Cover image from Reuters: Mariupol Children's Hospital in the aftermath of an attack.
The launching of Russia's Invasion of Ukraine has severely strained the Ukrainian healthcare
system. The war has not only damaged healthcare infrastructure but also resulted in a massive
influx of soldier patients, further straining the system. The pre-existing healthcare system in
Ukraine, already weakened by corruption and limited resources, faces additional challenges due to
the war. Comparatively, Russia, while not experiencing direct attacks on its healthcare
infrastructure, faces challenges due to extensive sanctions and its influx of soldier patients. Iraq's
wartime health system also faced similar infrastructure destruction and corruption challenges.
Much can be learned from what is being done in Iraq and Russia. The lessons can help identify
priorities for Ukraine. For Ukraine, recommendations include monitoring and controlling corruption,
centralizing aid distribution, retaining medical personnel, and rebuilding healthcare infrastructure
with a focus on community health centers.
The Invasion of Ukraine
On February 24th, 2022, Russia launched an air and land invasion of Ukraine. After 24 hours, Russian forces had reached the capital of Kyiv and began an assault on the city.
The war has had a significant impact on Ukraine’s health system. One impact is damage to healthcare infrastructure. Russia has been consistent in striking medical facilities in Ukraine. As of May 30th, 2023, the WHO has recorded over one thousand attacks on healthcare. These attacks have killed 101 workers and patients. Along with the human impact, the WHO has recorded 896 attacks on health facilities, 121 on transport, 72 on personnel, and 17 on warehouses in Ukraine during the war. Furthermore, taken territory has contributed to the loss of healthcare facilities.
Another health system impact is the influx of soldier patients. BBC and an independent Russian media outlet, Mediazona, have confirmed the deaths of 25,528 Russian soldiers through body and document identification. Killed-to-wounded ratios have been estimated to be about 1:4 or 1:5. Therefore, Russia has had a minimum of 100 to 125 thousand troop casualties. This is a minimum because these are only identified deaths, and many estimates claim Russia to have lost in the 200 to 300 thousand casualty range. In an equal arms war, as this has become, losses will be relatively similar on both sides. Therefore, Ukrainian casualties are likely at a minimum of 75 thousand and potentially up to 250 thousand. As of 2018, Ukraine had over 2200 hospitals and over 400,000 hospital beds for its civilian population alone. The soldier patient population could be occupying half of these beds, especially as soldiers may take serious injuries that require long-term care.
Another impact of the war on healthcare is the infrastructural and logistical damage the war has caused to the Ukrainian health system. Attacks on energy and water systems have cut the supply of necessities to health facilities. Strategic attacks on Ukraine’s supply chains have strained healthcare logistic systems. Transporting materials through Ukraine has become more expensive, difficult, and dangerous.
This problem will continue in the future. The war looks like it will be heading into its third year with an end potentially years away. The war needs to be resolved for health system strain to be reduced. If Western support for Ukraine continues, it will be able to better address its needs. If Ukraine starts to lose support in the war, strains may be exacerbated and potentially could become worse.
The Pre-War Ukrainian Health System
The prewar healthcare system in Ukraine was already weak. The constitution states that citizens are entitled to the right to a comprehensive guaranteed package of health services that are free of charge at the point of use. Half of the financing for the system is raised through government revenue. In contrast, the other half is raised through out-of-pocket payments. The biggest out-of-pocket costs are medications and in-patient care. Ukraine was known to be extremely corrupt. It was found that the medical system had some of the highest corruption rates. In a study that surveyed 1120 citizens and 513 medical and pharmaceutical professionals, 63 percent reported being involved in corruption schemes.
Current wartime policy in Ukraine has largely excluded the healthcare system. There has been extensive discussion on post-war policy. However, the wartime health system continues to operate on the pre-war guidelines. In the first year of the war, the Ukrainian economy shrunk by 45%, while in 2023, the Ukrainian economy is projected to grow by 2%. With 50% of health system financing stemming from government revenue, there has been an added financial strain on the Ukrainian health system and reduced the ability for the government to pay.
