YEAR 1 WORK-PLAN HIV REFORM IN ACTION COOPERATIVE AGREEMENYEART- HEALTH 1 SYSTEMS WORK STRENGTHENING-PLAN FOR A SUSTAINABLE HIV / AIDS RESPONSE IN UKRAINE (HSS SHARE)

ANNUAL REPORT October 1, 2016 – September 30, 2017

AWARD NUMBER: AID-121-A-13-00007 DELOITTE CONSULTING, LLP

This report is made possible due to the funding provided by the U.S. President’s Emergency Plan for AIDS Relief through the United States Agency for International Development (USAID) under the terms of the HIV Reform in Action project, award number AID-121-A-13-00007. The content of this report is the sole responsibility of Deloitte Consulting LLP and its implementing partners and does not necessarily reflect the opinion of PEPFAR, USAID, or the United States Government.

Contents LIST OF ACRONYMS ...... 4 GENERAL PROJECT INFORMATION...... 7 CURRENT AND CUMULATIVE PROGRESS ...... ERROR! BOOKMARK NOT DEFINED. EXECUTIVE SUMMARY ...... 8 Objective 1: Enhance national leadership and capacity for evidence-based and gender-sensitive HIV policy programming and implementation ...... 8 Objective 2: Improve and optimize resource allocation and financing for the national and selected regional HIV/AIDS programs targeting key populations ...... 9 Objective 3: Optimize and strengthen human resources for health (HRH) for the delivery and scale-up of gender-sensitive HIV/AIDS services targeting key populations ...... 9 Regional pilots ...... 10 Cross-cutting activities ...... 10 Health Reform Component ...... 10 Highlights and Challenges ...... 11 OVERALL PROJECT PERFORMANCE ...... 15 SECTION 1. HIV REFORM SUPPORT ...... 15 Objective 1: Enhance national leadership and capacity for evidence-based and gender-sensitive HIV policy programming and implementation ...... 15 Sub-objective 1.1: Support national government institutions in AIDS policy development, programming, and implementation ...... 15 Sub-objective 1.2: Strengthen capacity of local government entities to implement regional AIDS programs with emphasis on key affected populations ...... 16 Sub-objective 1.3: Advocacy for improved policy dialogue and to ensure a transparent policy development environment ...... 17 Objective 2: Improve and optimize resource allocation and financing for the national and selected regional HIV/AIDS programs targeting key populations ...... 18 Sub-objective 2.1: Develop evidence pool to create support for funding decisions in HIV response at the national and regional level ...... 18 Sub-objective 2.2: Support the development of HIV strategies and policies at the national and regional level which reflect optimized resource allocation and lead to the most cost-efficient and effective ...... 19 Sub-objective 2.3: Strengthen capacity of national and regional partners in finance planning, budget preparation and execution to match the needs to optimized HIV/AIDS service-delivery operations .. 20 Objective 3: Optimize and strengthen human resources for health (HRH) for the delivery and scale-up of gender-sensitive HIV/AIDS services targeting key populations ...... 21 Sub-objective 3.1: Strengthen evidence base data for HIV workforce planning and development ...... 21 Sub-objective 3.2: Support the introduction of systemic and operational changes in HRH for the provision of sustainable and integrated HIV/AIDS services at the national and regional levels ...... 22 Sub-objective 3.3: Strengthen capacity of Ukrainian institutions in HRH policy development and implementation ...... 22 4. Regional Pilots. Building a sustainable model for the provision of critical services to key populations and people living with HIV at the local level ...... 23 Cross-cutting activities ...... 35 Gender Equality/Women’s Empowerment issues ...... 35 Institutionalization and Grants Management ...... 35 Capacity Building ...... 39 Gender and Stigma Sensitization ...... 41 Communication and Knowledge Management ...... 41 SECTION 2. HEALTH SYSTEM FINANCING REFORM SUPPORT ...... 43 Objective 2: Improve and optimize resource allocation and financing for the national and selected regional HIV/AIDS programs targeting key populations ...... 43 Sub-objective 2.4: Build the capacity of the national and selected regional/local GoU entities to design and establish a national purchasing agency ...... 43

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Sub-objective 2.5: Support the MOH and relevant Parliamentary Committees to define and develop a basic benefits package of service, in consultation with civil society and patient organizations ...... 44 Sub-objective 2.6: Support MOH and selected local authorities in the design and establishment of a performance-based payment system under ‘money-follows-the client’ approach ...... 44 Sub-objective 2.7: Support the National Purchasing Agency and MOH in developing and implementing effective IT solutions to launch, manage and administer health system financing reforms ...... 46 Cross cutting: Strategic Communication and Knowledge Management ...... 47 PROJECT MANAGEMENT ISSUES ...... 49 RELEVANT INDICATORS FOR REPORTING PERIOD ...... 50 $6,371.21 TO PREVENTION, PROMOTION OF TESTING AND LINKAGE TO CARE PROGRAMMES FOR PRISONERS ...... 52 EVALUATION OF ACTIVITY WITH RESPECT TO ENVIRONMENTAL IMPACT ...... 62 PROJECT ACTIVITY MONITORING MATRIX ...... 63 Section 1. HIV REFORM support ...... 63 Section 2. HEALTH SYSTEM FINANCING REFORM SUPPORT Under Objective 2...... 88

