The problem of the pandemic has receded into the background; however, “COVID-19 still continues to circulate, take lives, and additionally contributes to the fact that the burden on the health care system continues to grow”. This is evidenced by the adopted Resolution of the Cabinet of Ministers of Ukraine No. 1423 of December 23, 2022 regarding the extension of the quarantine throughout the territory of Ukraine until April 30, 2023 (Law of Ukraine No. 1423, 2022).

Thus, the levels of epidemic safety in the regions were canceled; the mask mode is exclusively of a recommendatory nature; the need to have a COVID-certificate for visiting restaurants, cultural institutions, gyms have been abolished; suspending the suspension of employees who were suspended from work due to lack of vaccination against COVID-19; no COVID-19 documents are required for travel between regions of Ukraine (Zagorodnii 2022). We can see the changes before the start of a full-scale war (2022) and during martial law in Ukraine in the Fig. 1.

Fig. 1

Ministry of Health of Ukraine summary

Apparently, mobilizing people in response to a larger threat helped to deal with even COVID-19 for a while. But the SARS-CoV-2 virus has not gone anywhere. He simply enters a new level of relations with humanity and, we hope, will no longer be able, even when it is mutated, to cause such serious damage. The active fight against infectious diseases continues with all available methods and measures. This priority still has a place in the work plans of the public health system both in Ukraine and in the world.

Among the urgent problems of public health in Ukraine, which determined the priority tasks of this sphere, in addition to threatening infections, a complex demographic situation, high morbidity and distrust of the medical system due to corruption and lack of healthy partnership, the following can be highlighted:

Non-infectious diseases (cardiovascular diseases, diabetes, oncological diseases, chronic obstructive pulmonary diseases), which are the cause of more than 80% of disability and mortality, including premature, and, shortening the duration of active life, leads to physical and psychological suffering of a person and social and economic overloads of the state. These health problems are associated with risk factors of an unhealthy lifestyle, untimely diagnosis and lack of control over certain health conditions, etc. Here, it is worth noting that quarantine restrictions in the conditions of a pandemic and the unavailability of proper medical care in conditions of war will provoke an increase in advanced stages of these pathologies and disability and mortality from them.

The level of preventive vaccinations, because it is believed that vaccine-controlled infections should be controlled to eliminate the possibility of outbreaks and the development of epidemics, with the corresponding consequences. Thus, in the speech of Ihor Kuzin, Deputy Minister of Health, Chief State Sanitary Doctor of Ukraine it is noted that “…the full-scale invasion of the Russian Federation put many everyday issues on the back burner. However, health should always be a priority…children should be vaccinated according to the National Immunization Schedule. After all, vaccine-controlled infections are an enemy that cannot be seen, but which can sometimes cause considerable problems” (Ministry of Education and Science of Ukraine 2022).

Establishing a “work team” to fight the disease, based on the principle of a patient-oriented approach, forming the patient’s trust in the doctor and greater loyalty on the part of doctors—this is about the ability of medical workers to increase their professional skill in matters of respectful attitude to the patient, to his problems (for example, giving time to questions about the impact of the disease on the patient’s daily life or family, forming an understanding of the need for health care, hopes for the effectiveness of the treatment applied in the case of the disease, explaining information about the diagnosis and treatment in detail and clearly, answering questions that arise, etc.). Such cooperation promotes trust, open dialogue and helps to achieve better results, which is especially important in tense times of emergencies and war.

It is vital during times of conflict when people need treatment and support more than ever to create conditions that impact motives and values. These scenarios include trust in the doctors, the ability to fight “as a team”, and the state’s institutions. According to data from the Razumkov Center, 55% of Ukrainians currently have faith in government institutions, up from 35% in 2020. A similar dynamic is also illustrated by Gradus Research, according to which 68% of Ukrainians rate the actions of the Ukrainian authorities since the beginning of the war as effective (Boyko 2022). Among social institutions, in 2022 Ukrainians have the most trust in the Armed Forces (96% trust them completely or to some extent), the President of Ukraine (82%), humanitarian and charitable organizations (78%), the Church (70%), universities (62%), women’s organizations (59.5%), state institutions (55%), police (55%), environmental organizations (54%) (Razumkov Center 2022).

