One of the biggest fears for many active Ukrainian citizens right now is that when the war ends, despite the terrible sacrifices made by the country, we will all return to February 23, 2022.. Let's just rebuild what was destroyed and leave the old system intact. With its populism, insolvency, corruption and nepotism, with loyalists instead of specialists in key positions. How to prevent it? How not to miss the window of opportunity for change? This worries specialists from all areas of the country's life..

About what needs to be done in the post-war period, so that instead of simply restoring Ukrainian medical institutions, which Russia is now destroying, to build a new effective healthcare system ZN. UA spoke to Ukrainian Health Center (UHC) co-founder Pavel Kovtonyuk.

— Pavel Anatolyevich, what is UHC doing now

- Since the beginning of a full-scale war - documenting attacks on hospitals. It grew into a big serious project, and we began to promote the interests of Ukraine on the diplomatic front. In the health sector, they are represented by the World Health Organization and professional associations. We are pushing for Russia to receive sanctions. In general, it seems to me that it is necessary to revise the logic of the work of WHO, which is very outdated and does not meet modern challenges..

In addition, we are starting to think and initiate activities for the post-war development of the healthcare system. It's called recovery. But we have other plans, not restoring what is outdated.

— How many medical institutions have suffered as a result of the war to date?

- We actually record not so much destruction (the Ministry of Health deals with this in order to receive compensation), but attacks on hospitals. We are doing this in order, firstly, to help hold Russia and certain people in the Russian army accountable in international courts.. Secondly, to help the world fight a new menacing phenomenon. Using the example of Ukraine, we want to show that Russia purposefully and systematically uses the issue of health as an instrument of war. And the attacks on Ukrainian hospitals are not an accident that accompanies the war.. We want to form public opinion on this issue, primarily international. Ideally, we would also like international organizations to change their policies and mechanisms for responding to such cases.. In order, if not to warn, then at least to deter future aggressors from such behavior.

- Are there any figures on the destruction?

— As of May 28, we recorded 167 medical facilities that were attacked. There were also 33 attacks on medical workers and ambulances.. 18 doctors were killed, 43 medical workers were injured.

- So you want to say that Russia is resorting to, let's say, medical genocide?

— to terror. Russia exerts psychological pressure on the population, central and local authorities through terror in the humanitarian sphere. When civilian life and the civilian sector become the targets of targeted attacks, this creates a sense of danger in people, causes panic, migration and, as Russia obviously thinks, puts pressure on the Ukrainian authorities, forces them to surrender.

Unfortunately, this tactic is not successful.. Because the number of people who migrated both within the country and abroad is a record. We want this to be known and such actions to be punished.. Not just once, but so that systemic mechanisms appear that prevent all this in the future.

- As far as it is possible to prove that these are targeted attacks on medical facilities, and not accidental hits?

— There are two types of attacks on medical facilities. Targeted, that is, aimed. And indiscriminate, when a medical facility is not a target, but the civilian territory where it is located is fired from different types of weapons. According to the Geneva Convention of 1949, both the first and second types are war crimes. Warring parties must avoid destroying civilian infrastructure. And the hospitals in the mentioned convention are listed separately as a special type of civil infrastructure. Because, firstly, the hospital is an object of increased humanitarian importance. And secondly, it is impossible to stop the work of the hospital during the war, even if hostilities are underway..

We detect both targeted and indiscriminate attacks. More recent. Most often, the Russians use the tactics of massive, carpet shelling of civilian territory, under which most hospitals fall..

But there are also targeted. Recently, my team and I traveled to all the suburbs of Kyiv, where hostilities were taking place.. In Makarov, there are examples of indiscriminate attacks, when a private institution was damaged, where the entire center was razed to the ground - shops, kindergartens, and so on.. And purposeful – Makarov Primary Care Center. It is obvious that this was done on purpose, with a mortar. We found traces of four adjustments - four funnels in the same direction are located at a distance of about ten meters. It should be noted that mortar fire is conducted from a short distance - 1-1.5 kilometers, in the zone of visual observation. Soldier looking at an object through binoculars. That is, the Russians clearly saw that this was a hospital (by the way, a new one was built in 2018), and they corrected the fire on it, completely destroying. This is an example of a targeted attack..

It is a crime. So there is no war. And there are many such examples.. There are fewer targeted ones, because we have air defense. We are working with colleagues who documented Russian attacks on medical facilities in Syria. There, hospitals were simply shelled from planes, since there was no way to shoot them down.

How do you think WHO should have reacted to this and how?

