Dr Jarno Habicht, WHO Representative in Ukraine, speaks about the main healthcare risks Ukraine may face during current winter in exclusive interview to Interfax-Ukraine

Text: Anna Levchenko

How do you assess the situation of the healthcare system today? What are the main changes after 3 years of war? What are the main changes now compared to the pre-war period?

What we can observe overall, regarding the system's functioning in the country, is that it became more resistant, largely due to the continuous reform of health, which started during the war in 2016. The national healthcare system is working, adjusting the numerous challenges, and, in a few areas, also gaining some better results than before. There is no doubt that at the same time, the system faces big challenges especially on the frontline dedicated to 10 years of war, daily attacks on health, shortage of personnel, and many others I will mention further.

During 1000 days of war, WHO has verified 2,147 attacks on healthcare in Ukraine that took the lives of at least 197 health workers and patients, and injuries to 676 health workers and patients. More than 40% of attacks are directed to primary care, which is the patient’s gateway to the rest of the health system, including referrals to specialist care and prescriptions for medicines in the Affordable Medicines program (AMP).

With growing health needs, two areas require more attention. First is the all-Ukrainian mental health program initiated by the First Lady of Ukraine, Olena Zelenska. The second is rehabilitation for injured patients and those who postponed their chronic care, like stroke patients.

Also, we are entering the winter season, which is predicted to be the harshest winter if attacks on infrastructure continue. In UN recent report, it is clearly stated that attacks on energy infrastructure are attacks on the civilian population.

During the cold season, vulnerable groups of people across the country need support. The efforts should include enhancing vaccination coverage as winter approaches with an expected rise in respiratory infections, providing health facilities with alternative heat and electricity sources, and implementing cold response strategies, which are crucial to mitigate risks and safeguard the well-being of affected populations.

Situation with access to healthcare in frontline territories? What are the challenges? Is there access to specialized medical care and inpatient medical care?

As I mentioned before, the country faces an issue with a shortage of healthcare workers, especially on the frontline and in rural areas. When we look at the frontline – only 20-30% of the healthcare workforce is there. So we need to invest now in the workforce, including educating and motivating new healthcare workers.

 

The decrease in healthcare personnel is not a new issue. Ukraine has been losing around 3%, or 5000 of its doctors annually, since 2019. Certain key specialties related to trauma care, epidemiology, and mental health have a shortage of doctors. Since 2017, the number of nurses has been declining by around 6%, which is around 11,000 nurses per year. In recent years, after the start of the war, the rate of decline has become faster.

The main problems in most affected regions were related to the cost of medicines (46%), cost of treatment (26%), and time to get to health facilities (27%) as some of them can be destroyed. In coordination with the Ministry of Health and local authorities, WHO started to install modular primary care units in frontline communities where health facilities were damaged or destroyed. As for now, we have installed around 30 such units, which are fully functional health facilities, in 5 regions, and this work continues.

To support vulnerable population we disseminate Over-the-counter (OTC) kits with necessary medications and medical supplies to families and households living in hard-to-reach areas at the front-line territories where pharmacies are absent.

Overall, during these 1000 days, WHO delivered 4,500 metric tons of supplies to Ukraine.  The deliveries consist of trauma and emergency surgery and other types of kits, essential medicines, other critical supplies, including about 140 ambulances, 50 buses for vaccination,  equipment for laboratories and hospitals.   

What are the difference with the organization of work of HCF in frontline territories? Is medical equipment being evacuated? Is there data on the loss of equipment in hospitals after occupation of the territories? Are there international mechanisms for compensation or the return of this equipment to Ukraine?

I would like to start with priorities, which are, by all means, people. Evacuating healthcare workers to safer places is much more important than equipment that can be and is provided by partners, including WHO. This is what happened, for instance, some time ago, with the team of the modular primary unit in Lyptsi, Kharkiv region, that was destroyed when Russian Federation forces occupied the area. Healthcare workers from this modular primary healthcare unit are working now in another community.

International aid workers from humanitarian organizations are also integral to Ukraine’s health workforce and system. They support the provision of essential services, trainings, and enhance the capacity of local health workers where war has decreased their numbers. WHO coordinates via the Humanitarian Health Cluster around 125 national and international organizations in Ukraine to maximize support in frontline areas, but the challenges remain.

According to estimates by the World Bank, the Government of Ukraine, the European Union, and the United Nations, the total recovery and reconstruction needs for the health sector are over US$14 billion by the end of 2023 with immediate priority needs for healthcare in 2024 for US$873 million. These costs consider building back better principles, including a shift toward lower energy intensity, modern standards, including climate resilience and inclusive design, etc.

