Resilience of Primary Health Care in Ukraine: Challenges of the Pandemic and War

ABSTRACT

This commentary examines the resilience of primary health care in Ukraine amidst the ongoing war, drawing a few reflections relevant for other fragile and conflict-affected situations. Using personal observations and various published and unpublished reports, this article outlines five reflections on the strengths, challenges, and necessary adaptations of Primary Health Care (PHC) in Ukraine. It underscores the concerted efforts of the government to maintain public financing of PHC, thereby averting system collapse. The research also highlights the role of strategic adaptations during the COVID-19 pandemic in fostering resilience during the war, including the widespread use of digital communication and skills training. The commentary emphasizes the role of managerial and financial autonomy in facilitating quick and efficient organizational response to crisis. It also recognizes emerging challenges, including better access to PHC services among the internally displaced persons, shifting patient profiles and service needs, and challenges related to reliance on local government financing. Finally, the authors advocate for a coordinated approach in humanitarian response, recovery efforts, and development programs to ensure the sustainability and effectiveness of PHC in Ukraine.

Keywords:

• Fragile and conflict-affected situations
• primary health care
• resilience
• Ukraine
• war

Introduction

Amidst the suffering and disruption caused by the full-scale invasion in Ukraine, Primary Health Care (PHC) services play a pivotal role in addressing the immediate health needs of individuals and families, as well as in fostering community resilience and promoting long-term recovery.¹ In Fragile and Conflict-Affected Situations (FCAS),¹ PHC can help (re-)build “trust in the health system—and in the government it represents.”² Restoring access to PHC serves not only to improve health but also to promote social cohesion³ and a sense of normalcy.⁴ First during the COVID-19 pandemic and then through the war, PHC providers have been tested and continued to adapt and serve the population of Ukraine.

Drawing on personal observations, unpublished surveys and reports as well as published studies, we share five reflections about what makes primary care in Ukraine strong, what are its main challenges, and how we can ensure that the people of Ukraine continue having access to essential care. We hope that the lessons drawn from Ukraine will be relevant to other FCAS.

Reflection 1: Ensuring Public Financing of PHC and Maintaining the Role of the National Health Service in Contracting Providers are Vital Elements of Ukraine’s Resilient Health System

PHC was at the core of the health financing reforms initiated soon after the Revolution of Dignity that took place in 2014 (Box 1).⁵

Table

Box 1: Brief on Ukraine’s health financing, primary health care and out-patient medicines related reform

Since 2015, the Ukrainian government embarked on reforms of its health care system. In October 2017, parliament adopted the Law on “Government Financial Guarantees of Health Care Services” (Law 2168) and associated regulations, laying the foundation for the new health financing system.^Citation6 On 1 April 2018, a new single purchasing agency, the National Health Service of Ukraine (NHSU) was established, and already by July, it started contracting PHC providers. For the first time in Ukraine’s health system, the population had free choice of providers and could register with any provider, regardless of the place of official residence. There was a notable increase in the funding allocated to primary healthcare, accompanied by substantial investments in information systems. Primary care providers changed status, becoming autonomous entities able to sign contracts with purchaser, as NHSU. Input-based line-item payment method was replaced by capitation with providers having autonomy to manage their own funds.^Citation6

To increase the availability of outpatient medicines and to address one of the key drivers of catastrophic spending, the government also introduced the Affordable Medicine Program for outpatient prescription medicines reimbursement. ^Citation7,Citation8 Although modest in size, it was an important step in line with global evidence on measures for increasing financial protection and strengthening the role of PHC providers. ^Citation9

Although still low when compared to other European countries, the share of government health expenditures allocated to PHC saw a sizable increase in the initial phase of the reforms.⁶ The share of government health expenditures allocated to PHC has increased from the average of 9.5% to 12% (Figure 1) between 2014 and 2022 with the biggest boost seen in 2019 when the allocation to PHC reached 14.9%. Although PHC has received less priority in subsequent years due to challenges initially posed by the implementation of the hospital reform process during the pandemic, further worsened by the demands of the war, the government is making efforts to maintain public spending on PHC.

