Multilateral Health Response in Ukraine: World Health Organization

Journal of International Affairs (JIA): To start, provide a brief overview of WHO’s activities in Ukraine, both on the coordinating side and on the service delivery side as well.

Dr. Jarno Habicht (JH): When we look at what WHO has been doing since the 24th of February 2022, our focus in the early days was on much of the humanitarian response, because the humanitarian needs were great.

Gradually, we have moved to work on three tracks. To summarize, we work on the response, we work in recovery, and we work on reforms. For the response, the last year has been busy, for the team to reach 8.4 million people, now it is more than 9 million people and more than 10,000 health care workers, from mass casualty management to laboratory technologies and techniques and addressing a number of public health matters that reach millions of people in Ukraine with various materials. Related to this is communication, so that people know about public health, know about the risks and how to manage that as well. We have been delivering more than 3,000 metric tons of supplies, from ambulances to very specific supplies, such as trauma care and medicines, especially for chronic diseases. That has kept us busy on the humanitarian side.

But, as I said, the recovery has started fast. Where the health system is resilient, including building back the primary care centers that have been attacked. Today, based on our monitoring, we have verified more than 1,000 attacks on health. At the same time, we see how people go back to their homes in both contested and liberated areas, how doctors start to work again, how health services are available. The recovery is already starting now, and it is not only about physically building back the buildings but actually getting the health system to function and services to be available, from vaccination programs to actually managing chronic diseases.

Finally, the third track is about reform. Ukraine started health sector reforms in 2016 and 2017, setting up various institutions and building a new health system, from health financing to primary care, from digital health to increased transparency in procurement. All of this has also continued, so that is why I am saying that in many parts of the world, when the war starts, everything else stops. But in Ukraine, what is unique is that we really see the aspiration for the reforms continuing, in spite of all the pressure: recovery that starts as soon as possible and the response which gradually has moved more to the east and south, where the hostilities are the greatest. These are the three tracks that have been keeping us busy.

JIA: In the humanitarian space, who are some of the critical partners or collaborating organizations or institutions, for coordination on the ground both at the local level and also at the national or international levels?

JH: We have been working with our own team, first of all, so we are now over 250 personnel on the ground. We were a smaller team of 100 people around the 24th of February 2022, and what is very important is that all of our work has continued with national authorities and with local authorities, as well as with the community. For WHO, during the COVID-19 response, our role has been not only policy advice and dialogue or broader technical assistance, but also very much on the ground. What is happening in the hospitals? What happens in the primary care centers? How do we work in public health for disease surveillance? This has continued with all of our work, but scaled up.

Second, we work through many of our partners, including volunteers who have been helping to deliver supplies and medicines to the front line. We work with other organizations, humanitarian organizations that also benefit from WHO supplies while they have their own doctors and nurses in the front line. This is another stream.

The third, which is very important, is the health cluster, and so as a cluster lead agency, we have more than 200 partners: local NGOs, international NGOs, UN agencies, and multilateral agencies who are a part of the health cluster. They each play different roles there. Some are providing services, others are also delivering supplies, so it varies. But there are 200 partners in the health cluster.

And also, we work as a whole UN. That’s important: “as a whole UN.” We are conducting inter-agency convoys to the front line, and we are delivering packages from WHO sites: medicines and supplies which are needed for the primary health care workers who are there. But also, at the same time, other UN agencies are providing the food, water, blankets. What we do is we have combined support to the communities on the front line, where we try to go as close as we can to the villages where civilians are living. Many of them are elderly, with chronic diseases, and don’t want to leave their homes.

In humanitarian settings, we are trying to complement each other. But what is very, very important is that we complement also what the country is doing, and what’s important in this humanitarian setting is we need to complement much of the government work, how it is working and functioning. This is something that allows us to deliver.

In conclusion, we work with the government, health care workers, volunteers, and civil society organizations. We coordinate through the cluster, and we work as a whole UN. I think I have seen hundreds and thousands working, so on the one hand, it’s organizations, but on the other, which is also very important, is all the individuals who are on the front line.

JIA: How has the COVID-19 response in particular informed this wartime response, either by providing a kind of institution-building or by enabling adjustment to adapt to these new circumstances?

JH: Three aspects come to mind. First, I think, the COVID response more broadly in the health sector, compared to many other sectors, made us more ready to do security coordination. It’s very important that WHO was already working with the authorities in Ukraine and local communities, from the very top levels of emergency coordination to oblast level and down to the towns and villages. While the coordination for COVID response was already in place, however, the same coordination had to be scaled up since the 24th of February. The health sector has already been in the emergency response because of COVID-19. From where we enter to the first year of the full-scale war is something to take into account. It makes the health sector also more experienced in coordination. But from another angle, we need to take into account that it has taken a while to reach that level.

Second, I would bring up agility. We had new evidence, we had new information, and we need to be very agile in the response. As we now look back, we first applied measures of social distancing, and then we moved to the vaccine. Then we look to the next level. The same is in the war response. You need to be very agile. What we have seen in the last one year plus of the response, from attacks on health facilities to adjusting the supply lines, thinking about where to get diesel and how actually medicines are again accessible in the liberated areas. That requires very agile response, and learning from the COVID response has been extremely valuable.

