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Natural ecosystems face significant pressure from climate change, biodiversity loss, and increasing socio-economic and political stressors-all of which are exacerbated by military conflict. This paper focuses on Ukraine and examines the root causes of disturbances in the country's forest socio-ecological systems (SES), as well as the impacts of the ongoing war, to identify recovery pathways. Using a multi-method approach, we assess factors affecting Ukraine's forest SES and identify three key recovery pathways: (1) an economic focus through forest use for low-carbon recovery, including timber for reconstruction and small-scale energy production; (2) a "close-to-nature and close-to-people" approach, leveraging digital tools and innovations for climate-resilient recovery; and (3) anticipatory governance and socio-ecological innovation. Relying on a single pathway risks long-term vulnerability. We highlight that integrating recovery pathways creates synergies. Coordinated actions within Ukraine and from international actors are essential to enable a recovery aligned with "build back better" principles. Our findings offer valuable insights for Ukraine and other conflict-affected regions.

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 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.

Primary Health Care (PHC) is vital to supporting emergency preparedness and health care resilience. There is limited evidence of the impact of crises on PHC services and financing. We aimed to explore the impact of the full-scale invasion of Ukraine in February 2022 on PHC services in the country. We used a mixed-methods approach. Survey data were collected using an online questionnaire sent to a sample (n = 86) of PHC providers in Ukraine in January-February 2023. Fifteen providers were then randomly selected for semi-structured interviews from among those that reported an impact of war and from those areas most affected by conflict. Interviews took place in March 2023. 37% of PHC providers reported being affected by the full-scale invasion. Qualitative data revealed greater impacts at the beginning of the invasion, to which facilities adapted by the time of the survey. The most reported disruptions were electricity cuts (76%) and currency depreciation/price increases (72%). The most reported increased medical need was cardiovascular disease (CVD; 58%) (with qualitative data suggesting an increase in CVD among younger patients) followed by mental illnesses and disorders (55%). 59% of PHC providers reported an increase in remote consultations. Among those facilities that reported a change in revenues, the nature of the change depended on the type of ownership. For example, only 9% of private providers reported increased revenues from humanitarian aid, while 79% (n = 58) of public providers indicated an increase in these sources. To continue strengthening Ukraine's PHC system, the benefit package must be aligned with clinical guidelines, particularly for CVD and mental health; increases in remote consultations should be closely monitored for quality; and payment systems must be adjusted to ensure equity of financing regardless of provider ownership. These findings offer insights for strengthening PHC and emergency-preparedness in other contexts.

The ongoing war in Ukraine has severely disrupted the health system, with repeated attacks on energy and health infrastructure, as well as damage to transport routes, posing a major threat to maintaining the vaccine cold chain. In this context, the authorities, along with WHO, took action to strengthen the preparedness of subnational vaccine stores to effectively respond to emergencies and minimize the risk of temperature excursions during vaccine storage and transportation. Ukraine's vaccine cold chain operates through 25 newly established subnational vaccine stores. These facilities play a critical role in storing and distributing vaccines to lower levels of the health system. Following recent modernization, most stores use WHO-prequalified cold chain equipment, remote temperature monitoring, power backup systems, and specialized vehicles. However, the ongoing conflict exposes them to frequent disruptions in power, logistics, and communications. To address this need, we co-created on-site functional simulation exercises. The 7-h programme combined a locally led risk analysis with three progressively complex simulated emergencies, testing responses to equipment failure, prolonged power outages, and transport incidents. Between July and November 2025, simulation exercises were conducted in 18 oblasts, revealing recurring gaps in alert systems, backup storage and transport capacity, procedures implementation, and staff training. After the exercises, each store developed a tailored action plan to address these. Participant feedback indicated improved technical readiness, clearer roles and responsibilities. Co-created, on-site simulation exercises proved effective and cost-efficient for enhancing cold chain preparedness, offering a replicable model for other public health functions in conflict settings.

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The full-scale Russian invasion in February 2022 severely impacted the organizational structure of Ukraine's healthcare system. The devastation wrought by the Russian aggression requires the Ministry of Health to find ways to address the most pressing healthcare issues and limit impacts on the health of the population. We summarize a series of papers that assessed the challenges to the health and trauma system in Ukraine since the Russian invasion. We performed a framework synthesis of 10 manuscripts using data from a qualitative study of Ukraine's health and trauma systems. We synthesized the findings using the Doctrine, Organization, Training and Education, Materiel, Leadership, Personnel, Facilities, Policy (DOTMLPF-PI) framework developed by the DoD to assess system efficiency and effectiveness and includes NATO's domain of Interoperability. The assessment of Ukraine's military medical system under large-scale combat operations (LSCO) revealed key systemic limitations across the DOTMLPFP-PI domains-particularly training category (27), materiel (19), doctrine (18), policy (17), and interoperability (17). The overall assessment reveals a health system under severe strain, operating within outdated frameworks that are misaligned with modern warfare realities. This work generated a comprehensive set of recommendations that, if implemented, would enhance the effectiveness of Ukraine's military medical system in both the current conflict and into the future. The recommendations are also broadly applicable to other state-actors and their military-health systems, particularly in the context of the evolving realities of modern LSCO.

