Adjusting primary health care (PHC) provider payments in Ukraine to better meet the population’s needs, and understanding the war’s impact on their work, are essential steps to enhancing the quality and accessibility of care, reveal two reports released by WHO/Europe.
As part of the support for the ongoing health financing reforms in Ukraine, the report “Results of costing for provider payments in primary health care in Ukraine” provides a comprehensive cost analysis, offering valuable insights for recalculating and adjusting payments to PHC providers. The second report “Impact of the conflict on the costs of primary health care and investments in Ukraine” delves into survey results from providers, to assess the impact of the war on PHC providers across the country.
The reports were launched at a PHC conference on 15–16 May 2024 in Kyiv, Ukraine, where over 500 PHC professionals along with health authorities and international partners exchanged knowledge and mapped the future of PHC during and after the war. Participants and PHC providers had the chance to review the conclusions of both studies and engage in discussions on how to ensure adequate funding for PHC.
“Both reports allowed primary health care providers to voice their concerns regarding the current financing system affecting their work and provided evidence to make changes in service delivery to enhance quality of and access to care,” explained Dr Jarno Habicht, WHO Representative in Ukraine.
In 2018, Ukraine initiated a health financing reform to strengthen PHC access for all Ukraine residents. The transformative agenda included several actions to reform service delivery, such as designing the Programme of Medical Guarantees, defining a publicly funded benefits package, and improving autonomy and work conditions for providers.
As a result of these actions, 33 million Ukrainians had registered with a family doctor by early 2022 and over 2000 PHC facilities signed contracts with the National Health Service of Ukraine (NHSU) to provide guaranteed services.
Analysing costs for PHC providers
Refining the PHC providers payment design in Ukraine has become a priority to accurately align with the costs associated with meeting population health-care needs.
The dedicated report offers a comprehensive cost analysis reflecting the situation before the full-scale invasion and well-documented assumptions and scenarios for adjusting provider capitation rates, which is the fixed payment per person a provider receives to deliver health-care services.
The report offers input to validate the existing capitation rate, and provides a tool to calculate revisions and estimate the budget to cover the PHC benefit package. The cost analysis study was meticulously supervised by a taskforce, headed by the NHSU and including senior representatives from the Ministry of Health, Ministry of Finance and local authorities.
The study findings have prompted the Ministry of Health to introduce a new regulation, guiding the evidence-based revision of provider payment rates. Additionally, a process has been established for the NHSU to conduct cost studies and determine capitation rates accordingly.
“The data collected from the costing study is instrumental in refining the provider payments in primary care. Furthermore, it serves as a strategic instrument for assessing the budgetary implications of various policy options for 2025 and beyond, while offering recommendations for the government on how to define provider payments better," added Natalia Husak, Head of the NHSU.
The analysis concludes that:
- The majority (61%) of PHC payments cover labour costs, with the remainder addressing regulatory requirements like equipment availability and diagnostic services.
- The current payments do not fully cover the costs of providing services outlined in the PHC benefits package. It should account for utility and capital expenses, for example.
- Most of the utility and capital expenses are covered by local governments, but private providers lack access to this funding. While some local governments allocate extra resources to PHC, others may not do so due to a lack of unified approach and coordination.
- There are significant cost variations across provider types and regions. Rural providers incurred higher costs and often sought additional funding sources.
War impact on PHC service delivery and financing
A survey was conducted in the beginning of 2023 to examine the impact of the conflict on PHC providers, complementing the costing analysis. The report based on the survey provides practical insights to support the health financing reform considering the evolving PHC landscape and presents options to improve service delivery amid the full-scale invasion. The analysis identifies the critical disruptions, the costs impacting PHC service delivery after the 2022 invasion and providers current needs.
After initial uncertainty, most PHC providers stated that they managed to stabilize their situation by the summer of 2022.
“Patients came to us, but we could only provide limited help. Without transport or fuel, it was challenging. We distributed medicines to those with chronic diseases like diabetes. To pay salaries to doctors, we relied on catching roaming signals at the border to transfer funds. Lack of resources caused chaos and fear, making it very difficult,” stated a PHC doctor in Chernihiv Region.
The main challenges included:
- The shelling of critical infrastructure led to massive electricity cuts across the entire country. PHC providers have needed to switch to alternative electricity sources, like generators, which are expensive and require availability of fuel.
- Initially, displacement of people and people being afraid to leave the house shifted PHC services towards remote consultations. As the situation stabilized by summer 2022, missile alerts and blackouts continued to interrupt PHC service delivery, requiring staff to leave premises or interrupt their service; therefore, remote consultations are still frequently used.
- The depreciation of the currency and price increases led to a rise in expenditure of PHC providers. Some providers have received support from donors and local governments and others have used their own reserves to cover the increased costs.
- Staff shortages and changes emerged as other critical issues, as many health-care professionals left the country or were internally displaced. This movement further strained PHC facilities, particularly in conflict-affected regions, leaving many providers understaffed and struggling to meet patient needs.
Technical assistance and financing for the study
The two reports, “Impact of the conflict on the costs of primary health care and investments in Ukraine: survey of war effects” and “Results of costing for provider payments in primary health care in Ukraine: technical report” received financial support from the Government of Canada and the United Nations Joint Sustainable Development Goals Fund.