War is catastrophic for the health system of a country under siege. The current war in Ukraine is no exception—the Ukrainian health system is suffering immensely. Not only must the health system cope with the influx of wounded soldiers and civilians, but also with the destruction of its physical infrastructure and power supply. As the war in Ukraine continues, the Ukrainian government, allied governments and the non-governmental community seek to rebuild the health system in perilous conditions. 

There are two main stages in rebuilding a healthcare system. Initially, the priority is to maintain core healthcare services during a time of conflict. The second stage is to rebuild the health infrastructure damaged by attacks. In this article, we discuss what Ukraine should prioritise when forming a strategy to rebuild its health sector, and explore best practices from other countries that have rebuilt their health systems during and after conflict, and in post-disaster environments.

Rebuilding in a time of war

The Ukrainian health system is currently under immense strain and experiencing widespread destruction. Russian forces have deliberately targeted healthcare facilities with airstrikes and artillery bombardments, with more than 700 such instances documented by the World Health Organization (WHO) at the time of writing. Healthcare workers have been forcibly displaced and access to healthcare in the worst-affected areas is practically non-existent. According to the WHO, almost half of the healthcare facilities in the east and south of Ukraine (Donetska, Zaporizka, Mykolaivska and Kharkivska oblasts) are either partially or completely non-functional. In 2022 it was estimated that about 14.5m people in Ukraine are in need of major health assistance, and that number is likely to have grown. Large-scale rebuilding efforts of physical facilities cannot take place while the war is still ongoing, but smaller rebuilding efforts are taking place.

The WHO, the European Union and the Centers for Disease Control and Prevention (CDC) currently provide training and monetary support to the Ukrainian Ministry of Health (MOH). Much of this is put towards maintaining basic health services, but there are also efforts to train Ukrainian health personnel, provide medicine and generators, and to plan the larger-scale rebuild that can begin once hostilities subside. Additionally, numerous small international and Ukrainian non-governmental organisations operate in Ukraine. These include Project Hope, which is training health personnel and working to repair a limited number of healthcare facilities, and the Ukrainian Tabletochki Charity Foundation, which provides life-saving interventions to children with cancer. In order to rebuild the Ukrainian healthcare system in a sustainable and cost-effective way, stakeholders should consider best practices from other countries that have undertaken similar rebuilding processes.

Examples from other war zones: best practices

Ukraine should start rebuilding the health system by addressing current efforts to coordinate humanitarian response and bring stakeholders together. This may include adopting a humanitarian cluster information system or streamlining aid through centralised coordination. In the case of the post-disaster environment in the Philippines in 2013, after the destruction caused by a super-typhoon Haiyan, a humanitarian information system was deployed to collect data and help to coordinate a post-disaster response. Despite best efforts, international and national responders encountered difficulties at a strategic and operational level in synchronising responses, owing to limited information about what was occurring at the local level. There were challenges around the interoperability between the Philippines’ response system and the humanitarian cluster information system. Additionally, data from local responders were not reported owing to issues of standardisation. Information is the foundation for effective collaboration and coordination, which is why establishing standards in communication and reporting is considered a best practice.

In addition to establishing effective reporting mechanisms, strategising how to coordinate response is just as critical as responding to the crisis itself. One of the many hard lessons learned from reconstruction efforts in Kosovo and Afghanistan is the importance of alignment of stakeholders for effective collaboration in the planning, implementation, monitoring and evaluation of health system rebuilding efforts. More than 400 aid organisations came together to help rebuild Kosovo at the end of the war, requiring effective coordination to begin the reconstruction of the country.

In Afghanistan, several stakeholders were responsible for providing basic water, food and sanitation services, and constructing facilities. However, the Special Inspector General for Afghanistan Reconstruction (SIGAR) reported critical shortfalls in project planning and delivery. SIGAR published findings from an audit conducted in 2020 of 269 health facilities in ten Afghanistan provinces. At the time of the report, nearly half of the health facilities had structural deficiencies and lacked reliable electricity and adequate access to clean drinking water. Other reports indicate that US contractors failed to provide the necessary accountability, transparency and delivery of contractual obligations, increasing project costs and failing to deliver successful project outcomes, affecting the delivery of care. This may be attributed in part to fragmented planning and ineffective coordination of response. 

As countries pledge their support for Ukraine, Ukrainian leadership should establish mechanisms to ensure the realisation of their Recovery Plan 2022-2032. The first strategy is to rebuild the health system in free and liberated territories by strengthening institutions and ensuring effective intersectoral co-operation. As seen in the case of Kosovo and Afghanistan, collaboration for effective coordination will require transparency, accountability and follow-through. Rebuilding the health sector will require more than the repair of damaged facilities and coordination with aid agencies, but also sustainable sources of financing, retraining and restaffing of the health workforce, and deduplicating of services.

As we consider the lessons learned from previous conflicts and post-disaster environments, it is critical for Ukraine to use a standardised and interoperable reporting system to help stakeholders understand local needs and better coordinate responses. Once the Ukrainian government establishes mechanisms for transparent, accountable and efficient coordination, then they should prioritise the rebuilding of the health sector.

Contributors:

Michael Guterbock

Senior Consultant, Policy and Insights, Economist Impact

Michael is a Senior Consultant with Economist Impact’s Policy Team. He works with global clients developing and delivering evidence-based policy projects across a wide range of priority areas and manages Economist Impact research teams. Prior to consulting with the Economist Group, Michael worked in disaster preparedness and humanitarian assistance consulting, as well as on policy design and implementation with the US Federal Government. Michael holds a Master’s degree in International Relations from Johns Hopkins University School of Advanced International Studies (SAIS), a Master’s degree in Global Health from The University of Michigan, and is currently pursuing a Doctorate in International Affairs from Johns Hopkins SAIS.

Alcir Santos Neto

Senior Analyst, Public Health, Economist Impact

Alcir is a public health analyst with a multidisciplinary background in global health, international relations, economic development and military medicine. Before joining Economist Impact, Alcir contributed to various multi-sector and international organisations, such as the U.S. Military, academic institutions, non-profit organizations and private consulting companies. His areas of interest include cross-cutting applications of technology in healthcare, post-conflict reconstruction of the healthcare system as well as the intersection of economic development and health in Latin America and Africa.