A failure in policy has been in the handling of humanitarian aid. Humanitarian assistance is generally provided to consumer institutions without an external assessment of the allocation of needed resources. This has made health system resource allocation uncoordinated and unable to fulfill general public needs. Clear and specific priorities for the health system have not been identified. Pre-war strategies are inept for wartime care, and with ongoing conflict, post-war strategies do not consider the wartime context for existing resources. Current health policy failed to consider the local contexts of the war on the health of different populations. The health needs of different regions of Ukraine are variable. Communities around the front lines have vastly different needs than those in the “safe” parts of Ukraine. Without a coordinated and centralized system for distributing wartime healthcare and humanitarian aid, Ukraine has struggled to fulfill the changing needs of its population.
Map of belligerants on June 20th, 2023.
Comparison Countries
Russian Wartime Healthcare
Russia is on the other side of the war in Ukraine. Russia’s initial invasion force was between 169,000 and 190,000 personnel in and around Ukraine. Hundreds of thousands of additional Russian troops have been added to the conflict. With an estimated 200 to 300 thousand casualties, Russia will have to find space to care for these injured troops. Unlike Ukraine, Russia’s healthcare infrastructure has not been affected by the war. Ukraine does not have the capability or military need to strike Russian healthcare infrastructure. Therefore, Russia will not see healthcare strain from losing healthcare infrastructure. Russia does face a unique healthcare challenge due to extensive sanctions. There have been 12,968 recorded sanctions against Russia, and this number continues to grow.
The sanctions have caused the Russian healthcare system to face severe shortages of modern therapies and medicines, especially those that come from Western countries. This has been evident in the decrease in available oncological and rare disease therapies. In response to this shortage, Russia is attempting to increase the proportion of domestically produced medicine to 88%. Sanctions have also caused an increase in drug prices of many drugs, including antibiotics. This has forced some clinics to halt procedures that rely on imported medicines, such as joint replacements.
There is also an indirect effect of sanctions on Russian healthcare. Sanctions have caused an increase in the cost of living in Russia. A cardiologist at the district hospital in Tarusa, south of Moscow, states that some patients are opting not to purchase medicines due to their other financial obligations. The sanctions have also hindered Russia’s ability to repair high-tech medical equipment. In response, Russia has allowed medical institutions to repair equipment with non-original spare parts.
The war has also strained medical staff in Russia. To prevent a medical staff shortage, Russia banned medical professionals from leaving the country in September 2022 in case they were called to serve as army medics. A doctor reported that Russia’s medical system is facing low staff morale. Russia’s authorities have cracked down on medical workers, and they can be jailed for mentioning medical supply shortages.
Average length of stay (days) in EU members and Russia. Figure adapted from Health Economics Review.
The Russian Healthcare System
The Russian healthcare system was the model for the original Ukrainian system. It promises universal health coverage in the Russian Federation. All citizens are entitled to free care in state and municipal medical facilities. The system is funded through a combination of general taxation and employer contribution. The system uses primary care as a gatekeeper to more advanced care. It relies on a polyclinic system. Polyclinics are clinics that perform outpatient preventative, primary, and specialist care. Though services are supposed to be covered under the Russian healthcare system, patients are often expected to provide informal out-of-pocket payments for care. Surging oil prices in 2000 allowed Russia to increase health funding.
Russia has used this additional funding to invest in vertical programs. These vertical programs were the “Priority National Health Project” (2003-2012), the Prophylactic Program (2008 – present), and regional programs for the modernization of health care (2011–2013). These programs attempted to develop high-priority sections in preventive, obstetric, cardiovascular, surgical, and oncological care. Russia has lagged in the development of horizontal integration of medical care. In 2018, Russia had an average hospital size of 223 beds, more than France and Germany at the time, with 130 and 215, respectively. Their consolidation of regional polyclinics into larger hospitals has increased the vertical component of care at the expense of accessibility of care to a broader area.
Corruption is prevalent from patient care to the educational aspect of Russia’s healthcare system. It was reported that students from one of Russia’s top medical schools, I.M Sechenov First Moscow State Medical University, would openly give professors envelopes with thousands of rubles or hundreds of US dollars for good grades. There is a culture of corruption among medical staff. Corruption at the medical staff level has left millions of patients without care. These patients are unable to afford to pay for private hospitals and rely on state hospitals. At state hospitals, patients are forced to pay bribes to receive timely care or even care at all. Infrastructure projects in Russia require bribes and kickbacks at every step of the process. The cycle of bribery absorbs exuberant amounts of money out of infrastructure projects and leaves healthcare infrastructure underdeveloped, mismanaged, and underfunded.
