Introduction
Poor mental health affects individuals and their social environment, with impacts on the entire fabric of society. According to the World Health Organization (WHO), poor mental health has detrimental effects on overall health and well-being—for example, increasing incidence of cardiovascular diseases and decreasing life expectancy. Mental health disorders constitute a major global challenge, with common conditions such as depression and anxiety rising worldwide. In 2017, the incidence of mental health issues had risen by 13 percent over the previous decade, and 20 percent of children and adolescents reported having a mental health condition. From a macroeconomic perspective, mental illness leads to job absenteeism and a loss of productivity and economic growth, with depression and anxiety costing the global economy $1 trillion a year. There is also widespread recognition that investing in comprehensive mental health treatment and the support system at the community and family levels far outweighs the socioeconomic costs of leaving individuals untreated.
Prior to Russia’s full-scale invasion of Ukraine in 2022, approximately 10 percent of the Ukrainian population was living with some degree of mental health conditions. This figure has likely gone up noticeably with the ongoing war and its aftermath. Mental health carries a significant stigma among Ukrainians, and the healthcare infrastructure remains frail. Ukraine inherited the Soviet healthcare structure, designed under the Semashko model and characterized as a centralized, impersonal, and inflexible system. Prior to the health reform efforts that started in 2017, most efforts to reform the system failed, leading many Ukrainians to seek out private medical care or pay bribes to receive the care they are constitutionally guaranteed.
After the 2014 Revolution of Dignity and the start of hostilities in the Donetsk and Luhansk regions, the Ukrainian government began reforming its healthcare system, applying the principle “the money follows the patient.” The establishment of the National Health Service of Ukraine in 2018 is arguably one of the most prominent achievements of these reforms. It shifted the medical supply within one agency’s purview and ensured greater operational autonomy to healthcare administrators through its healthcare facility contracting stipulations at the primary and secondary levels of service delivery. Additionally, the approval of the Programme of Medical Guarantees that same year codified every Ukrainian’s right to a baseline of healthcare. As a result, many inroads were made. However, the Covid-19 pandemic and Russia’s full-scale invasion of Ukraine on February 24, 2022, contributed to the stagnation of the nationwide health reform efforts. Health service delivery was severely affected given a major redistribution/depletion of the health workforce, physical destruction of healthcare facilities and pharmacies, and disruption of the supply chain.
In December 2022, Ukrainian first lady Olena Zelenska, with support from Prime Minister Denys Shmyhal and the WHO, made mental health a priority. Zelenska’s initiative—the National Program of Mental Health and Psychosocial Support (MHPSS)—aims at creating a Ukrainian MHPSS system that incorporates global and domestic best practices to provide affordable and high-quality services to those in need.
As Ukraine looks to survive, recover, and rebuild, the provision of quality mental healthcare and the promotion of psychological well-being are central to the country’s path to recovery. The promotion of MHPSS is crucial for building human capital and incentivizing Ukrainians abroad to return to their homeland. There are both immediate actions and long-term interventions that the Ukrainian government and its international partners can take to build a strong healthcare system in the country.
The promotion of MHPSS is crucial for building human capital and incentivizing Ukrainians abroad to return to their homeland.
Challenges to the Ukrainian Mental Health Infrastructure before the War
Ukraine’s mental healthcare system has remained largely unchanged since the country gained independence in 1991; it received only 2.5 percent of Ukraine’s health budget in 2020. Designed under the Soviet-era Semashko system, Ukrainian mental healthcare services before the war centered on inpatient psychiatric care, while outpatient care and psychosocial support received limited resources. Outpatient services comprised only 11 percent of total mental healthcare funding, while psychiatric institutions received the remaining 89 percent. A relic of Soviet times, Ukraine’s healthcare system operated on an input basis under which regional health administrators would determine each hospital’s needs and allocate funding from the national health budget accordingly. Although it appeared to allow for decentralized decisionmaking, this system continued to reflect norms set out by national health planners. Crucially, funding allocation decisions were based on the number of inputs used by the end of each fiscal year, incentivizing hospitals to lengthen patient stays and maximize costs. Ukraine’s mental healthcare resource allocation limitations have contributed to the country’s psychiatrists and psychologists being overworked and underpaid.
