Background: Healthcare labor market shortages due to migration, inadequate investments, and lack of continuous training are essential concerns in the Eastern European region. This article aims to describe and reflect on the experience with the implementation of continuous medical education among mother-and-child healthcare providers in Ukraine, including achievements, challenges, and barriers. We analyze this case based on two international collaboration initiatives: the Swiss–Ukrainian program in mother-and-child health that ran from 2000 to 2015, supplemented by the recent Ukrainian–Swiss project “Medical education development” in 2018–2023. Methods: We use a case study approach as the methodology for our study. We collected data from documents (project reports reviews) and in-depth interviews with stakeholders. We apply the method of directed qualitative content analysis. Results: As a result of the Swiss–Ukrainian collaborations, the knowledge and awareness of medical personnel were greatly improved. Modern clinical concepts not well understood at the outset became commonplace and were incorporated into clinical activities. Nevertheless, obstacles to the implementation and rapid uptake of changes were found in the lack of knowledge of the English language among medical doctors, the fear of changes, and the lack of openness and readiness for novel evidence-based clinical practices. However, primary healthcare practitioners in this new project seem to be more inclined to change. Conclusions: A modernized continuous medical education which is based on the values of openness, respect, dialogue, and professionalism can be implemented with the input of an international assistance program despite the resistance of the system towards change. Healthcare labor markets are experiencing growing shortages in terms of an insufficient number of healthcare professionals and a lack of specific skills to tackle emerging health and environmental risks. The increased use of technology is not sufficient to fill the healthcare labor gap. This creates a mismatch between supply and demand in healthcare. The problem has manifested itself in all geographical regions, though to a different extent within and between countries . There iSuch labor market challenges have been reported for the maternal healthcare sector as well. The shortage of skilled maternal healthcare providers results in overburdened and fatigued staff, which affects their well-being as well as the quality of services they offer . InsuffiIn the Eastern European region, the shortages in the healthcare labor markets described above, including insufficient staff and lack of skills in the maternal healthcare sector, are even more pronounced than in other parts of Europe . As in WThis article focuses on modernized approaches to continuous medical education (CME) for medical personnel of maternity wards and hospitals in Ukraine. In this paper, continuous medical education refers to the life-long professional education of medical personnel who have completed post-graduate schools; it covers a variety of activities, including different types of training, simulation courses, conferences, self-education, distance learning, and e-learning . SimilarThe aim of this article is to describe and reflect on the experience with the implementation of CME among mother-and-child healthcare providers in Ukraine. In particular, we explore achievements, challenges, and barriers in implementing modernized complex CME approaches  in the Ukrainian healthcare context. We define CME as “the set of training activities that contribute to keeping physicians’ competencies and skills up-to-date” , and we The rest of the article is organized as follows. The background information and case description are presented in the following subsections, which provide details on the peculiarities of the Ukrainian healthcare system and maternal healthcare sector at the time of the Swiss–Ukrainian program and subsequent reforms. In addition, they provide information on CME in Ukraine, i.e., the system of postgraduate education that was transformed into a continuous professional development (CPD) system in 2018. The case of the two Swiss–Ukrainian collaboration initiatives is described. This is followed by the presentation of the research methods applied in the study, as well as the results of the Swiss–Ukrainian program in mother-and-child health and the subsequent Ukrainian–Swiss project “Medical education development”. Discussion and conclusions focused on complex CME approaches in Ukraine close the article.Ever since 1991, when Ukraine became an independent state, socio-political and institutional changes have been taking place, with gradual and sometimes contradictory tendencies to move away from the Soviet Union structures, practices, and attitudes while trying to approach Western European standards. Many aspects of society have been impacted, including the healthcare and medical education systems. Initially, vertical institutional self-nourishing hierarchies maintained coercive and paralyzing attitudes and rules , which sIndeed, informal patient payments penetrated the healthcare system of Ukraine at most levels. On the side of the provider, informal payments led to higher income for underpaid medical staff while coercing incentives in service provision and restricting knowledge sharing within teams, which led to an outflow of patients to more competent providers (as subjectively perceived by the patients) . By natuApart from the health financing transformation, in 2018 the once-in-five-years postgraduate development system was changed into a more modern one linked to the CPD system of collecting points based on the training and conference activities of medical doctors . PreviouAs reported in the recent WHO country profile , the numFurthermore, human resource practices are not always transparent and provide limited educational opportunities. As noted in the literature, process quality, i.e., how care is provided, is moving ahead of structural quality ,19. The After the collapse of Soviet Union, maternal healthcare services were largely underfunded . Maternal care was provided at healthcare facilities  that were state-owned and had line-item budgets ,20. AfteThe composition of the childbirth teams has not changed over the 30 years of Ukraine’s independence: the obstetrician–gynecologist has remained the leader of the team, with a midwife as a member (who has never been an independent service provider), along with other medical specialists when relevant, such as an anesthesiologist, neonatologist, surgeon, and others . Most poIn the Ukrainian maternal healthcare sector, the delayed reforms in the healthcare system and the shortage of healthcare professionals have frequently meant inadequate care and cure, for instance due to insufficient capacity to treat severe maternal and neonatal cases. Over