Ukraine crisis strategic response plan for January–December 2023

iUkraine crisis strategic response plan for January–December 2023 ii Document number: WHO/EURO:2023-7906-47674-70284 © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC- SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition: Ukraine crisis strategic response plan for January–December 2023. Copenhagen: WHO Regional Office for Europe; 2023”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Ukraine crisis strategic response plan for January–December 2023. Copenhagen: WHO Regional Office for Europe; 2023. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover photo: © WHO/Christopher Black Designed by: Rooftop Abstract The WHO Strategic Response Plan (SRP) for health in Ukraine is entering its second phase with a continued emphasis on collaboration alongside partner organizations. WHO and its partners remain committed to providing crucial assistance to individuals affected by the ongoing war in Ukraine, both within the country and beyond its borders. The SRP serves as a comprehensive framework, drawing upon key documents like the Ukraine Flash Appeal 2023, the Humanitarian Response Plan 2023 led by the United Nations Office for the Coordination of Humanitarian Affairs, and the Regional Refugee Response Plan 2023, led by the United Nations High Commissioner for Refugees. These plans guide the allocation of resources and aid efforts based on access and location, supporting national and local authorities in their leadership of readiness, response, and ongoing recovery activities. This SRP outlines response pillars that address the health needs of both Ukraine and the countries hosting refugees. This plan has a timeframe of 12 months, ensuring a sustained and coordinated approach to tackle the many challenges faced by affected populations. iUkraine crisis strategic response plan for January–December 2023 ii Corrigendum Ukraine crisis strategic response plan for January – December 2023 Document number: WHO/EURO:2023-7906-47674-70284 A correction was made to Refugee response pillar title 7.1, page 38, changing “Risks to health system functioning” to “Health leadership and governance mechanisms are streamlined and reinforced”. This correction was incorporated into the electronic file on 01 November 2023. iii U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Contents Abbreviations iv 1 Overview 1 2 Current context 7 3 Health risks in Ukraine 11 4 Scenarios and planning assumptions 19 5 Strategic Response Plan Goal 21 6 Ukraine response pillars 22 7 Refugee response pillars 31 8 Cross-cutting areas for Ukraine and the refugee response 39 9 Operational strategy 43 10 Early recovery and transition 49 11 Monitoring and evaluation 51 12 References 55 iv Abbreviations AGD age, gender and diversity CBRN chemical, biological, radiological and nuclear COVID-19 coronavirus disease 2019 DTP3 three doses of diphtheria-tetanus-pertussis vaccine ECDC European Centre for Disease Prevention and Control EMS Emergency Medical System EU European Union EMTs emergency medical teams GBV gender-based violence GOARN Global Outbreak Alert and Response Network IDPs internally displaced persons IOM International Organization for Migration LGBTQIA+ lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual and more MHPSS mental health and psychosocial support services MoH Ministry of Health NCDs noncommunicable diseases PHC primary health care PRSEAH prevention of and response to sexual exploitation, abuse and harassment RCCE risk communication and community engagement SRP Strategic Response Plan SEAH sexual exploitation, abuse and harassment TB tuberculosis UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund 1This WHO Strategic Response Plan (SRP) will be implemented in collaboration with partners providing life-saving support to people affected by the war in Ukraine, whether they are inside or outside Ukraine. © WHO/Marta Soszynska Overview 1 It is an overarching framework built on the Ukraine Flash Appeal 2023 (1), the United Nations Office for the Coordination of Humanitarian Affairs led Humanitarian Response Plan 2023 in Ukraine (2) and the United Nations High Commissioner for Refugees (UNHCR) led Regional Refugee Response Plan 2023 (3), to guide priorities and work, according to access and location, in support of national and local authorities who are leading the preparedness, readiness, response and early recovery activities. The SRP has been developed to strengthen national health systems and services, so that they are resilient and have the capacity to adapt to context changes – instead of only putting parallel systems in place – and closely linked to recovery efforts. It is based on the foundation of universal health coverage to ensure that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship and aims to protect gains in the health-related Sustainable Development Goals. The timeframe of this SRP is 12 months, January–December 2023, to reflect the protracted nature of the crisis. 2U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Year in review 1.0 Since Russia’s invasion of Ukraine on 24 February 2022, Ukraine continues to experience acute stress and implications across all aspects of its society, not only the health sector. More than a year into the war, intense hostilities and fighting continue in Ukraine, with particular focus in the eastern regions of Donetsk, Luhansk, and the Donbas, while waves of missile attacks continue to damage energy security and infrastructure across the country. The war has led to the largest displacement and humanitarian crisis in the European Region since the second world war, with further waves of displacement possible as hostilities and vulnerabilities continue to escalate. To date, almost half of Ukraine’s entire population has been displaced: 5.4 million people have been internally displaced (4) and, as of April 2023 over 19.7 million people – the vast majority women and children – have fled across the border to neighboring countries, with the UNHCR reporting 8.2 million people from Ukraine registered across Europe (5). It is also important to note that authorities have reported 12.9 million movements back into Ukraine. The International Organization for Migration (IOM) reports that the number of internally displaced persons (IDPs) has been steadily declining since August 2022. WHO’s Incident Management Support Team continues to provide an agile, adaptive framework to respond to the situation; first initiating its work by declaring the war as a Grade 3 emergency on 25 February 2022, which as of April 2023 remains within Ukraine – with a protracted Grade 2 emergency for the refugee receiving and hosting countries. The Incident Management Support Team developed a tailored strategy across all three levels of the organization, guiding WHO’s actions to respond and support Ukraine and refugee-hosing countries to improve access to emergency and routine health services and strengthen the heavily impacted health systems. The WHO Regional Office for Europe’s response was built around the comprehensive Strategic Response Plan June–December 2022 (6), implemented in collaboration with partners providing life-saving support to people affected by the conflict, whether inside or outside Ukraine. The World Health Assembly resolution developed in 2022 and updated and endorsed again in 2023, outlined WHO support to the humanitarian and emergency health response (7), which included the backing of the Director General, to provide the additional staff, financial resources and leadership support needed across the response, including for critical health cluster functions under the WHO Health Emergencies Programme, for an effective and accountable humanitarian and emergency health response. Governments in all countries receiving and hosting refugees from Ukraine have generously kept their borders open and local communities have welcomed Ukrainian refugees and other persons of concern. As detailed in the SRP in 2022, WHO has scaled up capacity in neighbouring countries and remains committed to providing operational and technical support to the national governments and health authorities of refugee-receiving countries as their health systems continue to cope with an unprecedented wave of refugee arrivals. The priority refugee-hosting countries that received support from WHO in 2022 were Bulgaria, Czechia, Hungary, Poland, Republic of Moldova, Romania, and Slovakia. 3Key figures: Ukraine (as of April 2023) 2196 tonnes Supplies delivered 1100 Number of people trained 2158 Medical evacuations (8) Partner coordination: 221 international and local partners make up the Health Cluster providing activities in 828 Ukrainian settlements Key figures: Refugee-hosting countries (as of April 2023) 150 tonnes Supplies delivered 52.5% of the supplies requested by refugee-hosting countries have been delivered since the beginning of the response > 6500 Number of people trained 21 Health assessments supported Estimated people reached by WHO 8.4 million people in Ukraine 4U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Coordination and leadership: The WHO Regional Office for Europe set up the Refugee Health Extension in Kraków, Poland from 21 March–31 December 2022 to support refugee receiving countries and coordinating partners, namely the European Centre for Disease Prevention and Control (ECDC), IOM, United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA) and UNHCR. As of 2023 the Extension continues to exist in a hybrid format and serves as an extension of the coordinating partners’ respective regional offices/bureaus – providing immediate operational support to the refugee-hosting countries, and drawing on the expertise, comparative advantage, and complementary mandates of each partner. WHO has supported countries with coordination around the refugee response as well as contingency planning, as an active member of national health working groups. Partner coordination: WHO has worked closely with the Health Cluster in Ukraine which as of April 2023 includes 221 partners working in 828 Ukrainian settlements and reached 9.4 million people in 2022. In addition to its work through the Refugee Health Extension, WHO worked in close collaboration with the ECDC, the IOM, UNFPA, UNHCR and UNICEF in 2022. Within all refugee hosting countries, WHO has also partnered with local nongovernmental organizations, national authorities and international organizations present on the ground. Prevention of and response to sexual exploitation, abuse and harassment (PRSEAH): PRSEAH has been mainstreamed through deploying experts to Ukraine and priority refugee- hosting countries to build capacity for prevention, reporting and response, and to contribute to joint interagency preventive actions. In 2022, 21 trainings and workshops were carried out across refugee hosting countries, reaching 400+ participants who were trained on the principles of PRSEAH. Procurement of essential medicines and supplies: As of April 2023, WHO has delivered 2196 tonnes of supplies for Ukraine, which were distributed to all 24 oblasts and totaled US$ 75 million. An estimated 450 350 people have been reached with trauma supplies; 1 896 000 with emergency health supplies; and 3 740 000 with supplies for noncommunicable diseases (NCDs). Additionally, WHO has provided 150 tonnes of supplies and equipment to refugee-hosting countries, including Hungary, Poland, the Republic of Moldova, and Romania with a value of over US$ 10 million, to support the response. 5Ensuring the continuity of routine services: WHO worked closely with countries and local organizations throughout 2022 to ensure that continuity of health services was available to refugees arriving with existing health needs. WHO has provided policy guidance and technical support to relevant ministries of health in areas such as HIV and tuberculosis (TB). In addition, WHO has worked closely with countries to reduce language barriers for refugees when accessing health services and supported the provision of services in Ukrainian where possible. Capacity building: WHO has supported the health sector in Ukraine via training provided to more than 11 000 health workers on trauma, mass casualties, chemical exposure, epidemiology, and laboratory diagnostics. In 2022 WHO also provided webinars, workshops, and training to over 6500 health-care workers in refugee-hosting countries to support and strengthen the respective health workforces. Monitoring attacks on health care: From the onset of the conflict and using the WHO surveillance system for attacks on health care, WHO has been monitoring ongoing attacks on health facilities. As of the end of April 2023 a total of 971 attacks had been recorded (10). Assessing mental health and psychosocial (MHPSS) needs: By co-chairing the MHPSS Technical Working Group comprising 270 partners, WHO has been actively working to address mental health needs in Ukraine as well as of refugees in receiving countries. In refugee-hosting countries, WHO has actively sought to identify acute mental health needs and to coordinate with mental health working groups as well as local partners to ensure MHSPSS service provision to those most in need. Providing essential health services: As of April 2023, with the coordination of 21 emergency medical teams (EMTs), WHO supported trauma care, patient transfer, training, outpatient and inpatient care and the response to newly accessible areas, as well as helping to mobilize 90 mobile health units providing care to 3103 patients. WHO is also providing technical and operational support for medical evacuation and repatriation; to date 2158 medical evacuations for cancer and conflict-related injuries have been completed with the support of the European Union (EU). In refugee-hosting countries WHO has significantly scaled up operations to support and strengthen health systems, including by providing support in the areas of financial protection, culturally appropriate service delivery, risk communication on how to access health care and assessing the needs of Ukrainian refugees. In 2022 WHO contributed and carried out over 21 health assessments across the seven priority refugee-hosting countries (9). 