Also, despite the experience of other countries, Ukraine's recovery started in 2022, with international community and organizations joining it. This support to the country will continue.

How is healthcare system preparing for winter? Are HCF ready to provide complex medical care in conditions of possible blackouts? What are the biggest challenges now? What is the electricity shortage to provide medical institutions? How has the situation changed compared to last year?

Together with the Ministry of Health and partners, WHO supports healthcare facilities to be autonomous in light of future threats during the upcoming winter.

According to our information, the regions near the frontline have the highest prevalence of energy, heating, and water supply issues. The most severe challenges were noted in Kharkiv, Mykolaiv, and Kherson, where about 30% of facilities experienced significant disruptions.

Despite the challenges, most facilities (93%) have Emergency Plans in place, and 79% have conducted training for potential winter supply issues. The preparedness for electricity problems is notably high, with only 5% of facilities expressing concerns about energy readiness. However, concerns are greater regarding heating (19%) and water (20%).

To provide hospitals with independent sources of heat on alternative fuel, WHO is installing an independent modular heating units to ensure uninterrupted healthcare services during winter and potential blackouts, providing a stable and safe environment for patients. Four units were already installed in Kharkiv, Chernihiv, and Odesa regions; five more units are in the process of installation.

Summarizing all the above, I can assume that the country is better prepared for possible upcoming challenges as of now.

How serious is AMR problem? What are the solutions? Are consultations being held with international and domestic pharma? Is there scientific research to overcome the problem? Are there calculations of costs associated with overcoming/solving the problem of antibiotic resistance?

Ukraine has a high burden of AMR and the war exacerbates the issue for the next reasons.

We observe increased number of infections that require antibiotic treatment, including war-related wounds, but also other community-acquired infections such as pneumonia, etc. At the same time, hospitals have limited capacity to implement high Infection prevention and control standards while having limited human resources and high influx of patients.  Also, patients need to change several healthcare facilities during care, which also contributes to the spread of healthcare-associated infections and AMR.

Talking about the way to AMR solutions, we need to start with the surveillance system to know exactly how big is the problem. MoH approved several orders that define approaches for AMR surveillance and data collection and reporting. Ukraine, despite the war, was able to expand its surveillance network, and currently, WHO supports the introduction of genomic surveillance for AMR, which will provide more data. The limited capacity of microbiological laboratories and limited human resources are among the main challenges.

The AMR issue cannot be solved with stand-alone solutions. Improvements in clinical guidelines and adherence to them, infection prevention, including vaccination and infection prevention control, and culture change are required. This highlights the need to address issues and strengthen health systems overall.  We have reliable and robust evidence on what works to reduce the AMR burden, as well as great examples from countries (e.g., Scandinavian countries). However, we understand that implementing evidence-based practices requires time, resources, and a high level of determination.

How does WHO assess the pharma market in Ukraine? Is there a shortage of certain groups of drugs? Can Ukrainian manufacturers meet all market needs? How effective can certain international assistance programs be in case of a shortage of drugs? To what extent are international organizations ready to meet Ukraine's needs?

Access to medicines is a long-standing problem in Ukraine, which we observe as long as we have data available - about half of all funds that people spend on health from their own budgets are spent on medicines. Consequently, medicine expenditures are one of two main drivers (together with inpatient care) of financial hardship for families.

Ensuring access to medicines isn't a short-term emergency solution. It requires a comprehensive approach to build a robust pharmaceutical ecosystem. This includes aligning with EU regulations to ensure quality and safety standards before EU accession. Now, this process is ongoing in the country.  

The NHSU had assumed management of the Programme of Medical Guarantees (PMG) and its companion program, the Affordable Medicines Programme (AMP), which provides an opportunity for citizens of Ukraine to receive groups of medicines for free or with some small additional payment.

For 2024–2027, NHSU's priorities are to expand coverage for cardiovascular combination medicine, medical devices, mental and behavioral disorders, oral therapy for diabetes, and anticoagulants.

The situation was worsened by the war, but based on the population survey, we see that there are positive trends when we compare 2022 and 2024. For instance, in September 2022, 22% of households could not buy medicines when needed, compared to 6% in April 2024. Still, overall 81% of households said they experienced some difficulties when obtaining the medicines. The main problem is the increase in the price of medicines; 71% of respondents faced it during the WHO health needs assessment.

Our team also supports MOH, authorities and community with a system-building approach, as this is the main way to ensure the availability and affordability of medicines at the country-wide coverage level.