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LIST OF ACRONYMS Acronym Description AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy ARV Antiretroviral (drug) BBP Basic benefit package BCC Behavior Change Communication CB Capacity building CCEC City Council Executive Committee CDC US Centers for Diseases Control CDH Central District Hospital CEAs Central Executive Agencies CME Continuous Medical Education CMH Central Municipal Hospital CMU Cabinet of Ministers of Ukraine CSO Civil Society Organization CSSFCY Center of Social Services for Family, Children and Youth COP Chief of Party DCOP Deputy Chief of Party DOT Directly observed treatment DNA Deoxyribonucleic acid DRG Diagnostic Related Groups ECOM Eurasian Coalition on Male Health ECOU The international charitable organization “East Europe and Central Asia Union of PLWH” FTCI Fast-Track Cities Initiative FSW Female Sex Workers GAM Global AIDS Monitoring GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit GF or GFATM Global Fund / Global Fund to Fight AIDS, Tuberculosis and Malaria GoU Government of Ukraine GP/FM General Practitioner/Family Medicine HC Health Care HCF Health Care Facilities HCT HIV Counselling and Test HIV Human Immunodeficiency Virus HIVRiA HIV reform in Action HR Human Resources

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HRH Human Resources for Health HRIS Human Resource Information System HSS-SHARe Health System Strengthening for a Sustainable HIV/AIDS Response I-CAP International Center for AIDS Care and Treatment IDP Internally Displaced Persons IT Information Technology I-TECH University of Washington International Training and Education Center for Health IWG Inter-sectoral Working Group KP Key Population KCSA Kyiv City State Administration KH Knowledge Hub KM Knowledge Management KPI Key performance indicator KSE Kyiv School of Economics LEA Legal Environment Assessment LGBT Lesbian, gay, bisexual, and transgender MARPs Most-At-Risk Populations MAT Medication-assisted treatment METIDA CDC-funded Project “M&E-related Technical Assistance and Improved Data application in HIV” MOET Ministry of Economic Development and Trade MOF Ministry of Finance MOH Ministry of Health MOU Memorandum of Understanding MSM Men who Have Sex with Men MSP Ministry of Social Policy MVP Minimal Viable Product M&E Monitoring and Evaluation NAP National AIDS Program NAPA National Academy of Public Administration under President of Ukraine NASA National AIDS Spending Assessment NGO Non-Governmental Organization NMEWG National M&E Working Group NMU National Medical University NPHC National Public Health Center OSA Oblast State Administration OST Opioid Substitution Therapy PBF Performance-based financing PEPFAR President's Emergency Plan for AIDS Relief

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PIP Performance Improvement Plans PH Public Health PHC Primary Healthcare PHCC Primary Healthcare center PLHIV or People Living with HIV/AIDS PLWH PM Project Management PMEP Performance Monitoring and Evaluation Plan PPP Private Public Partnership PWID People Who Inject Drugs RAP Regional AIDS Program RCC Regional TB and HIV Coordination Council RESPECT USAID Project “Reducing HIV-related Stigma and Discrimination for Most-at-Risk Populations in Health Care Facilities in Ukraine” RESPOND USAID Project “Improving HIV/AIDS Services for Key Populations in Ukraine” RFA Request for Applications RSA or DSA Rayon State Administration or District State Administration SOE State Owned Enterprise SOW Scope of Work SPH School of Public Health STI Sexually transmitted infection STTA Short-Term Technical Assistance SWOT Strengths, weaknesses, opportunities, and threats TA Technical Assistance TB Tuberculosis Test and WHO guided treat-all approach recommending ART for everyone living with HIV at START any CD4 cell count. START - Strategic Timing of Antiretroviral Treatment TI-Ukraine Transparency International Ukraine TOR Terms of Reference TWG Technical Working Group UTCFM Ukrainian Training Centre of Family Medicine UCSF University of California, San Francisco UNAIDS Joint United Nations Program on HIV/AIDS UNDP United Nations Development Programme USAID United States Agency for International Development USG United States Government WB World Bank WHO World Health Organization

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GENERAL PROJECT INFORMATION

Country: Ukraine Project: HIV Reform in Action

Regions/oblasts: Cherkasy, Dnipropetrovsk, Short name: HIVRiA Kherson, Mykolaiv, Odesa, CoAg number: AID-121-A-13-00007 Poltava regions and Kyiv city Implementer: Deloitte Consulting LLP Agreement Officer Start Date: October 1, 2013 Representative (AOR) Paola Pavlenko End Date: September 30, 2018

Alternate AOR Alina Yurova Latest modification Mod 7 signed September 19, 2017 Date of Report October 30th, 2017 # and date: Submission: Period covered by the October 1, 2016 – September 30, report: 2017

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Executive Summary

The HIV Reform in Action (HIVRiA) project made significant progress in Project Year 4 towards achieving the overall project outcomes. The project continued to implement HIV and public health system activities and began a wide range of technical interventions to support Ukraine’s health reform.