- The WHO has a charter - a constitution that each country ratifies if it becomes a member. It states that all countries should make every effort to achieve the highest level of health for their peoples.. Through international cooperation between governments.

WHO is an organization for cooperation between governments of countries, which is very important to understand. This is not a volunteer organization. For example, the Red Cross, which is much criticized in Ukraine, is a volunteer organization that helps people in need, war and natural disasters.. Even though we don't like it, they have the right to be apolitical. It's individual people going to people.

WHO is an association of states. She can't stay apolitical. In our case, Russia, being a member of this organization, grossly violated its charter and began to systematically destroy the healthcare system in another country. It seems to me that the organization should react harshly to flagrant violations of the charter.

In fact, as it turned out, there are not so many mechanisms. WHO obviously did not prepare for such cases. But still there is Article 7, which deals with the possibility of applying various sanctions in exceptional cases, for example, depriving certain privileges, as well as the right to vote. In my opinion, it is difficult to imagine a more exceptional case, and WHO should immediately convene an extraordinary World Health Assembly - an analogue of the UN General Assembly, consider this issue and make a decision in order to prevent further destruction of hospitals in Ukraine at an early stage. The WHO did not. She was silent for a very long time..

At the very beginning, she issued a statement stating that she was deeply concerned about the situation in Ukraine.. For more than a month, WHO has been saying that “Ukraine is a tragedy, a crisis,” avoiding calling it a war.. Didn't even use the word " By the way, Hans Kluge, regional director for Europe, has never once said “Russia” in his official statements.. Twice retweeted other people who said " There were 231 applications.

CEO Tedros Ghebreyesus said that Russia should stop the war only on the 42nd day, after already a hundred destroyed Ukrainian hospitals. I remember this day.

WHO says very little and cautiously about the war in Ukraine. After arriving in Ukraine, visiting Bucha, Borodyanka, Makarov - a little more. But it still doesn't look like there is political will to impose sanctions..

Although at an extraordinary meeting on May 10, at the suggestion of 38 countries (including Ukraine), the Regional Office for Europe adopted a resolution condemning the war and suggesting that the regional director consider the possibility of moving the office for infectious diseases from Russia (one of the interstate offices is a privilege for the country) and not hold. But this is still only a proposal to the regional director to study the issue.

We will monitor it. But there is a suspicion that the regional director will not be decisive.

- You are only monitoring?

— Monitoring is not an end in itself. He needs to understand the situation. We promote the idea that the use of health for war deserves a much stronger response. And we help the Ukrainian government to work on the diplomatic front, in particular in the preparation of draft resolutions and demands. Including for the recent 75th World Health Assembly.

88 countries supported a resolution holding the Russian Federation responsible for the destruction of Ukraine's healthcare system and condemning Russia's aggression, which led to a humanitarian crisis. But Russia continues to have the right to vote in the WHO, while the ministers of health of the Russian Federation and Belarus remain in their positions..

At the same time, the draft resolution is rather conditional.. The document must be completed within seven months.. During this time, Russia can continue to destroy Ukrainian hospitals with impunity..

International institutions are very inertial. It's a long fight.

— You do not like the word “recovery” in the context of healthcare strategies in Ukraine. Which one is better in your opinion?

- " We need to create a health care system. It is not necessary to restore what was before the aggression. We tried to reform it, because we didn't like it.. It will be very wrong and insulting if Ukraine does not take advantage of the money and the window of opportunity. More precisely, he will use it to simply rebuild the old.

We believe that Ukraine should rethink its medical system in the light of joining the EU, ensuring its security, modernizing the country. We have a number of lessons to take from this war.. One of them is that Ukraine was able to resist Russia militarily, because some people made efforts to modernize the troops. If today we had the same Soviet army as in 2014, Russia would indeed be in Kyiv in 72 hours. From this we must conclude: it is necessary to modernize everything.

Hospitals were ready for war?

- Were not. Same as covid. More precisely, some were, but in general the system of hospitals was not modernized.. And, as the covid example showed, many institutions called hospitals could not provide assistance, there was no oxygen. Same here. The hospital claimed to treat polytrauma, wounds and burns.. People were brought, but she cannot. maybe another. That is, the hospitals were ready, like everyone else. Something was, something was not.

There was and is a lot of heroism of doctors, nurses, ambulance workers. But this heroism often had to cover the shortcomings of the system. Do the work for the system. It shouldn't be like this in the future..

