Health System Organization and Logistics of Trauma Care Since the Russian Invasion of Ukraine: A Qualitative Assessment

Abstract

The February 2022 Russian invasion in Ukraine delayed healthcare reforms. The conflict has led to disruption of medical supply chains and a rapid need for integration between military and civilian entities. This study aims to assess the organization and logistics of the Ukrainian trauma system since the Russian invasion. Qualitative key informant interviews were conducted among Ukrainian military and civilian health care workers using a Ukraine Trauma System Assessment Tool from September 2023 to February 2024. Thematic content analysis was used to derive key themes related to medical logistics and organizational leadership from interviews. Thematic saturation was reached after 36 key informant interviews. Respondents described the roles of the Ministry of Health and Ministry of Defense, as well as the collaboration and integration between military and civilian trauma systems with medical logistics as a key area of focus. Respondents discussed on-going efforts to develop a centralized logistics system to better coordinate supplies and overcome current bureaucratic and communication challenges. The organizational structure and the logistics of the trauma care system in Ukraine are integral to the facilitation of healthcare delivery among both the civilian and military health systems. While rapid coordination has supported triage and increased the efficiency of resources, barriers are still recognized by healthcare personnel including disruptions in the medical supply chain, unpreparedness for large-scale combat operations, inadequate training, outdated equipment, and attacks on infrastructure.

What do we already know about this topic?

The February 2022 Russian invasion in Ukraine had significant consequences for the Ukrainian healthcare system and led delayed ongoing healthcare reforms. The conflict has led to disruption of medical supply chains and a rapid need for integration between military and civilian entities.

How does your research contribute to the field?

This qualitative study of Ukrainian healthcare and healthcare adjacent personnel attempts to assess the organization and logistics of the health and trauma system during the invasion in Ukraine to develop an understanding of the current situation to inform medical operations and support for Ukraine, the United States, and the North Atlantic Treaty Organization. To our knowledge this is the first study assessing the impact of the Russian invasion on the Ukrainian trauma care system. Understanding the organization and logistical needs of the trauma system is integral to improving medical delivery within Ukraine.

What are your research’s implications toward theory, practice, or policy?

Insights from Ukrainian healthcare and healthcare adjacent personnel working within the system help to understand the barriers currently facing the system. As the invasion continues, these lessons may drive improvement in the Ukrainian trauma care system and serve as insights for medical systems that may face large-scale combat operations.

Introduction

The Russian Federation’s Invasion of Ukraine in February 2022 severely impacted the organizational structure of Ukraine’s healthcare system. The invasion challenged efficiency in the healthcare sector, as a shortage of medical personnel compounded by indiscriminate attacks on health facilities led to an ongoing loss of personnel, infrastructure, and services.^1,2 Furthermore, supply chain issues have impacted the availability of medications, consumables such as bandages, and other provisions necessary for adequate trauma care.^1,3 The ongoing crisis and the escalating pressures upon Ukraine’s military health system have forced providers to reassess how trauma care is organized and how to get supplies to where they are needed in a large-scale combat operation.

Prior to the invasion, the state of the Ukrainian health system was undergoing significant reform. The once highly centralized Semashko system inherited from the Soviet Union was gradually becoming more decentralized, with regional and local health authorities increasingly empowered to take responsibility for health care facilities within their regions.^4,5 With this decentralization, the role of the Ministry of Health (MOH), the national healthcare body within the Ukrainian government, transitioned from full provision of health care services and administration to solely focusing on administration, which includes developing and approving quality standards for treatment and clinical protocols, organization and accreditation of health care facilities, and regulation of health care providers and manufacturers of pharmaceuticals and medical equipment.^4,5 The Ministry of Defense (MOD), like the Ministry of Internal Affairs, Security Service, and Ministry of Transport and Communications, also maintains its own health care facilities with independent financing that operate in parallel to the MOH facilities, providing services for military personnel. ⁴ The authority of the MOD in matters of healthcare for the Armed Forces of Ukraine was expanded with the establishment of a Department of Health in 2023.^6,7

The Ukrainian trauma system faced reform and challenges before the start of the war.^5,8 A trauma system is a system of care that includes different levels of care working together to care for trauma patients. ⁹ Components of a formal trauma system include coordinated functions, institutions, and personnel and span the continuum of care, including point of injury, prehospital and hospital care, rehabilitation, reintegration, and prevention and quality improvement.^8,9 The lack of a formal trauma system complicates coordination of care for trauma patients.^8,9

