USAID-Ukraine Rehab4U RFA 72012124RFA00001.pdf

Key

Issue Date: January 23, 2024 Deadline for Questions: February 6, 2024 Closing Date and Time (Phase 1 Applications): March 5, 2024, 3:00 p.m. local Kyiv time

Subject: Notice of Funding Opportunity Number 72012124RFA00001

Program Title: Rehabilitation for Ukraine (“Rehab4U”) Activity

Federal Assistance Listing Number: 98.001

Ladies/Gentlemen:

The United States Agency for International Development (USAID) is seeking applications for a cooperative agreement from qualified entities to implement the Rehabilitation for Ukraine (“Rehab4U”) Activity. Eligibility for this award is not restricted.

USAID intends to make an award to the applicant(s) who best meets the objectives of this funding opportunity based on the merit review criteria described in this NOFO subject to a risk assessment. Eligible parties interested in submitting an application are encouraged to read this NOFO thoroughly to understand the type of program sought, application submission requirements and selection process.

To be eligible for award, the applicant must provide all information as required in this NOFO and meet eligibility standards in Section C of this NOFO. This funding opportunity is posted on www.grants.gov, and may be amended. It is the responsibility of the applicant to regularly check the website to ensure they have the latest information pertaining to this notice of funding opportunity and to ensure that the NOFO has been received from the internet in its entirety.

USAID bears no responsibility for data errors resulting from transmission or conversion process.

If you have difficulty registering on www.grants.gov or accessing the NOFO, please contact the Grants.gov Helpdesk at 1-800-518-4726 or via email at support@grants.gov for technical assistance.

Please be aware that this funding opportunity will utilize a multi-tiered review process under Automated Directive System (ADS) Chapter 303, Section 303.3.6.1.c.; specifically, the evaluation of applications will occur in the following phases:

Phase 1: Applicants will submit an initial application or concept paper pursuant to Section D.5 of this NOFO. Based on USAID’s evaluation in accordance with the merit review criteria set forth herein, the applicant(s) whose initial application best meets the objectives of this funding opportunity will be requested to submit a full application.

Phase 2: The Merit Review Committee will transmit a second-level solicitation to the selected applicant(s), as noted above. Upon receipt of the full application(s), the Merit Review Committee will conduct a review thereof, using more specific merit review criteria.

Additional details regarding the review process are provided in Section D of this NOFO.

USAID may not award to an applicant unless the applicant has complied with all applicable unique entity identifier and System for Award Management (SAM) requirements detailed in Section D.5.b(3). The registration process may take many weeks to complete. Therefore, applicants are encouraged to begin registration early in the process.

Please send any questions to the point(s) of contact identified in Section G. The deadline for questions is shown above. Responses to questions received prior to the deadline will be furnished to all potential applicants through an amendment to this notice posted to www.grants.gov.

Issuance of this notice of funding opportunity does not constitute an award commitment on the part of the Government nor does it commit the Government to pay for any costs incurred in preparation or submission of comments/suggestions or an application. Applications are submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s expense.

Thank you for your interest in USAID programs.

Sincerely, Amy McQuade Agreement Officer

NOFO No. 72012124RFA00001 Integration of Rehabilitation Services within the Health System in Ukraine (Rehab4U) Activity

TABLE OF CONTENTS

SECTION A: PROGRAM DESCRIPTION

SECTION B: FEDERAL AWARD INFORMATION

SECTION C: ELIGIBILITY INFORMATION

SECTION D: APPLICATION AND SUBMISSION INFORMATION

SECTION E: APPLICATION REVIEW INFORMATION

SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION

SECTION G: FEDERAL AWARDING AGENCY CONTACT(S)

SECTION H: OTHER INFORMATION

SECTION A: PROGRAM DESCRIPTION

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

1. Introduction

The primary goal of the Rehabilitation for Ukraine (Rehab4U) Activity is to create sustainable quality physical rehabilitation services within the health system across all levels of care, including the primary health care (PHC) level, by addressing both urgent, short-term gaps and long-term systems requirements. Sustainable, quality, physical rehabilitation services will enable all Ukrainians to optimize their functioning, fully integrate within society, and participate in the economic recovery and growth of the country. For implementation of this activity, USAID seeks to utilize a systems approach, focusing on government ownership, development of physical rehabilitation services for long-term sustainability, and simultaneously applying a person-centered approach to address the distinct rehabilitation needs of individuals and the communities that support them, while also addressing urgent needs and gaps in rehabilitation.

The specific target population will be civilian victims of war, persons with disabilities, veterans1, the rehabilitation workforce, training institutions, and the Government of Ukraine (GOU).

USAID/Ukraine plans to provide up to $40 million, subject to availability of funds, over a five-year period to support this Activity.

