Keywords: Primary health care (PHC); quality indicators; wartime healthcare; Item Impact Score (IIS); Ukraine; performance assessment; indicator relevance

Background:

Since the war began, Ukraine’s health system—especially primary care—has operated under immense strain. State-recommended quality indicators may not reflect wartime realities. We assessed the external validity of PHC indicators from the perspective of family doctors, based on UMoH and NHSU frameworks.

Research questions:

How to assess the external validity of PHCI in Ukraine using the Item Impact Score (IIS) based on physicians’ ratings of importance for practice, doctors and patients during wartime?

Method:

A pilot survey of 13 family doctors from 4 Ukrainian regions used a structured Google Forms questionnaire. They rated 25 official PHC indicators (UMoH/NHSU) on a 5-point Likert scale across 4 dimensions.Item Impact Scores (IIS)were calculated to assess external validity.

Results:

Not all UMoH indicators were equally relevant during wartime.The ≥1 annual visit indicator was rated low due to population displacement. Physician workload was valued by providers (IIS 2.3–3.8) but underestimated by patients (IIS 1.34). Physician availability (IIS 3.9), child vaccination (IIS 4.3), and developmental monitoring under 1 year (IIS 3.9–3.77) were highly rated.BMI and smoking assessment were important to providers (IIS 2.66–2.71), but not to patients (IIS 0.53).Mental health indicators were highly ranked by doctors (IIS 3.3–3.9), yet perceived as less important by patients (IIS 0.78).Secondary prevention (breast, colorectal cancer, HIV, TB) had support (IIS 2.17–3.49), while prostate cancer screening was questioned (IIS 0.31–1.18).Hypertension management was valued (IIS 3.77 for doctors, 3.37 for facilities, 2.71 during war).Referral rate to specialists scored low (IIS 0.85 for patients, 0.93 during war), possibly due to concerns about undermining family doctors.“Affordable Medicines” coverage was seen as less relevant (IIS 1.27–2.07),likely due to limited access to combination therapies.

Conclusions:

Not all official PHC indicators remain relevant during wartime.Primary prevention, physician availability, and mental health were prioritised. Providers noted that patients may undervalue mental health, BMI, and smoking. Prostate cancer screening and referral rates were least supported.

Points for discussion:

Can this study guide the quality monitoring systems evaluation in conflict-affected countries?

What other indicators may assess PHC performance evaluation under crisis conditions?