Opinion: Wartime recovery offers chance to transform Ukraine’s health care

The Ukraine Recovery Conference, taking place in Rome this week, will see the international community pledge to increase financing for Ukraine’s wartime reconstruction. Ukraine is moving quickly to implement a more strategic, coordinated approach to recovery. The country’s health system can be a major beneficiary of this. After more than 2,500 attacks on Ukraine’s medical facilities since the start of Russia’s full-scale invasion, health care remains a priority for enhanced support. The cost of meeting recovery needs in this sector is estimated at $19.4 billion — and with escalating attacks on civilian infrastructure in recent months that figure is likely to rise. International support can ensure that damaged facilities are repaired and that some of those destroyed are rebuilt. But merely restoring what has been lost is not where the real opportunity lies. Ukraine needs a smarter, future-ready health system that delivers high-quality care at a sustainable cost — enhancing its ability to strengthen human capital, which is so important for long-term productivity and growth, deepen social cohesion, and encourage millions of displaced people to return. A fundamental restructuring of Ukraine’s health care infrastructure is required to deliver this, in alignment with ongoing reforms that Ukraine’s international partners are already supporting both technically and financially. These reforms aim to reduce reliance on hospitals and provide more services in local clinics and community settings, delivering better access for patients and lower costs for the government. At the same time, Ukraine must streamline its overlarge hospital network, creating a smaller number of better-equipped facilities that deliver a comprehensive range of services and provide a professionally rewarding environment for health care workers. Linking investment to strategic reform goals is challenging in any country. In the context of a full-scale war, it is harder still. Yet, in 2024, the Ukrainian government acted on this challenge, introducing new regulations to improve investment management across the public sector. One result of this is the Single Project Pipeline, hosted for transparency on the publicly available DREAM platform. This will eventually include the country’s highest priority projects, helping to ensure local and national investment decisions align with broader development goals. But it remains a work in progress, and in the meantime, Ukrainian authorities and international partners have a shared responsibility to ensure that their money flows to the highest-impact investments. Currently, the pipeline includes 153 health care schemes with a combined value of $3.7 billion. Roughly half of this relates to the modernization, extension, or safety enhancement of hospitals. With investments in hospitals, the stakes are always high — such investments can absorb significant financial, human, and technical resources, and can define a suboptimal pattern of service delivery in local health systems for many years, even decades. State authorities and international partners need to adopt a highly selective approach to such projects. Some guidance for investment decisions is provided by the “capable hospital network,” which is defined as groups of hospitals that meet set standards and are sufficient to address each region’s specialized care needs. By applying this concept, oblast health authorities have assigned a long-term role to about half of the existing hospitals in the country. The rest are due to be phased out over time — at least as acute inpatient care facilities. Many of the hospitals due to keep functioning in the long term require upgrading to meet modern standards. However, not all investments proposed for such upgrades will be justified. In urban areas, it is common for different hospitals that offer similar services to operate close to one another. For many hospitals in this situation, a merger is a more efficient option than a new project — especially if that project would lead to additional duplication of services. Conversely, some projects for hospitals due to be phased out may be warranted, if these allow for a transition away from acute inpatient care into areas such as long-term care, for which needs are currently unmet. Notably, investments for primary care and community-based facilities — theoretically, core strategic priorities — account for a small fraction of the value of the health projects in the pipeline. A key reason is the small scale and dispersed nature of individual facilities at this level — as a result of which, projects tend to involve a high ratio of transaction costs (legal, due diligence, monitoring, etc.) to the amount of capital invested. This makes them less attractive to development banks and other donors. Projects like these may need to be aggregated at a local or regional level to be viable. As primary care is the most effective clinical setting for preventing disease, managing chronic conditions, and reducing costly hospital admissions, finding a solution to this is fundamental. This will require agreement on a strategic approach, to determine what gets built, where, and why, as well as new modalities. In Rome, there is an opportunity to build a framework that ensures capital flows to the right projects — laying the groundwork for a renewed health care system in Ukraine aligned to the highest European standards.