Statistical Analysis of Pre-War Primary Healthcare Costs in Ukraine: Variations by Location and Ownership and Implications for Financing Reform

Strong primary healthcare (PHC) is associated with lower costs and better population health outcomes when supported by appropriate financing. Costing analysis enables evidenced-based decisions for estimating budgets for PHC and defining provider payments. In 2021, a project supported by the World Health Organization was launched in Ukraine to collect cost data from 100 PHC providers. The objective was to assess costs for delivering services within the state-funded benefits package, with the aim of informing tariff-setting, and assessing budget need. This study used statistical analysis on the collected cost data. We applied multivariable linear regression (MLR) to assess variation in cost-per-person across locality (rural vs. urban) and ownership type (public vs. private) of the providers, after adjusting for confounders. The mean (standard deviation) cost-per-person across the sample providers was 45.46 (18.46) USD. MLR analysis showed that rural providers had a higher cost-per-person of 6.70 USD (95% CI: 1.54, 11.85) compared to urban providers, after adjusting for confounding (p=0.011). We also found strong evidence that private providers had a lower cost-per-person of 36.15 USD (95% CI: -41.82,-30.48) compared to public providers, after adjusting for confounding (p<0.001). Although our findings do not capture the impact of the Russian hostile invasion of Ukraine, they still provide valuable insights for policy discussions within Ukraine and for other nations examining PHC financing reforms. Our findings align with international evidence suggesting that rural providers incur higher costs, supporting the need to adjust capitation payments for providers in these areas. Ownership type also affects costs, potentially reflecting differences in quality standards between public and private providers. These differences allow private providers to opportunistically reduce costs by limiting staff numbers and optimizing facility size to maximize profits. To ensure equitable access to high-quality PHC, uniform service delivery standards should be applied to all PHC providers, regardless of ownership type.