6U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Resource allocation: To strengthen the response, WHO deployed 191 people on short-term contracts with support from standby partners and the Global Outbreak Alert and Response Network (GOARN) to ensure a seamless continuity of response activities. A total of 32 GOARN deployments were identified and deployed to support the WHO response. Challenges and lessons learned in 20221.1 As the WHO European Region emerges from three years of the coronavirus disease 2019 (COVID-19) pandemic, health systems and health-care workers are still pushed to the brink. This has been further driven by the combined impact of winter viruses, a health workforce crisis, and the fact that health systems are not set up or resourced to cope with an additional crisis – namely the war in Ukraine. The war in Ukraine is still an acute event, with the situation continuing to deteriorate, and its wider impacts both regionally and globally (e.g., energy costs, food security, etc.) have persisted. Through the implementation of its strategy, WHO has faced numerous challenges in Ukraine due to the nature of the emergency and the ongoing conflict which has reduced health access to populations in need and slowed the health data collection process. In addition, although field presence has been increased, supply distribution capacities must be maintained and further intensified to ensure continuing health-care needs are met in a very unstable and volatile environment. Working within the priority refugee-hosting countries, WHO faced challenges at the beginning of the war due to the rapid influx of a large number of refugees coming from Ukraine. The high bi-directional mobility of refugees between Ukraine and neighboring countries has made it challenging to collect health data and information about the needs of the refugee population. However, it is evident that continued support is needed for refugees from Ukraine throughout the Region. With over a year having passed since the first refugees arrived in hosting-countries, barriers to access remain and these must be addressed as volunteerism decreases, discrimination rises, and particularly, considering the worsening energy crisis and inflation rates across the Region. To address these challenges, WHO has established strong relationships with the Ukrainian government, national authorities in refugee-hosting countries and other partners on the ground. In the priority refugee- receiving countries, WHO has significantly scaled up their country offices to be able to support governments in providing refugees access to health services via a health system approach. Furthermore, as the lead of the Health Cluster in Ukraine, WHO has been able to collaborate with other organizations to ensure that information is being collected within the country with a focus on providing minimum datasets and further developing data collection tools (e.g., technical guidelines and tools, toolkits, and terms of reference). WHO remains present on the ground in Ukraine to strengthen the health system, ensure services and supplies for the civilian population and to support ongoing recovery efforts. 7© WHO As the war continues to have a devastating impact on civilians in Ukraine. Nearly 18 million people – about 40% of the country’s population – are in need of humanitarian assistance and protection. As of 23 April 2023, the Office of the United Nations High Commissioner for Human Rights recorded 23 015 civilian casualties in the country: 8 574 deaths and 14 441 injured, although the actual figures are believed to be considerably higher (11). Current context 2 8U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 The war has triggered one of the largest forced displacement crises in the world today. Around 8.2 million refugees from Ukraine have been recorded across Europe, while 5.4 million people are still internally displaced within Ukraine (12). Over 5.2 million refugees from Ukraine have registered for temporary protection or similar national protection schemes (5). The Temporary Protection Directive (TPD), activated by EU Member States for the first time on 4 March 2022, grants refugees’ access to national health services at the same level as host communities, including free access to health services in line with national regulations. However, as refugees continue to reside in host countries, they face an increased risk of discrimination and a potential reduction of rights under, or loss of, the TPD, as well as barriers in accessing health care (i.e., financial, linguistic, and cultural), administrative hurdles, a lack of information on entitlements and worsening living conditions. Although more than 11.2 million people have returned to their place of origin within Ukraine, population movements remain unpredictable. Challenges including continuing attacks in Ukraine, the energy crisis, increasing scarcity and cost of fuel, continued threats such as COVID-19, and the possibility of a nuclear event, could lead to further displacement both internally within Ukraine and cross-border to surrounding countries, placing further strain on already overstretched health-care systems. Since October 2022, critical civil infrastructure has been increasingly targeted, including that related to electricity and water, in several major cities such as Kyiv, Lviv and Dnipro. This, and with temperatures having dropped to as low as -20°C during the winter conditions of 2022, have brought a new dimension to the humanitarian crisis. Millions face daily power cuts, and the lack of electricity is affecting water pumping stations, adding to the pre- existing challenges and insecurities faced by millions of people to access clean water, or run heating systems. The destruction of houses and lack of access to fuel or electricity due to damaged infrastructure can become a matter of life or death in the cold winter months. The situation is particularly critical in some areas of the Kharkivska and Khersonska oblasts, which were until recently under the temporary control of the Russian Federation, as well as large parts of the Donetska, Luhanska, Mykolaivska and Zaporizka oblasts due to active fighting and destruction of civilian infrastructure. Furthermore, incidents involving mine accidents are increasingly being reported across some of these areas (13). Additionally, fighting hotspots have cropped up, such as the small town of Bakhmut in Donetska Oblast, forcing residents to shelter in places with no access to regular food stuffs or health-care access due to the ongoing hostilities. Populations living in areas that are now accessible in the Kharkivska, Donetska and Khersonska 9Oblasts are in dire need of life-saving support after months of war and challenges in accessing essential services. According to the Ukrainian Ministry of Health (MoH), health facilities in areas that have been retaken by the Government of Ukraine have suffered significant damage – with some completely destroyed – and smaller health facilities have been heavily mined. These health facilities have also lost approximately half of their staff. One of the critical needs in these areas is the provision of medicines and medical assistance to people with chronic diseases who have been deprived of access to health care for months. As of April 2023, the Zaporizhizhia Nuclear Power Plant remains an on-going focal point of concern for the International Atomic Energy Agency and other international actors as power supply to the plant continues to be disconnected, forcing staff to rely on diesel-powered back-up generators to perform essential nuclear safety and security functions. The war continues to disrupt access to health care due to infrastructure damage, loss of staff, security concerns, mass displacement of the population and increased costs combined with the population’s diminished capacity to pay for health care (14). © WHO 10 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Attacks on health care across the country, including those against health facilities, transport, personnel, patients, supplies and warehouses, are still being reported. Between 24 February 2022 and end of April 2023, WHO has verified 971 attacks, resulting in 136 reported injuries and 101 reported deaths. Simultaneously, the war has increased health needs in areas such as emergency medical services, trauma and burns, rehabilitation and mental health conditions (14). Since 24 February 2022, humanitarian organizations have reached 13.6 million people in Ukraine with various types of humanitarian aid, including 1 million people in areas under the temporary military control of the Russian Federation, where access remains a challenge (15). WHO has continued to respond to the crisis in Ukraine, including by supporting refugee-receiving countries by activating the WHO emergency response mechanism across all three levels of the organization, delivering lifesaving supplies, training health-care workers, supporting medical evacuation and coordinating EMTs and Health cluster partners. 11 The impact of the war on the health of the Ukrainian population has been devastating and is projected to worsen as the war enters its second year. This year, 14.6 million people are estimated to require humanitarian health assistance. With more than 20 000 casualties recorded as a direct result of the war as of April 2023 and no sign of an end to violence, Ukraine will not only need to expand its capacity to provide acute trauma care, but also manage the long- term consequences of injuries and rehabilitation needs and expectations. Although trauma risks are higher in areas close to the contact line, armed attacks have been recorded across the country. Given limited primary morbidity and mortality data, essential for monitoring of the health status of the population, identifying emerging health trends and risks and developing effective responses remains a challenge. Disruption of data collection and reporting, coupled with the strict policy to access data for security reasons, and continuous population movement within, and to or from, neighbouring countries have made it difficult to plan and evaluate health interventions and measure the impact of the ongoing war on the health of the population (7). As the entire population continues to live in fear, uncertainty and deprivation of basic necessities, coping capacities are increasingly under pressure and the risk of mental health problems grows as the war continues. Among the tens of millions directly impacted by violence and those who have had to abandon their homes for safety, this risk is even higher. This year, close to 9.6 million people in Ukraine are estimated to be at risk of, or living with, a mental health condition – ranging from mild depression or anxiety to psychosis – and close to 3.9 million people are estimated to need psychiatric care, many of them requiring long-term care (16). Prior to the war, Ukraine’s vaccination coverage was already low and despite a substantial increase in coverage from 2017 to 2021 – DTP31 vaccination coverage rose from 50% to 78% for example – the country has not yet reached the regional target of 95% coverage rate for any antigen under routine vaccination and has not implemented at the required scale the supplementary immunization activities on measles, polio, and hepatitis (14). From April to December 2022 up to 400 000 people across 1500 locations in eight regions were reached with outreach immunization services (17), but disruptions to health services caused by the war have further reduced this coverage, notably around the contact line and in areas not under the control of the Ukrainian government. In 2022 the level of DTP3 vaccination had dropped (to 73%) as had that of measles containing vaccine 2 (from 86% in 2021 to 74%) and polio 3 (from 78% in 2021 to 69%) (18). The lack of vaccination compounded with poor living conditions and increased social mixing is increasing the risk of outbreaks of vaccine preventable diseases. 1 Three doses of diphtheria-tetanus-pertussis vaccine. Health risks in Ukraine 3 Direct health risks3.1 12 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 In 2022, 11 cases of measles were reported, and further cases have been confirmed in 2023 (17). The current crisis in Ukraine has also increased the risk for the spread of vaccine derived polio virus 2 (VDPV2) both within and outside of the country, due to reduced vaccination rates throughout most of the country (including known coverage dropping to near zero in occupied territories); and mass displacement – including transit through areas in which VDPV2 had been circulating in late 2021 and early 2022. The overall risk is currently assessed as moderate according to the Public Health Situation Analysis 2023 (17). The risks of outbreaks of other communicable diseases are also increasing as people continue to be displaced and/ or live in crowded and poor conditions without adequate access to safe drinking water, nutritious food, shelter, and health services. The spread of pathogens, including COVID-19, seasonal influenza, and respiratory syncytial virus, is expected to increase during winter months (14). COVID-19, particularly, remains a substantial threat, given the low vaccination rates even prior to the war, and newly emerging variants, despite COVID-19 cases and hospitalization remaining relatively low (April 2023). Cases of acute intestinal infections also increased by 40% in the first half of 2022 compared to the same period in 2021 and remain a serious risk in 2023. Botulism cases, associated with meat and fish contamination, have also been reported in several oblasts. A lack of access to clean water caused by infrastructure damage has resulted in increased reliance on well water, rainwater, and water run-off, increasing the risk of water-borne diseases such as cholera and dysentery, especially in areas around the Azov Sea (14). As the summer season approaches, risk will further increase as rainwater and water run-off will not be as plentiful, causing increased reliance on well water or other stagnant bodies of water, as available. © WHO/Christopher Black 13 There is also an increased risk of the spread of HIV and multidrug-resistant TB due to treatment disruptions: already prior to the war in 2020, TB was the cause of 2927 deaths (7 per 100 000 population) in Ukraine and the country had the second highest rate of newly diagnosed HIV infections (39 cases per 100 000 population) in the WHO European Region (19). With the resumption of travel and trade between Ukraine and the rest of the world, these public health risks are relevant beyond Ukraine’s borders especially in refugee-receiving countries if prevention, testing, and treatment are not continued. Escalation of the conflict and active hostilities has made deliveries of medicines and commodities extremely challenging, due to the difficulty in securing access corridors across active conflict zones. Damage to some health-care facilities providing care to persons with HIV and TB has been reported. However, access to diagnostic services and treatment has been largely maintained, especially in areas and territories with few immediate