RFI 72012124RFI00005 Ukraine Mental Health 7.8.24.pdf

REQUEST FOR INFORMATION (RFI)

Subject: Request for Information 72012124RFI00005

Issuance Date: July 8, 2024

Issued by: USAID/Ukraine

Issuing Contracting Officer: Craig Riegler

Response to: kyivrcohealth@usaid.gov

Reference: USAID/Ukraine Mental Health Activity - Ukraine Mental Health Initiative for National Development (U-MIND)

Purpose

USAID/Ukraine is in the process of designing a new Mental Health Activity, Ukraine Mental Health Initiative for National Development (U-MIND), for implementation in Ukraine and is seeking to obtain additional information and input from interested stakeholders, US entities, and non-US organizations including local Ukrainian organizations. The information will be used to help make planning decisions and may inform activity design to improve development outcomes.

This Request for Information (RFI) is issued solely for information gathering purposes and is published in accordance with FAR Part 10 and FAR 15.201(e). Responses to this request for information are not binding on the U.S. Government, do not obligate USAID to issue a NOFO, nor do they commit USAID to pay any cost incurred in the preparation and submission of comments.

Brief Description

The primary goal of the Ukraine Mental Health Initiative for National Development (U-MIND) activity is to contribute to Ukraine’s economic resilience by establishing an evidence-informed, inclusive mental health ecosystem. This mental health framework will be fully integrated across various sectors and programs. By promoting mental wellness, U-MIND seeks to enhance productivity, resilience, and social cohesion, thus fostering sustainable economic development and growth in Ukraine. Implementation should focus on efficacy, accessibility, scalability, adaptiveness, accountability, and cultural fit, in order to effectively respond to the evolving mental health landscape.

mailto:kyivrcohealth@usaid.gov

RFI 72012124RFI00005

USAID/Ukraine Mental Health Activity -

Ukraine Mental Health Initiative for National Development (U-MIND)

Requested Information

USAID/Ukraine invites the public to submit constructive feedback and comments on the DRAFT Program Description (PD) (Attachment B) in response to any or all of the questions presented in Attachment A. These comments will be taken into consideration in the design of the final activity. An organization’s response must not exceed four (4) pages in total length.

Please focus solely on answering the questions provided in Attachment A. Your responses to these questions will be crucial for the design of the final activity. Thank you for your cooperation.

Cover Page

All submissions must also include a cover page (one page maximum) that includes the following information:

● Organization name and address

● Organization point of contact name, Unique Entity Identifier (UEI) (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

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 RFI does not restrict the Government's assistance 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.

Through this Request for Information (RFI), USAID seeks to enhance the design of the new Activity. This RFI does not constitute a Notice of Funding Opportunity (NOFO) and is issued solely for information gathering and planning purposes. Responses to this RFI are not applications and will in no way be deemed to form any binding agreement with the issuing authority. Please do not submit applications, proposals, resumes or promotional materials, as they will be discarded. Proprietary information should not be sent. USAID may use any information provided without incurring any obligation. USAID reserves the right to, or not to

Ukraine Mental Health Initiative for National Development (U-MIND) incorporate any, some, or none of the comments received from this RFI into any subsequent solicitations or design documents.

Responses to this RFI must be submitted to USAID via email to kyivrcohealth@usaid.gov. The subject line must read “Mental Health Activity,” and comments must be submitted no later than August 5, 2024 at 17:00 (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 Calibri 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, or otherwise non-compliant responses, will not be reviewed. Submissions must not exceed the page limitations for each part indicated above. Submissions exceeding the page limits will not be read. Only one submission will be accepted per organization.

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, Craig Riegler Contracting and Agreement Officer USAID/Ukraine mailto:kyivrcohealth@usaid.gov

Ukraine Mental Health Initiative for National Development (U-MIND)

ATTACHMENT A: RFI QUESTIONS

1. Do you know of evidence (published or otherwise) that documents the economic impact or results of mental health and psychosocial support (MHPSS) interventions in conflict, post conflict or in Ukraine? Please summarize and/or provide links.

2. One of the priorities of USAID's Country Development Cooperation is the economic recovery of Ukraine. How can the PD further create and measure the economic impact of mental health and psychosocial support (MHPSS) interventions?

3. What should be built into the PD to best leverage the ongoing mental health and psychosocial support (MHPSS) humanitarian response in Ukraine and ensure continuity of evidence-based services? Please provide rationale/justification for your response.

4. Is the Program Description clearly written, in particular the Theory of Change, Objectives, and Outcomes?

Ukraine Mental Health Initiative for National Development (U-MIND)

ATTACHMENT B: DRAFT PROGRAM DESCRIPTION

Ukraine Mental Health Initiative for National Development (U-MIND) Activity Program Description

This funding opportunity is authorized under the Foreign Assistance Act (FAA) of 1961, as amended. The resulting award will be subject to 2 CFR 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, and USAID’s supplement, 2 CFR 700, as well as the additional requirements found in Section F.

