Health Financing for Universal Health Coverage in an Era of Polycrisis: Good Governance Rules for Ukraine’s Program of Medical Guarantees

The Program of Medical Guarantees (PMG) is Ukraine’s central instrument for public financing and purchasing of essential health services. The PMG brings together four health financing functions: (i) budget formulation and allocation; (ii) benefit design (the services and medicines purchased by the National Health Service of Ukraine (NHSU)); (iii) payment methods and tariffs; and (iv) provider contract specifications and requirements. Ukraine provides a distinctive setting for analysing governance of health financing under polycrisis conditions, in which overlapping shocks place sustained strain on public institutions. Since the 2014 Revolution of Dignity, reforms have emphasised accountability, integrity and civil-society engagement, with the aim of reducing scope for corruption and state capture. In the health sector, the PMG has created a platform for more explicit and accountable financing arrangements, reinforced by external expectations associated with EU accession and donor financing. In practice, however, PMG implementation has unfolded amid successive shocks - first the COVID-19 pandemic, then full-scale war - resulting in compressed timelines and informal working methods for preparing and approving PMG changes. This presents risks to timeliness, predictability and feasibility of implementation - limiting the scope for evidence-informed deliberation, consultation, and transparent communication of decisions. This paper analyses the PMG policy framework against ‘good-governance’ principles, specifying seven core requirements for sound decision-making: explicit goals, criteria, decision rules and processes for PMG development and revision; a codified institutional framework clarifying roles, responsibilities and decision-making authority; objective use of evidence and impact analysis; transparent consultation with broadly representative stakeholders; clear communication and reasons-giving; monitoring and evaluation; and dedicated resources for the process. Using these requirements as evaluative criteria, we examine the PMG policy cycle and its linked components, tracing how institutional arrangements shape the timing, transparency and coherence of decisions across the four health financing functions (budget formulation and allocation, benefit design, payment methods and tariffs, and contracting rules). We structure the analysis around three interlocking problems observed in practice: (1) the extent to which ministerial oversight and strategic direction are exercised; (2) the extent to which the PMG cycle is (or is not) codified, and the implications for timeliness, predictability and transparency within fiscal and budget-calendar constraints; and (3) the extent to which internal procedures and responsibilities within the NHSU support or hinder consistent application of criteria across PMG components. Finally, we draw on this to define a reform model centred on clearer mandates and decision rights, codified timelines and processes, and strengthened purchaser procedures supported by analytical capacity, with the aim of improving the timeliness, transparency and feasibility of implementing PMG decisions. The paper advances understanding of health policy and governance by showing how the ‘rules of the game’ for public financing and purchasing of health services are tested in polycrisis conditions. It identifies practical reforms for policy-makers that can make health financing decisions more timely, transparent, and feasible to implement in such conditions - strengthening legitimacy and accountability while preserving the capacity to adjust budgets, benefits, payment methods and tariffs, and contracting rules as needs and constraints evolve.