threats of treatment interruption. For HIV, the delivery of antiretroviral prevention, testing and treatment in active conflict zones is proving difficult. Prior to the war, the main cause of premature deaths in Ukraine was coronary heart disease followed by cerebrovascular diseases, with these diseases, along with diabetes, cancer, chronic respiratory disease, and mental health conditions accounting for 84% of all deaths (20). Approximately 36% of adults between the age of 18 and 69 are estimated to suffer from hypertension and about 120 000 people are living with type 1 diabetes and need to receive regular doses of insulin to survive (17). Treatment interruptions resulting from disruptions of health services and reduced access to medicines are increasing the risks of complications and deaths from these NCDs. According to one survey, 32% of households reported that at least one household member has had to stop taking their medication due to the war, with 63% of these reporting cardiovascular disease medications were stopped and 51% reporting anti-hypertensives were stopped (21). © WHO 14 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 violence services are available in less than one third of public health-care facilities in the southeast area of the country with a relatively higher access rate in secondary and tertiary-level facilities (23). There are also reports of human trafficking and challenges with accessing services related to GBV by populations displaced beyond the Ukrainian border, either due to non-existing services or to a lack of knowledge on how to access them. In countries receiving refugees, barriers to access to GBV and sexual and reproductive health services differ from country to country, but include: restrictive laws on abortion and emergency contraception; high cost of sexual and reproductive health services; language barriers and other difficulties navigating complex foreign health system requirements; lack of robust health-system protocols for certain sexual and reproductive health services; longstanding delays in access to specialized care in gynaecology and obstetrics; lack of cooperation between the public health system and civil society support structures; and weak protection frameworks for certain population groups (7). As introduced above, the risk of a radiation emergency due to the shelling of nuclear power plants, the failure of a reactor’s power supply or the inability to provide necessary maintenance, remains significant. Ukraine has 14 reactors located in four nuclear power plants – Khmelnytskyi, Rivne, South Ukraine and Zaporizhzhia – in addition to the closed reactors in Chernobyl. The International Atomic Energy Agency continues to raise serious concerns about the risk of a severe accident that could jeopardize human health and the environment as a result of reported shelling incidents near the Zaporizhzhia nuclear power plant (25). References being made to the use of nuclear weapons in Ukraine is also extremely concerning (26). Although the likelihood of such an event is small, its health impact would be catastrophic and far reaching. Furthermore, Ukraine has several chemical plants. Thirty open-sourced media signals were captured on the release of industrial chemicals as a result of the war in the Donetsk, Kharkiv, Luhansk, Sumy and Zaporizhzhia oblasts, reportedly with no confirmed public health consequences. WHO and partners continue to monitor and verify such signals. Ukraine’s maternal mortality ratio was among the highest in the Region prior to the war; it was already nearly 10 times that of neighbouring Poland, and the war has likely worsened the situation. It is estimated that there were around 265 000 women pregnant in Ukraine at the start of the war and mortality data remains limited (22). According to data shared by the Ukrainian MoH, prior to February 2022, up to 10% of all newborns were born prematurely in Ukraine (23). Around 30% of the health facilities in the Donetska oblast and 40% of the health facilities in the Sumska oblast do not have skilled care for childbirth. The situation in these two oblasts is similar for basic emergency obstetric care, mainly due to lack of trained personnel (23). For many pregnant women, lack of access to good-quality obstetric care, including emergency obstetric care, and newborn care, is a challenge – increasing the risk of maternal mortality and morbidity (23). Furthermore, disruption to the national medical supply chain within the country is impacting the ability of health workers to deliver life-saving sexual and reproductive health services. Inconsistent access to hard-to-reach areas makes last- mile delivery to health and protection facilities in some oblasts complex and unpredictable (23). The Independent International Commission of Inquiry on Ukraine has reported multiple incidents of gender-based violence (GBV) with the age of victims ranged from 4 to 82 years (24). Throughout Ukraine, professionals lack the specific knowledge and skills needed to deal with survivors of this violence. In addition, humanitarian actors have reported difficulties in delivering emergency contraception to survivors of rape, both due to inconsistent access in Ukraine and due to pre-existing laws in refugee-receiving countries related to sexual and reproductive health. According to the Health Resources and Services Availability Monitoring System data collected from public health facilities in the ten oblasts most affected by the war, clinical management of rape and intimate partner 15 The war has caused significant infrastructure damage, leaving at times millions of people without electricity or water, and susceptible to rolling blackouts. In the eastern and southern oblasts, the population depends on drinking water imported through degraded infrastructure, with limited possibilities of alternative sources, which creates considerable challenges when it comes to water quality (16). As of January 2023, half of Ukraine’s power capacity had either been occupied, damaged, or destroyed and the oil refining industry completely destroyed, with the consumption of gas and electricity decreasing by one third compared to 2021 (27). The lack of power is directly impacting health service delivery, delaying non- emergency interventions and increasingly jeopardizing life-saving support. Furthermore, 41% of the housing sector and 30% of the transportation sector are estimated to have been damaged or destroyed – both of which are important determinants of health (28). The energy crisis is also altering the ways people are generating indoor heating – most notably during the winter season – which can pose health risks, particularly if boilers and cooking and heating appliances used are unsuitable, poorly maintained or malfunctioning. Additionally, alternate sources of heating may cause fire and burns or release toxic emissions, and thereby exacerbate respiratory diseases – potentially further aggravated by reduced ventilation or inappropriate handling of heating sources. Inadequate heating and exposure to cold weather may also result in the exacerbation of chronic diseases, including cardiovascular diseases and endocrine and musculoskeletal disorders. Ukraine’s Gross Domestic Product shrank by 15.1% year over year in first quarter of 2022, and poverty is expected to increase from 2 to 21% (based on the poverty line of US$ 5.5 per person per day), further compromising people’s purchasing power, including for health services and medicines (29). The projected increase in poverty, though large, is expected to be much larger if existing financing gaps are not addressed by a scale-up in external financing (28). The war has already pushed millions of people to flee their homes, and more are likely to be compelled to leave as people increasingly fear for their lives and as living conditions become unbearable. More than 8 million refugees from Ukraine have been recorded across Europe and close to six million people are internally displaced, with 2 to 3 million more people estimated to be at imminent risk of leaving their homes in search of safety and warmth (5). While the first wave of displacement in 2022 involved a larger proportion of people with the means to sustain their lives independently, those displaced in these later waves would most likely need more support to meet their basic needs. The health risks associated with humanitarian displacement is multifaceted and targeting assistance to the right places, including disruptions to treatment and care and access barriers, will become increasingly challenging as displacement continues. For the rest of the population remaining in Ukraine, frequent attacks have forced people to seek temporary shelter in basements, bomb shelters, and metro stations underground with poor ventilation, heating, provisions, and access to sanitation. The war is also exacerbating gender and social inequities. Gender, age, disability, and minority status play a key role in determining how people are affected by the war and their barriers to services. Women and children constitute the majority of displaced Risks to social determinants of health3.2 16 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Risks to health system functioning 3.3 populations and face significantly increased protection risks and health consequences. Towards the end of September 2022, women represented 61% of the displaced population within Ukraine (16). Furthermore, many people with disabilities have not been able to safely evacuate or seek refuge in shelters and older women and women with disabilities are more likely to be abandoned by family and have more limited decision-making power over their living conditions. Additionally, with the escalation of the war, lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual and more (LGBTQIA+) people in Ukraine have also reportedly faced increased risk of discrimination, including refusal at internal checkpoints, the inability to leave the country and regarding military conscription due to their identity documents not matching their gender markers (12). Prior to the war, Ukraine had a functioning health system with 1630 hospitals and 10 140 primary health care (PHC) facilities. Ukraine had also taken several steps to reform its health system, combat corruption and to improve public trust (16). Although the Ukrainian health system has demonstrated its resilience to date, increased health needs, continued attacks on health care, the energy crisis, damage to key infrastructure and the lack of financing will impact the functionality of all health system capacities this year. Health personnel have also been displaced and across Ukraine people are reporting the rising costs of medicines and a lack of supplies in pharmacies. This situation is worse in areas close to the contact line and among displaced populations (21). The conflict © WHO 17 has disrupted supply lines, limiting the movement of medicines and consumables between and across institutions, cities, and regions. Cargo movement by air has stopped, many roads are blocked and trains as well as train stations are badly damaged. The data from needs assessments using a crowdsourcing approach, in areas such as Kharkiv and Kherson, have shown additional barriers to essential health services at primary and specialized level of care, in addition to low access to medicine for chronic conditions. The assessment revealed cost and availability of services and medicines are the two main barriers. WHO also conducted two rounds of representative health needs assessments, in September and December 2022, which demonstrated that among respondents that sought services, three in four reported one or more barriers, with the main barriers being cost and time (21). The assessments also show that IDPs and residents closer to the frontline have a relatively lower level of access to care – 11% reported no access to medicines due to cost or unavailability in the most recent assessment, compared to 20% in the first round (19). A Health Resources and Services Availability Monitoring System covering 10 priority Oblasts from the northern, eastern, and southern parts of Ukraine was conducted in 2022 covering different domains of health service delivery at health-care facilities, including operational status and accessibility, basic amenities, health information system and service availability. The preliminary result shows up to 13% of assessed facilities are either partially or fully non-functional, with the situation being worst in Donetska oblast with up to 55% of state-owned health facilities not fully functional. Looking at service availability, more than 15% of health facilities are not providing full NCD services, 13% are © WHO 18 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 either not or only partially providing maternal and new- born care, and the services are much scarcer in oblasts like the Chernihiv, Donetska and Sumy oblast, where between 20 and 35% of health facilities are unable to fully provide such services. Although systems have improved, disease surveillance continues to be challenging particularly in areas facing the heaviest fighting due to disruptions. Currently, much of the available information comes from event- based surveillance using open sources and historical data on the burden of diseases. Recent progress in health need assessments, both qualitative and quantitative, is expected to bring more visibility to the true gaps in needs and information. A recent survey conducted by the Health Cluster showed that 29 partners are delivering mobile health services in 24 oblasts (21). © WHO However, there is currently no standardization of the packages of services, supplies and medicines, nor the approach to service delivery. Moving forward, a system linking the national health system with humanitarian providers may provide a foundation for a comprehensive package of services deliverable via mobile health services. By leveraging comparative advantages of both the national health system and humanitarian actors, the most acute needs may be ascertained and accommodated at oblast level. 