Request_for_Information_Ukraine_Furthering Health Reform FINAL Dec 18.pdf

REQUEST FOR INFORMATION (RFI)

Subject: Request for Information No. 72012124RFI00001 Issuance Date: December 18, 2023 Issued by: USAID/Ukraine Issuing Contracting Officer: Craig Riegler Response to: kyivrcoeg@usaid.gov; criegler@usaid.gov

Reference: Furthering Health Reform and Recovery in Ukraine Activity (FHR)

Purpose

USAID/Ukraine is in the process of designing the new “Furthering Health Reform and Recovery Activity (FHR)” for implementation in Ukraine. We are seeking public comments on the DRAFT Statement of Objectives to inform the design process. Responses to this request for information are not binding on the U.S. Government and do not obligate USAID to issue a solicitation, nor does it commit USAID to pay any cost incurred in the preparation and submission of comments.

Brief Description

The overall goal of this five-year program is to improve the health system’s accountability, efficiency and transparency in Ukraine to meet the new and emerging health needs for Ukrainians during and following the war.

Requested Information:

USAID/Ukraine invites the public to submit constructive feedback and comments on the DRAFT Statement of Objectives (SOO). This includes, but is not limited to, comments on the feasibility of proposed objectives under identified critical technical areas and the identification of any potential gaps. In addition to general feedback, USAID would like to receive comments related, but not limited, to the questions listed below. These comments will be taken into consideration in the design of the final activity. We have provided the draft SOO and questions in Attachment A.

Comments must be submitted to USAID via email to the Regional Contracting Officer at kyivrcoeg@usaid.gov, and Craig Riegler, Supervisory Contracting Officer, at criegler@usaid.gov. The subject line must read “72012124RFI00001 Furthering Health Reform and Recovery Activity (FHR),” and comments must be submitted no later than January 10, 2024 at 5:00 PM (Kyiv Local Time). Only electronic submissions will be accepted. Responses to this RFI must be written in English. Responses must be typed in 12-point Times New Roman font, single spaced with one-inch margins on the electronic equivalent of 8.5 x 11-inch paper.

Responses sent by any other means or in any other format will not be reviewed. Submissions must not exceed the page limitations for each part indicated below. Submissions exceeding the page limits will not be read. Only one submission will be accepted per organization.

mailto:kyivrcoeg@usaid.gov mailto:criegler@usaid.gov mailto:kyivrcoeg@usaid.gov

72012124RFI00001

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Cover Page:

Whether responding to the Questions or providing general feedback on the SOO or both, all submissions must include a cover page (one page maximum) that includes the following information:

• Organization name and address

• Organization point of contact name, DUNS number (if applicable), telephone number, and email address

• Organization type, i.e. commercial, public sector, educational institution, NGO, etc.

• If applicable, socioeconomic status, e.g., other than small business, small business, woman-owned, veteran-owned, etc.

• Primary field(s) of expertise/work

• Geographic presence, e.g., countries in which your organization is currently working, also noting the countries in which your organization is legally and formally registered

• North American Industry Classification System (NAICS) code, if applicable

In response to the Question below or providing General Feedback on the SOO, an organization’s response must not exceed five (5) pages in total length.

This Request for Information (RFI) is issued solely for planning purposes and is published in accordance with FAR Part 10 and FAR 15.201(e). This RFI is open for comments from any interested US and Non-US Organizations. It should be noted that responding to this RFI will not give any advantage to any organization in any subsequent procurement. Likewise, organizations that choose not to respond will not be precluded from submitting a proposal in response to a subsequent solicitation, if one is ultimately issued. Any information submitted in response to this notice is voluntary. This is not a solicitation or a call for proposals. Please do not submit proposals, resumes or promotional materials, as they will be discarded. Proprietary or otherwise sensitive information must not be sent. USAID may use any information provided without incurring any obligation. USAID reserves the right to, or not to, incorporate any, some, or none of the comments received from this RFI into any subsequent solicitations or design documents. This RFI does not restrict the Government's acquisition approach on a future solicitation, and USAID reserves the right to modify the scope, scale or other details of the planned activities. Similarly, USAID is not obligated to modify its planned approach or otherwise incorporate the input that organizations offer.

Respondents will only receive an electronic confirmation acknowledging receipt of your response but will not receive individualized feedback on any suggestions. Questions regarding this announcement will not be answered.

We know that responding to our RFI requires time and effort on your part. We appreciate your assistance and interest in USAID programs.

Sincerely, /s/

Craig Riegler Supervisory Contracting and Agreement Officer USAID/Ukraine

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Attachment A : Draft Statement of Objectives (SOO) and Questions

ATTACHMENT A

RFI QUESTIONS:

1. Is the proposed SOO, including the activity’s purpose, objectives and expected results clear and understandable? What sections should be clarified, or elaborated on?

2. Are there key aspects missing from the proposed approach that would be critical to include to achieve its purpose and expected results? In particular, are there additional critical elements, opportunities, or constraints that need to be accounted for in the proposed approach?