Figure 1. Prioritization of PHC in government spending, 2014–2022.

Notes. PHC includes feldsher—midwife points of contact (budget code 0725) and PHC centers (budget code 0726).

Sources: Consolidated budget expenditures based on functional classification from the State Treasury Service of Ukraine; National Health Service of Ukraine Budget Programme Passports.

Through the National Health Service of Ukraine (NHSU) as a single purchaser, the government continues to play a key role in contracting and paying PHC providers. Although in areas most affected by the war the destruction is such that one third of affected service delivery units had to rely on humanitarian actors to support basic health services, in most of the country PHC providers contracted by NHSU are still functioning.⁷ With continued public financing through NHSU, the government can ensure that health system does not collapse or becomes replaced largely by the humanitarian operations, as it too often occurs in FCAS.^8–10

Continued public financing and contracting through NHSU enable further development of PHC services even with the ongoing war, adapting to emerging health needs of the population. For example, in line with WHO recommendations and good practice, mental health services were added to the services provided at the PHC level under the Programme of Medical Guarantees.^11,12 To be contracted for mental health services, providers are required to have a nurse and a doctor who received training in WHO Mental Health Gap Action Programme (mhGAP). The training equips them with skills to manage various mental health conditions, aiming to enhance mental health services within PHC practice in Ukraine. As of June 2023, the number of PHC providers that signed contracts with NHSU to provide mental health services has reached 673 facilities (out of 2473 PHC providers contracted for PHC with NHSU) with equal geographic distribution.¹³

Reflection 2: Strategic Adaptations During the Pandemic May Have Contributed to the Ability to Adjust During the War

In Ukraine, teleconsultations are facilitated using different methods, such as doctor-owned phones with messaging apps or specialized telemedicine equipment. However, not all healthcare providers have access to this equipment, and not all who do, know how to use it. Furthermore, teleconsultations with specialized equipment are only available to patients within the country, while messenger-based consultations are accessible also those outside of the country.

Widespread use of digital communication services to facilitate communication between patients and their health providers during the pandemic is well-documented¹⁴ and Ukraine was not an exception. Similar to other countries, there was wide use of teleconsultations in Ukraine during COVID-19 where 77% of providers reported using teleconsultations through telemedicine equipment, phones, and text messages.¹⁵ During the war, providers continued using technology to provide services (41% reporting use of digital platforms), even though these were affected by severe challenges with internet and electricity supply.¹⁵ Although the evidence is only anecdotal, this also allowed internally displaced persons (IDP) and refugees to maintain connection and receive consultations with their primary care providers. As the Health Needs Assessment conducted in late 2022 demonstrates, a considerable proportion of the population reports accessing their family doctor by phone, messaging tools, or online calls.¹⁶ However, the increased volume of teleconsultations has not been yet reflected in how providers are reimbursed, and teleconsultations are covered within the capitation rate.

Intense training coverage at the time of COVID-19 served as a basis for adding new skills relevant to health needs during the war. However, the type of skills required, and training provided changed: for example, training on personal protective equipment or provision of remote care was more frequent at pandemic time (89% in April 2021 compared to 59% in February 2023 and 84% compared to 54%, respectively).¹⁵ Training on chemical, biological, radiological, and nuclear materials and agents was a new type of training that many facilities (81%) started to conduct after the beginning of the full-scale invasion along with mental health and psychosocial support training (80%) and a growing demand in training for provision of rehabilitation services provided for veterans or disabled persons (28%).¹⁵

Introducing several outpatient mental health medicines into the Affordable Medicine Program, an outpatient drug benefit package, during the pandemic played a key role for integrating mental health services into PHC later in 2022 when the need for mental health services increased dramatically due to the war.^17,18 As such, the number of mental health medicines prescriptions in AMP changed from 19,000 in 2021 to 82,000 in 2022 and 127,000 in 2023 (2024 letter from the National Health Service of Ukraine to WHO Country Office; unreferenced).

