Three years after Russia invaded Ukraine, the country’s health system has been forced to adapt in the face of mounting challenges; from attacks to staff burnout and elevated risks of disease.
On July 8 last year, Dr Lesia Lysytsia was preparing a patient for eye cancer surgery at Okhmatdyt, Ukraine’s largest children’s hospital, when sirens started blaring, warning of a possible Russian air strike.
Lysytsia tried to ignore the alarms. If the doctors stopped and went to a bomb shelter every time an air raid alert sounded in the capital city Kyiv, they’d never get through all the patients who travel from across the country for treatment.
What’s more, the 39-year-old needed to get home on time for her two young children.
Then a missile struck Okhmatdyt, killing three people and injuring dozens of others. It was one of 40 missiles that Russia launched toward Ukraine that day. About 630 children were in the hospital at the time.
Kyiv, altered by years of war, partially reopened Okhmatdyt a week later. Now, Lysytsia says, “it’s like normal days” with the hospital mostly operational.
“We changed mentally,” she said. “But because we have a goal and because we are responsible for other people, [we] don’t show it”.
‘Significant resilience’ in the face of war challenges
After Russia launched a full-scale military invasion of Ukraine on February 24, 2022, experts say the country’s health system was unprepared to handle the ensuing chaos and surge of combat-related injuries.
The war has since wreaked havoc on the country and sparked a refugee crisis, with the United Nations (UN) saying the population has plummeted by over 10 million people.
“No healthcare system in the world is geared for a full-scale war,” said Eric Adrien, who coordinates medical evacuations from Ukraine on behalf of the European Commission.
Health workers have adapted to treating patients in a warzone, with doctors performing amputations, operating without electricity, and handling the psychological pressures of being under constant threat of attack.
A World Health Organization (WHO) report published late last year found that Ukraine’s health system, which underwent government reforms in 2017, showed “significant resilience in responding to the challenges brought about by the war”.
The reforms aimed to modernise Ukraine’s medical apparatus, expand access to treatments, eliminate widespread corruption, and distance it from the Soviet-era system.
Yet three years on from the start of the war, doctors, non-profit groups, academics, and international officials told Euronews Health that there are disparities between the war’s eastern and frontline regions and further west as well as growing threats from infectious diseases, antibiotic-resistant infections, ongoing attacks, and worker shortages.
“When you travel today from Lviv to Kyiv, you think the country is quite used now to this war, but that is not true for the eastern regions,” said Dr Tankred Stöbe, an emergency medicine doctor who has been Doctors Without Borders’ (MSF) medical coordinator for Ukraine since 2022.
Speaking from Berlin, he said going forward the situation looks “more bleak than hopeful”.
Attacks on medical facilities limit access to care
Russian forces have made more than 1,760 attacks on hospitals, clinics, ambulances, and medical workers since 2022, according to an analysis from the non-profit group Physicians for Human Rights (PHR). The WHO’s tally is even higher.
That’s an average of 1.6 attacks per day, which human rights groups say could constitute war crimes. The Kremlin says it does not attack civilian targets and denies striking Okhmatdyt last summer.
These persistent – and, according to British intelligence, targeted – attacks on health facilities and the energy grid have chipped away at medical workers’ ability to manage patients facing everything from battle injuries and trauma to simmering chronic conditions, cancer, and infections.
Since the strike on Okhmatdyt, there have been at least 41 attacks on medical facilities, according to PHR. Two centres were destroyed in January alone. Another 22 were damaged.
And last week, hours after diplomats from the US and Russia met in Saudi Arabia to discuss an end to the war, a strike damaged a children’s clinic in Odesa, Ukraine’s third-largest city.
“It was one of the best in the country. And just in one night, we don’t have it,” said Inna Ivanenko, executive director of the advocacy group Patients of Ukraine, which represents 4.5 million people with chronic or rare diseases.
The damage has limited access to medical care for millions of Ukrainians. Nearly 16 per cent of households cannot get treatment due to destroyed facilities or unavailable staff, according to a recent survey of 2,000 households from the Kyiv School of Economics and the University of Oxford shared exclusively with Euronews Health.
That level is even higher for people who have experienced property damage since the war escalated in 2022, the survey found.
The destruction is most severe closer to the eastern frontline and the occupied territories. Given the frequency of attacks on health centres in these areas, “it is even dangerous to go to the hospital for your treatment,” Ivanenko said.
Much is unknown about the state of medical centres and healthcare access in the eastern regions Donetsk, Luhansk, and Crimea, which Russia illegally annexed in 2014. Aid groups have limited, if any, communication there, but say they fear the situation is dire.
Diseases are ‘signs of a collapsing health system’
There’s also a “high” risk in Ukraine for gender-based and conflict-related sexual violence, measles, winter respiratory illnesses, tuberculosis, HIV, and conflict-attributable injuries, according to an August 2024 analysis, with that risk at times “very high” in frontline regions.
Risks tied to chronic conditions such as heart disease, cancer, and diabetes, and to mental health overall, are “very high” nationally, the analysis found.
