RFI_FHR 121_22_000001.pdf

REQUEST FOR INFORMATION

“Furthering Health Reform in Ukraine” (FHR)

Subject: Request for Information No. RFI-121-22-000001 Date of Issuance: Monday, November 1, 2021 Response due: Monday, November 15, 2021, 12:00 pm Kyiv Time Response to: bwoody@usaid.gov; llomonosova@usaid.gov

This Request for Information (RFI) relates to an activity with the preliminary title of “Furthering Health Reform in Ukraine (FHR).”

The purpose of this RFI is to:

1. Obtain details concerning interest in USAID’s anticipated requirements; and

2. Obtain public comments on the DRAFT Statement of Work (SOW) to inform the design process.

*NOTE: Submissions from respondents must be limited to a maximum of 3-pages, 12-point font Times New Roman. Any pages over this limit will be discarded.

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. This is not a solicitation or a call for proposals. Please do not submit proposals, resumes or promotional materials, as they will be discarded.

Responses to this RFI should be submitted to USAID via email to Brian K. Woody, Regional Supervisory Contracting and Agreement Officer at bwoody@usaid.gov and Larissa Lomonosova, Acquisition and Agreement Specialist at llomonosova@usaid.gov and with a subject line “Response to RFI- Furthering Health Reform in Ukraine” no later than November 15, 2021, 12:00 pm Kyiv Time. Only electronic submissions will be accepted. Responses to this RFI must be written in English.

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. After USAID reviews and considers any responses, a decision will be made regarding whether and how to proceed with the new potential activity.

Not responding to this request does not preclude participation in any future solicitation/opportunity, if any is issued.

FAR 52.215-3 Request for Information or Solicitation for Planning Purposes (OCT 1997) mailto:bwoody@usaid.gov mailto:llomonosova@usaid.gov mailto:bwoody@usaid.gov mailto:llomonosova@usaid.gov

(a) The Government does not intend to award a contract on the basis of this solicitation or to otherwise pay for the information solicited except as an allowable cost under other contracts as provided in subsection 31.205-18 Bid and Proposal Costs, of the Federal Acquisition Regulation.

(b) Although “proposal” and “offeror” are used in this Request for Information, your response will be treated as information only. It shall not be used as a proposal.

(c) This solicitation is issued for the purpose of obtaining public comments on the draft statement of work.

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

Sincerely, Brian K. Woody Regional Supervisory Contracting Officer

Attachment : Draft Statement of Work (SOW)

DRAFT STATEMENT OF WORK

USAID FURTHERING HEALTH REFORM IN UKRAINE ACTIVITY (FHR)

List of Acronyms and Abbreviations

CSO - Civil society organizations CTC - Consolidated territorial communities DRG - Diagnostically related groups GOU - Government of Ukraine FHR - Furthering Health Reform HCF - Healthcare facilities HRH - Human resources for health IRI - International Republican Institute ITC - Information, Technology and Communication KPI - Key performance indicators MIS - Medical information systems MOH - Ministry of Health NGO - Non-governmental organizations 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) PPP - Public-private partnerships (in health sector) UAH - Ukrainian Hryvnia (local currency, $1 ≅ 27 UAH in 2021) UHC - Universal health coverage

C1. PURPOSE AND SCOPE

The purpose of Furthering Health Reform (FHR) activity is to improve health system accountability and transparency in Ukraine, leading to improved equitable access to quality services, optimized use of scarce resources, and ultimately expanded universal health coverage (UHC) for the people of Ukraine with reduced financial hardship on patients. Mitigation of corruption across the health system is a key overarching aim of FHR.

The Activity has five objectives:

Objective 1: Strengthen sustainable health financing and governance of healthcare.

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: Strengthen the enabling environment for private sector engagement in healthcare system modernization.

Objective 5: Strengthen public support for the healthcare reform implementation.

The FHR activity 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.

