The issue of security is a priority for humanity since it creates conditions for the realization of life-sustaining rights. Crisis phenomena in the world and national economy have increased attention to the issues of guaranteeing the safety of people, property, and the state in various aspects. Such recent aggravating circumstances for society, such as war, COVID-19, and natural disasters, require unstable forms of work to provide safety for people. As a result, a socio-economic crisis arose in many countries, leading to a significant decrease in wages, lack of proper nutrition, lack of quality water, unsanitary conditions, and limited access to medical services.

"The establishment of a comprehensive system of peace and security consists of ensuring the effective functioning of the mechanism for the maintenance of peace, maximizing the potential of existing regulations, strengthening the existing international legal order, and developing new international legal obligations, principles, and norms" [1]. Most scholars tend to understand security as one of the main characteristics of human life, which combines the purpose and possibilities of development in the conditions of uncertainty and risk environment [2].

We note that social security is primarily security for human life and health, which includes demographic, ecological, economic, food, and other conditions of residence or stay. Such an important factor of social security as the provision of health care contributes to the creation of a safe environment for health, the availability of adequate medical care, and the protection of a person from various diseases.

At the same time, personal security is interpreted by the UN as freedom and protection of a person from physical violence and threats [3]. But it is worth noting that the concept of personal safety should also include a person’s moral state as a mandatory component and his protection from harmful influence.

The World Health Organization defines the social determinants of health as "the conditions where people are born, grow, live, work and get old," which are "formed by the distribution of money, power, and resources" [4].

The Law of Ukraine’s “On Public Health System” defines social determinants of health as the availability of food, housing, work, education, and medical care [5]. It should be noted that this Law regulates many urgent issues, particularly regarding the population’s sanitary and epidemiological well-being, and is essential in European integration. However, Ukraine has not recognized the population’s epidemiological well-being as an integral part of the state’s national security at the regulatory level [6].

Social determinants of health form a multi-level system. The main structural factors, such as the macroeconomic policy of the country, the state policy in the health care sector, education, housing, and social security, form the distribution of resources in society and the social position of people there. These structural factors influence individual social factors such as living and working conditions and access to money to buy food, clothing, and other essential resources that form the circumstances of people’s daily lives. The interaction of these factors determines the security of the healthcare sector and health equity.

The framework of the health care system is divided into four parts, which include determinants of health, health care planning, health care services’ financing, control over expenses, and provision of convenient services [7].

Therefore, the indicated tendencies demonstrate the deterioration of socio-economic conditions since the health status of the population reflects the changes taking place in the country under the influence of such factors as the availability of medical care, the availability of qualified physicians, the age and gender structure of the population, etc. Therefore, the state must take several practical measures to ensure the proper organization of health care as an important factor of social security.

The article aims to comprehensively study the health care system as an important factor of social security and elaborate a modern paradigm of its development under the conditions of existing challenges and problems. The main task of the article is to find out the basic tendencies in the detection of any deterioration of social security and to respond in order to prevent undesired consequences promptly; to determine the regularity of the influence of health care on social security, to identify the shortcomings of the health care in socially dangerous conditions, as well as to formulate suggestions for their elimination, taking into account positive world experience.

A. Literature Review

Many scientific works have been focused on studying the provision of health care. However, there have been no studies on health care as an important social security factor. Scientific works of previous years did not consider the challenges and threats that primarily arose from the war in Ukraine and the worsening of the security background worldwide. Therefore, the conduction of the research on the chosen issues is relevant and in demand at the time.

A general review of the theoretical foundations of social security and its factors has been carried out in the scientific studies of [2, 7, 8, 9]. A comparison of the parameters of the personnel potential of the health care system in Ukraine and other countries of the world has been carried out in the scientific article of [10]. The study of administrative and legal principles for forming the unified medical space of Ukraine has been carried out in the dissertation of [11]. The publication by [12] is focused on revealing the current state of administrative and legal provisions for implementing the right to health care, identifying problems, and determining areas for its renewal. Areas for improving the state policy in the health care sector are studied in the works of [13, 14, 15]. International experience of legal regulation of the relations in the health care sphere, which uses private, state, and mixed models of the organization and financing of the health care system, has been studied in one of the publications by a group of Ukrainian scholars [16].

Taking into account the research results by the specified scholars and other scholars, we consider it expedient to concentrate attention on organizational and legal measures necessary to guarantee health care as an important factor of social security.

