SOL-121-17-000009_REVISED_RFP_Health_Reform_Support.pdf

1. THIS CONTRACT IS A RATED ORDER RATING PAGE OF PAGES

UNDER DPAS (15 CFR 700)

2. CONTRACT NUMBER 3. SOLICITATION NUMBER 4. TYPE OF SOLICITATION 5. DATE ISSUED 6. REQUISITION/PURCHASE NUMBER

SEALED BID (IFB)

NEGOTIATED (RFP)

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

NOTE: In sealed bid solicitations "offer" and "Offeror" mean "bid" and "bidder".

9. Sealed offers in original and _____________________________ copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the depository located in until local time _______________________ (Hour) (Date)

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All Offers are subject to all terms and conditions contained in this solicitation.

A. NAME B. TELEPHONE (NO COLLECT CALLS) C. E-MAIL ADDRESS

AREA CODE NUMBER EXT.

(X) SEC. DESCRIPTION PAGE(S) (X) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM I CONTRACT CLAUSES

B SUPPLIES OR SERVICES AND PRICES/COSTS PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

C DESCRIPTION/SPECS./WORK STATEMENT J LIST OF ATTACHMENTS

D PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

E INSPECTION AND ACCEPTANCE

F DELIVERIES OR PERFORMANCE

G CONTRACT ADMINISTRATION DATA L INSTR., CONDS., AND NOTICES TO OFFERORS

H SPECIAL CONTRACT REQUIREMENTS M EVALUATION FACOTRRS FOR AWARD

K REPRESENTATIONS, CERTIFICATIONS AND OTHER

STATEMENTS OF OFFERORS

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within _180_ calendar days (60 calendar days unless a different period is inserted by the Offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT 10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%) (See Section I, Clause No. 52-232-8)

14. ACKNOWLEDGEMENT OF AMENDMENTS AMENDMENT NO. DATE AMENDMENT NO. DATE

(The offeror acknowledges receipt of amendments to the SOLICITATION for offerors and related documents numbered and dated:

CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER 15A. NAME AND

ADDRESS OF

OFFEROR

(Type or print)

15B. TELEPHONE NUMBER 17. SIGNATURE 18. OFFER DATE

AREA CODE NUMBER EXT. 15C. CHECK IF REMITTANCE ADDRESS IS DIFFERENT FROM

ABOVE - ENTER SUCH ADDRESS IN SCHEDULE

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION: 23. SUBMIT INVOICES TO ADDRESS SHOWN IN ITEM (4 copies unless otherwise specified)

10 U.S.C. 2304(a) ( ) 41 U.S.C. 253(c) ( )

24. ADMINISTERED BY (If other than Item 7) 25. PAYMENT WILL BE MADE BY CODE CODE

26. NAME OF CONTRACTING OFFICER (Type or print) Daniel Harter

27. UNITED STATES OF AMERICA 28. AWARD DATE

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

(Signature of Contracting Officer)

(REV. 9-97)

10. FOR INFORMATION CALL:

11. TABLE OF CONTENTS

STANDARD FORM 33

SOLICITATION, OFFER AND AWARD N/A

SOLICITATION

OFFER (Must be fully completed by Offeror)

AWARD (To be completed by Government)

SOL-121-17-000009

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07/21/2017 REQ-121-17-00042

USAID/Ukraine/Regional Contract Office Department of State 5850 Kyiv Pl.

Washington D.C. 20521-5850

17:00 (Kyiv LT) 08/29/2017

Ms. Larisa Lomonosova Acquisition Specialist llomonosova@usaid.gov

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USAID/Ukraine/Regional Contract Office

USAID/Ukraine/Office of Financial Management

TABLE OF CONTENTS

Table of Contents

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1. PURPOSE

B.2. CONTRACT TYPE

B.3. ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

B.4. BUDGET

B.5. PAYMENT OF FIXED FEE

B.6. INDIRECT COSTS

B.7. CEILING ON INDIRECT COSTS (if applicable)

B.8. COST REIMBURSABLE

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

C.1. PURPOSE AND OBJECTIVES

C.2. PROBLEM STATEMENT AND PURPOSE

C.3. BACKGROUND

C.4. SUPPORT OF INTERNATIONAL DONORS TO HEALTH SECTOR REFORMS

C.5. USAID ONGOING SUPPORT OF REFORMS

C.6. TECHNICAL APPROACH

C.7. COLLABORATING, LEARNING AND ADAPTING

C.8. MONITORING AND EVALUATION

C.9. GENDER ANALYSIS

C.10. SUSTAINABILITY

SECTION D - PACKAGING AND MARKING

D.1. AIDAR 752.7009 MARKING (JAN 1993)

D.2. BRANDING STRATEGY

D.3. BRANDING AND MARKING POLICY AND CREATION AND DEVELOPMENT OF

WEBSITE

D.4. BRANDING IMPLEMENTATION AND MARKING PLAN

SECTION E - INSPECTION AND ACCEPTANCE

E.1. NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

E.2. INSPECTION AND ACCEPTANCE

SECTION F - DELIVERIES OR PERFORMANCE

F.1. NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

F.2. PERIOD OF PERFORMANCE

F.3. PLACE OF PERFORMANCE

F.4. PERFORMANCE STANDARDS

F.5. KEY PERSONNEL

F.6. AUTHORIZED WORK DAY/WEEK

F.7. AIDAR 752.242-70 – PERIODIC PROGRESS REPORTS

F.8. REPORTS AND DELIVERABLES

F.9. AIDAR 752.245-70 GOVERNMENT PROPERTY—USAID REPORTING

REQUIREMENTS (JUL 1997)

