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What now for the future of Ukraine’s healthcare system?

Elizabeth Kuiper

Date: 20/02/2023
One year on, the Russian invasion of Ukraine is, above all, a human tragedy. The humanitarian scale of the disaster and the raging nature of the conflict are horrific and will have tremendous long-term consequences for Ukraine’s healthcare system. The EU must start looking beyond the immediate impact of the war and address the future challenges for Ukraine’s healthcare sector. This can be achieved by prioritising investment to support the recovery and modernisation of the healthcare system, tailoring the needs of veterans and civilians, developing a long-term vision on how to expand the country’s rehabilitation and mental health services system, and allowing Ukraine to join EU health agencies.

According to the World Health Organization (WHO), there have been 747 verified attacks on healthcare facilities since the start of the Russian invasion on 24 February 2022, resulting in 131 reported injuries and 101 reported fatalities of healthcare personnel and patients. As of December 2022, there have been 17,994 civilian casualties in Ukraine, of which 6,919 people were killed, and 11,075 were injured. Many healthcare professionals and health researchers have fled the country, people lack adequate medical support, ambulances are damaged, and there is a shortage of healthcare products and equipment for medical facilities. Thousands of people, particularly soldiers, have prosthetic limbs due to war injuries or as a result of stepping on landmines.

According to the Rapid Damage and Needs Assessment (RDNA) carried out by the Government of Ukraine, the World Bank, and the European Commission, the estimated cost of health sector damage is $1.4 billion. A further $6.4 billion is calculated for losses, such as missed immunisations of children and adults due to the lack of access to clean water or the absence of proper care (both screening and missed treatments). The overall figure, including the damage to infrastructure, is estimated at $15.1 billion, which would be almost three times the annual government spending on health.

Humanitarian crisis

The continuous Russian attacks on Ukrainian towns and cities, infrastructure, and citizens have led to disruptions in access to healthcare services and hospitals, especially for people living close to the front line, for internally displaced people, and for people who have remained in the recently liberated territories. For example, many people with type 1 or type 2 diabetes do not often get the treatment they need and are left in perilous situations due to their lack of access to insulin. Clinical trials are at risk of disruption, and a huge number of patients are no longer able to get the treatment they need. Furthermore, since the beginning of the war, there has been a drop of almost 50% in recruiting sites for clinical trials.

Ukrainian healthcare professionals are working under very challenging circumstances and precarious conditions, having to deal daily with trauma surgery and mass casualties. Physiotherapists are in short supply, which will likely lead to major long-term consequences due to the demand for rehabilitation skills. Furthermore, their work is aggravated by health workforce shortages caused by the casualties of war, the forced displacement of staff to other countries, and the number of displaced health workers in Ukraine.

The war has increased immediate-term mortality, due to the prevalence of diseases and disruptions in treatments, for example, for cardiovascular and respiratory diseases. Another area of concern is the treatment of noncommunicable diseases, which are a leading cause of premature death in Ukraine. The country has the second highest prevalence of HIV/AIDS patients in Europe, with an estimated 59,000 people affected by the war. The lack of treatments due to the Russian invasion increases the risk of resistance even more for this vulnerable group.

Mental health

Already before the start of the Russian invasion, mental health was a major challenge in Ukraine. According to Ukraine’s First Lady, Olena Zelenska, mental health has been surrounded by a stigma that existed in Ukrainian society for generations. The atrocities of the war and violations of human rights have only increased the need for mental health treatment, particularly for vulnerable groups such as women, the elderly, children, people with disabilities, LGBTI people, and Roma. For some groups like the visually impaired, disabled, and children, it is almost impossible to escape the atrocities (as it is much more challenging for them to reach bomb shelters) and get the appropriate care they need. Often there is a correlation between their chronic condition and the increased risk of mental health related issues.

People are likely to suffer the psychological consequences of the war long into the future. The extreme stress the war is causing leads to post-traumatic stress disorder (PTSD), substance use disorders, depression, and anxiety. Many girls and women are struggling with the sexual violence carried out by Russian soldiers, which seriously impacts their mental health. These vulnerable groups face even more difficulties accessing the care they need. Acute psychological trauma care and mobile teams that can travel into the regions and more remote areas are, therefore, essential for people at risk. As studies have shown, longer-term PTSD and depression increase the risk of dementia. The war may even affect children who have not yet been born, as parents can transfer trauma to future generations.

