A qualitative assessment of war-related rehabilitation needs and gaps in Ukraine

Abstract

Background

Ukraine’s Ministry of Health formally recognized rehabilitation as an essential component of universal health coverage in 2020. However, services remain fragmented and under-resourced, particularly following the full-scale invasion by the Russian Federation in February 2022. Widespread injuries due to trench warfare, drones, and large-scale ground combat have placed unprecedented strain on the Ukrainian trauma and rehabilitation systems, which continue to lack a cohesive national strategy. This study aimed to (1) assess the trauma and rehabilitation system in Ukraine during the ongoing conflict; (2) identify current needs, gaps, and opportunities for strengthening rehabilitation services; and (3) inform national and international stakeholders—including the United States and NATO—about urgent priorities to support Ukraine’s rehabilitation infrastructure, reintegration pathways, and gender-sensitive care delivery.

Methods

We conducted 36 qualitative key informant interviews across all NATO levels of care using an adapted Global Trauma System Evaluation Tool. Thematic analysis focused on rehabilitation-related domains.

Results

Respondents highlighted shortages in staff, equipment, and mental health integration. Rehabilitation remains unevenly implemented, with better access for military versus civilian patients. Care for survivors of conflict-related sexual violence and support for women’s equitable access were consistently cited gaps.

Conclusions

Ukraine’s growing burden of war-related injuries necessitates urgent investment in a coordinated national rehabilitation strategy. Priorities include workforce development, equipment supply, mental health integration, and inclusive care models that address the needs of women and conflict related sexual violence survivors. Evidence-based rehabilitation, supported by validated training for clinicians, is essential for long-term recovery, societal reintegration, and national resilience.

Introduction

Prior to the Russian Federation invasion of Ukraine in February 2022, the Ukrainian health system was undergoing reforms to improve care despite significant financial constraints [1–2]. One of the landmark reforms was the Ministry of Health’s formal recognition of rehabilitation as a core component of universal health coverage through the 2020 law “On rehabilitation in health care” [3–4]. This law advanced the definition of “disability” and imbedded multidisciplinary rehabilitation into the Ukrainian health system at all levels [3–4]. However, despite legal integration, a national rehabilitation strategy has not yet been implemented to coordinate system-wide or emergency response efforts [4]. Rehabilitation services remain fragmented and severely understaffed, a situation exacerbated by the ongoing destruction of healthcare infrastructure and displacement of healthcare personnel due to continued hostilities [5–8].

Ukraine’s rehabilitation burden was substantial even before the war, with an estimated 50% of the population in 2019 potentially benefiting from rehabilitation services due to the high prevalence of non-communicable diseases such as cardiovascular disease and diabetes [7]. Since then, the COVID-19 pandemic and the war have further intensified these needs. The nature and scale of war-related injuries—including those caused by trench warfare, drone strikes, and large-scale ground combat operations—are unprecedented in recent conflicts [9]. These injuries frequently result in complex, long-lasting physical and psychological complications [7]. Early rehabilitation, ideally initiated during the acute care phase, has been shown to improve recovery, reduce complications, and shorten hospital stays [7, 10].

Despite this evidence, rehabilitation is often neglected in the early stages of conflict, resulting in avoidable negative outcomes [7]. Ukraine has responded by introducing rehabilitation-focused health professions, supported by international partners to address complex trauma, amputations, and brain and spinal injuries. Rehabilitation must also encompass care for conflict-related sexual violence (CRSV), as such cases have been documented among both men and women during the war [11]. Ukraine, as a signatory of United Nations Security Council Resolution (UNSCR) 1325, has committed to addressing the rehabilitation and reintegration needs of women and girls in post-conflict recovery [12, 13].