F.10. GEOSPATIAL REPORTING REQUIREMENTS

F.11. AIDAR 752.7005 SUBMISSION REQUIREMENTS FOR DEVELOPMENT

EXPERIENCE DOCUMENTS (September 2013)

F.12 AUDIT

SECTION G - CONTRACT ADMINISTRATION DATA

G.1. ADMINISTRATIVE CONTRACTING OFFICE

G.2. CONTRACTING OFFICER’S AUTHORITY

G.3. CONTRACTING OFFICER’S REPRESENTATIVE

G.4. AUTHORITY/LIMITATIONS OF CONTRACTING OFFICER’S REPRESENTATIVE

G.5. AIDAR 752.7003 DOCUMENTATION FOR PAYMENT (NOV 1998)

G.6. PAYING OFFICE

G.7. INVOICING INSTRUCTIONS

G.8. ACCOUNTING AND APPROPRIATION DATA

SECTION H - SPECIAL CONTRACT REQUIREMENTS

H.1. NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

H.2. AIDAR 752.225-70 SOURCE AND NATIONALITY REQUIREMENTS (FEB 2012)

H.3. AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

H.4. AIDAR 752.228-70 MEDICAL EVACUATION (MEDEVAC) SERVICES (JULY 2007) 54

H.5. AUTHORIZED GEOGRAPHIC CODE

H.6. EXECUTIVE ORDER ON TERRORISM FINANCING

H.7. FOREIGN GOVERNMENT DELEGATIONS TO INTERNATIONAL CONFERENCES

H.8. AIDAR 752.229-71 REPORTING OF FOREIGN TAXES (JUL 2007)

H.9. AIDAR 752.222-70 USAID DISABILITY POLICY (DEC 2004)

H.10. AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION

REQUIREMENTS (APR 2014)

H.11. ENVIRONMENTAL COMPLIANCE

H.12. DISCLOSURE OF INFORMATION

H.13. ADDITIONAL APPROVAL REQUIREMENTS

H.14. GOVERNMENT FURNISHED FACILITIES OR PROPERTY

H.15. LOGISTICAL SUPPORT

H.16. FRAUD REPORTING

H.17. AIDAR 752.222-71 NONDISCRIMINATION (JUN 2012)

H.18. ADS 302.3.5.19 USAID-FINANCED THIRD-PARTY WEB SITES (AUG 2013)

H.19. ADS 302.3.5.22 SUBMISSION OF DATASETS TO THE DEVELOPMENT DATA

LIBRARY (DDL) (OCT 2014)

H.20. ADS 302.3.5.16(a)(4) PROHIBITION ON THE PROMOTION OR ADVOCACY OF

THE LEGALIZATION OR PRACTICE OF PROSTITUTION OR SEX TRAFFICKING (SEP

2014) 64

H.21. AIDAR 752.7007 PERSONNEL COMPENSATION (JUL 2007)

H.22. ADDITIONAL REQUIREMENTS FOR PERSONNEL COMPENSATION

H.23. AIDAR 752.209-71 ORGANIZATIONAL CONFLICTS OF INTEREST DISCOVERED

AFTER AWARD

H.24. CONSENT TO SUBCONTRACT

H.25. GRANTS UNDER CONTRACT

H.26. ELECTRONIC PAYMENTS SYSTEM

H.27. CLOUD COMPUTING (MAY 2016)

H.28. ADS 302.3.5.16(a)(2) CONSCIENCE CLAUSE IMPLEMENTATION (FEB 2012) H.29. ADS 302.3.5.16(a)(3) CONDOMS (ACQUISITION) (SEP 2014)

H.30. INSURANCE AND SERVICES

PART II - CONTRACT CLAUSES

SECTION I - CONTRACT CLAUSES

I.1. FAR 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

I.2. 752.252-2 AIDAR CLAUSES INCORPORATED BY REFERENCE (MAR 2015)

I.3. FAR 52.204-1 APPROVAL OF CONTRACT (DEC 1989)

I.4. FAR 52.229-8 TAXES-FOREIGN COST-REIMBURSEMENT CONTRACTS (MAR

1990) 80

I.5. AIDAR 752.7101 VOLUNTARY POPULATION PLANNING ACTIVITIES (JUN 2008)

I.6. AIDAR 752.7025 APPROVALS (APR 1984)

I.7. FAR 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

I.8. AIDAR 752.7036 USAID IMPLEMENTING PARTNER NOTICES (IPN) PORTAL FOR

ACQUISITION (JUL 2014)

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

SECTION J - LIST OF ATTACHMENTS

PART IV REPRESENTATIONS AND INSTRUCTIONS

SECTION K - REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS

K.1. NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERNCE

K.2. 52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS (JAN 2017)

K.3. 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (OCT 2015)

K.4. 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JUL 2013) .. 91

K.5. FAR 52.209-11 REPRESENTATION BY CORPORATIONS REGARDING

DELINQUENT TAX LIABILITY OR A FELONY CONVICTION UNDER ANY FEDERAL

LAW (FEB 2016)

K.6. 52.222-22 PREVIOUS CONTRACTS AND COMPLIANCE REPORTS (FEB 1999)

K.7. 52.222-25 AFFIRMATIVE ACTION COMPLIANCE (APR 1984)

