Ukraine’s health care system was not prepared for this war
An interview with Olena Chernenko, founder and CEO of the Ukrainian Medical Alliance. Interviewer: Adam Reichardt.
ADAM REICHARDT: As a medical professional, you have worked in Kyiv for many years before the war. Are you still there at the moment?
OLENA CHERNENKO: No, unfortunately, I had to leave Kyiv after the war started. Yes, I worked in healthcare for more than 15 years. I worked in top positions in healthcare facilities during that time; and from 2019, I established my own consulting firm which aimed to advise on management in health care. Now due to the war, I established a charity fund to help hospitals in the regions which are in great need of assistance, and not only in the areas where the conflict is, but in all of Ukraine.
What does the situation look like now from the perspective of Ukrainian healthcare and medical services at a time of war?
We should start from the point when the war began. I need to say that the Ukrainian health care system was not in great condition at that moment. We have a great burden of the Soviet legacy in our health care system which is present until today, in many aspects – from the main laws to the laws for construction in health care. All of this is very obsolete and needs to be modernized and changed.
We had a health care reform that was started in the last few years, and I personally have a lot of criticism about the reforms that were and were not taking place before the war. So, the Ukrainian health care system has experienced a lot of problems. It is not a mature or stable system like in many European countries. For example, the public and private health care fields were not consolidated and this has also caused a lot of problems.
So the health care system was already in a difficult situation before the war?
Yes, all of those problems have compounded and led to even more tragedies during these difficult times. Now we see the problems clearly. What’s more, is that we were not prepared for those challenges which were predictable. Now imagine how difficult it has been because of the war.
In every management system, we should consider two kinds of threats, problems, and risks. There are those which are unpredictable, like COVID-19, and then those which are predictable.
Do you think the war was predictable? And how did the medical system prepare for the war?
The last months before the war started, the word “war” was everywhere in media and public communication. Nevertheless, our hospitals were unprepared on a systemic level. For example, they had no plans in place on how to move to bomb shelters. From the first days of the war, doctors were forced to do surgeries or deliver babies in shelters. So we can admit, that despite the threats ahead of time, we were not prepared for the war.
Some like to say that Ukrainians are not good at making strong predictions; reactivity is a feature of our national mentality. We react very, very effectively, we can consolidate ourselves in the moment of external threat… maybe as nobody else in the world. But we aren`t good at making strategic preparations in advance – for even obvious threats. This is a big tragedy for us and a lesson for all of Europe. When we think about such critical infrastructures like healthcare we have to make predictions, we have to prepare. Every country should learn from our experience. And not only in healthcare, but in other critical fields as well: nuclear energy, civil aviation etc.
What has been the experience of Ukraine’s hospitals during the war?
We should clearly divide two types of hospitals now in Ukraine. The first ones are those located in the war zone. The second are outside the areas of fighting. The status is dynamic, not permanent. In other words, the status of a hospital could change quickly at any moment, depending on where the fighting is. We clearly see that the needs for these two types of hospitals are different.
Those that are situated in the war zone have problems conducting their core activities which are core medical care to the local population (not only traumas, caused by war, but also common admissions for medical care) and combats. The flow of patients in the war zone has been draining these hospitals. Their patients arrive with serious injuries, often requiring intensive care or complex, combined, difficult surgery surgeries. This flow is so big that many hospitals are overloaded. In the war zones, some of the hospitals are destroyed, completely or partially, so those which are still working have to take on the patients from the ones which cannot function. It’s a huge challenge.
Another issue is related to the destruction of the supply chain to these hospitals. They lack medicine, devices, consumables and so on. It’s another lesson here: to create some back up long-term storage or create a hub of supplies for regions.
At the most dramatic first weeks of the war, when we could not believe that it was happening to us – the missile attacks on Kyiv, for example – the strong hierarchal system was unable to respond to this full-scale challenge. A lot of problems arrived simultaneously. To respond, it was our national ability to consolidate at the time of big crisis – which includes all the volunteers and those who began to act – which helped fill in the gaps in the existing healthcare system. And this national ability is what has saved us. The network of volunteers (also from abroad) quickly supplied medicines, consumables, and medical devices to hospitals all over the country. Sometimes hospitals received medicines that were not needed, and some hospitals were provided with more than they needed. In other words it was a chaotic process; but it brought quick results and saved lives.