The war caused new challenges to the health care system, such as:

The emergence and increase in the number of certain groups of people in need of psycho-social and medical assistance: internally displaced persons (hereinafter IDPs); war-affected military (participants in combat events) and civilians (including those who were and are in temporarily occupied territories, orphaned children, disabled from injuries) and those who were forced to leave abroad, but dream of returning after the end of the war;

A change in the demand for certain medical services in different regions and an aggravation of the disproportion of resource provision in the health care sector (The Pharma Media 2022a), for example, due to the increase in the number of gunshot wounds and polytrauma, psychological health problems (including from experiencing losses, violence, grief, witnessing shocking and traumatic events) and the increase in the number of people due to IDPs. Currently, in response to such a problem, there is a restoration of compliance with the provision of health care services, in particular for IDPs, and jobs for workers in the medical field—that is, strengthening the capacity of health care workers. Also, networks of mobile dispensaries are being deployed, the need for which is significant—currently almost a third (30%) of IDPs have problems with access to medical care (National Institute for Strategic Studies 2022).

Destruction of infrastructure, establishments, equipment, disruption of logistical connections, lack of heat and electricity, lack of financial resources, which hinders the ability to provide high-quality medical care, medical care facilities, local response efforts, etc.

The military actions directly affected the availability of medicines: from the beginning of 2022, the State Enterprise “Medical Procurement of Ukraine” purchased medicines and equipment in the amount of 53% of the need; the draft of the State Budget for 2023 lays down the amount of financing for the purchase of medicines, which taking into account the projected level of inflation, the growth of the exchange rate of foreign currencies (a large part of the medicines in Ukraine are imported) and the exacerbation of chronic conditions, as well as the appearance of new diseases in population in need of medical treatment will lead to a shortage of quality pharmaceutical products. The problem will partly have to be solved by the citizens themselves, which will have a negative impact on their standard of living (Kotlyar 2022).

The need to make quick management, political and regulatory decisions in the absence of adequate data and information, including in the temporarily occupied territories.

The impossibility of observing the norms of prevention and treatment, leading a healthy lifestyle, lack of knowledge about the provision of pre-medical and psychological care in conditions of full-scale war and traumatic events, self-help, etc.

Lack of professional staff in the health care sector, medical workers of all levels, especially those with experience in providing assistance for gunshot wounds, military polytrauma, contusions of various degrees, post-traumatic disorders, etc.

Thus, this problem also concerns medical workers, doctors and nurses who were forced to move to other cities and regions to escape the war—thousands of them (The Pharma Media 2022b). According to the Ministry of Health, the problem of a critical shortage of doctors in connection with the war is being solved through effective mechanisms: the potential opportunity to attract foreign medical workers who are ready to work in Ukraine temporarily on a volunteer basis in accordance with the adopted Law of Ukraine dated July 29, 2022 No. 2494-IX (Law of Ukraine No. 2494-IX, 2022). At the same time, this is an exclusively auxiliary step, since first of all it is necessary to stabilize the sectoral labor market, providing comprehensive support for the employment of IDP medical workers (National Institute for Strategic Studies 2022); the possibility of employment in another medical institution—the temporary involvement of IDP doctors in health care institutions is regulated by the order of the Ministry of Health of Ukraine dated March 4, 2022 No. 414 (Law of Ukraine No. 414, 2022), which for December 2022 was used by 4290 IDP who are medical workers, these are: 2,006 doctors, 1,503 specialists (nurses/brothers, midwives, paramedics, pharmacist assistants), 781 technical workers. The largest number of employed doctors and other healthcare professionals are registered in Lviv region, 284; Dnipropetrovsk region, 214; Poltava region, 150; and Kharkiv region, 130 (Ustinov 2022).