The invasion has strained the healthcare resources of both the MOH and the MOD as well as the other agencies involved in disaster management. ¹⁰ Attacks on healthcare facilities and infrastructure have had far reaching impacts beyond direct casualties, disrupting acute and routine care, maternal and childcare, and may have resulted in increased incidence of infectious diseases. ¹¹ Since the February 2022 invasion, the World Health Organization has recorded over 1900 attacks on healthcare facilities. ¹² Restoration of these facilities has been a priority. ¹³ According to the MOH and as of August 2024, 530 damaged facilities have been fully restored, and another 355 partially restored. ¹⁴ In addition to the impact the invasion has had on medical services, the invasion has also had a devastating impact on medical logistics and supply, already strained as a result of the COVID-19 pandemic. Despite the challenges, allied nations and non-governmental organizations, in partnership with the Ukrainian government, are working to supply critically needed items in a responsive, safe, and secure manner.^{15 -17}

While previous literature has focused on the impact of the Russian invasion on the Ukrainian healthcare system at large, there has been limited research into the impact that the conflict has had on Ukraine’s developing trauma system. This study attempts to bridge this gap in knowledge by assessing the organization and logistics of the health and trauma system during the invasion in Ukraine to develop an understanding of the current situation to inform medical operations and support for Ukraine, the United States, and the North Atlantic Treaty Organization (NATO). To our knowledge this is the first study assessing the impact of the Russian invasion on the Ukrainian trauma care system. Understanding the organization and logistical needs of the trauma system is integral to improving medical delivery within Ukraine.

Methods

Study Design and Participants

The methods for this study have been previously described in Lawry et al^18,20,21 and Koehlmoos et al, ¹⁹ which used this same cohort to understand different domains of the Ukrainian trauma system.^{18 -21} Additional domains explored in previously published studies include use of the MOVES-SLC Life Support system, ¹⁸ use of telemedicine, ¹⁹ combat-related injury patterns and injury prevention, ²⁰ and disease and nonbattle injuries. ²¹ None of these previously published studies have discussed the organization and logistical needs of the Ukrainian health system, nor is there any overlap in study results.

We conducted semi-structured, in-depth qualitative key informant interviews (KII) of Ukrainians working in the health and trauma system of Ukraine during the current invasion to obtain detailed descriptions of their experiences and needs related to Ukraine’s trauma care system.

The research team included 8 females and 5 males and was multidisciplinary: 2 university professors (TPK, LLL), 1 university assistant professor (CB), 1 general surgeon (JM), 1 psychiatrist (OB), 1 Vice President of Global Research Development (TEH), 6 research associates (MJ, JKB, KPA, LJ, VM, AK), and 1 undergraduate student (ZA).

Inclusion criteria required that participants were healthcare or healthcare-adjacent personnel (eg, administrators or logisticians) who were currently working in some capacity supporting health and trauma care in Ukraine across applicable NATO levels of care. ²² We recruited participants from trauma and combat-casualty care-related themed symposia and training events held in Warsaw, Poland from June 2023 to February 2024 via purposive and snowball sampling methods and attended either in-person or virtual interviews.^{18 -21}

Instrument

We adapted the Global Trauma System Evaluation Tool (G-TSET) developed by military and civilian trauma specialists as an assessment tool for use in low- and middle-income countries. ²³  The adapted Ukraine Trauma System Assessment Tool (TSAT) evaluates trauma systems by assessing the functional capacity of domains including leadership and organization, prevention of injuries, access to injury care, initial injury care, acute injury care, rehabilitation, and education, research, and quality improvement.^{18 -21} The first component of the TSAT collects quantitative demographic information. The remainder of the tool collects qualitative data and limited quantitative data (yes/no responses) from participants on different domains of the trauma system. (see Supplemental Materials) The instrument was written in English and translated to Ukrainian to account for culturally sensitive wording while holding true to the intent of the instrument.^{18 -21} The TSAT was piloted by the researchers with the Ukrainian translators who were present during the interviews prior to use to ensure the accuracy of the translation.

