Psychological support providers embedded within military and law enforcement organizations during armed conflict are exposed to both direct and secondary trauma, placing them at elevated risk for posttraumatic stress disorder (PTSD). In Ukraine, the staff title "psychologist" designates psychological support providers employed by security organizations, encompassing providers with varying levels of formal training. The "security sector" comprises three uniformed branches - the Armed Forces, the National Guard, and the National Police - with distinct operational missions and combat exposure. Little is known about how the PTSD burden and its correlates differ across these branches when examined concurrently. This study examined PTSD symptom severity and probable DSM-5 PTSD among psychologists in each branch during the ongoing war. A cross-sectional survey conducted in 2024 also measured adverse childhood experiences (ACEs), lifetime trauma exposure, depressive symptoms, and anxiety symptoms. Ordinary least squares and logistic regression models were estimated for pooled and branch-specific samples. Psychologists in the Armed Forces showed higher PTSD symptom severity and a greater prevalence of probable PTSD than those in the National Guard or National Police. Across branches, cumulative lifetime trauma exposure and depressive symptoms were the most consistent correlates of PTSD outcomes, whereas anxiety showed more variable associations. Childhood adversity was weakly associated with PTSD after adjustment for adult trauma exposure and current emotional symptoms. Branch differences in PTSD burden persisted beyond measured individual-level risk. Findings underscore the need for branch-specific, broad-spectrum strategies to support provider well-being during prolonged conflict.
IntroductionThe HEART-UA (Healthcare Extracorporeal Assessment and Resource Tracking in Ukraine) survey represents the first nationwide evaluation of extracorporeal life support (ECLS) and renal replacement therapy (RRT) availability in Ukraine. The study aimed to systematically characterize national ECLS and RRT capacity, assess temporal changes before and during the conflict, and identify major operational limitations affecting access to extracorporeal organ support.MethodsA structured cross-sectional survey was conducted among Ukrainian hospitals providing ECLS and/or RRT. Data collection included institutional characteristics, ECMO device availability, case volumes in 2021 and 2023, staffing models, barriers to ECLS provision, and the availability of CRRT and intermittent hemodialysis. Responses were clustered at the institutional level, and duplicates were merged. Categorical variables were compared between the pre-war and wartime periods using Fisher's exact or chi-squared tests where appropriate.ResultsTwenty-two institutional responses were analyzed, including 15 ECLS centers, 16 CRRT centers, and 19 IHD-capable institutions. Geographical distribution showed regional clustering of ECLS resources. No statistically significant expansion in ECMO device availability or procedural volumes was observed between 2021 and 2023. The predominant barriers to ECLS provision included shortages of consumables (60%), insufficient trained personnel (53%), and inadequate numbers of ECMO devices (47%). CRRT availability was higher, but most centers reported major limitations due to shortages of consumable circuits, machine availability, and infrastructural instability. Humanitarian aid related to extracorporeal support was received by only 27% of institutions and was irregular, fragmented, and insufficient to meet national needs.ConclusionsThe HEART-UA survey demonstrates that Ukraine's capacity to provide extracorporeal organ support has remained critically constrained during the war. Device availability, trained personnel, and consumable supply chains are still major limiting factors. Although many centers continue to provide lifesaving ECLS, CRRT, and IHD despite extreme operational challenges, the overall system is highly dependent on inconsistent humanitarian aid.
This paper investigates how Ukrainian judges respond to the challenges of wartime adjudication following Russia's invasion. Based on 17 interviews with judges across Ukraine, it explores their adaptive legal strategies amid uncertainty and institutional strain. The study conceptualises judges as legal bricoleurs, who drawing on international human rights norms - such as the Namibia exception and the European Court of Human Rights caselaw - balance civil liberties with national security. It argues that war has served not only as a site of crisis but also of legal creativity, fostering engagement with international law and laying groundwork for Ukraine's post-war transitional justice and alignment with global legal standards.