the years, there have been various reports on over-diagnosis and over-medicalization of pregnant women and infants with no or minor diseases, as well as iatrogenic complications through aggressive long-lasting treatments ,21,22. PAlthough the health outcomes in Ukraine continue to lag far behind the European Union average, recent data on mother-and-child health reveal positive tendencies, namely, exclusive breastfeeding until six months after the puerperium has become more spread, which increased from 6% in 2005 to 20% in 2015 ,23. In tMajor national institutional achievements pairing with international initiatives have resulted, among others, in: (1) the creation of third-level perinatal centers with the aim of regionalization of perinatology services ; (2) the introduction of new registration criteria for newborns in 2007 , and (3) the establishment of updated clinical protocols within national health programs and recommendations ,26,27.The idea of regionalizing of perinatology services was adopted from an international approach to providing perinatal services for mothers and newborns at different levels of healthcare depending on a risk assessment of the mothers’ health conditions, thereby decreasing neonatal mortality . This waEach of the above improvements has been assisted by international partners. A total of six international initiatives and one national project have worked for the improvement of mother-and-child health in Ukraine over the past two decades. These initiatives are presented in In Ukraine, as a former Soviet Union republic, CME has been a matter of great importance in the maternal healthcare sector. In the 1990s, many health professionals lacked information on perinatal regionalization, modern obstetrics and neonatology, and critical care approaches . The conTraditional post-graduate medical education included obligatory category improvements or recertification; every five years, medical doctors were expected to apply for a higher category delivered after points-based assessments  and training attended, as well as exams submitted at state-recognized post-graduate institutions. According to Belli and colleagues , 60% of Hence, until 2020 the CME and organization of healthcare service provision were characterized by top-down hierarchical decision-making and rather outdated (and most probably unsafe) medical practices. Despite the sporadic innovative approaches in healthcare services made possible by individual international collaborations, the overall environment did not facilitate local leadership for an efficient response to the multiple needs of healthcare users and medical doctors. The CPD system is now being modernized; however, because this revision is ongoing, certain aspects lack clarity, e.g., in terms the responsibility for accrediting CPD providers.The Swiss–Ukrainian program in mother-and-child health was initiated in Ukraine in 1997. The goal of the initiative was to improve availability, quality, effectiveness, and access to promotional, preventive, and curative maternal and child health services in selected Ukrainian oblasts (regions), rayons (districts), and communities linked in a system of regionalization . During More specifically, activities on CME in obstetrics and neonatology were implemented with the collaboration and support of the Ministry of Health of Ukraine (MoH), the National Medical Academy of Post-graduate Education (NMAPE), medical universities, regional authorities, and international agencies . Based oEducational materials were developed in collaboration with Ukrainian professionals and were accredited by NMAPE, and were later introduced into teaching curricula. This aided in promoting and enforcing dissemination at a national level, eventually reaching different regions of the country that were not initially involved in the project. NMAPE supported the implementation of innovative educational approaches and institutionalized them within its curriculum of certain courses. Capacity-building regarding key mediators, such as representatives of local and regional medical and managerial authorities, was targeted through the program activities as well. Details on the Swiss–Ukrainian program in mother-and-child health are presented in The Swiss Tropical and Public Health Institute was selected as the implementing agency for the “Medical education development” project. Hence, at the level of international partnership, there has been continuity in terms of lessons learned and partnership relations. Moreover, the ‘Swiss’ cross sign on medical and educational activities was already recognized in 2018 when this project started. The current project is focused on medical education and primary healthcare. The project collaborates with medical and nursing schools, building jointly with partners their capacities in eLearning, teaching excellence, curricula revision, strengthening skill labs (which are key infrastructure investments of the project), and supporting research capacity-building. On the primary healthcare level, the key areas are the advanced nurse practitioner pilot program, CPD activities for family doctors, and development of eRepository and peer groups. In addition, the project is contributing to policy-making , experience exchange , and communication on medical education (via podcast). Details on the MED are presented in We used a case study approach as a methodology for our study. The case study approach allows focus on a particular setting or area . The casDifferent steps of data collection and data analysis were applied. First, data were collected through a review of documents within the Swiss–Ukrainian program in mother-and-child health (2000–2015). This document review employed reports of monitoring visits, observation notes, interim reports, and digests. From these documents, we extracted information relevant to the design and implementation of complex educational activities and adherence to evidence-based medicine (EBM).Second, in-depth interviews were conducted during the closing phase of the program at the end of 2015 to explore the opinions of key stakeholders. The sample included 23 professionals, who were representatives of MoH, NMAPE, international organizations, regional decision-makers, chief medical doctors, healthcare staff, and non-governmental organizations who worked within the area of mother-and-child care. The stakeholder representatives were selected based on the method of convenient non-random sampling. The core idea of the program was presented to them by the program developers and managers through personal communication and further correspondence with the stakeholders. The participants had various job positions and levels of embeddedness in the program. We included both medical doctors who were involved in project activities and those who were not . Hence, triangulation of the sources of information was achieved by the