And most importantly, we must learn a lesson: efficiency and modernization are a matter of our national security.. Therefore, we need not to restore, but to rethink. Draw for yourself what kind of hospital system we want to have by 2040 or 2050. And then invest the money that will come to the country into the future, not into the past. Why am I talking about the 2040s-2050s? Because a hospital is an institution that must remain relevant and not obsolete for 20-30 years.. And today, investing in the hospital, we must understand this..

And then the question is: is this what we're talking about? Should we just renovate hospitals where windows were blown out by explosions and consider that a rebuild I believe no. This must be done because help is needed now, and in some places there is no alternative.. But I don't call it recovery. This is a quick repair.. And we need to talk about new medicine for a country that is a member of the EU.

I hear very little about it so far.. And it worries me.

- let's go in order. The President said that we need to think about the future. Started creating working groups. You have been included in the health group by consent. Last week, its meeting took place online. What format of work was proposed? What did you see?

— The meeting was chaired by the Deputy Minister of Health. There were 69 participants. Listened to the reports of the Deputy Minister, from WHO. Then they offered to submit written proposals within a week, since the president set the task: in six weeks there should be a recovery plan throughout the country in all areas.

I am ready to continue working on this platform. But I doubt that any breakthrough ideas will be born in this format..

- Why? Due to timing? Because of the proposed format?

- Yes, this is not done in a week, and even in six. Of course, if we set ourselves the goal of structurally reforming the country. Compensate for damages - yes.

I understand that the process will continue. There will still be discussions on this topic on different platforms.. There will be different proposals, they will compete with each other to enter the agenda. And the real course of recovery, I think, will have a different look than now.

— What can we do to prevent this from becoming “Potemkin villages”? So that we can finally build something new and efficient?

— We must be subjects and create our own vision of our own future. This is our homework. No European expert will tell us what we want. We must say it out loud to ourselves - what kind of medicine should we have, a system of hospitals where we will treat our children and parents. Then we will understand that this is our vision. And then we will understand how much it costs, what needs to be done to make it. Then a serious conversation will begin. Because it turns out that our resources do not match what we have planned for ourselves.. This is how the real strategy begins to be born.. When we measure our capabilities with our vision.

I think no one will deny that we want to have the best European-style hospitals.. But when we start counting and see that it is impossible for all hospitals to be European-style, we will have to choose which ones and how many there should be, in order to also finance the education system. Have to prioritize. What services can we pay for in these hospitals?. Will all people have access there, or will they have to wait in line for a year and a half. This is an equation with many variables that will have to be solved by experts.. And the government, politicians need to have an articulated vision. And then it will be a serious process with chances of success.

There are experts in Ukraine who changed the system, studied abroad and contacted the best practices here. These people need to be recruited. In addition, any foreign expert, a star in any field will come to Ukraine today. Because Ukraine is now in the spotlight of the world. Gotta think big. Great times call for great changes.

— But we see that little by little interest in Ukraine is fading away. The world is getting used. Less money and opportunities.

- Money will not be less. But the governments of the countries that will give us money will be interested in that their investments go not to “let's just fix everything”, but to what makes the country stronger, more modern and safer. The country that this world needs on the border with Russia. And we first of all.

Therefore, we will hear these serious conversations from where the money will come from.. But in order not to find ourselves again in a situation where the West dictates something to us, we must decide for ourselves what we want. Then we will be able to speak the same language with the West and prove our point of view.

Part of the vision for the post-war period is a radical modernization of medical education. I think directions should be. First, of course, is the infrastructure.. Everyone will be doing it. In fact, somewhere in this lies the key to modernizing medicine.. We now have a modern financing system that continues to finance the old infrastructure. And we don't feel the effect. It is necessary that the modern financing system - NSZU - finance the modern system of hospitals.

— What principle should be laid down in modern infrastructure?

— The modern approach to hospital networks is the consolidation. Western European countries are adopting long-term strategies whereby the number of hospitals is greatly reduced, but they are becoming larger. For example, Denmark wants nine hospitals per country by 2050, Britain only a few dozen.. First, it is economical and medically effective. Large branched hospitals allow a large amount of the best equipment to be concentrated. There is a large flow of patients, resulting in an increase in quality, because doctors have a large practice. They see many different cases, improve their skills. This is possible due to the fact that logistics is more developed - roads, cars, the cost of transportation has significantly decreased.. The modern system is a small number of hospitals, an extensive system of primary care and high-quality logistics of patients to medical facilities. That is, nine out of ten problems are solved locally in their primary. A patient with serious problems is taken to a large, well-equipped hospital. These are very schematic principles for building infrastructure..