This study aimed to assess the health and trauma care system in Ukraine during an active conflict using a real-time, qualitative approach to identify rehabilitation needs, gaps, and opportunities for improvement. Specifically, we sought to (1) characterize current rehabilitation capacity and access across regions and levels of care; (2) identify system-wide challenges related to workforce, infrastructure, and integration of mental health and gender-specific services; and (3) inform national and international stakeholders, including the United States (US) and NATO, of strategic opportunities to support Ukraine’s rehabilitation system.

This research represents a novel effort to evaluate rehabilitation system readiness and capacity using an adapted trauma system assessment tool during an ongoing war. Unlike retrospective reviews or post-conflict assessments, this study provides real-time insights from frontline Ukrainian health personnel to guide immediate and long-term planning. The invasion of Ukraine remains ongoing, and the country’s health and trauma care systems continue to evolve. This article presents a snapshot of the rehabilitation landscape based on qualitative interviews conducted between June 2023 and February 2024, reflecting the status and perceptions of the system during this phase of the conflict.

Materials and methods

Study design and participants

We conducted semi-structured, in-depth key informant interviews (KIIs) of Ukrainians working in the health and trauma system of Ukraine during the current conflict to obtain detailed descriptions of their experiences and needs related to Ukraine’s trauma care system. Participants were from all regions of Ukraine.

Participants were included if they were healthcare or healthcare-adjacent personnel who were currently working in some capacity supporting health and trauma care in Ukraine across applicable NATO levels of care [14]. These include small unit/prehospital/Role 1, Role 2/small aid clinic (no surgical care), Role 2+ (limited surgical care), Role 3 (District hospital, some specialty care), and Role 4 (Academic Hospital, specialty care, rehabilitation) [14]. Participants could also be identified as an ‘Other’ level of care if in a research or leadership position. There were no other inclusion criteria. Individuals who did not work in a healthcare or health care adjacent capacity during the current conflict were excluded. Participants were recruited from trauma and combat casualty care related themed symposia and the Advanced Surgical Skills for Exposure in Trauma (ASSET) training events held from June 2023-February 2024 in Warsaw, Poland. At these events, participants were recruited for participation via purposive and snow-ball sampling methods and attended either an in-person or virtual interview.

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 [15]. 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, education, research, and quality improvement [16]. The first component of the TSAT collects quantitative demographic information including the date of the interview, study region, subject interview ID number, affiliation (military or civilian), position title and description, rank and service if military, organizational affiliation, time in current position, and experience with trauma. The remainder of the tool collects qualitative data from participants on different domains of the trauma system [16]. (Table 1)

Table 1.

Domains of the Ukraine trauma system assessment tool (TSAT)

Leadership/Command and Control	Critical Care in Definitive Care Facilities
Planning and Coordination	Telemedicine in Definitive Care Facilities
Resource Assessment	Injury Patterns in Definitive Care Facilities
Logistics and supply	Blood Product Use in Definitive Care Facilities
Communications	Disease and non-Battle Injuries (DNBI) in Definitive Care Facilities
Mass Casualty Plan	Mental Health
Logistics and Supply	Rehabilitation
System Triage and Patient Transfer	Injury Registry, Epidemiology, and Process Improvement
Prehospital care/ Emergency Medical Services	Technology/ Products/ Devices
Prehospital Chemical, Biological, Radiological, Nuclear, and Explosives	Injury Prevention
Prehospital Training	Environmental Factors and Dental Trauma
Prehospital Training Definitive Care Facilities	Summation Questions

The semi-structured directed qualitative instruments were developed in cooperation with the consortium involved in this study and its stakeholders. These interviews provided an in-depth understanding of the complicated health and trauma system as understood by individuals working in Ukraine’s health and trauma system during the current conflict. 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. The Ukrainian version was back translated for consistency and correctness, reviewed for content validity and pre-tested among six healthcare workers. Changes were made to establish clarity of questions and cultural appropriateness.

