The Ukraine Crisis Effect On Healthcare Delivery
As a member of the board of the Sunflower Community Fund (www.sunflowercommunityfund.org) which provides support in Ukraine to children in orphanages or with disabilities, and as a consultant to Ukraine-based IT firm Proxet (www.proxet.com), I have witnessed firsthand how war can transform a country almost overnight. The disruption of the Russian invasion on February 24th has upended everything in the country including access to and availability of healthcare in the region. This paper seeks to address the Ukraine crisis effect on healthcare delivery from the citizen or patient perspective. First I examine the current, near-term and longer-term effects of war on the status of healthcare in Ukraine as well as the emergent health effects of war. Then I leverage the work of the Building a Better Response and Sphere organizations in addressing complex humanitarian emergencies. Finally, I examine the particular effect of the war on pandemic response which is further degraded by the war in Ukraine.
Quality healthcare in any country or region is heavily dependent on infrastructure (hospitals, clinics and utilities), staffing (from clinicians to custodians), transportation (auto, bus, and ambulance), and a reliable supply chain (for medical supplies and drugs). Moreover, customary care such as primary and elective care, elder care (e.g., skilled nursing), maternity and disabled care relies on the stability of infrastructure, staffing, transportation, and supplies. In wartime, all of these systems are compromised, challenged and, as the conflict drags on, potentially destroyed by the war. Further, victims of the conflict often require chronic care which can easily overwhelm a healthcare system now unable to deliver any routine care to its citizens. Much like the pandemic’s effect on healthcare systems during surges, it is as if a Chernobyl-like disaster hit every corner of Ukraine, from its eastern border with Russia to its western borders with Poland and Moldova, to the north with aggressor Belarus and to the south, Crimea and the Black Sea. According to The Conversation (https://theconversation.com/ukraine-war-has-an-impact-on-peoples-health-beyond-bullets-and-bombs-178062): “Wars are complex health emergencies that lead to the breakdown of society, cause considerable damage and destruction to infrastructure, create insecurity and have a significant economic impact. They also exacerbate pre-war issues.” Hospitals and clinics have been bombed, key staff have evacuated, travel is hampered, and inventory of critical medical supplies is often depleted. This war will be a long-term challenge to Ukraine’s healthcare delivery system.
While the conflict in Ukraine is less than two months old, the country is already beginning to see the emergent health effects of war as well . The availability of clean water and healthy food is compromised in all of the country’s major cities and rural communities. Sanitation and hygiene too have been compromised as plumbing and sewage systems are damaged. The starkest pictures from the war show destroyed homes and apartment buildings whose residents are taking shelter in underground subways as an emergent housing crisis becomes a health crisis, hastening the transmission of disease — waterborne and airborne. Ukraine’s pandemic response is now non-existent (testing, treatment and vaccination) as is pediatric, elder, and maternity care. Added up, the country faces the triple threat of the elimination of the availability of routine care, pandemic care, and chronic care whose need existed before the war, and which has emerged from war as conflict-indiced injury. The entire country is experiencing the collective trauma of the war and its effect not only on physical well-being but also on mental well-being. An expert on public health in Ukraine, Dr. Judyth Twigg, was quoted recently by The Washington Post (https://www.washingtonpost.com/world/2022/03/24/ukraine-public-health-hospital-war/ ): “There’s going to be tremendous need for expanded capacity to diagnose and treat long-term anxiety, depression, post-traumatic stress disorder, and other conditions. We should also be paying attention to treatment and management of chronic, noncommunicable disease, which is the primary part of Ukraine’s existing health burden.” Even if the war were to end tomorrow, its effect on the citizens of Ukraine will be felt for quite some time.
