The war in Ukraine has had a devastating impact on the health system in the country, following several years of advancing important health financing reforms. Thousands of civilian war casualties, and millions of internally displaced people (IDPs) moving throughout the country, have heavily impacted the need for health services. Health facilities have also been destroyed, WHO has reported 859 attacks on healthcare facilities in Ukraine, as of March 2023 [1]. In this context, the NHSU has also faced cuts to the health budget due to an economic crisis caused by the conflict. To help manage this, the World Health Organization’s (WHO) health financing experts from the country, regional and headquarters supported initiatives and outreach at all levels of the national health service of Ukraine (NHSU). This has included high-level policy forums and trainings involving policy makers and international partners, regular support and capacity-building activities for NHSU managers and staff, and support for primary health care (PHC) service providers, allowing these frontline health practitioners to better understand their facility costs and resources. These health financing skills, at all levels of the NHSU, have proven to be a key factor in maintaining the health system in the face of adversity.

How did Ukraine, with the support of the WHO secretariat, achieve this?

WHO's support to the NHSU has been extensive in 2022, covering policies, operational implementation, and on-the-ground activities performed by health care providers. Soon after the invasion of Ukraine by the Russian Federation in February 2022, forums were organised with Ukrainian policy makers to address specific questions regarding how to adapt the NHSU to the context of the war. Regular briefings were provided by WHO Ukraine to support contingent decision making by managers and administrators within the health system. In addition, family doctors and other medical centres were equipped with health financing skills and knowledge to help them manage their practices amidst disruption.

Specific health financing policy questions facing the NHSU were addressed across a range of WHO reports, backed by face-to-face engagement with NHSU personnel. These included how to update the NHSU contracting and payment system, how to adapt strategic purchasing of medical services, and how to maintain access to medicines. In published reports, WHO Ukraine recommended for partially resuming a case-based payment system, in which patients using health services across different oblasts could be better identified, with the funding made available according to health needs [2]. On strategic purchasing, WHO Ukraine argued that health financing strategies can stimulate new service models, such as the mental health mobile teams established in 2021. These community-based mental health teams provide services in across all oblasts. WHO Ukraine also published a report in 2022 on disruptions to access to medicines in Ukraine, for the period February–June, making key policy recommendations [3]. On a broader scale, WHO country and regional office  elaborated the principles to guide health systems recovery for Ukraine to feed into the policy forums with the national authorities, convening key partners such as the World Bank, EU and USAID for their insights. These actions further led to a separate joint paper on priorities for health system recovery in Ukraine, further elaborating the vision and plans for early recovery efforts.

NHSU operations have also been supported by WHO’s health financing teams, by engaging NHSU managers, administrators and decision makers in weekly calls and knowledge exchanges. WHO Ukraine has convened these ‘fika’ meetings since March 2022, named after the Swedish tradition of coming together over coffee during work hours. These sessions have provided a forum for feedback on the implementation of the NHSU’s goals, as well as for policy reflection. Topics covered include the provision of rehabilitation and mental health services in emergencies, the practicalities around contracting health care providers, and health financing monitoring and evaluation systems, as they currently operate in Ukraine, as well as within other health institutions across Europe.

These meetings between the NHSU and WHO teams also involved international partner organizations, along with colleagues from neighbouring countries such as Estonia, Lithuania, Moldova, Poland, Slovakia, and the Czech Republic. The World Bank and USAID health financing experts have also taken part. The forums therefore ensure that NHSU administrators and managers are in regular contact with experts implementing the best practices from around the world. The policy options are discussed with NHSU personnel, along with colleagues from the Ministries of Health and of Finance, at health financing training events. For example, WHO Ukraine conducted a capacity-building camp in August 2022 for more than 30 participants from these bodies [4]. 

“Holding these meetings with international partners is a sign that our work is ongoing, and we have felt supported in the process.”

Mariana Hladkevych, former NHSU Chief of Strategic Project Management and International Cooperation

WHO’s health financing team also acted as a reliable partner and consultant for preparation and development of Ukraine’s Programme of Medical Guarantees (PMG) for 2023. This is the programme through which Ukrainians access free and subsidized medical care.  On-the-ground NHSU health care providers have also received support from WHO technical teams to help build their health financing skills and knowledge. The PHC costing study provided training in health financing for PHC service providers [5]. The programme thereby helps to safeguard free access to PHC in Ukraine, by ensuring medical facilities are better able to optimise the resources available to them. This study is part of a broader effort to provide accurate data to the NHSU, to inform the development of the PHC payment system and to ensure that all the necessary costs of delivering PHC services are adequately covered in the benefits packages designed in the future. Following a request from the NHSU, and in cooperation with WHO Ukraine, up to 100 health service providers have agreed to share their cost data. The findings will help the NHSU to make necessary adjustments, and the recommendations will improve the national payment system to strengthen healthcare delivery in Ukraine. In addition to the PHC costing study, WHO Ukraine is preparing several case studies on recovery of small-to-medium sized health care facilities to contribute to the recovery efforts.