representation of various stakeholders within the sample based on the notion that participants dependent on the program  may not be truly open about the program. Participants were asked to share their opinion on the program’s impact and role in mother-and-child care in Ukraine . Based on Bardin’ theoretical approach , contentFourth, we supplemented our analysis of the CME experience within the mother-and-child program with an analysis of the experience in the more recent Ukrainian–Swiss “Medical education development” project (2018–2023). We reviewed internal project reports  and publications . This additional review allowed for updates on the perception and practice of primary healthcare providers and medical educators in terms of professional development.It is important to note that a number of the authors of this paper are or have been managers in both the Swiss–Ukrainian program in mother-and-child health (2000–2015) and the Ukrainian–Swiss project “Medical education development” (2018–2023). This allowed for access to all relevant documents.Our data analysis of the Swiss–Ukrainian program in mother-and-child health showed that educational initiatives in the frame of the program aimed at setting and raising the standards in mother-and-child clinical practices both adapted to Ukrainian reality and were supported by EBM within neonatologists, obstetricians, anesthesiologist, midwives, and other professional groups less represented in the program  were reasons for dynamic evolutions in educational methodologies resulting in multimodal teaching designs. However, in obstetrics and neonatology the teaching content was consistent and could be resumed for repeatedly tackling educational goals and key messages  were important steps in consolidating partnership and adherence of neonatologists and obstetricians in the program.What has changed between the projects regarding the external stimuli for professional development? With a new MoH decree in 2018, physicians started regularly checking opportunities for CPD points collection and became more responsible for their CPD. However, during the first years of the new policies, the system has not been able to flourish due to the COVID-19 pandemic and Russian–Ukrainian war. The MoH has loosened the requirements in light of the challenging environment. Nonetheless, through joint efforts the large number of motivated medical doctors who take care for their professional development has created demand on the one hand, while on the other the small number of providers of high-quality training programs for medical doctors have received the green light for additional capacity-building with respect to their training initiatives.Moreover, the transformation of primary healthcare through new financing principles, greater autonomy for healthcare providers, and access to public finances on the part of private organizations and individual family doctors, has stimulated the development of healthcare providers. As they have obtained more funds, they are able to pay for the services and training they need, and more motivation has been brought about by a competitive environment in which patients select their GPs on their own.Additionally, the Ukrainian–Swiss project “Medical education development” began its educational activities on already-prepared ground, as the medical community had previously heard about the developments facilitated by the Swiss–Ukrainian program in mother-and-child health. Hence, the project had no need to explain the overall logic of the interventions despite the different target audiences .The educational activities launched by the Swiss–Ukrainian program in mother-and-child health are presented in This educational approach impacted the increase of practical knowledge in only a limited number of professionals, and as such had a limited influence on improving the quality of work of clinical teams. Hence, in-country training for obstetricians, neonatologist, midwives, and child nurses in selected (pilot) regions was implemented during the further stages. To ensure efficiency and sustainability, teaching was later expanded to training of trainers; one team per pilot region was trained, and this team then trained other professionals. In this way, it was estimated that more than 1500 participants could be directly or indirectly trained from 2008 to 2015 in the frame of the program.It has to be acknowledged that the development of regional trainers’ capacities was a long-lasting process that demanded regular and documented supervision. However, due to the rigid healthcare system described above, the sustainability of these teams’ work in a given environment was always at risk. For example, when national or regional power shifted after elections or for other context-specific reasons, this could affect the availability of the medical doctors involved in the teams .The content of the training was developed by a team of international and Ukrainian experts, mainly obstetricians and neonatologists familiar with international medical practice and with knowledge of the English language. Professionals from medical universities, referral maternities, and regional hospitals were involved. Obstetrical modules focused on specific topics not covered by standard Ukrainian clinical protocols or manuals, i.e., multiple pregnancies or vaginal childbirth after a previous Caesarean section (C-section). Neonatology modules covered a broader spectrum of topics related to intensive care of newborns , taking into account the major gaps in neonatal care provision described in further detail below.Training was provided in the form of lecturing and hands-on training or articulated within the model of Ongoing Professional Practice Evaluation with concrete case descriptions, review of morbidity and mortality, discussions, and definition of lessons learned. Handouts resuming the main topics and teaching objectives were delivered. During the implementation of the training of trainers, pedagogic materials containing teaching modules, participants’ guidance, and lecturers’ manuals were developed and published see .Manuals for parents and nurses were developed and disseminated among medical facilities in all regions of Ukraine. For example, pediatric nurses received handbooks containing practical issues on emergency procedures with illustrations, photos of medical equipment, advice regarding the choice and correct use of consumables, modern achievements in neonatology and intensive care, current MoH legislative documents, and principles of communication with parents of healthy and sick newborns.