Reflection 3: Managerial and Financial Autonomy Played a Crucial Role in the Resilience of Medical Facilities

Evidence from countries that enabled innovations in service delivery during COVID-19, highlights the importance of adaptive organizational structures¹⁹ where decision making is devolved to teams on the ground new ideas and operational changes can be created in a short time frame. In Ukraine, unlike many other low- and middle-income countries,² PHC providers have autonomy in management and decision making—meaning autonomy to manage and retain income, top-up the salaries of their staff to reward performance, or hire and fire staff—which gave “adaptability and flexibility” during the pandemic and the war.¹⁹ As WHO PHC facility survey shows, both during the pandemic and the war, providers could quickly re-plan, budget, and manage their own resources and find own solutions. For example, approximately two thirds of facilities reported re-assigning staff to new tasks while slightly more than half of the facilities shifted staff to different units.¹⁵

Many FCAS have been characterized as following the “command and control” model where decentralization has been described as “a missed opportunity for resilience.”²⁰ This is not the case with Ukraine where decentralized decision-making is one of the factors that has sustained its resilience and contributed to building trust in public institutions and empowerment of local communities.^21,22 Although decentralized decision making brings its own challenges, as highlighted in the next section, autonomy and ownership of local decision making enabled PHC providers and communities to collaborate with one another and attract support from outside, including from international partners and donor agencies.^21,23

Reflection 4: New Challenges Emerge

Similar to other FCAS, one of the main challenges is the provision of services to the internally displaced persons (IDPs),¹⁰ who constituted 6.4 million people in Ukraine as of December 2022.²⁴ Two rounds of the Health Needs Assessment Survey conducted by WHO in 2022 showed that even after a year since the start of the full-scale invasion, access to services for IDPs was still limited: 21% of IDPs in December 2022 reported they could not access a family doctor compared to 5% among nondisplaced population.¹⁶ Partly, this may be because only IDPs with a formal IDP status are eligible to receive free primary care services without signing a new declaration, and displaced individuals have less knowledge about the locations of PHC facilities compared with those who have remained in their home communities.^25–28 Also, there are no special incentives to provide services to IDPs. Physicians are mandated to address the needs of IDPs alongside their regular patient lists, without receiving additional funding for these services.²⁵ Better understanding of and addressing barriers to accessing health services among IDPs is one of the key priorities for PHC as the war continues.

In 2024, the Government initiated the process of validating the declarations, which shall be done by October 1, 2024.²⁹ On the one hand, this update may benefit PHC providers with a high influx of IDPs, resulting in an increase in the total number of declarations. However, the declaration verification process may also result in the termination of some declarations impacting the financial sustainability of the PHC providers, especially in rural or conflict-affected areas. In general, a localized approach should be considered in areas where hostilities continue and specific incentives and financing methods may be necessary: for instance, lump-sum payments could be considered to compensate for the loss in revenues due to a limited number of people in the region to sustain access to services.²⁵

The war has significantly altered patient profiles, thereby affecting the types of services provided (Figure 2). This shift necessitates an adaptation in the skills of healthcare providers and the organization of service delivery to cater to these evolving needs. For instance, in comparison to pre-war period in January 2023, there has been a decrease in services related to child health, partially due to large-scale emigration of mothers with children since February 2022. Conversely, facilities have reported an increase in services associated with noncommunicable diseases (NCDs). Specifically, PHC providers report an increase in service provision for chronic cardiovascular disease diagnosis and treatment (55%), mental health (42%), and diabetes (30%).¹⁵

Figure 2. Changes in service delivery since the full-scale invasion on 24 February 2023.

Notes. Survey covered 500 PHC facilities.

Source: WHO survey on continuity of essential health services, 2023.

