The war can additionally stimulate full implementation of healthcare reform – WHO representative
Coodinator for Health Financing Policy at the World Health Organization (WHO) Joe Kutzin, who is also the author of the recommendations for the revival of the public health system in Ukraine, told the Interfax-Ukraine News Agency in an exclusive interview whether Ukraine should continue implementing healthcare reform after the war, what the benefits of this reform are, and how the WHO recommends to revive the medical care system after the war.
By Anna Levchenko
Joseph Kutzin, Head of Health Financing at WHO Headquarters. The author of recommendations on the recovery of the health care system in Ukraine
Q1. What are the recommendations for the reconstruction of Ukraine after the war and the place of health in this system?
There are several reasons why health and the health sector are critical to Ukraine’s recovery. First, the magnitude of the attacks on health care has been unprecedented – even though WHO is still in process of verifying many attacks, since Feb 24, 2022 we verified 323 attacks on health in Ukraine – that’s more attacks in 4 months than in Syria since beginning of 2018 (298 attacks), for example. The physical destruction, combined with the psychological effect of the war on health workers and the general population, will have lasting consequences. So, rebuilding the health system is critical for national recovery by ensuring that essential services are restored and that there can be response to new and increased needs, such as for mental health, rehabilitation, public health surveillance.
Secondly, health is both an intrinsic element of human welfare and an investment for the long-term recovery and growth of Ukraine. The availability of high-quality health services and medicines convey a sense of security and normalcy for all, giving people the confidence to return to their homes and promoting reconciliation and trust in local and national government.
Third, investing in health system is critical for overall development of the country: the sector is a key economic actor, as for example can be seen with domestic pharmaceutical production and distribution. The stimulus to science, technology and high-end industry / jobs that health provides is potentially significant. The health sector is also an important employer, especially of women, and has important multiplier effects on local economies.
Q2. How health care system should be financed (local budgets and NHSU with examples of how this can be done differently, taking into account the impact of war on health care and budgeting)
The direction of reforms begun in 2016 is consistent with international good practice. The war does not change this; indeed, it should provide further impetus to carry the reforms to full implementation. WHO believes that countries should pursue the goal of Universal Health Coverage (UHC), which means (a) reducing the gap between the need for services and their use; (b) improving quality; and (c) ensuring that no one becomes poor as a consequence of having to pay for care. At the same time, governments should ensure that core functions for prevention, preparedness, and response to crises are funded.
Ukraine’s health financing reforms to date support these UHC goals but can be taken further. Its strength is that the main funding source for the system is general tax revenues, and that all Ukrainians are entitled to services under the Program of Medical Guarantees (PMGs). The pooling of funds for the PMGs at national level in the NHSU enables the system to direct resources to where the needs are. Even before the invasion of 24 February, getting better results from available public spending (efficiency) was crucial. To take the reforms further and more fully realize their gains, the following will be needed:
a) restructure the health delivery system so that a greater share of funds is devoted to patient care and less is devoted to maintaining buildings. One legacy inherited by the Ukrainian health system is that each level of government owns and operates a network of health facilities. This is why the capital city of each oblast has so many hospitals – the system is organized by level of government administration (city hospital – oblast hospital – national hospital) rather than by the needs of the population. It is one of the things that should change, and why we agree with the Ministry of Health that the aim of health system recovery is not to just rebuild buildings that were destroyed or damaged by the war, but to focus on the best ways to get needed services to the population. Such an approach can enable a positive transformation of the service delivery network.
b) Local budgets in Ukraine are still financing the utility costs of health facilities that they own. This undermines the potential of the payment incentives used by the NHSU and impedes restructuring of health facilities. These funds should be pooled within NHSU and, as a consequence of this, facility managers will have a greater incentive to manage their resources more effectively.
c) Organizing the delivery system on a population basis and pooling local government budgets for health care in the NHSU will better align the incentives to improve efficiency. However, the gains from downsizing are limited by the design of the old infrastructure, much of which was built prior to 1990 when there were no concerns about the costs of running these buildings. The new investments to come in the recovery period should be based on energy efficient design criteria. This will gradually make the delivery system less costly to run (enabling the shift in the use of funds from buildings to patients), greener (more environmentally friendly), and less dependent on foreign sources of energy.