2. Background

Current data on physical rehabilitation needs in Ukraine is extremely limited. Prior to the Russian invasion on February 24, 2022, a World Health Organization (WHO) publication2 noted that as of January 2020, 2.7 million Ukrainians were registered as persons with disabilities, including 163,000 children. However, this figure is likely a gross underestimate as it only represents persons with disabilities who are registered and not all persons that were in need of physical rehabilitation services. Globally, according to the WHO, 2.4 billion people, or 1 in 3, would benefit from physical rehabilitation services.

The Ministry of Veterans Affairs (MVA) estimates Ukraine currently has up to 1.5-2 million veterans, with a significant percentage of them requiring physical rehabilitation services. By the end of the war, Ukraine could have more than 5 million veterans. The number of MVA hospitals is insufficient to care for the number of wounded active military and veterans, therefore many

1 Please note that USAID is not able to work directly with the Ministry of Defense. Veterans are defined as those fully discharged from military service, who are receiving services from public health facilities.

2 Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p 11.

are cared for outside of MVA hospitals. Active military or veterans receiving health services in a Ministry of Health (MOH) facility will be covered through the National Health Service of Ukraine (NHSU). If any active military or veterans receive disability status while hospitalized, their support will be funded through the Ministry of Social Policy (MOSP), including the provision of assistive technology (AT).

As a result of the war, increasing prevalence of conditions such as spinal cord and open and closed head injuries, burns, amputations, and complex limb trauma, compounded by limited numbers of skilled and available rehabilitation professionals, population displacement, safety and security, and other factors are impacting the ability of the Government of Ukraine (GOU) to respond appropriately and in a timely manner to individuals requiring physical rehabilitation services. The availability of physical rehabilitation for conditions not directly related to the war, such as existing limitations in functioning, non-communicable diseases, aging or accidents, has been impacted, particularly due to disruptions in routine health care services. Increasing economic constraints on the population and the GOU’s need to redirect state funding, has significantly impacted physical rehabilitation services at all levels.

Approximately 80,000 rehabilitation providers have been trained since 1994, predominantly physical therapists, however statistics on the exact types of providers are not known.3 Information is unavailable on the existence of education and training programs, and regulatory standards available to certify rehabilitation professionals, such as physiatrists, rehabilitation nurses, occupational therapists, recreational therapists, speech and language therapists, clinical social workers, psychologists, dieticians, prosthetists, orthotists, and others. Physical rehabilitation services remain severely understaffed - there are not enough rehabilitation professionals equipped with the evidence-based knowledge and skills to handle complex polytrauma cases or who have the ability to navigate the demands of these new emergency situations due to war. Evidence-based continuing education courses that meet international standards are limited with insufficient opportunities to practice clinical skills.

Education standards for physical, occupational, and speech therapists and physical rehabilitation medicine (PRM) physicians are not standardized across educational institutions, and there is no national or professional accreditation process for these academic programs. Additionally, rehabilitation professional certification competencies are not established for Ukraine, and there is no standardized testing or licensing system. Ukrainian Catholic University has the only master’s degree program for physical and occupational therapists, but because it is structured as a combined program of physical therapy (PT) and occupational therapy (OT), future international accreditation is unlikely. There is no internationally-recognized training program in Ukraine for prosthetists and orthotists (P&O), although a cadre of P&O providers have benefitted from short courses and on-the-job training programs, primarily funded by donors.

3 E-mail communication of September 29, 2023 from Vasyl Strilka, General Director, Directorate on Highly Technological Health Care and Innovations, MOH and Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p 32 and p 34.

Many people in Ukraine rely on AT, such as mobility aids, wheelchairs, and self-care products, in order to optimize functioning and engage in everyday activities. It has been reported that many of these essential products may have been damaged or left behind during widespread population evacuations/displacement, starting in February 2022, further increasing the overall need that existed before the war. Currently, the MOSP, through its Fund of Social Protection for People with Disabilities, processes approximately 200,000 requests for AT products annually.

However, large gaps in the provision of P&O and AT products and services remain.4 Procurement and supply chain challenges remain considerable barriers, with purchasing decisions often defaulting to the lowest cost option due to budget limitations or inadequate training. The GOU requires capacity strengthening to address AT needs forecasting, procurement, and stock management to ensure these products are available, along with the necessary physical rehabilitation services, for those who require them.

To address these needs, Ukraine’s public and private sectors are mobilizing resources. The GOU is elaborating plans to expand physical rehabilitation services through investment in public facilities, including through partnership with the World Bank’s Health Enhancement and Lifesaving (HEAL) Ukraine project, which, subject to availability of funds, may support both training and provision of equipment and vehicles to PHC and specialized facilities. At the same time, Ukraine’s private sector has significant and growing capacity to meet needs related to physical rehabilitation and P&O, including through private, for-profit institutions, as well as non-profit service providers. Non-profit service providers have experienced growth, often with support from humanitarian agencies or private investors and foundations, particularly since Russia’s full-scale invasion. To date, there has been limited collaboration or partnership between the public and private sectors, and limited engagement of private providers in providing state-subsidized services under the Program of Medical Guarantees as described in Section 2a below.

