Ukraine has shown remarkable resilience and strength in the face of war. With Russia’s invasion in February 2022, Ukraine’s healthcare system was suddenly under enormous strain and facing unprecedented challenges. Bombings damaged facilities and disrupted healthcare delivery. People stopped going to the doctor for regular preventative checkups. The war intensified new healthcare needs, including more support for mental health, rehabilitation, and gender-based violence. 

The government moved quickly to keep health services—particularly primary care—running.  

Back in the mid-2010s, the government had started making significant progress toward revamping the healthcare system to improve the quality of medical services, develop new infrastructure, and fight the COVID-19 pandemic.

As a result, even in the midst of war, the Government of Ukraine has managed to sustain critical health services—adapting to circumstances, innovating where possible and meeting new needs.           

Steady donor support has been crucial to this effort, as this assistance has helped cover payments for health services through the World Bank-mobilized Public Expenditures for Administrative Capacity Endurance (PEACE) project.

The Health Enhancement and Lifesaving project (HEAL) is reconnecting people with preventative healthcare, restoring regular checkups, recovering childhood immunization coverage, and improving access to medication for people with chronic conditions. HEAL is also training primary care providers to provide initial mental health help and support victims of gender-based violence. It also helps scale up development of rehabilitation services, an underdeveloped field in Ukraine. 

“We worked with the government to identify what kinds of needs are pressing. We knew the government was going to expand essential services and set up additional structures to be able to provide more services. For example, improve access to mental health help by training primary care providers, or improve access to medication for outpatients,” says Olena Doroshenko, World Bank task team leader for the HEAL project.

The project supports government expenditures needed to scale up these essential services as well as investment needs to modernize facilities and train medical staff.

This is how HEAL works: After a doctor sees a patient and the service is recorded, the doctor and the facility receive a payment for rendered services from the National Health Service of Ukraine. The government and the World Bank share the cost which opens additional fiscal space for the government.

“Every day, our medical system is tested for resilience. Every day we are forced to respond to new challenges. Thanks to the support of international partners and the self-sacrificing work of our heroic doctors, we have been able to uphold our medical frontline. I thank the World Bank for a reliable shoulder of support,” said Viktor Liashko, Minister of Health, Ukraine at the time of the HEAL Project signing.

Reconnect patients with health care

In the last two years, there has been a decline in preventative health care. “During wartime people often deprioritize health,” stresses Doroshenko.

The indicators of preventive screenings—such as the number of people who received a cardiogram or a mammogram—were down twofold in September 2022. Immunizations and childhood vaccination fell by over 40% at the beginning of the invasion, and although they picked up during 2022-2023, they still lag the target coverage.

HEAL is helping to reconnect patients with primary healthcare providers and reestablishing preventative screenings—for hypertension, diabetes, cancer, and more—as well as other services, such as childhood immunizations.

The project is also helping to expand the program of affordable medicines, which was established before the war. Now roughly 800,000 people are receiving medications through the Affordable Medicines Program, at no cost or a small copayment.

Ensuring that healthcare and medications are more affordable to a larger number of people is helping to dampen poverty. And this is critical because poverty in Ukraine increased with seven million more Ukrainians falling in poverty by the end of 2022—erasing 15 years of progress.

Expanding access to mental health services through primary care doctors

Living under constant stress brought on by the uncertainty of the war has frayed the nerves of many Ukrainians.

The need for mental health services has grown dramatically. One in five people in Ukraine may be suffering from mental health issues due to war and conflict.

“I was worried for a very long time about all sorts of problems, but with the beginning of the war, these problems simply intensified,” says Nikita Vitvitsky, a patient.

The government has launched a large training program for primary care providers to screen for and address mental health issues, where appropriate.