I. Introduction

The primary goal of the Ukraine Mental Health Initiative for National Development (U-MIND) activity is to contribute to Ukraine’s economic resilience by establishing an evidence-informed, inclusive mental health ecosystem. This mental health framework will be fully integrated across various sectors and programs. By promoting mental wellness, U-MIND seeks to enhance productivity, resilience, and social cohesion, thus fostering sustainable economic development and growth in Ukraine. Implementation should focus on efficacy, accessibility, scalability, adaptiveness, accountability, and cultural fit, in order to effectively respond to the evolving mental health landscape. USAID/Ukraine plans to provide up to $100 million, subject to availability of funds, over a five-year period to support this activity.

II. Background

Amid Russia’s full-scale invasion and throughout Ukraine's reconstruction efforts, pressing mental health needs have emerged. A January 2024 survey found that 77% of Ukrainians reported stress or severe nervousness recently.1 Another study found that 44 to 48% percent reported moderate to severe anxiety and 32 to 39% reported PTSD symptoms, with Internally Displaced Persons (IDPs) reporting worse outcomes than those who had not been displaced.2

According to an audit of mental health needs conducted in 2022,3 it is projected that 40 to 50% of Ukraine’s population (up to 18 million people) will need psychological support of varying intensity, including people who were in captivity, IDPs, veterans, first responders, health workers, unemployed, and children. The World Health Organization estimates that 22% of individuals impacted by conflict experience a mental health disorder (depression, anxiety, 3 Audit conducted by BarrierFree and CIVITTA NGOs, with the financial support of USAID Public Health System Recovery & Resilience activity.

Gradus. (2022). Health status of residents of Dnipropetrovsk, Kherson, Lviv, Poltava and Rivne oblasts with non-communicable diseases during the war.

2 Lushchak, O., Velykodna, M., Bolman, S., Strilbytska, O., Berezovskyi, V., & Storey, K. B. (2024). Prevalence of stress, anxiety, and symptoms of post-traumatic stress disorder among Ukrainians after the first year of Russian invasion: a nationwide cross-sectional study. The Lancet Regional Health–Europe, 36.

1 Gradus. (March 2024). Mental health and attitudes of Ukrainians towards psychological assistance.

https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(23)00192-8/fulltext#:~:text=The%20first%20survey%20report%20provided,anxiety%2C%20and%2047%25%20depression.

https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(23)00192-8/fulltext#:~:text=The%20first%20survey%20report%20provided,anxiety%2C%20and%2047%25%20depression.

https://gradus.app/en/open-reports/mental-health-and-attitudes-ukrainians-towards-psychological-assistance-during-war/

Ukraine Mental Health Initiative for National Development (U-MIND) post-traumatic stress disorder, bipolar disorder, schizophrenia).4 For Ukraine, that is equivalent to 9.6 million people.

The economic implications of untreated mental health conditions are stark. Globally, common mental health disorders are associated with direct and indirect costs, including lost productivity and labor force participation; with depression and anxiety alone costing an estimated US $1 trillion per year.5 Ramifications of mental health conditions include increased physical health costs (chronic mental health disorders are linked with cardiovascular disease, stroke, type II diabetes, and some cancers), decreased productivity and labor participation, and increased social costs (family members investing time and financial resources for care, children negatively impacted on multiple levels, including socially and educationally, by parents’ poor mental health).6

Scaled-up treatment for common mental disorders has a positive impact on economic productivity gains. Research shows a significant and strong pathway between addressing mental health issues and increased productivity, reduced job absenteeism, and lower healthcare costs associated with untreated mental health conditions.7 Globally, the return on investment (ROI) is nearly triple the economic benefits for every dollar spent on treating anxiety and mental health (2.3-3.0 to 1).8 The value is even greater for middle income countries, with an ROI of 5.4-5.7 in economic benefits for every $1 spent on treatment.9

Ukraine’s mental health system is not currently positioned to scale up quality mental health treatment. It bears the legacy of Soviet-era approaches and past human rights abuses.10 11

Ukraine does not have an effective mental health ecosystem in place and although it took early steps towards system reforms prior to the war, the mental health system remains highly centralized. The current system relies on inpatient psychiatric hospitals with few community-level access points (such as community mental health providers, mental health services within the primary healthcare system, or outpatient care centers within secondary care centers/general hospitals) and an extremely weak referral system between levels of care. There is an over-emphasis on long-term hospitalization–approximately 90% of the government’s budget for mental health is spent on inpatient care.12 A continuum of care, including community-based and outpatient services, was virtually non-existent before the war and is still

12 World Bank Group. (2017).

11 University of Washington Global Mental Health (July 2020). Ukraine WHO Special Initiative on Mental Health Situation Assessment.