Procedures

Invitations for symposia and ASSET training events were sent to participants via email based on existing relationships through volunteer work and recommendations from the Ukrainian Ministry of Health and Ministry of Defence. Interviews (n = 36) were conducted in Warsaw, Poland from 28 September– 28 February 2024 in a setting that offered privacy and confidentiality. Two researchers and a translator conducted interviews. One researcher asked questions in English and the discussion was translated to Ukrainian if necessary. Another researcher took digital notes using the KoboToolBox platform. Probes were used to gather as much detail as possible along the TSAT domains. A subset of interviews occurred virtually over Zoom using the same methodology as used for in-person interviews due to scheduling issues or travel changes. The sample size was determined by saturation, when no new meaningful themes emerge from the data, which was reached at 36 interviews. Ethical approval for this study was granted through the WIRB-Copernicus Group (23-17597) and the Ethics Committee, First Territorial Medical Unit of Lviv.

Data analysis

Deductive thematic content analysis was used to identify patterns or themes in the data and was guided by the assessment objectives and research questions using NVivo and open coding techniques [17]. We used the G-TSET tool as our framework for analyzing the TSAT to identify patterns that we expected to see in the data [15–18]. Any new patterns were identified and recorded through open coding where themes are identified as they are found in the data. NVivo was used to organize the data and pull-out themes identified. The research team then manually summarized, categorized, and compared interview data and NVivo results to identify common themes from transcribed documents including expected themes from the G-TSET tool and any new themes. For the purposes of this analysis, emphasis was placed on discussions involving the needs and gaps for rehabilitation as expressed by respondents. Rehabilitation themes crossed many of the domains in the trauma system. (Table 1) Research team members selected and agreed upon illustrative quotes for each prevailing theme identified to limit any biases, subjectivity, assumptions, and experiences that may shape the research process and outcomes.

Data availability

Data that support these findings are curated by the study team and are not available for public distribution.

Results

Demographics

Between June 2023 and February 2024, 16 civilian and 20 military healthcare or healthcare adjacent participants were interviewed including 22 (61%) males and 13 (36%) females, (missing n = 1). Participants were between the ages of 28 years and 55 years (mean: 34.9 years). (Table 2) Most of the participants worked in Eastern and Northern areas of Ukraine. The study was able to obtain experience from across all NATO roles. Of those in the military who reported rank (10), 60% were officers. Participants were mostly from the Ukraine Ministry of Defence or Ministry of Health. Results are presented by themes identified through deductive analysis of interviews using the TSAT instrument.

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)
Othera	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 (5.0)
Captain	1 (5.0)
Lieutenant	4 (20.0)
Sergeant	4 (20.0)
Missing	10 (50.0)
Organization Affiliation, n (%)
Ministry of Defence	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

Rehabilitation context

In addition to the qualitative questions in the TSET survey, quantitative questions were also utilized to better quantify the current state of rehabilitation according to respondents. Half of the respondents interviewed noted a rehabilitation program at their facility. (Table 3)

Table 3.

Characteristics of rehabilitation programs in Ukraine

Characteristic N = 36	Yes n(%)	No n(%)	Don’t Know n(%)
Do you have a rehabilitation program at your facility	16 (45)	17 (47)	3 (8)
Do you have communication between rehabilitation and acute care?	18 (50)	13 (36)	5 (14)
Is the electronic health record integrated between acute care and rehabilitation care?	13 (36)	17 (47)	6 (17)
Are there differences in rehabilitation care for each sex?	4 (11)	19 (53)	13 (36)
Are there differences in rehabilitation care between military and civilian patients?	12 (33)	10 (28)	14 (39)

Most respondents mentioned there was communication between rehabilitation and acute care, however, respondents stated the electronic health record is not integrated between the two systems. Most respondents stated there were no differences in rehabilitation for males and females, however, more than a third did not know if this was the case.