Before Russia's full-scale invasion in February 2022, Ukraine maintained a well-functioning oncology system, supported by universal health coverage and expanding access to advanced diagnostics and clinical trials. The war caused profound disruptions across all aspects of cancer care-diagnostics, treatment, research and palliative support-yet the system demonstrated exceptional resilience. While hospitals in combat zones were forced to pivot to trauma care, oncology facilities in safer regions were rapidly reorganised and adapted. By late summer 2022, core cancer care in government-controlled territories largely recovered to near pre-war levels through coordinated leadership, emergency regulations and international support, though this recovery remains fragile and uneven, with some patients still facing barriers related to displacement, insecurity and disrupted pathways. Partnerships with the WHO, European Union and oncology societies helped with drug supply, telemedicine, workforce training and patient evacuation abroad. Despite early shortages, drug and radiotherapy capacity has rebounded, aided by modernisation efforts and advocacy networks. Clinical trials, initially halted, are being gradually restored under decentralised and cross-border collaboration models. Grassroots and non-profit organisations have been essential for patient navigation and advocacy, also addressing challenges of treatment delays, drug access, psychological support and palliative care. Looking ahead, Ukraine's National Cancer Control Strategy 2030 prioritises workforce development, early cancer detection and quality improvement to strengthen system resilience. Ukraine's experience demonstrates that even amid prolonged conflict, coordinated governance, adaptive regulation and international collaboration can sustain complex cancer care and offers a practical framework for rebuilding oncology and other non-communicable disease services in conflict-affected settings.
The war in Ukraine has disrupted access to maternal and infant nutrition services, intensified commercial milk formula marketing risks, and increased demand for accessible, evidence-based breastfeeding support. To respond, FHI 360 and UNICEF Ukraine deployed Harmony of Parenthood, a closed-domain, ethically governed Artificial Intelligence (AI)-enabled breastfeeding and Infant and Young Child Feeding in Emergencies (IYCF-E) support system, integrated with facility-based counseling and a national mentorship programme for lactation counselors. The aim of this study was to evaluate the feasibility, safety, acceptability, and operational contribution of an AI-enabled hybrid counseling model to continuity and quality of Infant and Young Child Feeding in Emergencies services during protracted conflict, including its integration with facility-based counseling and mentorship systems and its potential influence on caregiver feeding practices and counseling quality. A convergent mixed-methods approach triangulated: (1) chatbot analytics (user characteristics, interaction volume, response quality); (2) facility counseling data from four conflict-affected oblasts; (3) structured competency assessments following >600 mentorship visits; and (4) qualitative feedback from caregivers and health workers. Governance, safety, and Code-compliance safeguards were assessed against the World Health Organization (WHO) AI ethics guidance, the Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE), and Ukraine's breastfeeding policies. Between November 2024 and October 2025, 2,066 caregivers generated more than 38,000 chatbot interactions. Ninety-eight percent of answers met accuracy and safety criteria; one hallucination event was detected and corrected through real-time review. Caregivers used the system predominantly during periods of insecurity or when services were inaccessible, valuing its 24-h availability, emotional reassurance, and escalation to human counselors. In parallel, facility data showed improved quality of counseling, strengthened referral pathways, and increases in early initiation and exclusive breastfeeding among women receiving repeated support. Mentorship visits demonstrated competency gains among lactation counselors, enhanced adherence to the Code, and more consistent use of MoH-aligned counseling tools. An AI-enabled, human-supervised hybrid model is feasible, acceptable, and safe for sustaining breastfeeding and IYCF-E support during active conflict. When anchored in authoritative guidance and embedded within national systems, AI tools can complement skilled counselors, strengthen continuity of care, and uphold Code-compliant, evidence-based support for mothers and infants. To our knowledge, this is the first documented evaluation of an AI-enabled IYCF-E intervention implemented during an active conflict.