10 World Bank Group. (2017). Mental Health in Transition: Assessment and guidance for strengthening integration of mental health into primary health care and community-based service platforms in Ukraine. World Bank

9 Ibid.

8 Ibid.

7 Alonso, J., Petukhova, M., Vilagut, G., Chatterji, S., Heeringa, S., Üstün, T. B., ... & Kessler, R. C. (2011). Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys. Molecular psychiatry, 16(12), 1234-1246.

6 Chisholm et al.

5 Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., & Saxena, S. (2016). Scaling-up treatment of depression and anxiety:

a global return on investment analysis. The Lancet Psychiatry, 3(5), 415-424.

4 Charlson, F., van Ommeren, M., Flaxman, A., Cornett, J., Whiteford, H., & Saxena, S. (2019). New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. The Lancet, 394(10194), 240-248.

https://cdn.who.int/media/docs/default-source/mental-health/who-special-initiative-country-report---ukraine---2020.pdf?sfvrsn=ad137e9_4 https://documents1.worldbank.org/curated/en/310711509516280173/pdf/120767-WP-Revised-WBGUkraineMentalHealthFINALwebvpdfnov.pdf https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30934-1/fulltext

Ukraine Mental Health Initiative for National Development (U-MIND) very nascent.13 A notable but recent change is to allow some primary care physicians to treat common mental health disorders in adults and children under services covered by the Program of Medical Guarantees (PMG) funded through the National Health Service of Ukraine (NHSU).

However, for the most part, government budgeting practices still incentivize inpatient care.

Psychiatrists are only licensed via public hospitals, but not psychologists, clinical providers, social workers or psychotherapists. This concentrates providers in large institutions (in large cities) and makes practice in non-institutionalized or community-based settings more difficult.

Public perceptions include viewing psychiatric care as low-quality or ineffective; with the majority seeing psychiatric hospitals as prison-like. High levels of stigma include concerns about being excluded from employment opportunities if labeled as a mentally ill person, which may relate to corruption concerns (paying bribes to avoid being diagnosed with certain disorders).14

There is also a market of private mental health practice, but the data on the private providers is limited.

III. Problem Statement

Common mental health disorders were already taking an economic toll in Ukraine even before the full-scale Russian invasion in 2022. Mental, neurological and substance use disorders were the second-leading cause of disability in Ukraine, after cardiovascular diseases, with associated loss of economic productivity and need for increased care.15 Ukraine had the highest disability burden due to depression in the entire region.16 Exposure to multiple Adverse Childhood Experiences (ACEs–such as exposure to violence, household mental illness or substance abuse, education disruption) is generally acknowledged to have lifelong, negative impacts with serious cost implications. ACEs in Ukraine (using 2019 data) were estimated to cost the country an estimated US$9.3 billion annually, or 6% of the GDP.17 PTSD is known to negatively impact labor force participation and productivity (due to increased absenteeism and presenteeism).18 About 25% of Ukrainian veterans from hostilities in 2014 had PTSD, with impacts on family and social functioning (interpersonal difficulties, increased alcohol/substance use, employment concerns, health complaints).19 Indeed, 28% of veterans who were employed before their military service were subsequently unemployed following an average of 18 months of service in the Anti-Terrorist Operation of 2014 (Russian’s 2014 invasion).20 While published peer reviewed research is limited since the beginning of the full-scale war, it is safe to assume that the

20 World Bank Group (May 2017). Socio-economic impacts of internal displacement and veteran return: Summary report. World Bank.

19 Omolovska, I., Botswick, M., Grant, L et al. (2023). Scars on their souls: PTSD and veterans of Ukraine. Globsec.

18 Alonso, J., Petukhova, M., Vilagut, G., Chatterji, S., Heeringa, S., Üstün, T. B., ... & Kessler, R. C. (2011). Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys. Molecular psychiatry, 16(12), 1234-1246.

17 Hughes, K., Ford, K., Bellis, M. A., Glendinning, F., Harrison, E., & Passmore, J. (2021). Health and financial costs of adverse childhood experiences in 28 European countries: a systematic review and meta-analysis. The Lancet Public Health, 6(11), e848-e857.

16 Ibid.

15 World Bank Group. (2017). Mental Health in Transition: Assessment and guidance for strengthening integration of mental health into primary health care and community-based service platforms in Ukraine. World Bank.

14 Quirke, E., Klymchuk, V., Suvalo, O., Bakolis, I., & Thornicroft, G. (2021). Mental health stigma in Ukraine: cross-sectional survey. Global mental health (Cambridge, England), 8, e11.