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 20151, corruption in state bodies continues to be a top problem for an overwhelming majority of citizens, impacting their daily lives - especially in healthcare which potentially affects everyone’s daily lives.

Corruption is related to broader inefficiencies that contribute to poor health outcomes and higher financial burdens on Ukrainian households, which pay a larger proportion of health costs and receive less than their European neighbors. A key feature of the Ukrainian system is a highly inefficient delivery structure, arising from misaligned incentives that favor hospital care. Ukraine has many hospitals and many beds (6.57 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. Aside from widespread inefficiencies at all levels of the system, informal payments are widely accepted, arising from limited transparency and oversight and poor governance of the healthcare system.

High-level commitment exists in the country to undertake reforms and Ukraine made initial progress with reforms since 2017. These developments 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

1 https://www.iri.org/sites/default/files/wysiwyg/2015-05-19_ukraine_national_municipal_survey_march_2- 20_2015.pdf; https://www.iri.org/sites/default/files/wysiwyg/municipal_poll_2016_-_public_release.pdf;

https://www.iri.org/sites/default/files/2017-11-28_ukraine_poll_presentation.pdf;

https://www.iri.org/sites/default/files/wysiwyg/2019_december_survey_of_residents_of_ukraine_ngproof_toct_030 32020_comments_removed_final.pdf https://www.iri.org/sites/default/files/wysiwyg/2015-05-19_ukraine_national_municipal_survey_march_2-20_2015.pdf https://www.iri.org/sites/default/files/wysiwyg/2015-05-19_ukraine_national_municipal_survey_march_2-20_2015.pdf https://www.iri.org/sites/default/files/wysiwyg/municipal_poll_2016_-_public_release.pdf https://www.iri.org/sites/default/files/2017-11-28_ukraine_poll_presentation.pdf https://www.iri.org/sites/default/files/wysiwyg/2019_december_survey_of_residents_of_ukraine_ngproof_toct_03032020_comments_removed_final.pdf https://www.iri.org/sites/default/files/wysiwyg/2019_december_survey_of_residents_of_ukraine_ngproof_toct_03032020_comments_removed_final.pdf

Since 2016, following significant advocacy and engagement from local 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 UHC and address widespread dissatisfaction of the population 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 estimated2 to be wide-spread and deeply entrenched.

The overarching strategy for 2015-20203 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 as an accelerator. In line with this strategy, USAID and other key 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 enterprises. In June 2018, NHSU started contracting with the new, autonomous primary healthcare providers to provide a new publicly-guaranteed package of 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

2 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 stoke 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”.

3 National Health Reform Strategy for Ukraine 2015-2020. - MoH, Kyiv-2015.

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 enrolment 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 31 million of people (or 75% of the population) selected and signed declarations with their family doctors. A recent survey found around 70 percent of the patients are satisfied4 with their services.

The second phase of health financing reform 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) starting on April 1, 2020. Phase 2 implementation has progressed and expanded to the vast majority of public facilities since April 2020. 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. Under this Phase 2, line item budget funding for hospitals was eliminated in favor of payment of an agreed amount for services under the global budget, with additional tariffs established for provision of defined packages of care. Treatment of heart attacks, strokes, early diagnosis of oncology, childbirth, and emergency care were among the priority services with the highest tariffs. In response to COVID-19, the GOU also introduced specific COVID treatment packages to finance hospital-based care. In the first 12 months of the Phase 2 reforms, more than 1,600 healthcare providers representing nearly 95% of public specialized healthcare facilities entered into contracts with NHSU, and received more than 75 billion UAH (USD $2.8 billion) for services provided, including COVID19 treatment.

4 Rating Sociological Group survey conducted in May 2019:

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

Ukraine has made a number of promising achievements to build on and strengthen reform implementation since 2020. These include expansion of the PMG financing in 2021 by more than 30 percent (112 billion UAH vs. 75 in 2020) and introduction of a consultative process for determining PMG based on evidence; expansion of the ePrescription and Affordable Drugs Reimbursement programs; evolving hospital payment mechanisms that are better linked to 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.