BACKGROUND: This study aimed to monitor risks of temperature excursions along vaccine distribution routes in Ukraine to identify weaknesses and recommend improvements. METHODS: This cross-sectional study followed the World Health Organization’s temperature monitoring protocol. Vaccine shipments along randomly selected distribution routes were monitored using loggers, recording temperatures at 20 min intervals across all levels of the cold chain. The collected data were analysed to assess compliance with the recommended range and identify instances of heat and freeze exposure. RESULTS: A total of 72040.1 h were recorded from July 2024 to October 2024 across 48 distribution routes. The recorded temperature ranged from − 13.6 °C to + 28.4 °C. The level of compliance with the recommended temperature range varied by immunisation supply chain level and across facilities at a given level. The highest compliance (~ 100%) was observed at national and oblast stores and during transits between these levels. At the same time, the lowest compliance (88.8%) during storage was observed at primary healthcare centre (PHC) sub-offices, with three of such facilities failing to maintain the recommended range at any point during the study. Additionally, 20 freeze and five heat alarms were recorded at this level, indicative of prolonged exposures. During transits to PHC and sub-offices, compliance was achieved during 54.8% and 60.3% of the recorded time, respectively. Furthermore, eight transits to PHC and 15 to PHC sub-offices failed to maintain temperatures within the required range throughout the transit. CONCLUSIONS: While Ukraine’s vaccine cold chain system is effective at higher levels, temperature excursions were common at lower levels, particularly in PHC sub-offices and during transport to lower-level facilities. Equipment malfunctions, gaps in knowledge and lack of procedures, compounded by power outages and lack of power supply contingencies, are probable causes. Systematically identifying and documenting temperature excursions and assessing the potential damage to vaccines are recommended immediate actions. Providing further qualified equipment, ensuring resilient power supply, strengthening training, and improving procedures and supervision to prevent and mitigate risks of temperature excursion incidents are longer-term recommended actions. Implementing these actions would strengthen Ukraine’s immunisation supply chain resilience, ensuring safe and effective immunisation services.
This paper explores the management of mass casualty incidents in Eastern Ukraine, focusing on the application of the Eight Domains of Mass Casualty Management by the Ukrainian Medical Service. Following the Russian invasion, Ukraine's military and civilian health services have had to adapt to unprecedented casualty rates to prevent overwhelming the healthcare system. The Eight Domains-distribution, decompress, delay, delegate, deliver faster and deliver better, dynamic levels of care, and de-escalation-serve as compensatory mechanisms to manage this chronic major medical incident. The paper highlights the innovative approaches and adaptive strategies employed by the Armed Forces of Ukraine (AFU) Medical Services to maintain effective medical care despite the high demand and constrained resources. The report underscores the importance of international support and continued research to enhance the resilience and capability of the AFU Medical Services in responding to ongoing and future conflicts and proposes future direction for all military medical services to meet the challenges of large scale conflict operations and warfighting at scale.
The full-scale invasion of Ukraine in 2022 created unprecedented pressures on the national immunization supply chain (ISC). Despite large-scale energy disruptions, population displacement, and insecurity, vaccine availability and storage conditions were largely maintained. This study aimed to examine how Ukraine's ISC has adapted to war-related disruptions and to identify key enablers, barriers, and priorities for strengthening its resilience. A mixed-methods approach combined 15 semi-structured interviews with stakeholders from national, oblast, and facility levels, a review of literature, regulatory documents, and programme data. Data were analyzed using thematic analysis and interpreted using the Blanchet et al. health system resilience framework. Analysis found that the digitalization of the vaccine stock management system and the wide availability of training strengthened the knowledge capacity of the ISC. Large-scale investments by international partners in WHO-prequalified cold chain equipment during the COVID-19, complemented by the deployment of backup power solutions, significantly improved the system's ability to manage uncertainty related to electricity outages. The centralization of ISC function enhanced governance and coordination, contributing to legitimacy capacity. Strong collaboration across government institutions and with international partners also helped sustain ISC in the face of the war disruptions, demonstrating the importance of interdependence capacity. However, several barriers persist, including gaps in population data for forecasting vaccine needs and coverage monitoring, unequal distribution of new cold chain equipment, and continued reliance on donor support. Despite repeated attacks, Ukraine's ISC has continued to function. The findings highlight key enablers of resilience and remaining bottlenecks and provide actionable recommendations. Ukraine's experience offers transferable lessons for strengthening ISC resilience in other conflict settings.