One of the reasons behind this could be the healthcare backlog due to COVID-19 but also the demographic shift within country and changed profile of the patient due to large outflow of children and younger women: according to some estimates, the majority of Ukrainian refugees were children under 18 years of age (33%) and adults aged 18 to 64 years (60%), with females constituting 65.8% of these.³⁰ The reported increase in mental health service provision is likely to be due to the increase in exposure to traumatic events for civilian population.^17,18 One recent nationwide study suggests that after 9–12 months of the 2022 Russian invasion, 93% of surveyed people (n = 3173) faced at least one of the mental health issues, such as anxiety, depression, post-traumatic stress disorder at moderate or severe levels.³¹ Also, several PHC providers participating in the war impact survey mentioned that they had observed increasing numbers of young patients with cardiovascular diseases and conditions than normal.¹⁵

Although autonomy and decentralized decision making with empowered communities played a positive role in resilience of PHC services, it also poses challenges. Dependence on local financing for key inputs in PHC services may contribute to inequitable access and quality across the country, worsening challenges posed by the differentiated impact of the war.³² PHC providers and the populations they serve in communities with less revenue-raising capacity, or those giving lower priority to health, or with less innovative leadership have been put in further disadvantage—an issue which was already highlighted before the full-scale invasion.²³ A recent WHO costing study indicates that while according to the budget regulations, all utility expenses should be covered by local government authorities, approximately two-thirds of PHC facilities had to cover their own utility costs, despite it being the obligation of local authorities.³³ Therefore, it has been suggested that utilities, equipment, and premises costs are included within the central budget to address current inequalities in financing between regions.²⁵ Where local authorities are to continue playing a role in financing and service delivery, there is a need to define their role more clearly, reducing duplication and encouraging them to focus on PHC performance.²⁵ Aligning health and decentralization reform aims continues to be one of the key challenges in Ukraine, as it is also in other low- and middle-income countries.^34,35

Reflection 5: Upholding the Grand Bargain Commitments to Make Humanitarian Aid More Effective and Efficient through More Durable Solutions Driven by National Authorities and Stronger Engagement Between Humanitarian and Development Actors: Implications for Primary Care in Ukraine

The war had a devastating impact on health services. Since February 2022 and as of April 22, 2024, WHO verified over 1774 attacks on health including around 1336 attacks on health facilities and 746 attacks particularly on PHC.³⁶ As of October 2023, main barriers impeding service delivery were lack of staff (49%), medical equipment (28%), medical supplies (39%), or financial resources (37%).² Certain parts of the country, such as Khersonska, Zaporizka, Donetska, and Kharkivska oblasts have suffered devastation.³⁷

The use of Mobile Health Units (MHUs) and outreach services is a typical approach to fill critical gaps in health service delivery in humanitarian emergencies.^38,39 In Ukraine, in response to the lack of access to PHC services in areas particularly affected by the war, international partners supported the establishment and operation of MHUs in recently deoccupied regions, front-line zones, and remote rural areas with IDPs. Supporting access to PHC services through MHUs continues to play a vital role in particularly devastated areas.⁴⁰

However, with relatively high costs on fuel, management, and incentives for staff of these units they are highly dependent on financing provided by external partners. Longer-term sustainability of this approach is therefore a question. At the same time given the ongoing war and the time it will take to rebuild completely devastated services, MHUs are likely to continue. Hence, building on the lessons from other FCAS and data collected by WHO,^38,40 there is a need to discuss and develop an approach on how to integrate MHUs and teams providing outreach services better into PHC system, including contracting with NHSU and data exchange. This would provide a feasible exit strategy without undermining the continuity of access to essential services to some of the worst affected population groups.⁴⁰

As exemplified by the experiences of the MHUs , there is a need for humanitarian approaches to come together with longer-term health system development thinking, in line with the Grand Bargain 2.0.⁴¹ Increased engagement between humanitarian and development actors (also known as the humanitarian-development nexus) is an important element of the Grand Bargain 2.0 Framework, which aims to achieve “better humanitarian outcomes for affected populations through enhanced efficiency, effectiveness, and greater accountability.”⁴²

