Modern aspects of social protection of combatants depending on the severity of disability

The urgency of the problem is due to the significant increase in recent years in the number of young and middle-aged people who have passed the war, the need to develop adequate measures of social assistance and protection. An important task in the organization of the rehabilitation process is to determine the structure of the needs of servicemen with disabilities in various types of medical and social care and the development of individual rehabilitation programs (IRP) based on them. The purpose of the study: to determine the structure of the needs of servicemen with disabilities in medical and social rehabilitation depending on the severity of disability. Statistical data from 25 administrative territories of Ukraine for 2018 are analyzed, the needs of participants of military service with disabilities in medical and social rehabilitation measures, their structure are calculated. The data of the information base of the centers and the bureau of medical and social examination of the regions were used. Processing of the primary material was performed using the universal statistical package "Excel". In 2018, medical and social expert commissions (MSEC) of Ukraine for the first time and re-certified and recognized persons with disabilities 7843 combatants. Of these, disability of group I (IA and IB) was established in 2.6 %, II in 29.2 %, III in 68.2 % of cases. All victims for MSEC were formed IRP. The dependence of the needs of combatants in medical and social rehabilitation measures on the severity of disability has been established. For persons with disabilities of groups II and III, priority is given to medical and professional rehabilitation, group I social rehabilitation and technical means of rehabilitation with medical support. Of the medical rehabilitation services for persons with II and III groups of disability, sanatorium treatment is significant, and group I rehabilitation therapy. Among vocational rehabilitation services, employment in production conditions is important for persons with group III disabilities, in specially created conditions for persons with group II disabilities, at home for persons with group I disabilities. Vocational training was offered to a small number of people with disabilities of all groups. Among social rehabilitation services and technical means of rehabilitation, the services of social workers of territorial social service centers were significant for representatives of all disability groups, simpler means of transportation for persons of group III disability and more complex means for persons of group I. Determining the characteristics of the needs of servicemen with disabilities depending on its severity allows MSEC specialists to better form the IRP, develop targeted rehabilitation programs at the regional level, assess shortcomings in the organization of the rehabilitation process and build a rehabilitation system for combatants.


Introduction
The use of military force in armed struggle is accompanied by casualties and an increase in the number of casualties among servicemen and special services [3]. Therefore, in the total number of persons with disabilities, a special group consists of persons with disabilities due to injury, contusion or mutilation received in the performance of military service [10]. Thus, in the United States in 2012 there were 2.73 million people with disabilities due to hostilities (combatants) and military service [11]; in the Russian Federation -more than 120 thousand people [12].
According to the General Staff of the Armed Forces of Ukraine (AFU), since the beginning of the anti-terrorist operation (ATO) in eastern Ukraine, the format of which was changed in April 2018 to Operation United Forces (OUF), as of March 2019, 9,423 servicemen of AFU were wounded. [9].
Social protection of persons with disabilities who participated in the ATO/OUF is one of the priorities of the state and society [1,13,15,16,18]. The urgency of the problem is due to the significant increase in recent years in the number of young and middle-aged people who have passed the war, as well as the need to develop adequate measures of social assistance and protection. These individuals are in dire need of state guarantees in obtaining employment, housing, education, medical care, social assistance, spiritual development, including rehabilitation. According to experts, up to 80 % of combat victims are shown rehabilitation measures [6,7,19].
An important task in the organization of the rehabilitation process is to determine the structure of the needs of servicemen with disabilities in various types of medical and social care and develop individual rehabilitation programs (IRP) based on them, the main function of which is comprehensive rehabilitation of victims [4,5,17]. It is aimed at the end result -improving the functioning of the sick person, overcoming the limitations of life, achieving social independence [14].
The purpose of the study: to determine the structure of the needs of servicemen with disabilities in medical and social rehabilitation depending on the severity of disability.

Materials and methods
The analysis of statistical data from 25 administrative territories of Ukraine for 2018 is carried out, the needs of participants of military service with disability in measures of medical and social rehabilitation, the structure of these needs are calculated. The data of the information base of the centers and bureaus of medical and social examination of oblasts are used -annual statistical reporting forms (form № 14 -Report on the causes of disability, indications for medical, professional and social rehabilitation; order of the Ministry of Health of Ukraine dated 10.07.2007, № 378).
Research methods: statistical, analytical, method of expert assessments. Processing of the primary material was performed using the universal statistical package "Excel". The difference at p<0.05 was considered significant.