At the same time, there are reports of difficulties with employment for medical workers with the status of IDPs—they are forced to either accept less qualified professions or leave Ukraine, which worsens the personnel potential of the industry. The situation is complicated by the lack of up-to-date information on the exact number of available medical workers (Kotlyar 2022), since such accounting is not carried out centrally and systematically in wartime conditions. The World Health Organization (2022) recommends building a personnel policy with regard to the return of medical personnel, as well as developing a digital register of medical personnel. At the same time, in order to facilitate the search for vacancies for doctors, the Ministry of Health has collected them all in one place—on the Portal of vacancies in health care institutions of any form of ownership.

The solution to the personnel problem should not just be on preserving the capacity that already exists, but also on training medical professionals in accordance with plans for the demands of the war and the post-war period, particularly in the fields of physical rehabilitation and mental health care. It is important to note that the issue of safeguarding, maintaining, and enhancing mental health was not given enough consideration when it reached the first tier of significant tasks facing the nation, the healthcare system, and that it is now a priority for the advancement of public health in Ukraine. After all, as a result of the full-scale war, Ukrainians continue to experience extreme negative emotions and suffering—capture, violence, occupation, loss, etc. The fact that the number and importance of treating traumas caused to the mental health of Ukrainians has increased is already indisputable—after the end of the war, at least 15 million people will need psychological help (Lyashko 2022b).

At the initiative of the First Lady of Ukraine, together with the Ministry of Health of Ukraine, WHO and international partners, the National Program of Mental Health and Psychosocial Support is being formed to help everyone get the necessary support and help in mental health issues, as needed, in order to preserve psychological resources for the future, revival and reconstruction. The Ministry of Health of Ukraine is actively establishing intersectoral interaction with other departments and partners in order for the Program to become effective and full-fledged (Mykychak 2022). Despite the fact that the state emphasizes the importance of rehabilitation, particularly psychological, its availability is currently low. The Ministry of Health provides information on the success of certain rehabilitation programs of the Ministry of Defense and the Ministry of Veterans, while a national rehabilitation policy has not yet been developed.

There is no doubt that the situation is worse in certain regions that are closer to the combat events, and terrorist missile attacks are hitting all over Ukraine, increasing the number and severity of the problems. So, for example, as of November 2022, according to the published statistics of the Minister of Defense of Ukraine, Oleksiy Reznikov (2022), “Russian troops have launched 16,000 missile strikes on the territory of Ukraine since the beginning of the full-scale invasion, and 97% of Russian targets are civilians: more than 12,300 strikes were carried out in the suburbs and villages, about 1.9 thousand hits are on houses, more than 500 hits are on military facilities, more than 250 hits—on transport infrastructure, about 220 hits aimed on energy infrastructure and more than 800—on other facilities”.

The adoption of the Law “On the Public Health System” (hereinafter the Law) was a positive thing for Ukraine in the war conditions, which provides an opportunity to update the health care system, unbalanced by years of sporadic unfinished transformations, to make it a modern, comprehensive system of public health, integrated to the European healthcare network. This is extremely important, because ensuring the proper level of health, prevention of diseases and quality of life requires organization, systematicity, consolidated efforts and responsibility of the government, society and every individual. These are the steps that build participation and trust. The development of the public health system is the science and practice that enables the synergy of joint efforts to prevent the increase in morbidity, injuries, disability, and mortality and to promote the preservation and improvement of health, including mental, to create a healthy environment for many years for sustainable prospective development and prosperity of future generations. In addition, the public health system provides effective intersectoral coordination and cooperation, operational management and monitoring of the processes of meeting needs, solving problems and gradual post-war recovery, especially in matters that require multisectoral solutions and interventions at the national and local levels (such as preparedness and responding to emergency situations, solving social, including special, needs of vulnerable groups, etc.).