Procedures

Interviews were conducted in Warsaw, Poland between 28 September 2023 and 28 February 2024 by LLL, JM, TEH, and TPK, and lasted between 1 and 3 h, depending on participants knowledge across trauma system domains. All interviewers received training in conducting qualitative interviews. The interviewer asked questions in English and the discussion was translated to Ukrainian, if necessary. Digital notes were recorded by another researcher (MJ, JKB, LJ, VM) using the KoboToolbox software. ²⁴ A subset of interviews occurred virtually over Zoom, a virtual meeting platform. All participants provided consent before participation. The study objectives and voluntary nature of the study were explained to participants. All methods were carried out in accordance with relevant guidelines and regulations. Oral rather than written consent was approved by the IRBs because of the need for this information to remain confidential. Confidentiality was assured by using a numerical code for each interview to deidentify transcripts. The sample size was determined by saturation which was reached at 36 interviews. No potential participants refused to participate or dropped out of the study. No repeat interviews were conducted.^{18 -21}

Data Analysis

A deductive thematic content analysis was conducted to identify patterns or themes in the data, guided by the assessment objectives and research questions, utilizing NVivo and open coding techniques. ²⁵ The G-TSET tool was used as a framework for analyzing the data to identify patterns.^23,25 Following transcription, the research team manually analyzed the interview data and NVivo results. This analysis involved summarizing, categorizing, and comparing the data to identify common themes across the documents. This process considered both anticipated themes identified through the G-TSET and any emergent themes that arose during data analysis. For this analysis we emphasized discussions involving organization of the trauma system, coordination of patient care, and logistics (Table 1). MJ, JKB, and LJ performed initial coding on all transcripts. To limit any biases, subjectivity, assumptions and experiences that could alter the research process or outcomes, all research team members selected and agreed upon illustrative quotes from each prevailing theme. Study participants were not invited to review transcripts or develop themes. Reporting was done in accordance with consolidated criteria for reporting qualitative research (COREQ) guidelines for reporting practical thematic analysis of qualitative research (see Supplemental Materials).^{8,18 -21}

Table 1.

Subheading and Questions for Leadership & Organization, Planning & Coordination, Resource Assessment, and Logistics & Supply.

Leadership & organization

• Please describe your medical system for trauma care.

• What are the leadership positions in your system and are they military or civilian?

• How well are they integrated?

• What care is not covered by universal healthcare for patients?

Planning & coordination

• How do you coordinate trauma care and evacuation at your location or facility?

• Is the coordination effective?

• Do you have a written plan for trauma and evacuation?

• Were one or both of these updates and if so, when?

• How would you improve the trauma plan and/or the evacuation plan?

• Who develops the strategies and plans for trauma systems at a national or regional level?

• Are these strategies and plans centralized or decentralized?

• What are the strategies and plans for balancing the evacuation of multiple casualties across the hospital system?

Resource assessment

• Have you assessed what resources you need for your trauma system?

• Do you have a formal gap analysis of your trauma system?

• Are you able to share it?

Logistics & supply

• How does your medical logistics system work?

• Do you have someone at your facility who coordinates medical logistics?

• What are your barriers to adequate and timely resupply?

• How would you improve the process/system for logistics and supply?

• Are you receiving medical supplies in a timely manner?

Ethics Statement

Ethical approval for this study was granted through the WIRB-Copernicus Group (23-17597) on March 21, 2023 and the Ethics Committee, First Territorial Medical Unit of Lviv on May 19, 2023. Verbal consent was obtained at the beginning of each interview prior to all other study activities and response was recorded with “Yes” or “No.” To ensure anonymity and protect participant confidentiality, written consent was not obtained.

Results

Demographics

We conducted a total of 36 interviews with civilian and military healthcare or healthcare-adjacent participants between June 2023 and February 2024. Participants were mostly male (61%), between the ages of 28 and 55 years (mean; 34.9 years), worked in Eastern and Northern areas of Ukraine, and represented all NATO Roles. Among military participants who reported their rank, 60% were officers. Most participants were from the Ukraine Ministry of Defense or the Ministry of Health (Table 2).

Table 2.

Demographics of Study Participants.