19 Scenarios and planning assumptions 4 The most likely scenario is a protracted emergency due to continuing war with continued disruption to health services – leading to diminishing treatment, preventive rehabilitation, and palliative care options – and a saturation of available emergency health-care and routine health services. © WHO 20 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 © WHO Ongoing waves of displacement within Ukraine and across borders, with potential periods of conflict escalation, can also be expected with consequent disruption to services as well as surges in displacement. Fluctuations in movements back into Ukraine should also be considered. Contingency planning should be conducted for a worst-case scenario with intensification of the war, mass casualties and population movements as well as for technological hazards. While responding to health needs during the emergency, WHO will also focus on the health-development-peace nexus, aiming to ensure that all the interventions address and provide solutions focused on ensuring short- and long-term solutions for a resilient health system in Ukraine and countries with refugees. The cessation of conflict would require a revision of this SRP with a stronger phased health system strengthening and recovery focus, to support the development of the health sector component of the national postwar recovery plan in line with the Priorities for health system recovery in Ukraine – joint discussion paper (14), and to identify the strategic shifts needed to strengthen the health system, initially focusing on PHC to progress towards universal health coverage. Assumptions to achieve this SRP in support of relevant ministries of health are that: • WHO and partners have the ability to access populations • affected populations can access health services • open border policies and access to health care in refugee-receiving countries are ongoing • funding is adequate and sustained • human resources are available and have sufficient capacity. 21 © WHO/Petru Cojocaru Strategic Response Plan goal 5 The goal of this SRP is to minimize mortality and morbidity for all people affected by the war in Ukraine, wherever they are, by providing a cohesive response strategy for countries to implement time-critical, life-saving assistance, and to provide actions for nondiscriminatory access to emergency and essential health services and priority prevention programmes, while simultaneously supporting and strengthening health systems to cope and recover from this crisis. 22 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Ukraine response pillars 6 Continuity of treatment and care for people with NCDs, TB and HIV and access to care for sexual and reproductive health, maternal, newborn and child health continue to be a priority. This SRP for 2023 continues to focus on the acute response while simultaneously contributing to a resilient health system that is able to prepare, be ready, respond and recover while more closely linking to the ongoing work on health system recovery. A strategic approach to the integrated delivery of services should be carried out according to local context via community outreach, mobile and fixed PHC clinics, or hospital-based services with the flexibility to adjust the level of service delivery as conditions change. In areas with active conflict and/or where health facilities have been damaged or are not functioning, priority services need to be agreed upon and delivery platforms adjusted, for which the WHO Universal Health Coverage Compendium (30) and High Priority Health Services in Humanitarian Settings guidance (31) will serve as references. WHO’s in-house technical expertise will play an essential role in monitoring the evolution of health risks to inform service prioritization and dynamic adjustment to the most effective delivery platforms in response to changing conditions. Conflict and displacement indicators will also contribute to the risk analysis. In all situations, an integrated service delivery approach must be maintained based on PHC principles. The following objectives are meant to serve as a guide to develop a more specific action plan with detailed activities and indicators adaptable to the changing context, linked with clear budget lines and funding sources. The activities are in support of national health systems and implemented with partners. Saving lives and protecting mental health continue to be the priorities of the health sector response in Ukraine. Actions focus on ensuring access to emergency health care and basic health services to wounded people and others affected by the armed conflict, COVID-19, polio, and other health threats – including technological, industrial, chemical, biological, radiological and nuclear (CBRN) hazards. 23 Support should be provided for the delivery of critical life-saving emergency trauma and medical care, including for prevention and control of infectious diseases in clinical settings and necessary emergency preparedness activities, prioritizing assistance to severely wounded, trauma-affected individuals, survivors of sexual abuse and violence, women, children, and the elderly. The following activities will be prioritized to achieve this. Strengthen essential trauma and emergency medical services including prevention and control of infectious disease outbreaks in clinical settings, to prevent and respond to life threatening health risks of vulnerable, conflict affected communities. 6.1 i. Strengthen policy, regulatory frameworks, capacities, and management of the Emergency Medical Services (EMS) at national and regional levels and strengthen the capacity of the National Centre for Disaster Medicine. The EMS can be strengthened in Ukraine through securing a strong pipeline of ambulances, medical equipment for emergency care, emergency WHO kits and clinical training on advanced life support and critical patient management during transportation. ii. Deploy or strengthen existing EMTs and EMT coordination cells to provide emergency and trauma services, to improve the quality of care, optimize response times and provide predictable and timely responses to affected populations through ongoing technical support, training, and supplies. National-EMTs should also be established, and their capacity, capabilities and equipment strengthened. iii. Provide technical support and training to ensure standard infection prevention and control practice including via the implementation of respective clinical bundles in health facilities. iv. Support the capacity and leadership of the Ukrainian MoH regarding EMTs as well as to coordinate medevac including repatriation, and to maintain the referral system and the medevac hubs in Ukraine and Poland via technical support, training, guidelines, and Standard Operating Procedures. © WHO 24 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 v. Provide technical support and training to post traumatic rehabilitation services across the continuum of the health emergency response for people injured or affected by the war. vi. Conduct capacity building and training for the national EMT to provide first line support and interventions (i.e., emergency contraception, sexually transmitted infection prevention, and HIV post-exposure prophylaxis) for survivors of conflict-related sexual violence. vii. Support protection and rehabilitation services for survivors of sexual abuse and violence. viii. Provide training, technical support and supplies for the preparedness and response readiness of health systems to technological hazards, such as chemical and radio-nuclear hazards, and establish, support, and strengthen CBRN emergency response teams under the EMS. ix. Strengthen national and WHO supply chain management including the supply and procurement processes, reception of supplies and warehouse management, kitting, picking and dispatch of goods to final beneficiaries, providing a donation certificate and coordination of transportation. x. Procure and deliver an end-to-end supply of medical commodities, including medication, medical equipment and kits, and blood bank commodities, particularly to primary and secondary health-care centres. xi. Measure and monitor access to essential medicines including cost, utilization of delivered medicines and stock management and rational use. xii. Train providers in primary and secondary health- care centres in managing medical commodities and maintaining equipment. xiii. Develop an over-the-counter kit, which will include low-risk, highly demanded items, for delivery to areas where the health system has entirely or almost entirely collapsed, and health facilities are non-functional. The kit will be designed to be delivered at the household level and other pre-identified distribution points. xiv. Collaborate with the Health Cluster to design and implement a system for partners to request urgent emergency medical supplies from other partners in the network (using the Health Requests, Planning and Response tool). © WHO 25 Access to health-care services through national systems should be strengthened, ensuring inclusive access to quality primary and emergency health services (preventative and curative), mental health services, access to quality care for sexual and reproductive health (including maternal and newborn care) and GBV, child and adolescent health care, PRSEAH, continuity of care and referrals for NCDs and chronic communicable diseases (particularly HIV and TB) and prevention and control of communicable diseases. Risk communication and community engagement (RCCE) should be integrated to strengthen understanding, uptake and utilization of prevention and treatment programmes. The following activities will be prioritized to achieve this. Enable access to PHC services and continuity of care for people suffering from infectious and chronic NCDs in conflict- affected areas at risk of or impacted by service disruptions. 6.2 i. Provide access to essential health services, including quality PHC, through both equipping and deploying mobile/outreach teams, supporting fixed health facilities, contracting partners to deliver services in hard-to-reach areas, utilizing mobile and telehealth, and via the engagement of local volunteer networks to deliver services and supplies. ii. Improve NCD health services through enhancing clinical guidelines, building the capacity of the PHC workforce, and by policy development within health financing and health systems. iii. Provide life-saving sexual and reproductive health care, including antenatal care, with a focus on the Minimum Initial Service Package for Sexual and Reproductive Health in crises (32). This should include ensuring the availability of skilled birth attendants and emergency obstetric and newborn care; health care for the survivors of sexual and domestic violence; sexually transmitted infections and HIV management; clinical management of rape; and family planning services, to the full extent of the law. iv. Provide training for PHC health-care workers and managers on the clinical management of rape and intimate partner violence survivors to ensure the availability of quality and efficient health-care service provision through the correct organization of the processes within health-care facilities. v. In line with the National Mental Health and Psychosocial Support Programme and Operational Roadmap, Ukrainian Prioritized Multisectoral Mental Health and Psychosocial Support Actions During and After the War (33), provide © WHO 26 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 psychological first aid through community-based interventions, mobile mental health teams and support clinical mental health-care services including through the implementation of the WHO Mental Health Gap Action Programme (34) to ensure mental health and psychosocial support services (MPHSS) meet the needs of conflict-affected and/or at-risk populations including the frontline health workforce. vi. Provide health information, communicate risks and protective measures based on people’s perceptions and concerns, and engage health partners and communities. This will enable health protective behaviours that reduce exposure to health risks, increase access to health services and treatment, maintain continuity of care and decrease the mental health impacts of the war. vii. Provide support to restoring health facility functionality to maintain access to essential health services focusing on the restoration, rehabilitation and strengthening of existing facilities particularly at the PHC and EMS infrastructure at community levels. viii. Support health sector preparedness and response to biological threats that could cause disease outbreaks, especially in areas retaken by the Government of Ukraine – such as waterborne, food-borne, and respiratory diseases – with a focus on seasonal and pandemic influenza, polio, cholera, diphtheria, measles, and hepatitis A and E. ix. Support COVID-19 outbreak preparedness, response, and recovery, by ensuring local authorities and other stakeholders are equipped with the skills and resources required to provide quality, non-discriminatory and equitable emergency care, public health-care and social services to the affected population, with a special focus on vulnerable groups. x. Provide training, technical support and supplies to conduct routine and outreach vaccination campaigns and outbreak response planning focusing on priority infectious diseases, such as measles, polio, diphtheria, and pertussis, among others, with a focus on catch-up immunization and addressing coverage gaps. This requires coordinated action by public health structures and PHC providers. xi. Respond to the ongoing vaccine-derived poliovirus type 2 outbreak, supporting coordination, the provision of supplies and equipment, human resources, and technical support, where needed. xii. Provide technical support and training to strengthen laboratory capacity and surveillance systems at regional centres for disease control and hospital laboratories to detect and monitor outbreaks and other life-threatening conditions. xiii. Provide training, technical support and supplies for continued screening, laboratory testing, treatment and clinical management for HIV and TB, including multi-drug resistant TB to prevent excess disease spread and mortality. xiv. Procure and provide medical supplies, vaccines, rapid tests, reagents, and equipment to outbreak response teams, health facilities and laboratories, as needed. xv. Communicate risks and protective measures based on people’s perceptions and concerns and engage health partners and communities to enable affected people to take informed decisions that will reduce exposure to infectious pathogens, prevent disease outbreaks and improve access to health services, as needed. xvi. Strengthen linkages with PHC services to enhance the integration of core public health services for a timelier response to health threats (e.g., immunization coverage, timely notification of infectious diseases cases, contact-tracing, and health promotion through community engagement). 