This article examines Ukraine's Global Fund "Transition Plan" as a governance technology that reorganised time, responsibility, and uncertainty in HIV prevention, rather than as a policy instrument that simply succeeded or failed. Introduced in 2016 as a condition of continued donor support, the Plan promised a "gradual" shift from zero state financing of prevention to 80% by 2020. While the assessments concluded that Ukraine met-and even exceeded-its budgetary commitments, substantially less funding reached frontline services. We show how this gap was produced through performance-based spending, procurement rules, and audit procedures tied to pre-set coverage and service-volume targets that proved difficult to realise under punitive drug policy, repeated cycles of forced client mobility and disappearance, and broader precarity. Drawing on multi-sited qualitative fieldwork and policy analysis, we trace how donors, state bodies, and NGOs reproduced vertical governance through metrics, tenders, and accountability regimes. We situate these dynamics within a "double becoming" of Western and (post-)Soviet modernities, in which future-oriented targets produce (un)certainty while displacing attention from present constraints. The Plan thus appears simultaneously feasible, as an auditable system, and fantastic, as delivery depends on stabilising criminalised, mobile lives-producing an interpretive impasse between budgetary overfulfilment and service underdelivery. This, we argue, constitutes the Transition Plan as a broader condition, as a metaphor for post-Soviet transformation towards the "West".

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.

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.

The full-scale invasion of Ukraine by Russia in 2022 caused immediate and extensive damage to healthcare facilities, particularly those close to the frontline. A new Irish charity, driven by the business community, undertook to identify and replace facilities in key areas, using philanthropic funds. Consultation with local health authorities identified areas where facilities were destroyed, damaged or inaccessible and staff were available to continue to provide services. Purpose designed, equipped and built transportable medical modules in 20' containers were installed. No costs were incurred by local authorities, to whom ownership and operational responsibility were transferred. Data was collected on viability, initial patient contact rates and operation into 2025. 19 modules were installed (eight trauma, five maternity, four primary care, two laboratory), by September2023 and most in frontline communities, at a total cost of €1.7 m. One module was unused and three had to be relocated because of nearby fighting. All active units reported patient contacts (weekly average range 4.2-80.5). Of the 19, 13 remained active in 2025, three have had to close in November 2025 due to nearby fighting and three are unknown/inactive. Local access to healthcare is central to the life of communities. This project developed and delivered medical modules to frontline communities in Ukraine swiftly and at reasonable cost. Many of those units remain active in 2025. The ability of a 'pop-up' charity to deliver 'plug-in', bespoke assistance may have wider application.

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.

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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.

The full-scale invasion of Ukraine has increased demand for rehabilitation services, exacerbating preexisting deficiencies in the rehabilitation system. This policy brief examines Ukrainian legislation, scientific and grey literature, and findings from stakeholder consultations to reveal persistent marginalization of persons with disabilities (PwD) and limited inclusion in education, employment, and public life. The rehabilitation system and its governance remain fragmented and overly institutional, resulting in poor continuity of care, weak interdisciplinary collaboration, and limited community integration. Resource provision is strained by the war and rising demand for assistive devices. Yet, the influx of humanitarian and development actors presents an opportunity to rebuild and modernize systems and narratives. We propose (i) establishing an integrated governance and coordination mechanism for rehabilitation services (ii) launching scalable patient pathway models linking hospitals, community-based rehabilitation, and accompanying service providers, and (iii) developing a case management system for smooth assistive device provision. Improving Ukraine's rehabilitation ecosystem can advance destigmatization, social reintegration, and a rights-based disability framework, offering lessons for other conflict-affected contexts.

Significant concentrations of artificial radionuclides have been detected in drinking water sources not only in areas contaminated by major radiation accidents, but also in the vicinity of operating nuclear power plants. Therefore, the use of effective, broad-spectrum sorbents produced from readily available Ukrainian raw materials in water treatment and purification technologies should be regarded as a strategically important social measure. However, technologies that rely on oxidation to decompose organic components require the recycling of this process. Other promising methods, such as plasma treatment, photocatalysis, and electrocatalysis, currently lack industrial-scale equipment. Meanwhile, there are established water treatment technologies that, despite their proven effectiveness, have not yet been adapted for the treatment of liquid radioactive waste (LRW). This paper investigates the potential application of conventional water treatment technologies for removing the organic component from LRW at nuclear power plants. By employing sorption (using activated carbon and powdered bentonite), coagulation (with ferric chloride), and filtration. We achieved a 75% removal efficiency of the organic component, as measured by COD(Cr) (dichromate oxidizability). The use of a 20% w/v FeCl₃ solution as a coagulant and activated carbon as a sorbent significantly enhanced the purification process. Reducing the concentration of bentonite had little effect on the degree of LRW purification, whereas increasing its concentration noticeably diminished purification efficiency. Nevertheless, the addition of bentonite as a turbidity agent substantially accelerated coagulation and sedimentation. Conversion models were developed to recalculate COD(Cr) (dichromate oxidizability) indicators into corresponding COD(Mn) (permanganate oxidizability) or total organic carbon (TOC), with prediction accuracy validated by experimental data. It should be noted that using such technologies will significantly reduce water and energy consumption, as well as saving time, all of which is extremely important in Ukraine’s current wartime economic situation.

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).

Global trade is shaped by a complex mix of factors beyond supply and demand, including tangible variables like transport costs and tariffs, as well as less quantifiable influences such as political and economic relations. Traditionally, economists model trade using gravity models, which rely on explicit covariates that might struggle to capture these subtler drivers of trade. In this work, we employ optimal transport and a deep neural network to learn a time-dependent cost function from data, without imposing a specific functional form. This approach consistently outperforms traditional gravity models in accuracy and has similar performance to three-way gravity models, while providing natural uncertainty quantification. Applying our framework to global food and agricultural trade, we show that low income countries experienced disproportionately higher increases in trade costs due to the war in Ukraine's impact on wheat markets. We also analyse the effects of free-trade agreements and trade disputes with China, as well as Brexit's impact on British trade with Europe, uncovering hidden patterns that trade volumes alone cannot reveal.