Some non-profit service providers rely exclusively on donor or private funding, limiting their capacity to provide services. As a result, access to private sector services is potentially limited to those with the ability to pay out of pocket or secure other external financing, leading to uncertainty in terms of sustainability and meeting longer-term needs.

2a. Role of GOU in Rehabilitation Sector

The GOU has undertaken major health care system reforms since 2016, aimed at eliminating corruption and informal payments and making health care services more available and accessible to the population. In 2017, the GOU established the NHSU, which today contracts more than 95 percent of all public health facilities to provide government-covered health services. Before the war, the NHSU covered more than 33 million Ukrainians (79 percent of the population), purchasing health services and medicines under the Program of Medical Guarantees, which the NHSU began implementing in April 2020. The Program of Medical Guarantees currently covers 31 health benefit packages, of which, three are specific to

4 Consultation meetings: MOH (5/9/2023); Protez Hub (5/10/2023); National Assembly of People with Disabilities (5/12/2023) and MOSP (5/23/2023) rehabilitation: 1) medical rehabilitation for children aged 0–3 years, 2) persons with neurological conditions, and 3) persons with musculoskeletal conditions. However, overall, these three packages do not sufficiently respond to the existing needs, let alone the growing rehabilitation needs related to the war. Moreover, funding for AT, after discharge from a hospital, is not included in rehabilitation packages which further delays the optimization of function.

According to the MOH, its role related to rehabilitation includes: organizing and providing physical rehabilitation services; organizing health workforce training; standardizing physical rehabilitation services; licensing and accreditation for health facilities offering physical rehabilitation services; coordinating the activities of regional and municipal executive authorities as they are related to the rehabilitation sector; and introducing innovation to the rehabilitation services. 5

In addition, the MOH is responsible for funding and oversight of the Medical and Social Expert Commissions (MSECs) for adults and Medical Advisory Commissions for children that specifically work with persons needing rehabilitation. These special entities, including representatives of the MOH, the MOSP and other state entities function at the central, oblast, rayon and city level and report to the MOH. They conduct medical-social assessments of individuals and assign disability status to them after the individuals’ functioning limitations are established through various diagnostics, treatment and rehabilitation procedures. There are at least 363 Commissions employing approximately 1,400 doctors.6 These Commissions are responsible for developing individual treatment plans, prescribing AT products and issuing disability status certificates.

Disability certificates are required in order to seek funding assistance for AT products and obtain assistive devices through the MOSP.7 However, the process to acquire the disability certificate is lengthy. Currently, during the ongoing war with Russia, MSECs have been revitalized, in an effort to satisfy the growing needs of civilians with complex injuries who are seeking disability certificates in order to access GOU-funded AT products. Overall, the process can be difficult and cumbersome for individuals and their families.

In 2017, Ukraine began to transition from the MSEC approach of assigning a disability status, to the International Classification of Functioning, Disability and Health (ICF), although the shift is still in progress.8 ICF is a framework for describing functioning and disability in relation to a health condition and environmental factors.9 The MOH of Ukraine has started the process of adopting ICF in Ukraine by using ICF coding in the current ehealth system, but officially, the transfer to ICF for the entire health system is scheduled to start on January 1, 2025. The WHO advises that the International Classification of Disease (ICD) codes (current iteration is ICD-11), which provide a diagnosis of diseases, disorders and other health conditions, should be utilized

5 Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p. 17.

6 Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p. 12.

7 Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p.52.

8 Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p. 44.

9 https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health together with ICF to enrich the information available on health services users. Even with adoption of ICF by selected health facilities in Ukraine, there is still a lack of information on population-level functioning, rehabilitation workforce data, and outcomes of rehabilitation treatment.

The MOSP is the central executive body that ensures the formation of State policy in protecting the rights of persons with disabilities. The MOSP role in rehabilitation includes, but is not limited to: supporting rehabilitation centers for persons with certified disabilities (including children);

early identification/early intervention for children needing rehabilitation and/or social services;

and all issues related to AT (procurement, product, policy and provision). The MOSP oversees facilities that manufacture, supply and repair AT products.10

As of January 2023, the NHSU has contracted 421 health care facilities, of which 37 are private, to provide rehabilitation packages. Among them, 262 provide inpatient services, and 411 offer outpatient services. The State Rehabilitation Program for 2023 has allocated 4.2 billion Ukraine Hryvnia (UAH) or around $110 million in total: over 2.6 billion UAH ($66 million) for inpatient care and over UAH 1.5 billion ($40 million) for outpatient services. By the middle of 2023, the state budget had already financed over 1.5 billion UAH ($40 million) for rehabilitation services11;

however, services are highly specialized and are not available at the PHC or community levels, and are heavily concentrated in urban areas in the western regions of the country and in Kyiv.