13 University of Washington Global Mental Health (July 2020).

https://documents1.worldbank.org/curated/en/571011497962214803/pdf/116489-REVISED-Updated-Report-Socioeconomic-Impacts-Internal-Displacement-Veteran-Ret.pdf https://www.globsec.org/sites/default/files/2023-09/GLOBSEC_PTSD%20Report.pdf https://documents1.worldbank.org/curated/en/310711509516280173/pdf/120767-WP-Revised-WBGUkraineMentalHealthFINALwebvpdfnov.pdf https://doi.org/10.1017/gmh.2021.9 https://doi.org/10.1017/gmh.2021.9

Ukraine Mental Health Initiative for National Development (U-MIND) increasing rate of mental health disorders related to the war is likewise driving up economic costs and, with an already strained/limited workforce pool, a decrease of available workforce would have serious implications for the country’s recovery.

Ukraine’s current mental health system is unable to meet treatment needs on the scale needed to prevent further deleterious economic impacts.21 Even prior to the war, mental health care was outdated and inadequate, primarily centered around institutional care.22 With more than two years of war, the mental health system has been completely strained despite soaring needs and increased demands.23

Ukraine's mental health system faces numerous issues that impede its ability to provide comprehensive, holistic, integrated, and effective (evidence-informed) mental health support to its population. There are three main challenges:

● Lack of access and availability of care through holistic, community-based services.

● Absence of professionalization and workforce capacity within the mental health sector.

● Weak systems, regulations, policies and relevant legislation to create an enabling environment for mental health service provision.

A holistic approach is essential to address these challenges, with consideration of how specific interventions will interact with each other and will explicitly fill critical gaps to ensure integration into the larger system that the GoU is currently building.

Ultimately, a robust Ukrainian mental health system will foster a healthier population and a healthier workforce to fuel the nation’s economic recovery. Pre-2022, it was estimated that every $1 invested in scaled-up treatment of common mental disorders in Ukraine (depression, anxiety, PTSD, etc) would result in $2 in restored productivity and added economic value.24

When the benefits of improved physical health are also included, the ROI improves to $4 for every $1 invested in treatment of common mental disorders in Ukraine.25 In the private sector, some Ukrainian businesses are already recognizing the needs and benefits of supporting the mental health needs of their workers and are exploring ways to partner with the mental health sector or provide MHPSS services.26

IV. Relationship to USG Strategies

26 Focus group discussion with private sector stakeholders and USAID. US Embassy in Kyiv, April 19, 2024.

25 Ibid.

24 World Bank Group, 2017. Mental health in transition. .

23 30% of displaced Ukrainians had sought some form of psychological support since 2022. International Federation of Red Cross and Red Crescent Societies. (April 2024). A sense of ‘futurelessness’: new data shows severity of mental health challenges for people from Ukraine.

22 World Bank Group, 2017. Mental health in transition.

21 Seleznova, V., Pinchuk, I., Feldman, I., Virchenko, V., Wang, B., & Skokauskas, N. (2023). The battle for mental well-being in Ukraine: mental health crisis and economic aspects of mental health services in wartime. International journal of mental health systems, 17(1), 28.

https://www.ifrc.org/press-release/sense-futurelessness-new-data-shows-severity-mental-health-challenges-people-ukraine#:~:text=30%25%20of%20displaced%20Ukrainians%20had,demand%20for%20mental%20health%20services.

https://doi.org/10.1186/s13033-023-00598-3

Ukraine Mental Health Initiative for National Development (U-MIND)

Since February 2022, the United States Government (USG) has prioritized integrating mental health into its efforts to support the Ukrainian population and communities. This commitment extends across various governmental agencies to ensure that mental health and psychological support align with the overall mission strategy. Notably, the USG's largest combined mental health programming effort worldwide is currently underway in Ukraine. This effort contributes to the US goal of helping Ukraine win the peace.

The U-MIND activity will advance the overall goal of USAID Ukraine’s Country Development Cooperation Strategy 2019-2026, by contributing to an independent, democratic, prosperous, and healthy Ukraine united around core European values. Additionally, the activity is aligned with and will contribute to broader USAID and USG strategies.

USG Strategy Alignment

USAID/Ukraine Country Development Cooperation Strategy (CDCS)

● DO 1: Corruption Reduced in Target Sectors: IR 1.1 Increased health system transparency

● DO 2: Impact of Russia’s Aggression Mitigated: IR 2.1 Conditions Improved for Reintegration (by improving access to health services including mental health services for veterans and war-affected populations)

● DO 4: Inclusive, Sustainable, Market-Driven Economic Growth:

IR 4.1 Strengthened SME competitiveness (by investing in human capital via mental health services)

US Embassy Ukraine’s Integrated Country Strategy

(ICS)

● Win the Peace, Mission Objective 2.3: Ukraine implements international best practices and continues decentralization while rebuilding social, physical, and critical infrastructure.