“Our training materials have several advantages over those state materials–they are evidence-based, which is new to healthcare personnel here. The training format is different from typical Ukrainian medical conferences and certificate courses because of interactive communication and the ability to actively participate in the discussion of the topics and issues. And this is very important and effective”.Particular attention was devoted to the active participation of attendants in training activities, which was regarded as crucial for the learning processes. This concept represented a rupture with previous social and educational contexts and model success situations with regard to fears of expressing own thoughts. Hence, participants were encouraged to freely express their opinions and to treat such expression respectfully.“The participants are often afraid to express their opinion openly, and this can be explained by the fact that they are asked their own opinion rarely, they are not sure whether their opinion is valued, they worry whether their opinion is not different from other staff or the trainer”.In order to adapt to the working schedules of medical practitioners, short-term courses were organized lasting 1 to 2 days. Frequently, trainers visited peripheral maternity wards and assisted in clinical activities. In general, this form of training was very appreciated by the participants and perceived as concrete, useful, and effective.“In most areas, we employed a neonatologist and opted for short-term courses: one or two full days. Our trainers visited the area, and during the day, they worked with doctors who requested to continue this design of the training because of its perceived usefulness and effectiveness”.In addition to in-class training, distance education through e-learning was introduced in order to support medical personnel at partner hospitals in their practice and to transfer basic knowledge and approaches.“When a person comes without adapted basic training, you have to spend a lot of time to explain the obvious principles”.(Trainer)E-learning was recognized as a very innovative educational approach. Between 2003 and 2008, computers and internet connections were installed and program participants with computer skills had to be found and trained. While the implementation of distance learning and compliance by program partners were somewhat complex and time-consuming, they stimulated and facilitated the shift from the post-Soviet type of post-graduate medical education to a modern CME approach.“Now, the lexicon of the lecturers and medical doctors contains a new concept–“continuous professional development”. This is a new approach to medical education, including distance learning, telemedicine technology, new knowledge in the workplace, the emphasis on practical skills, professional competence, communication and teamwork as well as the modular approach to designing training programs and electronic textbook”.CME in this program was designed for partner regions; however, educational activities covered the whole country through national conferences, guidelines and educational manuals, and courses  were accredited by NMAPE. Consequently, even those regions which were not directly involved in the program received program outcomes through other disseminative channels, including NMAPE.“First, training modules were developed by a working group of the Swiss-Ukrainian program. Obstetricians from rayon hospitals in four program partner regions received training on multiple pregnancies, and management of pregnancy, and childbirth in women after C-section. The program was consequently accredited and became the first certified postgraduate training course at the department of obstetrics at the NMAPE, which used the materials developed by Swiss-Ukrainian program in 2012. It was officially integrated in the academy’s training curricula”.In order to foster the introduction of developed materials into medical practice and promote administrative changes related to clinics according to priorities, regional healthcare administrators’ adherence and advocacy were stimulated by the program with the provision of parallel managerial training.“So as the clinical protocol does not stay in the drawers of chief doctor but worked efficiently–it is an understanding of the chief ‘what we do’, ‘why we do it’ and ‘who wants to get the result. We implement our initiatives more efficiently when “perinatal thinking” is present among heads of healthcare facilities, districts and regions”.The case of vaginal childbirth after C-section illustrates the impact of evidence-based medical practices introduced in obstetrics in 2011–2012. Courses on theory and practice implemented through the program were an eye-opener for many medical doctors, as well as for parents-to-be. This newly introduced clinical approach stipulating that natural childbirths were possible after C-section under clearly defined clinical conditions not only raised patient safety and was cost-effective, it helped to reinforce the status of mothers, as their social role might be impaired in case of non-physiological births.“Rural women regard a C-section as an action that indicates the inferiority of their body, as a drawback. Therefore, learning from their friends or acquaintances that they can give birth naturally after a previous C-section increases relevant requests to doctors”.(Head of the maternity department)“Today we are using state-of-the-art protocols for the management of pregnancy and childbirth after the previous C-section. It has been proven that assessment of risk factors, quality selection of patients and quality of follow-up, patients’ awareness and striving for success are the prerequisites of a desired outcome. And we see these outcomes ourselves. If previously we had only single cases of vaginal childbirths among women with scars on the uterus from previous C-section, then in the seven months of the current year, we have already had 30 such childbirths”.(Deputy chief doctor)More recent experiences of the Ukrainian–Swiss project “Medical education development” demonstrate that: (a) e-learning has become widely used since 2020 due to COVID-19 related lockdowns, with some return to face-to-face offline activities after summer 2021, while the war put a pause CPD during spring 2022; since summer 2022 CPD has returned to online, though less to offline modes; (b) EBM as a concept is recognized by healthcare providers and medical educators; however, due to the lack of EBM methodology being integrated in medical school curricula and lack of English language, we observe that EBM is not yet a core principle of care provision; (c) ‘fear of expressing one’s own thoughts’ is especially noticeable among nurses during training with medical doctors, and critical comments from participants and discussions are not yet typical practice during educational activities; (d) the Swiss project’s designed and supported training and conferences are highly appreciated by participants because of the relevance of the topics, interactive approaches, practical instruments, skills which can be applied in professionally, and competence gap-driven rather than available trainer-driven approach; (e) administrative decisions on process improvement are seen as being the result of high-quality training.In the Swiss–Ukrainian program in mother-and-child health, the first training of trainers took place in 2008; since 2014, regular training and CME in the field of Obstetrics and Neonatology has been implemented for medical students and professionals. This teaching activity has enhanced interregional and international exchanges of experience through meetings, workshops, and conferences. Apart from clinical skills, the training is aimed at the development of additional professional skills such as communication and personal management.