K.8. 52.222-56 CERTIFICATION REGARDING TRAFFICKING IN PERSONS

COMPLIANCE PLAN (MAR 2015)

K.9. 52.225-2 BUY AMERICAN CERTIFICATE (MAY 2014)

K.10. 52.230-1 COST ACCOUNTING STANDARDS NOTICES AND

CERTIFICATION (OCT 2015)

K.11. 52.230-7 PROPOSAL DISCLOSURE – COST ACCOUNTING PRACTICE CHANGES

(APR 2005)

K.12. INSURANCE - IMMUNITY FROM TORT LIABILITY

K.13. AGREEMENT ON, OR EXCEPTIONS TO, TERMS AND CONDITIONS

K.14. SIGNATURE

SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

L.1. 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

L.2. 52.216-1 TYPE OF CONTRACT (APR 1984)

L.3. 52.233-2 SERVICE OF PROTEST (SEP 2006)

L.4. GOVERNMENT OBLIGATION

L.5. GENERAL INSTRUCTIONS TO OFFERORS

L.6. PROPOSAL SUBMISSION

L.7. INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL ... 103

L.8. INSTRUCTIONS FOR THE PREPARATION OF THE COST/BUSINESS PROPOSAL

L.9. INSTRUCTIONS FOR THE PREPARATION OF BRANDING IMPLEMENTATION

AND MARKING PLAN

L.10. ADS 302.3.5.16(a)(1) CONSCIENCE CLAUSE IMPLEMENTATION (ACQUISITION) –

SOLICITATION PROVISION (FEB 2012)

SECTION M - EVALUATION FACTORS FOR AWARD

M.1. GENERAL AND SOURCE SELECTION INFORMATION

M.2. TECHNICAL EVALUATION CRITERIA

M.3. COST PROPOSAL EVALUATION

M.4. DETERMINATION OF THE COMPETITIVE RANGE AND CONTRACT AWARD 122

M.5. SOURCE SELECTION

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1. PURPOSE

The purpose of this contract is to strengthen the Health System in Ukraine through the activity entitled “Health Reform” as described in detail in Section C. STATEMENT OF WORK.

B.2. CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee (CPFF) Completion Contract. For the consideration set forth in the contract, the Contractor must provide the level of effort described in Section F.5. The Contractor must also comply with all other contract requirements.

B.3. ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

a. The estimated cost for the performance of the work required hereunder, exclusive of fixed fee, if any, is __________ [ TBD ]. The fixed fee, if any, is _________ [ TBD ]. The estimated cost plus fixed fee, if any, is ___________ [ TBD ].

b. Within the estimated cost plus fixed fee (if any) specified in paragraph (a) above, the amount currently obligated and available for reimbursement of allowable costs incurred by the Contractor (and payment of fee, if any) for performance hereunder is _________ [ TBD ]. The Contractor shall not exceed the aforesaid obligated amount.

B.4. BUDGET

The following summary budget captures the final negotiated cost elements for the performance of the work required hereunder:

Cost Category _ Amount Program Costs TBD Grants Under Contract $2,000,000 Incentive Fund $163,260 Fixed Fee TBD Total Cost Plus Fixed Fee TBD

B.5. PAYMENT OF FIXED FEE

Payment of fixed fee, subject to the terms stated in FAR 52.216-8, may be made upon receipt of a proper invoice. Subject to FAR 52.216-8, Fixed Fee, if applicable, payment of fixed fee shall be allocated based upon the proportion of the invoiced amount in the period covered by the invoice to the total estimated cost of the periods of the contract not including fixed fee. In the event that the Contractor does not invoice for the total estimated cost the total amount of fixed fee will be reduced in similar proportion.

B.6. INDIRECT COSTS

a. Pending establishment of revised provisional or final indirect costs, USAID will reimburse allowable indirect costs on the basis of the following negotiated provisional or predetermined rates and the appropriate bases pursuant to the Contractor’s current executed Negotiated Indirect Cost Rate Agreement:

Description Rate Base Type Period

% 1/ 1/ 1/

1/Base of Application:

Type of Rate:

Period:

b. The Contractor will make no change in its established method of classifying or allocating indirect costs without the prior written approval of the Contracting Officer.

B.7. CEILING ON INDIRECT COSTS (if applicable)

[determination to include this clause in the contract will be made at the time of award in accordance with FAR 42.707(b)(1)]

a. Reimbursement for indirect costs shall be at the lower of the negotiated final (or predetermined) or the following ceiling rates:

Description Rate Base Type Period % 1/ 1/ 1/

1/Base of Application:

Type of Rate:

Period:

b. The Government will not be obligated to pay any additional amount should the final indirect cost rates exceed the negotiated ceiling rates. If the final indirect cost rates are less than the negotiated ceiling rates, the negotiated rates will be reduced to conform to the lower rates.

c. This understanding will not change any monetary ceiling, obligation, or specific cost allowance or disallowance. Any changes in classifying or allocating indirect costs require the prior written approval of the Contracting Officer.

B.8. COST REIMBURSABLE

The U.S. dollar costs allowable will be limited to reasonable, allocable, and necessary costs determined in accordance with FAR § 52.216-7, “Allowable Cost and Payment,” FAR §

52.216-8, “Fixed Fee,” FAR § 52.232-20, “Limitation of Cost,” and FAR § 52-232-22, “Limitation of Funds,” if applicable, and AIDAR 752.7003, “Documentation for Payment.”