US Department of State’s EUR/ACE Ukraine Assistance Strategy

● Objective 1: Enable Ukraine to win the war against Russia’s aggression: Assistance Objective 1.3 Enable the GOU to provide services to and govern its people

● Objective 2: Support Ukraine in its recovery from the war, and its Euro-Atlantic integration: Assistance Objective 2.3 Support macroeconomic stability and restoration of key government services

USAID’s E&E Bureau Strategic Framework (Engagement in Ukraine’s Recovery & Reconstruction)

● #1: Immediate Economic Recovery and Sustainable, EU-Oriented Rebound

● #4: Improved Health Services advancing the dignity and wellbeing of every Ukrainian

By prioritizing mental health alongside other critical areas, USAID contributes to Ukraine's overall resilience and capacity to function as a self-reliant partner. This integrated approach not

Ukraine Mental Health Initiative for National Development (U-MIND) only addresses immediate challenges but also strengthens Ukraine's ability to navigate complex threats and emerge as a stable, prosperous nation aligned with European values and interests.

Addressing mental health needs will reduce the disability burden and improve productivity and labor force participation over time.27 Decentralizing mental health care away from psychiatric hospitals to high-quality community-based care can ultimately reduce human rights violations, increase transparency within the health system, and foster cost-effectiveness through improved outcomes for service users and their families.28

V. Government of Ukraine (GoU)

The Ukrainian government is actively addressing mental health needs as a result of the Russian invasion and is starting to build the ecosystem needed to promote mental health in a person-centered approach. The First Lady's Initiative on Mental Health, launched in April 2022, demonstrates high political will to improve and de-stigmatize mental health care in Ukraine, allowing all citizens in need to access mental health support services. This Initiative garnered support from multiple donors and international organizations who understand that investments in strengthening and expanding mental health services and making them accessible for the people of Ukraine is essential for the country’s future. As a result of this Initiative, in May 2022, the Cabinet of Ministers (CabMin) created the National Mental Health Coordination Center (NMHCC), responsible for implementing the First Lady’s Initiative on Mental Health. The NMHCC enhances collaboration and streamline efforts across various government agencies and has designated 24 regional coordinators responsible for creating mental health infrastructure in their relevant regions through cooperation with regional authorities. In addition, the GoU made a strategic decision that the main entry point for mental health services should be primary health care providers and institutionalized/began to roll out the WHO mhGAP model of screening mental health conditions at the primary health care level. This model is now included in the Government funded package of the Program of Medical Guarantees , with international organizations also supporting the training of primary health care providers .

In June 2022, the NMHCC, in collaboration with the Ministry of Health (MOH) and other partners, launched an All-Ukrainian Mental Health and Psychosocial Support Program called “How are you?”, further emphasizing the government's commitment to addressing mental health concerns. This program catalyzes a new mental health project, integral to key GoU plans, and is also embedded in the 2022–2032 Ukrainian Healthcare System Post-War Recovery Plan, targeting Priority #4: to enhance healthcare services for war-affected populations. As part of the All-Ukrainian Mental Health Program, a draft National MH Action Plan for 2024-2026 was created that focuses on: 1) improving coordination, leadership, and sustainability; 2) adjusting legislation; 3) strengthening workforce development; 4) expanding mental health services to other levels of care including outpatient care; and 5) assigning a number of ministries with

28Knapp, M., Beecham, J., McDaid, D., Matosevic, T., & Smith, M. (2011). The economic consequences of deinstitutionalisation of mental health services: lessons from a systematic review of European experience. Health & social care in the community, 19(2), 113-125.

27 Chisholm et al, 2016.

https://www.kmu.gov.ua/npas/pro-zatverdzhennia-planu-zakhodiv-na-20232024-roky-z-realizatsii-natsionalnoi-stratehii-iz-stvorennia-bezbariernoho-prostoru-v-ukraini-na-period-do-2030-roku-i250423-372

Ukraine Mental Health Initiative for National Development (U-MIND) development of their relevant mental health initiatives and programs. This demonstrates a transition from a reactive to a strategic approach (and from an institutionalization to a decentralized/outpatient focus) to tackle Ukraine’s increased mental health needs, further amplifying Ukraine's commitment to mental health reform.

Ukraine’s acceptance as a candidate member of the European Union (EU) led to the GoU’s commitment to align mental health development with EU standards by 2030 as well as with the WHO Mental Health Action Plan for 2013-2030. To do so, the GoU aims to establish an integrated, evidence-informed mental health system capable of functioning at all levels of care (specialized, secondary, primary and community levels) with individuals being at the center of the system. The GoU also aims to strengthen leadership and management in mental health systems, provide integrated medical and social support at the community level, improve the population’s mental health, increase prevention efforts for mental health conditions, and strengthen information systems, data and research in mental health.29 Despite projections indicating a substantial increase in demand for mental health services in the coming years, such a system does not exist yet. As part of its EU accession preparations, the Ministry of Health prioritized completing the primary self-assessment process for EU legislation and then implementing the provisions outlined in the Association Agreement with the EU. Nevertheless, Ukraine falls short of EU standards, particularly in mental health, where preventive measures, access to quality, affordable care, and successful societal reintegration post-recovery are emphasized. As Ukraine progresses in various assessment areas, including health system reform, healthcare infrastructure investment, workforce development, and aligning mental health practices with EU standards remain pivotal for its integration efforts.

