Health needs increasing rapidly due to war – Head of WHO Country Office in Ukraine
Head of the WHO Country Office in Ukraine Jarno Habicht told the Interfax-Ukraine News Agency about operation of the healthcare system in wartime and what disease outbreaks Ukrainians should be prepared for.
Text - Anna Levchenko
What is the overall situation with the health care system financing during the war? Are there any peculiarities about this as the country is in the state of war? Is there any international experience like that?
First of all, what we see since the Russian Federation invasion in February 2022, and now more than 600 days, is that the war has caused enormous damage to the economy, as well as to the human capital, both people and also health and care workers. And it has also influenced how much resources we have for the healthcare and how healthcare is financed.
Ukraine's health system has been resilient but it also has been supported by many of the international partners to have resources available, including resources which are available through the budget support to the National Health Service of Ukraine. The budget for 2024 is increasing, but also health needs are increasing rapidly.
This brings me to the second aspect: what we need to look at is how the public funding is used? It is very much commendable that we will have increase of the public budget as we analyze 2024 health budget and what the government has put forward. However, we need to pay more attention also how the funding is used, and to ensure that the services are reaching those who are mostly in need, and we need to pay attention more to essential services and vulnerable.
And why I bring up this aspect how money is used? It is that we see that more and more Ukrainians have difficulty to access the health care. Latest surveys show three out of four people find medicines, for example, not to be affordable and overall, as the war goes on. The estimates available show the poverty levels are moving up, reaching soon every fifth person living below the poverty-line. And that means that people have less resources for healthcare.
When we look and compare to other countries, we also need to compare what it was before the war. (Before full scale invasion, in Ukraine) every second Hryvna in health came from the pocket of the patient. And in the wartime, the situation has become more difficult especially because the poverty levels are increasing, prices are increasing, because the needs are higher, and because of disruption of the health system functioning. If we compare it to other countries and how many people are paying for health care, then while in Ukraine the level in 2020 is 48%, in the EU candidate countries it is 31%, and in the European Union countries it is 19%. So, it is more than two times less.
Thus, we need to look at how public financing is available and used in key areas of need, to ensure better access to care. We need to look for what the people are paying in health care. And then also we need to ensure that people don't have catastrophic payments because of the health care. That is because before full scale invation, we had more than two and a half million households who had catastrophic health spending. So, the complexity of Ukraine continues, and the war is putting a lot of pressure to the health system. And we also see that people have difficulties in accessing health care.
What should be the share from the total amount for the healthcare system which we can allocate to the civilian health care? Should we cut down this amount during the war?
What we see, and I am talking today about civilian health care and the funding available, is that the health needs are increasing due to ongoing war and overall disease burden is increasing.
Lets bring few examples. We have increasing needs because of the challenges and mental health needs. We have more than 10 million people who need support in one way or another way - either through advice, through primary health care or support, and through the care in the health care facilities by nurses and doctors. The disease burden also increases due to chronic diseases including due to the late care, because of the late approach to stroke or heart attack. In turn late treatment would increase needs for rehabilitation. And that has also implications how much resources we should have available now and in future.
So I see that there is need to invest more to health, there is need to have more public funding, because if we don't have more public funding available, supporting every Ukrainian, then the other alternative is that people need to pay for their care themselves. And as Ukrainians and people are becoming more vulnerable, those elderly who have led back at home, those who are living in the rural areas, those who have big families, because if we put all that burden on them, then they will have too high health care payments directly. So, I think we are facing the situation where we need more resources for the public health system. But also, we need to ensure that these resources are well used, and they really reach the vulnerable and we can protect them.
Funding of what health care areas need to be increased during war? And what can be downsized a bit?
That is exactly the challenge! We have an increased disease burden that will translate into the bigger needs of resources. And the question is how we can also use the resources in a good and transparent manner. So, few of the aspects we have also learned during this 600+ days of war.
First is to continuously invest in the primary health care. And that is extremely important, because if we invest more into the primary care, if we also ensure that the affordable medicines program is available and the medicines are available in pharmacies, that helps to ensure that number of conditions can be taken care of in the ambulatory outpatient setting.
