Contracting as a tool for recognizing the management capacity and leadership of the rehabilitation network of healthcare institutions in Ukraine

Abstract

Purpose. The primary purpose of this study is to provide a comprehensive theoretical substantiation and practical analysis of the contracting mechanism for rehabilitation care packages under martial law. The research positions contracting with the National Health Service of Ukraine (NHSU) not merely as an administrative procedure, but as a critical integrated proxy-indicator for recognizing the management capacity and strategic leadership of healthcare institutions. These institutions form the backbone of the national rehabilitation network, ensuring systemic resilience during a period of unprecedented external shocks caused by full-scale military aggression. Materials and methods. The study is based on an extensive analysis of aggregated statistical data provided by the NHSU for the period 2023–2025. The core information source includes the dynamics of concluded contracts and total funding allocations for the Program of Medical Guarantees (PMG) packages: No. 53 (“Rehabilitation assistance for adults and children in inpatient conditions”) and No. 54 (“Rehabilitation assistance for adults and children in outpatient conditions”). The research methodology incorporates statistical analysis, the comparative method to evaluate national versus regional trends, content analysis of regulatory NHSU documents, and a systems approach to validate a multifaceted model of institutional capacity. Results. The research demonstrates that during the war, NHSU contracting transformed into an objective national “stress test” of institutional capacity. At the national level, despite the destruction of approximately 23 % of medical infrastructure in the eastern and southern regions, the rehabilitation network showed significant growth. The number of contracts increased by 33.0 %, and total funding volumes grew by 61.8 %, rising from UAH 4.11 billion in 2023 to an estimated UAH 6.66 billion in 2025. Inpatient care (Package No. 53) became a strategic priority, with funding increasing by 81.7 % to support the intensive treatment of severe combat-related injuries, particularly those classified under the highest severity ratings (SR1–SR2). At the regional level, using the Rivne region as a representative rear-area hub, the study recorded a funding growth of 105.3 %, which significantly outpaced the national average. This confirms the region’s vital role as a “rear rehabilitation hub” for evacuated military personnel and civilians. The study validated a five-component capacity model encompassing strategic, operationaltechnological, financial, organizational-personnel dimensions, and resilience to external shocks (such as blackouts and mass evacuations). The management capacity rating for the Rivne region revealed a critical concentration of 80.0 % of financial resources among 11 leading providers. The Rivne Regional Clinical Hospital for War Veterans emerged as the absolute leader, accumulating 22.5 % of regional funding (UAH 53.9 million) by implementing a “quality leadership” strategy through large-scale international investments and specialized spinal rehabilitation programs. Conclusions. Successful contracting with the NHSU serves as the most accurate indicator of management leadership and systemic resilience in a conflict-affected environment. However, the analysis identified systemic imbalances: a significant gap between inpatient and outpatient care (an 8.5:1 ratio in the Rivne region compared to 2.26:1 nationally) and extremely low private sector participation at the regional level (0.93 % vs 13.5 % nationally). These findings suggest that while the network has adapted for emergency stabilization, it currently lacks the infrastructure for a full long-term functional recovery cycle. Recommendations. It is recommended that the NHSU revise its tariff policies for Package No. 54 to stimulate outpatient recovery and conduct targeted research into barriers for private investment in rear regions. For regional authorities, the study suggests a strategy of “managed decentralization”, focusing on transferring expertise from flagship hubs to second-tier district hospitals to improve geographical accessibility and reduce the over-concentration of resources in regional centers.