In Ukraine, the humanitarian response has proven instrumental in providing essential services and medical access to populations residing near the frontline, thus averting potential life-threatening interruptions. In 2022, humanitarian organizations reportedly delivered high-quality, life-saving healthcare to approximately 9.4 million individuals and provided support to 1,173 health facilities in Ukraine.⁴³ The same continues, however to a lesser extent, in 2023, and the humanitarian community aims to reach to 3.8 million people with life-saving health support in 2024.^44–46 These concerted efforts significantly contributed to the resilience of the health system by facilitating its adaptation to the crisis. However, it is now imperative to ensure that the ongoing response to the war and subsequent recovery efforts align with the national reform process that has progressed over last year through the COVID-19 pandemic and war. Humanitarian, recovery, and development programs should collectively explore midterm solutions that could synergize their impact and bolster PHC.

The resilience of PHC is contingent upon consistent investments in service delivery, infrastructure, and workforce. Even before the war, concerns pointed to an aging profile of family doctors, with half of the workforce over 50 and a quarter beyond retirement age.³² The war has further impacted the availability and distribution of the health workforce with disparities in funding levels and priorities among local governments. The Ukrainian PHC system remarkably has withstood the test of the pandemic and continues to endure despite the war. However, the question is how long PHC providers can sustain the mounting pressures of the ongoing war and changing patient profiles and needs, aging health workforce, and uneven investments. There is a crucial need for sustained commitment and investment in the PHC, also from development and humanitarian partners using coordinated approaches and supporting the public system and reform direction, whenever possible.

Author Contributor Statement

Conception of the work was led by Jarno Habicht and Elina Dale. Data curation and analysis was led by Julia Novak, Denys Dmytriiev, and Olga Demeshko. Drafting of the article was done by Elina Dale and Julia Novak with inputs from Olga Demeshko and Denys Dmytriiev. Critical revision of the article was led by Jarno Habicht. All named authors approved the article prior to submission.

Ethical Approval

Ethical approval for this type of study is not required. Ethical approval was received for published and unpublished reports used in the commentary.

Acknowledgments

The commentary uses many of the published and unpublished reports to which all members of the WHO Country Office in Ukraine have made significant contributions, working hand-in-hand with the Ministry of Health of Ukraine and the National Health Service of Ukraine.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors gratefully acknowledge support from the WHO Universal Health Coverage Partnership, including financial support from European Union and the Government of Canada, and the Ministry of Health and Care Services of Norway under the grant [UKR23/0016] Institutional Cooperation in the Health Sector. The contents of this publication are the sole responsibility of the authors and do not necessarily reflect those of the European Union, the Government of Canada, or the Government of Norway.

Notes

1. Definition of what constitutes FCAS is complex. One widely accepted definition comes from the World Bank, and it is used here. Accordingly, fragility is “defined as a systemic condition or situation characterized by an extremely low level of institutional and governance capacity, which significantly impedes the state’s ability to function effectively, maintain peace, and foster economic and social development. Conflict is “defined as a situation of acute insecurity driven by the use of deadly force by a group—including state forces, organized non-state groups, or other irregular entities—with a political purpose or motivation. Such force can be two-sided—involving engagement between multiple organized, armed sides, at times resulting in collateral civilian harm—or one-sided, in which a group specifically targets civilians.” 1. World Bank. Classification of Fragile and Conflict-Affected Situations for World Bank Group Engagement. 10 July 2023. https://www.worldbank.org/en/topic/fragilityconflictviolence/brief/harmonized-list-of-fragile-situations (accessed 24 April 2024).

2. Excluding Luhanska oblast, Avtonomna Respublika Krym, and the areas of Donetska, Khersonska, and Zaporizka oblasts temporarily under Russian Federation military control, as well as health facilities within 0 to 10 km from the frontline or the Ukraine-Russia state border.