Age, years; mean (range)	34.9 (28-55)
Region, n (%)
Southern	4 (11.1)
Eastern	13 (36.1)
Western	4 (11.1)
Northern	13 (36.1)
Missing	2 (5.6)
Sex, n (%)
Male	22 (61.1)
Female	13 (36.1)
Missing	1 (2.8)
Occupation, n (%)
Trauma surgeon	5 (13.9)
Physician	5 (13.9)
Chief of medicine	3 (8.3)
Nurse	3 (8.3)
Anesthesiologist	3 (8.3)
Director, Emergency Services	2 (5.6)
Researcher	2 (5.6)
Medic	1 (2.8)
Chief, Rehabilitation	1 (2.8)
Commander, Role II	1 (2.8)
Mental Health Services Associate	1 (2.8)
Head, Moral Psychological Service Branch Combat Stress Control Group	1 (2.8)
Deputy Director, Health Care Innovations	1 (2.8)
Deputy Director, Health Development Department	1 (2.8)
Other a	4 (11.1)
Missing	2 (5.6)
NATO role equivalent, n (%)
Pre-hospital/role 1	4 (11.1)
Role 2	3 (8.3)
Role 2+	7 (19.4)
Role 3	7 (19.4)
Role 4	4 (11.1)
Other	6 (16.7)
Missing	5 (13.9)
Civilian/military provider, n (%)
Military	20 (55.6)
Civilian	16 (44.4)
Military rank, n (%) (n = 20)
Major	1 (2.8)
Captain	1 (2.8)
Lieutenant	4 (11.1)
Sargeant	4 (11.1)
Missing	10 (27.8)
Organization affiliation, n (%)
Ministry of Defense	17 (47.2)
Ministry of Health	12 (33.3)
Ministry of Interior	1 (2.8)
National Guard	2 (5.6)
Commercial Company	1 (2.8)
Charity	1 (2.8)
Missing	2 (5.6)
Years in current position; mean (range)	4.6 (0.33-19)

^aOther: Grant manager, Deputy Director – General, Project Lead – Commercial Company, Sergeant.

Leadership

Respondents described the organization of the Ukrainian trauma system as a joint effort led by both the MOH and MOD, with the MOH leading and coordinating efforts within civilian facilities and the MOD leading and coordinating efforts within military facilities.

“Military hospitals are under [the] Medical Commander of Armed Forces of Ukraine. Civilian hospitals follow the MOH but are usually owned by the local governmental authority,” (Deputy Director of Healthcare Innovations, North).

Because of this, respondents who worked at military facilities reported that leadership was composed of only military members, and respondents working at civilian facilities reported that leadership being composed of civilians. However, in some cases, military and civilian leadership work nearby as needed; a few civilian respondents reported that a portion of their facility had been converted into a military facility.

“There is a military hospital based in our facility which is under the Ministry of Defence, but I work in the civilian side for the Ministry of Health,”

(Head of Clinical Trials, West).

Overall, the role of the MOH is to provide guidance on patient care and to oversee trauma care throughout Ukraine, which includes care provided by the MOD.

“MOH has a department/area, Disaster and Catastrophic Support, [that] can develop protocols, standards, orders, and make laws to govern the care of patients. MOH is responsible for the care of all patients to include trauma in UKR. [The] commander [of Medical Forces for UKR and MOH would provide approval for new processes such as whole blood. This has now occurred for hospitals by MOH and then at the military unit, it has been allowed through the MOH,” (Role 2+, Trauma Surgeon, East).

However, 1 participant indicated that the guidelines developed by the MOH are not necessarily universal, that when it comes to military facilities, “It can be separate guidelines, standards. Separate patients”, (Role 3, Trauma Surgeon, South).

The role of the MOD, as it relates to trauma care, is to ensure appropriate care for service members, oversee military hospitals and facilities, and coordinate with civilian facilities for referrals.

“The MOD has armed medical forces, and they provide medical services at all the stages, in general,” (Role 2, Commander Armed Forces of Ukraine, East)

Organization of Care

Participants described differences in the organization of trauma care for civilian and military patients differs, with military trauma patients passing through several levels of care, while civilians receive most of their care at the city hospital level.

“. . .With the civilian it is very simple - it is happening in the city. EMS ambulances are bringing patients into the hospital. From there we provide care, surgery, reconstruction. We also provide rehabilitation, which is unusual in Ukraine. For military personnel there is a lot of trauma, stabilization points, different levels of care - front line hospitals and rear hospitals. We are the rear-based hospitals and we are receiving patients by train. They come to us from military hospitals. [We provide] ICU, trauma, surgery ward, rehabilitation, construction.”(Role 4, Mental Health Services, West).