Adding a little to the chaos, the ministry of health soon began to try to manage the situation and tried to restrict the volunteer chains; insisting on the hierarchical supplying system instead. But what we learnt is that volunteer networks are more effective in times of crisis, at least with healthcare, which wasn`t prepared to crisis. Our success was not in structures or hierarchy, but in providing some rules and mechanisms and using all the informal distribution networks. The situation was very dynamic and completely unpredictable. And any rigid structure was unable to respond to this.
What about the hospitals outside the war zone?
Also very challenging but in a different way. Yes, it is true that there is no fighting in some of those regions, but it does not mean that they are not affected. These hospitals admit a lot of people who are internal refugees, which is overloading them. A lot of people who moved into western Ukraine from the eastern and southern regions are in very bad condition. If they have chronic diseases, the difficult situation has exacerbated their conditions. Some people dramatically interrupted their life-saving therapies, such as people with diabetes or oncological patients. Some people have PTSD and emotional problems in need of mental health care. So the hospitals are now tasked with providing care to all of these patients. We had some several waves of internal refugees already, due to combat features.
Are there also wounded soldiers who end up in these hospitals?
Not so much in the western regions, but it is the case in central Ukraine. For example in Vinnytsia. When I ask our foreign partners to provide us with a vacuum device for treating wounds, they ask – “Why for this region? There is no fighting there”. And I have to explain that a lot of soldiers from the Odesa region are admitted to hospital in Vinnytsia – those regions are very close. So in central Ukraine, a lot of hospitals are treating wounded soldiers, many of whom are transported directly from the war zone by special trains.
But in western Ukraine, it is more related to the internally displaced people – and that means they face similar problems as I mentioned earlier – supplies, medicines, consumables, and devices.
In many places, there is also the problem of obsolete medical equipment. We can see a huge difference between those regions and the Kyiv, capital of Ukraine. I saw, for example, equipment that was produced in the 1960s and 70s still being used for physical therapy! Just imagine it. The same I can say about surgical equipment; radiological equipment or ultrasound scanners and cardiologic thermographs, etc. In this situation when the number of people dramatically increased; it is very hard to provide all of them proper care when the equipment is so obsolete. Which has also led to huge wait times for simple procedures. In Uzhhorod, for example, for the main clinic, the term for a non-urgent ultrasound examination is more than one month. The obsolete equipment constantly needs maintenance and this adds to the waiting times. Hence, we try to help them with not just medicines and supplies, but with equipment as well.
Can you talk more about your foundation and the work that you do?
First, I would say that we have a lot of general goals for all of Ukraine’s hospitals. It is to provide an adequate supply of medicines that are regularly used in hospitals; such as anaesthesia, medicine for cardio patients, and a long list of consumables that are widely used. We ask the hospitals to send us requests which we share with potential suppliers and partners. We know that if we can obtain these supplies, they will be used definitely.
We also focus on the supply of more specific medications and equipment based on precise needs. We help them to receive specific consumables for surgery. The process is dynamic but also chaotic. A hospital might send a request everywhere – to us, to the ministry, to volunteers … hence we have to double-check to make sure such a request wasn’t already fulfilled. Was it already supplied? This is an additional step for us in order to avoid duplication. If the request was already fulfilled, we can share the supplies elsewhere. I also provide a lot of specialized consulting for both suppliers and recipients and try to connect them in order to be effective and strategic.
And who are your suppliers? Are the supplies donated? How does it work?
In most cases, the suppliers are from specialized organizations. For example, we work very well with the Insulins for Life – Global Fund, Ukrainian Medical Society in Germany etc. . In fact, a lot of medical communities in many western countries are working with us to assist Ukraine’s medical system during the time of war. And they provide consumables, instruments, devices, etc. based on the requests, as I mentioned. It is easy to talk with them about our needs. When I speak with common volunteer communities it is very difficult to explain the specific medical needs. So luckily we have the medical communities who are able to understand the requests and know where to find the supplies. We try to connect professionals with professionals.