3. Are the proposed purpose and expected results feasible and achievable within the proposed scope, budget, time frame, and ‘country-at-war’ and post-war environments?

4. What are the major stakeholders, existing or planned processes and initiatives that need to be taken into account and coordinated with while designing and implementing this activity?

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SECTION C – DESCRIPTION/ SPECIFICATIONS/ STATEMENT OF OBJECTIVES

USAID FURTHERING HEALTH REFORM AND RECOVERY IN UKRAINE ACTIVITY

(FHR)

List of Acronyms and Abbreviations

CSO - Civil society organization

CC - Consolidated communities

DRG - Diagnostically related groups

GDP - Gross Domestic Product

GoU - Government of Ukraine

FHR - Furthering Health Reform and Recovery

HCF - Healthcare facilities

HRH - Human resources for health

IDP - Internally Displaced Person

IRI - International Republican Institute

ITC - Information, Technology and Communication

KPI - Key performance indicators

M - Millions

MIS - Medical information systems

MOH - Ministry of Health

NCDs - Non-communicative diseases

NGO - Non-governmental organization

NHSU - National Service of Ukraine

OECD - Organization of Economic Cooperation and Development

PHC - Primary health care

PMG - Program of Medical Guarantees (i.e., state-guaranteed healthcare benefits package)

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PPP - Public-private partnerships (in health sector)

UAH - Ukrainian Hryvnia (local currency, $1 ≅ 37 UAH in 2023)

UHC - Universal health coverage

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C1. PURPOSE AND SCOPE

The purpose of the USAID/Ukraine Furthering Health Reform and Recovery (FHR) Activity is to establish a transparent, accountable and effective health system that optimizes the use of scarce resources and is capable of providing equitable access to quality services and expanding universal health coverage (UHC) to meet the new and emerging health needs of Ukrainians during and following the war to expedite economic recovery of the country. Strong accountable health system is not only essential for public well-being but also plays a crucial role in economic recovery and growth. As Ukraine marks over 20 months of war, burdened with spiraling costs, logistical hurdles and damaged infrastructure, access to essential services is all the more challenging for a growing number of civilians. By November 2023, nearly 6 million people had left Ukraine, more than 5 million became internally displaced within the country, over 20,000 civilians had been injured by the conflict and 1,311 attacks on health care had been verified (WHO 2023) since the start of the war.

With Russia’s full-scale invasion pushing over 7 million Ukrainians (which is about 24% of the population, versus 5.5% prior to the war in 2021) into poverty (World Bank 2023), the need to optimize the use of scarce resources, transparently restore and improve equitable access to essential quality services is critical to have a healthy workforce for expedited economic recovery and reducing financial hardship on patients. Improving health system efficiencies and ensuring that corruption does not divert resources and exacerbate health inequalities across the health system is an overarching program goal.

Government reforms, including health reform, are critically important to further develop Ukraine’s capacity and commitment to function as a self-reliant economic, diplomatic, and security partner.

Ukraine must reduce corruption to advance its plans for European integration, ensure sustainable economic development, rebuild the social contract, and finance solutions to its own development challenges. The FHR activity is essential to achieving USAID’s Country Development Cooperation Strategy, driving the approach to the design of the activity.

The Activity has four objectives:

Objective 1: Strengthen sustainable financing and governance of healthcare to support health reform and recovery

Objective 2: Improve health workforce capacity for accountable provision of quality healthcare

Objective 3: Expand reach and capacities of digital health platforms and tools driving transparency and accountability

Objective 4: Restore health services and reconnect people to care https://www.who.int/europe/publications/i/item/WHO-EURO-2023-5319-45083-71438 https://documents1.worldbank.org/curated/en/099184503212328877/pdf/P1801740d1177f03c0ab180057556615497.pdf

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FHR will advance the USAID/Ukraine Mission strategic objective of reducing corruption by supporting the refinement and implementation of national healthcare reforms, and helping to institutionalize improved accountability and efficiency mechanisms in the health system.

The Activity must have an impact on the overall national health reform building upon the gains already made, while demonstrating and consolidating successes and innovations in reform implementation at national and subnational level. At the subnational level, FHR will establish focus oblasts in consultation with USAID and the GoU to develop deeper partnerships with local authorities to advance reforms; coverage and focus may be adjusted as needed based on need, opportunity to demonstrate impact, and availability of funds.

C2. BACKGROUND AND PROBLEMS TO BE ADDRESSED

C.2.1. Health Sector Overview

According to nation-wide public opinion polls conducted in Ukraine by the International Republican Institute’s (IRI) since 2017, corruption in state bodies continues to be troubling for an overwhelming majority of citizens - especially in healthcare which potentially affects everyone’s daily lives.

The GoU is trying to address endemic corruption that is deeply rooted in government services across Ukraine. FHR will be a critical tool for the GoU to take a systematic approach to root out corruption from the healthcare system by improving financial management, accountability, efficiency and the strategic and transparent allocation of resources.

