Providing care for those fleeing war: challenges and solutions for Polish doctors looking after refugees from UkraineBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1440 (Published 10 June 2022) Cite this as: BMJ 2022;377:o1440
- Mateusz Babicki, family physician and doctor of philosophy student12,
- Agnieszka Mastalerz-Migas, family physician and professor13
The ongoing armed conflict in Ukraine has caused the biggest migration crisis Europe has faced in the 21st century. Over this period, more than seven million people have fled the country, the largest number of which have come to Poland—almost four million according to the United Nations High Commissioner for Refugees.1 The Polish Parliament passed a special law in March that allows war refugees from Ukraine to access many public benefits, including free healthcare, as well as the reimbursement of medicines and medical products on the same terms as people insured in Poland.2
Yet given Poland’s severe shortage of medical staff (we have one of the lowest ratios of physicians per 1000 inhabitants in Europe),3 providing refugees with access to services without straining healthcare services or increasing staff workload will be a challenge.
The vast majority of refugees are women, children, and older people so their medical needs will be diverse. Most of them are likely to come into contact with primary care physicians, especially as the conflict drags on, and many already have. From among the members of the Polish Society of Family Medicine, we’ve heard that regardless of age, the services primary care doctors have provided to Ukrainian refugees have mainly been related to acute infections. For many refugees, especially children, the long journey results in colds, infections, dehydration, and weakness, which requires urgent medical attention. However, some of Ukraine’s refugees will be chronically ill, which means they’ll need follow-up care and continued treatment.
Providing care for refugees will present many new challenges, but chief among them is the lack of medical records for these patients, which will be a significant impediment to continuity of care for chronic diseases, as well as a legal problem when prescribing reimbursed medicines. According to Polish law, a prescription for a reimbursable medicine can only be issued if medical documentation confirming the diagnosis is available—a paper trail that refugees are unlikely to have. This will mean that doctors have to carry out a new diagnostic procedure just to confirm the disease so that the treatment can be reimbursed. Otherwise, in the event of a government audit, a physician without proper documentation will be financially charged for an “incorrect” reimbursement indication for a drug. The only solution seems to be the introduction of an appropriate law that allows the reimbursement of medicines for refugees based on their written statement of its use, without the need to show proof from a medical record.
Some of our members have already reported that mental health disorders are a common health problem among the refugees they’ve treated. The recent events experienced by Ukrainian refugees increases their risk of developing depression, anxiety, as well as post-traumatic stress disorder (PTSD). This will be a huge challenge for Poland’s health workforce because of the extremely low percentage of psychiatric specialists in Poland, especially when it comes to the treatment of children and adolescents. According to data from the Central Register of Physicians, there are 15 000 children per one specialist in child psychiatry in Poland, while to ensure adequate care the ratio should be one specialist per 10 000 children.4 The situation is not much better for adult psychiatry.5 According to 2018 data, Poland has 9.2 psychiatrists per 100 000 inhabitants, while in the UK the ratio is 18 and in Germany 27.4.6
Increasing the availability of psychiatric treatment could be done by introducing remote consultations for refugees by doctors from other countries who offer their help. We should also tap into the potential resource of psychologists and psychotherapists, who in mild cases of depression or anxiety can often independently conduct appropriate non-pharmacological treatment.
A key part of caring for refugees will also be continuing those preventive measures that they would have received in their home country, such as child health checks and immunisations. Ukraine has fairly low vaccination rates against tuberculosis, polio, and measles among Europe so the immunisation of refugees and promotion of accurate vaccine information should be a key focus for Poland’s public health system.7 This is even more important as there has been a growing reluctance among Polish parents to vaccinate their children in recent years, which may significantly increase the risk of local outbreaks.8
Giving Ukrainian refugees access to and education on covid-19 vaccines will also be important to ensure that everyone is protected from the virus. In Poland all refugees have been given the opportunity to get vaccinated against covid-19 free of charge. The responsibility for having informed conversations about covid-19 vaccines will often fall on family physicians, as well as the actual task of carrying out the vaccinations since that’s where the vast majority of vaccination sites are located. While the registration process is not in need of improvement, the promotion of vaccination among refugees is. The government should be carrying out targeted information campaigns that help to build refugees’ confidence in vaccination.
Another difficulty will be the language barrier. Those arriving in Poland usually speak Ukrainian and/or Russian, languages which are not widely spoken in Poland. There is currently no interpreter support for these patients in the Polish healthcare system and many physicians are relying on volunteers who’ve offered their free translation assistance. However, this is not a long term solution and it should be up to the government to hire appropriate interpreters. Since it is not possible to provide enough interpreters that one could be physically present in each medical centre in Poland, a good solution would be to create a hotline for doctors, where you can call and get help from an interpreter during your patient’s visit. This would relieve a lot of the organisational burden and uncertainty for family doctors.
Some of the solutions to these challenges could come from the Ukrainian refugees themselves who also include medical personnel—physicians and nurses who could potentially work in the Polish healthcare system. To make this possible, the Ministry of Health has significantly simplified the procedure for applying for a job and the right to practise in Poland. From 24 February 2022 to 12 April 2022, 70 doctors from Ukraine started employment in Poland.9 Intensive Polish language courses for medical personnel from Ukraine are currently being carried out.
Of course, it should be borne in mind that most refugees will probably want to return to Ukraine after the end of the armed conflict, but a clear resolution is not in sight and both financial resources and organisational support are now needed to meet the challenge of providing social and medical care for those fleeing the war. The Polish government needs to remove what obstacles it can so that doctors are able to provide the medical care Ukraine’s refugees need. However, the international community must also step up, with financial and other logistical support from the European Union and international organisations such as the World Health Organization crucial.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not peer reviewed.