Results
In 2018, medical and social expert commissions (MSEC) of Ukraine for the first time and re-certified and recognized persons with disabilities 7843 combatants in the database. Of these, disability of group I (IA and IB) was established in 2.6 %, II -in 29.2 %, III -in 68.2 % of cases.
All victims during MSEC were formed IRP. The total number of medical and social rehabilitation measures was 21952 or 2.8 measures per victim, regardless of the severity of the disability.
In the general structure of needs of servicemen in measures of medical and social rehabilitation, medical rehabilitation services make up 64.1 %, professional -2 5.5 %, social -10.4%.
Medical rehabilitation is the main type of rehabilitation process. In the structure of needs of combatants with disabilities of the I group, it amounted to 52.9 %, of the II group -62.5 %, of the III group -65.2 %.
Among the medical rehabilitation services for people of all disability groups, the most important were rehabilitation therapy and sanatorium treatment; reconstructive surgery and orthoses are in demand in isolated cases (Table 1). Persons with group I disability were significantly more often in need of rehabilitation therapy than patients with group II and III (p<0.05), and with group II and III -spa treatment (p<0.05), which is associated with the severity of the general condition patients, and with the presence of indications and contraindications to stay in sanatoriums.
Vocational rehabilitation included vocational training and employment services.
The issue of professional training and retraining of servicemen with disabilities is very important. Retraining of servicemen with disabilities should be carried out considering the state of their health, individual characteristics, consistency of professional development before and after discharge from military service, based on good knowledge of labor market needs in specialists of various fields, be focused on fundamentally new areas of activity (business and other modern professions that appear in the labor market) and provide employment for those who have been trained.
In the structure of needs of persons with disabilities of group I, vocational training amounted to 0.4 %, group II -0.6 %, group III -2.1 % ( Table 2).
Vocational training and retraining were offered in the conditions of production and in higher educational institutions of I-IV levels to combatants of II-III groups, only in higher educational institutions of I-IV levels -I groups without statistically significant differences in groups (see Table 2).
Employment services based on the structure of needs of persons of group I accounted for 4.2 %, group II for 22.3 %, and group III for 25.3 %. For persons of group I employment in domestic (p<0.001), group II -in specially created conditions (p<0.001), group III -in normal conditions of production (p<0.001) was relevant (see Table 2). Combatants with disabilities who underwent vocational rehabilitation and were employed in group II disability accounted for 18.9 %, in group III -81.1 %. The number of servicemen who want to work and are registered with the social security bodies is 27.1 %, of persons with disabilities of group I -3.5 %, group II -23.8 %, group III -29.4 % with a significant predominance of those wishing to group III disability (p<0.05).
In the structure of needs, social rehabilitation measures for group I combatants amounted to 42.5 %, group II -14.5 %, group III -7.4 %.
The most popular among all groups of disabilities were technical aids that facilitate mobility, prosthetic and orthopedic products and services of social workers of territorial centers, who help in self-care, household issues. However, each group of disabilities has features (Table 3). Thus, for persons with disabilities of the first group additional means for walking, wheelchairs, services of social workers, prosthetic and orthopedic products, adaptation of housing for own needs were needed; for persons with disabilities of the II and III groups -services of social workers, technical means for movement, prosthetic and orthopedic products. Statistically significant indicators were found for the first group of disability -the provision of wheelchairs (p<0.001), the second group -the services of social workers of territorial centers (p<0.001), the third group -the provision of additional means of transportation (p<0.05).