The main focus of the public health care system’s development is disease prevention, as well as individuals’ duties and responsibilities to look after their own health, the health and hygienic upbringing of children, and not to endanger the health of others. These guidelines align with the goals and provisions of the Association Agreement between Ukraine and the European Union, the European Atomic Energy Community, and their member states regarding disease prevention and control, as well as the implementation of the Sustainable Development Goals, which also call for the creation of public health initiatives that correspond to the Goals (Ukraine is a member of the United Nations).

The main provisions of the Law include preventing diseases, strengthening the health of the population, and increasing life expectancy; ensuring epidemiological surveillance and monitoring, preparedness and response to threats and emergency situations; preserving the function of ensuring biological safety and protection; development of an integrated approach, etc.

Timeliness, quality and availability of the following services were determined as priority areas of development in the field of public health in November 2022:

1.

Primary care, outpatient, with the coordination of medical screening that are required and the support and treatment of patients with mental disorders;

2.

Medical services for expectant mothers, labouring women, newborns, young children under the age of five, and users of assisted reproductive technologies;

3.

Mental health care and psychological support;

4.

Emergency medical care and disaster medicine, transplantation of human anatomical materials and rehabilitation;

5.

Specialized medical care, rehabilitation services in the field of health care and psychological support for war veterans and their family members, family members of the deceased, IDPs.

6.

Prevention, early diagnosis and treatment of non-infectious diseases (cardiovascular, cerebrovascular, bronchopulmonary, oncological diseases; type 2 diabetes; mental and behavioral disorders);

7.

Treatment, localization and elimination of outbreaks of infectious diseases, epidemics, prevention of their occurrence and spread (vaccine-controlled diseases, including COVID-19, HIV/AIDS, tuberculosis, viral hepatitis B and C).

The provision of critically necessary medications (as listed in the list) and methods for implementing the programme of governmental guarantees of medical care for the public in accordance with those suggested by the World Health Organization are among the priority actions; as well as conditions and opportunities for leading a healthy lifestyle (observing a rational and balanced diet; reducing the level of use of tobacco products, alcohol and narcotic substances; increasing physical activity; including increasing the level of population coverage with preventive vaccinations, etc.); ensuring the needs of the health care system in professional medical personnel and measures of continuous professional medical education (including the development, approval and implementation of programs for training specialists (doctors and nurses) in infection control); strengthening the management capabilities of the health care system at the level of territorial communities; standardization of medical care and creation of an effective system of quality control of medical services, etc. (Law of Ukraine No. 1832, 2022).

International support and assistance for health care of Ukraine during the war is positive. According to the European Commission, more than 1000 medical evacuations of Ukrainian patients have already been carried out to EU countries (European Commission 2022). Since the beginning of the full-scale war, more than 4 billion hryvnias have been transferred to the needs of the health care system. At the same time, according to the estimates of the Ministry of Health, Ukraine will need from 14.6 to 20 billion euros to rebuild the health care system.

The problem of a low level of vaccination against a number of infectious diseases, including measles and poliomyelitis, remained relevant in 2022 (Rigby 2022). The seasonal incidence of infectious diseases, including COVID-19, is increasing as well (Zaxid.net 2022). Vaccination rates have fallen sharply, in the vast majority due to security issues. An increase in the number of hospitalizations was observed, on average by 14% compared to a week earlier, almost 3 thousand Ukrainians were admitted to hospitals (Kuzin 2022).

The cooperation of civil society and volunteering is an effective strategy for the provision of resources for the healthcare system. Due to the lack of knowledge about the true needs of the healthcare system, coordination of this resource is still not ideal, making it challenging to provide aid to the areas that require it the most. This is specifically because the Ukrainian Cabinet of Ministers permitted medical facilities to stop keeping records of humanitarian help (National Institute for Strategic Studies 2022).

Consequently, war has a devastating effect on the health of the population: “immediate and long-term on the physical and mental health of all persons in the radius of the armed conflict” (Sheather 2022; Levy and Sidel 2008, 2016), its consequences, multifactorial, multifaceted and multidimensional, affect people, society, the state of the environment, including and on the infrastructure of the health care system.