Understanding Ukraine's immunization supply chain resilience in the face of war: a mixed-method study

The full-scale invasion of Ukraine in 2022 created unprecedented pressures on the national immunization supply chain (ISC). Despite large-scale energy disruptions, population displacement, and insecurity, vaccine availability and storage conditions were largely maintained. This study aimed to examine how Ukraine's ISC has adapted to war-related disruptions and to identify key enablers, barriers, and priorities for strengthening its resilience.

A mixed-methods approach combined 15 semi-structured interviews with stakeholders from national, oblast, and facility levels, a review of literature, regulatory documents, and programme data. Data were analyzed using thematic analysis and interpreted using the Blanchet et al. health system resilience framework.

Analysis found that the digitalization of the vaccine stock management system and the wide availability of training strengthened the knowledge capacity of the ISC. Large-scale investments by international partners in WHO-prequalified cold chain equipment during the COVID-19, complemented by the deployment of backup power solutions, significantly improved the system's ability to manage uncertainty related to electricity outages. The centralization of ISC function enhanced governance and coordination, contributing to legitimacy capacity. Strong collaboration across government institutions and with international partners also helped sustain ISC in the face of the war disruptions, demonstrating the importance of interdependence capacity. However, several barriers persist, including gaps in population data for forecasting vaccine needs and coverage monitoring, unequal distribution of new cold chain equipment, and continued reliance on donor support.

Despite repeated attacks, Ukraine's ISC has continued to function. The findings highlight key enablers of resilience and remaining bottlenecks and provide actionable recommendations. Ukraine's experience offers transferable lessons for strengthening ISC resilience in other conflict settings.