“Communication skills when providing care is a new and interesting topic to study and further develop health professionals of the former Soviet Union. Getting basic medical knowledge at universities and colleges, we have not received the knowledge and skills for good communication, e.g., what you say, especially if you are leading a team. The ability to hear the other person, to communicate with the patient and relatives are greatly needed”.(Neonatologist)Establishing Simulation Centers in Ukraine went beyond the usual frames of training in mother-and-child health. This innovative concept needed special assistance in terms of practical, institutional, and economic aspects. Considerations such as infrastructure requirements, defining and procuring required equipment and technology, capacity-building, writing educational curricula, and defining its role in the Ukrainian educational context all had to be taken into account. Except in Odesa, simulation centers had not been established by state universities or hospitals because of a lack of funds. However, the manikins were not the only element of enhancing practical skills via simulation-based learning approaches. An essential role was given to higher learning and development objectives such as evidence-based methodology, scenarios adapted to the Ukrainian clinical reality, and the selection of relevant cases. Hence, after establishing four simulation centers in Vinnytsia, Volyn, Ivano-Frankivsk, and Sevastopol, particular emphasis was placed on improving capacity by employing interpersonal and group coaching as a major attribute in effective learning. A program handbook covering all these aspects was developed and made available nationwide.Institutionalization of medical training through simulation, specifically its introduction as a mandatory step in CME and certification of medical practitioners, is ongoing. However, a number of lessons learned can be defined. For instance, the low-fidelity (simple and cheap) manikins are preferred to higher-fidelity ones. The program experience has clearly shown that the maintenance of expensive manikins places a high financial burden on the teams and their administration. In addition, institutionalization of simulation should include the development of regulatory norms that create a motivating environment for the trainers to devote their time to training courses. At the same time, clear requirements for the trainers should be agreed upon.During the preceding decade, and with the support of the Swiss–Ukrainian program in mother-and-child health, simulation approaches have become popular in medical education. Nonetheless, those who launch simulation centers and skill labs are more focused on infrastructure and manikins than on trainers’ competencies (including an understanding of debriefing), revision of medical students’ competencies, the skills to be a part of skill labs training, and their integration into the curriculum. Hence, the Ukrainian–Swiss project “Medical education development” is not only supporting the development of existing skill labs or new ones, it is concentrating on the professional growth of skill lab trainers and their skills in scenario development and assessment. Presently, policymakers are discussing certification of skill labs and simulation centers to ensure their adequate functioning and the maintenance of national standards.Our review of documents from the Swiss–Ukrainian program in mother-and-child health showed that monitoring and evaluation were important supplementary activities to the training delivered. Follow-up visits were conducted in order to consolidate knowledge and skills gained during theoretical and practical training and to facilitate their implementation. The monitoring scheme included several follow-up visits that were initiated about ten weeks after the training. The follow-up visits usually happened at 6-month intervals. A focus was placed on the evaluation of general factors affecting hospital performances and bringing to light the problems faced by health professionals in the provision of perinatal care, as well as identifying solutions with clear guidelines for action.“Some doctors are already responding constructively. They say that after monitoring visits, they want to change something–do differently and better. I would not say that the attitude towards monitoring visits is 100% positive in hospitals, and probably absolutely positive perception will never be reached. But the perception that “the chief will come and punish” is not already there. In contrast, most teams say that these visits are an opportunity to have “a fresh view” in terms of where and how you work–as it is difficult to objectively assess the reality when you do the same from the morning till the night”.The program monitoring visits used to be agreed upon two weeks in advance with the administration of the healthcare facilities. Monitoring teams consisted of neonatologists, obstetricians, and/or pediatricians, usually leading regional professionals. They assessed the situation through observation of work and interviews with health professionals and child-bearing women. The visits corresponded to a new horizontal reciprocal exchange of information and expertise, increasing the chances for further dissemination and implementation of the issues addressed during training seminars. Moreover, the program introduced the practice of inter-regional visits, which was accepted positively and implemented by the program teams.