1000 days of war in Ukraine: resilience in health response, recovery and reform efforts despite attacks and ongoing challenges

19 November 2024, marks 1000 days since the Russian Federation's full-scale invasion of Ukraine. The toll on the health of the Ukrainian population and its health-care system has been immense. The war has escalated health needs, especially in areas such as mental health, trauma care and noncommunicable diseases (NCDs), affecting millions who face continuous attacks, trauma and restricted access to health care due to ongoing hostilities and financial barriers. Ukrainian citizens are bearing increased physical and psychological strain, heightening the need for accessible care across all health services.

With over 6 million Ukrainians displaced as refugees and an additional 3.5 million internally displaced, health-care worker shortages, especially near frontlines, have deepened. These shortages include doctors, nurses, midwives and other essential personnel, who are crucial for delivering care in a system under severe stress. Despite the challenges, Ukraine's health workforce has shown remarkable resilience, working tirelessly to sustain services and support both the country's recovery and ongoing health-care reforms.

This war remains the largest ongoing emergency in the WHO European Region, with 2134 confirmed attacks on health care as of 18 November. WHO has actively monitored and reported these attacks, noting a troubling rise in both frequency and severity this year again.

These attacks severely impact health-care delivery and have resulted in the tragic loss of health-care workers. The highest casualty levels were seen in early 2022 at the beginning of the war, with a new peak observed from July to September this year. In 2024 alone, 27% of health-related attacks led to injuries, and 8% to fatalities. Casualties and fatalities of health workers and patients from these attacks have nearly tripled compared to last year, with 65 deaths reported this year, up from 24 in 2023, and injuries increasing from 132 in 2023 to 377 this year.

As Ukraine faces a third winter of war, attacks on health and public infrastructure will bring additional challenges, including lack of heating, water and electricity. WHO is supporting the delivery of uninterrupted health-care services by installing high-capacity heating units and water stations.

Workforce challenges and initiatives: building resilience through human capital

The health-care system's resilience relies heavily on its human capital - the collective skills, knowledge and dedication of health professionals across the country. The war has critically affected Ukraine's health-care workforce, especially in rural areas, where the availability of family doctors, nurses and other health-care workers has sharply declined. There is a worrying trend in relocation and migration of health-care professionals to cities or abroad, and there has been a sharp decline in those entering medical professions, threatening the future supply of skilled workers.

Recognizing these challenges, WHO has expanded its support for workforce development by strengthening data collection and workforce planning, focusing on human capital as an essential element of a resilient health system.

In addition to supporting this vital area of work, WHO is working to enhance the nursing sector in Ukraine, recognizing its crucial role in health-care delivery. WHO has expanded professional development opportunities for nurses and other health workers, acknowledging their contributions. These efforts aim to address the anticipated workforce shortages in nursing and strengthen the overall health system.

Supporting health system recovery and community stability with focus on primary care

WHO's support has shifted this year from emergency relief to capacity-building across critical areas such as managing NCDs, mental health, antimicrobial resistance, HIV, tuberculosis and infection control, in addition to providing ongoing training on trauma care and mass casualty response. The focus on primary health care is one of the priorities. WHO collaborates with Ukrainian authorities to strengthen health responses, provide expertise exchange, and enhance recovery and reform efforts.

WHO's commitment to Ukraine's health recovery underpins national rebuilding efforts. Investments in resilient health-care facilities and community infrastructure enable residents to remain in their local areas, fostering community stability. WHO has installed 24 modular primary health-care clinics across severely affected regions, providing a mix of immediate and long-term health-care solutions.

In supporting broader health reforms, WHO is working with Ukraine on financing improvements, primary care enhancements, procurement transparency and expanded NCD care initiatives. A recent analysis reveals that pre-war reforms and ongoing efforts are paving the way for a more resilient health-care system.

In the area of health finance, WHO is supporting with capacity-building and strategic planning, with regular reviews, establishing costing models with a focus on primary care, mental health and medical rehabilitation financing. Collaborating closely with Ukrainian policy-makers, WHO promotes data-driven decision-making and aligns efforts with development partners to streamline health policies. This includes support for introducing essential tools to aid the National Health Service of Ukraine in contracting health-care services effectively.

Ukraine's recovery journey is a unique example of how a country can implement health reforms and innovative solutions, such as digital health systems and emergency response tools, even in the face of war. WHO is also collaborating with the European Union to strengthen Ukraine's access to the Early Warning and Response System to improve health security management in the country.

WHO's support for Ukraine's long-term recovery aligns with the Sustainable Development Goals, with a focus on building a stronger, more resilient health system capable of enduring current and future challenges.