Care coverage also differs between civilian and military according to respondents.

“With the military, they are all covered. With civilians, not everything is covered,”

(Role 3, Trauma Surgeon, North).

However, many respondents noted that there are options for civilian patients to go to a private facility and pay for care if they have the means to do so.

Trauma Care Coordination Between MOD and MOH

Some respondents reported that due to the challenges posed by the ongoing conflict, despite the separation between military facilities managed by the MOD and civilian facilities managed by the MOH, an informal agreement between the MOD and MOH allowed military personnel to be seen at civilian facilities when military facilities are overwhelmed.

“Since the start of the war, the capability of caring for combat patients at many of the military hospitals was overwhelmed and not capable of providing full trauma surgical care. Many of the civilian hospitals ended up caring for military casualties. Care has not been well integrated,”

(Role 2+, Trauma Surgeon, East).

Another respondent echoed this sentiment saying,

“Military hospitals are only for military and civilian is for both,”(Role 1, Nurse, East).

Another respondent noted that civilians may be seen at military facilities during emergencies.

“We do provide emergency to civilians after mission attacks if they come to our facility for care,” (Role 2+, Chief of Medicine, East).

Participants noted that due to the targeting of military healthcare facilities by Russian forces, treatment of military personnel at civilian facilities can present a security hazard.

“It is a nightmare for all of us. My view and that of my friends, the way they did this was not very good. A floor of military hospital and a floor of civilian hospital so it is not good to keep security at the hospital because of this. They do not feel safe at our facility because of the exposure to external visitors and it makes the civilian hospital a target for Russian missiles. Because we are located in the city center with a university, a park, and a high school, with so many children and people walking around it is like a real target in the city center,” (Head of Clinical Trials, West).

Respondents reported that military and civilian coordinators work to ensure that facilities are not overwhelmed. These coordinators help to facilitate the evacuation of multiple casualties across facilities.

“. . . they have a coordinator who knows how many places for casualties there are. If I need to move patients, I call the coordinator. The coordinator asks what type of injuries, and they tell me what hospital to go to,” (Chief Medicine, North).

Respondents noted that coordination between military and civilian facilities can be challenging, however, 1 participant noted that it is improving.

“Cooperation has been developed - we are working together with both military and civilian. It’s not easy sometimes - in the beginning it was difficult, but with experience, we are able to work together,” (Role 4, Mental Health Services, West).

Trauma System Planning and Coordination

Respondents indicated that coordination between the MOD and MOH extends to larger-scale strategic planning for the trauma system at a national level through joint working groups.

“The MOH and MOD create working groups and those groups have representatives from different areas and those groups actually work on the strategies,” (Role 3, Chief Rehabilitation).

However, 1 respondent indicated that at the regional and local level civilian facilities have more control over trauma system planning.

“. . . at the regional level it is the Dept of Health, but locally every hospital can come up with its own patient pathway within the facility,”

(Head of Clinical Trials, West).

When respondents were asked whether their facility had a written plan for trauma and evacuation, the majority reported that they do have written and updated plans, though the exact time frame of updates varied. Multiple military respondents reported that the plan is updated before each combat mission. However, civilian respondents indicated that the written plans tended to only be updated when new information is being added rather than at regular intervals.

Logistics and Supply

Respondents describe their logistics system as a combination of centralized and decentralized supply sources, with both MOD and MOH coordinating logistics and supply for their respective facilities.

“. . . there is a national supply and local supply for equipment and medicines and different supplies. We receive something procured from the state budget from the MOH and distributed to the hospitals from there. But we also have local procurement of certain devices like stents or implants,”

(Head of Clinical Trials, West).

Nearly all respondents reported that their facility has a logistics coordinator who manages medical logistics and/or supplies, with some having a department dedicated to procurement, others having a logistics coordinator or officer, and others indicating that this is a responsibility of their facility’s Chief, Commander or Director. One respondent whose facility had a dedicated department for procuring supplies described this process.

Respondents reported barriers to supply, including a lack of funds, difficulties with the importation of goods, and the invasion itself. Communication gaps were also highlighted by several respondents as being additional barriers to supply.