Corruption is related to broader inefficiencies that contribute to poor health outcomes and higher financial burdens on Ukrainian households, who pay a larger proportion of health costs (48% versus 20% in Poland or 13% in Germany) and receive less than their European neighbors. At the time of the full-scale Russia’s invasion, around 7% of GDP was spent on healthcare, which is in line with other countries with similar GDP. However, an important feature of Ukraine’s pre-war healthcare system was that around half of these payments were direct payments made by healthcare users, despite over a third of the population believing that healthcare should be free (Rating Group of Ukraine 2020).

On the delivery side, the Ukrainian health system is characterized by inefficiencies, arising from misaligned incentives that favor curative in-patient hospital care. Ukraine has many hospitals and many beds (6.5 beds per 1,000 people in 2018, compared to OECD average of 4.5 beds), driven by a history of top-down budgeting for hospitals and an under-capacitated primary care level. In addition to these structural inefficiencies, health workforce salaries are low and staff are poorly trained, which contributes to the deep-rooted problem of informal payments by the patients stemming from lack of transparency and oversight and poor governance of the healthcare system.

https://www.usaid.gov/sites/default/files/2023-06/Ukraine_CDCS%202019-2026_EXTERNAL.pdf https://ratinggroup.ua/en/research/ukraine/ocenka_medicinskoy_sfery.html https://ratinggroup.ua/en/research/ukraine/ocenka_medicinskoy_sfery.html

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High-level commitment exists in the country to advance reforms launched in 2017 and where Ukraine has made substantial progress, especially at the primary healthcare level, despite the COVID-19 epidemic in 2020 and then the full-scale war in 2022. These challenges create an opportunity for USAID to partner with in-country organizations to address health challenges under the FHR activity.

C.2.2. Evolution of Healthcare Reforms in Ukraine

Since 2016, following significant advocacy and engagement from civil society, leadership from reform-minded members of the Government of Ukraine (GoU), and support from partners, including USAID, Ukraine successfully developed, launched, and began implementing massive reforms to its health system. The reforms aimed to move towards universal health coverage (UHC) and address widespread dissatisfaction over the low quality of services provided in healthcare facilities; perceived high levels of corruption; and inadequate protection from out-of-pocket spending (especially informal payments). Through the development of a guaranteed package of services financed under a single-payer model, the reforms focused on systemic changes expected to improve efficiency, transparency, and access to quality essential health services. Reforms also were intended to ensure financial protection of Ukrainians from excessive out-of-pocket payments, including by reducing informal payments that are estimated1 to be wide-spread and deeply entrenched.

The GoU overarching strategy for 2015-20202 consisted of focusing first on health financing reforms to catalyze transformation in service delivery (both individual and population based healthcare), incentivize results and outcomes, and use data to inform decision-making In line with this strategy, USAID and other partners provided significant technical assistance to the Ministry of Health to develop the legal, regulatory, and system-level blueprints for reforms in line with the national reform vision.

The new health financing Law on “Government Financial Guarantees of Health Care Services” was approved by the Ukrainian Parliament in October 2017. This law created the National Health Service of Ukraine (NHSU) as a single purchaser of healthcare services, leading to the establishment of NHSU in early 2018.

In parallel, Ukraine designed and launched a national eHealth system as the vehicle for all the NHSU transactions related to the contracting and payment of healthcare services, and reforms to the ownership structures for primary healthcare facilities shifted these facilities from being categorized as government institutions into autonomous public communal enterprises. In June 2018, NHSU started contracting with these new, public primary healthcare providers to provide a new package of

1 On average, 76% of patients of the four priority specialized PMG services during July 2019 – March 2020 paid informally to healthcare providers on average 10,917 UH (eq. to approx. $404) [ranging between 6,300 UAH/ $230 and 17,200 UAH/$635 per service, starting from less expensive cases of childbirth to more complicated stroke and myocardial infarction cases]. In comparison, the average salary in Ukraine in 2020 was approx. $400, and the minimal

- $200. Source: USAID Health Reform Support. - Kyiv, 2021. Report on the results of the baseline survey “Informal payments at specialized healthcare facilities for four priority services under the Program of Medical Guarantees” 2 National Health Reform Strategy for Ukraine 2015-2020. - MoH, Kyiv-2015.

- 9 -services entitled, the Program of Medical Guarantees (PMG), and pay these providers on a capitation basis.

This financing mechanism shifted Ukraine’s health system from input-based financing to a system in which “money follows the patient,” starting at the primary healthcare level. The benefits package under the PMG is now reviewed and updated annually, and approved on an annual basis by the Cabinet of Ministers of Ukraine.

This first phase of health financing reforms (2017-2019) in Ukraine focused on establishing the institutional structures and systems for roll-out of the PMG, expanding and strengthening its implementation at the primary healthcare (PHC) level and expanding enrollment of the Ukrainian population through registration in the eHealth system and declaration of a family doctor. These key PHC reforms (including free enrollment of the population and reimbursement of selected medicines on an e-prescription basis) have progressed well, withstanding the shock of the COVID-19 epidemic, with family doctors managing the overburden of huge surge of patients with active and suspected COVID-19 cases. More than 32 million of people (or nearly 90% of the population) opted into the State-funded health program (PMG by NHSU) and selected and signed declarations with their family doctors. A recent survey found around 70 percent of the patients are satisfied with their services. Another survey3 conducted in 2021 showed a decrease of informal payments at the primary healthcare level over a three year period (2019 vs 2021).