[END OF SECTION B]

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

HEALTH REFORM SUPPORT

C.1. PURPOSE AND OBJECTIVES

The Purpose of the activity is to support a transparent, accountable, and effective health care system that is capable of meeting the health needs of the Ukrainian people. Advancing health sector reforms, enhancing transparency, and tackling corruption will reduce out-of-pocket payments and improve access and availability of high quality, evidence-based health care services for Ukrainians. Elimination of corruption is a cross-cutting theme across all objectives to be achieved by this activity, which include:

1. Improve health sector governance.

2. Support the transformation of the healthcare financing model.

3. Strengthen the health workforce.

4. Enhance transparency, accountability and responsiveness of the health care system.

5. Improve service delivery system at all levels.

C.2. PROBLEM STATEMENT AND PURPOSE

This contract must address pervasive corruption in the health sector. This corruption results in the loss of a significant portion of limited healthcare resources and ultimately contributes to poor health outcomes.

Corruption in Ukraine’s health sector has many faces. It includes high informal out-of-pocket payments for health services, deterring patients from seeking care in a timely manner. It is persistent in vertical public financing of subventions for health services, channeled from the center to Oblast Healthcare Departments and then to hospitals and clinics. It is health workers facing corruption through their entire career, starting from being asked to pay bribes for interim exams in medical school and thereafter “buying” positions with a symbolic official payroll from a hospital chief doctor; charging patients informal fees to make up for the investment;

prescribing brand name drugs that a patient doesn’t need to receive a kickback from pharmaceutical companies; and paying a tuition fee for the post-diploma qualification course that a doctor will never attend, but will receive a certificate in order to reach the next, higher attestation level.

The first and most important victims of the current situation are patients, required to “contribute” to semi-formal hospital “charity funds,” asked to buy and bring necessary drugs and materials into the hospital for a surgery, while still receiving substandard care from a run-down facility with obsolete medical equipment and unhappy medical personnel.

Therefore, the goal of this activity is to support a transparent, accountable, and effective health care system that is capable of meeting the health needs of the Ukrainian people. Advancing health sector reforms, tackling corruption, and enhancing transparency will improve access to and availability of high quality health care services for Ukrainians, while boosting the health system as a significant sector of Ukraine’s economy.

C.3. BACKGROUND

C.3.1. Health Sector overview in Ukraine Ukraine inherited from the Soviet Union an extensive, centralized, command-and-control type health care system, which struggles to meet the needs of its population. The system has not changed much in the 25 years since independence, with the exception of incremental changes in decentralization and delegation of limited functional and managerial powers to the 27 regions.

According to the State Statistics Service of Ukraine, the average life expectancy in Ukraine in 2015 was 71.1 years (76.2 for women and 66.3 for men), well below the European Union average of 84 years for women and 79 years for men. Non-communicable diseases (mostly cardiovascular diseases and cancers) and injuries are the leading causes of death and disability. Nevertheless, Ukraine also suffers from a concomitant burden of infectious diseases such as HIV/AIDS and tuberculosis. Ukraine has one of the fastest growing HIV/AIDS epidemics in the world. Ukraine also has one of the highest DR TB rates in Europe. Child routine immunization coverage rates are significantly below both average European figures and world figures largely due to misbeliefs and myths about the harms of vaccination, in many instances cultivated by medical personnel. The Maternal Mortality Ratio has steadily declined after a rapid spike in the early 1990s and has stagnated at the level of 24 for the last several years, which is about three times higher than the European average. The Infant Mortality Rate, at the level of 8, is twice as high as in the European Union. Ukraine has 3.5 physicians per 1000 population – equivalent to the average in the European Union.

Oblast (regional) Health Departments are functionally subordinate to the Ministry of Health (MOH). At the same time they are accountable to the regional governments. The public funds for health, collected through general taxation (value added tax, income tax, customs fees, excise tax, etc), are allocated to an extensive network of publicly owned health facilities based on their existing infrastructure (number of hospital beds, staff, and building size). Such an input-based, line-item financing system bears inefficiencies in itself. There are few incentives for rationalizing use of resources or controlling funds allocated for health care services. Hence, Ukraine is the fourth country in the world for the number of hospital beds per population: there are 879 hospital beds per 100,000 people. The average length of hospital stay is 11.8 days, compared to seven days as the European average. According to estimates, one third of all hospitalizations in Ukraine are unnecessary.

With only a few exceptions, hospitals are outdated, poorly maintained and equipped. Low patient turnout in many facilities results in poor quality of services and potential harm to patients. In addition to the extensive network of the MOH affiliated health care services, Ukraine also retains parallel health service delivery systems belonging to railroads system, military, Ministry of Infrastructure, maritime, Interior Ministry, and the penitentiary system. These parallel systems account for more than one tenth of total public expenditure on health, and about 9% of total hospital beds.

Total health spending in Ukraine constituted 7.4% of Gross Domestic Product (GDP) in 2014, with only 46% of it coming from public sources. According to the Article 49 of the Constitution of Ukraine, all Ukrainian citizens are entitled to a comprehensive guaranteed package of health care services provided free of charge at the point of use. However, this constitutional commitment is not backed by the available public financing of health.

Out of pocket payments, mostly for medicines and informal fees for health services, are a serious deterring factor for timely care-seeking by patients. According to estimates, about half of health care expenses are paid from patients’ pockets. Nine out of every ten Ukrainians have a fear of financial hardship in case of an episode of illness. So called “Charity Funds,” existing at many hospitals and clinics, are semi-formal methods of requiring patients to pay for health services. Formal salaries of medical personnel are at or below the subsistence level. Clinics primarily use the funds accumulated through the “charity funds” for supplementing salaries of medical personnel, and sometimes for upgrading the infrastructure and equipment of the hospitals. According to some health sector experts, doctors often have to “buy” their position:

despite the physician’s formal salary averaging only $200/month, some of the positions cost $10,000 to $25,000.