“The requests for mental health services grew,” says Roksolana Tkach, a family doctor in Lviv.  “The war is a hard challenge to bear for our society. The symptoms include loss of ability to sleep, increased anxiety, decreased physical capabilities, and loss of interest in everyday life—on the emotional level. That is why our first and foremost task is to help these patients recover and return to their lives, improving the quality of their lives. It is important that these depression episodes or PTSD are not worsened and that the patient stays out of the deep psychological pathology.”

Also, equipping primary care providers to handle mental health issues is making access to mental health services more available and is helping to tackle stigma.

“For my generation, having such mental health services in the clinics means popularizing and normalizing these services among younger generation,” says Vitvitsky.

Rehabilitation

Rehabilitation, as a medical service, has been relatively underdeveloped in Ukraine and other countries once part of the Soviet Union. The war has only increased the demand for such services as there have been many injuries, amputations, burn victims, etc.

HEAL is an opportunity to set up systems to support rehabilitation services for war and non-war-related needs alike. Stroke patients, for example, are usually one of the largest groups of people who require these services.

“I think the demand for medical services has increased. We have more military personnel and many are developing various diseases due to the overloads they experience. Many of them have degenerative diseases, herniated discs, and high blood pressure. On the other hand, many people who have family members in the military or are worried, many people are now suffering from such post-traumatic stress disorder,” says Oleksii Leontiev, head of the neurosurgical department at a local hospital.

Now that the government has recognized this need and contracted providers, there are now more than 160,000 people who have received these kinds of services.

The response has been overwhelming. “It is clear that there was a demand, that was not addressed,” Doroshenko says.

The government is now implementing the International Classification of Functionality, which is helping to assess a patient’s condition before and after rehabilitation care has been provided.

“You can see the results of your work with your own eyes,” says Petro Skodliak, head of neurorehabilitation department at a local hospital. “It inspires you in a way. It uplifts you. I love this profession.”

Equipping primary healthcare workers with gender-based violence training

There is a lot of interest in learning how to help the victims of gender-based violence (GBV). One in three women in the country will experience physical or sexual violence in her lifetime. Experts estimate that four million people in Ukraine needed services last year (in 2022) to prevent violence and support survivors.

 “We surveyed primary care doctors and they said that they see a lot of patients, especially now during the war, especially in the areas near the war zone. They said that they do not have enough understanding of how to handle these cases, how to recognize, how to properly register information about this patient and how to provide a consultation to these patients in terms of what they can do,” Doroshenko says.

Based on this survey, consultations with primary care doctors, and cooperation with the government, the World Bank has supported the preparation of self-paced online training available through an online platform operated by Ukraine’s National Health Service of Ukraine. This GBV training was developed specifically for primary healthcare providers and was launched in December 2022.

The uptake has been incredible. To date, over 2,800 healthcare providers have taken the training. Many in Kyiv, as well as the Kharkiv and Dnipropetrovsk Oblasts, which are close to the frontline, signed up for the course. Demand for training grows as doctors and nurses continue to register.  Participants’ positive feedback indicates that the course is useful and that it enabled them to help victims of GBV.

“There is demand and we were able to offer a systemic approach, equipping all interested doctors to understand what they can do in these cases and to make sure that there is adequate attention and support provided,” Doroshenko says. 

“There’s more work to be done in terms of assisting gender-based violence victims,” says Yaryna Pikulytska, a pediatrician in Lviv, who completed the GBV training. “Now we’re all living in stress, and I’m sure it’s very difficult for those who have experienced such violence to approach a doctor and talk about it… I feel that I can provide them with a safe environment where they can heal, recover and move forward in their lives.”

The HEAL Project aims to raise $500 million for Ukraine’s massive healthcare needs. This ongoing project has been set up as a so-called “framework project,” to mobilize partner resources through a flexible design to disburse funds quickly and be scaled as necessary when additional financing becomes available. As of September 2023, the project is supported by a €100 million guarantee from Spain, a $10 million grant from the Global Financing Facility (GFF), and a $10 million grant by the Ukraine Relief, Recovery, Reconstruction and Reform Trust Fund (URTF).