27 The government of Ukraine should be supported through nationally led and country-focused interagency health coordination, including health working groups, as well as through developing health sector response and contingency plans. Policy guidance and technical support should be provided to continually assess and address the emerging health needs of vulnerable populations. Governments and health authorities should be supported to review health financing modalities to allow access to health services and remove barriers to service utilization, while monitoring access and health-seeking behaviour. Health information systems should be strengthened to be able to produce regular, timely and accurate data Lead effective coordination of humanitarian interventions, assessments, and information management in public health to deliver value-added partnerships and reinforce evidence-based decision-making in the sector. 6.3 on health status, threats, health resources, service availability and health system performance. The following activities will be prioritized to achieve this. i. Strengthen and support the MoH’s strategic and coordination functions – as well as central, regional, and local government coordination – and data collection to ensure effective implementation of response mechanisms and key functions of the MoH across the health sector to meet the most urgent needs of the population. ii. Continue Health Cluster and health sector coordination systems with key capacities activated at the national and regional levels including for MHPSS and PRSEAH, with regular © WHO 28 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 updates provided to government and health partners on needs, constraints, and priorities. iii. Enhance intersectoral coordination with actors driving investment in other sectors that impact public health such as heating, housing, water and sanitation and preparedness for CBRN exposures. iv. Continue to support the technical working groups and include participation of all health partners, such as those involved in HIV/TB; MHPSS; trauma and rehabilitation; sexual and reproductive health; maternal, newborn and child health; communicable disease and NCD; and RCCE. v. Conduct regular public health situation analyses to identify priority risks and to guide WHO and health sector preparedness and response. vi. Report regularly on attacks on health care – including hospitals and health facilities, as well as ambulances, medical staff, patients, and warehouses – through WHO’s Surveillance System for Attacks on Health Care (10). vii. Support health partners with medical supply donation and global health pipeline monitoring to avoid gaps and overlaps. viii. Promote contributions to joint interagency actions in the areas of increased capacities for community reporting systems and PRSEAH capacity building for implementing partners. ix. Conduct Training of Trainers course on the clinical management of rape and intimate partner violence for Health Cluster partners involved in GBV service provision, in line with WHO guidelines and national legislation. x. Support national surveillance systems to detect and monitor outbreaks, through timely notification of public health events of concern, including through event-based surveillance, syndromic surveillance, or epidemic intelligence from open sources (35), as applicable, and as per established International Health Regulations (IHR) (2005) procedures (36). xi. Assess public health surveillance capacity, identify gaps, and support critical needs in surveillance and laboratory capacity, as needed. xii. Map health services through the Health Resource Availability Monitoring System (37) to provide a clearer picture of the functionality of health facilities including damage, energy infrastructure and availability of health services, health actors and decision-makers. xiii. Map health facilities by type of service packages, such as hospitals providing inpatient surgery, and rehabilitation services, based on data availability. xiv. Strengthen health information and intelligence by conducting health needs assessments and health impact assessments and monitoring drivers of morbidity/mortality, as well as conducting relevant analyses based on the best available data, including through the triangulation of different sources for better situation analysis, under the Health Cluster umbrella and in collaboration with all other relevant partners. xv. Establish a monitoring system for the utilization of different service packages based on data reported through eHealth and based on accessible information. xvi. Monitor the number of patients treated outside their area of registration, indirectly monitoring the burden on the health system, including through existing EU medical evacuation mechanisms – data from the Early Warning Alert and Response System (38) and the EU Civil Protection Mechanism’s Common Emergency and Information System (39) can be used in this regard. xvii. Support digital technologies within health information management systems, especially related to the movement of IDP and refugees. xviii. Prepare regular health sector situation reports covering health-related matters, the ongoing emergency response and potential health threats. xix. Provide visibility to health information in user- friendly modes through relevant communication platforms, including dashboards, as needed. 29 Galvanize emergency recovery and resilience of public health systems through support to priority clinical and health- care services and essential preparedness activities. 6.4 © WHO 30 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Strengthening PHC as the foundation for people- centred services is vital to enable Ukraine to reconnect people with services (including vaccination, screening for TB and other critical infectious diseases, and screening and treatment for chronic diseases) that have been interrupted due to the war and displacement of the population. Expanding the scope and extending the reach of PHC services, combined with skills and quality improvements, are also prerequisites for modernizing the hospital network to function more efficiently (14). iii. Support policy reforms in public health to enable response readiness and foster systemic resilience. iv. Strengthen core International Health Regulation (2005) (35) capacities in priority areas. v. Support the recovery of health governance system and its capacity. The following activities will be prioritized to achieve this. i. Facilitate health service reinforcement and resilience building. ii. Support national laboratory and surveillance systems to detect and monitor disease outbreaks and other life-threatening conditions. © WHO 31 services and fragile political situations in the region can threaten this generosity. A year into the response, protective measures to ensure access to health care need to be continued and reinforced on behalf of Ukrainian refugees, focusing on addressing all barriers – notably cultural, language, financial and administrative barriers. Refugee response pillars 7 Governments in all countries receiving and hosting refugees from Ukraine have generously kept their borders open and local communities have welcomed refugees and other persons of concern. However, over time, reduced volunteerism, and increased discrimination toward refugees in the context of a worsening economic crisis, unequal access to national National governments and health authorities are leading the response to the crisis, with United Nations agencies and partners supporting and complementing state authority initiatives and efforts. © WHO 32 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Guiding principles for WHO and partners acting in refugee-receiving and hosting countries include the following. • Reinforce a government-led response with local actors by supporting a locally led approach consisting of MoHs and other government authorities and local actors with capacity-building, tools, and technical assistance as needed, through the teams and offices of partners and other agencies in countries. • Align the response with the EU temporary protection mechanism and health-related response. Note that some EU mechanisms, such as the European Commission’s Directorate-General for Health and Food Safety (40) and the Directorate- General for Civil Protection and Humanitarian Operations (39), which support health and humanitarian needs, were already in place, and that some countries, such as the Republic of Moldova, which is not in the EU, will require specific assistance regarding health protection and access. WHO aims to support national authorities in the neighbouring countries of Ukraine through nationally- led and country-focused interagency coordination – notably national and international nongovernmental organizations and community-based organizations, as well as the ECDC, IOM, UNFPA, UNHCR and UNICEF, among others. The following activities will be prioritized. i. Enhance health leadership and coordination capacity within the MoH to improve multisectoral, interdepartmental and inter- ministerial action on refugee and migrant health at all levels, as well as close collaboration with external partners that provide technical and operational support in this area. Health leadership and governance mechanisms are streamlined and reinforced 7.1 • Align with UNHCR’s Regional Refugee Response Plan (3), which outlines the anticipated support from partners to national authorities in this refugee crisis. • Align with the WHO Global Action Plan Promoting the health of refugees and migrants (41). • Harness the comparative advantages of partners. The WHO-led Refugee Health Extension, the joint initiative by the ECDC, International Organization for Migration (IOM), UNFPA, UNHCR, UNICEF and WHO, aims to support strategies, guidance, and systems through interagency and intercountry coordination within and among participating agencies for the Ukrainian refugee health response. The following objectives are meant to serve as a guide to develop a more context-specific country level action plan with detailed activities and indicators adaptable to the changing situation, linked with clear budget lines and funding sources. The activities are in support of national health systems and implemented with partners. ii. Mainstream refugee health in all government policies including in national health strategies and develop or strengthen health sector policies and regulations that are inclusive of refugees and response and contingency plans in coordination with all relevant ministries. iii. Continue to support interagency coordination mechanisms, including health sector working groups – notably thematic working groups, such as MHPSS, sexual and reproductive health, GBV, PRSEAH, information management and RCCE, as appropriate. 33 WHO aims to support governments and health authorities in refugee-receiving countries to design policies to increase the access of refugees to health services and to medicines and medical products (42). The following activities will be prioritized. i. Remove administrative and communication barriers to accessing health services and simplify the registration process for people fleeing conflict. i. Allocate additional and/or reallocate public funds to address increased health needs. ii. Make external funding available through pooling with existing budgets. Financial barriers for accessing health care are reduced or removed Entitlements and access to needed health services Additional funding 7.2 7.2.1 7.2.2 ii. Advocate to extend entitlement to the full range of publicly financed health services to refugees. iii. Advocate for and support policies to reduce or eliminate financial barriers (direct and indirect costs) to accessing health services and to medicines and medical products. iv. Provide financial support to meet immediate financial needs for medicines, supplies and equipment that are not covered by national health insurance where applicable. v. Provide supplementary communication and language support to make refugees aware of entitlements and help them to navigate the health system. This includes advocating for and providing language support when accessing both PHC and specialized health services. vi. Address health insurance costs and high out- of-pocket payments including by identifying alternative sustained health-care financing options for refugee, migrant and vulnerable host populations who do not have, or have lost, health insurance or are unable to meet out-of-pocket costs for health services in host countries. vii. Advocate for and address support to allow health-care staff to understand the full benefits available to refugees at all levels of provision of care. Advocate for further support allocation to general practitioners in particular to areas where systems are overwhelmed with need/requests. © WHO/Petru Cojocaru 34 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 WHO aims to support refugees to have access to adapted and appropriate health-care services through national systems, ensuring inclusive access to quality health services (both preventative and curative); diagnostics; and continuity of care and referrals for chronic NCDs and chronic communicable diseases (particularly HIV and TB), MHPSS, maternal health i. Integrate the purchasing of health services for refugees into existing contracting and payment systems. ii. Provide additional incentives for the timely and effective delivery of services for refugees, including flexibility in existing allocations, new funding allocations to providers and rapid Access to adapted and appropriate primary and emergency health-care services for refugees regardless of legal status Purchasing arrangements 7.3 7.2.3 reconfiguration of service modalities, reflecting the potential added cost of service delivery and increased patient numbers, as well as contracting services out to nongovernmental organizations. iii. Monitor and report on spending and quickly establish mechanisms to do so for people fleeing conflict to help measure the impact on the health budget and its allocation, and to assess additional domestic and external funding needs. and child health, immunizations, and sexual and reproductive health, including the clinical management of rape and referral pathways for GBV. Additional focus will include health information and covering emerging gaps in access. The following activities will be prioritized. © WHO 35 i. Provide technical support, training and supplies as needed to ensure referral and medical evacuation pathways exist and are resourced. ii. Strengthen trauma care and rehabilitation via capacity-building, including through deployed EMTs and relevant EMT coordination cells. iii. Strengthen emergency medical, surgical, and obstetric care. i. Provide policy guidance and technical support to continually assess and address the emerging health