Quality of rehabilitation care

The wait for rehabilitation beds was mixed with everything from no wait to “long waits”, especially if prosthetics were needed. Due to the wait, some patients were being sent to foreign countries for rehabilitation. Respondents did not describe a robust system for rehabilitation calling it “…a mix of Soviet model of rehabilitation best called hotel services that include smoking with buddies, playing cards, and sitting in the spa and more traditional rehabilitation where patients actually receive services and are not there just to rest”(MOH, north). Others consider it a system in progress: “[We are] working on physical rehabilitation combined with psychotic [psychological] rehabilitation. But we don’t have such thing yet” (Role 2 + physician, east). And “…rehabilitation; it’s new in Ukraine… we don’t [didn’t] expect that we will have a war and there’s so many casualties, so we don’t have a wide system of rehabilitation, now we need to start to build it very fast [in] a very simple form” (MOH, north). There is non-governmental organization (NGO) support for rehabilitation specialty centers or “Severely injured military members are going through long rehabilitation centers at foreign countries” (Captain Medical Forces, Armed Forces). Respondents stated there were better and more rehabilitation options for injured military members compared to injured civilians and there were specialized prosthetics for military, not available to civilians. Rehabilitation is not covered under the universal health care program for civilians: “…time to time [civilian] patients have to find the possibility to [seek] rehabilitation on his own, to cover themselves” (Role 3, Trauma Surgeon, south).

Components of rehabilitation

The components of rehabilitation were described as having physical therapy, mental health care and amputee care. Citing the 2020 Law on Rehabilitation in Health Care^3–4, respondents described components that suggest rehabilitation is multidisciplinary. “It is a law that we have our rehabilitation; there is a strategy for a cluster that each cluster will have a rehabilitation unit with a multidisciplinary rehabilitation team with [occupational therapy] OT, psychologist, speech therapist, social worker…a rehab unit must have all of these specialists…also prosthetics” (Role 3 physician, north). It is not clear if mental health care was integrated into rehabilitation or if mental health care was separate: “…most mental health care is transferred to psychiatrists” (Nurse, east) and “specific institutions and facilities [have] psychological department[s] that help with this post-depression, [and] have people that do rehabilitation” (Nurse, east). Whereas it was a stated belief that: “military are more motivated to rehabilitate” (Role 3, Physician in Rehabilitation), some reported worse mental health outcomes for military: “The military personnel are in worse condition than the civilians. Before [the large scale invasion] only 20% had mental [health] problems, now it is 90–95%. I think part of it comes to rehabilitation. It is very hard to bring them back to life so to say” (Role 2+, surgeon, east). Others felt mental health problems were equally impacting everyone, military, civilian and medical staff.

Traumatic Brain Injury (TBI)

Most of the respondents stated they were seeing and/or treating TBIs. However, treatment capabilities varied widely from referral of patients to neurosurgeons for pressure monitoring or to more mature programs to address TBI: “We have a full-scale diagnostic screening and a TBI department. We need more training here. Some procedures are performed by non-neurosurgeons” (Role 4, MOH, mental health services, west).

Rehabilitation equipment

Respondents stated prosthetics came from a factory in Dnipro, or from NGOs, or were supplied at the specialized rehabilitation center through the MOH or MOD and “international partners”. Equipment such as wheelchairs and beds are donated by charitable organizations and NGOs. There was one respondent who was concerned that prosthetics were being sold to injured patients privately instead of being provided through the universal health care program: “I saw that one hospital was not ordering the number of protheses needed to cover the number of amputations, they only ordered 50 from procurement when they had 300 amputations…that means someone is profiting from selling them privately” (MOH, north). Respondents were asked about devices that did not work well. Among the devices listed, one respondent noted “physical therapy devices” among the non-approved innovations in clinical care: “Many devices could be improved. During my career evolution [and] in the beginning, a lot of physiotherapy devices, [such as] ultrasound.. along the way there was no evidence and we stopped using them and currently we seldom use them for physical therapy” (Role 4 physician, north).

