HEALTH POLICY DEVELOPMENT AND IMPLEMENTATION IN POST-CONFLICT COUNTRIES OF THE FORMER YUGOSLAVIA: INSIGHTS FOR UKRAINE

Abstract

The full-scale invasion of Ukraine by the Russian Federation in 2022 led to a significant reduction in the availability of medical services in Ukraine due to the disruption of healthcare facilities. It included the destruction of facilities restrictions on operations in life-threatening situations and a lack of electricity, water and heating. Staff shortages were also a factor, due to the death or forced migration of medical workers. The war has disrupted vital public health processes, including vaccination programmes, sanitation measures, and epidemiological surveillance. It has also negatively impacted the physical and mental health of the population, resulting in an increased premature and avoidable mortality. In the post-war period, Ukraine will inevitably face the consequences of damaged infrastructure and depleted resources. Drawing on the experience of other countries will therefore be essential for rebuilding the healthcare system and shaping effective demographic policies. Therefore, the experience of the countries of the former Yugoslavia, which underwent a series of armed conflicts between 1991 and 2001 is relevant for Ukraine. This article aims to summarise the conclusions of scientific publications on specific programmes and reforms implemented in the healthcare systems in countries of the former Yugoslavia were that affected by armed conflict at the end of the 20th century. It also aims to identify common reasons for the greater or lesser effectiveness of healthcare system reforms in these countries, and to seek and formulate applicable experiences for Ukraine. This study employed a systematic search of the PubMed and Web of Science bibliographic databases, as well as Google Scholar, to identify academic publications based on criteria relating to the study’s objectives and the comprehensiveness of the reform analysis. A content analysis of the legal frameworks of countries in the former Yugoslavia was also conducted. It has been found that successful healthcare reforms shared several features: compulsory health insurance, a focus on primary healthcare strengthening, and targeted national programmes for preventing and treating non-communicable diseases. Slovenia’s experience has demonstrated that transitioning to social insurance, improving primary care, and implementing consistent policies on non-communicable diseases can reduce mortality long-term. It has been shown that in countries where reforms have not yielded the expected results, they were characterised by chronic underfunding, inefficient resource allocation, a lack of substantial organisational change, the persistence of informal payments, and the emigration and displacement of medical staff. High mortality rates from avoidable causes suggest a combination of inadequate investment and poor communication with the population regarding prevention and timely access to care. Frequent changes in leadership in the healthcare sector, alongside political instability, have created additional obstacles to strategic development. Based on an analysis of the experience of post-war healthcare reforms in the countries of the former Yugoslavia, the following recommendations can be proposed for Ukraine: the fastest possible restoration of universal healthcare coverage with an emphasis on primary care; effective cooperation between the central government, local authorities and domestic professional associations in the process of rebuilding the healthcare system; timely and reasoned initiation of requests for assistance from international donors, and the rational use of this assistance; organisation of effective physical and psychological rehabilitation measures; development and implementation of public awareness campaigns on health issues and personal responsibility for own health.

REFERENCES / ЛІТЕРАТУРА

1. Uppsala Conflict Data Program (2026). https://ucdp.uu.se/

2. Attacks on Health Care in Ukraine (2026). https://www.attacksonhealthukraine.org/

3. Wilkens, J., Harris, M., & Kolesnyk, P. (2025). Primary health care in Ukraine is acornerstone in both health reform and response to the full-scale invasion. Scandinavian Journal of Primary Health Care, 43 (2), 255—257. https://doi.org/10.1080/02813432.2025.2477787

4. Bogale, B., Scambler, S., Mohd Khairuddin, A. N., & Gallagher, J. E. (2024). Health system strengthening in fragile and conflict-affected states: A review of systematic reviews. PLoSONE, 19 (6), 1—33. https://doi.org/10.1371/journal.pone.0305234

5. Jawad, M. et al. (2021). Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000—2019. PLoS Medicine, 18 (9), 1—18. https://doi.org/10.1371/journal.pmed.1003810

6. Chol, C. et al (2018). Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990—2015: a literature review. Global Health Action, 11 (1), 1—15. https://doi.org/10.1080/16549716.2018.1517931

7. Chi, P. C., & Urdal, H. (2018). The evolving role of traditional birth attendants in maternal health in post-conflict Africa: A qualitative study of Burundi and northern Uganda. SAGE Open Medicine, 1—9. https://doi.org/10.1177/2050312117753631

8. Mbaeyi, C. (2023). Polio vaccination activities in conflict-affected areas. Human Vaccines & Immunotherapeutics, 19 (2), 1—8. https://doi.org/10.1080/21645515.2023.2237390

9. Baig, R., Aborode, A. T., & Novman, S. at al. (2022). COVID-19 vaccination in conflictaffected areas in Nigeria: challenges and recommendations. Medicine, Conflict and Survival, 38 (1), 13—19. https://doi.org/10.1080/13623699.2021.2017441

10. Pattanshetty, S., Dsouza, V. S., & Shekharappa, A. et al. (2024). A Scoping Review on Malaria Prevention and Control Intervention in Fragile and Conflict-Affected States (FCAS): A Need for Renewed Focus to Enhance International Cooperation. Journal of Epidemiology and Global Health, 14 (1), 4—12. https://doi.org/10.1007/s44197-023-00180-7

11. United Nations, Department of Economic and Social Affairs, Population Division (2024). World Population Prospects 2024, Online Edition. https://population.un.org/wpp/

12. Transitional Justice in the Former Yugoslavia (2009). ICJT.org. International Center for Transitional Justice. https://www.ictj.org/sites/default/files/ICTJ-FormerYugoslavia-JusticeFacts-2009-English.pdf