Corruption across all sectors, including health, is a pervasive and persisting problem in Ukraine. Public procurement has been considered for years as one of the most corrupt areas. Lack of transparency in the state procurement of medicines, supplies and medical equipment created opportunities for complex and highly lucrative schemes to pocket funds from the state budget. According to Ukraine’s Security Service estimates, up to 40% of public funds allocated annually for the medicines and equipment procurement were misappropriated through artificially inflated prices.

Private sector engagement in health, albeit developing in larger cities, is still nascent. According to the current budget code of Ukraine, public funds cannot be used to purchase services from private facilities. Emerging private clinics in Kyiv and larger cities are mostly confined to outpatient specialist services, diagnostics, family planning and obstetric care, dental care and cosmetic surgery. Demand for private health care services, generally perceived to be of higher quality, is growing steadily. Managers of the private clinics complain that even when offering salaries many times higher than in the public clinics, it is often difficult to attract highly qualified doctors. Private voluntary health insurance is underdeveloped, with only 1% of total healthcare expenditure coming from this source.

The health services provision system in Ukraine is hierarchical, consisting of outpatient and inpatients blocks. The outpatient level consists of primary health care (PHC) clinics and district consultative-diagnostic centers, offering specialist and more sophisticated diagnostic services. As a result of reforms from 2010, more than half of all PHC doctors have been retrained as family doctors. Family Medicine, as a standalone medical specialty, has been recognized in Ukraine. At present, there are about 560 family medicine centers /ambulatories functioning in Ukraine. However, patients often bypass the PHC level and self-refer directly to specialists or for diagnostic tests as a result of the lack of trust in the qualification of family doctors. Self-diagnosis and treatment is also a common practice since most medications are available through pharmacies without prescription.

The inpatient system in itself is also tiered and consists of small rural hospitals, providing basic inpatient services; district (central) and municipal multi-profile hospitals; and the tertiary, regional and national level hospitals and specialized clinics, for provision of highly specialized care to the patients with severe conditions and complications.

The regional level is administratively and financially responsible for emergency medical care, after the adoption of law on Emergency Medical Care in 2012. The system differentiates between emergency and urgent care. With the new law, emergency care and disaster centers have been created in all regions.

Mental health services in Ukraine have been traditionally overly medicalized, but not based on modern evidence-based guidelines. There is a high level of stigma attached to the field of mental health and those who seek mental health care. An average Ukrainian is typically not willing to openly seek mental health services because of this stigma. Currently, with the ongoing military conflict in the East of Ukraine, the need for mental health services is growing. The experience of participating in armed conflict, being displaced, and living through protracted conflict has significant impact on mental health and psychological well-being of combatants, their families, displaced persons and communities.

The health workforce in Ukraine is aging. According to MOH data, one fourth of all physicians are of retirement age. There is also a significant out-migration of qualified doctors and nurses. Generally, long-term planning of the health workforce is not done by the MOH. There is a striking imbalance between specialists and primary health care physicians, with too few primary health care physicians in the country.

Every year, thirteen public medical universities in Ukraine, affiliated with the MOH, produce about 10,000 graduates. One third of the graduates are foreign students who will not remain and practice in Ukraine. Public funds spent on medical education equaled 650 million UAH in 2016. The pre-service medical education system has not undergone significant changes since the collapse of the Soviet Union.

The standards for higher medical and pharmaceutical education are set jointly by the MOH and MOES. An independent Testing Board, officially called Center for Testing Professional Skills of Health Workers, established in 1999 as a result of USAID supported US-Ukrainian partnership in the early 1990s, successfully administers a three-step exam. The testing is mandatory for every Ukrainian medical university. Though affiliated with the MOH, the Center does not receive direct budgetary funding for its operations. Its funding comes from the universities for which testing services are provided. The modernization of testing is not necessarily reflected in the curricula and teaching methods of the universities, which are in most cases outdated and not responsive to the current demands of the health care system. As some healthcare experts have reported, bribing is widespread in medical universities, and there are “prices” set for every interim examination mark.

Another inheritance from the Soviet Union relates to an inefficient health workforce regulatory framework. There is no formal licensing process for physicians, but every doctor is required to go through periodic (every five years) so called post-diploma qualification courses, offered by one of the three existing National Medical Academies of post-graduate education or medical universities. Attendance at those courses determines “attestation categories” of physicians: 2nd, 1st, and highest. The courses in most cases are lecture type, with no practical or case based approaches used. Tuition fees for the courses are sometimes paid by attendees themselves, and often, with few exceptions, physicians just need to pay the fee to receive the certificate without even attending the course. Overall, the system does not ensure that physicians keep up-to-date with the ever-evolving medical knowledge and evidence, and focus on continuous and lifelong professional development.

There are about 8.5 nurses (including midwives and feldshers) per 1000 population in Ukraine. Declining salaries and limited career prospects for nurses contributed to a decline in the nursing force. Existing nursing education options include both recently introduced University level Bachelor of Science in Nursing (BSN) degree, and the traditional vocational level education through more than 100 medical nursing colleges. Graduates of BSN often have no advantages as compared to the college graduates in terms of pay scale or employment prospects. Although some health care facilities formally have job descriptions for nurses, functions between physicians and nurses are not clearly delineated and teamwork is not exercised.