The inpatient, free of charge, rehabilitation package covered by the NHSU, for most individuals, includes a maximum of 42 days per year, with three hours per day of rehabilitation services. The outpatient rehabilitation package is a maximum of 28 days per year with one hour per day of therapy. However, on June 16, 2023, due to the increased number of severe injuries resulting from the war, the Cabinet of Ministers increased the in-patient rehabilitation package for individuals with complex conditions such as spinal cord injuries, severe head injuries and amputations to 168 days per year that will also be reimbursed through the NHSU12.

Consistent with overall health system reforms, the MOH is also working to digitize medical records relating to rehabilitation and AT, based on ICF principles, as mentioned above. In addition, the MOH is utilizing telemedicine to expand access to key rehabilitation services for people in high need and when feasible.

3. Problems to be addressed and Ukraine Rehabilitation Sector Challenges

Although the GOU has accomplished significant health system reforms, the draft 2030 Health Care System Development Strategy emphasizes that the war with Russia has created an

10 Situation assessment of rehabilitation in Ukraine. Copenhagen: WHO Regional Office for Europe; 2021, p. 18.

11 Ministry of Health of Ukraine website, Press Center tab, July 21, 2023.

12 From: https://moz.gov.ua/article/news/zbilsheno-kilkist-seansiv-reabilitacii-jaki-oplachujutsja-z-programi-medichnih-garantij-z-42-do-168-dniv, the Ministry of Health of Ukraine increased demand for certain types of care and services that were not common previously. The draft Strategy further states that the development and reconfiguration of systems of rehabilitation and mental health care now require comprehensive resource planning and preparation.

Current challenges facing the Ukraine rehabilitation sector are many and should be viewed for both quick wins and through a systems lens13 to address issues with governance, finance, health information, workforce, service delivery and assistive technology for long-term sustainability.

Critical issues of the Ukraine rehabilitation sector that must be identified and mitigated by the Implementing Partner are described below.

Insufficient Governance. The rehabilitation system in Ukraine is lacking sufficient governance, which includes absence of a structure to enhance internal coordination among GOU entities and ministries with rehabilitation sector roles (MOH, MOSP). External coordination of international organizations and donors needs to be strengthened to improve alignment with the GOU, to ensure that each donor understands their role, and can respond to the current needs and avoid duplication of efforts. The GOU does not yet have a national rehabilitation strategy. While laws and decrees to support the work in the rehabilitation sector in Ukraine exist at the national level, implementation at regional and municipal levels is not uniform. Quality of care standards for rehabilitation are not yet developed at the national level.

Fragmented Financing. Financing for rehabilitation is fragmented and there is, as yet, no system for consolidating information on rehabilitation spending. While the NHSU has designated funding packages for rehabilitation, these are focused on the number of days and services provided, rather than on rehabilitation outcomes achieved. An optimal funding mechanism would be individualized to match the functional needs of each person. Since financing for AT is not included in the existing rehabilitation packages supported by NHSU, many individuals are discharged from clinics or hospitals without the necessary AT to optimize functioning and facilitate participation in society.

Limited Health Information and Data for Decision Making. While the existing electronic medical records system is beginning to incorporate rehabilitation medical records, and some facilities are starting to use the ICF, there is further progress to be made. Data collection and availability on the number and types of conditions seen and services provided, as well as geographic distribution of rehabilitation service needs, could inform new policies and substantiate the need for services at primary and community levels. In addition, there is limited data on the rehabilitation workforce and no information on outcomes of rehabilitation treatment, or on population-level functioning.

Lack of Rehabilitation Workforce. The pre-service education system for training physical, occupational, and speech therapists, as well as PRM physicians does not utilize a uniform

13 The systems’ approach to the rehabilitation sector was emphasized by responders to USAID RFI issued in May 2023.

curriculum for each speciality across universities. As noted above, pre-service education does not incorporate evidenced-based treatment or clinical skills, with the exception of Ukrainian Catholic University. No international standard training program exists for P&O providers at Ukraine’s higher educational establishments - there are only donor-funded programs for this speciality. In addition, the limited opportunities for advanced education in the rehabilitation professions can be a challenge for the development of rehabilitation researchers, academic leaders, faculty, and clinical instructors, and for advancement within the profession in Ukraine.

Finally, there is a lack of rehabilitation professional regulatory standards for licensing, certification, and continuing education.