Reintegration

Most of the respondents are unaware of reintegration programs. For those who are aware, casualty integration programs are administered in collaboration with NGOs and by the military. Some expressed a lack of a reintegration process: “We don’t have a special program on how to reintegrate them, reassociate them. That’s why I hope in our government we will provide special veteran program” (MOH physician, north). Whereas some were able to describe a process (in collaboration with NGOs): “We try to improve physical health and movements, ambulation, and self-care for patients. Try to improve their mental health. We have volunteers and their families who discuss[the] next phases with them. If a patient stays for one month or two months, need to know what is next. Get together with patients, volunteers NGOs determine what is best for the patient” (Role 4 physician, north). One respondent described a hotel where patients could stay with their family during rehabilitation. There are government administered military reintegration programs according to the respondents.

Barriers to rehabilitation

The barriers listed include the overwhelming numbers of injured patients needing rehabilitation: “There are a lot of casualties and not enough specialists and supplies for everyone” (Role 2 nurse, north). The lack of trained providers for rehabilitation medicine and a dearth of specialists were a concern of respondents in addition to the numbers of rehabilitation centers that are under construction: “We can build so many buildings for rehabilitation centers, but walls don’t treat, only people can treat people” (Role 2 + physician, east). Equipment shortages were also stated as a barrier such as shortages of beds and the capacity to produce prosthetics.

Conflict Related Sexual Violence (CRSV)

Many of the respondents stated they were seeing CRSV cases but felt they needed better training to respond to victims of sexual violence and torture. One respondent reported a hospital was using online training: “… it was kind of videos that we had to watch and a test we had to do. [We need] more about awareness of psychological issues but there was a section on sexual violence, it was for doctors but not for nurses or other staff” (Role 3 physician, north). Others stated: “some training is provided but not enough for domestic violence” (MOH, north). When the research team asked about the prevalence of CRSV, female respondents were more likely to identify this as an issue. One respondent stated the following: “When the Russian military entered/invaded there were such examples of sexual assault. If we talk about sexual assault in the context of war. If there are transgender or the LGBT people coming to serve in the Ukrainian Army, then they may also have this happen. Among the population of Ukraine such cases may appear. It would not be correct to say that this is a huge problem, but such cases do happen. It is a society problem…in each country”. (MOH, north).

Recommendations for improvement

Mental health providers such as psychologists, psychiatrists, and those who specialize in post-traumatic stress disorder (PTSD) were an important recommendation by many for improvement to rehabilitation: “The military personnel are in worse condition than the civilians. Before only 20% had mental problems, now it is 90–95%. I think part of it comes to rehabilitation. It is very hard to bring them back to life so to say” (Role 2 + physician, east). Provision of education and training for rehabilitation providers was an overall recommendation from many due to the lack of a specialized track for rehabilitation medicine. A “roadmap” and national strategy for rehabilitation were also mentioned as a necessary improvement: “[we] have to change the general definition of rehab, living in post-Soviet country; we have to understand about rehabilitation using old soviet methods, [and we] need to work with expanding rehabilitation” (Captain medical forces). More centers and equipment were stated as a need in addition to “small clinics” all around Ukraine. “There are a few bigger ones, but there is a big waiting list for them. In rural areas I don’t think people are getting any kind of support so I would pay attention to these areas and invest. You don’t need big centers in rural areas, but you can create different types of programs for reintegration and rehabilitation for these areas”(Moral Psychological Service Branch Combat Stress Control Group, east).

Discussion

This study contributes to the understanding of the current situation to inform current and future needs for rehabilitation. Respondents discussed major issues in continuity of care during rehabilitation, significant quality issues with rehabilitation services provided, and major gaps regarding the types of conditions treated and types of rehabilitation staff available in Ukraine. Furthermore, there was a noted lack of integration of mental health providers. There is a need for education and training programs across all areas of rehabilitation—physical medicine and rehabilitation, physical therapy, occupational therapy, nursing, speech therapy, social workers, and more to expand the capacity of rehabilitation especially in the context of mental health and CRSV. Development of a unified plan or National Strategy for rehabilitation and reintegration is also crucial to fill the growing rehabilitation needs due to injuries from the war.

