The war in Ukraine, a conflict entering its second year in February 2023, has led to the largest movement of people in the European Region since the Second World War.
Millions have fled the hostilities and left behind their lives and livelihoods. Governments in neighbouring countries immediately welcomed people from Ukraine, offering a wide range of services – health being a key priority.
“We believed strongly in making health services available to people fleeing the war, so we did, without hesitating,” said Ms Mădălina Turza, Counsellor of State and Strategic Coordinator of Humanitarian Assistance to Refugees at the Chancellery of the Prime Minister, Romania, where in January 2023, 107 000 refugees were recorded in country.
Providing health services to such a big influx of people in a short time is a massive undertaking. In order to continuously improve and refine the response, it is key to engage with refugees themselves to understand the barriers they face.
In large-scale health emergencies, however, that is no easy task, as Heather Papowitz, WHO Incident Manager for the Ukraine Emergency, states: “During a crisis, it’s often very hard to fully understand and incorporate the perspectives of those we’re trying to help”.
People-centred perspectives
To explore health service needs and gaps from the perspective of Ukrainian refugees in Romania, WHO supported national health authorities to carry out qualitative interviews with refugees over a 5-month period in 2022.
The study was conducted by the Behavioural and Cultural Insights Unit at WHO/Europe and the WHO Country Office in Romania, supported by the Ministry of Health, the Presidential Administration, the National Institute of Public Health and other stakeholders. Initial interviews were conducted in May 2022, with follow-up interviews in October, to monitor changes in their experiences.
These in-depth interviews provided information that now enables Romanian health authorities to take a people-centred approach in their response to the health needs of Ukrainian refugees. Other countries are already following the same model; similar studies are being conducted in Poland, Slovakia and Slovenia, which in total host 1.7 million refugees from Ukraine, as of 10 January 2023.
The longer displaced people stay in a host country, the more important it is that they understand the health system in question and how to access it.
It is women that make up the majority of Ukrainian refugees, in Romania as elsewhere. New mothers, who are often alone, need support in particular. Language remains a barrier to many, preventing them from being comfortable with accessing services. In order to get medications or see health professionals, some even return to Ukraine when and if possible.
Refugees need support to access services
In the study, refugees expressed gratitude toward the Romanian people and authorities for the warm welcome they received, especially from volunteers. However, in those first months, uncertainty about how the health system worked, what services refugees were eligible to receive and at what cost, made accessing health care challenging.
Among the findings is also that over time, through sharing experiences among fellow refugees and through efforts made by health authorities, people report feeling more settled and confident in seeking health services.
After 6 months or more in Romania, respondents said they were more confident overall and had learned much more about how the health system works. As a 50-year-old Ukrainian woman put it: “At first it was a disaster. The children got sick and I didn’t know where to go. But now it’s easier and I know what to do”.
Translating results into action
After discussions with the Romanian Ministry of Health, the Office of the President, the National Health Insurance House, and members of the Romania Health Working Group (made up of representatives of development partner organizations), WHO has now begun taking coordinated decisions and actions directly inspired by the needs and solutions voiced by study participants.
“This study is important because it gives us structured, reliable information that we can use to inform the national response. We may hear stories, anecdotes, here and there about someone’s experience, but that is no basis for policy. With this data, I am confident we are gaining important insights,” said Health Minister, Dr Alexandru Rafila.
WHO health-care clinics for Ukrainian refugees now operate with the support of County Public Health Directorates and local authorities in Romania, while both health-care providers and refugees are targeted with tailored information.
“The research was undertaken quickly and the results are now shaping interventions and policies, such as employing health mediators at the county level to link people to services,” says Ms Papowitz.
Among challenges that remain and are being worked on are access to prescription medications, dentistry, and vaccination for both children and adults, as well as accessing quality mental health services.
Ms Turza explains that together, all actors are working on improved access, and then adds: “What the study did was to help us understand the challenges from the viewpoint of refugees”.