“Monitoring visits–when the teams from other regions came to our region, and vice versa–were a unique opportunity to see how other doctors work and what methods and achievements they have. You notice many positive aspects and then you bring these positive insights into your medical institution. Also, after the seminar on the principles of the monitoring visit, I observe that the attitude of medical doctors towards monitoring has changed. Each next visit is conducted much easier”.Monitoring visits on the part of training providers remain a rare practice. From the perspective of the Ukrainian–Swiss project “Medical education development”, such visits seem to be more relevant in the case of practical skill development of healthcare service providers and less feasible for medical educators , in addition to being less functional in revealing changes in primary healthcare facilities due to the distracting matters of uncertain environment and lack of physical safety. Priorities in service provision seem to be more focused on staff retention and mental health support rather than new developmental challenges. Nonetheless, in this difficult context, reflection on the practices and changes is helpful. Student or patient feedback is helpful to review what has changed after the training, as is feedback from providers and trainees (educators or physicians/nurses). For example, in the Ukrainian–Swiss project “Medical education development”, nurses who extended their roles and competencies in service provision could recognize the pre-heart failure condition after recent ECG training, and shared this achievement with the training organizers.The Swiss–Ukrainian program in mother-and-child health placed special attention on integrating training activities in the context of poor healthcare infrastructure, and as such it concentrated on upgrading facilities and procuring essential equipment. Maternity and neonatology wards and neonatal intensive care units (NICUs) of third-level referral centers and second-level regional health structures were involved in facilitating the creation of a functional network with basic minimal infrastructure for perinatal regionalization. Medical communities and local authorities were involved in defining needs, participating financially, and organizing the reconditioning of the premises. Special training on fundraising strengthened the capacities of head doctors and administrators in negotiating state and private funding. Partnerships between government bodies, non-governmental agencies, and private organizations in financing the development of health services were created.“The recommendations of the program experts who came to our institution helped very much for proper zoning premises, so, we did everything correctly from the first attempt. The local budget funds were allocated to buy a part of the necessary medical equipment, and then our institution was officially included in the program, and the program provided the rest of the equipment. Nowadays, our maternity ward and intensive care unit are well-equipped with everything we need”.(Chief doctor)Renovations of buildings and facilities aimed to create patient-friendly premises. New spacious, comfortable, and bright obstetric wards and patient individual or two-bed rooms were set up with the aim of closeness to medical facilities such as operating theatres and NICUs. These fitting-outs created space for a partner to be present during childbirth, rooming-in, skin-to-skin policies, and the introduction of “responsible parenting schools”, as well as for “open days” at the hospital.“The real innovation is the Open Day in the maternity hospital–each Saturday, from 10.00 to 12.00 the couple can visit the maternity ward, its atmosphere and conditions where they will give birth to their baby. Doctors believe that this promotes better psychological preparation for childbirth”.(Obstetrician)“When school started, we did not expect high attendance, but now we have to work in several shifts because the demand is very high. Most pregnant women come with partners and we are preparing them for the process of birth. You will not believe it, but in 2007 we had no partner births in our hospital, and already in 2013, the rate increased to 82%”.Value-focused locations have been a focus of the Ukrainian–Swiss project “Medical education development” from 2020–2021, e.g., student-centeredness in medical education should be supported by student spaces (hubs) in which students have the opportunity to discuss their ideas, develop projects, and organize informal or additional non-formal educational activities. Such infrastructure developments support the overall strategic values of being client-oriented, and are one of the distinctive features setting the present approach apart from the Soviet approach to education (teacher-focused) and healthcare (doctor-focused). Unfortunately, the reduction in the financial capacity of partner and the damage to infrastructure due to the war have negatively impacted such infrastructure projects designed earlier; however, new construction and reconstruction of hospitals and schools are taking place even during the war.According to the documents of the Swiss–Ukrainian program in mother-and-child health, the progressive advance of practitioners in terms of knowledge and awareness toward international standards could be clearly observed. Among other examples, we note routine continuous monitoring policies in NICUs . Another example is the improved capacity provided for ventilatory assistance of sick newborns, whether invasive or non-invasive . Protocols for the management of multiple pregnancies, primary resuscitation of newborns, prevention and cure of Hyaline Membrane Disease, in-utero transfer, etc., have begun to be routinely implemented. Out of all educational and connected initiatives that contributed to the changes in clinical practices, the main reason for these improvements can be attributed to CME. It is certain that this educational activity has met the needs of clinicians and has helped substantially in improving practical skills as described. Practitioners were unanimous in acknowledging that the new training experiences were helpful in their practical work and that they would certainly recommend the training course to their colleagues. Mothers saw positive changes in the attitude and in the clinical recommendations they received in peripartum.“There are the same people working here, but their attitude towards the patients, as well as their practices, has changed a lot”.(Mother)“Thanks to our joint efforts in collaboration, we achieved a lot, for example, the loss of children up to 1 year of life  has significantly decreased. And I can say that this figure is 90% possible because of the training and improved knowledge and skills of medical staff”.We found during the document review that the obsolete system of healthcare service provision in Ukraine represented an important reason for the slow pace of healthcare improvements. Obstacles included poor financing that led to the lack of medicines, equipment, and consumables; inadequate human resource development and the outdated official system of CME; and rigid management practices, including in the area of quality improvement. Other barriers that the program had to take into account during training and coaching activities were poor knowledge of the English language among the medical and paramedical professionals, which sometimes, especially initially, led to a reluctance to open up to new advice and international standards.A general atmosphere of fear generated by a vertical long-distance hierarchy  contributed to these attitudes. Superiors in Ukraine were often disconnected from clinical reality, and this might have increased over-diagnosis and over-prescription as a mechanism of self-protection on the part of practitioners.