Overall, there are insufficient numbers of qualified rehabilitation professionals to provide rehabilitation services, partially due to the exodus of staff as a result of the war, as well as the increased need for and complexity of services. The GOU, out of necessity, is focusing on emergency rehabilitation needs resulting from the war, which leaves persons with other types of rehabilitation needs with limited to no access to services and to adequately trained providers.

Inaccessible Services. Rehabilitation services in Ukraine are provided mostly through specialized inpatient units at national and regional levels and have been focused on neurologic rehabilitation. Historically, services and workforce have not been designed or trained to provide multidisciplinary and complex services for injuries and conditions associated with war, such as spinal cord injuries, traumatic brain injuries and amputations. The acute rehabilitation phase of recovery is insufficiently addressed in these units, and there is no system to monitor quality of care or measure outcomes of treatment. As noted above, rehabilitation services are not provided at PHC and community levels which limits access. Additionally, PHC providers are not equipped to identify an individual’s rehabilitation needs and refer them for appropriate services.

Persons receiving rehabilitation services are not routinely screened for mental health and psychosocial needs, and mental health and psychosocial services are not routinely provided.

Additionally, while a formal assessment has never been conducted and thus the numbers not known, anecdotally we know that there are limited rehabilitation services provided in the private sector.

Limited Assistive Technology. As noted above, many people in Ukraine rely on AT, such as mobility aids, wheelchairs, and self-care products, in order to optimize functioning and engage in everyday activities. However, the GOU has not yet addressed the significant gap between inpatient and post-discharge availability of AT. At the same time, through the MOH’s new Decrees from May and July 2023 or Orders,14 they are attempting to equip health facilities and AT cabinets with the necessary rehabilitation equipment and devices and reform the mechanism for obtaining appropriate assistive products for care within hospitals and clinics. This process is only at a nascent stage and is supported by a number of donors (WHO, Swiss Agency for

14 MOH Order #995 as of 05/31/23, “On Approval of the Equipment Table for In-Patient Departments and other Facilities Providing Rehab Care to adults in acute and post-acute period’; MOH Order #1462 as of 12/16/22, “Selected topics of organization of rehabilitation in the health sector”; MOH Order #1338 as of 7/21/23, “On the Procedure of AT cabinets Functioning”.

Development and Cooperation (SDC) and the World Bank (WB)). However, it is unclear at present how the mechanism will be fully operationalized and sustained.

As previously noted, the MOSP funds AT for persons who have received disability status certificates through MSECs. However, after receiving a disability status, there is a significant waiting period for an individual to receive an assistive product, like a wheelchair, that will be funded by the MOSP. For individuals receiving inpatient services, the multi-disciplinary team should ideally prescribe and provide the most appropriate AT prior to discharge. Instead, the MSEC unit provides a recommendation on AT to the MOSP that may not be sufficiently individualized to the user. This fragmented approach detracts from sustainable rehabilitation and AT services within the health system.. Additionally, not all persons that need an assistive product have a registered disability, so they are excluded from funding assistance for AT.

Ukraine has private sector AT supply and manufacturing capacity and staff with limited training to provide fittings, adjustments, and replacements. This sector needs to be explored to determine the most useful inputs to increase locally available AT products and services.

Other issues facing both the MOH and the MOSP, include AT forecasting, procurement, stock management, financing, and delivery. It is unclear to what degree costing and/or feasibility studies have been undertaken to ensure efficiency, effectiveness, and the optimization of resources. Additionally, little information is available on how private providers and non-profit service providers are procuring and providing AT devices.

3a. Participation and Inclusion Issues for Persons with Disabilities

Persons with disabilities in Ukraine face many challenges when seeking to participate and be included in society. Issues such as stigma and discrimination, institutionalization, lack of access to information, and poor or inaccessible infrastructure, transport and communication channels underlie this challenge. The war itself has brought on additional challenges for persons with disabilities, especially in evacuating and migrating to safer regions or another country, loss or damage of assistive products, and decreased access to health services, including rehabilitation services. Lastly, persons with disabilities historically had greater difficulty accessing education and economic opportunities and the war has exacerbated this situation.

Overall, access to rehabilitation and AT services for persons with disabilities has been negatively impacted, as services are being prioritized for persons injured due to the conflict. This lack of access can have a long-term impact on functioning, further decreasing a person's ability to participate in society and live independently. In their response to the USAID/Ukraine Request for Information issued on May 17, 2023, the International Organization for Migration also noted that social inclusion approaches constitute a large gap in the rehabilitation process and need to be mainstreamed.

