variables: population density and catchment size; availability of existing health cadres in the area; access time, meaning the actual time it takes a patient to reach a facility; urban or rural character of the community; poverty rates; and the state of basic infrastructure, including power and connectivity. Each factor is scored and weighted. The output is a ranked list, produced separately for primary and secondary care.
The matrix is imperfect, and the underlying data is uneven in quality, but it produces a defensible allocation logic, which matters more than precision at this stage, because it means we can explain to any observer, and to ourselves, why we are investing here rather than there.
One variable carries particular weight right now: displacement. Communities absorbing large numbers of internally displaced persons, such as southern rural Idlib, Deir ez-Zor, parts of Homs, and parts of eastern Aleppo, move up the priority list because they are receiving large displaced populations, and rehabilitating their health infrastructure is both a service delivery decision and a returns policy. Our goal as a country is to bring people home, and you cannot bring people home to places without functioning health systems.
Where are the workforce gaps most severe?
We are finalizing the first draft of a health labor market assessment, the most comprehensive picture we have been able to build of the sector’s human resource situation. It has taken time. The workforce has been highly dynamic: movement across the country, structural changes inside the Ministry, the difficulty of counting cadres in regions only recently reconnected to the central system. The data is imperfect. But the shape of the problem is clear.
Nursing is the most critical gap, and specifically specialized nursing, including intensive care nurses, dialysis nurses, and other technical roles that require targeted training and cannot be filled by general clinical staff, and these shortfalls are deep enough that they will not close quickly.
Among physicians, the gaps concentrate in specializations with long training pipelines, such as anesthesiologists, nephrologists, hematologists, and certain surgical subspecialties, which are precisely the categories where emigration hit hardest and where the distance between what we have and what we need is most difficult to close.
Geographically, the damage follows the conflict: the northern and eastern governorates, the areas that saw the most sustained destruction and displacement, carry the largest deficits, while some coastal and central governorates have relative sufficiency. The problem is heavily concentrated in the periphery, which is precisely where the capacity to attract staff through market mechanisms is weakest.
This last point is worth naming plainly: the public sector cannot currently compete with the private sector on salary, specialist physicians can earn more in private practice, and that gap will persist for the foreseeable future. Compensation alone will not close it, so the approach has to be broader, encompassing the professional environment, training, recognition, and the sense that working in the public system means being part of something that matters.
What is the digital infrastructure reality, and what is the path forward?
Syria’s digital infrastructure was degraded by war and neglect simultaneously: in many facilities, basic network connectivity does not exist, equipment is absent or non-functional, and the institutional reflex at every level of the system is still to reach for paper.
The ambition is clear: we are moving toward DHIS-II as the foundation for a national health information system, and from there, over time, toward electronic medical records across Ministry facilities. That is not aspirational language but the actual plan, though it requires simultaneous progress at multiple layers, including physical infrastructure, legal frameworks, equipment, and a genuine shift in how staff think about documentation, because progress on one layer without the others does not produce a functional system, and each constraint is real and has to be addressed.
We are not trying to recover to 2010; we are building for where Syria needs to be now.
What do you say to investors looking at the Syrian health sector?
Syria has 23 million people and a health system built for a fraction of what they need, and that gap is not a risk narrative; it is a market.
The sector took extraordinary damage. Secondary care, tertiary care, diagnostics: these are areas where demand is real, where the public sector cannot move fast enough on its own, and where private investment, properly regulated, can generate returns and deliver genuine impact for Syrian patients simultaneously. You will not find that combination easily in this region.
What the Ministry offers in return is a commitment to reduce bureaucratic friction, to work within a clear and consistently applied regulatory framework, and to facilitate the approvals and operational conditions that serious capital requires. We are not asking for a leap of faith; we are asking investors to look at Syria clearly, at the need, at the political direction, at the pace of reform, and to make a considered judgment, because those who come in good faith will find the Ministry a genuine partner.
Close your eyes and open them in 2031. What do you see?
I see a health coverage index of 70, up from 63 today, with out-of-pocket spending brought down to 40% from 45%, government health expenditure reaching 10.3% of the budget, and external funding dependence, currently between 25 and 28%, reduced to 20%.
I see every damaged facility rehabilitated and operational, with a second wave of renovation underway for facilities that function but are deteriorated, and hospital capacity, particularly in intensive care, grown by 5 to 10% above current levels.
I see a workforce strategy that has stabilized staffing across governorates, alongside a revitalized national board certification and training system, one that restores what Syria was genuinely good at, which is producing outstanding physicians and sending them into the world, except this time we send them into our own communities first. Every Ministry employee trained, current, and connected to global clinical standards.
I see health insurance reaching well beyond 1.6 million people, and an essential services package available to every Syrian, everywhere in the country.
Syria had a health sector it could be proud of, and we lost it, but we are going to build it back, not to what it was, but to what it should have become. That is the mission, and it is achievable.
Conclusion
What emerges from this conversation is not a portrait of a ministry improvising its way through crisis, but of one attempting something considerably more ambitious: the construction of a coherent national health architecture from the wreckage of three parallel systems, under conditions of severe fiscal constraint, workforce depletion, and infrastructural damage that touches the majority of the country’s facilities. The challenges Dr. Safadi describes are not sequential but simultaneous, and simultaneous, and the interdependencies between them are what make the work so demanding. A digital transformation cannot proceed without connectivity; a staffing strategy cannot hold without incentives that extend beyond salary; a regulatory framework for private investment cannot function without the institutional capacity to enforce it.
Yet the specificity of the Ministry’s targets, including a health coverage index of 70 by 2031, out-of-pocket spending at 40%, insurance coverage extending well beyond 1.6 million people, and government health expenditure rising to 10.3% of the national budget, suggests a leadership team that has moved past the diagnostic phase and into the harder business of planning against measurable outcomes. The prioritization matrix for facility rehabilitation, the phased approach to system unification, and the essential services package under design all point in the same direction: a deliberate attempt to replace the improvised structures of the war years with something durable and nationally accountable.
For investors, the signal is clear: Syria’s health sector represents one of the most significant unmet-demand environments in the region, and the Ministry is actively building the governance and regulatory infrastructure needed to channel private capital productively. The question is no longer whether the need exists, but whether the institutional conditions are forming fast enough to support serious deployment, and on the evidence of this conversation, the trajectory is credible.
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