needs of Ukrainian refugee populations, to understand priority health service needs and tailor health-care services. ii. Provide information and health education to refugees and train health-care workers to provide adapted and appropriate health services to address barriers including institutional and administrative, language and cultural, and transportation and financial. iii. Facilitate systematic access to health care, emergency treatment, referral and continuity of essential health services through existing systems, EMTs and international and local nongovernmental organizations to protect and improve the health and well-being of women, children and adolescents living in refugee, asylum, migrant and displaced settings. Priority should be given to the provision of essential health services such as the continuity of care for communicable diseases – particularly TB, HIV/ AIDS – NCDs, including diabetes, cancer care and renal dialysis, sexual and reproductive health, establishing specialized care for survivors of violence including victims of sexual violence and GBV, and PRSEAH. Access to emergency health and trauma care Essential health service access and delivery 7.3.1 7.3.2 iv. Provide support for mental health and psychosocial services, including psychological first aid, referral pathways, capacity-building for health workers and volunteers, by integrating Ukrainian health workers into the local health- care workforce, and clinical management of mental health conditions, including ensuring compatibility with Ukrainian prescriptions. v. Provide priority preventive care, including vaccination and early detection and response (e.g., measles, polio, and COVID-19) through health messaging and RCCE. This messaging should also include an active policy on improving vaccination demand and uptake among refugee populations, the provision of vaccinations, and, where indicated, the purchase of vaccines and operational support for vaccination. vi. Provide information to refugees on health-care services and entitlements in their host country and engage communities to build trust between government, the host community, and Ukrainian refugees, connecting Ukrainian refugees to health-care services through strategic positioning and addressing the health needs of both residents and Ukrainian refugees. Additionally, behavioural change interventions should be initiated through promoting vaccination and other preventive measures, targeting both Ukrainian refugees and host communities. Target the prevention of GBV, including PSEAH. vii. Provide support for CBRN event readiness, including laboratory support, based on risk assessment. 36 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 In refugee-recipient countries, strong existing information systems need to be supported to consistently understand health needs and gaps, through aiding the government and partner agencies to engage in the following activities. i. Conduct needs assessments, and health situational and risk analyses, to understand the needs of refugees, their health status, and potential risks, as well as refugee population movements. ii. Conduct health system assessments to assess essential public health functions, capacities and processes and the readiness of health facilities to provide essential health services for refugees as well as host communities. iii. Include refugees into health information systems including disaggregation by status along with confidentiality and protection of refugee data. Develop a short list of core health indicators (maximum 10–15) for the routine monitoring of refugee and migrant health. iv. Monitor and evaluate access to and utilization of health services and gaps and barriers, especially among vulnerable populations, including refugee health-care entitlements under and beyond EU temporary protection, to ensure meaningful access to health care. v. Support national health systems to set up early warning mechanisms to strengthen surveillance systems that detect and respond to potential threats including activities such as: conducting an evaluation of national early warning alert and response systems; provide training in the core concepts of early warning alert and response in emergencies based on new global guidance; and scaling up event-based surveillance by incorporating the global Epidemic Intelligence from the Open Sources initiative (35). Health information and surveillance are reinforced for evidence-based decision- making in public health 7.4 vi. Conduct RCCE situational analyses and implement on-going social listening and feedback mechanisms through building inclusive networks; engaging individuals with potential vulnerabilities to take an active part in protecting their health; and assisting programmes that serve at-risk individuals to develop continuity of operation plans. vii. Conduct targeted research activities for innovation and evidence-based decision-making in public health. © WHO/Aleksander Binek 37 Sustainable access to quality and affordable essential medicines and health products is critical for both refugees and host populations. WHO will support national health systems as well as relevant partners in acquiring the medicines and supplies needed to provide health-care continuity for refugees and host communities through the following activities. i. Support the government through advocacy, technical support or supplies to provide equitable access to medicines, medical supplies, vaccines and equipment of assured quality, safety, efficacy, and cost effectiveness as well as their scientifically sound and cost-effective use including through training on how to use and maintain newly procured equipment and the removal of financial and administrative barriers. ii. Provide information and support to refugees and training to health workers to deliver health education and heath literacy for the effective and appropriate use of medicines. Equitable access to essential medical products, vaccines, and technologies to vulnerable refugee populations 7.5 iii. Support the government to procure essential medicines and other health products as needed, such as diagnostics, vaccines and medical materials and equipment – including personal protective equipment, rapid diagnostic testing kits, vaccines and HIV and TB treatments – to cover emerging needs as identified by governments and partners supporting the health response. iv. Support the government to source either the equivalent, or to develop or update policies for the use of medications formerly not used or those which may be unavailable in EU countries (e.g., TB and HIV medications). v. Support the government to conduct national quantification and forecasting of essential medications and health products to ensure sufficient quantities. vi. Conduct capacity-building and training in procurement and medical supply management. vii. Conduct quality assurance for local procurement of medical products. © WHO 38 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Support the national health workforce to provide targeted health services for refugees through the following activities. i. Provide technical support for national planning to continue services in anticipation of the phasing out volunteer-led responses in case of a protracted emergency. ii. Provide training, guidance and tools for health workers working with refugees including through WHO’s Global Competency Standards for refugee and migrant health to provide people-centred and culturally sensitive health care (43). iii. Provide support for the translation and adaption of global and regional guidance and tools into the local language. iv. Provide additional roles to the health workforce such as interpreters and cultural mediators, adapted for the needs of the refugee receiving country. v. Assess Ukrainian training curricula for medical professions and, where feasible, develop short- duration up-skilling programmes to meet the minimum training standards required for certain professions in host countries. vi. Provide technical support and training to Ukrainian health workers to continue to work in refugee-hosting countries including mechanisms to initiate credentialling, understanding the local health system, language learning and provision of specialized staff for cultural and mediation support. vii. Identify good practices where non-EU health professionals can participate in fast-track programmes to facilitate their accreditation to work in their professions in EU refugee-hosting countries. Health workforce is supported and strengthened to provide health-care services to refugees 7.6 © WHO/Petru Cojocaru viii. Develop technical capacities for effectively responding to CBRN emergencies including risk assessments and laboratory support. ix. Provide training and support to detect and respond to GBV, sexual exploitation, abuse, and harassment (SEAH) and sexual and reproductive health. x. Provide mental health and psychosocial support to health-care staff to avoid stress and burnout. 39 Cross-cutting areas for Ukraine and the refugee response 8 The large-scale movement of Ukrainians within Ukraine and to neighbouring countries requires tailored RCCE interventions to address health needs, encourage access to health services, break down barriers to access health care and ensure that people affected by the war adopt healthy behaviours, based on their own perceptions and concerns. This includes the development, implementation, and evaluation of country RCCE strategic plans in coordination with United Nation agencies, civil society organizations, community actors and other health partners to: i. Build trust and support social cohesion between relevant government, host community, and Ukrainian IDPs and/or refugees. ii. Provide health information connecting Ukrainian IDP and/or refugees to health services. iii. Provide information on mental health and psychosocial support and connect Ukrainian IDP and/or refugees to mental health services. iv. Promote acceptance and uptake of protective health measures, including vaccination. RCCE8.1 v. Increase health literacy to protect health and prevent disease outbreaks. vi. Strengthen the infodemic management system in Ukraine and neighbouring countries to promptly detect and address rumours and misinformation. vii. Engage communities in decision-making concerning their health and to co-design intervention. viii. Strengthen resilience of both refugee and resident communities. A system of online and offline social listening, capturing behavioural insights at the country level will ensure that RCCE and other response interventions are informed by evidence about people’s perceptions, concerns, needs and cultural norms and traditions, and that rumours and misinformation are promptly detected and addressed at a broad level. Partnership and collaboration with civil society organizations, influencers and community actors will enable a system of feedback from communities to be established and to support the overall response by co-designing and testing interventions and monitoring emerging health 40 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 issues and perceptions. RCCE interventions will need to consider that: i. providing health information to IDPs and/or refugees is a public health intervention; ii. human interactions are necessary to maximize trust and achieve behavioural change outcomes; iii. outreach to the most vulnerable population groups, including people living in the newly retaken areas, is critical to ensure no one is left behind; and iv. communications need to recognize and balance the needs of both resident and IDP/refugee populations to maintain social cohesion. Mass population displacement has resulted in vulnerabilities and increased risk for GBV, including all forms of sexual misconduct, for refugees. While many refugee-hosting countries have strong health and legal systems and have established measures to accommodate and ensure equal access to services and protection to Ukrainian refugees, these countries are experiencing this unique crisis for the first time. During the first phase of the response in 2022 WHO worked to identify needs, challenges, and resources with regards to PRSEAH and will continue to integrate these into the response in 2023. In Poland, where a large number of refugees are being hosted, a mission report (44) revealed that over the course of the crisis, those arriving are increasingly vulnerable, with little to no means of personal protection. Overall, gaps have been identified in the health systems of refugee hosting countries, presenting risks to the health and well-being of survivors of GBV and SEAH, presenting opportunities for WHO to support in system strengthening, advocacy and awareness raising in respective countries. As WHO is moving into a phase where implementing partners are being onboarded, and interagency coordination is deepening, the capacities of all partners engaged in the response has been strengthened in regard to PRSEAH. Leveraging PRSEAH 8.2 WHO’s added value as the lead health agency is paramount. Assuring that dedicated, sustainable capacity is available at the national level, to lead and provide technical support for ongoing capacity-building in this area is also essential. A lesson learned over the previous year is the need to deepen links between PRSEAH and RCCE to assure that affected communities are engaged with and have an adequate understanding and awareness of the vulnerabilities affiliated with SEAH. These efforts necessitate continued strong agency leadership on PRSEAH and close collaboration with interagency mechanisms to ensure that global standards are met, and that partners and volunteers supporting the response operations abide by international standards and are held accountable. To achieve this goal, WHO is contributing to government- led efforts through the interagency mechanisms to © WHO 41 ensure PRSEAH is mainstreamed into the emergency operations in Ukraine and in refugee-hosting and receiving countries by: i. integrating and mainstreaming SEAH risk mitigation and prevention measures into both the programme and operation response including by providing technical support to increase capacity for reporting, referral and timely investigations, by enhancing appropriate linkages and through capacity building activities at operational sites; ii. strengthening national capacities for PRSEAH and access to victim support services; Priority activities will include: i. two-way communication and transparency ii. feedback mechanisms and response iii. meaningful participation and inclusion iv. learning and adaptation. Accountability to affected populations may be achieved by supporting local and community-based actors, including IDP/refugee- and women-led organizations. Accountability to affected populations 8.3 An AGD approach requires inclusive policies and activities that respect age, gender, and other individual attributes, which include, but are far from limited to, disability. To ensure an AGD approach partners will seek to make sure that all people of concern fully participate in decisions that affect them and that they experience their rights on equal footing with others. The AGD approach can be achieved by using participatory methodologies to incorporate the capacities and priorities of people of diverse Age, gender, diversity, and disability (AGD)8.4 backgrounds into protection, assistance, and solution programmes. Ensuring the AGD approach encompasses the collection and analysis of data disaggregated by AGD and disability along with other attributes where contextually appropriate and possible, in order to inform programme design, monitoring and reporting and to ensure disparities are met. As a whole, the humanitarian community will work rapidly together to ensure a greater commitment iii. assuring that adequate prevention and safeguarding measures are in place among personnel, partners, and vendors; iv. leveraging WHO’s added value on health; v. v. contributing to interagency coordination forums on PRSEAH; and, vi. assuring that sustainable, dedicated capacity is available at the country level on PRSEAH to support long-term capacity building. This will also include coordinating relevant initiatives and ensuring collective approaches, such as joint and standardized products, tools, and standard operating procedures to support risk communication, information needs assessments and safe and trusted complaint and feedback mechanisms, which can also be used to adjust the response, as needed. Participatory methodologies using an age, gender, and diversity (AGD) lens will be implemented throughout the response to engage with affected populations, as well as through collaboration with local volunteers, outreach workers and refugees. 