B. Methodology of the Study

The article’s authors have used general theoretical and unique methods of scientific cognition. Thus, the theoretical analysis method assisted in determining the concepts and features of social security. Methods of analysis and synthesis were used while determining social determinants of health, which contributed to identifying the main conditions for creating a safe environment for health. The systematic and structural method was used to determine specific factors of social security that contributed to the creation of a safe environment for health: the availability of medical care, medical personnel, the functioning of medical institutions in the unified medical space, digitalization of the medical area and patients’ routing. Sociological and statistical methods were used to generalize the empirical data regarding the staffing of medical institutions in Ukraine with physicians, available vacancies in the healthcare sector, and losses of the healthcare system during the war. Using the logical and semantic method provided an opportunity to systematically analyze the concept of the unified medical space and the importance of combining the forces and means of state, municipal, private, and departmental medicine. The real threat to social security in general and human life and health, in particular, was demonstrated by moving from the abstract to the concrete. Forecasting and generalization methods were used to determine perspective organizational and legal measures to ensure health care and guarantee social security.

A. Availability of Medical Care

Health is of great importance, especially in crisis situations caused by war or natural disasters, since it is the first and foremost thing that people need after an incident. Therefore, it is quite likely that the demand for medical services will increase. Hospitals must maintain maximum capacity and remain available during and after incidents, emergencies or other crises, to provide adequate patient care, and essential health services to ensure public health.

Social factors – community characteristics, financial stability, social relationships, access to services or employment status – can both increase and limit people’s ability to be healthy. At the same time, strengthening protective factors in the social environment, such as access to education, medicine, family and other social support for children and youth, can contribute to people’s health.

The indicator of availability to medical care should take into account the following main elements: the presence and proximity of a medical facility in space, the need for health care, and the mobility of the population.

According to the Ministry of Health of Ukraine, the state of health of Ukrainians worsened during the wartime, in particular, due to the difficulty of accessing medical care. 1,218 healthcare facilities were damaged, including about 540 hospitals; 173 facilities were destroyed, more than 90% (information as of the beginning of 2023). Experts from the World Bank and the World Health Organization calculated the losses according to their methodology: not only the restoration up to the condition that was on February 24, 2022, but also the lost investments and other lost potentials that each hospital could generate. They estimate the damage to Ukraine’s healthcare system at tens of billions of dollars. In particular, the last figure they presented at the end of September 2022 was 26 billion dollars [17].

When a health care facility providing medical services is located remotely, people, especially those who require outside medical care for their health problems, are forced to make compromise decisions regarding their safety by making forced travel to meet their health care needs. Therefore, challenges related to timely and regular access to a health care professional, continuity of information and organization of care for people with chronic diseases, as well as relationships with experts and conduction of diagnostic procedures pose problems for people who live or are geographically distant from medical facilities.

Destruction of medical infrastructure, logistical transportation, problems with availability of medicinal products in certain regions, in particular to the “Affordable Medicinal Products” Program, postponement of preventive medical examinations, physicians’ consultations and screening programs – all this has a negative impact on public health and social security in general. The issues of the population’s accessibility to medical facilities on temporarily occupied territories or territories where active hostilities are taking place are of particular concern.

As a result of the general economic situation in the country, the situation of the pharmaceutical market, the principles of taxation of pharmaceutical products and the form of ownership of business entities, the pharmaceutical market currently has objective and subjective prerequisites for maintaining a stable tendency to raise the prices for medicinal products [9]. Therefore, it is important not to exceed the maximum prices for medicinal products during retail sale within critical conditions.

The main task both for Ukraine and other countries is coordinated and effective actions to preserve the health of the population. It is worth noting that economically developed countries of the world also have problems in providing medical care to patients (even regarding the need for beds, personal protective equipment, lack of medical personnel, etc.). Therefore, it is advisable to form options for solving problems in cases of various force majeure circumstances, as well as to have strategic stocks/reserves. For example, modular systems, when mobile hospitals or temporary housing for people affected by war, natural disasters, etc. can be built in the shortest possible time [8].

Threats are successfully counteracted by the relative autonomy of health care facilities, as well as decentralization while making local management decisions, taking into account the specific situation. To ensure uninterrupted operation of those medical facilities that are functioning, capable of alternative sources of electricity supply. Therefore, a medical facility should be an autonomous entity, capable of ensuring full functioning at the expense of its own resources, if necessary.

B. Medical Personnel

The health care system in Ukraine needs qualified medical personnel. Analysis of the tendency to reduce the number of medical employees with the subsequent extrapolation of the data demonstrates that the staffing of medical facilities of Ukraine by 2030 will be 75% with physicians, and with paramedical personnel and nursing staff - 73.6% of the need [18]. There is currently a shortage of vacancies in the healthcare sector (as of the end of 2022 - 2026 positions). However, we have to note an important dynamic. Thus, the number of registered unemployed in the health care sector as of the end of 2021 was 14,452 persons and as of the end of 2022 - 8,215 persons.