EU solidarity with Ukraine  

The EU has responded to the humanitarian crisis in Ukraine with support and solidarity in health and research. Within weeks following Russia’s aggression against Ukraine, the Council issued an Implementing Decision establishing temporary protection in response to the mass influx of persons fleeing Ukraine as a result of the war. Access to medical care is part of this temporary protection mechanism.

In July 2022, Ukraine was allowed to join the EU4Health Programme, enabling Ukrainian stakeholders (patient organisations, civil society organisations etc.) to get EU funding in health and respond to immediate public health needs. More specifically, this includes support for internally displaced people, as well as the long-term recovery of the healthcare sector.

In addition, a few months after the start of the war, Ukraine was granted access to the EU’s research programme Horizon Europe as well as the EU’s nuclear programme Euratom. This allows for the participation of Ukrainian researchers in a similar way to EU member states and creates opportunities in (health) research. The Commission has also launched calls to support displaced health researchers from Ukraine and announced it would open the Horizon Europe Office in Kyiv, which will be hosted by the National Research Foundation of Ukraine.

Long-term recovery

Considering Ukraine’s status as an EU candidate country, the European Union and its member states need to look beyond the immediate challenges of the Russian invasion and develop a longer-term vision for the reconstruction and modernisation of the Ukrainian healthcare system in line with EU standards. Given the magnitude of the attacks on healthcare facilities, the EU needs to facilitate further policy alignment in the areas of health and research between Ukraine and the EU. Otherwise, there is a real risk that short-term support and longer-term restoration are not aligned with Ukraine’s health reforms and post-war needs.

Since Ukraine’s independence in 1991, the country has tried to modernise its healthcare system. According to a joint WHO-World Bank report on the 2016-2019 health financing reform, these reforms are in line with international good practices to improve access, quality, and efficiency of health services. However, already before the Russian invasion, healthcare spending in Ukraine remained low compared to the WHO European region overall, and there is a risk that the increased level of defence and security spending in Ukraine will lead to further trade-offs to the detriment of the health sector. Therefore, the EU should ensure that investment to support the recovery and modernisation of the healthcare system is prioritised in order to rebuild and modernise the healthcare and hospital infrastructure in Ukraine.

The EU should also support Ukraine in tailoring the needs of veterans and civilians and developing a long-term vision of how to best expand the rehabilitation and mental health services system in the country. Attention should be paid to avoiding the brain drain of healthcare professionals as well as strengthening the capacity to ensure screening for mental health diseases. The Commission’s dedicated health stakeholders’ network, ‘Supporting Ukraine, EU neighbouring Member States and Moldova’, which is linked to the EU Health Policy Platform, and could be used to further facilitate exchange between NGO’s and healthcare providers in the EU and Ukraine on how to implement best practices and coordinate initiatives.

In addition, Ukraine should be allowed to participate in EU agencies such as the European Medicines Agency (EMA) and the EU’s Health Emergency Preparedness and Response Authority (HERA), given that this would help strengthen rules and standards in areas such as communicable diseases, cross-border health threats, pharmaceutical products, and public health. Furthermore, considering Ukraine’s application for EU membership, the Union should continue to measure progress to further align legislation in public health with the EU acquis.

Healthcare is an important part of rebuilding Ukraine and making sure that its people are both mentally and physically healthy. The EU needs to monitor closely how Ukraine’s faster integration into the Union’s policy framework evolves and supports its national post-war recovery plan. In this context, Ukraine should further benefit from integration into EU policies and instruments in the areas of healthcare and research. The EU needs to provide all the support the country needs to develop its health reform vision and recover from the atrocities of the ongoing Russian invasion. The reconstruction of a modern Ukraine will only succeed when the physical and mental health of its citizens are at the centre of the country’s future recovery plans.

Elizabeth Kuiper is an Associate Director and Head of the Social Europe and Well-Being programme at the European Policy Centre.

The support the European Policy Centre receives for its ongoing operations, or specifically for its publications, does not constitute an endorsement of their contents, which reflect the views of the authors only. Supporters and partners cannot be held responsible for any use that may be made of the information contained therein.

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