The One Health approach integrates human, animal, plant, and environmental health through multisectoral collaboration and is increasingly recognized as essential for addressing zoonotic diseases, antimicrobial resistance (AMR), food security, and ecosystem degradation. Ukraine has formally adopted One Health principles through national strategies and international partnerships; however, the ongoing full-scale military conflict has profoundly disrupted health, veterinary, and environmental systems, challenging effective implementation. This study aimed to evaluate the current status, achievements, and constraints of the One Health approach in Ukraine, with particular emphasis on the effects of armed conflict on governance, surveillance capacity, and intersectoral coordination, and to outline strategic priorities for strengthening One Health resilience. A mixed-methods approach was used, combining bibliometric analysis of Scopus-indexed literature on zoonoses, AMR, food security, and environmental safety with targeted case studies and a review of policy documents. National legal frameworks, international guidelines, and reports from global organizations were systematically analyzed to assess institutional capacity and operational readiness. Ukraine has established a solid policy foundation for One Health, notably through the national Strategy for Biosafety and Biosecurity, which is grounded in the One Health principle and aligned with quadripartite frameworks. Active initiatives address priority zoonoses (rabies, leptospirosis, tuberculosis), AMR surveillance, and food safety. Nevertheless, implementation remains fragmented. Armed conflict has caused extensive damage to laboratories, displaced the workforce, created surveillance blind spots, and disrupted multisectoral communication. AMR trends have intensified due to healthcare strain, while environmental and plant health components remain under-integrated despite their relevance to food security and long-term resilience. The Ukrainian experience demonstrates that policy commitment alone is insufficient in the context of conflict. Effective One Health operationalization requires institutionalized governance mechanisms, interoperable surveillance systems, and sustained investment in human resources and laboratory infrastructure. Environmental and plant health integration remains a critical gap. Reinforcing the One Health framework is essential for Ukraine's recovery and long-term health security. Sustained international technical and financial support, coupled with national institutionalization of One Health principles, is crucial to rebuilding integrated surveillance, mitigating biological risks, and enhancing resilience in conflict-affected settings.
In response to the February 2022 Russian invasion of Ukraine's, international aid and foreign investment from the U.S. Government and regional allies flowed into the country. As part of this support, the Department of War (DoW) has supported multiple research initiatives aimed at strengthening Ukrainian healthcare, further advancing the objectives of the U.S.-Ukraine partnership. Given the scope of U.S. involvement, a thorough investigation into the outcomes of this critical research was essential to ensure accountability and improve resource allocation. To gauge the impact of these investments, the Center for Health Services Research at the Uniformed Services University of the Health Sciences conducted a Buxton-Hanney Payback Framework assessment, which systematically identifies the outcomes generated by these projects. From January 2025 to April 2025, the research team employed snowball sampling and grey literature review to identify principal investigators involved in DoW-funded Ukrainian health research. The team conducted virtual consultations to collect outcome data pertaining to the framework's domains, which were catalogued into a structured data collection instrument. The team identified 7 DoW-funded projects dedicated to Ukraine's health and trauma system. These projects yielded a total of 80 outcomes across the Buxton-Hanney framework domains, revealing a broad spectrum of impacts. These included academic knowledge outputs through publications and workforce training; policy-level contributions for healthcare; direct health benefits; and economic returns driven by workforce resilience and expansion of business operations. Identified outcomes underscore the strategic value of sustained investment in military healthcare research. Investments not only support allies but also provide crucial lessons that can strengthen healthcare delivery for the U.S. Military, particularly in dynamic and conflict-affected environments. Even in their early stages, projects demonstrated immediate value by providing real-time insights that advance the partnership's objectives. Furthermore, this assessment advocates for the utilization of the Buxton-Hanney Framework as a standardized tool for assessing the outcomes and impacts for programs within the DoW.