Health administrators at facility or local government levels lack essential managerial knowledge and skills to adjust to the current realities and planned changes in the health care sector. Salaries are not competitive and many positions at the MOH are left vacant. The MOH often relies on donor funded highly qualified temporary consultants to perform its daily duties. Overall, it is mandatory for health care managers to have a degree in medicine and specialization in health care organization and management. The specialization course is provided by the same National Medical Academies and only lasts two months. Some of the recent initiatives (e.g. Health Care Management Master of Science Program offered by National University of Kyiv Mohyla Academy) improved opportunities for advanced specialization in health administration, but their penetration is still low. The situation with other allied health professionals, such as paramedics, medical rehabilitation specialists or medical technologists is even worse.

There is no integrated nationwide health information system in Ukraine that would allow for real-time, evidence-based policy and decision making. Periodic (monthly, quarterly and annual) paper based standard statistics reporting, mandatory for health care facilities, is collated by the Regional Health Departments in an electronic datasheets format and accumulated upwards by the Medical Statistics Center of the MOH. Based on this data, Ukraine’s State Statistics Service publishes a statistical yearbook on health, reflecting both administrative and clinical data. There are certain incentives for health care facilities to skew or misrepresent data reported through the standard paper-based statistical forms, which ultimately reflect in the yearbook. Facility level health management information system initiatives, in the absence of uniform standards, often are not compatible with each other and do not allow for aggregation of data at sub-national or national levels. Non-existence of a national, integrated and functional electronic health information system, and hence, lack of transparency, creates an excellent ground for corruption at every level.

Until recently, the state Sanitary-Epidemiological Service (SES) was the MOH’s main instrument responsible for public health service delivery and surveillance. SES monitored the distribution and administration of vaccines. In 2016 SES was disbanded, with some national level functions like epidemiological surveillance and data analysis and immunization, went to a newly created MoH Center for Public Health (on the basis of the MoH Ukrainian Center for Socially Dangerous Diseases/ HIV and TB Control). Other functions, like food safety and veterinary control merged into other government agencies. Local SES stations and laboratories are still in the process of transition to the MoH and then, potentially to be given to the local public health centers that will be created under the new GoU Concept of Public Health System Development, approved by Cabinet of Ministers on November 30, 2016. The corresponding Action Plan to implement this concept was approved in July 2017. Another public health service funded through the public purse, until recently, was mass medical screening (from dental checks to eye-sight, heart, lungs, orthopedic, urinary system/ gynecologic check-ups, and bio-chemical blood analyses) of certain groups of people, like school children, university students, military conscripts, big enterprises workforce. Most of these screening programs are not evidence-based and remain primarily as inertia from the soviet style mass “dispanserization” programs.

Responding to the challenges above, GOU and MOH, with the support of international donors implemented several waves of Ukrainian health care sector transformation. In the past most of these reforms were of incremental value and left the old system practically intact. The current wave of reforms was initiated after the 2014 Revolution of Dignity and intensified with the appointment of the new Acting Minister of Health in September 2016.

C.3.2. Ongoing Health Sector Reform Initiatives In 2015, the MOH commissioned the development of the National Health Reforms Strategy for Ukraine 2015 – 2025. The strategy documented problems existing in the sector, namely long-lasting absence of modernization, a disregard to population needs, and substantial pockets of inefficiency and corruption. Mismatch between what the state promises in terms of health service access, and what it is able to provide was identified as one of the major obstacles. The Strategy defined the vision, principles, priorities, objectives and key measures of the sector and identified key principles for Ukraine’s health care system reforms: a state-guaranteed package of services available for all; the national standards of excellence and professionalism; single purchaser of health care services instead of fragmented funding via local administrations;

patients’ empowerment; collaboration across organizational boundaries; value for money and effective use of limited resources; and accountability to the public, communities and patients. The Strategy stipulates major directions for the reform, which include PHC strengthening, reforming the hospital sector and public health, emergency services, and dental care. The Strategy also circumscribes the role of the MOH, re-profiling it from operational functions to policy making, steering and regulatory oversight. According to the Strategy, those changes should come along with enhanced autonomy of the formerly vertically governed health service providers. The strategy also paid special attention to reorienting the health workforce and reforming the pharmaceutical sector. All of the changes rely on timely and valid health information.

Following the strategy development, the MOH drafted the Healthcare Financing Reform Concept, consequently approved by the decree of the Cabinet of Ministers of Ukraine on November 30, 2016 #1013-p. According to the concept, under the new health financing arrangement, the money will follow the patients. This will change the old input-based financing system and create incentives for improved quality through free choice and competition. Other major changes, envisioned in the Concept, include establishment of the new national health purchasing agency – National Health Service (NHS), enhancing provider autonomy, introducing strategic purchasing (contracting) of health services from providers, and developing the new Government Guaranteed Healthcare Benefits Package (GGHBP). The Package will define the scope of primary, secondary and tertiary services and medicines, to which every citizen of Ukraine will be entitled, with co-payments in certain cases. A component of the GGHBP, guaranteed package of primary health care services (GPPHCS), has been drafted by the MOH and circulated for discussion within the medical community. The draft also defined a package of essential equipment that PHC doctors must have in order to provide GPPHCS.