Third, I would bring up digital. What we learned from COVID times—and I think everybody is a bit tired of Zoom and Microsoft Teams and all the virtual meetings—but in the war situation, I think, being digital, being able to connect, has allowed us, as the WHO, to work with authorities from day zero, because, while people were in different secure locations, the meetings still took place. It is also very important to have the digital tools and the digital experience, having these skills that allow you to connect and to respond. To review, I mention these three aspects: previous coordination structures, agility to adjust the every day, and the digital, as something that comes to my mind of what we learned from COVID and brought to the war time.

JIA: You mentioned attacks on health facilities and personnel. What does the process of assessing and reporting those attacks look like? Then, once WHO does report on them, who is the audience: implementing partners in the country, so that they have some sort of protocol to follow, or the international community, which can then respond?

JH: First, for attacks on health systems and personnel, it is the WHO’s role to monitor, verify, and report attacks on health. It is important to ensure that we protect the health system and health care workers and that we provide security to people so that they can actually access health care. For us, it is very, important that we monitor attacks on health and make the public aware. There is a special site on the website where these are published. This is so that many can understand that there are health care facilities under attack, including health care workers, facilities, ambulances—and that should not happen. That is our role as a monitor for attacks on health.

As of today, we have monitored over 1,000 attacks and have also made that report about the taxonomy of attacks on health, which can have multiple effects. It reduces the security for health care workers to provide care, which is why many deliveries are happening in shelters, surgeries are done in shelters, etc. Second, it reduces the security for people, because you don’t know if you can go to the facility because it could be attacked, or it is not there anymore to provide care. That is very disruptive for people who are already struggling.

Now let me come to the recovery. Recovery is not only about facilities. Recovery for me is actually that services are restored. That could mean that the facility needs to be restored, or it means that there is a temporary facility established. But most importantly, it is that health care workers are returning. This is what we saw in Bucha and Makariv. When we go back to April and May 2022, where we regained access, what recovery meant very practically was that we donated the generator to the hospital, so that the oxygen was actually flowing in the hospital, next to a hospital bed, and that they were able to provide care for those who had COVID or for those who needed oxygen for other reasons. What that meant was that we restored service. The same is that primary care workers are going back to villages, providing essential chronic care and support for the elderly who remained. What I myself saw were the smiles among the people who moved back to their houses after regaining access, who had shops around essential transport, who also knew where to go to get their medicines for the next day. That all allows them to do gardening, to have breakfast and dinner and start to restore their lives. So, we need to look both at the recovery and also a bit broader than only facilities.

What WHO has been working on is where to put the focus. When your system is under pressure, where do you first place emphasis? We see how important it is when we restore services for primary health care, then scale up central care for chronic diseases, especially for the elderly but also vaccination services as well. We first needed to restore COVID vaccination and a basic vaccination calendar having all vaccines available, even though the cold chain was broken as well, in addition to the closure of pharmacies.

We also ensure that the funding is available and salaries are paid out. Budget support plays a very important role, contributing to doctors and nurses actually doing their everyday work. A large role has been played by the U.S. and the World Bank and other countries who are providing the budget support, which is why doctors and nurses can work.

Recovery and restoration mean many things. It means health care workers go back to facilities that are functioning. We also need to ensure that electricity is there and water is available and heating is in place. Often, this needs to be restored, because what we see now, for example, in accessible districts of Kherson oblast, is that more than 35%, at least every third facility, is not fully functional. But what gives us hope at the same time is that we see that even if facilities are not the fully functional, they continue to provide health services. Even if you might have issues with electricity, you might have issues with water, we see heroic healthcare workers going there every day and providing services, as much as they can, to the local community. And this is very important because that builds the trust, but then also actually provides very essential care for those who need it. After the Nova Kakhovka Dam Explosion on June 6, WHO is in touch with government for assessing health needs and support to people by providing the needed assistance.

This is what a story of restoration and recovery would mean, but it’s still very complex. On a practical level, where we need to pay attention to is health financing: is the funding available? Services starting from primary care ensure that health care workers are motivated and are in the field, and all of this happens if the institutions are working. That’s why it’s very important that the institutions, which were founded in 2016, 2017—the National Health Service of Ukraine, the central procurement agency Medical Procurement of Ukraine which ensures medicines are available—all these institutions continue to function. These institutions are the cornerstone on which the national system works and is also why we can actually work at the same time on response, recovery, and reform simultaneously. If the institutions would fail, then it is much more difficult to move ahead with this complex agenda.

JIA: As the reform agenda is government-driven, what kinds of expertise does WHO provide? At the same time, how does WHO strike a balance between long-term reform and short- and medium-term recovery?