Objective 1: Enhance national leadership and capacity for evidence-based and gender-sensitive HIV policy programming and implementation Under Objective 1, the project continued to support national institutions in policy development and programming, focusing on the National Public Health Center as a leader in the HIV response. The HIVRiA team provided support to the Ministry of Health (MOH) in the area of public health system reform. The project played one of the leading roles in the public health working group, helped to finalize the Public Health Concept, and developed the roadmap for the public health system reform in collaboration with CDC, EU Commission, WHO, and other partners. As a direct result of the project’s efforts, the Government of Ukraine (GOU) approved the Public Health System Development Concept for Ukraine along with the implementation plan that defines the approach and key stakeholders in development of the public health system. The project participated in the development of the comprehensive HIV management guidelines to adapt policies aligned with the WHO Test&START strategy and other evidence-based protocols. HIVRiA also expanded efforts to advocate for increased HIV funding allocations for local HIV response and for implementation of the HIV/TB Sustainability Strategy and START guidelines. Further, HIVRiA developed and presented the HIV Legal Environment Assessment (LEA) report to key national stakeholders. The report provides clear and actionable recommendations on improvements needed to policies, laws and regulations to improve HIV response outcomes. In Y4, the project also conducted a review and presented ART co-payment options and international best practices in this area. The HIVRiA Project supported the Kyiv City State Administration (KCSA) with planning and implementation of the UNAIDS 90-90-90 Fast-Track Cities Initiative (FTCI) and provided technical advice in developing the Kyiv City AIDS program. Kyiv adopted the program and funded it in the amount of 283M UAH, which are crucial steps to achieving Fast Track targets. HIVRiA also provided technical assistance to KCSA in establishing regional Public Health (PH) center, including the situational analysis, legal framework assessment, and developing a charter for the Kyiv PH center. The HIVRiA Project initiated the development of the MOH-MSP joint order to approve procedures around social services and care to families and individuals affected by HIV/AIDS and TB. HIVRiA team supported an order that streamlines procedures and increases local government authority to manage community-based TB/HIV social services, so that solutions can be tailored to and better meet local needs. The project participated in the working groups and provided technical assistance in developing health systems and financing components of Ukraine’s GF application in May 2017. HIVRiA engaged the All-Ukrainian Network of People Living with HIV (PLWH) via a grant mechanism, to conduct advocacy activities in support of AIDS programming and funding allocations for HIV. Under this grant, PLWH completed an analysis on the status of AIDS programs’ implementation in the regions. The HIVRiA team took lead in organizing meetings with representatives from the GOU, MOH, Ministry of Finance (MOF), Ministry of Economy and Trade (MOET), National Public Health Center (NPHC), donors, and other key national and international organizations with the aim of advocating for increased funding for HIV programs, including extended national ART funding and initiating funding for MAT. As a result, for the first time in Ukraine, funding for the MAT program was allocated from the state budget. The 2017 state budget allocated 13 million UAH to the MAT program which will provide therapy for an additional 8,000 people.

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Objective 2: Improve and optimize resource allocation and financing for the national and selected regional HIV/AIDS programs targeting key populations In project Year 4, HIVRiA team made impact in improving costing methodologies to facilitate data driven and transparent approaches to budgeting and funding of healthcare in Ukraine. The team developed several tools and guidelines to facilitate wide-spread use of these costing methodologies at the national and regional level. The HIVRiA team focused on finalizing the Investment Case Phase II Study (IC) which evaluates cost effective service design. The team led efforts to translate study findings into improved HIV/AIDS policies and planning frameworks for national and regional HIV programs. The project completed the data analysis, modelling, and discussed results with national experts. The draft report includes an analysis of the optimal mix of services based on cost-effectiveness to achieve UN 90-90-90 goals. As part of this activity, the project also finalized and published a study on the perceived quality of HIV care across different HIV service providers in three regions of Ukraine and contributed to the analysis of linkages between quality and costs of HIV services. Additionally, HIVRiA conducted a financial gap analysis and provided unit cost estimations, obtained through IC Phase II study, for program budgeting for Ukraine’s GF application. HIVRiA completed a cost-effectiveness analysis of the use of Rapid HIV Tests that MOH will use to optimize provision of tests and budgeting. The team’s analysis fills a critical information gap by quantifying the cost of identifying one HIV positive case. The team then developed a policy paper to summarize the findings and recommendations for the MOH for standardizing regulations for Rapid HIV Testing. Ultimately, these studies will allow GOU policy-makers to make evidence-based decisions in achieving 90-90-90 targets in a cost-effective matter. Continuing to progress on Rapid Tests and to support development of HIV strategies and policies, HIVRiA developed an electronic tool to forecast regional programmatic and financial needs for Rapid HIV Tests and trained regional stakeholders to facilitate tool roll-out and adoption. This tool supports the regional level in projecting financial needs to purchase Rapid HIV Tests based on their regional epidemiologic situation and incorporates strategic 90-90-90 targets for an optimal HIV response in a specific region. The tool further enhances transparency and accountability in decision making and program planning at the regional level. The Project also further refined the National AIDS Spending Assessment (NASA) tool, which is an online tool to support national and regional administrations monitor HIV spending. The team provided guidelines for reporting HIV expenditures and hosted trainings to institutionalize NASA tool use with the National Public Health Center and regions. HIVRiA supported cost estimations for implementing Test&START for 2018-2020 in Ukraine and held stakeholder consultations to determine the priority factors and parameters for this analysis. HIVRiA team developed a performance-based financing (PBF) framework for primary health care, selected five priority healthcare areas, defined key performance indicators, and created a database from national and international data sources. The team hosted presentations with national and regional leaders on the indicators and international PBF approaches in five countries. The HIVRiA team held a two-day workshop in collaboration with Harvard University to strengthen the capacity of Kyiv City authorities and primary health care center to manage decentralized HIV budgets and funding. Finally, HIVRiA supported institutionalization of the short-term Health Systems Reforms and Sustainable Financing course developed in collaboration with the Harvard School of Public Health, within the Ukrainian post-graduate curriculum at the National Academy of Public Administration and Kyiv School of Economics. The course utilized modern education methods such as case studies, group work, and discussion, and was well-received and praised by faculty and participants.