Discussion
The needs of people with disabilities, including servicemen, in medical and social rehabilitation measures form a system of rehabilitation in the state. At present,  Ukraine has a mixed system of rehabilitation, mainly a decentralized form with the opening of mostly professional and social rehabilitation centers of the Ministry of Social Policy. In the structure of the system of medical and social rehabilitation of ATO/OUF participants with disabilities, the main place in providing medical, vocational, psychological, social rehabilitation, provision of technical means and medical devices is given to civilian institutions. The corresponding role is played by public organizations that provide psychological, labor, physical culture, sports, social and domestic rehabilitation. The Concept of the State Target Program was approved by the Order of the CMU of 12.07.2017 № 475-r, and on 5.12.2018 the Resolution of the CMU "On approval of the State Target Program on physical, medical, psychological rehabilitation and social and professional readaptation of ATO participants and persons involved in the implementation of measures to ensure national security and defense, repulse and deter the armed aggression of the Russian Federation in Donetsk and Luhansk regions, ensuring their implementation for the period up to 2020". Its adoption will help ensure the implementation of measures for rehabilitation and readaptation of combatants, aimed at administering their needs, raising their awareness of participation in the relevant processes of readaptation to civilian life, strengthening their social protection, maintaining proper moral and psychological condition, addressing urgent issues. medical, psychological, physical, professional, physical culture and sports, social rehabilitation and readaptation, as well as to increase the effectiveness of interaction between central and local executive bodies, local governments, public and international organizations on these issues.
The procedure for providing sanatorium treatment to combatants and persons with disabilities as a result of the war from among ATO participants is regulated by the CMU Resolution of 31.03.2015 № 200 "On approval of the Procedure for using funds provided in the state budget to provide injured ATO participants with sanatorium treatment" (with changes). And by the resolution of the CMU of 01.03.2017 № 110 the authority to purchase vouchers was delegated to the places, and the participants of the ATO/ OUF were given the opportunity to choose a sanatorium for rehabilitation. The existing system of procurement of sanatorium-resort services has been changed to reimburse the cost of sanatorium-resort treatment services (vouchers) for persons with disabilities and injured participants of ATO/OUF due to non-cash transfer of funds to sanatorium-resort establishments for services provided on the basis of a tripartite agreement (personmanagement -sanatorium) and determined by the managers of funds provided for these purposes, lowerlevel regional and district bodies of social protection.
The procedure for organizing social and professional adaptation of ATO participants, approved by the Resolution of the CMU of 21.06.2017 № 432, provides for: creation of an effective mechanism for restoring professional skills of ATO/OUF participants as an integral part of their adaptation to civilian life, ensuring their rights to education life, increasing the efficiency of solving problematic issues of database participants related to civilian professional activities, strengthening their competitiveness in the labor market.
According to the research data, in practice there are modest results of work with servicemen with disabilities in vocational training and employment, due to medical, demographic, socio-psychological characteristics of servicemen with disabilities, their lack of awareness, rent settings, difficult socio-economic conditions. which determines the need for an integrated approach to their solution, targeted planning and funding, coordination of efforts between participants in the rehabilitation process.
In connection with this order of the CMU "On approval of the action plan for the implementation of the Concept of the state system of vocational guidance of the population" from 4.07.2018 provides for the creation of conditions for intensifying work on vocational guidance, including professional reorientation and adaptation of servicemen who are discharged or discharged from military service, participants in hostilities.
The dependence of the needs of database participants in medical and social rehabilitation measures on the severity of disability has been established. For persons with disabilities of groups II and III, priority is given to medical and professional rehabilitation, group I -social rehabilitation and technical means of rehabilitation with medical support. Of the medical rehabilitation services for persons with II and III groups of disability, sanatorium treatment is significant, and group I -rehabilitation therapy. Among vocational rehabilitation services, employment in production conditions is important -for persons with group III disabilities, in specially created conditions -for persons with group II disabilities, at home -for persons with group I disabilities. Vocational training as an effective mechanism for professional adaptation, acquisition of a profession, retraining, socialization was offered to a small number of people with disabilities of all groups. According to other studies, the growing number of people with disabilities of group III requires the preparation of IRP, which would, in addition to physical and medical, also include vocational and occupational rehabilitation [2].
Social rehabilitation involves providing conditions for social adaptation of a person with a disability, independent social functioning in the family and society through the consistent use of functionality [8]. Among social rehabilitation services and technical means of rehabilitation, the services of social workers of territorial social service centers were significant for representatives of all disability groups, simpler means of transportation for persons of group III disability and more complex means for persons of group I.

Conclusions
Determining the characteristics of the needs of servicemen with disabilities depending on its severity allows MSEC specialists to better form the IRP, develop targeted rehabilitation programs at the regional level, assess shortcomings in the organization of the rehabilitation process and build a rehabilitation system for combatants.