Ukrainian citizens have distrusted mental healthcare services since the Soviet Union weaponized the system by hospitalizing dissidents and people considered enemies of the state in psychiatric institutions. Moreover, in post-Soviet Ukraine, mental health professionals and paraprofessionals often lacked evidence-based treatment methods, with a majority of Ukrainian psychologists having trained in pedagogical institutions rather than having a dedicated medical education. Evidence-based methods are crucial to addressing mental health challenges as they are supported by empirical evidence and scientific research that demonstrate their effectiveness. Not utilizing these efforts, along with the other aforementioned structural issues, discouraged many Ukrainians from engaging with any form of mental health services. A 2021 study of Ukrainian adults showed that 75 percent of respondents “agreed that psychiatric hospitals seem more like prisons than places where the mentally ill can be cared for.” Given that much of Ukraine’s mental healthcare has long focused on hospitalization, this is a worrying indicator for the prospect of integrating conversations surrounding mental health into social discourse.
At the same time, a significant stigma is attached to mental health, which has been an enduring obstacle to seeking any kind of treatment or psychosocial support. While a majority of Ukrainians sympathize with people with mental health issues, 86 percent of respondents to the 2021 study also believed that people with such conditions should be handled like young children. Additionally, the high level of social distancing from those with mental health conditions in Ukraine further underscores the pervasiveness of the misunderstandings surrounding mental health ailments, their interconnection with physical health, and the social and environmental factors behind them.
Despite the passage of the Budget Code in 2001, intended to facilitate interbudget transfers, hospitals continued to be prohibited from reallocating funding to areas of care as needed, as attested to by the National Health Reform Strategy for Ukraine 2015–20. These systemic inefficiencies contributed to a culture of corruption within the healthcare sector, with many Ukrainians forced to make exorbitant payments for treatment at public health facilities despite being guaranteed “universal access to unlimited care” by the constitution. Between 2005 and 2012, for example, people who sought medical care had to shoulder as much as 95 percent of the cost of prescription medications and other medical inputs necessary for their treatment. At the same time, Ukraine’s Ministry of Health hemorrhaged 40 percent of its annual budgetary allocation for medications due to corruption. These factors forced many Ukrainians to seek care at private institutions, offer informal payments to healthcare workers and administrators in exchange for treatment, or forego seeking out care altogether, deepening mistrust in the system. Further obstacles to the provision of quality care in Ukraine’s mental health system have included budget cuts and staffing shortages. The Covid-19 pandemic also exacerbated the strain on the system and its ability to provide quality mental healthcare.
Human Impacts of the War
Since the start of the full-scale Russian invasion on February 24, 2022, Ukraine has sustained significant damage to its healthcare infrastructure. As of May 31, 2023, the WHO announced that it had verified over 1,000 attacks on Ukrainian healthcare personnel, equipment, and facilities. Moreover, at least 10 percent of the country’s hospitals have come under direct fire from Russian forces, with most of the damage sustained in Ukraine’s eastern and southern oblasts.
Estimates of the damage to Ukraine’s mental health sector have ranged widely. An August 2022 report pegged the cost of direct damage to the country’s healthcare facilities at $1.4 billion. This sum balloons to over $6 billion when accounting for indirect factors like “demolition and debris-removal costs, revenue loss for private providers, and the estimated value of the health consequences of foregoing needed care.” The range’s highest estimate came from a report sponsored by the WHO, the U.S. Agency for International Development (USAID), and other international stakeholders that stated Ukraine would need $15.1 billion to cover its mental healthcare facility rebuilding process while providing funding to expand the country’s MHPSS services.
The human toll of the war in Ukraine has been dismal: the number of people in need of humanitarian assistance has risen to 17.6 million in 2023 and close to 6 million Ukrainians are estimated to be internally displaced. Amid this backdrop, at least one in three Ukrainians have been affected by the conflict’s disruption to healthcare. Additionally, an estimated 9.6 million Ukrainians may now be living with mental health issues and 3.9 million may now have conditions that would require intensive therapy, medication, or even hospitalization. Among those affected are veterans, their families and parents, children, the elderly, and people with disabilities, all of whom require varying degrees of care and treatment.