Such changes may indicate that; 1) national consciousness suddenly increased in terms of the war, the primary importance of medical professions is to help people, to save life and health; 2) the deterioration of economic conditions, the increase in the number of unemployed and the reduction of job offers in wartime conditions encourage people to rethink their values and accept less favorable offers when looking for sources of income.

Personnel shortage in Ukraine is especially observed at the primary level (30-40%). Besides, there is a characteristic territorial inequality in the supply of medical personnel to the population in the “town-rural” aspect. In rural areas, the number of physicians is almost four times lower than the average in Ukraine, and the number of paramedical personnel is two times lower [19].

Ukraine faced a certain personnel shortage because 1) 30,000 medical employees joined the ranks of the Armed Forces of Ukraine or became volunteers; 2) 2.3 thousand physicians went abroad; 3) 4.3 thousand forcibly became displaced persons [20].

Insufficient attention to the problems of providing the health care system with human resources has led to the emergence of several negative tendencies and processes, namely: a reduction in the number of physicians and nursing staff with medical education, especially in rural areas; leveling of the status and prestige of the doctor’s profession; a significant reduction in the volume of professional training of medical personnel by institutions of higher and postgraduate education; the existence of significant imbalances in the provision of medical personnel in urban and rural areas, at the primary, secondary and tertiary levels of providing medical care [10]; insufficient motivation of medical employees, unequal distribution of social guarantees depending on the region and level of medical care, the outflow of qualified employees abroad.

Regarding the above, we believe that effective methods of combating this phenomenon can be: 1) increasing the level of wages; 2) training of medical personnel within the most relevant specialties for the coming years (medical psychology, emergency medicine, cardiology, psychiatry, psychotherapy, physical and rehabilitation medicine, surgery, etc.); 3) regional programs to support medical employees in rural areas (provision of housing, preferential lending, preferential payment of utility bills, etc.).

C. Unified Medical Space

The unified medical space is a system of medical care organization that unites all medical resources of the state through joint management and defined financing mechanisms and ensures the availability, quality, and efficiency of all types of medical care to all citizens of Ukraine, including military personnel [21].

From the scientific point of view, the unified medical space should be understood as a functional union of forces and means of state, municipal, private, and departmental medicine to fully realize patients’ rights to receive affordable and high-quality medical care [11].

The functioning of medical facilities in the unified medical space through the unification of military and civilian medical systems becomes especially important in critical conditions. Due to this fact, civilian hospitals treat military personnel when necessary, and front-line hospitals provide medical assistance to civilians, demonstrating the humanity and comprehensive support of the country’s entire population.

Therefore, the functional and organizational model of medical support of the defense forces based on the unified medical space by using the capabilities of civilian health care facilities for providing medical care and treatment of wounded, injured, traumatized, and sick service members is rational, economically beneficial, expedient and perspective for the formation of an effective system of medical support of troops (forces) during the special period, which was confirmed during the full-scale armed aggression of the Russian Federation against Ukraine [13].

We note that a specific feature of European countries and the modern world, in general, is the growth of trust-to-market approaches related to the regulation of the healthcare sector by means of coordination and adoption of state-management decisions [15].

Regardless of funding sources, medical systems must act in harmony within the unified medical space for a common goal. For this reason, the activities of healthcare facilities should be regulated in a single legislative and regulatory field on healthcare issues in Ukraine. The unified medical space should functionally unite state, municipal, departmental, and private medical facilities to improve the quality and availability of medical care, equal competition for patients and resources, unification of effective methods, treatment approaches, technical capabilities, etc. Tangent areas of such unification should be an equal approach to the functioning of medical facilities, the interaction of different medical institutions, and the unity of the informational medical space.

D. Digitalization of the Medical Area and Patients’ Routing

Digital technologies are undergoing rapid development; therefore, modern requirements are related to establishing the digitalization of data and medical statistics. The risk of losing part of the data in socially dangerous conditions is significantly increased, affecting the quality and speed of critical management decisions.

The use of the “DIIA” application is a positive example of digitization in Ukraine and the possibility, for example, of obtaining an electronic COVID certificate there if a person has been vaccinated. Besides, the e-Health electronic system of health care has been implemented and is currently being used in Ukraine, which in turn consists of the Central database, which contains registries, software modules, the information system of the National Health Service of Ukraine provided by the legislation, in part necessary for the implementation of state financial guarantees, etc., and provides the possibility of creating, reviewing, exchanging information and documents between registers, state electronic information resources, electronic medical information systems, as well as with the electronic medical information system, which allows automating the work of business entities in the healthcare sector, create, review, exchange information in electronic form, in particular with the Central database [22].