The second phase of health financing reform remains ongoing, focused on introducing NHSU contracting for PMG services at the secondary and tertiary levels of care, including specialized care facilities (hospital and outpatient specialist facilities). Since April 2020, phase 2 implementation has progressed and expanded to the vast majority of public facilities. Progress occurred despite initial controversies, resistance from some stakeholder groups (including chief hospital doctors, rectors and staff of medical universities, medical trade unions), and the onset of the COVID-19 pandemic and subsequently Russia’s unprovoked invasion of Ukraine. Under Phase 2, line-item budget funding for hospitals was eliminated in favor of payment for the defined priority packages of care. Treatment of heart attacks, strokes, early diagnosis of oncology, childbirth, and emergency care were among those priority services with the highest tariffs. In response to COVID-19, the GoU also introduced specific COVID-19 treatment packages to finance hospital-based care. More than 1,700 healthcare providers representing nearly 98% of public specialized healthcare facilities have entered into contracts with NHSU, and received more than 75 billion UAH ($2.8 billion) for services provided, including COVID-19 treatment.

Ukraine has made a number of promising achievements to build on and strengthen since 2020.

These included expansion of PMG financing in 2022 by more than 60% (from 89.5 billion UAH in 2020 to 146.6 billion UAH in 2022, equivalent to nearly $5 billion) and introduction of a consultative process for determining PMG based on evidence; expansion of the ePrescription and Affordable Medicines programs; evolving hospital payment mechanisms that are better linked to

3 USAID Health Reform Support (Kyiv, 2021). Informal Payments at the Level of Primary Health Care after the Implementation of the Health Financing Reform. Study Report.

http://ratinggroup.ua/research/ukraine/ocenka_medicinskoy_sfery_v_ukraine_21-29_maya_2019_goda.html

- 10 -performance, including through nascent introduction of the diagnostic-related groups (DRG) system; gradual improving governance of hospitals and clinics through the launch of supervisory boards and ongoing elaboration of decentralization reforms. Despite the war, the reform continues:

new landmark legislation passed in 2022 provides a legal framework for the public health system, designates key public health institutions and outlines their roles and responsibilities in delivering essential public health operations. The Ministry of Health also established the National eHealth Development Coordination Office, released a road map of eHealth development priorities for 2023

– 2025, and developed the Law on Telemedicine, approved by the Verkhovna Rada (Ukraine’s Parliament) in August 2023.

Ukraine’s 2030 National Health Strategy envisions building back better in the medium-to-long term. The plan is aligned with Ukraine’s reform agenda and its aspirations for European integration.

Ukraine was recently granted EU candidate country status, and plans to align its legislation with relevant EU legislation in the medium term. This should contribute to strengthening rules and standards and steer investments in areas such as communicable diseases, cross-border health threats, pharmaceutical products and public health. These conditions create opportunities to steer investment in recovery towards improving the quality, efficiency, sustainability and resilience of Ukraine’s health system in the longer term.

C.2.3. Development Challenges and Opportunities

For Ukrainian patients and healthcare workers to feel the reform’s tangible benefits, further changes are needed to achieve efficiency gains expected from financing reforms in which “money follows the patient”. Such changes need to: (1.) address excess inpatient capacity and the related costs of maintaining this infrastructure; (2.) modernize healthcare workforce training and skills development; and (3.) continue to make progress against corruption at all levels, including informal payments. At the specialized care level (outpatient clinics and hospitals), implementation of reforms has faced significant challenges, heighted by the onset of the war in 2022. These challenges led, at times, to conflicting policies and approaches to financing for tertiary care that shielded some facilities and functions from the new incentives and efficiencies the PMG was expected to create.

In some ways, Phase 2 reforms have only “scratched the surface” of reform needs at the hospital level. Significant challenges to achieving meaningful structural reforms remain. These include: (1.)

a large number of low-capacity, outdated facilities, and an excessive number of hospital beds per capita; (2.) political resistance to optimizing and re-profiling the existing public sector health care facilities network; (3.) unclear and unevenly enforced politics around copayments for services not covered by the PMG; and (4.) inadequate capacity at local levels to implement reforms.

At the local level, continuing healthcare delivery challenges include: (1.) a lack of general and financial management skills among healthcare facilities managers and owners (i.e. local government officials); (2.) low quality and motivation of medical staff; (3.) limited use of the eHealth system for evidence-based decision-making; (4.) governance weaknesses in healthcare facilities for ongoing decentralization reforms; and, (5.) radically changed roles for the oblast/rayon and local governments regarding ownership and maintenance of healthcare facilities.