Disabled persons organizations (DPOs) promote the rights of persons with disabilities and provide social support to people that may be marginalized. Persons with disabilities report that DPOs do not have organizational or advocacy capacity to significantly influence decision-makers or engage with government bodies. Additionally, it is reported that DPOs often have unique priorities and messages which, in turn, weaken the overall voice and messages. The National Assembly of Persons with Disabilities (NAPD) is an umbrella DPO that is strongly advocating for greater engagement with persons with disabilities. The NAPD is working to strengthen advocacy and organizational capacity and lobbying for greater recognition of the rights of persons with disabilities. The MOSP, in an effort to elevate the voices of persons with disabilities, provides the Social Protection Fund’s competitive grants of up to $13,000 for DPOs and organizations supporting persons with disabilities.

4. USAID Involvement in Physical Rehabilitation Sector Support

USAID has been supporting the physical rehabilitation sector in Ukraine since 2015, starting with the Training, Economic Empowerment, Assistive Technology and Medical Rehabilitation (TEAM) project. Utilizing $3 million from the Leahy War Victims Fund, the centrally-funded TEAM project provided support to five neurologic rehabilitation departments through specialized training of rehabilitation health professionals delivered by international experts, and increased access to AT, such as wheelchairs.

From 2019 through 2024, the Strengthening Rehabilitation Services in Health Systems (SRSHS), with approximately $8 million in funding, has been working to professionalize the physical therapy profession, contribute to development of policies, regulations and standards at the national level, and help operationalize these standards within hospital settings. Since the beginning of the war, SRSHS has adapted its focus to respond to the needs of the war and has been building the capacity of physical and occupational therapists on how to work with patients having acute burns and amputations. In addition, SRSHS is establishing eight AT cabinets15 in regional health facilities to increase patients’ access to critical AT products. SRSHS is also supporting the establishment of a Spinal Cord Injury Department at the Lviv Territorial Multidisciplinary Hospital, building the capacity of academic staff and clinical supervisors to implement a clinical placement program for Master’s-level physical therapy (PT) and occupational therapy (OT) students based on national regulatory documents and international guidelines, and increasing the capacity of P&O providers. SRSHS is also currently collaborating with a USAID/Bureau for Humanitarian Assistance-funded rehabilitation activity that is supporting 24 PHC facilities near the frontlines of the war.

In addition, USAID/Washington funds the WHO to strengthen MOH rehabilitation leadership and governance, as well as coordination and planning with other partners and stakeholders.

However, subsequent support is needed in this regard.

15 AT cabinet - is a structural unit within a health facility or rehabilitation department where selection, fitting and production of AT products is conducted, along with the training on how to use them.

5. Program Approach

The Rehab4U Activity’s underlying development hypothesis is that IF Ukraine meets the growing needs of the Ukrainian population for rehabilitation services from different levels of the health system, and IF rehabilitation services, including AT, are centered on people, THEN individuals will be able to optimize their functioning and accelerate their integration into their communities, live independently and contribute to the economic growth of the country.

This Activity will operate in a highly dynamic, unpredictable environment during the ongoing war that will require flexibility in both program planning and implementation. The Activity will need to address urgent, short-term needs, as well as long-range systems strengthening efforts.

Challenges and uncertainties include: lack of mobility and displacement of populations due to the ongoing war; uncertain state budget financing of rehabilitation services; the current focus of the MOH on emergency rehabilitation rather than on a systemic approach that could further change due to altering conditions; lack of internal and external coordination in the rehabilitation sector, and the ongoing health care reform, including rehabilitation sector reform. While targeting and tailoring interventions to achieve the objectives is critically important, the Activity should nevertheless be flexible enough to adapt to changing circumstances and varying priorities. Comprehensive contingency planning and flexibility to adjust annual work plans will help ensure an ability to respond as needed, and in a timely manner.

The Activity will be implemented at both national and sub-national (oblast, rayon, and community) levels, with an anticipated greater focus at the subnational level. Some interventions will have an impact on the national level including overall governance and coordination of the rehabilitation sector, developing national standards of care and guidelines, and ensuring sustainable financing of the sector. Other expected results will focus primarily on regional and community levels, especially as these are related to improving services for persons in the most vulnerable situations, such as internally displaced persons (IDPs), persons with disabilities, the elderly, veterans,16 children and youth, and civilian victims of war. Models that are piloted will be evaluated for results and potential for scalability.

The Implementing Partner will collaborate with USAID, the MOH, the MOSP, the Social Protection Fund of the MOSP, and the NHSU to determine the geographic targeting throughout the life of the Activity. The GOU’s evolving priorities and needs related to implementation of rehabilitation reform and provision of rehabilitation services, availability of state funding, and the willingness of regions to cooperate and support changes in the rehabilitation sector would be considered as the major criteria for selection of regions and communities.

16 Please note that USAID is not able to work directly with the Ministry of Defense. Veterans are defined as those fully discharged from military service, who are receiving services from public health facilities.