13. Albreht, T. et al. (2016). Slovenia: health system review. Health Systems in Transition, 18 (3), 1—207. https://iris.who.int/server/api/core/bitstreams/200a7130-e888-456a8c27-5112360083fc/content

14. Integrated, person-centred primary health care produces results: case study from Slovenia (2020). Copenhagen: WHO Regional Office for Europe. https://iris.who.int/server/api/core/bitstreams/28d994bb-94c0-49a1-abdb-7b66c6e269b5/content

15. Zavod za zdravstveno zavarovanje Slovenije (2025). https://www.zzzs.si/en/about-us/

16. Albreht, T. et al. (2009). Slovenia: health system review. Health Systems in Transition, 11 (3), 1—168. http://www.hpi.sk/Documents/HIT/Slovenia_2009.pdf

17. Johansen, A., Vrackob, P., & West, R. (2020). The evolution of community-based primary health care, Slovenia. Bulletin of the WHO, 98 (5), 353—359. http://dx.doi.org/10.2471/BLT.19.239616

18. Albreht, T. et al. (2021). Slovenia: health system review. Health Systems in Transition, 23 (1), i-188. https://iris.who.int/server/api/core/bitstreams/21e0bc6e-cc04-4b28-b3b8-e1de9c8d2ecf/content

19. Voncina, L. et al. (2006). Croatia: health system review. Health Systems in Transition, 8 (7), 1—108. https://iris.who.int/server/api/core/bitstreams/9241bd18-31c5-44a5-9815-a3382adc54a2/content

20. Croatia Smoking Ban Restarts on April 9 (2010). Balkan Insight. https://balkaninsight.com/2010/03/11/croatia-smoking-ban-restarts-on-april-9/

21. Satylganova, A. (2016). Better noncommunicable disease outcomes: challenges and opportunities for health systems. Croatia Country Assessment. Copenhagen: WHO Regional Office for Europe. https://www.researchgate.net/publication/315493980_Better_noncommunicable _disease_outcomes_challenges_and_opportunities_for_health_systems_Croatia_ Country_Assessment_Copenhagen_WHO_Regional_Office_for_Europe_2016

22. Ivankovic, A. et al. (2010). Health Status of Population in Federation of Bosnia and Herzegovina in 15 Years of Transitional Period. Collegium Antropologicum, 34, Suppl. 1, 325—333. https://hrcak.srce.hr/51788

23. Masic, I. et al. (2006). Health Care System in Federation of Bosnia and Herzegovina. Materia Socio Medica, 18 (4), 212—218. https://www.researchgate.net/profile/Izet-Masic/publication/257359509_Health_Care_System_ in_federation_of_Bosnia_and_Herzegovina/links/00b7d5250317238d9f000000/Health-Care-System-in- federation-of-Bosnia-andHerzegovina.pdf

24. Hodgetts, G., Brown, G., & Batić-Mujanović, O. et al. (2020). Twenty-five years on: revisiting Bosnia and Herzegovina after implementation of a family medicine development program. BMC Family Practice, 21, Art. 7, 1—12. https://doi.org/10.1186/s12875-020-1079-4

25. Health Systems in Action: Bosnia and Herzegovina (2022). European Observatory on Health Systems and Policies. WHO. https://iris.who.int/server/api/core/bitstreams/70491093-87da-4c27-8a1a-880eef7af631/content

26. Bjegovic-Mikanovic, V. et al. (2019). Serbia: health system review. Health Systems in Transition, 21 (3). https://iris.who.int/bitstreams/3aa04311-94f3-4211-9471-b083684b3151/download

27. Awareness, attitudes, and behavior toward non-communicable diseases in Ukraine in 2024 (2024). Research agency CBR (Consumer and Business Research) as part of the Ukrainian-Swiss project “Act for Health”. https://www.actforhealth.in.ua/materialy/obiznanist-stavlennya-i-povedinka-shchodo-neinfekciynih-zahvoryuvan-v-ukrayini-u2024-roci

[Обізнаність, ставлення і поведінка щодо неінфекційних захворювань в Україні у 2024 році (2024). Компанія CBR (Consumer and Business Research) у межах україношвейцарського проєкту «Діємо для здоров’я»].

28. Kunitz, S. J. (2004). The Making and Breaking of Yugoslavia and Its Impact on Health. American Journal of Public Health, 94 (11), 1894—1904. https://doi.org/10.2105/AJPH.94.11.1894

29. Scepanovic, L. (2023). Health personnel and the reform of primary health care in Montenegro. Serbian Journal of the Medical Chamber, 4 (1), 27—40. https://doi.org/10.5937/smclk4-42596

30. Knezevic, R. (2015). Montenegro. In: Economic crisis, health systems and health in Europe, 445—447. https://www.ncbi.nlm.nih.gov/books/n/whohps41/pdf/

31. Mosca, I., & Tille, F. (2025). Health Systems in Action (HSiA) Insights — Montenegro, Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe. https://iris.who.int/server/api/core/bitstreams/7f5a6e58-f5dc4400-a45c-1543bd05d368/content

32. Milevska Kostova, N. et al. (2017). The Former Yugoslav Republic of Macedonia: health system review. Health Systems in Transition, 19 (3). https://iris.who.int/server/api/core/bitstreams/62d8e90f-c309-4204-b352-826c5bafd422/content

33. Milevska Kostova, N. et al. (2024). North Macedonia: health system review. Health Systems in Transition, 26 (6). https://iris.who.int/server/api/core/bitstreams/caa115d0-3bb6-4f87-9386-6b9e1078b28c/content