While physical rehabilitation needs have been emphasized in earlier assessments, our findings underscore the critical need for the integration of mental health services into the full rehabilitation continuum. Respondents frequently described fragmented mental health services, limited primarily to psychiatric consultation rather than embedded psychological care within rehabilitation settings. In particular, individuals with PTSD and survivors of CRSV face significant barriers to accessing coordinated, trauma-informed care.

Integrated care models should include routine psychological screening for all rehabilitation patients, co-location of mental health providers within rehabilitation teams, and coordinated case management between disciplines. For CRSV survivors, this includes embedding gender-sensitive services such as pelvic floor physiotherapy, trauma-informed mental health support, and reproductive health counseling into existing care pathways. Additionally, mental health rehabilitation must extend beyond large urban centers to reach injured civilians and veterans residing in rural and conflict-affected areas, where access to rehabilitation hospitals is limited. Community-based mental health hubs, mobile outreach teams, and telehealth platforms could be deployed to ensure continuity of care and support reintegration.

Building interdisciplinary capacity will require cross-training: rehabilitation professionals must be trained in psychological first aid and trauma-informed care, while mental health providers should be familiar with the physical rehabilitation needs common among war-injured populations. A national rehabilitation strategy should prioritize this integrated and decentralized model to maximize recovery and promote long-term resilience.

Access to rehabilitation underpins the rights of PwD as defined by the United Nations Convention on the Rights of Persons with Disabilities signed and ratified by Ukraine in 2010 [19–20]. Ukraine is one of 35 countries the World Health Organization which is assisting in developing a national strategy to elevate rehabilitation as an essential health service, especially in countries with universal health coverage. As of 2023, 25 other low- and middle-income countries have National Strategies [21]. Rehabilitation increases functional gains after discharge that are maintained for up to eight years post-discharge [22]. Additionally, there are documented gains in employment, education and independent living [22]. There are an estimated 1.2 million veterans who are participating in military operations of the Russo-Ukrainian war [23]. Ukraine, in cooperation with Sweden created a strategy for veterans, who represent 10% of the country’s workforce, to facilitate reintegration into society [23].

Prevention of injury and improvements in battlefield care saves more lives but effective rehabilitation still lags in many countries [7, 24]. In general, with the acceptance of the World Health Organization Trauma Pathway and continued strengthening of the national and international health system preparedness, surgical and immediate trauma response during conflict and disasters is becoming more effective and efficient [25]. As such, patients with life-changing injuries who would previously have died are now surviving. International guidelines recommend early rehabilitation [7, 24]. For the overwhelming numbers of both military and civilian patients needing rehabilitation, the continuation of insecurity due to war, lack of coordination and a national strategy, and scarcity of trained staff means patients in Ukraine may not receive quality early rehabilitation, raising the risk of complications and poor outcomes after life-changing injuries [24–25]. Comparing injury patterns in World Wars I and II, the Korean conflict, and the Vietnam conflict, it is estimated that between 2.5% and 10% of casualties (combining killed and wounded in action casualties) sustain a moderate to severe TBI [26–27]. The context, requirements and challenges for early rehabilitation provision will vary enormously between emergency situations.