Iraq's Wartime Health System
Iraq has been in consistent significant conflict since 1961, starting with the first Iraqi-Kurdish war from 1961-1970. This cost the lives of about 10,000 Iraqi soldiers. The next great Iraqi conflict was the Iran-Iraq War from 1980-1988. The estimates on Iraqi military deaths vary between 105 and 500 thousand soldiers, along with over 100 thousand Iraqi civilians. The Gulf War claimed the lives of around 10 thousand soldiers and around one thousand civilians. The largest conflict in Iraq was also the most recent, in the Iraq War and the War in Iraq. The Iraq war spanned from 2003 to 2011, and the War in Iraq spanned from 2013 to 2017. The Iraq war killed a minimum of 134 thousand civilians, while estimates can easily surpass 250 thousand civilian deaths. The estimated ISIL fighter deaths are estimated to be around 190 thousand soldiers, along with approximately 67 thousand civilian deaths. Since 1961, Iraq has lost a minimum of 600,000 thousand people, and because of difficulty counting these figures, the estimates can easily double or triple this number.
The Iraqi healthcare system has faced a similar challenge to Ukraine with the destruction of Iraqi healthcare infrastructure. Iraq has lost significant equipment and pharmaceutical stocks. The continuous state of war has taken a toll on the medical professionals in Iraq. The nation has witnessed a considerable brain drain, with many doctors, nurses, and other healthcare workers seeking opportunities in safer regions or abroad. The morale among medical staff is low, with many facing threats, violence, and even kidnappings. The Iraqi authorities, in their bid to maintain a functional healthcare system, have at times imposed restrictions on medical professionals, preventing them from leaving the country or relocating to safer areas.
Furthermore, Iraq has faced international sanctions, particularly after its invasion of Kuwait, leading up to the Gulf War. With restrictions on imports and financial transactions, Iraq has struggled to procure essential medical supplies, equipment, and medicines from the international market. The sanctions have led to severe shortages of critical therapies, especially those sourced from Western countries. This scarcity has been evident in the limited availability of treatments for chronic diseases, oncological conditions, and other specialized medical needs. To counteract these shortages, Iraq has attempted to bolster its domestic pharmaceutical and medical equipment production. However, years of war and economic challenges have hindered the nation's ability to produce medicines at the scale and quality required.
The Iraqi Healthcare System
The Iraq Ministry of Health was established in 1956. In the 1970s, it was configured into a centralized model that focused on hospital care. The Ministry of Health provided free universal health coverage. However, due to limited resources, most of the resources were concentrated in Baghdad. In 2013, health expenditure was 247 dollars per person. Physicians are employed by the state and supplement their income through working in private clinics and hospitals.
The growth of deliverable healthcare services has been slow between 2013 and 2018. This is expected as there was a war between Iraq, the US, and other allies against the Islamic State. In 2013, there were 360 public and private hospitals with 44,997 beds, in 2018. The number of total hospitals grew to 416 with 45,300 beds. The Iraqi healthcare system is funded by the central government through tax revenue.
Iraq has difficulty training new medical personnel. There have been claims of extensive training courses for doctors and other healthcare professionals. However, many of these courses are unaccredited and were mostly taught by unqualified personnel. Iraq has dealt with a significant brain drain of medical personnel. During times of war, hospital staffing was often augmented by doctors and nurses fleeing from other parts of Iraq. Iraq had shifted its healthcare strategy to focus on primary care. They provide primary care through 2504 primary health care clinics (PHCCs). However, half of these clinics were without a doctor.
Like Russia and Ukraine, the Iraqi healthcare system struggles with corruption. Corruption in healthcare has been a longstanding practice in Iraq. In 1996, the UN created a United Nations Oil for Food Program, which provided 25 dollars per person in medical imports. These UN funds were diverted to buy expensive cancer therapies for select wealthy patients. Hospitals focused on tertiary care and bought sophisticated equipment instead of purchasing needed items like soap, linens, stethoscopes, and blood pressure cuffs. Corruption also exists on the educational and leadership side of the Iraqi healthcare system. Heads of medical colleges, teaching hospitals, boards of medical specializations, etc., have been appointed in most instances without regard for their professional or scientific qualifications. Lawmakers have created laws that have enabled their supporters and friends to take the highest professional and academic ranks called “The special degrees.” The assumption of these positions by unqualified people has damaged health system infrastructure and leadership.