Objective 3: Optimize and strengthen human resources for health (HRH) for the delivery and scale-up of gender-sensitive HIV/AIDS services targeting key populations The HIVRiA team developed the human resources for health (HRH) model that estimates personnel requirements to achieve the 90-90-90 targets for Test&START. The team conducted a data analysis within three oblasts to calculate the Test&START HRH requirements and identified gaps. The project also conducted a training for national and regional specialists on estimating workforce demand for the Test&START approach implementation.

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Additionally, the HIVRiA team organized three regional stakeholder meetings to identify key priority areas for addressing the projected HRH needs, review recommendations for HRH planning based on 90-90-90 programmatic targets, and elaborate HRH rationalization options. The outcomes will inform both immediate regional actions and the development of the national and regional AIDS programs. Further, the HIVRiA team assisted the NPHC in establishing a formal HRH for HIV Intersectoral Working Group aiming to support the implementation of the National HRH Strategy and to strengthen the platforms for national HRH dialogue and leadership. The HIVRiA team also worked with the e-Health partners to develop a Human Resources Information System (HRIS) workforce registry. Finally, the project worked to improve public health education within Ukrainian universities. O.O. Bohomolets National Medical University (NMU), in partnership with the National Public Health Center and Ukrainian Training Center for Family Medicine (UTCFM) and University of San Francisco California (UCSF) developed and conducted a pilot foundational training course on "Modern Aspects of Public Health". As a result, two rounds of trainings were conducted and 57 participants received certificates upon successful completion of the course and are now equipped with modern approaches and tools to utilize public health approaches in Ukraine. The project continued working with the National Medical University, UTCFM, and NPHC on integration of the course within standard university curriculum and build the capacity of existing university faculty in training of the healthcare workforce.

Regional pilots During Years 3 and 4, local pilot projects titled “‘Building a sustainable model for the provision of critical services to key populations and people living with HIV at the local level”’ (Pilot) have been implemented in 15 selected geographical locations in seven high-burden regions. The pilots at the local level helped to achieve a significant increase in the sustainability of HIV services through local government strengthening, elimination of policy barriers in services provision, first time allocation of local funding for HIV services, mobilization of local financial resources, decentralization of HIV testing services (involvement of PHC in testing), provision of ART (opening of new ART sites), opening of new MAT sites, promotion of the provision of MAT upon prescription and piloting of the MAT co- payment model, introduction of social order, training of local change agents and service providers. Optimization and scale-up of HIV services through modifications of local policies and training staff enhances the sustainability of pilots after their completion. Cooperation at the oblast level was established to help to roll out some of the pilot best practices throughout entire oblasts.

Cross-cutting activities In Y4, the Project continued to implement multi-faceted cross-cutting activities to support national and regional level interventions. Capacity building support provided collaborative exercises and workshops, targeted trainings and ongoing organizational assessments for counterparts at the national and regional levels. During Year 4, capacity building activities concentrated mainly on non- governmental actors – both pilot-implementing actors in the regions and selected NGO grantees. HIVRiA’s support included interventions to improve operational and project planning, development of middle and top-level managers’ capacity, and fundraising opportunities. HIVRiA’s support led to organizational improvements, particularly in strategy/vision, human resources, time management, and overall planning in these organizations. Additionally, HIVRiA targeted capacity building interventions and trainings for change agents, during Year 4. In May 2017, the project organized a study tour to the US. The tour resulted in strengthened capacity of national and Kyiv City policy makers to support public health system reforms, design public health services that respond to priority needs, and determine how to fund these services through national and regional governments. Health Reform Component HIVRiA Project also led the implementation of health reform activities in Year 4, after its Scope of Work (SOW) modification in February 2017. HIVRiA has been supporting the GOU across a range of health reform activities that include: the establishment of the National Health Service and capacity building; review of the basic benefit package; development of the primary care capitation methodology; support of primary healthcare autonomy; hospital district strategic planning; e-Health system development; and strategic communications.