Russia's 2022 full-scale invasion of Ukraine has precipitated the largest and most destructive conflict in Europe since World War II, yet traditional notions of linear battlefields and clearly delineated combatants no longer apply. Russia's widespread use of drones, precision-guided munitions, digital disinformation, ecocide, and systematic attacks on civilian infrastructure has dispersed the risk of death and injuries across the entire Ukrainian population. The close proximity of major population centers to active combat, the large proportion of Ukrainians mobilized as military personnel or first responders, and the persistent threat of drone and missile strikes further blur distinctions between combatants and noncombatants. The U.S. military is incorporating strategic and tactical lessons from this conflict into its doctrine for large-scale combat operations (LSCO) with near peer adversaries, including revised approaches to battlefield healthcare and combat stress control. This case study examines current wartime conditions in Ukraine from a psychological perspective, identifies shared and unique war stressors among Ukrainian military personnel and civilians, and discusses Ukraine's actions to mitigate these stressors. The analysis synthesizes peer-reviewed research, governmental and non-governmental reports, technical documents, news media reports, and field observations. Current U.S. doctrine for managing combat stress has a relatively narrow focus, emphasizing actions at the military unit level. In contrast, the Ukrainian experience illustrates the need for a whole-of-society approach for LSCO level warfare. Insights from Ukraine offer critical understanding of the psychological demands of LSCO and can inform future U.S. doctrine, training, and policies for high-intensity conflict.
BRCA1 c.181T>G (p.Cys61Gly) is a pathogenic founder genetic variant prevalent in Central and Eastern Europe. The data on its clinicopathological manifestations in Ukrainian patients remain limited. This study aimed to characterize clinical presentation, tumor biology, and family history in Ukrainian women with BRCA1 c.181T>G variant. We conducted a single-centre case series of women with primary breast cancer (BC) and/or ovarian cancer (OC) harbouring BRCA1 c.181T>G genetic variant and treated at Lviv Regional Oncology Treatment and Diagnostic Center (Ukraine) between January 2024 and August 2025. Clinical presentation, tumor pathology, biomarker status, family history, treatment, and outcomes were analysed. Thirteen women aged 29-81 years (median 35 years) were included in this case series. Early-onset BC was recorded in 10 (76.9%) of patients diagnosed before 40 years. BC was the initial malignancy in 12 (92.3%) patients. OC occurred as a first tumor in 1 (7.7%) and as a subsequent cancer in 4 (30.8%) patients. Multiple malignancies were observed in 61.5% of patients, with intervals of 5-21 years between diagnoses. Family history revealed strong clustering of BC and OC across generations, often involving multiple affected relatives, consistent with hereditary breast and ovarian cancer syndrome phenotype. Among cases with known biomarker status (10/13), 2 were HER2-positive, 4 belonged to luminal-like type, and 4 cases represented triple negative BC. Most cases (10/13, 76.9%) were diagnosed at early tumor growth stage (pT1-2). However, more than half of primary tumors (8 of 13; 61.5%) had positive nodal status (pN1-2) reflecting invasive behaviour of cancer cells. This Ukrainian case series demonstrates that the BRCA1 c.181T>G genetic variant is associated with early-onset breast cancer, variable tumor biology, frequent multiple primary cancers, and strong familial clustering. These observations support the need for expanded genetic testing, targeted surveillance, and corresponding risk reduction strategies tailored to Ukraine's BRCA1 founder pathogenic variant landscape.
Russia's full-scale invasion of Ukraine has transformed both the modern battlefield and the microbial environment surrounding the war-wounded. Explosive injuries, prolonged evacuation, and limited opportunities for early decontamination have contributed to an unprecedented rise in multidrug-resistant organism (MDRO) infections. This paper describes how routine infection prevention and control (IPC) and antimicrobial stewardship (AMS) systems have become inadequate under conflict conditions and how contamination evolves into colonization and then systemic infection as casualties move through the evacuation pathway. Building on the national IPC and AMS strengthening, we outline a complementary crisis intervention: the application of chemical, biological, radiological, and nuclear-inspired decontamination principles to routine trauma care. These measures incorporate structured early irrigation and debridement, antiseptic cleansing, removal of contaminated materials, and the use of dedicated decontamination spaces at hospital entry. They are designed to reinforce existing programs by reducing microbial burden at the earliest point of contact. Implementing this approach aims to disrupt MDRO acquisition and transmission, protect fragile healthcare infrastructure, and mitigate escalating biosecurity risks. Ukraine's conflict experience has informed the development of this proposed concept, with formal implementation and impact evaluation planned as the next phase of work. LEVEL OF EVIDENCE: Level V (Current Opinion).