Our infrastructure is built on the opposite principle.. There was no primary care in the USSR. There were many hospitals, even in tiny district centers. And the equipment was concentrated only in large cities. That is, most hospitals were actually without equipment.. Now we need to turn this system upside down.

– Will the decrease in the number and enlargement lead to huge queues for solving already serious medical problems?

- Not. Because the queue does not arise in the capacity of hospitals, but in payment. So that everyone has enough money. Therefore, if a person wants for free, then he has to wait in line. In most countries where there are queues, this is the problem.

— Infrastructure. What's next?

— The legal field of the doctor's work. This is his career, financial and economic freedom, which is not now. The institution has. It is autonomous. The general director of the hospital can make management decisions himself, can be flexible. He has a contract with the National Health Service and is independent of the Ministry of Health. These are the results of the reform in 2017-2020.

But there is still no freedom at the level of a doctor. Everything there is still regulated by the outdated Soviet code and old collective agreements, which the doctor, who wants some flexibility and freedom, simply hobbles. For many in Ukraine, nothing changes. The doctor must become a free economic agent. He should have much more freedom in his career, in earnings, training. And here we have a sea of \u200b\u200bwork. For example, to finally introduce an individual license for doctors, a transparent system of continuous training, a public register of doctors, where the results of this training would be reflected..

Must have professional liability insurance. These are changes to the labor code. Creation of economic forms of work of a doctor that will allow him to be independent and work in many places - as a civilian or FLP. There must be competition, the labor market.

And third, is education.. Ukrainians need to be treated well. We will have an outflow of doctors, no matter how insulting it is. He already is. Many specialists have already left, especially nurses. Some will return, some won't. But even this outflow will seem to us just a warm-up for the wave that will rise when Ukraine becomes a member of the EU, or at least approaches membership.. Countries that joined the EU have already gone through this. This means that we will have to replenish our resource from somewhere.. Doctors from other countries will come to us. And Ukraine needs to get used to the idea that it doesn’t matter who treats a Ukrainian – Ukrainian, Indian, Moldovan, Kazakh or Belarusian. The main thing is to be treated well. And for this we must have a very cool, competitive education system.. For the future doctor to come here as a student, get an education here that is not inferior to education in Western Europe, but much cheaper. And worked here.

We have a big country, a lot of patients. It's fun to work here. We have things like transplants, for example. And then the doctors will stay here. The way Poland is doing with the Ukrainians, Germany with the Poles, America with the Germans. Super-competitive education system needs radical reform. Because our education is very retrograde.

These are the three main directions.

- You remembered NSZU. What's going on with her now?

- Degradation.

- It seems to have rapidly accelerated with the war.

- Yes. War in general accelerates all processes - good and bad. In the NSZU, degradation began before the war. now accelerated. First, NSZU is not visible. During the war, she was not a player, a subject. Secondly, everything that was healthy is being squeezed out of there.. People are demoralized, ready to leave, and leave little by little. The organization becomes very passive, dependent and institutionally very weak. “Help”, of course, and decisions of the government. For example, regarding civil servants.

And without a strong NHSU, we will never have a strong healthcare system.. Drawing conclusions.

- As for civil servants. Why do you think it affected? It is logical that civil servants should be in the country, and not be abroad.

- Most of the work can be done remotely. And they are returning. But. it can be organized in different ways. Yes, civil servants must serve, this is an additional responsibility. But I know ministries that have taken care of their employees.. We did everything so that they could return. Could restore their ability to work, settle the issue with families. With housing - for many. I know people in NSZU from Irpen. They just have nowhere to go back to. But this is of no interest to anyone in the NSZU. People just get fired.

Therefore, the rule on the return of civil servants to the NSZU has become another tool to worsen the situation..

I expect that after 2022 (hopefully the war ends this year) we will have a unique window of opportunity for change. It can be just incredible.. Because money will come to us. In 2014 we had a window of opportunity, but no money. Now there will be both money and support. Of course, our need is supposed to be so great that any money will seem insufficient.. But they will. And we must not miss this historic time.. All modern healthcare systems arose after World War II. There has been a huge leap. The system that we introduced in Ukraine with the NSZU was created in 1946, and its concept was written in 1942, during the war.

Wars give impetus to development. And we will have this unique moment. It's very important not to miss it.. This will require a huge effort.. Until February 24, populism dominated in Ukraine, loyal rather than professional people were appointed to positions, institutions were destroyed. Now this is all somehow closed by the war, but when it ends, we must not return to February 23. This is extremely important for us tomorrow. Everyone who does not fight must think, speak and do something for this..

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Read more articles by Alla Kotlyar at the link.