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In support of MOH efforts to establish a national purchasing agency, HIVRiA brought health financing and health insurance experts to provide recommendations for establishing the National Health Service and to draft the health insurance law. The HIVRiA Project mobilized the team of legal specialists to support the MOH in legal issues crucial to implementing the reform. Additionally, HIVRiA provided legal support to review and incorporate international best practices into the legislative documentation of the relevant executive bodies as part of the model for defining the National List of Essential Medicines review. HIVRiA team provided recommendations to the WHO Ukraine office for the provisional list of services developed as part of the PHC basic benefit package. To conduct capitation rate development, the Project awarded a grant to the Kyiv School of Economics for data collection and aggregation. HIVRiA developed utilization and cost data-collection tools and a preliminary capitation rate for 2018 was calculated based on demographics, utilization, budget and cost data from 10 regions and 100 primary health care facilities. The capitation rate and HIVRIA analysis is scheduled to be presented to the MOH in early Y5Q1. HIVRiA also selected Balta and Tsarychanka hromadas for targeted technical assistance in primary health care management to support primary healthcare facilities in becoming community owned not- for-profit enterprises and improve operational and financial management. The project developed detailed roadmaps for each PHC center to become autonomous organization. The roadmaps and process will establish the framework for a wider set of PHC facilities to become autonomous not-for- profit organizations. HIVRiA also initiated support for hospital district strategic planning to support regional administrations and hospital councils develop strategic plans. The project developed strategic planning tools and a methodology based on international best practices and facilitated sessions with two hospital districts to vet the methodology within Ukraine’s context. HIVRiA supports the MOH to develop innovative IT solutions capable of supporting capitation and reimbursement processes. HIVRiA team supported the eHealth Project Office of the MOH in areas of project management, methodology, and quality review. The Project established an effective eHealth team including Project staff and STTA experts from Deloitte US and Deloitte Ukraine, which resulted in the successful development of the minimum viable product (MVP). The current pilot of eHealth MVP solution can fully support the capitation process with required reporting and integration with external medical information systems. The project also assisted the MOH and facilitated the launch of thematic groups on key health reform components and helped organize proper planning and reporting processes. This resulted in developing roadmaps and close monitoring task implementation, identifying risks and issues, and early response. Finally, the HIVRiA project focused on assisting MOH in strategic communications for health reform efforts. The project launched several activities, including health reform communications, capacity development of MOH communication department, technical assistance in website content management, and development of the MOH Brand Identify Concept. Highlights and Challenges

Year 4 Highlights National public health system reform and approval of the Concept for Public Health System Development With considerable support from the HIVRiA Project, the GOU approved the Concept for Public Health System Development in November 2016. The Concept defines the roles, objectives, timeline and mechanisms of public health system development. The implementation of the Concept will give impetus to the development of the public health system in Ukraine. Also, the HIVRiA Project provided assistance in preparing a medium-term plan of priority actions of the Government for 2017-2020 for the "Development of the public health system" objectives. The Strategy for a sustainable response to TB, including drug-resistant TB, and HIV/AIDS for the period until 2020 HIVRiA team provided technical assistance to the Ministry of Health in developing the Strategy and implementation plan for a sustainable response to TB, including drug-resistant TB, and HIV/AIDS for