Building a Better Response (BRR) (https://www.buildingabetterresponse.org/) defines a Complex Humanitarian Emergency as one with mass violence and loss of life, widespread damage to essential infrastructure, mass displacement of populations, the need for large-scale assistance, the presence of non-state actors, decreased security, and the deployment of military and defense. As discussed previously, all of these conditions exist in Ukraine after just a few weeks of conflict, putting stress on the nation’s healthcare system. In that time, 10m citizens, or 25% of the population, have fled to neighboring countries as refugees, overseas as asylum-seekers or have been displaced in-country, from east to west and north to south as the war has raged and moved on. Proxet, for example, has moved its primary operations and staff to Warsaw, Poland with many other staff relocated to and working from temporary homes in Turkey and Portugal. How will all those who flee receive continuity of care in their new home cities or countries? How will those who decide to stay be ensured that the care they were receiving before the war might be continued during and after the war?
Geneva Solutions recently reported on the important role that telehealth is beginning to play in bringing care during the conflict to Ukraine citizens where they are (https://genevasolutions.news/peace-humanitarian/how-virtual-healthcare-services-are-coming-to-the-aid-of-ukraine). Because of Ukraine’s digital health preparedness emerging from the pandemic, most medical records are now digitized. Further, in 2021 ‘UNICEF and Giva Care Group, a Ukrainian medical technology company, launched 50 digital healthcare companies in the east, where the conflict (with Russia) has been ongoing since 2014.’ These healthtech companies provide everything from remote medical examination kits to tele-maternity care to virtual mental health screenings. This partnership between the government agency UNICEF, the start-up Giva Care and Ukraine healthcare providers is an example of the overriding principle of the BRR Humanitarian Imperative to ‘prevent or alleviate human suffering arising out of disaster or conflict.’ This imperative is achieved through the Four Pillars of Humanitarian Reform — Coordination, Leadership, Financing, and Partnership.
Funding, another reform pillar, is achieved through the coordination of many entities, some governmental, some non-governmental and some privately sourced, as is the case with The Sunflower Community Fund. BRR describes this concept as ‘pooled’ funding which relies on multiple funders working through a cluster humanitarian assistance entity (e.g., The World Health Organization-WHO) to support a single coordinated system of local, national, and international humanitarian assistance. One such cluster would be healthcare through the WHO, working to insure continuity of care, even in times of war and in concert with International Humanitarian Law, restricting the means and methods of war.
The Sphere Standards (https://spherestandards.org/) address humanitarian action through a charter that includes Health (both Health Systems and Essential Healthcare) as shown in the following diagram.
Sphere Standards applied to Healthcare depends on adequate resource mobilization to replace or bolster clinical staff on the ground during a conflict, as well as proper monitoring and evaluation of progress, quality and healthcare outcomes. The WHO (https://www.who.int/emergencies/situations/ukraine-emergency) is delivering medical supplies, coordinating the deployment of medical teams, and providing protection to health workers and health systems in Ukraine to ensure the adequacy of humanitarian healthcare relief. This work is being done in partnership with NGOs on the ground in Ukraine providing services as varied as cybersecurity for medical records to local transportation. All the while the back story of this war in Ukraine is the now endemic Covid-19 pandemic.
In 2020 and 2021, I conducted qualitative and quantitative research at over thirty US hospitals to understand the relationship between leader behavior, team performance and organizational resilience in US healthcare during the pandemic. The research question being explored was how healthcare crisis preparedness systems in the US were able to respond to the multi-system breakdown caused by the pandemic. As the following theoretical framework shows, the answer to this question was complex. Much like the conflict in Ukraine, resilience depended on the adaptability of leadership to make rational choices, the emergence of agency that groups of individuals (teams) felt that they had to act as needed, the ability for the organization or entity to absorb rapid change and to deploy their social capital as needed, and the impetus of the various stakeholders to act in the best interests of the (healthcare) system while not depleting their adaptive reserve.
As we have seen from the effects of war in Ukraine on their healthcare delivery systems, this too catalyzed a multi-system breakdown with little opportunity for fail-over protection as there was nowhere to fail-over too. BRR and Sphere teach us standards for humanitarian action but what they are lacking are essential leadership, teamwork, organization, and system resilience and sustainability standards that were found at hospitals in the US during the pandemic. That would be an area for improvement for both standards bodies. However, as any military or political leader in Ukraine might say, there is little need for pandemic response or standards for that matter when survivability is at stake.
