NHSU STRATEGIC PURCHASING AS A DRIVER OF HUMAN CAPITAL TRANSFORMATION IN THE REHABILITATION SYSTEM UNDER MARTIAL LAW

Abstract

Introduction. Under martial law, Ukraine's rehabilitation sector faces a dual challenge: a rapid increase in demand for recovery services and a critical shortage of qualified personnel. The study aims to analyze the impact of strategic purchasing mechanisms employed by the National Health Service of Ukraine (NHSU) on the transformation of the organizational and human capital capacity of the rehabilitation network. The main goal is to determine how tariff incentives (specifically complexity coefficients) and contracting requirements reshape human capital management strategies, hiring processes, and remuneration. The study tests the hypothesis that the Medical Guarantee Program requirements act as a catalyst for the transition from extensive staff recruitment to the formation of highly qualified multidisciplinary teams.

Materials and Methods. This study of human capital in the rehabilitation system is grounded at the intersection of three discourses: the theory of human resource sustainability in conflict zones, contracting as a tool for preserving and developing human capital, and empirical research on professional burnout among multidisciplinary teams.  It has been established that it is precisely the NSZU contracts under Package No. 53 that are based on the requirements for forming multidisciplinary rehabilitation teams (MDRT) and standards that modernize the staffing structure of Ukrainian rehabilitation facilities, which has led to the phenomenon of “staffing overheating” and intense competition for specialists. Critical issues of the staffing crisis in the sector have been identified: a structural shortage of narrow specialists, gender imbalance and the mobilization factor, “cannibalization” of staff and regional differentiation, professional burnout, and work intensity. An analysis of the dynamics of funding for rehabilitation care in Ukraine and the Rivne region was conducted. The specific structure of rehabilitation services in the region, which determines staffing strategies, was identified. The activities of the Rivne Regional Clinical Hospital, a public enterprise that adopted a strategy of deep specialization, transforming from a general hospital into a powerful rehabilitation hub, and the phased evolution of its management were analyzed. Key trends in the preservation and development of human capital were identified: strengthening the “clinical core,” reactive reinforcement of the middle management level, and managerial flexibility. It has been established that the National Health Service of Ukraine (NSZU) contracts under Package No. 53 are based on requirements for the formation of multidisciplinary rehabilitation teams. It has been demonstrated that the NSZU’s procurement of medical packages through contracting has triggered a process of internal staff migration from less financially viable hospitals to financially successful centers. It has been established that during the 2023–2025 period, the region’s healthcare system lost 412.85 full-time equivalents (-2.26%), which is associated with migration, mobilization, and network optimization. At the same time, the leading institution’s staff increased by +13.6%. The identified disparities in funding and staffing dynamics align with the logic of the Matthew effect, which in healthcare system studies describes a mechanism of cumulative advantage: institutions with initial financial and organizational capacity are able to accumulate a disproportionately larger volume of resources in the future. In this case, this manifests through the concentration of funding for complex cases (SR1) and the subsequent flow of personnel to financially successful rehabilitation hubs. The example of the leading facility illustrates that the National Health Service of Ukraine’s (NSZU) contracting mechanism acts as an investment multiplier. By receiving funding for complex cases, the leading facility ensured a 43.1% increase in doctors’ salaries and a 25.2% increase for support staff, while at the regional level, nurses’ salaries decreased by 1.9%. High complexity-based rates (SR1) do not merely cover costs but create a resource for human capital development – hiring.

Results. It was established that NHSU contracting acted as a regulatory driver for the formation of multidisciplinary teams. The analysis revealed a distinct "concentration effect" (Matthew effect): against the background of a general staff reduction in the region by 2.26% (due to migration and mobilization), the leading facility increased its staff by 13.6%, accumulating human capital. A direct correlation between contracting success and remuneration levels was proven: the leading facility, receiving funding for complex cases, ensured a 43.1% increase in doctors' salaries and a 25.2% increase for nursing staff, while at the regional level, nurses' salaries decreased by 1.9%. This stimulates internal migration of personnel from the periphery to financially successful hubs.

Conclusions. NHSU strategic purchasing mechanisms have transformed the financing principle from "money follows the patient" to "money follows the team." High requirements for therapy intensity (3 hours/day) and the presence of narrow specialists create centers of excellence but pose risks of personnel imbalances for peripheral communities. To balance the situation, it is recommended to introduce an "educational coefficient" for hubs training specialists and to implement professional burnout prevention programs.