The human toll of the war in Ukraine has been dismal: the number of people in need of humanitarian assistance has risen to 17.6 million in 2023 and close to 6 million Ukrainians are estimated to be internally displaced.
The United Nations Development Program (UNDP) June 2023 report on Ukraine’s human capital raises concerns about the country’s mental health prospects. It estimates that 30 percent of Ukrainians may be affected by mental health issues, with up to 15 million in need of psychosocial support and 3–4 million of those requiring direct pharmacological interventions by mental health professionals.
The toll faced by mental health professions adds further strain to the system as frontline mental health workers face numerous challenges in their continued efforts to provide support. Not only are there not enough mental health providers to face the overwhelming need for MHPSS as the conflict continues, but these professionals are also facing traumatic events themselves by virtue of being in the midst of the conflict.
Responding to Immediate Mental Health Challenges
In light of these issues, the Ukrainian government, working with international partners, has rallied to respond to its country’s immediate and long-term mental healthcare needs. But it is critical to keep in mind that the MHPSS landscape is rapidly and continuously changing. To address many immediate needs, community mental health teams are providing services amid the ongoing war. Additionally, the WHO is working with partners to scale up mental health and psychosocial services in war-affected regions. Ongoing work to strengthen the emergency response system and build up primary and community mental healthcare provision is paramount.
Building on its 2017 Concept of the National Mental Health Program and the 2021 National Mental Health Action Plan, the Ukrainian government endorsed the publication of an operational road map for MHPSS services, which outlines a framework under which the Ministry of Health, as well as other Ukrainian ministries and government agencies, would coordinate with each other, aid agencies, and nongovernmental organizations (NGOs) to provide care to various groups affected by the conflict.
To expand the provision of MHPSS to Ukrainians, the road map lays out avenues through which the Ukrainian government and international stakeholders can build on existing healthcare structures. Over 300 different organizations provide MHPSS in Ukraine according to the WHO, but not all are evidence based and some may be harmful. The introduction of capacity-building programs to primary healthcare providers and community leaders, for example, would enable the provision of scalable evidence-based MHPSS where knowledge was previously absent. Additionally, the expansion of WHO and Ministry of Health–supported Community Mental Health Teams (CMHTs) would give millions of Ukrainians living with moderate to severe mental health conditions access to support many would otherwise not have. Given the immediate need for the support these types of programs offer, their growth has been monumental. The early success of some of these programs has supported the Ministry of Health’s aims to eventually scale and expand them, though plans for how to integrate these stopgap measures into Ukraine’s long-term mental healthcare goals remain to be seen.
The operational road map enumerates several measures to tackle immediate MHPSS needs for at-risk groups, including children, veterans, the elderly, internally displaced people (IDPs), and people with disabilities. Numbering approximately 7.5 million, Ukrainian children are especially vulnerable to the long-term effects of war-induced trauma and disruption. Recognizing the importance of this demographic, the Ministry of Education and Science has partnered with UNICEF and the MHPSS technical working group to promote the inclusion of MHPSS awareness in Ukraine’s education system. While awareness of MHPSS is a step in the right direction, it is important to note that much of the road map positions MHPSS within the healthcare system. In a comprehensive system, service would be expanded beyond the formal healthcare sector into other sectors such as education and social services to shift toward a more integrated approach. Other efforts include the UN Population Fund in Ukraine (UNFPA) program No Trivia, which has helped roughly 3 million adolescents meet anonymously with mental health professionals over social media platforms including Instagram and Telegram. Plans to establish systemic MHPSS care for children, however, remain in their infancy as the full impact of the war on Ukraine’s young is yet to be seen. Ukraine has a wealth of school psychologists and other such professionals that have not historically focused on services but are now being engaged to do so.