The NHS will become an independent purchasing agency under the MOH, with regional branches. In order to launch the new institution, the Ministry of Health created a dedicated Technical Implementation Unit. Its primary goal is to boost capacity, launch and support set up of the NHS to execute strategic purchasing of health care services, design key business processes and procedures, and help scale-up the NHS to its full capability.

As the vanguard of the new health financing model, the MOH plans to implement capitation payment for primary healthcare. The MOH placed priority on PHC by significantly increasing the budget allocation for PHC in 2017. According to the capitation method, the government will pay a set amount per patient registered with a particular PHC doctor for a pre-defined PHC benefits package in a defined period of time. The new capitation payment for PHC services is planned to come into force from January 1, 2018. In the meantime, people will have time to register with their preferred PHC physician. Those patients who do not register themselves will be randomly assigned to a physician based on geographical coverage. Patients will have the freedom to change their physician as many times as they wish.

For secondary and tertiary care, in order to enforce provider autonomy and exercise “money follows the patient” principle, the MOH plans to introduce a provider payment method such as Diagnosis Related Groups (DRG). Another MOH initiative - formation of hospital districts -aims to improve quality and streamline and consolidate provision of hospital services across the country. Oblast state administrations are forming the geographical boundaries of the hospital districts (HDs). By the end of March 2017, the Cabinet of Ministers of Ukraine approved hospital districts proposals from 11 oblasts (to include Dnipro, Zhitomyr, Zaporizhzhya, Kyiv, Luhansk, Poltava, Rivne, Ternopil, Kherson, Khmelnytsk, Chernigiv oblasts with 3-5 HDs in each) and Kiev city. Each hospital district should have at least one hospital with round-the-clock intensive care and specialized medical care capability. The coverage population should be at least 120,000 people and a patient should be able to reach the hospital within one hour. It is envisaged, that some of the smaller hospitals with low volume of services, where patient workload for individual physicians is lower than the necessary minimum to ensure maintenance of skills, ultimately leading to lower quality of services, will be converted into rehabilitation centers, diagnostic centers, outpatient clinics, hospices, etc.

The MOH is also restructuring the public health system of the country. USAID is assisting the MOH to streamline the public health service delivery system through the establishment of the National Public Health Center as a single national agency; developing human resources for the public health system; establishing regional public health centers; developing the appropriate regulatory framework; and developing financing models for provision of public health services.

As part of the child health and social care de-institutionalization, the Government of Ukraine, including the President’s Administration and the Children’s Ombudsman, jointly with the Ministry of Health, has started the reform process of residential care facilities. The Working Group, comprised of representatives of the specialized ministries and leading national and international NGOs, developed the reform care vision and strategy for 2017-2026. The strategy was approved the National Council of Reforms in March 2017. The Ministry of Health has 39 residential care facilities for children-orphans and children with special health needs. The Ministry of Health started the assessment process of these institutions, with the goal of integrating children into family settings in their community.

The MOH also plans changes in the pharmaceutical sector in order to improve access to essential medicines. Specifically, the MOH from April 1, 2017 introduced a drug reimbursement scheme for the three priority conditions: cardio-vascular diseases (CVD), diabetes type 2, and bronchial asthma. For this purpose the government allocated UAH 500 Million in the 2017 state budget. In total, 21 generic name drugs have been selected that will be reimbursed at a minimum generic price level.

In 2015, under civil society and patients’ groups pressure, the MOH launched the procurement of medicines through international organizations for the 18 state targeted health programs as an interim measure to fill the managerial capacity gap and reduce corruption in the state medicines procurement. By 2019, it is planned that Ukraine will have a functioning independent National Procurement Agency. Despite initial bureaucratic GOU delays to develop and approve regulations supporting the new international procurement law, in 2015 the international organizations succeeded in procuring 95% of the ordered medicines, with more than $26 million USD saving in comparison with the 2014 state procurement done by the MOH. There is still significant opposition to international procurement among the pharmaceutical community, with a strong lobby in Verkhovna Rada (the Ukrainian Parliament), fueled by a loss of lucrative bonuses and cashbacks that accompanied the previous corrupt procurement system.

In 2016, the GOU launched a new public e-procurement system, ProZorro, which replaced old paper based tenders and reduced the space for corruption in public procurement. In order to monitor public procurement, civil society organizations, with support of Transparency International Ukraine, launched the DoZorro e-platform in November 2016. The main feature of DoZorro is the establishment of a unique database of real assessment of certain tenders, contractors, and procurers. According to some assessments, introduction of the ProZorro system has reduced corruption in public procurement by 25%. More time is needed to demonstrate the effectiveness of the DoZorro civil monitoring platform.

The proposed initiatives necessitate a functional and integrated electronic health information system, or eHealth. The MOH, in collaboration with civil society and donor organizations, has developed the eHealth concept as an initial step towards developing a comprehensive information system. The goals of the new eHealth system are: increase the effectiveness of health care system; enforce the “money follows patient” principle for increased transparency and reduced fraud and corruption; improve healthcare quality; allow for evidence-based policy and decision making; empower patients and doctors; improve patient safety; build new relationships between patients and health workers; and ensure continuity of care across levels of health system.

Reform initiatives are being piloted at the sub-national level in parallel to national level health sector reform efforts. Specifically, the Health Department of the Kyiv City Administration has developed a Concept of Health Sector Development for Kyiv, aiming to ensure access to high quality medical services for every city resident. The components of the concept mirror the national level efforts, and cover changes in the funding mechanisms for health care services;

enforcing the “money follows the patient” principle; enhancing the autonomy of the PHC and inpatient care providers; modernizing infrastructure and equipment in the primary health care centers/ ambulatories and clinical diagnostic centers (CDC) ; introducing insurance principles;

developing the eHealth platform; and re-organizing the public health system in the city. In line with the concept, the legal status of the PHC and CDC of Kyiv has been modified from the budgetary (public) organization to not-for-profit municipal enterprise. This change allows primary healthcare and diagnostic centers to have an account in the commercial banks, and to reinvest surplus back into facilities.