“The approaches offered by the program have not resonated immediately with our doctors because all medical personnel used old approaches, and it was important first to prepare the personnel psychologically for the introduction of new perinatal technologies–to change the usual vision and to learn a lot. Later, during the training and visiting activities, doctors realized that these methodologies and practical skills were really effective, which in turn gave them more motivation to learn and to change”.(Chief doctor)“Not all medical professionals want to change their old stereotypes of pregnancy and childbirth”.It was recognized that the implementation of perinatal regionalization and its network needed further improvement. Scarce institutional commitment and the problematic financial situation hindered the adequate allocation of means for this purpose . More quotations that illustrate these statements are presented in On the clinical level, less encouraging results compared to the achievements already described concerned the understanding of vertical infectious diseases  and especially the misuse of antibiotics, which are prescribed excessively and not in line with international recommendations. This can be imputed to the insufficient capacities of microbiological laboratories to identify pathogens  and the myth of antibiotics being a prophylactic guarantee against  infections. Further training efforts are advisable. In addition, nutritional problems continued to subsist due to little availability of adapted consumables  and enteral feeding formulas.With the recent launch of the NHSU and new healthcare financing principles, healthcare facilities have more available funds and materials. Chronic underfunding has been responded to by these reforms; however, the war has led to lower fiscal capacity on the part of the state. What remains among the achievements are new and more efficient mechanisms of state funding distribution and its relevance to service provision as opposed to simply maintaining beds. New service provision policies require new and more extended competencies on the part of healthcare managers of autonomous facilities. A lack of studies limits the understanding of both areas. Because directors of healthcare facilities must deal with NHSU service packages, funding distribution, and related policies, this may be a sign indicating that managerial knowledge and skills are developing as well.The results presented above show how complex CME approaches , specifically those of the Swiss–Ukrainian program in mother-and-child health, have been applied in the Ukrainian context. The fresher lens of the Ukrainian–Swiss project “Medical education development” can supplement and update the findings of this program. While the implementation of these two international collaboration initiatives has had multiple benefits for the Ukrainian healthcare sector, it has faced various challenges and barriers as well. Below, we discuss these findings in light of the specific healthcare and education systems in Ukraine and the healthcare labor market shortages outlined at the outset of the article.Innovative education programs are required to ensure the necessary competencies of the healthcare workforce for tackling the current health risks . In partAs shown by our results, during the 15-year Swiss–Ukrainian program in mother-and-child health, clinical changes could be witnessed at many levels. Prior to program implementation, assessments clearly found a lack of awareness and expertise on the part of clinicians, as well as a lack of modern equipment ,39. ImpoAs described in the results section, the Swiss–Ukrainian program in mother-and-child health facilitated the rapid implementation of highly innovative simulation medical education that allowed Ukrainian medical doctors to avoid the thorny approach of trial and error, and provided an impetus to the further development of education scenario development. In addition, the program positively impacted the clinical safety of childbirth, and specifically the core concept of service quality. Simulation in medical education, which is a gold standard in many modern teaching institutions worldwide ,42,43, bHowever, chronic shortages in funding and a lack of experienced EBM staff make it difficult to install new simulation centers in Ukrainian educational and medical institutions. As mentioned earlier, the lack of necessary investment undermines the quality of healthcare provision and increases the healthcare labor gap in Ukraine as well as in the Eastern European region more generally ,6. This Healthcare professionals in the Eastern European region often lack motivation due to unsatisfactory working conditions and low reimbursement rates . UnderfuOur results describe numerous interventions in healthcare provision, including reorganization of the maternal department space, monitoring visits, and more patient-oriented approaches. Indeed, the attention paid to professionals , considering and responding to their professional needs, and development of interpersonal skills  and networking have become crucial in establishing a trustful and safe environment where changes in clinical practice have been possible .Before the Swiss–Ukrainian program in mother-and-child health, over-medicalization within care for women and newborns was widely spread. No individual birthing rooms were available; several women were sometimes giving birth in one room at the same time. Partner presence during childbirth and rooming-in was not allowed; newborns were kept all together in separate rooms. Frequently, nutritional needs essential for the healing of sick newborns were not met. Overall, the care provided to sick neonates was unsatisfactory ,38.Most of these practices have become remnants nowadays due to this program, which has improved mothers’ childbearing experience, as illustrated by our case study. More trustful relations between healthcare providers and families can have a large contribution to service providers’ job motivation as well. Moreover, the program has helped to develop communication skills, which contribute to establishing a trustful and safe clinical environment . Thus, tOne of the major obstacles to service improvement in Ukraine, as in other Eastern European countries, is the lack of financial incentives for individual healthcare providers . Recent The Swiss–Ukrainian collaborations, while bringing forward innovative CME and EBM practices, also promoted the values of openness, transparency, and integrity. This is illustrated by the findings of this case study. In the Ukrainian healthcare sector, strong formal and informal parallel structures exist in virtually