Q3. Whether to continue health care reform or change it (what is a priority now, the reconstruction of hospitals or, conversely, the search for other flexible solutions to meet urgent needs)
As reflected in the answer to the prior question, we strongly believe in the need to continue and deepen health reforms in Ukraine. Clearly, the first priority is to restore the functionality of the health delivery network and secure access to essential services to meet ongoing, increased and new health needs and public health threats. Broadly speaking, the aim is to find the best ways to get needed services to the population, recognizing the need for a flexible approach needed to make rapid adaptations and to meet priorities in very different contexts in the country.
We believe the best way to this is through establishing a modern, digitally enabled primary health care approach with the capacity to deliver expanded services and ensure continuity of care for people on the move. Some elements of this include:
a) shifting some services from inpatient to outpatient and outreach services to ensure maximum reach;
b) expanding the volume of services provided at primary health care level to address critical needs emerging as a direct result of the conflict, such as mental health care, and coordination of services for internally displaced people;
c) extending community-level service delivery by incorporating mobile teams currently delivering essential health services within the humanitarian response to later become part of local health service delivery as outreach services for hard-to-reach areas or patients with mobility problems, and ensuring catch-up on critical services such as immunization and screening.
Q4. Does the WHO have recommendations on how to restore health services when some doctors have left the country?
First, it is important to understand what the magnitude of this problem is. When I visited health facilities in Chernihiv in May, I was encouraged to see that despite all that had happened, many doctors and nurses remained and were doing great work. This does not mean that there is no problem with the departure of health workers, but it will be important to have an idea of the extent of this challenge.
Second, when it comes to recovery, we need to think beyond physical infrastructure and invest in the health workforce. They are closely linked: building back better health facilities is crucial to speed up the return of healthcare workers. Also, having a digital registry of available health workers, their qualifications and location will help the government to develop effective policies to attract and distribute health workers. Another important option to be considered over the medium term is changing the distribution of functions between doctors and nurses and improving the curricula of health education (such as integrating public health competencies in general medical education). Given the need for a new and more efficient service delivery model, the health workforce needs should also be quantified according to this vision for service delivery.
Q5. There is an opinion that after the system recovery, the number of health facilities can be 3 times less. How can you comment?
We do not have a target number of health facilities. Indeed, and as noted above, what we are concerned with is enabling more efficient and equitable use of funding in the health system. One way this will be reflected is to ensure that the relative amount spent on maintaining buildings (e.g. utility costs, heating, electricity, gas, etc.) will decrease and the amounts spent on patient care (e.g. medicines, supplies, staff) will increase. In addition to the needed shift towards population-based planning and greener design, there will also be efficiencies achieved by shifting from mono-specialized hospitals to multi-profile facilities that incorporate strong infection control mechanisms.
Q6. Private and business investments in the recovery of the healthcare system. It is obvious that the state will not be able to finance all the necessary recoveries and will turn to donors and entrepreneurs. What can they get in return?
The enthusiasm of donors and entrepreneurs to invest in the recovery of the health system is very welcome. But it is essential that this enthusiasm is channelled in the most productive way. This is why WHO has produced a report on Principles to Guide Health System Recovery and Transformation in Ukraine. We propose 5 principles to align potential investments with reforms aimed at enabling the health system to best get needed services to Ukraine’s population:
a) people-centredness: This means organizing a system around needs, rather around disease or government level. It means strengthening primary health care – putting prevention and promotion services into communities, equipping them with multi-disciplinary teams, from general practitioners to social workers.
b) equity and financial protection: This implies that investments support reforms to ensure that services are available and accessible to those most affected by the war. It also requires that people driven into poverty by the conflict – especially older persons with chronic conditions - should be protected from financial barriers and the need to make health expenditures. Investments and policies that increase the availability of affordable medicines will be vital.
c) resilience: This means that the health system should be able to absorb shocks, adapt and respond, to manage and limit disruptions, keep communities connected, and respond to emerging needs. There is great scope here for investments in further digitalization of health management systems to enable the needed flexibility.
d) efficiency and sustainability: As noted above, green design of multi-profile health facilities should be high priority for investors, where more upfront costs will yield lower running costs for the system over the medium to long term.
e) accountability: The recovery process, the health system, and the government, must deliver on its commitments while managing resources transparently. The roles and responsibilities at each level of the health system must be defined and agreed with citizen engagement, participatory planning, standardized budgeting accounting and financial reporting mechanisms.
We are confident that by adhering to these criteria, donors will be able to derive strong political and social returns, while non-government investors can generate reasonable private returns in certain parts of the sector. What is most critical is that the investments do not proceed in a chaotic, uncoordinated manner. The principles that we propose in our report are aimed at assisting the government to align resources with needs and Ukraine’s health reform agenda through application of a common set of national standards.