In the medium term, the MOH plans to continue reforms in the above-described directions. On the health financing side, the MOH will continue rolling out the PHC capitation system during 2017 and 2018. In parallel, preparatory work is underway for introduction of the DRG payment system for inpatient services, accompanied by hospital districts formation and activities aimed at enhancing health service provider autonomy.

In brief, during 2017 and beyond, the MOH plans to develop a comprehensive GHBP that will cover all levels of care and medicines, develop and strengthen the NHS, further expand eHealth, and continue to streamline the public health system. All of these changes will be accompanied by a strategic and targeted communication and information campaign in support of the reforms.

C.3.3. Challenges and opportunities Radical reforms face numerous barriers and challenges. Proposed reforms have met heavy resistance from medical personnel at all levels. Despite MOH communication efforts, many physicians still complain about not being informed and/or consulted about the directions of reforms. Many of them fear losing jobs and informal income. In many cases, chief doctors of hospitals and heads of Oblast Healthcare Departments are conservative and resistant to change. Regional health administrators and chief doctors fear losing their existing influence and formal or informal benefits. Incomplete and deliberately manipulative information about planned changes cultivates numerous myths, which MOH attempts to tackle in a reactive mode. Overall, there is a need to better structure and intensify communication in support of the ongoing reforms, with better targeting of the messaging to particular groups, identifying champions and change agents, and multiplying allies of this process.

Despite all the challenges, there are clear opportunities to accelerate reforms. The current MOH leadership is determined and motivated to implement changes. The Acting Minister seems to have strong political backing from the Cabinet of Ministers, the Prime Minster, and the President. Decentralization reforms, implemented in parallel to health care reform, create fertile ground for moving the health reform agenda forward.

C.4. SUPPORT OF INTERNATIONAL DONORS TO HEALTH SECTOR REFORMS

In 2015, the World Bank launched a five-year, US $215 million Serving People, Improving Health Project, seeking to improve the quality of health care services in eight selected Oblasts, with a special focus on primary and secondary prevention of cardiovascular diseases and cancer, and to enhance the efficiency of the health care system. Under the project’s Strengthening MOH Governance component, the World Bank intends to spend US $20.2 million for design, piloting and implementation of new provider payment systems such as DRG; strengthening the MOH’s stewardship role through developing the eHealth platform; preparing and implementing the public health services development strategy and action plan; supporting the information and communication campaigns to keep up the reform momentum; and improving the management of health services at regional and national levels through capacity building and learning activities.

The Swiss Agency for Development and Cooperation (SDC) is concentrating its efforts on strengthening the PHC level with a focus on health promotion and prevention. SDC supports ongoing health sector reforms through several of its projects. SDC is partnering with the World Health organization (WHO) through the Policy Dialogue for Better Health Governance project (2015–2019, CHF 1.85 Million) to strengthen the Government of Ukraine’s capacity to lead and steer reforms; endorse evidence-based policies; improve inter-sectoral and donor coordination and efficient communication; and strengthen the MOH’s institutional capacity to govern and deliver quality public health and people-centered, results-oriented, and inclusive health services. In the framework of the project, WHO is assisting the MOH to develop the GPHCS. SDC is also partnering with the World Bank through the Support for Reforms and Good Governance project (2016 – 2020, CHF 2.65 million) to tackle the root causes of poor health outcomes, support reform implementation at the regional level, and ensure transparent implementation of the World Bank project at a local level. SDC, jointly with UNICEF, is assisting the MOH in health promotion and communication in reproductive, maternal and child health, as well as communication about reforms (2013-2017, CHF2.83 million). SDC, through its Human Resources for Health – Medical Education project (2017-2026, CHF 10 million) is also planning to invest in the improvement of the medical education system in Ukraine with particular emphasis on preparation of family doctors / general practitioners and nurses. Finally, SDC is contributing to strengthening mental health care services provision through support for the mental health reform efforts of the MOH. These include introduction of modern evidence-based care guidelines, improving quality and standards of mental health education, and improving network collaboration and development of preventive programs for war-affected and general populations with mental health disorders.

C.5. USAID ONGOING SUPPORT OF REFORMS

The contractor must coordinate and collaborate with other activities (both USG and non-USG) implementing technical assistance in the health sector. The below are a selection, but not an exhaustive list, of ongoing USAID health support awards.

The USAID HIV Reform in Action (HIVRIA) project (2013-2018) aims to strengthen Ukraine’s health system to ensure effective and sustainable delivery of HIV/AIDS prevention, care and treatment services to key populations. The project assists the MOH and the GOU in modernizing and streamlining the public health service delivery system through establishment of the National Public Health Center and Kiev Public Health Center; providing high quality training opportunities in public health and health systems; assisting the introduction of new health financing models; supporting MOH’s move towards enhancing the autonomy of health service providers in line with the ongoing decentralization process; and assisting the MOH in designing and implementing a communications campaign in support of the current reforms.

The purpose of USAID Safe, Affordable and Effective Medicines for Ukrainians (SAFEMed) project (2017 – 2021) is to strengthen the…