“We have the necessity of commanders who understand the perspective of doctors - what they need and the conditions they are working under. Because they don’t understand this they are not providing us with what we need,” (Role 3, Trauma Surgeon, East).

Bureaucracy was also frequently mentioned by respondents as another barrier to supply.

“Bureaucracy is one of the barriers. I am not sure whether the formal supply chain can provide us with everything we need even if we overcame the bureaucracy,” (Role 2+, Physician, East).

Potential Improvements

To improve leadership and organization within the Ukrainian Trauma System, respondents requested additional training and capacity building.

“. . .[I] want training on how to build a working system, working with minimum people and minimum supplies, but with minimum, [we] must do maximum,”

(Role 3, Trauma Surgeon, South)

Respondents also described several improvements that could be made to improve logistics and supply. Many participants discussed the need for a unified system where the need and use of supplies could be documented. Some participants suggested that this system should be automated.

“We should start from our own to make some good system to understand what we used and get it off and how much this one and this one how much we have syringe and scalpel and this it should be more interactive in the brigade we are now working on this we are using tablets, QR codes, etc,” (Small Unit/Prehospital, Master Sergeant National Guard, South).

Another suggestion was the ability to update doctrine, specifically supply lists, and to improve communication between all levels of care. Respondents want the ability to receive updated supplies and equipment.

“. . .better communication from command level to medical chief of unit to combat medics. supply lists is old, from 2016, needs have changed over time. more need for training, need official supply list updated so we don’t need to keep requesting from NGO,”

(Military, Chief Medicine, North).

Most participants discussed the need to improve finances for logistics and supply but did not have suggestions for how to improve this issue.

Discussion

This qualitative study assesses the overall organization and logistics of the Ukrainian trauma care system using responses from Ukrainian healthcare personnel. As the Ukrainian government continues to enhance and coordinate the delivery of trauma care, aspects of administration and the supply chain are crucial to operational success. Barriers recognized by healthcare personnel include disruptions in the medical supply chain, unpreparedness for a large-scale operation, inadequate training, outdated equipment, and attacks on infrastructure. Previous studies on the impacts of the invasion on the Ukrainian trauma system also highlighted limited equipment and supplies, inadequate training, and a lack of maturity in the coordination and organization of the trauma system in comparison with more formal trauma systems.^{8,18 -21} These finding are in line with findings from Barten et al. ²⁶ that document the devastating impact of these attacks on healthcare infrastructure in Ukraine within the first year of the conflict and the ability of such attacks to dramatically limit the capability and capacity of a healthcare system

The long-term Russian invasion of Ukraine left the country devoid of critical infrastructure for trauma care and mass evacuation. Without a formal trauma registry system, Ukrainian healthcare facilities found themselves overburdened and lacking in effective communication, often utilizing handwritten notes to discuss patient care.^8,27 Deficiencies in governance and a challenged patient transport system, due to lack of air superiority, further hinder the effectiveness of the Ukrainian trauma care system. ⁸ Healthcare personnel requested modernization of healthcare coordination, while facilities have found themselves in desperate need of equipment, medications, and transportation as the medical supply chain has become further impacted by attacks across the region. ⁸

Ukrainian facilities have sought to remedy trauma care system organizational structure issues that emerged early in the invasion. Effective leadership is crucial to the success of patient outcomes and provider performance in healthcare settings, particularly in Ukraine where guidance is frequently updated in day-to-day operations. ²⁸ As national level agencies cooperate with a decentralized healthcare system, strong leadership only becomes more vital to manage administration and organization. Respondents highlighted that leadership roles have been filled to adequately direct the influx of both military and civilian medical personnel. Personnel in leadership roles also bring expertise in critical areas such as surgery, military medicine, and transportation, providing valuable wisdom in essential wartime healthcare domains. An established leadership structure introduces benefits such as emotional support and recognition, keen elements that can retain morale and enhance the delivery of care. ²⁹

Throughout the conflict, the distinct roles of the MOH and MOD have merged. The invasion has spurred these entities to work together rather than in parallel. This is evident by soldiers being treated at civilian hospitals and vice versa. Integration of military and civilian has been shown to improve care in both systems both during war and peacetime. ³⁰ Collaborations in training and organization can improve emergency preparedness and bolster response, potentially avoiding the “walker dip,” a cycle describing how medical care for soldiers improves during conflict but declines in peacetime, resulting in a skillset that needs to be relearned during the next conflict.^{31 -33} While integration between military and civilian trauma systems is usually beneficial, some respondents did note that military casualties being treated at civilian facilities posed a security risk. According to the World Health Organization this risk is even higher for health transport workers. ³⁴ This will be important to consider as integration and collaboration between civilian and military trauma systems continues in Ukraine, as well as for future conflicts.