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Nepotism, patronage, and corruption, deep-rooted in the context of historically low salaries of medical professions, continue to be commonly cited challenges at the facility level. Local governments and consolidated territorial communities (which now have an increased role as owners of the delivery network) often lack both the skills and the medium-to-long term strategic vision to implement health sector reforms originating from national, regional or local health policymakers.

The health workforce is facing many challenges - many health workers and managers perceive being under-paid, are dissatisfied, and are looking for exit options (which is more pronounced at the specialized, hospital care level). Productivity is low, due to the poor working environment and a high administrative burden. With relatively little progress towards greater competition in provision or upskilling of staff, the COVID-19 epidemic has highlighted long-standing systemic weaknesses that have since been exacerbated by the war.

Ukraine is not unique in having its healthcare system destroyed by conflict and there is growing understanding of how to reform healthcare delivery and financing in conflict-affected contexts to strengthen the health system and improve sustainability and resilience. Priority areas that the FHR activity will address are:

- Accountability: Healthcare facilities (HCF) receive more money from the state budget under the PMG via contracts with NHSU, but lack both upward accountability to the GoU/ NHSU and downward accountability to the HCF owners/ local self-government and end-users of services/ patients. Greater accountability and empowerment are needed to ensure financial autonomy leads to improved services, quality, and access. For example, some facilities have continued to pay low salaries and made limited investments in quality or safety despite having adequate funding to do so from capitation payments. Salaries are inexcusably low and/or facilities are not modernized to improve quality and infection control. The NHSU needs to further develop regulatory tools and oversight capacities to ensure proper financial and program monitoring of contracted healthcare providers.

- Transparency: Hospitals are only starting to learn and use the DRG system for the coding and reporting of all the services they provide, being paid primarily via simplified, global budget method, with only 5 percent of payment based on the fee-for-service/case-based payment from July 2021. Performance-based funding is yet to be introduced, with few basic key performance indicators, at the primary health care (measles & rubella immunization coverage of children) and emergency care (correct pathways of patients with acute strokes and infarctions).

- Efficiency: Capable hospital networks are still at the planning stage in all of Ukraine’s regions controlled by the GoU. Despite a slight reduction of hospital bed density since 2008, the hospital network is still excessive and highly inefficient. Even for acute hospitals, there are more hospitals per 1 million population in Ukraine than in any comparable country except the United Kingdom. Too many hospitals, mostly in rural districts, conduct only a small number (between 10 and 50) of operations per year, potentially representing inefficiencies and quality concerns. Parallel healthcare delivery systems of other, non-health, Government agencies (including Ukrainian Railways, Ministry of Defense, State Security Service, Ministry of Justice with State Penitentiary

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Service), with hundreds of hospitals and clinics, still co-exist with the public sector HCFs in the same towns and cities, exacerbating potential for redundancies and fragmentation of service delivery and management.

- Access to quality services: Though out-of-pocket spending on health in Ukraine as a proportion of total health expenditure has historically been the highest in the region, the quality of services still remains low. Services are often characterized by outdated or lack of life-saving equipment; lack of modern, evidence-based standards of care; limited oversight care standards at the facility level; and limited availability of skilled and appropriately compensated human resources for health. Up to 40% of stroke patients in Ukraine die within 30 days of being admitted to hospital for stroke, which is one of the main killers in Ukraine. In comparison, in the 23 OECD countries, this figure is almost three times less (12.3%). Out of more than 500 wards admitting stroke patients in Ukraine, less than half have the necessary equipment and trained qualified personnel for the diagnosis and treatment of stroke. Low quality of service affects average life expectancy in Ukraine, which is 72 years (66.3 and 76.3 years for men and women, respectively), much lower than that of its neighbors.

- Recovery: An important factor in Ukraine’s ability to regain control of territories and secure its sovereignty is to provide services to its citizens. It will be critical to restore essential health services in targeted oblasts that were under attack and/or were partially occupied and, therefore, are experiencing disruption of services and depleted health resources (e.g., goods, financing, workforce), dynamic population changes, including both displacement and returning IDPs and unmet emerging health needs. A key component of the FHR Activity will be to concentrate and align USAID resources with local governments, civil society organizations, private sector, UN agencies and other donors.

The FHR activity will support the Government of Ukraine in consolidating and deepening reforms to address these ongoing challenges, while at the same time will help to restore the health system and recover essential healthcare services impacted by the war. It will also help ensure that continuing refinements to the legal, regulatory and policy frameworks, as well as implementation arrangements, advance broader reform goals of efficiency, transparency, accountability, and financial protection. It will seek opportunities to engage with a variety of partners committed to Ukraine’s health reform agenda including the private sector, non-governmental organizations, and key governmental bodies at the central and local levels.