C.2.3. Development Challenges and Opportunities

At the specialized care level (outpatient clinics and hospitals), implementation of reforms has faced significant challenges related to the onset of the COVID-19 pandemic and a lack of unified leadership over the reform process and priorities across the GOU. 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, the Phase 2 reforms have only ‘scratched the surface’ of the reform needs at the hospital level. Significant challenges to achieving meaningful structural reforms remain. These include: a large number of low-capacity, outdated facilities, and an excessive number of hospital beds per capita; political resistance to optimizing and re-profiling the existing public sector health care facilities network; unclear and unevenly enforced politics around copayments for services not covered by the PMG; and, inadequate capacity at local levels to implement reforms.

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

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 policy-makers.

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. The Covid-19 epidemic has highlighted long-standing systemic weaknesses, such as in the management, deployment, career development, and motivation of human resources for health (HRH) that are vital to address performance issues.

By mid-2021, Ukraine’s healthcare reforms were institutionalized to a significant extent in the financing of primary health care, but remained nascent at the hospital level. Reforms have not yet led to the anticipated broader restructuring of the healthcare system. While there is some indirect evidence that informal payments have reduced at the primary healthcare level5, Ukraine has not yet been able to demonstrate dramatic reductions in either informal or formal out-of-pocket spending or improved financial protection. A number of challenges lie ahead in the coming years for Ukraine to consolidate reforms and ensure that the PMG successfully leads to improved quality of care, improved efficiency and accountability, and financial protection.

Key problems and challenges remain in the Ukraine health system, even after extensive reform efforts. The problem areas the FHR activity will address are: i

- 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 is 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 modernised to improve quality and infection control. The NHSU needs to further develop regulatory tools and oversight capacities to ensure proper financial and program monitoring.

- 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 very few basic KPIs, at the primary health care (measles & rubella immunization coverage of children) and emergency care (correct pathways of patients with acute strokes and infarctions) from mid 2021.

- Efficiency: Capable hospitals networks are only in the planning process in all the Ukraine’s regions. 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 UK. 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 in certain industry sectors (like Ukrainian Railway, Defense, Security 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: While Ukrainains pay one of the highest proportion of total health expenditure out-of-pocket pin the world (49.2% in 20196), the quality of services still remains low. Services are often characterized by outdated or lack of life-saving

5 Ukraine Health Reform Support Activity Mid-term Performance Evaluation, USAID/DGC, LER-II, October 2021.

6 http://www.ukrstat.gov.ua/ http://www.ukrstat.gov.ua/ equipment; lack of modern, evidence-based standards of care; limited oversight care standards at the facility level; and limited availability of skilled and appropriately compesnated human resources for health. Up to 30-40% of stroke patients in Ukraine die within 30 days of being admitted to hospital for stroke7, which is one of the main killers in Ukraine. In comparison, in the 23 OECD countries, this figure8 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 years9 (66.3 and 76.3 years for men and women, respectively), much lower than that of other European countries.

- Private Sector Engagement: The full potential of the private sector (which is very quickly growing in Ukraine’s health sector, especially in the context of COVID-19 with online medical consultations and diagnostics) has yet to be realized for better health care. The private sector offers opportunities for: better governance; modernization; efficiency;

client-centeredness of service provision; facility management; and the motivation and professional development of the health workforce. While about 30% of primary healthcare providers contracted by the NHSU are from the private sector, less than 6% is for the secondary specialized care. The background foundational conditions, including clear and easy-to-navigate and apply legislation, for the public-private partnerships in health are almost non-existent.

The FHR activity will support the Government of Ukraine to consolidate and deepen reforms to address these ongoing challenges. 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.

C3. RELATIONSHIP TO USAID STRATEGY

This Activity will contribute to USAID/Ukraine’s Country Development Cooperation Strategy (CDCS) for 2019-2024, 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.