42 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 to the Inter-Agency Standing Committee Policy and Accountability Framework for Gender Equality and Empowerment of Women and Girls (45) so that the voices and needs of women and girls are met and prioritized within all response plans. To achieve this, partners, in cooperation with local authorities and host communities, will advocate and implement targeted, gender-sensitive coordination, programming and financing within responses, particularly for those groups facing complex challenges, threats and barriers, and who often experience discrimination, abuse and violence, including women, young people, persons with disabilities as well as LGBTIQ+ persons. © WHO Partners will ensure that the principles of gender equality – which affirms that women, men, girls, and boys should enjoy rights, responsibilities and opportunities on equal terms – are fully respected and that the AGD approach is mainstreamed across all technical sectors, with any barriers that different AGD-related groups face in accessing services and opportunities to thrive addressed. 43 Overall, WHO will take a health systems approach, focused on resilience, with the ability to be flexible and adapt to prepare, respond and recover according to the rapidly changing context. In Ukraine, WHO will continue with the existing response priorities committed to the MoH and included in this SRP for 2023 by using an area-based and decentralized approach as appropriate for the context in each location. In addition, WHO will provide contingency planning and services for other risks such as the intensification of fighting, weather related and CBRN events, and outbreaks of epidemic-prone diseases. Across the priority refugee-receiving countries, WHO has significantly scaled up its country offices to support governments in providing access to health services via a health system approach. This includes the coordination of health actors and policy dialogue; supporting financing mechanisms to ensure access to the EU TPD; the gathering of health information and establishing early warning surveillance systems; purchasing arrangements and supplies, including vaccines; Operational strategy 9 The Level 3 Response is used to support the delivery of a rapid, concerted mobilization of capacity and systems to enable accelerated scaled-up assistance and protection over a short and focused duration. In- country, regional, and global coordination mechanisms are continuing to be strengthened to support a protracted response to, and eventual recovery from, the conflict. WHO is committed to being in Ukraine and in the priority refugee-receiving countries both now and in the longer term, addressing immediate health challenges and humanitarian needs and supporting recovery and strengthening of health systems in line with the United Nations Office for the Coordination of Humanitarian Affairs led Humanitarian Response Plan for 2023 (2) and the UNHCR’S 2023 Regional Refugee Response Plan (3). Based on an analysis of the five Inter-Agency Standing Committee activation criteria – scale, complexity, capacity, urgency, and reputational risk – the committee’s Principals activated a Humanitarian System-Wide Emergency Activation (Level 3 Response), to the conflict in Ukraine on 5 March 2022, which was lifted as of 5 March 2023. 44 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 human resources for health focusing on training and integrating Ukrainian health workers into the host- country health system; as well as priority health service delivery interventions. Looking forward, WHO will continue these activities, targeting the most vulnerable populations in refugee and host communities including through addressing discrimination; enhancing understanding of the situation through surveys on access and utilization of care; addressing known access barriers; strengthening the overall capacity of the health system to provide support to refugees and migrants under the WHO Global Action Plan for promoting the health of refugees and migrants (46); conducting contingency planning and preparedness for an increased influx of refugees, weather related considerations, outbreaks of epidemic- prone diseases and additional heath threats such as a CBRN emergencies. Operational locations9.1 The health response will target the entire country of Ukraine and countries where there is an influx of or significant numbers of refugees residing in these countries. Under the humanitarian core principles, this SRP aims to meet the essential health-care needs of all affected populations regardless of where they may be and to ensure that the required services are accessed in safe environments consistent with the principles of protection. Irrespective of the modality of operations being implemented, this may require both cross-border and crossline operations. WHO will continue to focus on the following geographical areas concerning emergency response: i. Ukraine, including: • continued advocacy to access areas under the temporary control of the Russian Federation and attempts to provide services along with other United Nation agencies; • areas recently retaken by the Government of Ukraine; WHO is working through global and regional partnerships and mechanisms, including GOARN, the EMT Initiative, the Health Cluster and Standby Partners, among others, in support of government-led responses in relevant countries. As the crisis continues and evolves, the health response will need to be flexible according to security and access. Below is a framework for health sector operations in response to the conflict in Ukraine and refugee-receiving and hosting countries based on the current context. • emergency response measures in areas under constant attack or bombardment; • imminent risk areas along the line of active conflict for continued health-care and readiness; and, • the rest of the country including IDP to continue critical services, readiness, and recovery. ii. refugee-receiving and hosting countries primarily in the European Region iii. other countries in the Region impacted by the crisis in Ukraine iv. global context and linkages with other WHO regions. 45 Key principles and assumptions for all operations 9.2 The following common principles must be adhered to in the implementation of operations across all locations. i. Maintain the safety of personnel throughout the response, including through the availability of security measures, such as armoured vehicles, personal protective equipment, and appropriate security staffing. ii. Support operations with an innovative and agile operational support platform base on a no- regrets principle, particularly in the deployment of expertise, staffing, supplies and resources. iii. Build and maintain situational awareness through monitoring and assessing, including through a security lens, to review the situation on an ongoing basis and determine the appropriateness of the response across the country. iv. Implement through partners or directly when appropriate/needed and never duplicate governmental systems, but rather reinforce and support them. v. Localize the response to build and support local capacity, mobilize local partners, local professional networks, and local contractors first and foremost, and engage international partners when necessary. vi. Implement operations through partner field offices and hubs in collaboration with national, oblast and municipal health authorities, with health facilities and other health partners, such as professional networks, local partners, and Health Cluster partners. vii. Coordinate with national authorities and other organizations to ensure complementarity of activities and full implementation of flash appeals and the Humanitarian Response Plan strategic objectives. viii. Mainstream PRSEAH at all levels in the response, programmes, Incident Management Team, and business operations (BOS). Mainstreaming will be tailored and in alignment with Inter-Agency Standing Committee PSEAH global strategy from 2022–2023 (47), the PRSEAH tenets of the WHO Emergency Response Framework (48) and the recently launched WHO Preventing and Addressing Sexual Misconduct policy (49). In addition, contribute to risk mapping and mitigation activities, strengthen awareness of, and access to reporting mechanisms, as well as referral and access to victim/survivor support services. This includes active participation in interagency mechanisms, specifically PRSEAH networks/taskforce in-country and at regional level, as well as adjacent Inter-Agency mechanisms such as GBV, protection, health, and Gender in Humanitarian Action. ix. Continue to work within the established interagency coordination mechanisms, such as the Health Cluster. x. Continue ongoing negotiations for the safe passage and evacuation of civilians and the wounded, and for the provision of humanitarian aid. xi. Implement actions to manage risks for the prevention of aid diversion. In regions hosting IDPs and in refugee-hosting countries, health facilities must be supported to absorb the health needs of displaced populations without compromising the health care of the host populations. Service delivery platforms need to be scalable based on where people are displaced to and sheltered, and the rising burden on local health systems as well as the need to address barriers to health-care access. If there is another wave of refugees, health partners will play an important role in expanding outreach, triage and referral services in reception sites and transit/ transportation hubs, such as bus terminals and train stations. 46 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Programming within Ukraine9.3 Response activities are based on the Ukraine response pillars outlined above in Section 6 of this SRP and aligned to the specific needs of the population as well as to the operational context. Overall, WHO will support the provision of health services that are resilient with the ability to adapt, prepare, respond, and recover according to the rapidly changing context. To operationalize the response, WHO has decentralized its approach through the activation of six hubs to operate close to areas with the greatest needs (Dnipro, Kyiv, Lviv, Odesa, Poltava and Vinnytsia). From these hubs, WHO in support of government efforts and with partners conducting assessments, is gathering critical health information for national decision-making; coordinating partners; conducting training; deploying mobile clinics; providing hands-on technical support to the government on areas such as mental health and psychosocial support, PHC, immunizations, trauma, rehabilitation, TB and HIV, NCDs, sexual and reproductive health, PRSEAH and GBV; providing risk communication messages; and delivering lifesaving supplies, among others. The operational strategy will be flexible and aligned with operational priorities with the other United Nation agencies in Ukraine and provide health services in areas such as those recently retaken by the Government of Ukraine, locations with large amounts of IDPs, and other relevant areas to ensure health systems readiness. WHO will continue to advocate at all levels for access to areas under temporary control of the Russian Federation and to support the MoH to coordinate medical transfers to other countries for In refugee-hosting countries, vulnerabilities, and health risks particular to the refugee population must be addressed to protect both refugees and country nationals – such as differences in vaccination coverage, and higher burden of disease for certain conditions. patients with severe conditions who are unable to receive treatment in Ukraine. While continuing with the emergency response, the government of Ukraine is preparing for recovery and reconstruction for all sectors of the economy, including health. WHO and partners will support this process and facilitate multisectoral recovery planning for national authorities and the international community, ensuring that the health and well-being of Ukrainians is placed at the centre of all post-war recovery strategies. © WHO/Christopher Black Additionally, efforts must be made to ensure critical services that are normally available in Ukraine are provided to the refugee population. 