11 the period through 2020. The Project served as a technical secretariat for the Strategy development process, which included facilitation of the working group meetings and coordination with key stakeholders, including MOH, UCDC, USAID, the Global Fund, UNAIDS, other government agencies and non-governmental organizations. As a result, the Strategy and the implementation plan were approved by Ukraine’s Country Coordination Council for HIV and TB (CCM). With the endorsement of the Cabinet of Ministers, the strategy will serve as the country’s main document for formulating new national and regional AIDS programs and informs international assistance decisions. Kyiv City HIV Program for 2017-2021 and Fast-Track Cities Initiative implementation The HIVRiA Project supported KCSA in the planning and implementation of the UNAIDS 90-90-90 Fast-Track Cities Initiative (FTCI). On December 8, 2016, the Kyiv City Council approved the Kyiv City HIV Program for 2017-2021 and allocated an unprecedented budget of 238 million UAH for program implementation. Adoption of the program is a crucial step to implement Fast Track targets. The allocation of these resources will result in increased coverage of HIV testing, antiretroviral treatment (ART), medication-assisted therapy (MAT), and enrollment in care of people living with HIV. To support the implementation of FTCI, the HIVRiA Project expanded its regional Pilots to 5 districts in Kyiv. Building a sustainable model for the provision of critical services to key populations and people living with HIV at the local level’ (Pilot) The focus of the regional pilots is to build a sustainable model for the provision of critical services to key populations and people living with HIV at the rayon (city) level in each of the 7 targeted oblasts. As a result of the pilots the total budget for HIV response in pilot areas increased from USD 225,000 to 1.96 million contributing to sustainability of HIV services at the local level. The pilots also resulted in elimination local policy barriers in services provision. The pilots targeted expansion of HIV testing services to PHC sites through training of over 1100 PHC providers in PHC testing, advocating for procurement of HIV rapid tests from local budgets, and improving local protocols, that has resulted in HIV testing scale-up at 225 PHC facilities. The pilots achieved 6 times increase in HIV rapid tests procurement from the local budgets. Targeting improving access to ART at the local level the project trained 24 health professionals and supported 21 ART sites at 6 pilot areas. The pilot projects also achieved substantial progress in MAT access scale-up through training 79 local health professionals and preparing to open 12 new MAT sites, some of which are testing MAT co- payment model, introduction of social order, and training of local change agents and service providers. Fifty seven patients are currently participating in co-payment scheme to receive MAT services. Technical assistance in review of the application to the Global Fund At the special request of the MOH and NPHC, HIVRiA provided technical assistance to the GOU in the development of Ukraine’s application to the Global Fund for 2018-2020 funding. This included technical inputs to the working groups, including financial gap-analysis, costing and budgeting, and health system strengthening, and coordination of the overall application development process. HIV Rapid Test Cost-Effectiveness Analysis and Forecasting Regional Programmatic and Financial Needs for Rapid HIV Tests provision In order to assist policy-makers in providing evidence for more cost-effective HIV testing strategies the HIVRiA team conducted HIV Rapid Test Cost-Effectiveness Analysis (CEA). The study provides evidence that the cost of identifying one new HIV+ case in population with 1% is estimated at 4 048 UAH for rapid HIV tests and 8 144 UAH for conventional ELISA HIV test (3rd generation). Based on CEA Study results HIVRiA developed and tested an Electronic Tool for Forecasting Programmatic and Financial Needs for Rapid HIV Tests at the regional level. The tool enables developing projections for the regions with diverse epidemic burden and testing targets. Evidence-based Regional HRH for HIV Planning HIVRiA team continued on generating evidence for HRH decision-making, through conducting multi- site workload analysis, service standards study and developing a model for estimating human resources requirements to implement the Test & START approach. HIVRiA projected HRH for HIV

12 requirements for Mykolayiv, Odesa, and Poltava regions and conducted gap analyses vis-à-vis existing human resource capacities in those regions. Developing Public Health Workforce of Ukrainian Institutions through “Modern Aspects of Public Health” Short-Term Training Course To address the qualifications gap for the new PH system of Ukraine the project established collaboration between UCSF and Bohomolets National Medical University that resulted in the development and institutionalization of the four-week certificate training program on Modern Aspects of Public Health. The project trained 57 public health professionals from 8 different regions on modern principles of public health policy development, programming, epidemiology and biostatics. HIVRiA plans to include teams from all regions in the training program in Y5, so that Ukraine’s public health system will receive strong workforce equipped with knowledge and skills to implement PH reforms at the national and regional level. Support the Government of Ukraine in developing the capitation rate for primary care services under ‘money-follows-the client’ approach HIVRiA provided technical support to the MOH in capitation rate development for primary health care. The Project collected utilization and unit cost data from 100 PHC facilities in 10 regions of Ukraine and analyzed data related to population size and demographics, PHC staffing, budgets and tariff rates. As a result, the project calculated the preliminary capitation rate for primary care services for 2018 and developed a methodology for rate estimation on the annual basis. Support the Government of Ukraine in e-Health implementation HIVRiA project is one of the key counterparts of MOH in eHealth implementation aimed to ensure that MIS support is in place for the launch of the primary healthcare capitation payments on January 1, 2018. The project supported development of a MVP for the e-health system, provided expert support in system testing and legal support to allow the official launch of the eHealth system. Since the launch of the eHealth capitation module - 503 medical facilities, 800 doctors and 148 patients are registered in the eHealth system. The project also initiated eHealth strategic planning to ensure alignment of the eHealth agenda with the health reform strategic plan. Primary health care reform support Aiming to assist MOH in rapid launch of the primary health care reform, HIVRiA selected Balta and Tsarychanka hromadas to pilot targeted technical assistance. The project supports primary healthcare facilities in these hromadas to become community owned not-for-profit enterprise, improve operations and design community oriented health care services. The Project also facilitates development of the national PHC operational guideline that provides sets of practical recommendations to hromadas and PHC providers to get prepared for the new PHC payment and service delivery model. The MOH launched thematic groups, nominated team leaders, and provided milestones for each group as a result of provided recommendations and due to the Project team facilitation. Project representatives lead 3 thematic groups – “Hospital Districts”, “HCF autonomization”. “National Academy of Medical Science project on piloting new financial mechanisms” Weekly meetings with Team leaders are conducted in the MOH. Leads started the documentation of the tactical activities associated with milestones to better assist in the identification of key milestones and provide weekly progress-reports. Roadmaps were drafted and are continuously updated to enable tracking of all health reform activities and to help identify risks and issues early. Hospital districts strategic planning tool Targeting to support regions in accelerating the development of strategic plans for hospital districts the project developed a hospital district strategic tool that includes both national requirements and guidelines and international best practices in hospital system strategic planning. The tool will be pilot in one hospital district before disseminating through the series of workshops throughout the country. Health reform communication The Project supported the development, printing, and dissemination of 1 million copies of the MOH Health Reform Newsletter. This newsletter was sent to all health facilities in Ukraine and were