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

7 Prof. Mykola Polishchuk, Neurosurgeon, the President of the “Ukrainian Anti-Stroke Association”, 2019:

https://eso-stroke.org/stroke-care-in-ukraine-press-conference-held-in-advance-of-wsd2019/ 8 OECD Health Statistics 2019: https://www.oecd-ilibrary.org/sites/a489af86-en/index.html?itemId=/content/component/a489af86-en 9 Health Index. Ukraine – 2019: Results of the National Survey. Kyiv, 2020 https://eso-stroke.org/stroke-care-in-ukraine-press-conference-held-in-advance-of-wsd2019/ https://www.oecd-ilibrary.org/sites/a489af86-en/index.html?itemId=/content/component/a489af86-en https://www.oecd-ilibrary.org/sites/a489af86-en/index.html?itemId=/content/component/a489af86-en

This activity will also contribute to the CDCS DO4: Inclusive, Sustainable Market-driven Economic Growth and its IR 4.2: Infectious Disease Burden Reduced 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 the FHR will create specific linkages between the healthcare reform and infectious diseases goals of U.S. health assistance, so that consolidation of healthcare financing and governance reforms reinforces and advances public health outcomes.

C.4. COLLABORATION

C.4.1 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:

Health Reform Support (2018-2023); Local Health System Sustainability/ Ukraine (Telemedicine activity, 2021-2023); Safe, Affordable, and Effective Medicines for Ukrainians (SAFEMed) (2018-2023); PEPFAR and TB programs; USAID COVID response activities; and USAID support strengthen the public health system under the Public Health Resilience and Recovery activity (new 2022). 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.

The Contractor will also collaborate with the USAID activities supporting anti-corruption, good governance and decentralization reforms, including Governance for Local Accountability (GOVERLA) Activity, Democratic Governance - East (DG EAST) Activity, Cybersecurity for Critical Infrastructure in Ukraine Activity, State-Owned Enterprises Reform Activity, Competitive Economy Program (CEP) Activity, Transformation Communications Activity.

C.4.2 Collaboration with Other Development Partners

The Contractor shall coordinate extensively with relevant efforts funded by other donors, and, in consultation with USAID, will adapt contract activities over time to match with the changing character of these projects to ensure synergy of investments in strengthening Ukraine’s health system. The major donors in the health reform support arena are: the World Bank, with its 2021- 2024 ($135M) Extension to the “Serving People, Improving Health (2015-2020)” Loan supporting hospital modernization and public health/ COVID response and vaccination; Swiss Development Cooperation through its support for medical education reforms and health financing and policy technical assistance (via World Bank and WHO); and the Canadian International Development Agency’s program supporting eHealth development. WHO/Ukraine also plays a key role in providing strategic policy advice and expert consultation on models of care, supports enabling legislation to strengthen governance and accountability, and supports strengthening the health system to deliver on condition- and disease-specific service coverage results.

The Contractor shall work with Ukrainian government, non-government and private sector partners at the national, rayon, oblast, city and consolidated territorial community (CTC) levels as appropriate, including both sub-national government entities as well as local branches of national executive bodies. The Contractor will develop and maintain effective collaboration and partnership with key GOU entities and stakeholders involved in healthcare reform, including, but not limited to:

● Ministry of Health

● National Health Service of Ukraine

● “E-Health” State-owned Enterprise of the Ministry of Health

● Verkhovna Rada (Parliament) of Ukraine, particularly the Committee on Public Health, Medical Care and Health Insurance

● Ministry of Finance

● Ministry of Digital Transformation

● Oblast State Administrations and/or their successors

● Rayon State Administrations and/of their successors

● City Administrations and/or their successor bodies

● Consolidated Territorial Communities, councils, executive bodies, etc.

C.5 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 improve health system accountability and transparency in Ukraine, leading to improved equitable access to quality services, optimized use of scarce resources, and ultimately expanded universal health coverage (UHC) for the people of Ukraine with reduced financial hardship on patients.