Prior to the war, a systematic assessment of Ukraine’s rehabilitation services revealed services transitioning from post-Soviet practices to a more contemporary understanding of approaches to rehabilitation [28]. This assessment accounted for veterans from the 2014 war in Donbas with an estimated 21,000 persons needing physical and or psychiatric rehabilitation; the vast majority (18,000) needing psychological care [26]. Completed in 2021, this report does not account for the current war or the unprecedented numbers of war-related and mine-related injured that will need care. With 31,000 Ukrainian military members killed, we expect a tenfold increase in the numbers of injured [28, 29]. Additionally, given the extensive use of mines in the eastern Oblasts, a significant number of mine-related casualties are expected for decades to come, as has been seen in every conflict with widespread utilization of mines. Our interviews echo the challenges in the report such as a lack of a national strategy, equipment issues (including prosthetics), especially those not covered by universal healthcare, the lack of multidisciplinary rehabilitation support staff and an overall lack of community-based services [28]. Emphasis should be placed on education and training over infrastructure improvements—bracketing the obvious need to repair damaged facilities to a usable state—given the remarkably higher return on investment seen with instructional inputs compared to spending on facilities [30].

With mental and physical health intricately linked, rehabilitation efforts are needed to address secondary mental and physical health conditions to promote readiness, health, improved health-related quality of life, and overall wellness of injured service members [31]. Many of the respondents felt that mental health is worse among military members, even though the extent of civilian trauma significantly exceeds that of military personnel in conflicts [32]. The war in Ukraine is likely to predispose both its civilians and military to adverse mental health outcomes due to rapid upheavals and civilians taking up volunteer military roles, or being exposed to trauma [33]. Additionally, although some studies show higher rates of PTSD among military members, the lack of significant differences among the groups in a systematic review suggests PTSD treatment provided during and after the war is necessary for both groups [32–34].

Although respondents reported no differences in rehabilitation care between males and females, there is evidence that strengthening equitable access and support for females is a necessity for female military member access to rehabilitation systems [12, 35]. Furthermore, the systematic assessment of rehabilitation services from 2021, did not discuss women as a priority population (including military women) for rehabilitation. Women must have the same opportunities for rehabilitation as per UNSCR 1325 [12, 35]. It is well established that women’s participation promotes long-term stability, both within and between states in fragile environments, particularly during democratic transitions, is critical to sustaining lasting democratic institutions, is associated with lower propensity for conflict, both between and within states, and increases the likelihood that peace agreements will hold by 35% [36, 37]. Women’s participation in Ukraine requires equitable access and rehabilitation care to allow them meaningful participation both as military and civilian members of Ukrainian society [37].

Emerging anecdotal reports suggest Ukraine may be challenged across the four pillars of WPS (prevention of CRSV, protection from CRSV, participation of women in the resolution of conflict, peace negotiations, peace operations, and advancement of relief and recovery measures to address international crisis through a gendered lens) [38]. This is despite serving as a non-permanent member of the United Nations Security Council for the period 2016–2017, as a signatory to UNSCR 1325 and adapting a new National Action Plan for 2020–2025 that specifically changes institutional policies to enhance protection for women and girls affected by armed conflict [12, 39]. Further in-depth research is necessary to better understand CRSV and the specific rehabilitation needs for females in Ukraine, however, given the US Department of Defense (DOD) commitment to WPS through its strategic framework and DOD’s and the US government’s commitment to Ukraine as the largest donor to the war effort, a better understanding of the WPS issues of the 60,000 female soldiers and the civilian population is necessary [40, 41]. Integrating rehabilitation for CRSV survivors into existing rehabilitation services must include integrated care for those who suffered CRSV and services specific to the violence such as pelvic floor physiotherapy for traumatic fistulas, mental health care, and reproductive health care. Females comprise 54% of the population of Ukraine and as they move towards European Union (EU) integration, there is a requirement to meet the EU’s Gender Equality Index [40, 41]. Increasing availability, quality, acceptability, affordability of, and access to these much-needed services will save lives provide everyone an opportunity for meaningful participation to make decisions in shaping policies which lead to more representative, inclusive institutions, policy choices, and ultimately peace and security [37–39].