C3. RELATIONSHIP TO USAID STRATEGY

This Activity will contribute to USAID/Ukraine’s Country Development Cooperation Strategy (CDCS) for 2019-2026, Development Objective 1 (DO1) Corruption Reduced in Targeted Sectors and its associated Intermediate Results (IRs). The Activity is part of USAID/Ukraine’s Anti- Corruption Project, which encompasses activities contributing to CDCS DO1 and its IRs and Sub- IRs.

https://www.usaid.gov/ukraine/country-development-cooperation-strategy-ukraine https://www.usaid.gov/ukraine/country-development-cooperation-strategy-ukraine

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DO1: Corruption Reduced in Targeted Sectors

IR 1.1: Increased health system transparency

Sub-IR 1.1.1: Improved health sector governance and finance

Sub-IR 1.1.2: eHealth system developed and implemented

This activity will also contribute to the Intermediate Result - IR 4.2: Infectious Disease Burden Reduced (under CDCS DO4) by supporting more effective governance and sustainable financing for the public health system and the provision of essential services addressing HIV/AIDS, tuberculosis, immunization, COVID-19 and to improve public health emergency preparedness and response. USAID expects FHR will create specific linkages between the healthcare reform and infectious diseases objectives of U.S. health assistance, so that consolidation of healthcare financing and governance reforms reinforces and advances public health outcomes.

FHR will also contribute to the EURACE Ukraine Assistance Strategy January 2023 - December 2025, specifically to the Assistance Objectives 1.3: Enabling the GoU to provide services to and govern its people [while at war], and 2.3: Supporting macroeconomic stability and restoration of key government services.

C.4 ACTIVITY OBJECTIVES AND KEY EXPECTED OUTCOMES

This section contains Activity Objectives and Key Expected Results the Contractor’s approach is expected to achieve that will contribute to the achievement of the activity's main purpose:

Purpose: To establish a transparent, accountable and efficient health system that optimizes the use of scarce resources and is capable of providing equitable access to quality services and expanding universal health coverage (UHC) to meet the new and emerging health needs for Ukrainians during and following the war to expedite the economic recovery of the country.

The objectives described below are based on the following theory of change:

IF Ukraine's health financing and governance reforms are strengthened, AND supported through health workforce capacity, digital health tools, and aligned with recovery efforts to reconnect people to care, THEN Ukraine’s health system will be more transparent and accountable, leading to expanded financial protection and universal health coverage of the population resulting in healthy workforce to contribute to and participate in the economic recovery of Ukraine.

The new activity will build on USAID’s long-standing support for Ukraine’s public sector anti-corruption and health reforms, and recognizes the importance of improving governance at both the national and local levels for evidence-based and patient-centered healthcare planning, financing, and provision. Transparent access to and use of information is a key component of health reform that can be advanced through continued development and roll out of the e-Health system, which is

- 14 -fundamental for achieving tangible results in enhancing efficiency, tackling corruption in healthcare, and delivering better quality essential health services to the people of Ukraine.

Objective 1: Strengthened sustainable financing and governance of healthcare supporting reform and recovery.

Deepening and ensuring sustainability of financing transformations at the specialized healthcare level, while consolidating initial successes at the primary healthcare level, are at the core of this objective. This will entail work at the national level to strengthen the costing, oversight and implementation of the PMG to create the necessary incentives for system transformation and reduction of out-of-pocket payments (OOPs), while supporting the transformation of the governance structures and supporting systems (such as health facility corporate governance structures) to enable reforms to be fully implemented at the local level in the context of decentralization. This approach is important for achieving the highest-level expected outcomes of expanding access to quality essential services, and reducing incidence and regressivity of OOPs (both formal and informal payments) for essential healthcare services.

The key guiding principle for the activities under this objective is not to get “more money” for health but getting “more health” for the available money – in a transparent way, reducing the loopholes for corruption and improving quality of care – by increasing the effectiveness and efficiency of financing, governance and delivery mechanisms. Activities will help to strengthen and institutionalize quality improvement and quality assurance functions within healthcare reforms and systems. It will also entail optimizing and rationalizing hospital inpatient care, while at the same time enabling hospital consolidation and modernization. Approaches must take into account health needs including the unique pressures related to managing future pandemic threats, recovery following the war, along with refining the health services covered under the PMG. At the central level, efforts will strengthen strategic purchasing of the NHSU and its financial planning, resource allocation, contractual and quality monitoring functions.

Strengthening the general public and stakeholder support for health system reforms will need to complement these efforts. To build a broad coalition of support for health reform, FHR will seek new partnerships with Ukrainian institutions, particularly universities, think-tanks, and civil society organizations to conduct applied research, develop policy papers and technical guidance to inform policy makers and the public on the impact of health reform and how to adapt its implementation.

Other key stakeholders include health sector institutions in both the public and private sector, the medical professional community, and Ukrainian government policymakers and decision-makers.