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

IF Ukraine's healthcare financing and governance reforms are further consolidated and strengthened, AND supported by strengthened health workforce capacity, digital health platforms and tools, enabling environment for private sector engagement, and awareness and support among the Ukrainian people; THEN Ukraine’s health system will be more transparent, efficient and accountable to citizens, who will not have to pay exorbitant out-of-pocket and informal payments to get better access to quality essential healthcare services, enabling the country to expand universal health coverage.

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 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 health financing and governance of healthcare.

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 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 out-of-pocket/ informal payments for essential healthcare services.

The key guiding principle for the activities under this objective is not so much getting ‘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. It will also entail optimizing and rationalizing hospital inpatient care, while at the same time ensuring hospital consolidation and modernization. Approaches must take into account health needs including the unique pressures related to managing ongoing COVID-19 illness and future pandemic threats, along with refining the health services covered under the PMG. At the central level, efforts will strengthen strategic purchasing of the National Health Service of Ukraine and its financial planning, resource allocation, contractual and quality monitoring functions.

Activities under this Objective will focus on achieving the following illustrative outcomes (the list is not exhaustive or exclusive)

Key expected outcomes:

1.1 Optimized and prioritized Program of Medical Guarantees (PMG, a state guaranteed benefits package) with explicit quality requirements that is institutionalized in the national legislation, policy and guidelines;

1.2 NHSU market power leveraged to improve efficiency and enable needed system restructuring;

1.3 Payment mechanisms lead to enhanced financial protection and progressivity of overall financing under the PMG;

1.4 Downsized and optimized capable hospital network, with effective referrals from and collaboration with primary healthcare providers, operational in targeted oblasts;

1.5 Improved public financial management of the healthcare facilities in targeted oblasts;

1.6 Evidence-driven prioritization of benefits and public expenditure under the State Guaranteed Health Benefits Package (Program of Medical Guarantees- PMG) introduced and institutionalized by the GoU;

1.7 Expanded Affordable Drugs Reimbursement Program integrated into the PMG;

1.8 Performance-based financing mechanisms for healthcare facilities reinforce quality improvements across all care levels

1.9 Increased efficiency of resource allocation and expenditures across primary health care (PHC) and specialized care level;

1.10 Improved accountability of the public sector healthcare providers due to strong oversight by the communities, patient organizations, and professional associations;

1.11 Primary health care level strengthened and incentivized to improve the quality of care and reduce unnecessary referrals to/ and from the specialized care.

Objective 2 - Improved health workforce capacity for the accountable provision of quality healthcare Aside from financial resources and transparent access to information, 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 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 fair and adequate remuneration for doctors, nurses and support staff in healthcare facilities, both monetary and nonmonetary is a key outcome for HRH transformation expected to be foundational for eliminating informal payments.

FHR will also strengthen the workforce of the NHSU (the steward of the PMG) and its management systems, including its regional bodies. It will also improve the capacity of the regional and municipal administrations to optimize and invest in the modernization of their hospital network while increasing access and use of services at the primary health care level.

Activities under this Objective will focus at achieving the following illustrative outcomes (the list is not exhaustive or exclusive):

Key expected outcomes:

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

2.2 Capacity of the MoH and NHSU to design, negotiate and review/ upgrade PMG contracts and packages measurably strengthened;

2.3 Capacity of the NHSU and its five supra-regional branches to contract, monitor and manage services under the PMG strengthened;

2.4 Supportive systems developed and institutionalized for the primary healthcare providers to build and sustain capacities to deliver priority services under the PMG (such asHIV, TB, mental health);

2.5 Targeted incentives provided to accelerate the transition from a specialised in-patient dominated system to a more capable primary care level and referral system;

2.6 Ability and capacity of the local regional and municipal administrations to optimize and invest in the modernization of their hospital network and capacitation of the PHC level;