JH: What Ukraine started, before COVID, in 2016 were the reforms on health financing and the creation of the National Health Service. We first started to work on the data: ensuring that there are data and transparency is in place. It’s very important, but also contracting hospitals, primary health care, and ensuring that more and more of the population are enrolled in primary health care. This then continued during COVID, with providers also allocating time with other patients and the government ensuring that health financing is flowing to facilities in the correct way. Finally, the data systems were established that allowed the health system to adapt.

When we saw millions of Ukrainians on the move—and we still have more than 8 million Ukrainians outside of Ukraine—we also had many people moving to western oblasts. And now, everybody is moving back home. So, having the data and this contract with the service providers, having the financial flows in place, helps to move ahead and to continue this reform path. Similarly, agencies were founded to do procurement of medicines, which has gradually reduced the wait time for the medicines. In the same way for public health: when I look back to last year, a new public health regulation was adopted that created the Central Ukraine Public Health Center while also clarifying the roles of Regional Public Health Centers. This is very important, because then you have coordination, you have surveillance systems in place. Somebody asked me how I know that the health system functions, and one example is from public health. When I see surveillance information and what is shared, and from time to time we see Ukraine is able to sequence the new COVID strains in wartime—as soon as we get the generator connected to the right laboratory, because after the 10th of October attacks on critical infrastructure it became more difficult—but with electricity, knowledge, and sequencing machines, Ukrainians can do it. Ukraine can also diagnose the monkey pox. Ukraine surveillance system picks up when there are cases of measles. So how I know that the system functions is that we see data coming in, and we see the response happening.

That’s why I say that reforms are ongoing, and we see that these reforms that Ukraine started in 2016, even if much is to be done, Ukraine is willing to do it and interested in doing it. When I discuss with decision makers and also specialists in the field, they note that these reforms have helped Ukraine to function in the time of COVID and in times of war. But it’s not only about the systems: I think we need to appreciate the health care workers who are doing tremendous work on saving lives, providing support, and everything else. This is also something that I see.

For the next step, I think there are two tracks that need to be moved ahead. One track is to continue these reform initiatives but also to adapt that to the war situation, to be focused on key issues that need to be solved. The second track, which is also very important for Ukraine, is European Union accession. For European Union accession, there are a number of aspects of public health that Ukraine needs to address, from nutrition to tobacco control and many other aspects of public health. So as Ukraine moves forward, it is harmonizing its regulation and practices to what we see in the European Union. And in that sense, if I bring in some more public health examples, we see that Ukraine is looking forward on stronger tobacco control regulation that will save many lives, while also allowing future generations to have a healthier environment and be healthier themselves. At the same time, Ukraine is also moving toward a trans-fat-free environment, to ensure that food is healthy and products are healthier.

Ukraine has never stopped. I have seen so many initiatives in the Parliament on health in the last year. It is important to recognize that the interest is there. This is why I’m saying that it’s a very exciting environment, in the sense that while stressed by the war, torn into different parts because of all the demands, Ukraine, as of now, is continuing these three tracks of response, recovery, and reform.

JIA: Any concluding remarks?

JH: It has been a long day since the 24th of February 2022. But I think what I really see here is the resilience of Ukrainians, when they see each other, how they hug, how they think about the future. This morning, I was walking, and you see people walking with children to school. You hear the birds singing. You see, summer is here. We have gotten through the winter. Everybody was so concerned about the winter, but at the same time, you see people walking around and talking.

Of course, the situation is different. We saw all the attacks on the civilian infrastructure that is happening. Our own team from time to time can be somewhere nearby, because we are working on primary health care to ensure that services are there. We continue to do that, and the situation is different. But you see this resilience and interest to move ahead. I think our role as the World Health Organization is to be there and to motivate and to move ahead. That’s the environment. You see the children going to school in the morning. You hear the birds singing. Unfortunately, you hear the alarm as well from two to five times, and then it’s time to go to the shelter. But that has not taken the spirit of Ukrainians, and I think that’s very important.

However, we also have new health needs that I didn’t mention. We see much greater needs for mental health. We see around ten million people needing mental health support, from learning how to do stress management to actually having support. Mental health is a topic that we need to address. The same with rehabilitation. Many are looking to the military, but we need to look at rehabilitation in a broader sense as well. Last month when I went to the Rehabilitation Department, I realized that we have a number of people who have maybe not been getting to health care facilities at the right time when they have a stroke. Many are learning how to use their hands, how to restore their muscles. There are also chronic diseases.

We looked at the time of COVID and how people didn’t get to hospitals and overall care-seeking behavior reduced. What we have also seen now, from our last health needs assessment, is that people may delay some care, because we see that the decrease of the care-seeking behavior. We need to look to those aspects as well. Because of that, we will assume that the disease burden will actually increase for various areas, from rehabilitation to chronic diseases, particularly non-communicable diseases as well as mental health. We need to ensure that the health system is continuously resilient.

There are many stories, I think, that we all have seen in different places. It’s still important to support Ukraine and to keep this support ongoing.

Dr. Jarno Habicht speaking at an event. Source: WHO Ukraine

A meeting between Dr. Habicht and a patient. Source: WHO Ukraine