Ukraine’s Health System Under Siege: Lessons in Resilience from a Country at War
A Ukraine operating theatre destroyed by a Russian airstrike.

On the morning of October 10, 2022, Russia launched a barrage of over 100 cruise missiles and suicide drones at Ukraine’s power grid and water supply, striking civilian areas across the country.

One of the first targets hit were the streets around Kyiv City Clinical Hospital 5, a medical facility with hundreds of beds in the heart of the Ukrainian capital.

“We were running down the corridor, falling down on the floor at every explosion,” Dr Yaroslav Basarab, medical manager for Ukraine at the AIDS Healthcare Foundation (AHF), told Health Policy Watch. “To be honest, it was barely running, because there were patients with us who could not move by themselves.”

On that cold October morning in Kyiv, doctors and nurses raced patients to safety as missiles rained down around the hospital, shattering windows around them. The patients had to be moved on foot: the elevators were unavailable due to the risk of power outages caused by Russia’s assault on the Ukrainian grid.

“We did not even think to leave the patients,” said Basarab. “We had to take our patients and 300 more people down to the bomb shelter.”

“The doctors and nurses did their best,” Basarab recalled. “They provided psychological assistance, they supported the patients, calmed them down, and helped them to the bomb shelter.”

Kyiv City Clinical Hospital 5, Kyiv, Ukraine.

Across Ukraine, doctors, nurses, and health workers like those at Kyiv City Clinical Hospital 5 continue to risk their lives to keep the country’s health system running.

In villages near the frontlines, doctors donning bulletproof vests and helmets ride bicycles to set up mobile health clinics for patients who cannot reach the few remaining health facilities.

Others accompany rescue teams beyond the line of contact to rescue civilians. Nurses fight through gruelling hours to provide essential health services to civilians and soldiers.

Their bravery has made them a symbol of Ukrainian resilience at home and abroad. 

“The secret to our resilience is Ukrainian doctors, who have become a [symbol] for our country and for the whole world,” Maryna Slobodinchenko, Ukraine’s deputy minister of health for European integration, told a panel organized by the AIDS Healthcare Foundation (AHF) at the Lithuanian Permanent Representation to the European Union last month.

“We never stopped medical services,” said Slobodinchenko. “During blackouts, the catastrophic consequences of the explosion at the Kherson dam of the threat of nuclear disaster, we never stopped.” 

The panel organized by the AIDS Healthcare Foundation (AHF) sought to draw lessons about the resilience of health systems from Ukraine’s experience of the war.

Russian strikes on health facilities in Ukraine have killed at least 107 health workers and patients, according to the World Health Organization (WHO)

The WHO’s Surveillance System for Attacks on Healthcare, which tracks attacks on health infrastructure and staff around the world, has documented over 1,100 attacks on health facilities across Ukraine. One in five ambulances in Ukraine’s medical fleet was damaged or destroyed as of May 2023

“In wartime, people put their personal lives and affairs on hold to save their families and country, and to be a shield to European families and countries,” said Slobodinchenko. 

“Our doctors continue their work irrespective of the circumstances.”

Lessons in resilience: Ukraine averts HIV catastrophe 

Ukraine has been battling a severe HIV epidemic for decades. Nearly 250,000 people in Ukraine live with HIV, the second-highest number of cases in Eastern Europe and Central Asia, after Russia.

Ukraine made significant progress in tackling HIV before the Russian invasion. More than 130,000 people living with the virus were receiving antiretroviral therapy (ART) and viral suppression rates at 96%. Viral suppression means that the amount of HIV in a person’s blood is so low that it cannot be transmitted to others.

Russia’s invasion put all of Ukraine’s progress in tackling HIV at risk. Within two months, more than 40 health facilities that offered treatment, prevention, and care for HIV patients were forced to close. 

The United Nations Joint Program on HIV/AIDS (UNAIDS) warned in April 2022 that the war risked a “humanitarian catastrophe” for people living with HIV.

“The situation for people living with HIV in Ukraine is desperate,” Dmytro Sherembel, head of the Coordination Council of 100% Life, Ukraine’s largest organization of people living with HIV in Ukraine said at the time

“We are trying to deliver medicines, food and other emergency assistance to people in need, but the work is dangerous and volunteers are putting their lives at risk,” Sherembel warned. “If we don’t get more help, I am not sure how much longer we can continue, especially reaching people in the front-line zones.” 

Despite the immense strain placed upon it by the war, Ukraine’s health system has – so far – managed to avoid the impending catastrophe for patients with HIV.

As of February 2023, the latest official data available, only 12,000 fewer Ukrainians living with HIV were receiving ART than before the war. 

Dr Yaroslav Basarab, AHF Ukraine medical coordinator, on the ground in Ukraine.

In August 2022, 3,529 Ukrainians were receiving their ART treatments abroad, Dr Yaroslava Lopatina, AHF country programme director for Ukraine told Health Policy Watch

“This is 3% of all those receiving treatment in Ukraine,” said Lopatina. “The main burden continues to be borne by Ukrainian doctors.” 

In fact, despite the pressures of war, more patients began taking pre-exposure prophylaxis (PrEP) — a daily pill that can be taken to prevent HIV infection — in Ukraine in 2022 than in any of the four years before Russia’s invasion. 

“Some doctors worked 24 hours a day. Active fighting was happening near their houses, and some of the territories [they worked in] had been occupied,” said Basarab. “Patients needed ART medicines and laboratory tests. They needed psychological help and support.” 