To strengthen the national and regional leadership, the governance and capacity in the rehabilitation sector, as well as the quality of rehabilitation services, the Activity will facilitate engagement with a diverse array of partners in the regions such as public and private health facilities, new and emerging local non-governmental organizations (NGOs), the National Assembly of People with Disabilities, WHO, and universities. As an integral component of promoting inclusion and participation of persons with disabilities, the Activity is expected to strengthen the capacity and engagement of DPOs and local civil society organizations (CSOs), including through provision of sub-grants that result in increased capacity of partners to support persons with disabilities in Ukraine.

The Activity will also collaborate with local and international private sector companies, ensuring these companies have an opportunity to provide expertise and resources related to their core business in the rehabilitation sector. Examples of collaboration with the private sector could include, but are not limited to: negotiating discounts for assistive products such as prostheses and orthotics; providing financial support for information campaigns regarding availability of rehabilitation services and AT; and supporting relevant training and capacity building of rehabilitation professionals. Additional potential avenues for collaboration include direct investment from international companies and engagement with other USAID projects that support the increase of manufacturing within Ukraine, that could target companies that produce AT, prostheses and orthotics.

6. Activity’s Goal, Objectives and Expected Results

The Goal of the Rehab4U Activity is to create sustainable and fully integrated rehabilitation services within the health system, that enable people to optimize their function, fully integrate in society and participate in the economic recovery and growth of the country. The target audience will include the general population of Ukraine with rehabilitation needs, persons with disabilities, injured civilians (adults and children), victims of Russian captivity, veterans,17 the rehabilitation workforce, training institutions for rehabilitation specialists, national and regional GOU entities, and DPOs.

To achieve this goal, this physical rehabilitation Activity will have the following three objectives:

Objective 1: Strengthen national, regional and local leadership, management and governance capacity related to the physical rehabilitation sector;

Objective 2: Increase access to and availability of affordable, quality sustainable physical rehabilitation services, inclusive of assistive technology; and

17 Please note that USAID is not able to work directly with the Ministry of Defense. Veterans are defined as those fully discharged from military service, who are receiving services from public health facilities.

Objective 3: Promote inclusion and participation of persons with disabilities and civilian victims of war within their families, communities and in economic recovery of the country.

Under Objective 1 ”Strengthen national, regional and local leadership, management and governance capacity related to the physical rehabilitation sector,” the Activity will collaborate with the MOH, the MOSP, the Office of the President and WHO to improve interministerial coordination for the implementation of existing rehabilitation sector policies and laws, and potentially develop new policies, strategies, regulations and legislative acts as needed. In addition, the Activity will focus on strengthening the capacity of relevant ministries and oblast authorities to lead, manage and advance the rehabilitation sector, including financing for rehabilitation and AT services and products. The Activity will also contribute to improving coordination among all stakeholders involved in the emergency response to rehabilitation sector needs, as well as to a longer term sustainable rehabilitation system collaboration.

The expected results could include, but are not limited to:

National multisectoral physical rehabilitation strategy finalized with WHO and implementation initiated

Interministerial coordination structure established and functioning Backlog of persons awaiting disability certification reduced Increased capacity of the national and regional leadership to manage and advance rehabilitation services Standards of quality and national guidelines based on patient outcomes developed New regulations governing rehabilitation services outside health facilities available Costing of rehabilitation, AT and associated services completed for consideration in the

NHSU finance packages Local authorities contribute financial resources for rehabilitation services Regional physical rehabilitation action plans developed and implemented.

Under Objective 2 “Increase access to and availability of affordable, quality and sustainable physical rehabilitation services, inclusive of assistive technology” the Activity will promote rehabilitation workforce development to contribute to economic recovery and growth of the country and will also invest in preparing a new generation of the rehabilitation workforce. It will work in partnership with relevant rehabilitation and health facilities, universities and training institutions, relevant line Ministries, and professional associations, as appropriate, to train a new generation of rehabilitation professionals and increase access to and availability of affordable, accessible, quality and sustainable physical rehabilitation services across the health system, including the PHC level. Affordable and accessible rehabilitation services’ and AT technologies’ availability close to where people live is the Universal Health Coverage principle that needs to be practically implemented in Ukraine at the national, regional, and local levels. The Activity will also create greater linkages to evidence-based, multidisciplinary rehabilitation services for the population, in accordance with international standards and will strengthen skills of physical rehabilitation professionals including P&O providers. Additionally, this Activity will address barriers to the availability of rehabilitation services by developing and piloting a PHC-level model of services, including obtaining appropriate and affordable AT, and will encourage local governments to invest more resources in rehabilitation, including at PHC level.