Tuberculosis (TB), a serious yet treatable bacterial infection affecting the lungs, has been a public health issue in Ukraine since the 1990s, but the incidence rate rose in 2022 and 2023, according to the 2024 Global Tuberculosis Report.
Ukraine is also considered one of the 30 countries worldwide with a high burden of multi-drug-resistant TB, which can make it harder to treat.
TB is also a leading cause of death among people with HIV.
“Tuberculosis, HIV, hepatitis, these are signs of a collapsing health care system, and you see growing numbers,” said MSF’s Stöbe.
“I think this is another alarming sign in Ukraine that those diseases are spreading that nobody notices, and even worse, nobody cares”.
The war has “severely disrupted” progress on HIV, according to UNAIDS. While the number of HIV infections has fallen, war often comes with high-risk behaviours such as sex work and drug use, and there have been challenges in gathering data from occupied territories.
Meanwhile, a survey of 74 hospitals last year found that while emergency admissions have increased, a host of other medical services have been put on the back burner, including laboratory testing, cancer screening, pharmacy services, gynaecological care, rehabilitation, anti-tobacco programmes, and telehealth.
Anna Uzlova, the director and co-founder of a cancer patient charity called Inspiration Family, said more cancers are being caught at later stages due in part to problems with early diagnosis and screening.
Uzlova, who is a breast cancer survivor, said patients also need more psychological support.
Overall, many experts repeated that the war and its uncertainty are taking a toll, and raised concerns about how cuts to US funding under the Trump administration could affect services.
“We now can see that a lot of programmes from the US were stopped… that we can’t [predict] our future even [over the] next three months is difficult,” Uzlova said. “Psychologically it’s very difficult”.
The mental health burden is expected to impact millions who will need specialised support. According to the Kyiv-Oxford survey, more than 30 per cent of households are under “severe psychological stress”.
“There is an increased number of different mental health disorders, and it’s very important because if it’s not treated, [it can lead to] depression, suicide and different food disorders within adolescents,” said Halyna Skipalska, CEO of the Ukrainian Foundation for Public Health, a non-profit created by HealthRight International.
“Mental health issues are very important now and particularly as a sort of third year [issue]. So [in the] first year, you are more optimistic, [by the] second, third year, [there’s] more fatigue,” she added.
These challenges follow them when they leave Ukraine. Adrien from the Commission said many of the patients evacuated for treatment elsewhere in Europe – most of whom have traumatic injuries – are grappling with post-traumatic stress.
“This is quite a serious issue here,” Adrien said. “This medical evacuation is also a very difficult process for the patients to undergo”.
Health worker shortages are a long-term problem
Health workers are also feeling the strain of the past three years. Many have fled the country, while others have retired, enlisted in the military, or been killed – with a death toll of 262 – and Ukraine is now staring down a gap in its health workforce.
The picture looks different across the country. In Kyiv and other major cities, doctors and non-profits say there are usually enough physicians available, partly because so many people have left Ukraine.
But experts said specialists can be hard to find, stymying access to medical care for chronic disease patients and the war-wounded alike.
There are also fewer doctors closer to the frontlines and in parts of the country that have been occupied by Russia – including regions that have since been reclaimed by Ukraine.
“You see a lot of aid coming in also to the frontline,” said Stöbe from MSF, listing prosthetic limbs, drugs, and other medical supplies.
“What’s lacking is the human factor,” he said, “the actual specialists going close to the frontline”.
Dr Yevheniia Poliakova is an obstetrician and medical director of a hospital in Zaporizhzhia, a city of about 700,000 in southeast Ukraine.
The city is about 30 kilometres from the warzone, and Russian strikes there have escalated in recent months, including on medical facilities.
Poliakova said doctors often leave when the region is heavily bombed, and then return a month or two later. But she is staying put.
“I will consider leaving in one case: if Zaporizhzhia will be occupied,” she said. “I like my job. I like my city… I won’t leave my home”.
Nurses are a bigger challenge. Ukraine was grappling with a nursing shortage even before the war began. Now, they are even more scarce, with about half as many nurses per 10,000 people as in the European Union.
Many nurses can find work in other countries, Poliakova said, whereas doctors have a harder time getting their medical licenses certified outside of Ukraine.
Health worker shortages are likely to reverberate for years to come. Today, more than half of Ukraine’s primary care doctors are over 50, and many are past retirement age.
It’s not clear whether there are enough young people to replace them, given applications to Ukrainian medical schools fell by 21 per cent between 2019 and 2023.
Burnout is another concern as healthcare workers are not immune to the ongoing psychological stress of the war.
“We want to be calm, brave,” Lysytsia said from the surgery unit at Okhmatdyt. “But in the depth of our soul, we are all afraid”.
For now, Ukraine’s healthcare system is still standing, largely due to international funding and support that has poured in over the past three years. Ukrainians hope that it will be enough to weather the next chapter of the war.
“Of course, there are a lot of problems,” said Ivanenko from Patients of Ukraine. “But the healthcare system has survived. It means that the construction of it is strong enough”.