Activities under this Objective will focus on achieving the following outcomes (the list is neither exhaustive, nor exclusive):

Key expected outcomes:

1.1 Improved public financial management and improved accountability of the healthcare facilities

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1.2 Expanded Affordable Medicines Program integrated into the Program of Medical

Guarantees (PMG, a state guaranteed benefits package)

1.3 Optimized and prioritized PMG with mandatory quality requirements under contracted packages of health services

1.4 Strengthened effectiveness and accountability of the NHSU as a strategic purchaser

1.5 Optimized capable hospital network, effectively interacting with enhanced primary healthcare services

1.6 Introduced performance-based financing for essential healthcare services

1.7 Established continuous healthcare quality improvement system

1.8 Increased capacity of government to attract and manage investments to restore essential health services

1.9 Increased public knowledge and support to health system reforms aimed at efficiency, accountability, and transparency.

Objective 2 - Improved health workforce capacity for the accountable provision of quality healthcare

A motivated and capable health workforce and human resources for health (HRH) is a key catalyst and enabler of the health system reforms aimed at quality, efficiency and accountability. The war has resulted in the displacement of workers and significant shortages of trained medical professionals. Given this, there is a need to “retain and retrain” human resources to address shortages and quality. This will involve both programs to upskill staff, the increased use of task-shifting for nurses and investment in improving managerial quality.

FHR activities under this objective will concentrate on supporting the development of cadres and skills essential for operationalizing reforms in financing, management, governance and delivery of care. FHR will also support HRH planning and systems to promote evidence-based, fair and transparent HRH production, employment, deployment, performance and retention, with the overarching aim of quality-assured patient-centered service provision free from bribes and informal payments. Ensuring that reforms lead to adequate and transparent remuneration for doctors, nurses and support staff in healthcare facilities is a key outcome for HRH transformation expected to be foundational for eliminating informal payments.

FHR will also strengthen the workforce of the NHSU and its management systems, including its regional bodies. It will improve the capacity of regional and municipal administrations to optimize

- 16 -and invest in the modernization of their hospital network while increasing access and use of services at the primary health care level, to support longer-term transformation of the service delivery network for increased efficiency.

Activities under this Objective will focus on achieving the following outcomes (the list is neither exhaustive nor exclusive):

Key expected outcomes:

2.1 Successful examples of strategic development, management and retention of health workforce in targeted regions inform the national HRH modernization process

2.2 Strengthened capacity of the GoU(including MOH) to oversee and coordinate efforts for restoration and modernization of essential healthcare services

2.3 Strengthened capacity of the NHSU and its regional branches to contract and monitor service providers under the PMG

2.4 Capacities and skills of primary health care strengthened to expand services for meeting war-related new and increased care needs

2.5 Established ability and capacity of the local government and communities to optimize and invest in the modernization of their healthcare facilities network

2.6 Strengthened capacity of the healthcare providers for effective financial management and operational development of their facilities in the war and post-war context

2.7 Strengthened self-governance of medical profession for introducing evidence-based standards of care and continuous healthcare quality improvement

2.8 Built foundations for the individual medical professional licensing

2.9 Equitable geographical distribution of medical professionals and specialists to increase access to services for people in distant rural and hard-to-reach areas.

Objective 3 - Expanded reach and capacities of digital health platforms and tools driving transparency and accountability

Continued development and roll out of the e-Health system is the key component of health reform, fundamental for achieving tangible results in enhancing transparency, efficiency and continuity, tackling corruption in healthcare, and delivering better quality essential health services. Support to

- 17 -the development of telemedicine, the demand and need for which has been accelerated by the war, will be adapted and synchronized with the current state of development of the national eHealth system of Ukraine to better reach the underserved. Increased operational reliability, interoperability, cybersecurity and data security of eHealth and telemedicine tools and platforms, with the overarching aim of their financial and institutional sustainability, will be a key focus of the Contractor’s efforts under this objective. Advancing system design and functionality to increase transparency, use of data for decision-making at all levels, and improved functionality for providers and system users in the field, are critical priorities for FHR.

Activities under this Objective will focus on achieving the following outcomes (the list is neither exhaustive nor exclusive):

Key expected outcomes:

3.1 Strengthened eHealth system digital infrastructure support transparent contracting, reporting, and monitoring of services under the PMG

3.2 Improved enabling environment for scale-up of digital health, telemedicine and remote monitoring technologies to restore and expand access to essential services

3.3 Increased penetration of digital health tools and telemedicine in the distant and rural areas

3.4 Increased interoperability of digital solutions for efficient exchange and use of critical health data for decision-making and effective patient’s control over their personal data

3.5 Built capacities of the healthcare providers and patients to use ehealth/ digital tools and platforms and analyze data, generated by eHealth system

3.6 Innovative digital solutions piloted for health system resilience to cyber threats and future emergency crises

3.7 Established digital platforms for generating and promoting quality of healthcare information (including data on outcomes and outputs of care), interoperable with the eHealth system.

Objective 4 - Restored services and people reconnected to care

Restoring critical services and reconnecting people with health care in response to the health system disruptions caused by the war remains a priority. In addition to restoring facility operations and exploring innovative service delivery approaches, including through private sector engagement --such as mobile teams and telemedicine solutions -- this includes a greater emphasis on

- 18 -multidisciplinary care and greater prioritization of public and community health including mental health to support Ukraine’s transition to a more efficient, better quality and more people-centered health delivery system.