2.7 Capacity of the HCFs managers for financial and data management (incl. MIS/ eHealth systems) and business development of their facilities built;

2.8 Secondary specialized care level strengthened/ optimized and improved to provide quality timely patient centered services;

2.9 Regional governments target financing of healthcare to complement the PMG and advance universal coverage.

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 and continuity, tackling corruption in healthcare, and delivering better quality essential health services. Support to the development of telemedicine, the demand and need for which was accelerated by the COVID-19 pandemic, will be adapted and synchronized with the current state of development of the national eHealth system of Ukraine in order to better reach the underserved. Increased operational reliability, interoperability, patient information and data security of eHealth and telemedicine tools and platforms, with the overarching aim of their financial and institutional sustainability, should be in the 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 illustrative outcomes (the list is not exhaustive or exclusive):

Key expected outcomes:

3.1 eHealth governance frameworks and sustainable solutions developed and upgraded in support of transparent contracting, reporting, and monitoring of services under the PMG;

3.2 Improved enabling environment for scale-up of telemedicine and remote monitoring technologies for health system resilience, transparency and accountability;

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, healthcare managers and patients to use ehealth/ ITC tools and platforms and analyse data, generated by eHealth system;

3.6 Innovative digital solutions piloted for health system resilience and preparing health systems for future emergency scenarios.

Objective 4 - Strengthened enabling environment for private sector engagement in healthcare system modernization.

The role of the private sector (both local civil society organizations (CSOs) and non-governmental organizations (NGOs), as well as for-profit companies) holds the potential to be critically important in the modernization and improved efficiency of health service delivery - as providers, producers of goods and services, drivers of quality and innovation, and sources of investment.

FHR will engage local governments, HCFs, and the private sector to stimulate innovative solutions and public-private partnership to achieve the health reform goals. FHR will work with the GOU and the private sector to build the foundational conditions, including legal and policy frameworks, to improve the enabling environment for the private sector to contribute positively and substantively in achieving health reform’s major goals of affordable, patient-centered, free-from-corruption quality health care.

Activities under this Objective will focus on achieving the following illustrative outcomes (the list is not exhaustive or exclusive):

Key expected outcomes:

4.1 High quality information on the private health sector collected, analyzed and used for building partnerships with government and public sector facilities;

4.2 Legal, regulatory and institutional barriers identified and addressed to enhance private sector engagement in healthcare modernization and investment in system development;

4.3 Dialogue established that brings all stakeholders together to overcome mistrust, agree on policy agendas, and identify specific partnership opportunities;

4.4 Capacity built within the government to effectively engage, partner with, and steward the private health sector;

4.5 Increased GOU adoption of public-private partnerships (PPP) initiatives while developing and implementing a program of identifying, tracking and managing PPP;

4.6 Tools developed and applied to identify, evaluate, manage, and implement successful PPPs in health, targeted for the government and private sector audiences;

4.7 Innovative joint solutions piloted for the private sector engagement for hospital sector modernization (better governance/ merit-based and fair remuneration of the staff, transparency/ efficiency) and value-based care collaboratives between the primary healthcare and specialized secondary healthcare providers.

4.8 Partner with and develop Ukrainian organizations capable of providing expertise and consulting services to support healthcare policy and system transformation (e.g. to support hospital reforms, develop local governance and quality of care tools, telemedicine, etc.).

Objective 5 - Strengthened public support for the health reform implementation The activities under this Objective will be focused at strengthening the general public and stakeholder support for health system reforms. 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 at achieving the following illustrative outcomes (the list is not exhaustive or exclusive):

Key expected outcomes:

5.1 Increased health sector stakeholders’ and the publics’ knowledge of and support to health system reforms aimed at accountability, transparency, and patient-centeredness of services;

5.2 Local champions of reforms nurtured to support and advance reforms (e.g. among medical community and local government - owners of facilities);

5.3 Evidence-based findings on the impact of the health reforms provided by the applied research and utilized by the champions of reforms among policy- & decision-makers, educators and practitioners.