Aim: To substantiate the strategic role of the resocialisation of veterans with PTSD as a critical factor in the security of Ukraine and the EU; to analyse the clinical specificity of contemporary combat-related disorders; and to demonstrate the necessity of implementing inclusive governance models of rehabilitation at the community level to prevent cross-border social risks. Materials and Methods: A comprehensive approach was applied, including statistical, comparative, and clinical-diagnostic analyses. The source base consisted of a secondary analysis of data from international organisations (GPI, GLOBSEC, UNODC) and departmental statistics for the period 2008-2025. A systematic selection of publications was carried out in the Web of Science Core Collection, Google Scholar, and the electronic catalogues of the V. I. Vernadskyi National Library of Ukraine using the keywords: resocialisation, veterans, PTSD. Of 68 identified sources (including 34 articles), 22 studies that fully met the criteria of scientific validity were included in the final analysis. Conclusions: It has been demonstrated that Ukraine's resocialisation policy represents a unique precedent for EU and NATO countries. It shows that the stability of the veteran community serves as an instrument for mitigating cross-border crime and social destabilisation in the region. Public administration bodies and local self-government play a decisive role in creating multi-level interventions. The transition from a punitive to a rehabilitative model proves its economic efficiency. Clinical advances by Ukrainian physicians in PTSD are fundamental for the European healthcare system, particularly in the context of rehabilitating foreign volunteers and preparing medical professionals for the challenges of modern conflicts.
Armed conflicts severely disrupt cancer care delivery, destroying infrastructure and limiting access to essential diagnostics and treatments. Evidence on service challenges, adaptations, and policy implications remains fragmented. This scoping review of four databases (Scopus, PubMed, ScienceDirect, and CINAHL) was conducted for original peer-reviewed studies published between January 2020 and August 2025. The search focused on the effect of wars on cancer service delivery in conflict zones, and its impact on cancer care. Wars in conflict-affected countries like Palestine, Sudan, Syria, Iraq, Ukraine, and Afghanistan caused widespread destruction of cancer infrastructure, unsafe hospitals, and interruptions in chemotherapy, radiotherapy, and surgery. Countries faced shortages of specialized centers, technicians/radiologists, and medical records, alongside high costs and supply chain disruptions. Despite these challenges, healthcare systems demonstrated resilience through adaptations including Ukraine's MedEvac program for EU treatment evacuation, cross-border referrals (Iraq→Lebanon, Afghanistan→Pakistan), telemedicine, mobile diagnostic units, and community-based care models. Policy responses emphasized international aid coordination, conflict-sensitive health planning, and supply chain restoration. Conflicts cause infrastructure destruction, workforce depletion/migration, treatment barriers/delays, drug supply disruptions, and psychosocial/economic impacts, which in turn create urgent policy/governance challenges. Although humanitarian aid may provide temporary relief, sustainable solutions require peace and global commitment, grounded in equity and the fundamental right to health.
Ukraine's HIV epidemic remains concentrated among key populations, with sex workers (SWs) facing overlapping vulnerabilities, including a history of injection drug use. Although overall HIV prevalence has declined, prevention coverage remains below national and global targets. Accurate mapping of sex work hotspots is essential for effective outreach, yet existing data are fragmented and incomplete, especially in privatized and digitally mediated environments. This study aimed to systematically identify and characterize sex work venues across eight Ukrainian cities and assess their coverage by HIV prevention services. In 2021, we conducted a two-stage, multi-informant mapping study across eight Ukrainian cities, interviewing 1,212 secondary and 2,277 primary key informants, including SWs. Hotspots were characterized by type, perceived safety, access modality, operating schedule, and presence of SW subgroups. We used descriptive statistics, exploratory factor analysis, and multivariable mixed-effects regression to identify factors associated with HIV prevention service coverage. Of 2,581 identified hotspots, 2,118 (82.1%) were validated as active. Apartments (43.2%), virtual platforms (11.7%), and street-based sites (11.1%) were the most common. Only 13.7% of hotspots were registered in the national HIV service registry, while 34.1% received prevention service delivery and 18.9% were reached by mobile vans. Coverage was highest at street-based and office-type venues and consistently lowest in private, virtual, and pimp-mediated settings. Service coverage was positively associated with 24/7 or daytime operation, higher perceived safety, open access, and the presence of SWs who inject drugs. This study provides comprehensive mapping of sex work hotspots in Ukraine, revealing persistent gaps in HIV prevention for less visible and harder-to-reach SWs. Community-led mapping achieved high validation rates (86.8%) and identified substantial unmet needs in digital and concealed hotspots. Routine hotspot mapping, combined with engagement with SW communities, is essential for data-driven, equitable, and adaptive HIV responses in rapidly changing contexts.