Recommendations
There are many courses of action that can be taken to alleviate the strains of the war on Ukraine’s healthcare system. The first priority should be to monitor and control corruption. Corruption with foreign aid could jeopardize future aid as well as jeopardize the people who need the aid. Both Iraq and Russia have not made significant progress in curbing corruption, and both have not made legal changes to target corruption. Ukraine has made significant legal and procedural changes to fight corruption. With a history of being one of the most corrupt countries in Europe, there has been considerable progress in the last several years. There has been recent concern about President Zelensky’s plan to make corruption a crime of treason. This plan would move corruption cases under the supervision of the Security Service of Ukraine (SBU), which falls under the direct command of the president, allowing the service to bury cases against certain officials and figures. I recommend creating a separate board to act as a watchdog for general aid and corruption. I recommend working with the UN to create a board that can act as a third party, ensuring that all funds reach their intended targets.
The next priority should be to create a centralized system for receiving and distributing foreign and humanitarian aid. The government can coordinate healthcare delivery to fulfill the varying regional health needs. Some aid will not be able to be distributed through this system. For example, a lot of pharmaceutical aid comes from the donation of near-expired medications. The time it would take to centralize the receiving and delivery of these medications could put them past their expiration date. In these cases, the current system of direct delivery would have to be used. Iraq does receive foreign aid. However, their aid is usually coordinated by the party that is providing it, and they generally do not give control over aid to the government.
The next priority is to address the strain on medical personnel. The influx of soldier and civilian patients into a hospital system that has shrunk has strained healthcare workers. Ukraine should adopt the same rule that Russia has and not allow doctors to leave the country. This rule would help Ukraine meet its increased healthcare demands as well as combat brain drain in the medical field. Ukraine should work with its neighbors to create programs where healthcare workers and students can come to Ukraine to learn and practice. This would be a great opportunity to further build international relationships and would alleviate some strain felt by Ukrainian healthcare workers.
Sasha Lawrence is a 4th Year student at the University of Virginia, the Review's Managing Editor, and a 1st generation Russian-American.
References
1. Mesot, Lorene, "Ukraine: Is Targeting Hospitals Always a War Crime?" Geneva
Solutions,
https://genevasolutions.news/peace-humanitarian/ukraine-is-targeting-hospitals-always-a-war-crime#:~:text=The%20Geneva%20Conventions%20and%20their,be%20the%20object%20of%20attack.
2. "WHO Records 1,000th Attack on Health Care in Ukraine over the Past 15
Months of Full-Scale War." World Health Organization (WHO) Europe, https://www.who.int/europe/news/item/30-05-2023-who-records-1-000th-attack-on-health-care-in-ukraine-over-the-past-15-months-of-full-scale-war
3. "WHO records over 1,000 attacks on Ukraine healthcare during war," Reuters,
https://www.reuters.com/world/europe/who-records-over-1000-attacks-ukraine-healthcare-during-war-2023-05-30/
4. "Russia's Losses: 25,500 In Ukraine War, By One Count," Radio Free
Europe/Radio Liberty (RFE/RL),
https://www.rferl.org/a/russia-losses-25500-ukraine-war-dead/32463400.ht
ml
5. Lawrence, Christopher. "Wounded-to-Killed Ratios in Ukraine in 2022" The
Dupuy Institute,
http://www.dupuyinstitute.org/blog/2022/06/06/wounded-to-killed-ratios-in-
ukraine-in-2022/
6. Romaniuk, P., Semigina, T. “Ukrainian health care system and its chances for
successful transition from Soviet legacies.” Global Health 14, 116 (2018).
https://doi.org/10.1186/s12992-018-0439-5
7. “Country Overview.” Eurohealth Observatory,
https://eurohealthobservatory.who.int/countries/ukraine
8. Batyrgareieva, Vladislava S et al. “Corruption in medical sphere of Ukraine:
current situation and ways of prevention.” Wiadomosci lekarskie vol. 72,9
cz 2 (2019).