13 distributed in trains through national Railway network in order to raise public awareness of the health reform goals and targets. Year 4 Challenges

Changes in public health leadership and a lack of decision making regarding implementation of public health reforms During Year 4, the project faced a challenge with lack of decision making among public health (PH) leadership at the MOH regarding a structure and a model of the PH system in the country. Despite approval of the PH concept by the CMU, MOH failed to act quickly on implementation of the concept, often sending mixed messages to local and international counterparts. This slowed the project’s progress in implementing strategic planning and capacity building activities for the NPHC and regional PH centers. Despite the lack of decisions, the project adapted technical assistance strategies and focused on training and capacity development of PH professionals at national and regional levels and conducted policy and financial analysis to provide evidence for decision making.

Lack of MOH formal staff engagement in health reform Due to resistance to change and turnover among many core MOH staff, the new MOH leadership relied largely on consultants hired through international projects. Many consultants are embedded professionals who work at the MOH, although they lack formal authority. This flexible strategy enabled MOH to hire young and motivated professionals, however, the lack of formal affiliation at the MOH often creates a problem for international counterparts to follow a proper administrative and regulatory process. The project worked with the MOH to develop an approach to follow procedures and established operation processes.

Ad hoc additional requests with a short timeline Due to rapidly changing needs and priorities, the project main counterparts - MOH and NPHC - often put in ad hoc requests that are in addition to the project’s core workplan activities. Due to the high priority of such requests, HIVRiA project tries to accommodate them as much as possible to ensure that priority needs of government counterparts are addressed. However, it creates a double burden on staff striving to address both these ad hoc requests and adhere to the approved project workplan timeline.

At times, insufficient coordination among international stakeholders Multiple donors support the MOH health reform efforts and often focus on the same health reform components. During Y4 the Project experienced successful cooperation with donor assisted projects, but at times also faced problems with lack of coordination and limited information sharing that created risks for the overlap and/or miscommunication in technical assistance provision. Proper coordination and coherent strategies to address MOH priorities can help synergize efforts to achieve best outcomes.

Availability and quality of health and statistical data The availability and quality of data continues to be a problem in numerous small and large scale studies and assessments conducted by the project. This challenge was particularly apparent with regards to the programmatic and costing data collected in the Investment Case II study that required several rounds of verification and subsequently slowed the analysis process. The project faced similar problems in conducting situational analysis in pilot districts, capitation rate estimations, Test and Start estimations, and other studies. This required multiple verifications and cross checking of data that is highly time-consuming and slowed down the process. The project focused on primarily collecting available health information, however in many cases it was difficult to avoid collecting specific data and indicators via direct outreach to health facilities and other sources.

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OVERALL PROJECT PERFORMANCE

SECTION 1. HIV REFORM SUPPORT

OBJECTIVE 1: ENHANCE NATIONAL LEADERSHIP AND CAPACITY FOR EVIDENCE- BASED AND GENDER-SENSITIVE HIV POLICY PROGRAMMING AND IMPLEMENTATION

Sub-objective 1.1: Support national government institutions in AIDS policy development, programming, and implementation The HIVRiA Project continued providing technical support to the Ministry of Health of Ukraine (MOH) for developing a public health system, with a particular focus on strengthening HIV/AIDS policy making and programming. Due to the HIVRiA Project's efforts, playing one of the leading roles at the MOH working group, the Government of Ukraine (GOU) has approved the Public Health System Development Concept of Ukraine, and its implementation plan in November 2016. The Concept outlined the general principles for developing the national public health system and roles of key players at the national and regional level. The project developed models and scenarios for the new public health financing to harmonize with the health reform thus allowing additional funds for priority areas, including HIV/AIDS. In Y4, the HIVRiA Project focused on building the capacities of the MOH, NPHC, and regional PH Centers. A number of activities like trainings, study visits, etc. took place with the aim of strengthening the capacity of national and regional policy makers and public health leaders to support public health system reforms, design public health services that respond to priority needs, and fund these services through national and regional governments. Special attention was paid to the development of the NPHC and its reform in line with the functions and structure proposed in the HIVRiA Project paper titled "Relevance of the establishment of the national public health and disease control center". The HIVRiA Project continues providing support to the MoH and the NPHC for developing updated the national comprehensive HIV management guide for the provision of health care to patients living with HIV (HIV Guideline). The HIVRiA Project organized two national level consultations. The first consultation discussed implementation of the Test&START concept in Ukraine, including the possibility of incorporating the main clauses of the concept into the draft HIV Guideline (February 28, 2017). The subsequent session addressed the draft new HIV Guideline, specifically prevention, diagnosis, and treatment, including those of opportunistic infections, as well as proposed amendments to effective legal acts with the aim to incorporate latest approaches (March 22-24, 2017). HIVRiA Project specialists also provided input during other meetings related to the HIV Guideline. During September 2017, the draft HIV Guideline underwent public discussion. The HIV Guideline was also shared with the WHO, CDC, I-TECH, and I-CAP for external expert review and evaluation. The HIVRiA Project developed and shared the HIV Legal Environment Assessment (LEA) Report among key national and regional stakeholders. Report was made based on UNDP operation guide to conducting national legal assessment for HIV and includes analysis of legal environment for main KP’s, including not only MSM, but also LGBT community in general with specific emphasis on transgender persons as a new group that was included in Comprehensive HIV Protocol in 2014. It is worth to say that this is the first national assessment that covers legal issues of all KP’s with gender-sensitive approach. Each part of the report includes clear recommendations on how to improve policies, laws, and regulations and may be serve as a road map to advocate for legal changes in Ukrainian HIV-related policy. Also, LEA used as reference for GF application and will be used for new national ADS program preparation. Based on the LEA, the HIVRiA Project supports finalizing amendments to some Ukrainian legislation in the field of HIV-associated disease response. On June 20, 2017, the HIVRiA Project, jointly with the MOH and NPHC, held the national and international stakeholder consultation to discuss the draft law of Ukraine “On making amendments in some legal acts of Ukraine in the field of HIV-associated diseases response”. The MOH endorsed the draft bill and submitted to other relevant ministries in line with the the Cabinet of Ministers of Ukraine (CMU) operational regulations of.