VI. Program Approach

Theory of Change

If Ukraine builds a holistic mental health ecosystem accessible and available to Ukrainians in need of mental health and psychological support, and

If the mental health workforce within the public, community and civil society spheres increases competencies to provide high quality, culturally reflective, and evidence-informed services, and

If the policy and regulatory framework supports sustainable mental health systems at all levels of care, Then the impact of individual and societal costs of mental health conditions will be mitigated, enabling social and economic recovery.

U-MIND will partner with GoU in supporting the establishment of a comprehensive mental health ecosystem, building on the emerging strengths of Ukraine’s existing system and previous

29 Concept of Transformation of Mental Health and Psychosocial Support System in Ukraine (in Ukrainian), BarrierFree NGO, Center of Economic Revival, MOH, 2023; Model of the System of Mental Health and Psychosocial Support in Ukraine - draft version for public discussion, 2023

Ukraine Mental Health Initiative for National Development (U-MIND) initial reforms, including political will to improve mental health services and reduce stigma. This will increase the availability and accessibility of high quality services, reducing stigma so that Ukrainians seek services from well-trained, competent providers. An enhanced, transparent regulatory framework can increase public confidence in the mental health system and also foster ongoing monitoring, evaluation and learning regarding mental health outcomes. This collaborative effort will facilitate the restoration of mental and psychological well-being among its citizens so they can actively participate in society and the workforce, contributing to the economic revitalization of the nation. Recognizing the collective trauma and intergenerational cycle of suffering, U-MIND is committed to addressing these challenges by simultaneously responding to urgent needs while also laying the foundations for long-term mental and psychological well-being. The forthcoming section further outlines the core objectives to achieve this vision through targeted initiatives.

Objectives

Objective 1: Increase availability of and access to quality mental health care services at various levels for all Ukrainians in need

Increasing access to quality mental health services to meet the mental health support needs of Ukrainians requires addressing the facilitators and barriers to availability and accessibility across levels of care, including various types of outpatient services, specialist care, and referrals between providers and sectors. It also responds to the EU Parliament Resolution of December 2023 on building ambulatory services in EU countries. Important initial efforts of the GoU and relief and development partners to date have included supporting mobile mental health teams, training primary health care providers in mhGAP (for screening and management of common mental, neurological and substance use disorders), providing psychological first aid and other MHPSS initiatives through humanitarian projects, and launching the First Lady’s “How Are You?”

campaign to reduce stigma and increase help-seeking behaviors.

Objective 1 will include initiatives such as: expanding the numbers and types of mental health providers (non-specialist/community health workers, counselors, social workers, psychotherapists, psychologists, etc); providing evidence-informed and culturally applicable types of mental health services; increasing options for accessing care, including mobile services, telemedicine/online care and innovative technology, especially for remote areas; and integrating mental health services into various settings including primary health care, social protection, educational, employment and veterans affairs sectors. A holistic mental health ecosystem will promote prevention, address stigma, encourage service uptake, and measure outcomes through indicators informed by service users and stakeholders. Furthermore, U-MIND will also address the mental health needs of caregivers (community providers, mental health workers, family carers, etc), including burnout and trauma exposure.

Ukraine Mental Health Initiative for National Development (U-MIND)

Objective 2: Enhance the competencies and professionalization of the mental health workforce to deliver high-quality services

A well-trained and competent mental health workforce providing care at multiple levels is essential for the delivery of effective services that enable Ukrainians to fully recover and participate in social and economic growth. Currently, the GOU is investing effort and resources for training and upskilling the existing mental health workforce, as well as building the knowledge of other key actors such as national and regional leaders. However, much is still needed to meet the training and capacity needs of mental health providers across Ukraine. The U-MIND activity will direct its efforts towards building and enhancing the competencies of existing mental health professionals, other outpatient providers, and PSS community providers through specialized on-the-job training programs, continuing education opportunities, and mentorship initiatives. This will ensure that theoretical learning is translated into application and practice, supported by ongoing clinical supervision and peer consultation opportunities.

Additionally, U-MIND will implement strategies to attract and retain skilled professionals within the mental health sector. This will include support to standardize, accredit, and establish evidence-based/global standards degree programs, including strengthening of faculty capacity to deliver updated programs that will prepare the next generation of MHPSS providers to serve Ukraine (counselors, social workers, psychotherapists, primary health care providers, psychologists, and psychiatrists). A review of post-graduate programs may also require subsequent review and analysis to be in line with the delivery of the undergraduate programs.

Mental health workforce oversight systems will help ensure sustained delivery of high-quality services for Ukrainians. Objective 2 will also support development of licensing and certification boards and other regulatory bodies, strengthening existing professional associations, and establishing new groups, including ethical oversight boards for various cadres.