C.6 PROGRAMMATIC APPROACH

Achieving USAID’s Development Objectives for Ukraine 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 Furthering Health Reform activity is essential to achieving USAID’s Country Development Cooperation Strategy, driving the approach to the design of the activity.

Zero Tolerance for Corruption 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.

Geographic Coverage 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.

Guidelines include:

● A certain number of oblasts shall be targeted with sustained interventions to accelerate reforms, demonstrate innovative solutions and inform the overall implementation of the health reform.

● A priority should be to optimize the allocation of resources within healthcare networks by incentivizing a more efficient allocation of resources and the rationalizing of health services.

● The contractor should collaborate with other USAID activities, development partner programs and/or local institutions to maximize its capacity to impact reforms at the subnational level.

● The Contractor shall collaborate with and obtain approval from USAID on targeted oblasts, CTCs/cities and rayons for longer-term sustained interventions, the associated selection methodology and graduation criteria as part of developing the initial Activity implementation plan.

● USAID expects at least one or more focus oblasts will be prioritized in Eastern Ukraine, in recognition of the severity of need and need to develop and deepen reform implementation and tools in this unique context.

Flexible, Rapid Response and Collaborating, Learning and Adapting Ukraine’s fluid political environment calls for flexibility in implementation. The Contractor shall be able to shift emphasis between and within components to concentrate resources where the opportunities to make progress are greatest, refine approaches in response to knowledge obtained through data collection and learning exercises, and/or accommodate shifts in political and social operating environment. The Contractor shall also be able to rapidly mobilize both short and long-term technical assistance to respond to unanticipated opportunities to advance health reform. The Contractor shall work in close consultation with USAID throughout implementation to ensure that the Activity responds programmatically and operationally, within scope, to changing realities in the operating environment and/or U.S. Government priorities, and the amount and type of funding available from USAID annually, which may vary.

Self-Reliance Increasing financial and administrative self-reliance: The Contractor shall support healthcare networks to become financially more sustainable through improved management of resources and greater efficiency in the utilization of health services. It is also envisioned that the contractor will facilitate public-private partnerships to modernize health facilities and expand eHealth to improve efficiency.

Grants Under Contract 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 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.

C.7 MONITORING, EVALUATION, AND LEARNING

A detailed draft Monitoring, Evaluation, and Learning Plan (MEL) shall be developed by the Contractor, establishing specific output, outcome and impact indicators (including, but not limited to the U.S. Foreign Assistance Framework list of standardized indicators and custom indicators) for quarterly, semi-annual and annual reporting, with baselines, targets, benchmarks and disaggregation by gender, age, and location where appropriate. The MEL Plan shall be approved by USAID.

NOTE: The MEL Plan must be developed strictly in accordance with the criteria stipulated in

ADS 201.

C.8 GENDER AND SOCIAL INCLUSION ANALYSIS

Background

On March 8, 2021, President Biden signed an Executive Order that established the White House Gender Policy Council ensuring that all United States Government policies rest on a foundation of dignity and equity for women and girls, in all their diversity. This Executive Order called for developing a government-wide strategy for advancing gender equity and equality, which will reflect increased access to comprehensive health care, address health disparities, and promote sexual and reproductive health and rights as one of the priorities. On October 22, 2021 the Biden- Harris Administration issued first-ever national gender strategy10 to advance the full participation of all people – including women and girls – in the United States and around the world. USAID will work with other U.S. Government agencies and stakeholders to implement the National Strategy on Gender Equity and Equality.

USAID requires that all its activities fully address gender considerations, ensuring that both men and women benefit from USAID support and that gender awareness is a built-in component of project activities. The 2017 Gender Analysis Report for USAID/Ukraine summarized major observations and recommendations for main technical areas of USAID support in Ukraine, including health.