War in Ukraine and health worker density

Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. At time of writing he was providing primary care to internally displaced people in the east of Ukraine. He is on twitter: @drricharmitage

Prior to the on-going conflict, Ukraine was fighting a losing battle to build a resilient health workforce able to satisfy the county’s requirements. This systemic, protracted and multifactorial problem, which threatens the country’s achievement of the United Nations’ Sustainable Development Goals (SDG), has been substantially exacerbated by the Russian invasion, and compounds the enormous harms to population health caused by on-going hostilities.

Ukraine’s progress towards achieving the health-related SDG target 3.C – which pertains to the substantial increase in health financing and the recruitment, development, training and retention of the country’s health workforce – was deemed to be insufficient and in need of urgent acceleration prior to the COVID-19 pandemic in 2020.¹  Although the country’s overall health worker density (including physicians, nurses, midwives and pharmacists) had increased from 8 workers per 1000 population in 1990 to 8.4 in 2000 and 12.9 in 2017 (physicians increased from 2.7 per 1000 population in 1990 to 4.0 in 2017, and similar trends took place for nurses, dentists and pharmacists),¹ the absolute numbers of health workers across all professions have fallen in recent years due to the high net migration of professionals out of Ukraine, the country’s ageing workforce (almost 25% of physicians in Ukraine are of retirement age), and the declining wages and poor career development opportunities for the country’s nurses and midwives.²  Health worker density is particularly low in Ukraine’s rural and hard-to-reach areas, which have been identified as in need of urgent action to attract, upskill, develop and retain a knowledgeable workforce to address the country’s substantial regional health inequalities.¹ 

While its current performance is comparable to that of other nations across Eastern Europe, Ukraine’s overall health worker density (workers per 1000 population) in 2017 was around half that of many Western European countries such as Germany, the Netherlands, and Norway (24.6, 26.1, and 27.4 health workers per 1000 population, respectively), and is only predicted to increase to 17.4 health workers per 1000 population by 2030.³  Now, this progress will be significantly impeded by the Russian invasion.

While many health workers in Ukraine did and continue to provide patient care following the outbreak of war, many have been forced to leave their clinical facilities and areas of residence to escape intensive Russian aerial bombardment designed to target both health system infrastructure and civilian communities.⁴  As a result, many have left the country entirely,⁵ or are internally displaced within neighbouring Oblasts and without the relevant authorisation to clinically practice, meaning the country’s frontline health workforce has substantially diminished at the time it is most urgently and increasingly required.⁶  Beyond the immediate impact on health worker density, the conflict has forced thousands of both national and foreign medical students in Ukraine to abandon their studies and seek to complete their training abroad, mostly in western Europe or their country of origin.⁷  This migration will substantially reduce the expected number of health workers graduating into and subsequently practicing within the Ukrainian health system in the approaching years.  Finally, the national finances earmarked for the delivery of strategic healthcare reform and achievement of the health-related SDGs in Ukraine, including the building of a resilient health workforce, are likely to be at least partially redirected due to the conflict, including directly into military and other defence spending, and indirectly into the delivery of reactive health services to address the enormous burden of physical and mental ill-health produced by the war.  As such, Ukraine’s existing suboptimal health worker density has substantially deteriorated, and will do so increasingly for as long as the war continues.

Since all healthcare professions will be similarly affected, the entire existing landscape of healthcare services will be severely impaired, population health outcomes will be substantially harmed, and prevailing health inequities will be further exacerbated.

The invasion of Ukraine is causing devastating harm to the country’s population health, including the direct effects of participating in and sheltering from the active conflict, and the indirect effects of mass human migration, reduced access to healthcare, and intentional destruction of health system infrastructure.⁷  The deleterious impact on the country’s health worker density, which was insufficient prior to the conflict, will compound these health-related harms on the Ukrainian population and generate a double injustice upon innocent people.

References

1. World Health Organization Regional Office for Europe. Towards a healthier Ukraine: progress on the health-related Sustainable Development Goals 2020. 2020. https://www.euro.who.int/en/countries/ukraine/publications/towards-a-healthier-ukraine-progress-on-the-health-related-sustainable-development-goals-2020 [accessed 17 May 2022]
2. European Observatory on Health Systems and Policies. Ukraine: Health system review. 2015. https://apps.who.int/iris/bitstream/handle/10665/176099/HiT-17-2-2015-eng.pdf?sequence=5&isAllowed=y [accessed 17 May 2022]
3. Institute for Health Metrics and Evaluation. Health-related SDGs. 2017. https://vizhub.healthdata.org/sdg/ [accessed 17 May 2022]
4. P Barakat, O Stakhovskyi, V Kopetskyi, et al. Oncology specialists’ perspective on caring for patients with cancer during the early days of war in Kyiv, Ukraine. The Lancet Oncology 25 April 2022. DOI: 10.1016/S1470-2045(22)00204-2
5. C Tilley. GPs fleeing Ukraine to be fast-tracked by GMC if they wish to practise in NHS. Pulse 24 March 2022. https://www.pulsetoday.co.uk/news/regulation/gps-fleeing-ukraine-to-be-fast-tracked-by-gmc-if-they-wish-to-practise-in-nhs/ [accessed 17 May 2022]
6. R Armitage. War in Ukraine and the inverse care law. The Lancet Regional Health Europe 30 April 2022; 100401. DOI: 10.1016/j.lanepe.2022.100401
7. BS Srichawla, MAK Tabari, MA Găman, M, Muñoz-Valencia, FJ Bonilla-Escobar War on Ukraine: Impact on Ukrainian Medical Students. International Journal of Medical Students 2022; 10(1): 15–17. DOI: 10.5195/ijms.2022.1468

Featured image by Olga Subach on Unsplash