Abstract
Background Disease and non-battle injuries (DNBI) often account for more military casualties than those from
combat wounds. The February 2022 Russian invasion of Ukraine has severely limited access to care in areas with
increasing patient care needs beyond combat injuries. The expansion of the draft resulted in an older military
population susceptible to musculoskeletal injuries, while trench warfare and harsh winters create conditions
conducive to cold weather injuries and infectious diseases. This study aims to assess the prevalence and scope of
DNBI in Ukraine.
Methods We conducted qualitative key informant interviews with Ukrainian military and civilian health care workers
from June 2023-February 2024 using an expanded version of the Global Trauma System Evaluation Tool which had
components focusing on DNBI. Thematic content analysis was used to derive key themes related to DNBI from
interviews.
Results We conducted 36 key informant interviews. Respondents described the wide range of DNBI that Ukrainian
soldiers are experiencing. Infectious disease, cold weather injuries, musculoskeletal injuries, sexual assault, and mental health emerged as prevalent concerns. Respondents described the critical shortage of resources and the high burden on military hospitals as barriers to the delivery of adequate care for DNBI.
Conclusions DNBI in Ukraine are directly related to the physical environment and the age and fitness of the military population. The troop shortage has resulted in soldiers with chronic illnesses returning to duty, while the physical environment limits prevention measures for weather-related injuries and infectious diseases. The complex healthcare challenges created by these factors highlight the importance of a military health system with the capacity to provide service members with the full spectrum of care beyond combat injuries.
Keywords Ukraine, Disease and Non-battle Injury, Conflict, Military Health

Introduction:
Ukraine’s health and trauma care system has been devastated by the Russian Federation’s invasion in 2022. Previous research shared insight of returned volunteers into changes in the system; however, as the war continues there is the need to understand how the observations of United States (U.S.) volunteers and Ukrainians working in healthcare in Ukraine may differ regarding perceptions of the trauma system’s current strengths and challenges.
Materials and Methods: We conducted structured interviews with U.S. healthcare or healthcare-adjacent returned volunteers and Ukrainian healthcare workers using the Ukraine Trauma System Assessment Tool Study Region Observation (TSAT SRO) Tool. Mean scores were calculated for each trauma system domain among both Ukrainian and U.S. groups. t-tests were used to determine if there were any statistical differences between these means among the 2 groups.
Results:
The overall score for the Ukraine trauma system combining scores from U.S. volunteers and Ukrainians was 1.89 out of a possible 3.00. The domains with the highest combined scores included Prehospital, Chemical, Biological, Radiological, Nuclear, and Explosive (score = 2.33), Prehospital Training (score = 2.25), and Definitive Care Facilities: Blood Product Use (score = 2.38). Domains with the lowest combined scores included Injury Prevention (score = 1.55), Definitive
Care Facilities: Disease and Non-Battle Injuries (DNBI) (score = 1.60), and Logistics and Supply (score = 1.55). U.S.
volunteers scored every domain lower compared to Ukrainian respondents. All differences between U.S. volunteers
and Ukrainian responses were statistically significant except Definitive Care Facilities: Telemedicine, Definitive Care
Facilities: Blood Product Use, and Definitive Care Facilities: DNBI.
Conclusions:
TSAT SRO component scoring from observations of U.S. volunteers and Ukrainian healthcare workers suggests the
current Ukrainian trauma system is in development. Domain scores differed between U.S. volunteers and Ukrainians; most were statistically significant, demonstrating the importance of including citizens of a nation versus only foreign healthcare workers in assessing a healthcare or trauma system

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.

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 fullscale 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 gendersensitive 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 conflictrelated 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.
Keywords Ukraine, Rehabilitation, Trauma system, National strategies