Conflict, crises, and other disruptions often drive countries to build more equitable health systems. Identifying successful models from nations that have made significant progress, like Ukraine, offers a blueprint for change.
Ukraine’s reforms gave patients the opportunity to get medicines for free or with small additional payment. Photo: European Union 2020
Improving healthcare systems that are insulated by layers of amour-plated inequalities is a Herculean task. Nudges and incremental changes have their place in stripping away inequalities but the goal of universal health coverage (UHC) can remain fixed on the horizon.
Growing research shows that the kinetic impetus of conflict and shocks, from wars and civil unrest to environmental trauma, can act as an accelerant to scorch rigid, malfunctioning services and replace them with more equitable systems.
From the UK’s enshrinement of a standard-bearing National Health Service (NHS) and Japan’s fresh approach to health following World War II, up to Eastern Europe’s reforms after Communism and Ukraine’s reforms in 2016 after the Revolution of Dignity that have served it well in the current conflict, the evidence is stacking up that disruption provides a platform to promote better care and reduce inequalities.
But this is far from a clean-slate rebuilding process; the mechanics of conflict and shock are complex and freighted with local geopolitical tensions. The challenge is to find templates from countries that have made huge progress with UHC and use them to catalyse improvements.
Ukraine reforms build resilient health system
Ukraine began to reform its healthcare system and expand the reach of its services after the 2014 Revolution of Dignity—a wave of pro-democracy, pro-Europe demonstrations—expelled pro-Russian corruption and inefficiencies and allowed a new, equitable framework to form.
The key areas that made the change effective were centralised financing, investment in training for primary care workers and healthcare workers, establishing new institutions, and promoting digital health.
“One of the main changes was to move to guaranteeing health benefits for the whole population that were funded by general government revenue,” explains Dr Jarno Habicht, World Health Organization (WHO) representative in Ukraine, speaking from Kyiv. “I visited a hospital in 2019 and a manager said the changes enabled more predictability in the system that allowed them to provide better services. It helped manage procurement and delivered value for money.”
“The way healthcare in Ukraine has been able to function and respond to a series of shocks is a testimony to what has been achieved.”
Ukraine’s suite of reforms gave patients the opportunity to get medicines for free or with small additional payment via an affordable medicines program. They could also choose their family doctor and have greater involvement in their own health with the introduction of a ‘money follow patient’ concept that directed government funds to local healthcare facilities. This also had the bonus of improving salaries for healthcare workers.
“Investment is needed, of course, but you really can get more for the same budget from this framework,” Habicht says. “It is a journey, but it is worth understanding that stable financing, investment in human capital, and infrastructure can deliver good results.”
The benefits to the public were swiftly evident—and continue to be felt today amid the ongoing war with Russia.
“Ukraine has made progress but the road to UHC is long and difficult. But we have created a better system that has resilience,” Habicht says. “We are still learning but the way healthcare in Ukraine has been able to function and respond to a series of shocks is a testimony to what has been achieved.”
Rethinking health financing after conflict and shock
Joseph Kutzin, a health financing expert who recently retired after nearly 30 years with the WHO, believes that progress on UHC—both generally and post-shock—is best funded through general tax revenues that can then be used to flex systems towards more efficient, equitable, and responsive healthcare that reaches more of the public.
“Just throwing more money at the problem doesn’t really do much,” he observes. “It's not about reaching spending targets—it’s about making more effective use of those resources. Increasingly, what we're seeing are changes in public financial management, the pooling of funds more centrally, and separating purchaser from provider to create a single fund to make necessary payments.”
Shocks can shake free the claws of vested interests on healthcare that perpetuate inequality…“There are a lot of countries that achieved major healthcare reforms after a crisis.”
This is what happened in Ukraine, Kutzin explains. “Even under great stress, the system they set up in 2016 has functioned during the invasion because you can still make electronic payments to providers from the national pool of funds. Even when facilities were being attacked and local government administrations were disrupted, it still worked. They also didn’t need external organisations to run things.”
He believes the challenge of reaching UHC differs from one nation to the next, but that global knowledge of core best practices is continually rising and providing templates for countries to meet their specific challenges.
Kutzin says this is especially important in the aftermath of the pandemic. “The global economic and social fallout from the covid-19 pandemic and other regional shocks has translated into more debt and increased inequalities in countries, providing an environment that is not particularly conducive to promote UHC,” he says. “More positively, many countries have demonstrated that they have a better technical understanding of what is required to enable them to make progress, despite these challenges.”
Sophie Witter, professor of international health financing and health systems at Queen Margaret University Edinburgh, points to an opportunity—namely, that shocks can shake free the claws of vested interests on healthcare that perpetuate inequality.
