Bogi Eliasen: Building Health After War

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We focus a lot on war these days, as Europe did not have such a full-scale war as in Ukraine in many decades. There have been and are still ongoing wars in other parts of the world, some quite close to Europe. However, all wars come to an end, and then it is time to re-build the society in the destroyed and affected areas right from its basic pillars. Healthcare is one such societal pillar. How Europe can help to re-build and re-imagine healthcare post war, we talk today with Bogi Eliasen, CIFS Health Director

Now with the ongoing war in Ukraine, what are your thoughts on health as a device to sustain peace? What is the role of the healthcare system while the war is going on?  

Health should be seen as a tool to provide better life conditions, equity and fairness and that in itself should diminish the drive towards war. If we want to provide better health with the technology we already have, it needs to be cross border where countries become more interdependent, also on delivering health.  

Let’s talk about a post war situation in Ukraine or elsewhere, perhaps you can present broader considerations on an optimal algorithm to restore healthcare post war? 

Let me first say that we have wars in many places, and we also see atrocities that are now so visible for us in Ukraine, in many other countries. War is often possible because there is a want or a need for resources and power.

Right there we observe the power asymmetry based on lack of equality and equity.

Sometimes there is more simple reasons to a war: it is a personal urge to remain in power, to gain more power or to get somebody out of a power structure.

Health as a fundamental societal pillar is needed because it is the most important attribute to build social contracts, fairness, equality & equity.

But it is also a responsibility that with time makes health the most important pillar for stability, development and growth. In the end, without health it is very, very hard to improve general living conditions. 

When a country is torn apart like we see with Ukraine now, basic needs are not met. Rebuilding will require a hard prioritization on where to start. It’s of uttermost importance to get primary care up and running from the beginning. We will also need to focus on mental care as there will be traumas for a huge portion of the population. At the same time treatments for chronic diseases needs to be reestablished as soon as possible. 

When talking about post war situations, is it more about re-building what had existed before or about re-imagining something new? 

If we go in as a coalition or maybe as “the international society”, we should have the courage not to re-establish what had been there before the war, especially as many places it was inadequate, but to build an inclusive, fair and effective health system, with the knowledge that we have. Our traditional view on health needs to be changed. Most agree that today we don’t get enough budgets for health. Hence, it should be a moral imperative not just to go in and simply re-build but to re-imagine how we can do most with the budget that we have for these populations that have been hit by these disasters of a war. We can take a more preventive, inclusive, advanced but not necessarily more expensive approach with a specific focus on keeping people as healthy as possible for as long as possible. We can establish a system where we can employ digital tools to re-imagine care delivery where necessary. Also, we will need to re-think how we provide the necessary knowledge, tools and thereby health literacy to everyone, to each community and the society at large. Similarly, the way we apply healthcare services need to ensure a better impact for everyone, individually and as a whole. 

European aid programmes have a long history. With this experience, what can Europe do to help in the best way and how? 

In general, I think aid programs really need to be subjected to a serious inner audit. When we go beyond emergency aid, and start to lay the foundations for the future, the aid is about learning people to fish, not to give them the fish. Money, equipment, and consumer goods constitute only a part to the equation. Capacity building and balanced but demanding cooperation should be the key. The balance is often hard to find, because simultaneously we need to build from within. The population shall own the re-building and have the responsibility to improve the system. It cannot be done from outside. 

Why shall Ukraine consider relying on Europe in re-building its healthcare after the war? What is so special about the integration capacity of Europe, with regards to healthcare?  

Ukraine should rely on Europe, among others, as Europe already has a dedicated focus on cross border health, especially on the digital side. The other part is that many of the refugees would want to return to Ukraine and we should help them to return, enriched with health knowledge, equipped with capacities to build and be part of a strong, equitable health system. 

What strategic changes, new approaches, policy shifts do you envisage? 

When we look at health as the most important societal pillar, re-imagining and re-building health in a postwar country has to have this fundamental question in focus: how do we deliver value to individuals and to the society with the health services that we provide? Another basic question: are we rebuilding towards the healthiest population possible, or do we want to have most specialized hospitals so we can provide most advanced surgeries and treatments for most diseases? We need parts of both, but probably the first one should have the higher priority. 

In building knowledge societies, it is paramount to invest in people. The most important investment we can do is to keep people as healthy as possible for as long as possible both to improve life conditions for as many as possible, but also because it is likely to be the most important factor behind a stable society with a healthy growth, that covers the many, not just the few. This is also where I see the WHO with an enormous opportunity but also with responsibility to exert pressure on its member states to re-imagine health so we can do much more for so many more. 

Many necessary concepts are included in the work of WHO. In most countries, political will is lacking to solve challenges which in the end are not technical but rather administrative and political. 

You are the Health Director at  Copenhagen Institute for Futures Studies. In your view, how will the post war efforts affect the European healthcare landscape? 

I think that there will be a great focus on taking responsibility to re-build Ukraine, in many areas. The discussion how to go in fast and re-build the health system of the country has started already. This discussion may take two directions. It can continue along the traditional competitive way where different stakeholders are competing to deliver what they have and what they know. If we take this way, we will have to re-build with the old mindset. The needs in Ukraine are so big, hence this logic will be a significant step forward, but we will lose the opportunity of re-building better for the Ukrainian population, and at the same time we will lack feedback: the accrued learnings may be transferred back to Europe. They are likely to focus on new concepts to get more value out of a health budget by leaning upon health data and digital functions, combined with new biology (biomarkers, genomics). I think that we will have an opportunity to build an advanced form of primary care in a very cost-efficient way which would help not only Ukraine and Europe but perhaps, the rest of the world as well. 

The core issue now: do we collectively have the guts to move from “feel good to do good” when re-building Ukraine and to a focus on “doing the right things right”.