1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health better systems, better health Ukraine Health System Assessment 2011 Lisa Tarantino Senior Associate, Abt Associates, Inc. April 25, 2012

2. 2 HSA Ukraine Objectives To assess the Ukrainian health system with a particular focus on HIV, TB and family planning (FP) Develop recommendations to help inform GOU and USAIDs integrated health strategy MAP OF UKRAINE

3. 3 Key Findings

4. Health Financing Relatively high level of total spending on health (7% of GDP) Low reliance on donor funding (mainly for HIV/AIDS, TB and FP) Economic crisis results in less funding for health Health financing system and budgeting norms need overhauling Budgetary norms create perverse incentives, inefficiencies and health services not aligned to needs High out-of-pocket costs for care Insufficient spending to address HIV/AIDS 4

5. 5 Service Delivery & Human Resources High chronic disease burden & resulting high mortality rates = mortality crisis. HIV/AIDS services are scaled up; NGO prevention, support efforts are valuable High levels of HIV & TB are high cost & divert resources from other programs. TB problems in penitentiary system & increases in MDR TB. Public health system needs strengthening (low rates of immunization, insufficient efforts to change unhealthy behaviors). Shortages of some cadres System doesnt motivate workers to provide quality services 5 LIFE EXPECTANCY TRENDS, 1990–2009

6. 6 Service Delivery: Levels, access points, and referral system 6

7. Governance and Leadership Government engaging in significant health care reform - high level of commitment was evident Laws governing HIV/AIDS, FP and new TB law reflect international best practices Donor language supports system strengthening (WHO, Global Fund, PEPFAR 2, Partnership Framework) Lessons from the Eastern European region abound One of few countries in region that hasnt reformed health sector since independence! Authority inhibited by: budgeting norms; financing flows; system of informal payments 7

8. Health Information Systems Established process of health data collection, reporting, and analysis Complete set of well-functioning components of the health information system Census outdated, population registers not accurate National Health Accounts (NHA) not updated Incentives to report inaccurate data at facility level Low level of information technology resources 8

9. 9 Essential Finding: Reform is Needed! …What is the Cost of NOT Reforming? WB estimates that reducing hospital beds and other inputs to EU levels would save $400 - $600 million per annum Current health outcomes not in line with income level Male Adult Mortality Rate and GNP per Capita, Ukraine and Selected Countries GNP per capita Male Adult Mortality Rates Togo 770 371 Haiti 1070 329 Ghana 1240 350 Ukraine 6110 384 Source: World Health Survey, in WB ECA January 2010

10. 10 Health System Strengthening Suggestions for Ukraine

11. 11 Political leadership is the key ingredient Consider creation of Health Reform Teams At national, oblast and rayon level (multi-sectoral) to guide process (include government, MOH, provider groups, NGOs, patient groups) Communication of health reform and tracking of results will be important

12. 12 Health Finance Reform is Essential Reduce fragmented pooling of funds Move to population/service-based budgeting : Per capita (primary) Case based (secondary and tertiary) Global (special programs such as HIV and TB) Health managers need greater autonomy to meet service needs (control of budget spending) Consider changing the status of health facilities

13. Invest in System Strengthening Take steps towards the goal of reorienting the health care system from inpatient / specialist model to primary health care focused model Reorient resources, including financial, capital and human Institutionalize improved pre-service training and retraining programs for family doctors (including the topic areas of HIV, TB, and FP) Institutionalize strategic planning process for HRH development Improve the capacity of HC managers to use info/data for planning and policy making 13

14. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health better systems, better health Reports related to this presentation are available at www.healthsystems2020.org Thank you! For more information contact: Lisa Tarantino, Ukraine HSA Team Leader Lisa_Tarantino@abtassoc.com