“The tectonic plates of who controls and benefits from the health agenda can be displaced by a crisis,” she says. “There are a lot of countries that achieved major healthcare reforms after a crisis.”
Witter cites the creation of the NHS in England after World War II as a prime example, along with advancements in Nepal after the civil war ended in 2006. A series of reforms extended free health care, initially to pregnant women and then further across primary care. “There was an agreement to decentralise to meet the dissatisfaction felt in rural areas, which had driven the civil war, and to provide better access to healthcare [in those areas],” Witter explains.
Shocks create political and fiscal space for change
A 2024 report for the Chatham House Commission for Universal Health, co-authored by Witter, accepted that affordability of UHC is a legitimate concern for many countries. But it argued that UHC offers an opportunity to improve efficiencies, stating: “Universal entitlement is key to both equity in access and cost-effectiveness in provision. By pooling resources, UHC offers the possibility of providing better healthcare for more people more cost-effectively than alternative models.”
UHC can provide better healthcare for more people more cost-effectively than alternative models. Photo: U.S Air Force, Staff Sgt. Kat McDowell
The report echoed the WHO’s recommendation that countries typically need to inject 1% of GDP to generate reforms to move towards UHC and further added that: “UHC can also build resilience and protect against shocks, including climate change. There are also substantial wider economic, social and political benefits from UHC. Economic benefits include improved workforce productivity, increased economic growth and reduced poverty. Social benefits include increased social cohesion. Politically, UHC can deliver electoral gains and expand trust in political systems.”
The political dividend is a powerful engine of change and a populist government in Thailand introduced sweeping healthcare reform in 2001 that revolutionised access to care and facilities for the public at a time of financial crisis in Asia, Witter adds.
“It is hugely popular and that shows there is a consideration for politicians that healthcare matters to people. It is an electoral proposition and once you bring in improved healthcare, it is very hard to reverse it,” says Witter, who is also research co-director of the ReBUILD for Resilience research consortium.
A landmark review of universal health coverage across 49 countries, funded by the Bill and Melinda Gates Foundation, sought to understand the political, economic, and technical issues associated with rolling out healthcare improvements after disruption or conflict.
Anthony McDonnell, a policy fellow at the Center for Global Development who co-authored the 2019 report for the Overseas Development Institute, highlights that shocks create political and fiscal space for change.
“A new government can come in and want to show they are there for the people—and that can apply to a left-wing administration or military regime. They want to demonstrate they have the people’s best interests at heart and that presents real moments of national conversations where things can change,” he explains.
“Fiscally, this is very important because money that was allocated for wars or disasters becomes available and you can fund reforms. But you can’t just press a button and a new healthcare system emerges. It takes time to find and train doctors and nurses, procure new medicine supplies, and build new treatment centres.”
Making the best of limited resources
McDonnell concedes that many countries lack the resources to create a system like the NHS off the back of conflict or major disruption, but “they can create very good healthcare systems given the resources available”. “Rwanda after the genocide is a great example—its healthcare provision greatly improved,” he says. “It’s not perfect but everyone has access to some form of reasonable care and community-based models.”
He believes that low- and middle-income countries (LMICs) can learn and be inspired by neighbouring countries, adding: “In terms of messaging, countries are often more likely to listen to countries in the same region because they are more culturally, politically, and practically alike. The success of a neighbouring nation makes for a compelling argument for UHC.”
The stresses continue to rain down on Ukraine, with six million of its people displaced as refugees and severe shortages of doctors, nurses, midwives, and essential healthcare staff deepening as the nation enters its third winter at war.
Ukraine is determined to continue pushing forward with UHC despite the devastation and disruption of conflict. Photo: The Emergency Medical Aid and Disaster Medicine Centre, Chernihiv
During missions to the east and south of Ukraine, Habicht noted that only one-third of healthcare workers were on duty compared to pre-war numbers, which is a concern as, in frontline regions, the needs related to mental health, trauma, and multi-trauma, as well as chronic disease of elderly people, have increased dramatically.
Yet a joint WHO-World Bank keynote report released in November 2024 highlighted that the health financing reforms that strengthened the resilience of Ukraine’s healthcare system after the 2014 Revolution of Dignity continue to underpin its response to the Russian invasion.
Ukraine is determined to continue pushing forward with UHC despite the devastation and disruption of conflict. Its experiences, along with the efforts of other nations in times of great stress, provide guiding principles and inspiration for better global healthcare.
The evidence that more equitable access to healthcare emerges from the ashes of conflict and shock may be tinged with political expediency, but it also displays that the driving force of humanity can be transformative and long-lasting, and shared experiences can lift health provision to levels many nations take for granted.
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