all areas, including education . This seThe Swiss–Ukrainian collaborations presented in this article are examples of how international projects can contribute to improving the managerial capacities of facility leaders through training and plans for facility development. In fact, chief medical doctors are advised to supplement such collaborative input with funds raised from other sources, e.g., public–private partnerships. Thus, the Swiss–Ukrainian collaborations have indirectly contributed to awareness of the importance of transparent policies in service provision on the part of healthcare staff, as well as the development of fundraising skills and project-based management of healthcare facilities. This example could be helpful for other Eastern European countries where openness, transparency, and integrity need to be promoted among the healthcare workforce.Ukrainian mother-and-child services previously had no tradition of CME. The CME philosophy was hardly even accepted at the beginning of the Swiss–Ukrainian program; however, in spite of the need for complex and integrated activities, this has become possible, as suggested by our findings. A complex approach in CME as a vital step towards better quality and access shows its sustainable nature . First, Importantly for Ukraine and other Eastern European countries as well, clinical and educational solutions cannot be directly transferred from one international project in one country to another. The priorities have to be (and were) defined according to the population’s health needs, feasibility, and local capacities . To provAs mentioned in the case description and explained in the results, the length of the program was almost two decades, which played a key role in achieving a real shift in the clinical practices and engagement levels of all stakeholders. One of the main lessons learned was the importance of the time factor; in order to allow efficient clinical implementation of complex CME in post-Soviet countries, a minimum period of 10 to 15 years has to be allocated . In thisThis study has disseminated the experience with CME in Ukraine, and specifically highlighted the benefits and challenges of the Swiss–Ukrainian collaboration. The main strength of this study lies in its analysis of long-term collaboration focusing on the healthcare environment and the complexity of the activities that bring about change in both the de jure and de facto dimensions. However, this study is not without limitations. As mentioned in the methods section, some of the authors are or have been managers in the two initiatives studied. While this ensured access to all relevant documents, it could have caused researcher bias. However, not all authors were involved in the programs, which means that the possibility of such bias has been reduced.Notably, the lack of a proper nationwide monitoring and evaluation system makes precise quantitative estimations involving the Swiss–Ukrainian collaboration impossible. Nevertheless, the study has generated evidence on the experience of this collaboration and the perceptions of stakeholders. In addition, the experience analyzed in this case study tackles several regions which were the focus of the program. Although the Ukrainian healthcare system is essentially centralized de jure, de facto there are substantial differences across the regions because of different historical, economic, and socio-cultural aspects. Prior to the healthcare reforms, obstetrics and gynecology were very specific areas of healthcare service provision having, e.g., higher status of healthcare service providers and more resources compared with primary healthcare ; therefoThus, the results must be transferred to other sectors and locales with caution and while ensuring careful understanding of differences in the sector features. For example, due to the latest health financing reforms the status of primary healthcare physicians has been substantially increased by financing, communication campaigns, and the organizational performance of primary healthcare centers.Based on the results presented in this article and their discussion, and considering our study aim, we are able to formulate several key conclusions regarding the experience with the implementation of complex CME approaches in Ukraine. We conclude that complex approaches to implementing CME, namely those in the Swiss–Ukrainian mother-and-child health program, have had positive effects according to the stakeholder representatives involved. Therefore, the experience of this program should be considered in further initiatives in the area of mother-and-child health. An example of such initiatives relates to the implementation of similar activities through the new Ukrainian–Swiss medical education development project.The effect of the numerous multi-level educational activities designed to change medical practice and patients’ health outcomes is especially visible in a long-term perspective . Times wAs shown in this study, the program activities in the Swiss–Ukrainian program in mother-and-child health were designed in view of the relatively weak institutional and technical capacities of the county, i.e., post-Soviet mentalities and an unstable political climate in a societal transition period. Despite the number of problematic areas in the Ukrainian healthcare sector, including the lack of funds, their inefficient allocation, constant changes of authority, and an unstable political situation, the program led to the introduction and adaptation of international practices, assuring its sustainable presence in the service provision.The experience of implementing this program clearly shows that the contextualization of educational activities has to be taken into account. The recent experience of the Ukrainian–Swiss project “Medical education development” implemented under the COVID-19 pandemic and war–related restrictions demonstrates that difficult contexts may bring about new insights and foster new practices .This study concludes that a shift from the old and often unsafe clinical practices to evidence-based and efficient mother-and-child care can be realized in the post-Soviet settings notwithstanding poor governance. A complex CME approach based on the values of openness, respect, dialogue, and professionalism can be successfully implemented by an international assistance program despite the resistance of the system towards change.In Ukraine and other Eastern European countries, such initiatives are of crucial importance for ensuring necessary competencies on the part of healthcare professionals, enhancing their job motivation, and improving the quality of healthcare provision. Investments in infrastructure and life-long learning programs can help to train and retain healthcare professionals in national healthcare systems by providing better work conditions and opportunities for professional development.