Limitations

Respondents were selected based on participation in ASSET training events and perspectives are limited to their location and the timeframe of June 2023-February 2024. As a qualitative study, these data represent those interviewed and cannot be generalized to all trauma care providers, all of Ukraine, or all rehabilitation facilities and care. The study volunteers interviewed represent their experiences in conflict-related trauma. This study does not represent views of non-conflict trauma systems. Interviewers were careful to explain there would be no material gain by participation in the study; however, respondents may have underestimated or exaggerated responses if they thought it would be in their interest to do so.

Conclusions and recommendations

Prior assessments of the rehabilitation systems in Ukraine could not account for the overwhelming numbers of injured military and civilians since the start of the war in 2022. A large-scale effort is needed to provide high quality education for all rehabilitation specialists including physical medicine and rehabilitation physicians, physical and occupational therapists, prosthetists, among others, with additional efforts needed on validated testing of educational program participants to ensure understanding of essential concepts. Significant capabilities to build rehabilitation capacity and capability are organic to many large NATO countries in addition to large multinational NGO’s; these resources should be leveraged to build institutional capability and capacity in Ukraine. Given the large number of casualties, there should be infrastructure renovated or built to support larger rehabilitation centers of excellence in larger cities as well as smaller community-based rehabilitation centers in smaller, more rural areas. In addition to addressing the lack of a National Strategy and equipment and staffing challenges, Ukraine should consider integration of mental health, care for victims of CRSV and ensure equitable access for women into rehabilitation as important considerations. Improved rehabilitation efforts are needed to address secondary mental and physical health conditions to promote readiness, health, improved health-related quality of life, and overall wellness of both male and female injured service members. This is even more important given the overwhelming numbers of injured and two recent Ukrainian laws lowering the draft-eligible age and extending the age for mobilization. These laws which do not address demobilization will keep soldiers at front lines longer and put them at higher risk for injury, increasing rehabilitation needs in the future.

Finally, to meet the long-term rehabilitation needs of both military and civilian populations, mental health services must be embedded within the rehabilitation system and made widely accessible in community settings. This is especially vital for individuals who do not live near large rehabilitation hospitals. Addressing psychological trauma through decentralized, trauma-informed care—delivered by cross-trained professionals and supported through mobile and telehealth services—will ensure a more equitable and comprehensive rehabilitation response. Integration of mental health with physical rehabilitation is not only clinically necessary, but foundational to Ukraine’s national recovery and reintegration efforts.

Abbreviations

ASSET

Advanced Surgical Skills for Exposure in Trauma

CRSV

Conflict-related Sexual Violence

DOD

Department of Defense

EU

European Union

GBV

Gender Based Violence

G-TSET

Global Trauma System Evaluation Tool

KII

Key Informant Interview

MOD

Ministry of Defence

MOH

Ministry of Health

NATO

North Atlantic Treaty Organization

NGO

Non-Governmental Organization

PTSD

Post Traumatic Stress Disorder

PwD

Persons with Disabilities

TBI

Traumatic Brain Injury

TSAT

Ukraine Trauma System Assessment Tool

UNSCR

United Nations Security Council Resolution

WPS

Women Peace and Security

Author contributions

LLL, TEH, and TPK designed the study. The instruments were adapted by LLL, TEH, JM, and TPK; Interviews were completed by LJ, MJ, JKB, LLL, TPK, JM, and TEH. LJ, MJ, JKB, and LLL completed data analysis. All authors contributed to writing and/or editing of the manuscript and have reviewed the final version prior to submission.

Funding

This study was funded by the Department of Defense, Defense Health Agency, Grant # HT942523P0013. The funding agency played no role in the design, analysis, or interpretation of findings.

Data availability

Data that support these findings are curated by the study team and are not available for public distribution.

Declarations

The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), the DOD, or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Ethics approval and consent to participate

Ethical approval for this study was granted through the WIRB-Copernicus Group (23-17597) and the Ethics Committee, First Territorial Medical Unit of Lviv. All participants provided consent prior to 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.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.