Improved management of patients and personnel has demonstrated success in reducing mortality, vitally important for Ukraine’s numerous regional hospitals with varying systems. ³⁵ Collaboration of diverse personnel also proves to be important when addressing differing levels of care in the trauma system, especially throughout integration of military and civilian facilities. ³⁰ Respondents have noted headway in the coordination of care for both soldiers and civilians, including the establishment of hospital specialties to facilitate triage, however, information flow is still not streamlined between each system and there is room for improvement.

Respondents expressed the need for a more unified medical logistics system as attacks on supply lines and infrastructure threaten the delivery of critical provisions. Prior to the invasion, Ukraine’s military was poised to establish a logistics system equivalent to NATO standards; however, Ukraine’s health reforms were halted when the conflict began in turn impacting the medical supply chain and the conflict required “out of the box” thinking to keep the supply chain running. ³⁶ The combination of the pandemic and the invasion has drained Ukraine of medical supplies, requiring allies to provide aid.^37,38 Despite developments toward a centralized medical logistic supply system, there are still issues in timely delivery of supplies due to targeted attacks. However, anecdotally, outside of this study, decentralized supply chains have developed especially at front lines for supplying medical units such as using dedicated military vehicles for ensuring adequate supply chains. ³⁹ These may prove beneficial as the conflict progresses.

Respondents addressed finances, bureaucracy, and attacks on transportation as key reasons for delayed deliveries. The Ukrainian government has offered methods of optimized distribution through projects such as Korovai, an initiative created to receive lethal and non-lethal aid from the international community, aiming to deliver supplies to facilities in dire need. ⁴⁰ Polished inventory practices can significantly improve facility operations. Medical personnel may assist in the supply system by communicating their inventory and rotating out expired items to prevent national mismanagement of supply distribution. ⁴¹ The military’s approach to an automated system of logistics has not yet extended to civilian facilities, leading to discrepancies in supply between military and civilian hospitals across all regions of Ukraine.

The continued collaboration, coordination, and integration of military and civilian systems and leadership can help to enhance trauma system capacity. ⁴² Though continued partnerships and refinement of medical logistics systems, Ukraine may be able to reduce dependency on international allies. Despite the success in rapid scale up of the trauma system, bureaucracy, finance, and communication issues have the potential to continue to disrupt the medical supply chain and organizational structure. The trauma care system has made considerable strides in integration and development, yet some improvements may be limited in the short-term due to the invasion. Continued integration and partnership between military and civilians will be crucial going forward for logistical and operational success.

Limitations

Participant perspectives were limited to their relative location and the timeframe of June 2023-February 2024. Therefore, their responses may not be representative of all Ukrainian healthcare personnel perspectives. The fluidity of the situation in Ukraine may limit the generalizability of these findings to the current state of trauma care. Biased assessment of the trauma care system may also manifest within participant responses. Additionally, participant perspectives are limited to the trauma care system and are not representative of the entire Ukrainian medical system.

Interviewers emphasized that participation in the study would not result in any material gain; however, respondents might have underestimated or exaggerated their responses if they believed it served their interests. Although not formally validated for Ukraine, the TSAT used for this study was an adoption of the G-TSET that was previously published by Remick et al. ²³

Conclusions

The organizational structure and the logistics of the trauma care system in Ukraine are integral to the facilitation of healthcare delivery amongst all Ukrainians. Insights from Ukrainian healthcare and healthcare adjacent personnel working within the system help to understand the barriers currently facing the system, including disruptions in the medical supply chain, unpreparedness for a large-scale operation, inadequate training, outdated equipment, and attacks on infrastructure. Despite these barriers, established leadership and enhanced coordination methods have supported triage and increased the efficiency of resources. As the invasion continues, these lessons may drive improvement in the Ukrainian trauma care system and serve as insights for medical systems that may face large-scale combat operations.