Objective 3: Improve the enabling environment via strengthened policies, strategies and regulatory frameworks related to mental health services and workforce

To build a strong, capable and sustainable mental health ecosystem, Ukraine needs to develop and update policies, legislation, and regulatory frameworks. This objective will use a holistic approach that considers filling in critical gaps within the existing enabling environment including policies, regulations, laws and strategies that are resilient and flexible to meet the evolving mental health care needs of the population.

U-MIND will work with the GOU, local governments, community members, local and national leaders and other stakeholders (including MHPSS civil society organizations) to develop and improve mental health policies, strategies, laws, legislation and regulatory frameworks that align with international best practices. In addition to addressing mental health considerations and services directly (including prevention of mental health disorders, suicide prevention and response, alcohol/substance use disorders), these frameworks should promote increased

Ukraine Mental Health Initiative for National Development (U-MIND) transparency in the health system, provide reporting and accountability mechanisms, and promote ethical practice. Consistent, transparent credentialing and licensing of mental health professionals will help safeguard the public and improve clinicians’ ability to practice in multiple settings (either public or private sectors).

The program also aims to support the implementation of enhanced policies and laws fostering the integration of mental health care within broader health system reforms in Ukraine, aligned with principles of human rights and tailored to the specific needs and context of the country as outlined in the National Concept Note on Mental Health 2030. This initiative will be led by the NMHCC, Ministry of Health (MOH) and National Health Service of Ukraine (NHSU) in collaboration with relevant stakeholders. In addition, the program aims to facilitate the enactment of relevant legislative changes at the highest level to systematize the provision of mental health care to Ukrainians and to regulate the roles of diverse professional groups, including psychologists, social workers, nurses and family doctors, within the mental health care system. This objective will complement the forthcoming MH Action Plan 2024-2026, which is in draft and poised to be approved and presented to the public, which includes lines of effort to enhance the integration and effectiveness of mental health services in Ukraine.

Overall Expected Results

The overarching expected results of these objectives will not only advance the GOU's vision for a comprehensive mental health system, but also contribute to the overall psychological well-being and prosperity of Ukrainians. By prioritizing the expansion of integrated mental health services, enhancing the capabilities of the mental health workforce, scaling up, and creating accessible community care, and improving mental health policies and regulations, Ukraine can align with EU standards and improve access to mental health support that citizens need to thrive – and that the country requires to build a workforce that is ready and able to support its economic recovery. U-MIND will remain adaptable in its approach, balancing a focus on urgent needs due to the war with the establishment of sustainable systems for the long term recovery of Ukraine.

Outcome 1: Increased availability, access and coordination of quality mental health services in Ukraine. U-MIND will scale-up the use of evidence-informed community-level and outpatient mental health care in Ukraine. The expansion will strengthen referral pathways and promote coordination of services. Rather than psychiatric institutionalization being a "first-stop" in Ukraine's mental health system, there will be lower-intensity interventions providing high-quality care at multiple levels. Service users, providers and other community stakeholders will be aware of and utilize referral pathways to access appropriate care. Decentralized services will bring mental health entry points closer to users–available at community and local levels, as well as regionally. This will include building on services that have been established by NGOs and international partners and other actors as part of the emergency response to the war and integrating these services into a sustainable mental health system. To promote uptake of

Ukraine Mental Health Initiative for National Development (U-MIND) services, psychoeducation and de-stigmatization campaigns will increase awareness of mental health issues and promote service utilization. Creating a holistic, tiered system of care will also help ensure that the mental health needs of the growing number of veterans (up to 5 million by the war’s end) are met and that individuals with more serious/intensive mental health conditions continue receiving appropriate services after they exit psychiatric institutions.

U-MIND aims to connect individuals with urgent MHPSS aid while concurrently establishing sustainable pathways towards long-term development support, ensuring a transition from rapid assistance to enduring solutions.

Illustrative Anticipated Results:

● Years 1-2

○ Urgent MH/MHPSS services delivered, offering multiple levels of care and access points in outpatient and community settings, including support for alcohol and substance recovery.

○ Ukrainians improved abilities to engage in work, experienced reduced burnout and absenteeism, and received enhanced care services for the existing MHPSS workforce.

○ Mental health support was integrated across multiple sectors, including education, protection, employment, and physical rehabilitation.

● Years 3-5

○ Continuum of care systems established, with strengthened referral networks and comprehensive care and prevention options.

○ Equitable distribution of resources and services responded to the needs and priorities of communities.

○ Community-driven approaches incorporated into monitoring-evaluation-learning systems tracking service quality and mental health outcomes, including service users’ daily and occupational functioning.

○ Ukrainian communities improved their functionality and increased their contributions to society and the economy.

Outcome 2: Enhanced cadres and capabilities of the mental health workforce in Ukraine.