The expected results could include, but are not limited to:

PHC model of care developed and piloted in selected regions Task-shifting models implemented where feasible Number of physical rehabilitation personnel demonstrating improved knowledge and clinical skills in accordance with international standards increased Relevant rehabilitation protocols and standard operating procedures developed in accordance with Ukrainian legislation Physical rehabilitation recipients demonstrate improved functioning Functioning referral pathway developed and utilized Adults and children that receive person-centered physical rehabilitation services demonstrate satisfaction with the services Standard physical rehabilitation curricula are developed and implemented at selected educational institutions at undergraduate and postgraduate levels P&O education is aligned with international standards Professional associations are created and strengthened Functioning integrated AT services, from procurement to provision, meet international standards Number of facilities with accessible physical rehabilitation services function in accordance with international standards.

Under Objective 3: “Promote inclusion and participation of persons with disabilities and civilian victims of war within their families, communities and in economic recovery of the country”, the Activity will collaborate with the Ministries of Health and Social Policy to strengthen the understanding of physical rehabilitation services among the population to decrease stigmatization; provide opportunities for greater inclusion and participation of all citizens, including people with disabilities, to fully integrate in society, and contribute to economic recovery; and increase access to rehabilitation services at various levels within the health system along with improved accessibility. Activities should also strengthen capacity and increase the visibility of the National Assembly of People with Disabilities, DPOs and other NGOs and CSOs that support persons with disabilities.

The expected results could include, but are not limited to:

Persons with disabilities participate in the national and local policy making process Persons with disabilities participate in economic recovery of the country Capacity of Local NGOs/CSOs/DPOs working in rehabilitation sector strengthened

Communities are able to access and are satisfied with rehabilitation services and resources

Local communities demonstrate reduced stigma towards persons with disabilities.

7. Alignment with U.S. Government (USG) Strategies

The Rehab4U Activity is aligned with the following three USG strategies.

1. The USAID/Ukraine Mission Country Development Cooperation Strategy (CDCS). The CDCS link is here. The new Rehab4U Activity is aligned with the USAID/Ukraine Mission Country Development Cooperation Strategy’s Development Objective 2: Impact of Russia’s aggression mitigated and Intermediate Result 2.1: Conditions improved for reintegration.

The Activity will help strengthen the provision of rehabilitation care that is essential for Ukrainians who have been injured or experienced an illness that affects their ability to live independently, work, or engage in their communities. Successful rehabilitation outcomes will improve social cohesion, contribute to economic recovery, reduce isolation of individuals, improve their mental health and demonstrate the care that the Government of Ukraine is providing its citizens.

2. U.S. Department of State Europe, Eurasia and Central Asia (EUR/ACE) Ukraine Assistance

Strategy.18 The Rehab4U Activity is expected to be aligned with and incorporate the principles of the EUR/ACE Strategy once published.

3. US Embassy/ Ukraine Integrated Country Strategy (ICS). ICS link The Ukraine ICS emphasizes implementing international best practices while rebuilding social and health services (Objective 2.3).

8. Linkage to GOU Plans and Strategies and Leveraging Other Resources

8.a. Linkage to GOU Plans and Strategies

The Rehab4U Activity is aligned with the 2022-2032 Ukrainian Health Care System Post-War Recovery Plan’s Priority 4: Strengthening health care services to meet specific war-related needs of the population, including IDPs and veterans. Priority 4 specifically notes the need to develop rehabilitation services and to improve the benefit packages of the Program of Medical Guarantees to address the needs of war veterans and survivors of the hostilities.

Ukraine’s National Recovery Plan of July 2022 lists 15 priority programs. Program 13: Upgrade Health Care System, states the intention to advance universal health coverage and financing reform, develop an efficient health care network, establish digital health, and conduct targeted intervention campaigns.

18 The Eur/ACE Ukraine Assistance Strategy is not yet available as a public document.

A draft 2030 Health Care System Development Strategy has recently been submitted to the Cabinet of Ministers for review and approval, having received extensive comment from stakeholders.

8.b. Leveraging Other Resources

The Rehab4U Activity will cooperate with and enhance efforts of other internationally-funded rehabilitation projects, including those of the World Bank, the Swiss Agency for Development and Cooperation, the Estonian Development Cooperation, and UKMed, as well as a new activity funded by the European Union which is yet to be defined.

The World Bank’s HEAL project, with estimated financing of $500 million, has four components including: 1) addressing new and urgent health needs for mental health and rehabilitation; 2) further improving and strengthening PHC; 3) modernizing and increasing efficiency of hospital care; and 4) supporting capacity building, digitalization and innovation. The first two components are relevant to USAID’s new physical rehabilitation Activity. The first component, pertaining to mental health and rehabilitation, will provide funding for inputs such as the development of clinical protocols, training, equipment, and deployment of facility-based services and mobile teams, using performance-based conditions (PBCs) to ensure delivery of quality services to people.