Also, I try now to have contact with medical authorities in different countries. The problem is that they are working with the Ukrainian authorities, not the NGO community. Even though I am a stakeholder, I do not represent the ministry of health. We have a lot of contacts inside and outside Ukraine and we are providing assistance. However, the ministry would rather keep a centralized and hierarchical approach to health care management – which isn`t enough, especially during the wartime. I have just visited the Annual conference of the European Healthcare Management Association in Brussels. There I widely discussed Ukrainian experience with delegates and with the president of the association. As a result, Ukraine was mentioned on the stage and in the panels. I am sure my mission there was a success. Also, I visited the House of Europe in the European parliament and spoke to representatives of the Ukrainian community. We agreed to collaborate.
Beyond the Ukrainian medical community abroad, we are also supported by Ukrainians inside the country – both specialists and those who are just willing to help with the problems faced by hospitals, business communities as well. Thirdly, which is unique, we receive help by religious communities. This was something new for me when they connected to us and suggested their help. For example, we have been constantly receiving outstanding support from Ukrainian Greek-Catholic Church of St. Barbara in Vienna.
To make all this work stable, I plan to widen my network of suppliers and I am working on that, including in Poland.
What do you think is needed the most right now by hospitals and the medical community in Ukraine? You described issues with equipment and general supplies. But what would you say is the priority?
During the first weeks, the main focus was on medicine and consumables. Those are things that are needed on a daily basis to conduct procedures and operations, both routine and specific to war trauma. Now we no longer have a critical problem with those supplies. In some regions, the hospitals even have too much of basic supplies. But the problem of obsolete medical equipment, mentioned earlier, remains actual. In order to truly understand the needs, we should investigate the condition of all the medical equipment in the country. Of course, this is the ideal situation. But we can start from just one region – for a pilot project, for example. And we could take a comprehensive approach to assess all the needs and understand what the situation looks like. To build a clear vision of where to go we should clearly understand where actually we are.
We know that things are only going to get more difficult. We are already experiencing a large number of injuries and wounded soldiers and civilians. Amputees are becoming more common also, and treating them requires state-of-the-art technical equipment, including prosthetics, and all resources for follow-up It is not only men these days. Women and children are also undergoing amputations and with children especially, as they grow their prosthetics need to be adjusted. This is the next task for me – to establish co-operation with European and American professionals in prosthetics. And this is only just one example from many. We will have a need for many specialists in Ukraine as a result of the ongoing war. That is why I stress the problem of obsolete equipment.
I know it is very difficult to imagine the situation after the war. But what do you think will be needed to rebuild the Ukrainian health sector?
As I mentioned at the beginning of our conversation, the Ukrainian healthcare system is still operating with the legacy of the Soviet healthcare system, and it` a huge burden. First of all we should established the adequate legal framework. Thus, the first thing that should be done after the war ends is a renovation of all the medical regulations and system of medical laws.
The second will be the difficult choice on our own strategic development. We have two main approaches for the health care system. The first is very centralised; and the second is distributed. This is about making decisions and providing finance for every aspect of health care. Before the war, our reforms were focusing on the first approach – the centralised one, like in the United Kingdom. For me, it is not the most appropriate choice if we think about the Soviet legacy, which was also centralised. And now, after this experience which is based on a more distributed network during the war – that should be a lesson for us and maybe even a model.
Lastly, we should also focus our planning and strategic management on two scenarios: for peacetime, and for wartime. In this way, we can clearly understand how we should shift our mode of operation based on the scenario we are in.
Olena Chernenko is the Founder and CEO of the Ukrainian Medical Alliance, an NGO which provides comprehensive professional assistance to the health care system of Ukraine and facilitates a global network of donor organisations, philanthropists, and recipients. She is also the Founder and CEO of “MedCapitalGroup”, a specialised consulting agency for Healthcare, which provides a full range of up-to-date services for public/municipal/private clinics in Ukraine and abroad, from 2019.
Adam Reichardt is the editor in chief of New Eastern Europe and co-host of the Talk Eastern Europe podcast.
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