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Background Diabetes is one of the leading causes of poor health and high care costs in Ukraine. An estimated 3 million adults live with the condition, placing diabetes in the top ten causes of years lived with disability. To prevent diabetes complications and alleviate the financial burden of diabetes care on patients, the Ukrainian government reimburses diabetes medication and provides glucose monitoring, but there are significant gaps in the care continuum. We estimate the costs of providing diabetes care and the most cost-effective ways to address these gaps in the Poltava region of Ukraine.Methods We gathered data on the unit costs of diabetes interventions in Poltava region in 2017 and estimated expenditure on diabetes care. We then applied the Cascade Analysis Tool, a model for analyzing and optimizing health service implementation, to estimate the optimal combination of facility-based and outreach screening and investigate how additional funding could best be allocated to improve glucose control outcomes.Results Of the ~40000 adults in diabetes care, only ~25% achieved sustained glucose control. Monitoring costs were higher for those who did not: by 10% for patients receiving non-pharmacological treatment, by 61% for insulin patients, and twice as high for patients prescribed oral treatment. Investments in initiatives to improve treatment adherence (e.g. medication copayment schemes, enhanced adherence counseling) would address barriers along the care continuum and we estimate such expenditures may be recouped by reductions in patient monitoring costs. Improvements in case detection are also needed, with only around two-thirds of estimated cases having been diagnosed. Outreach screening campaigns could play a significant role: depending on how well-targeted and scalable such campaigns are, we estimate that 10–46% of all screening could be conducted via outreach, at a cost per positive patient identified of US$7.12–9.63.Conclusions Investments to improve case detection and treatment adherence are the most efficient interventions for improved diabetes control in Poltava region. Quantitative tools such as the Cascade Analysis Tool provide essential decision support for targeting investment into services which close the gaps in implementation.