EVOLUTION OF THE HEALTHCARE FINANCING SYSTEM OF UKRAINE: COMPARATIVE ANALYSIS OF REGULATORY AND LEGAL TRANSFORMATIONS AND THEIR RESULTS

Abstract

The article presents a comparative analysis of the evolution of Ukraine’s healthcare financing system over the period 1991–2024, examined alongside quantitative indicators of the performance of successive normative-legal models. Three qualitatively distinct stages of transformation are identified: the conservative stage (1991–2009), characterised by the preservation of the Semashko line-item budgeting model under conditions of chronic underfunding (30–40% of actual need); the pilot reform stage (2010–2016), during which Law No. 3612-VI established the legal foundations for testing new financing models in four pilot regions; and the systemic transformation stage (2017–present), based on a contractual model of strategic purchasing through a single national purchaser – the National Health Service of Ukraine (NHSU). Drawing on data from the WHO Global Health Expenditure Database, the study establishes that throughout 2000–2021, private out-of-pocket (OOP) household expenditures consistently exceeded 44.8% of total healthcare spending, equivalent to 33% of the average wage. This pattern indicates a structural rather than situational dimension to patients' financial vulnerability. The mechanisms of the Law “On State Financial Guarantees of Medical Services for the Population” (2017) are examined, along with the institutional role of the NHSU in eliminating the fragmentation of financial pools. It is demonstrated that the implementation of the Medical Guarantee Program consolidated 68% of public healthcare expenditure by 2020 and reduced informal payments at the primary care level from 62% (2018) to 21% (2021). The impact of the 2014–2015 currency shocks and the full-scale invasion of 2022 on the financial accessibility of medical care is analysed. The general-taxation model with a centralised funding pool is shown to be structurally more resilient to external shocks than the line-item budgeting system. The study concludes that despite a systemic breakthrough in the financing mechanism, the full realisation of the reform requires addressing persistent challenges related to service quality, human resources, medicines reimbursement, and the integration of parallel departmental financing systems.