9. “Russian Invasion to Shrink Ukraine Economy by 45 Percent this Year.” The
World Bank
https://www.worldbank.org/en/news/press-release/2022/04/10/russian-invasion-to-shrink-ukraine-economy-by-45-percent-this-year
10. Harmsh, Olena “IMF raises Ukraine's economic growth outlook to 2% in 2023”
Reuters
https://www.reuters.com/world/europe/imf-raises-ukraines-economic-growth-outlook-2-2023-2023-10-10/
11. Khomenko, Valentyna “The Influence of The Concept of Community
Tragedy on The Ukrainian Healthcare System in The Conditions of War.” Literature reviews DOI: 10.29254/2077-4214-2022-4-167-99-103
12. Carpenter, Michael. “U.S. Statement for the Vienna Document Joint PC-FSC
Chapter III Meeting.” U.S. Mission to the OSCE,
https://osce.usmission.gov/u-s-statement-for-the-vienna-document-joint-pc-fsc-chapter-iii-meeting-2/#:~:text=We%20assess%20that%20Russia%20probably,about%20100%2C000%20on%20January%2030.
13. “Russia Sanctions Database.” Atlantic Council,
https://www.atlanticcouncil.org/blogs/econographics/russia-sanctions-database/
14. Holt, Ed. “Ukraine invasion impacting Russian health care.” The Lancet, Volume
401, Issue 10382, 2023, Page 1064,
https://doi.org/10.1016/S0140-6736(23)00674-8.
15. “Russian Federation Health System Information.” European Observatory on Health
Systems and Policies, https://eurohealthobservatory.who.int/countries/russian-federation/
16. Shishkin S, Sheiman I, Vlassov V, Potapchik E, Sazhina S. “Structural changes
in the Russian health care system: do they match European trends?” Health Econ Rev. 2022 Volume 12 doi: 10.1186/s13561-022-00373-z. PMID: 35616784; PMCID: PMC9133312. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9133312/#CR36
17. E.A. Mantzaris, Z. Ndevu. “Corruption, healthcare and society : a study of Brazil and
Russia.” African Journal of Public Affairs, pp. 78-90, Vol. 9, Doi:10.10520/EJC-ab54b6625 [doi]
18. “The Implications of the Iran-Iraq Agreement.” Unclassified CIA Document
https://nsarchive2.gwu.edu/NSAEBB/NSAEBB167/01.pdf
19. Heidenrich, John G. “The Gulf War: How Many Iraqis Died?” Foreign Policy, no. 90,
1993, pp. 108–25. JSTOR, https://doi.org/10.2307/1148946.
20. Heidenrich, John G. “The Gulf War: How Many Iraqis Died?” Foreign Policy, no. 90,
1993, pp. 108–25. JSTOR, https://doi.org/10.2307/1148946.
21. “Documented Civilian Deaths from Violence.” Iraq Body Count,
https://www.iraqbodycount.org/database/
“Iraq 2014: 48,590 Killed and 26,516 Wounded” AntiWar.com,
https://original.antiwar.com/updates/2015/01/01/iraq-2014-48590-killed-and-26516-wounded/
“Over 52,000 Killed in Iraq during 2015.” AntiWar.com,
https://original.antiwar.com/updates/2015/12/31/over-51000-killed-in-iraq-during-2015/
“52,369 Killed in Iraq during 2016; 3,174 Killed During December.” AntiWar.com,
https://original.antiwar.com/updates/2017/01/01/52369-killed-in-iraq-during-2016-3174-killed-during-december/
“36,898 Killed in Iraq During 2017” AntiWar.com,
https://original.antiwar.com/updates/2018/01/01/36898-killed-iraq-207/
22. Al Hilfi, Thamer. Riyadh Lafta. Gilbert Burnham. “Health Services in Iraq.” The
Lancet, Vol. 381, pp. 939-948, https://doi.org/10.1016/S0140-6736(13)60320-7.
23. Al-Mosawi, Aamir. “Iraq Healthcare System before Covid-19 Pandemic.”
International Journal of Research Studies in Medical and Health Sciences, Vol 5, Is. 12, pp. 16-23. http://www.ijrsmhs.com/pdf/v5-i12/3.pdf.
24. Wilson, Jennifer. “The Health Care Revival in Iraq.” Annals of Internal Medicine, Vol.
141, Is. 10, pp. 828-828. https://doi.org/10.7326/0003-4819-141-10-200411160-00027.
25. Cetorelli, V., Shabila, N.P. “Expansion of health facilities in Iraq a decade after the
US-led invasion, 2003–2012.” Confl Health Vol. 8, Is. 16. https://doi.org/10.1186/1752-1505-8-16
26. “The Russia-Ukraine War Report Card, June 21, 2023” Russia Matters,
https://www.russiamatters.org/blog/russia-ukraine-war-report-card-june-21-2023
Comentários