Access to assistive products remains highly uneven across health systems. Policy discussions in rehabilitation frequently emphasize workforce development, service delivery models, and clinical standards. Less attention has been given to the institutional mechanisms through which assistive products are procured and supplied. Ukraine's prosthetics sector provides a contemporary illustration of how procurement systems influence rehabilitation service delivery. Following the escalation of armed conflict in 2022, Ukraine experienced a sharp increase in demand for prosthetic services. National programmes expanded rapidly to support individuals requiring rehabilitation and assistive technologies. In this context, procurement arrangements - including decentralized purchasing across multiple providers and reliance on imported prosthetic components, have highlighted structural challenges affecting supply chain coordination, pricing transparency, and system scalability. This paper argues that procurement architecture represents an under-recognized determinant of rehabilitation system performance. Drawing on insights from Ukraine's prosthetics sector, the paper explores how fragmented procurement arrangements can reduce cost efficiency in access to assistive technologies even when financing and service delivery capacity expand. It further outlines procurement reform principles that may strengthen rehabilitation systems, including pooled purchasing mechanisms, framework agreements, demand forecasting integration, and digital procurement platforms.
Russia's invasion of Ukraine challenges the liberal international order and tests the capacity of Western democracies to maintain long-term military and financial aid for Ukraine in a foreign war. Understanding whether governments' pledges of resolve are backed by their citizens is crucial for the credibility of these commitments. Here we show, based on survey experiments with 10,011 respondents in the United States, the United Kingdom, Germany, France, and Italy, that these countries' publics share a similar pattern of preferences. In all countries, citizens strongly endorse Ukraine's sovereignty and self-determination while weighing human suffering and conflict escalation risk, but less so economic costs. However, within countries, attitudes are polarized: roughly one quarter of citizens with pro-Western orientations show firm resolve, whereas another quarter with anti-Western views remain largely indifferent to political outcomes for Ukraine. These divisions indicate that democratic party competition could constrain the unity and durability of Western resolve against autocratic aggression.
BACKGROUND: Recent assessments of Ukraine’s wartime health and rehabilitation systems highlight critical shortages in trained rehabilitation personnel. In response, Ukraine has undergone rapid expansion of rehabilitation services through health system reform. These changes created an urgent need to strengthen physical therapy education and align curricula with national and international competency standards. Despite urgent workforce needs, limited evidence exists describing structured, competency-based program reform models for health professions education in active conflict settings. This study provides a feasible framework for reflective educational reform in crisis-affected contexts. METHODS: This multiple-case design with cross-case synthesis describes implementation of the Academic Program Reflection Tool (APRT) across four Ukrainian universities offering physical therapy education. Program leadership teams engaged in a two-year reflective review process involving self-assessment, curriculum mapping, mentoring, and in-person workshops. Two members of each leadership team attended the in-person workshops. Data sources included institutional self-assessments, revised program documents, worksheets, and workshop transcripts. Findings were analyzed descriptively to identify themes related to curriculum development, assessment practices, faculty capacity, student progression, and resource constraints. RESULTS: Institutions reported improved clarity in program philosophy, learning outcomes, and alignment with competency frameworks. Curriculum mapping revealed gaps in areas such as treatment for conflict-related injuries, global health, and continuing professional development. Participants identified limitations in assessment validity, reliance on lecture-based teaching, variability in clinical education practices, faculty shortages, and constrained institutional resources. The APRT process supported development of quality improvement plans and strengthened local leadership capacity for ongoing program reform. CONCLUSIONS: This case study demonstrates the feasibility and educational value of structured program review in strengthening physical therapy education within a low-resource, conflict-affected setting. The APRT provided a framework for aligning curricula with competency-based education principles while supporting local ownership of reform. Findings may inform efforts in rehabilitation and health professions education in other low resource countries.