The immediate needs of Ukraine’s growing veteran community have also been recognized as a critical area for MHPSS services by the Ukrainian government. Swelled by wartime conscription, Ukraine’s veteran population, which prewar estimates pegged at approximately 1 million, represents a significant segment of the general populace that suffers a disproportionately higher rate of mental health issues. Despite this phenomenon, many veterans avoid seeking out MHPSS services due to stigma, with those who seek out support seen as “weak.” Similarly, there is a persistent belief among veterans “that psychiatry is . . . a punitive system and a recommendation for psychiatric help is seen as a punishment.” Additionally, many veterans feel they cannot fully trust or relate to MHPSS providers who have not previously served in the military. In responding to their needs, the Ukrainian government and MHPSS have trained counselors to be sensitive to veterans’ concerns and aim to aid veteran-led community-building and support initiatives. Although these efforts remain small, the sheer number of veterans who will return from war may help expand existing support networks, for which the Ukrainian government will need to provide support and systematization.
Similar to veterans, Ukraine’s IDPs following the 2014 conflict in Donetsk and Luhansk exhibited a disproportionately high rate of mental health issues when compared to the general population, a pattern that is likely to continue with more Ukrainians being displaced by the 2022 invasion. Since 2014 onward, many IDPs have struggled to reintegrate. Among other factors, social isolation has correlated with a significant level of alcohol use disorder, post-traumatic stress disorder, and depression. Consequently, the operational road map has set goals to increase MHPSS engagement of IDPs and ease the integration process into host communities.
At the same time, approximately 2.7 million Ukrainians with disabilities are among the country’s most vulnerable groups, facing heightened risks of abandonment amid the fighting. Although Ukrainians living with disabilities have historically faced significant human rights violations, the Ukrainian government has moved to pivot away from the country’s troubled institutional facilities, with the minister of social policy stating that “deinstitutionalization reform is highly needed in Ukraine, therefore together we are going to do everything possible to minimize the number of children in institutional care.” Additionally, the Ukrainian government has adopted a “no barrier” approach to governance, intending to ensure equal rights for citizens living with disabilities. Included in the operational road map are goals to make MHPSS services accessible to Ukrainians with disabilities and ensure that long-term care facilities (internats) provide care that meets international standards. Although these are steps in the right direction for the protection and promotion of disability rights, the Ukrainian government has not yet outlined a national strategy to ensure these actions are part of a broader framework.
A Systems-Based Approach to Mental Health
Addressing these diverse groups and challenges will require a comprehensive approach to the MHPSS ecosystem with a variety of interventions that are evidence and science based and culturally appropriate. Beyond significant financial resources, this endeavor requires extensive destigmatization campaigns, further workforce development that attracts young and innovative minds, and implementation of workforce support structures. In addition, MHPSS reform must assure full integration of mental health services into primary care, improved community-based care and family support, and enhanced public education programs and behavior change campaigns that are evidence informed and focus on self-help and help-seeking behaviors.
Addressing these diverse groups and challenges will require a comprehensive approach to the MHPSS ecosystem with a variety of interventions that are evidence and science based and culturally appropriate.
In this regard, the main framework that can guide mental health and psychosocial support interventions in Ukraine is a systems-based approach that takes into account the larger context of the healthcare system and the ability of individuals to access and use its resources effectively at the right time and in the right place. This approach recognizes the biological, societal, and psychological factors that affect mental health. Through a systems-based approach, the different systems of care that patients require are incorporated into a practitioner’s analysis of medical, psychiatric, criminal justice, employment, housing, social, and family systems.
Although a systems-based approach to mental health is the ideal target, this approach requires significant investments that Ukraine does not have at the moment, including financing resources, planning, and human capacity. Further magnifying the challenge is the need to train mental health professionals. As of 2017, Ukraine had 11.6 psychiatrists per 100,000 people, a relatively high number compared to the rest of the WHO’s European Region and reflective of the country’s previous medication-centered approach. At the same time, however, there were only 0.56 psychotherapists per 100,000 people in Ukraine as of 2016, representing a long-standing lack of adequate investment in less invasive mental health methodologies, such as talk-based therapy and community support frameworks.
Although mental health is recognized as an important challenge, the level of investment needed to address the issue does not match the scale of the problem. Further interventions include the following:
- Embrace digital technologiesto expand access to digital mental health and psychosocial support services and referrals. The most effective digital solutions are the ones that engage patients and other beneficiaries, such as children, adolescents, and their family members, in their codesign.