47 © WHO/Christopher Black The following priority actions should be undertaken to support refugees at border crossings and reception centres as needed. i. Provide information on health-care services and health-care entitlements of the country they are in. ii. Provide key health messages through RCCE. iii. Provide psychological first aid. iv. Ensure first aid and referral mechanisms are available for chronic and life-threatening conditions. v. Map risks and implement risk mitigation measures, including through providing information on SEAH and channels for reporting and receiving services. Border crossings and reception centers through the refugee journey Refugees residing in current country of destination or transit 9.4.1 9.4.2 The aim here will be to support national health systems to address the increase, and to accommodate any future surges, in the refugee population, and their unique needs. The following priority actions should be undertaken to support refugees residing in current country of destination, or transit. i. Provide information on access to health services, and behavioural change interventions through RCCE. ii. Provide emergency medical and primary health care to refugees in all settings, including prevention services (such as vaccinations), through existing health services, mobile clinics, or outreach services and EMTs. iii. Reduce the transmission of infectious diseases through the scale up of early warning systems, access to diagnostic, prevention and treatment services, and the implementation of RCCE. In collective centres, strengthen infection control practices, as well as the safe provision of water, sanitation and hygiene services. iv. Monitor access to and the utilization of health services and barriers. v. Monitor needs of vulnerable populations and ensure meaningful access to health care. vi. Reduce transmission of communicable diseases at the site where appropriate, including through implementing early detection and referral mechanisms, early warning surveillance systems and prevention measures, such as safe water, sanitation and hygiene services as well as infection prevention and control practices. vii. Inform people about and implement measures to prevent GBV as well as ensure referral pathways for its management. 48 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 vi. Scale up mental health and psychosocial support. vii. Support the provision of essential medicines, vaccines, and medical supplies. viii. Map risks and implement risk mitigation measures that include the provision of information on SEAH and channels for reporting and receiving services. ix. Inform people about and implement measures to prevent GBV as well as ensure referral pathways for management. x. Work with partners to support the joint provision of services. © WHO Medical evacuations, referrals, and repatriation from Ukraine to EU countries and beyond Returnees 9.4.3 9.4.4 The following priority activities should be undertaken to support medical evacuations, referrals, and repatriation. i. Provide support to the MoH of Ukraine to coordinate medical evacuations, referrals, The main priority for voluntary return to Ukraine is to facilitate the continuity of care including information on access to care on return, the availability of health documents outlining services they received, expectations for the duration of rehabilitation as appropriate and the provision of multi-month medicine refills for priority chronic diseases as needed. and repatriation from the oblasts to the three medical hubs that have been set up by the MoH of Ukraine, and then onwards to appropriate sites in the country of destination, in coordination with European Commission’s Directorate-General for Health and Food Safety and the Directorate- General for Civil Protection and Humanitarian Operations. ii. Provide transport and logistics, especially through the mobilization of EMTs. iii. Provide technical and operational support, including the procurement of medical equipment, as needed, for medical hubs that have been established in receiving countries, particularly in Poland. iv. Facilitate continuity of care required through the evacuation/referral process. 49 In Ukraine10.1 Given that the situation in Ukraine is still unpredictable and that there are numerous actors interested in supporting the recovery process on different scales and levels, a phased approach to recovery assessment and planning for the health sector is recommended. A phased and prioritized approach should be followed as defined in WHO’s guidance document on health system recovery in Ukraine (21), based on a rapid assessment of damage, loss and needs, and complimented by a more comprehensive assessment and costing of a detailed health system rebuilding plan. © WHO Key tenets are as follows: to be person- centered and responsive; ensure equity and financial protection; contribute to system resilience; ensure efficiency, sustainability and accountability; building on the strengths of Ukraine’s existing system; linking humanitarian assistance and medium-term system strengthening as early as possible; and planning for a realistic sequencing of implementation. Early recovery and transition 10 50 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 In refugee-hosting countries10.2 To meet the basic needs of refugees and mitigate risks a broad inclusion lens is essential from the start to advocate for and facilitate access to health services for refugees and host communities alike, identify barriers and gaps, and coordinate support. Ongoing assessments will be required along with refugee community engagement to understand evolving needs, knowledge, access and barriers, as well as host health system capacities and resourcing. Qualifications and skills of health staff will be required on behalf of hosting countries to better integrate Ukrainian refugees into local health services at all levels. At the same time, governments and partners need to prepare for a worsening situation in Ukraine and consequent increases in population influx, onward movements of refugees to other countries, as well as the return of refugees to Ukraine: contingency planning actions must be undertaken as before to ensure continuity of care. Both in Ukraine and in refugee-hosting countries, PRSEAH mainstreaming and safe programming in all recovery programmes and actions will be ensured, and with efforts made to integrate PRSEAH actions in national systems. © WHO 51 The SRP will be monitored through tracking a set of high-level key performance indicators. At country office level detailed monitoring and evaluation plans will be developed, including operational indicators, targets and use of collected data to inform and fine- tune programme interventions. More detailed action and operational plans will need to be developed to Table 1. Ukraine response Results hierarchy Indicators Source of data Assumptions Pillar 1: Strengthen essential trauma and emergency medical services including prevention and control of infectious outbreaks in clinical settings, to prevent and respond to life threatening health risks of vulnerable, conflict affected communities. Estimated number of interventions for trauma and emergency surgery enabled with the WHO trauma and emergency surgery kit. Operations Supply and Logistics. Humanitarian corridors are available in conflict areas to allow delivery of medical supplies and equipment. EMT/ emergency medical service responders continue to be available for training and to provide services. Funding is available to implement response interventions. Percentage of Emergency Medical Service responders and clinicians trained and equipped to provide trauma and emergency medical care. Training records Number of people reached with rehabilitation services. Rehabilitation records Number of people trained to provide trauma and emergency medical services. Training records Number of health evacuations successfully completed with WHO support. Directorate-General for Civil Protection and Humanitarian Operations publications on MEDEVAC. Monitoring and evaluation 11 tailor and enhance work planning, resourcing, and monitoring to individual and unique country contexts at national level. Table 1 and Table 2 show the high-level indicators, within each of the above outlined objectives that WHO and health partners can choose among to monitor and guide their response. 52 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Pillar 2: Enable access to PHC services and continuity of care for people suffering from infectious and chronic noncommunicable diseases in conflict-affected areas, at-risk of or impacted by service disruptions. Estimated catchment population covered for basic care by supplied Interagency Emergency Health Kits, NCD kits, Cholera and Pneumonia kits. Operations Supply and Logistics. Humanitarian corridors are available in conflict areas to allow the delivery of medical supplies and equipment. No breakdown in supply and distribution chains for health products. Funding is available to implement response interventions. Number of people reached with MPHSS support. MHPSS records Number of PHC facilities supported with medical supplies and equipment. Operations Supply and Logistics. Number of people in PHC facilities trained to ensure continuity and quality of service provision. Training records Number of people reached with health information through RCCE activities (online and print). RCCE records Total volume (tonnes) of medical supplies and equipment distributed to ensure continuity of services. Operations Supply and Logistics. Pillar 3: Lead effective coordination of humanitarian interventions, assessments, and information management in public health to deliver value- added partnerships and reinforce evidence-based decision-making in the sector. Number of public health assessments conducted and published by WHO. Health Information Management Service records. Funding is available to implement assessments and local authorities are willing to participate. Partners continue to be committed to collaboration and follow routine reporting. Number of weekly situation reports produced and published. Percentage of oblasts covered by the Health Resource Availability Monitoring System. Number of beneficiaries reached by Health Cluster partners. Health Cluster records. Pillar 4: Galvanize emergency recovery and resilience of public health systems through support to priority clinical and health-care services and preparedness activities . Policy reforms made to enable response readiness and foster systemic resilience . Funding is available to implement response interventions. Table 1 cont. 53 Table 2. Refugee Response pillars Results hierarchy Indicators Source of data Assumptions Refugee Response Pillar 1: Health leadership and governance mechanisms are streamlined and reinforced. A functional health sector coordination mechanism exists in the host country. a National Health Cluster meeting minutes. Partners are committed to collaboration in the response. Refugee Response Pillar 2: Financial barriers for accessing health care are reduced or removed. Policy and programming actions that have contributed to reducing financial barriers for refugees (qualitative description). WHO records Host governments are willing to expand entitlements to meet the health needs of refugees. Refugee Response Pillar 3: Access to adapted and appropriate primary and emergency health- care services for refugees regardless of legal status. Policy guidance and technical support to assess and address the health needs of the Ukrainian refugee population. WHO records/reports MoH in target countries welcomes technical support from WHO. Funding is available to implement the Response Plan. Number of people supported in accessing health-care services. b WHO records/reports Number of MPHSS consultations. WHO records/reports Refugee Response Pillar 4: Emergency health information and surveillance are reinforced for evidence-based decision-making in public health. Number of studies (needs, assessments, health situational and risk analyses, and targeted research) on the health of Ukrainian refugees conducted or supported by WHO. WHO records/reports Funding is available to implement studies. Host governments support the implementation of research activities. Refugee populations are willing to participate in health assessments. © WHO 54 U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 Refugee Response Pillar 5: Equitable access to essential medical products, vaccines, and technologies to vulnerable refugee populations. Total volume of supplies and equipment (in cubic metres) with total value (US$) distributed to health facilities, disaggregated by: 1. supply category - medicines and consumables - Diagnostics/Laboratory supplies - Hospital equipment - personal protective equipment 2. Receiving facility - number of PHC facilities - number of secondary health-care facilities - number of public health institutes/laboratories Operations Supply and Logistics. No breakdown in supply chains for health products Host governments have policies in place for procurement and use of medicines within the country. Refugee Response Pillar 6: The health workforce is supported and strengthened to provide health-care services to refugees. Number of people trained to provide health services to refugees and host populations. Training records WHO continues to take the lead in ensuring PRSEAH, safety and dignity of the population in the health response. Number of Ukrainian health workers supported in the process of getting temporary licenses to work in host countries. WHO records including from call centers. Number of or percentage of WHO staff and consultants that complete mandatory PRSEAH training. WHO Human Resources. Notes: a Functional in this context means that monthly meetings are held; there are functioning relevant thematic working groups; policy guidance on health sector policies and regulations are provided along with contingency plans. b Includes people provided with emergency services, essential health-care services, information on health-care services and entitlements, and health education. Table 2 cont. 55 1. Ukraine Flash Appeal 2023, 21 February 2023. Geneva: World Health Organization, 2023 (https://www.who.int/publications/m/item/who-2023-emergency-appeal--ukraine--- refugee-receiving-countries). 2. Ukraine Humanitarian Response Plan 2023, 15 February 2023. Geneva: Office of the United Nations High Commissioner for Human Rights, 2023 (https://reliefweb.int/report/ ukraine/ukraine-humanitarian-response-plan-february-2023-enuk). 3. Ukraine Situation: Regional Refugee Response Plan January – December 2023. 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WHO Policy on Preventing and Addressing Sexual Misconduct. Geneva: World Health Organization; 2023 (https://www.who.int/publications/m/item/WHO-DGO-PRS-2023.4). U K R A I N E C R I S I S S T R AT E G I C R E S P O N S E P L A N F O R J A N U A R Y– D E C E M B E R 2 0 2 3 59 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. 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