FHR will also work with other international donor partners and local non-government organizations to support the MOH in planning, coordinating, and implementing recovery efforts in line with Ukraine’s National Recovery Plan. In coordination with the GoU and under USAID guidance, FHR may also support the renovation of critical healthcare facilities, as well as procurement and installing essential equipment for selected targeted HCFs, having a separate budget line under the contract with the maximum amount of up to $20,000,000 USD.

Activities under this Objective will focus on achieving the following illustrative outcomes (the list is neither exhaustive nor exclusive):

Key expected outcomes:

4.1 Restored and expanded quality services offered through PHC facilities with mobile/outreach services available to meet the most pressing needs

4.2 Vulnerable populations targeted with information and outreach services in the community (eg. screening, referral, mobile team-based care)

4.3 Integration of mental health, rehabilitation and a full range of HIV, TB, and Hepatitis services, from screening to treatment, into primary health care service provision

4.4. Availability of new diagnostic and screening tools

4.5 Established dialogue and capacities for public-private partnerships for restoring and expanding healthcare services

4.6 Innovative joint solutions piloted for the private sector engagement in modernization of critical specialized hospital services

4.7 Developed capacity of Ukrainian expert organizations providing consulting services to support healthcare policy and system transformation.

C.5 PROGRAMMATIC APPROACH

Grants Under Contract ($10- $13M): USAID anticipates that there will be numerous “Grants Under Contract” (GUCs) to Ukrainian organizations, such as CSOs, universities, and think-tanks.

The Contractor shall be able to rapidly and simultaneously issue, manage and coordinate multiple GUCs to local and international organizations as part of this Activity. The GUC program is expected to broaden the set of stakeholders participating in health reform, accelerate the reform

- 19 -effort, allow for stakeholder input on the implementation of the reform, and disseminate information on the reform’s impact to help counter disinformation. It is expected that the contractor will provide targeted technical assistance to these participating organizations to sustain Ukraine’s health reform efforts.

Anti -Corruption

The Contractor must combat corruption by helping to establish a transparent and predictable regulatory environment that is less prone to corruption and abuses by utility managers and public authorities. The Contractor must incorporate specific anti-corruption elements in its approach, including but not limited to performing appropriate due diligence assessments and responsibility determinations on potential partners, including grant recipients and subcontractors.

Adaptive Management

The Contractor must use an adaptive management approach that incorporates ongoing monitoring for contextual changes, stresses, and shocks, determine when adaptations are needed, and quickly pivot to implement adaptations in a way that ensures no harm.

Pursuant to FAR 52.243-2, the Government anticipates that the Contractor may be required to procure additional equipment or commodities or small infrastructure activities in order to meet the goals of the contract. Russia’s on-going invasion and the unpredictable nature of events may require that the Contractor substantially increase resources dedicated to equipment or commodities procurement to meet programmatic goals. Equipment and commodity needs, in the event of expansion, may not be limited to strictly energy equipment but also e.g.construction equipment and commodities, vehicles etc. plus necessary management costs that will aid the health sector in Ukraine more broadly, directly and indirectly. The total additional funding is estimated as up to approximately 30% of the total estimated cost.

C.6. COLLABORATION

C.6.1 Collaboration with Other USAID Activities

The Contractor shall substantially collaborate with and/or expand tools/approaches successfully used by USAID’s most recent activities supporting various aspects of health system reforms:

1. Health Reform Support (HRS) (2018-2025) - build and expand on achievements from HRS as the activity concludes its final year of implementation;

2. Local Health System Sustainability/Ukraine (LHSS-Ukraine, 2021-2024) - build and expand on this time-limited technical assistance activity intended to stimulate the enabling

- 20 -environment in Ukraine for telemedicine to improve accountability, transparency and access to services;

3. Safe, Affordable, and Effective Medicines for Ukrainians (SAFEMed) (2018-2025) -collaborate on advancing health care reform with the USAID/Ukraine’s flagship supply chain program supporting; procurement reform for PEPFAR and TB programs - working closely with those activities supporting quality of and access to TB and HIV/AIDS services can deepen healthcare reform with respect to meeting the needs of patients affected by TB and HIV under the PMG; and

4. Public Health System Resilience and Recovery (PHS R&R) (2022-2027) - system strengthening and reform support should complement this activity’s efforts to support the GoU in building a more resilient public health care system that will better prevent, detect, and respond to public health threats, sustain critical public health services during a crisis, and protect the health of all Ukrainians.

While the nature of this collaboration and transfer of best practices will be different for each of these partners, the Contractor shall leverage these substantial USAID investments in health system strengthening and reform areas through each of these activities in its approach.

Under USAID’s guidance and facilitation, the Contractor will also collaborate with the USAID activities supporting anti-corruption, good governance and decentralization reforms, including Promoting Integrity in the Public Sector (Pro-Integrity) Activity, Governance for Local Accountability (HOVERLA) Activity, Cybersecurity for Critical Infrastructure in Ukraine Activity, and…