However, quite a lot of scholars and practitioners in the medical area point to the shortcomings of the electronic system: insufficient protection, lack of monitoring over protection and analysis of possible interventions, lack of integration between systems, focus on the preparation of statistical reports and standard forms of the Ministry of Health [23].

The state policy should currently be aimed at revising the functioning of medical registers and forming a model of their mutual integration. Unified medical document management within the framework of the unified medical space will not only contribute to the implementation of an effective policy in the healthcare sector but will also expand the patient’s capabilities when receiving medical care, will minimize the risk of data loss, and will contribute to the protection of medical information.

In particular, the WHO emphasizes the importance of human resources and already recommends building personnel policy given the return of medical personnel and developing a digital register of medical employees to update information on their exact number [24].

Patients’ “routing” is also an important organizational factor in ensuring health care. Its correct planning affects the efficiency of providing medical care and the effectiveness of the correct appointment of the complex of necessary treatment (therapeutic, psychotherapeutic, physiotherapeutic, psychological, etc.).

Routing in socially dangerous conditions becomes especially important when there may be little time for thinking and decision-making, and preserving health or life requires urgent actions. A transparent algorithm, both for medical employees and patients, should be in action in such cases, which determines the tasks and the sequence of their execution, directs to the appropriate medical facility, that is, forms a tactical route. The routing application is considered convenient and accessible in electronic applications, such as HELSI. Such information support can be useful to a wide range of patients, especially in emergencies (patients with heart attacks and strokes, gunshot wounds, burns, etc.). Routing is also in demand among military personnel who, due to injuries, are forced to go to medical facilities for medical assistance or rehabilitation.

Such valuable references as routing help focus on the most important outcomes for patients. In this context, health outcomes are opportunity, comfort, and peace of mind. Capabilities are the ability of patients to exercise their rights; they are often monitored by using functional measures. Comfort is freedom from physical and emotional suffering. Improving patient comfort, in addition to pain reduction, requires eliminating the distress and anxiety that often accompany or exacerbate the disease. Peace of mind is living normally and receiving medical assistance and care. This concept contains freedom from the chaos that patients often face in the health care system, and it is essential for people with chronic and long-term illnesses.

Most of the world countries strive in their progress to improve the quality of life of the population, focusing on the Goals of sustainable development [25], where ensuring a healthy lifestyle and promoting well-being for everyone at any age has been singled out among other things as a reference point.

The healthcare system is an important factor in social security. Therefore, an integrated nationwide approach should be applied to the proper level of its organization in order to guarantee the health and well-being of the population. This consists of providing it with high-quality medical care, forming the unified medical space, implementing information and communication systems, and applying other legal and financial mechanisms for the functioning of the sector according to the needs of the time.

Society suffers from an acute lack of adequate quality medical and social services and needs urgent humanitarian aid. All of humanity has been convinced of this by the tragic examples of the global COVID-19 pandemic, the war in Ukraine, the recent earthquakes in Syria and Turkey, etc.

Therefore, state authorities, local self-government agencies, and other interested parties must act together, collect and analyze information to be aware of new tendencies, identify any deterioration of social security, and promptly respond to prevent undesired consequences.

The basis of the new modern paradigm for the development of the health care system should be the understanding that it is not unprofitable but a priority and the most perspective area since it affects every person from birth to the last days of life. It must be transformed from socially expendable to socially investment since investments into a person and his potential acquire strategic importance [14].

Attention must be paid to the development of personnel potential in the health care sector. This will contribute to the proper functioning of the medical field in the difficult conditions of modern challenges and international problems.

The basis of national interests should be social security as a collective ability to counteract possible risks, which is enhanced by the appropriate level of health care provision with the help of the following organizational and legal measures:

1. physical and psycho-emotional conditions for maintaining health and living in a safe environment;
2. high-quality medical care of the population;
3. guarantees of availability of medical care;
4. the possibility of carrying out preventive and diagnostic measures, choosing medical services in order to ensure health potential;
5. responsible attitude of social entities to the preservation of health;
6. the flexibility of the financing system both within the framework of state programs and by involving the private sector to ensure the quality and volume of medical care in terms of unpredictable events (for example, in terms of emergency legal regimes, man-made and natural emergencies, military operations, etc.);
7. instant adaptation of the state policy and legal regulation in the health care sector in terms of limited or inaccurate initial data;
8. multifaceted motivation of medical personnel for the development and training;
9. improvement and expansion of the functionality of the electronic health care system, digitization of medical and statistical accounting documentation;
10. integration into the global medical information space.

Thus, the world uses a variety of experience in the organization of health care. This sector is a priority, since it is a public good for a person and an important factor of social security.

The authors declare no conflict of interests. All authors read and approved final version of the paper.

All authors contributed equally in this paper.

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