Building the capacity of the mental health workforce will entail improving the quality of services, expanding the size of the mental health workforce and preparing a new generation of providers. Mental health cadres will be defined at all levels and across sectors, with an emphasis on increasing mental health workers at the grassroots and community levels. All levels of the workforce, both clinical and non-clinical, including social workers, will have competencies to deliver evidence-informed care. This will be done through on-the-job training, standardization of qualifications at various cadre levels, establishing certification and accreditation systems for psychologists, psychotherapists and other professionals, and making changes in higher education programs and clinical practice. Mental health workers who have been involved in the delivery of humanitarian assistance will have opportunities to build skills and utilize bridging opportunities to integrate into the formal mental health workforce system.

Ukraine Mental Health Initiative for National Development (U-MIND)

Illustrative Anticipated Results:

● Years 1-2

○ More MHPSS providers trained in and delivered evidence-informed, culturally appropriate services.

○ Standards of care established and equitably applied, with vetted networks of providers established.

○ Ethical practices integrated into systems for training and quality improvement, including systems for clinical supervision.

● Years 3-5

○ Humanitarian MHPSS providers accessed clear pathways for training and transition to longer-term outpatient provider roles.

○ Formal education programs established and/or revised to align with international standards, for various cadres (social workers, psychologists, etc).

○ Professionalization of various cadres advanced through licensing and oversight systems.

Outcome 3: Improved mental health policies and strategies developed. U-MIND will support the development of an enabling environment for mental health, such as care standards, regulatory systems, new or revised legislation and policy, and enhancement of monitoring and evaluation systems. This will include the analysis and development of legal and policy frameworks to promote collaboration between various stakeholders across sectors, including healthcare providers, private businesses, government agencies and civil society. Mental health policy and legislation will be responsive to Ukraine's needs, creating a more supportive environment for mental health care delivery. This will also create a more transparent mental health system, increasing public trust from anti-corruption and human rights perspectives. Crisis coordination structures established after the war’s onset, such as the MHPSS Technical Working Group, will transition to greater GOU ownership or other sustainable systems.

Illustrative Anticipated Results:

● Years 1-2

○ GoU increased ability to coordinate mental health service provision at local, regional and national levels.

○ Increased partnership and decision-making with local actors, service user groups and marginalized groups.

● Years 3-5

○ Crisis coordination transitioned to sustainable, system-level partnerships and linkages across sectors.

○ Policies and legislation based on community needs; policies and legislation established standards of care, service user rights frameworks, reporting mechanisms, emergency response mechanisms, etc.

Ukraine Mental Health Initiative for National Development (U-MIND)

○ Regulatory and ethical standards, review boards and accountability systems established for various cadres (social workers, psychologists, etc).

○ Professional associations or oversight boards established and/or strengthened

○ Policies and legislation expanded mental health financing and increased coverage of outpatient and preventative systems of care.

VI. Adaptability, Scalability, & Sustainability

Adaptability: The progression of the war, fluctuating political circumstances in Ukraine and Europe, and the ever-evolving landscape of donor funding will require ongoing evaluation and adjustment to ensure optimal utilization of resources. U-MIND anticipates that a high degree of adaptability will be needed in Years 1-2, with a focus on more urgent mental health needs. A flexible approach should also allow for customization of initiatives to suit the specific context of the local area. Success of U-MIND hinges upon coherence combined with flexibility to cater to the diverse needs of vulnerable groups and local communities grappling with migration dynamics, limited service provision capacity, and various economic vulnerabilities. The program will engage closely with community members and stakeholders, to ensure that our strategies are effective in addressing the dynamic and complex realities on the ground.

Scalability: Effective practices that can be utilized by a multitude of providers and stakeholders are central to the U-MIND approach. Recognizing the importance of scalability, U-MIND prioritizes interventions that have the potential to be expanded or replicated across different contexts in Ukraine by different actors. Recognizing the widespread, urgent mental health needs, U-MIND anticipates that scaling up evidence-based services will be a major focus of Years 1 and 2. As MHPSS needs are addressed and MH conditions are reduced in intensity and duration, this will in turn promote greater productivity and participation in the economy, as mental health conditions are reduced in intensity and duration.

Sustainability is a core aspect of USAID’s development policy and programming. Both USAID’s global and country-level strategies recognize the critical importance of emphasizing sustainability in development cooperation. Taking into account cultural norms and local capacities, U-MIND seeks to develop solutions that are not only impactful but also sustainable in the long term. Through strategic partnerships and knowledge sharing based on USAID’s locally-led development principles, we aim to maximize the reach and impact of our interventions, ultimately contributing to positive change on a broader scale.

U-MIND will achieve sustainability by building national, regional, and local capacity to manage and implement a holistic mental health ecosystem. This includes the development of appropriate policies and regulatory frameworks, fundamental changes to the education and training of the mental health workforce, and maximizing financial investments through utilization of lower-intensity interventions.