Second, I think we need to face the reality that we need more resources to be invested into the mental health rehabilitation as well the chronic diseases, like cardiovascular diseases, and also what we have seen lately and while visiting the hospitals, is that we need to invest into stroke care, for example, or heart attack, which if not treated properly in the right time, will on its own increase the need for rehabilitation.
And of course, as third, we need to invest into care which is ensuring that the injuries and trauma can be treated.
According to the WHO estimates, what damage to health care system has the war caused in Ukraine? What are the losses? What is your estimate? And according to your estimates, will there be suffice resources to restore the system after Ukrainian victory?
WHO by now has verified 1 301 attacks on health. And this is unacceptable and unbearable damage that we have against the facilities be it on primary care or hospital. Moreover, we have also lost a number of our fellow doctors and nurses due to those attacks. So, the WHO’s who is role is to monitor, verify, and report attacks on health.
Second, when we look into the total needs in financial resources, this is something which is done by the World Bank, the European Union as well the United Nations. These are also who are contributing and they are constantly calculating the losses as well as the functionality of the health system. So, we are having the data about 2022, which shows us that billions are needed to recover. It is important that we realize that needs are increasing constantly.
Third, the good news is that 96% of the health facilities (area under control of Ukraine), if we look across the whole country, are still functioning. Of course the situation is different in different areas. So, for example in Donetsk oblast every third facility is well functioning, so their access to healthcare is much more difficult. Or when we look into Kherson region, we see that more than 70% of facilities have some damages. And in 58% of facilities, the equipment is damaged. In the East and South, the healthcare facilities are more attacked, and that's why they are not also functional.
Now, what has been done in these difficult times are two matters, on facilities, outreach teams in primary care and health workforce in specialized care.
One is the facilities are restored. This is something that the government and partners are doing. As the WHO, we have supported Ukraine with prefabricated primary care modular units, which are modular primary care units that can be easily installed. In July I was opening one in Izum. By now additional 8 modular units have been already opened in Kherson, Kharkiv and Sumy regions. And we continue to do that with the Ministry of Health. We are investing into primary care facilities that can stay there for 5 to 10 years. Furthermore, special attention is paid making shelters available.
The second, WHO supports fanily medicine accosiation hundreds healthcare workers, who work at mobile outreach teams in the areas we don`t have service available and in particular to provide care and medicines for chronic diseases.
The third, WHO has been supporting more than 300 healthcare workers to be available in regions after Kakhovka Dam explosion.
When we talk about restoration, is not only about the facilities. Large part of restoration is actually about our healthcare workers, our fellow doctors, nurses, engineers who need to be in the hospitals to provide the services. By only building back the facility does not ensure that we have actually health services available.
Thank you! And the last question. Nowadays, we have many prognoses saying that this war will be long lasting. According to the WHO prognosis, what should we expect with regards to health? What diseases rates will increase, if the war lasts for long?
One of what we see is that we will see increase in disease burden. We have millions of people in need of mental health support. And this is not only now but also for the generations to come. We have thousands in need of rehabilitation. And also we need support for chronic diseases, non-communicable diseases. So, the disease burden is increasing and continuously, every day the war continues. That is also putting more and more civilians at risk.
When we look into specific areas and take into account the disruption in some of the areas of the country, we need to look into the specific disease risks. Like, we need to be ready for increase in the number of cases of rabies. In the summer, we looked into such diseases like cholera. In Ukraine, we have gone though a number of vaccine preventable disease outbreaks. And I want to commend everybody who invested considerably to close the polio outbreak that we have had during the last two years. It is big effort of all the public health authorities together with partners like the WHO, UNICEF, and others to close the polio outbreak. We need to be ready also for other diseases like measles and diphtheria. So overall, we need to be ready for various communicable diseases but it varies also in different oblasts. So, this is one of the other aspects that has been in the mind of the WHO team working across the country.
We have more than 300 people in Ukraine now. And we need to look up oblast by oblast, and focus for the more tailored approaches because the risks are different. And it means also that as the war continues, we need to have different approaches. This is exactly what we need to do - to ensure that health system in Ukraine is able to provide services and particularly essential services and also support the vulnerable.