Aid from civilian organizations like AHF and 100% Life, Ukraine’s largest NGO fighting HIV, and financial and medical aid from international organizations like the WHO, the Global Fund, and PEPFAR, were critical in helping Ukraine avert a disaster for HIV patients during the war.

AHF provided flashlights, power banks, and lighting to HIV facilities vulnerable to power outages, while 100% Life ran nearly 40 mobile clinics to reach HIV patients out of reach of medical facilities.

The Global Fund, WHO, and PEPFAR rushed to donate ART treatments, helping to avert a disaster for HIV patients. At the onset of the war, Ukraine had just one month’s worth of ART treatments left in its major cities and as little as two weeks in some rural regions. 

“Given the desperate circumstances, it could’ve – and very well should’ve – been much, much worse,” Rama Hailevish, Ukraine country Director for UNAIDS, told Wired.

“Undoubtedly, living under life-threatening conditions has an unfavourable effect on medical personnel,” Dr Yaroslava Lopatina, AHF country programme director for Ukraine told Health Policy Watch. “These courageous people have to treat and support patients and never show how hard and scary it is for them.”

Ukraine’s mental health crisis deepens as war rages on

Two residents stand in the ruins of homes in Borodianka in the Kyiv region.

The resilience of the Ukrainian people and health system in the face of the Russian invasion masks the trauma and growing mental health burden placed on millions across the country. 

Nine million people are expected to suffer from common mental health disorders and two million from severe mental health disorders as a result of Russia’s invasion, according to a report published by Health Trauma International in April 2023.

The Ukrainian Ministry of Health estimates four million people need psychotropic medication and up to 15 million need other psychological support. 

“We have implemented a full-scale program of psychological support for our citizens, which is available at every level of medical care,” said Slobodinchenko, speaking at the AHF event in Brussels.

Mental healthcare was significantly underfunded in Ukraine before the war, with only 2.5% of healthcare expenditure – around $6 per capita – allocated to mental health. This is a fraction of what high-income countries spend, which average $58.71 per capita – in peacetime.

Mental health needs also vary widely across Ukraine, with those on the front line, in areas that have experienced Russian war crimes, and in areas impacted by weapons with wide blast radiuses more likely to have experienced trauma, the Health Trauma International report found. 

“The war in Ukraine has created a huge need for psychological support ranging from psychological first aid to comprehensive psychological care,” Médecins sans Frontières (MSF) Ukraine said in August. “People have experienced fear, trauma and isolation and are showing symptoms of anxiety, depression and stress. 

People facing the aftermath of a missile strike may experience shock, panic attacks, changes in appetite and sleep patterns, and withdrawal from daily activities, while displaced people may experience anxiety, intrusive thoughts, trauma, and stress management problems.

“One of the challenges of this war was the thousands of internally displaced people, who were in need of medical care,” said Slabodinchenko. “During the first period of invasion, we arranged temporary medical facilities in various places like sports gyms, schools, primary schools, recreational facilities and even theatres.” 

‘How are you?’: Overcoming stigma in times of crisis

Mental health is an acute and sensitive subject in Ukraine. Historically, discussion on mental health has been stigmatized.

But as families, health workers, and civilians across the country try to cope with lost loved ones and new lives as refugees after their homes were destroyed, the stigma is starting to break.

In March 2023, Ukrainian First Lady Olena Zelenska launched the “How Are You?” campaign, encouraging Ukrainians to talk to each other and reach out to loved ones about the difficulties of war.

On a podcast appearance in June, Zelenska noted that the reluctance to discuss mental health amongst Ukrainians can be traced back to Soviet-era attitudes when people who held dissenting political views were locked up in mental institutions for “psychiatric problems”. 

“This fear still exists,” said Zelekska. “But people need to understand that it is no longer the case. It’s different now. That’s why we need to inform people and help them understand about mental health care. It is not scary.” 

Stigma and self-stigma remain one of the main barriers to Ukrainians accessing psychological support, according to MSF Ukraine.

“Although MSF counselling is available for everyone, most of our patients are older women,” MSF Ukraine said in August. “Men also feel powerless, helpless, and it of course affects their mental health.”

Ukraine’s resilience hinges on continued international support

Ukrainian President Volodymyr Zelensky meets NATO Secretary-General Jens Stoltenberg at NATO headquarters in Mons, Belgium.

Ukraine’s resilience in the face of Russia’s invasion has been remarkable. But as the war drags on, an uncomfortable truth is becoming apparent: the resilience of Ukraine – and its health system – hinges on continued international support.

Ukraine’s path to military victory is narrowing, according to military experts. Delays in U.S. military aid due to congressional gridlock, the election of a Ukraine-skeptic party in Slovakia, and clashes with neighbour Poland over grain exports put into question the long-term reliability of its closest allies. 

In a somber speech to NATO leaders on Thursday, President Volodymyr Zelensky warned that Ukraine’s military is “scraping the bottom of the barrel” and needs more weapons and ammunition.

While ammunition, mortars, artillery shells and tanks fetch the headlines, international aid also props up Ukraine’s health system and the people brave enough to continue working in it. 

How long they will be able to keep up their lifesaving work if foreign aid dwindles is unknown.

“Our priority now is in prosthetics,” said Maryna Slobodnichenko, Ukraine’s deputy minister of health for European integration. “We have over 90,000 amputations. We also need professionals in this field.”

“The secret of resilience is in unity and in people,” said Slobodnichenko.

Image Credits: Matteo Minasi/ UNOCHA, UA, UA.

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