- Adopt evidence-based approaches to community-based psychosocial support. Community-based approaches allow mental health providers to train community members and capitalize on their context knowledge to provide basic mental health services and referrals. Such training should include mental health screening and a referral pathway depending on level of risk. Based on the WHO mental health pyramid, MHPSS interventions at the community level may include family and community supports and focused, nonspecialized interventions. Adopting an evidence-based approach to community psychosocial support will also dramatically expand its efficacy and reach and contribute to the reduction of stigma and discrimination associated with mental health disorders.
- Coordinate efforts among the Ukrainian government and international stakeholders. There are currently many programs that target various populations and provide a variety of services. For sustainability and scalability, proper communication and coordination among different stakeholders will prove critical to ensuring systems-level thinking. These efforts should also be mindful of the need for adaptability because there are phases of collective trauma and reconstruction that Ukraine will encounter.
- Strengthen and increase funding for MHPSS programming. Increasing funding for training programs will enable the Ukrainian government to achieve its goal of scaling up both programs and increasing coverage of rural areas. It is also imperative to strengthen these programs through additional grants and training in-country personnel. Evidence-based community programs work with community providers to reduce stigma and resistance to mental health services as well as address all age groups. Additionally, most people with mental health issues have conditions that could be treated by providers with the requisite training and oversight
- Redistribute mental health budgetary allocations. Outpatient facilities should receive more funding to further reduce Ukraine’s reliance on institutionalization. This change would further align the country’s system with global mental healthcare standards and practices as well as help address the stigma and distrust that Ukrainians generally associate with mental health and psychiatric treatments. The Ukrainian healthcare system needs to incorporate more community approaches to develop sustainable change and create a more localized approach to mental health strategies.
- Focus on vulnerable populations, particularly children and adolescents. Further considerations regarding children include reforming the orphanage system to be family oriented and provide community-based training to school counselors to address the gaps in MHPSS for infants and children. In addressing systemic failures in its youth mental healthcare system, the Ukrainian government should promote and sustain evidence-based training, particularly for school counselors. School counselors are often the first line of defense in protecting youth mental health, but they have long operated without evidence-based treatments, which stymies their ability to provide quality care to one of the most vulnerable segments of the population.
- Develop interventions that address the issue of provider distress. Workforce capacity is a critical component of a systems approach. Mental health providers in Ukraine face increasing levels of distress and adversity. Providers often find themselves overburdened by the mounting toll of the war as the conflict progresses, all the while facing the same tolls of the war their patients do. A support system for providers must be in place as they continue to provide care for those in need. Moreover, increased training on evidence-based interventions and clarifying and better coordinating the roles of different providers can help mitigate provider distress.
Conclusion
International partners and the Ukrainian government have a huge task ahead, not only rebuilding physical infrastructure but also ensuring that Ukraine’s human capital is strengthened going forward. The war has led to the destruction of healthcare infrastructure, such as hospitals and clinics, leaving Ukraine’s healthcare system hard pressed to meet the overwhelming demand it currently faces. When the war ends, 10–15 million Ukrainians may wish to return to Ukraine, and donors need to maximize the use of Ukrainian human capital in the reconstruction process. It will be important to establish deep understanding of mental health disorders and the core factors that contribute to them during and after the unjust Russian invasion; identify the best-available evidence-based options for patients and their families; rebuild social infrastructure such as housing, schools, and healthcare facilities; and focus on updating and modernizing mental health and psychosocial support services. Investing in mental health is critical for Ukraine’s economic future. It will incentivize Ukrainians to return and heal from the aftermath of the war and help Ukrainian children to grow to their full potential.
Romina Bandura is a senior fellow with the Project on Prosperity and Development at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Paula Reynal is a research assistant with the CSIS Project on Prosperity and Development.
The authors would like to thank Jedidiah Devillers for his excellent research support.
This report was made possible by the generous support of University Research Co., LLC.
The aim of the bipartisan and international CSIS Ukraine Economic Reconstruction Commission is to produce a policy framework that will help attract private sector investments to support Ukraine’s future economic reconstruction. To support the commission, CSIS will convene a series of working groups to examine a range of issue-specific areas that are critical for reconstructing and modernization of the Ukrainian economy, including in agriculture, energy, and transportation and logistics, as well as addressing the impact of corruption on private sector investment.
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