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Additionally, the HIVRiA Project organized a workshop in Kyiv oblast to review proposed amendments to the current HIV legislation: on September 12-14, 2017, nearly 20 HIV/AIDS and epidemiology specialists, representatives of the NPHC and NGOs discussed changes in HIV policies to align them with the proposed amendments to the current HIV legislation, the draft HIV management guidelines, and the recommendations of UNAIDS and WHO. The discussed changes referred to the following: • HIV surveillance strategies and reporting: to introduce case-based reporting and make necessary revisions to existing reporting forms; • Algorithms for HIV testing and laboratory diagnosis: to introduce a three-stage HIV testing procedure, including screening, confirmation, and identification; • Organization of medical care for HIV-positive people: to expand the list of healthcare facilities (PHCs, private clinics, penitentiary medical facilities, etc.) eligible to provide HIV care services, including ART and medical care for PLWH. The discussion of these issues will help to draft MOH orders to address them in the near future. According to the Strategy for a Sustainable Response to TB, Including Drug-resistant TB, and HIV/AIDS for the Period until 2020, the HIVRiA Project initiated development of the MOH-MSP joint order to approve procedures for planning and provision of social prevention, care, and support services to families and individuals affected by HIV/AIDS and TB. The order intends to streamline actions and extend mandates of local authorities in management and organization of community- based TB/HIV social services to key populations. The draft order was presented at the meeting of the Regional Committee of the National TB and HIV Council and is being currently reviewed by the ministries prior to approval (Annex 1). One of the core challenges in Ukraine is how achieve a substantial scale up of ART and other HIV services with limited financial resources. The HIVRiA Project prepared a review of international recommendations and best practices for establishing ART co-financing (Annex 2), and facilitated a national stakeholder meeting. Key recommendations are as follows: (1) the National AIDS Program should not implement a co-payment for ART since co-payment creates a barrier for uptake, maintenance, and adherence, especially for key affected populations and the poor; (2) include ART in a Basic Benefit Package (BBP) fully funded by Ukraine; (3) provide ART for free at the point of care as soon as HIV is diagnosed to maximize health outcomes for the population. To enhance data use for decision-making and improve access to HIV/AIDS strategic information in Ukraine, HIVRiA Project continues activity on the development of internet-based dashboards for the National and Regional AIDS Programs. The web-based tool "MONITORING AND EVALUATION OF IMPLEMENTATION OF THE NATIONAL PROGRAMME ON THE RESPONSE TO HIV/AIDS IN THE YEARS 2014-2018" was developed, piloted and integrated into the National Strategic Information Portal for HIV/AIDS. The resource is designed to track the progress of the National HIV Program for 2014-2018 as well as regional programs and contains the full list of indicators, which were included in the Monitoring and Evaluation Plan. During Y4 the whole National Strategic Information Portal for HIV/AIDS was transferred to the NPHC. The issues with the data availability timeliness and NPHC’s leadership role were raised. A set of the stakeholder’s meetings were conducted on partner coordination, data transparency and availability. It was decided with NMEWG there is no need to create separate Regional AIDS Programs Dashboards and use the National M&E Plan as arbitrary targets to compare regional indicators progress towards the targets. Additional visuals for progress towards targets will be created for SI Portal resource named NAP Dashboard. In Y4 the tool was further upgraded for transfer to the NPHC.

Sub-objective 1.2: Strengthen capacity of local government entities to implement regional AIDS programs with emphasis on key affected populations In Y4, the HIVRiA Project focused on supporting the Kyiv City State Administration (KCSA) in planning and implementation the UNAIDS 90-90-90 Fast-Track Cities Initiative (FTCI). The HIVRiA Project facilitated development of the Kyiv City HIV Program for 2017-2021, adopted on December 8, 2016, which received an unprecedented allocation of 238 million UAH for program implementation.

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The allocation of these resources will result in increased HIV testing, ART, MAT, and enrollment in care for people living with HIV. In Kyiv, in order to implement the FTCI, the following approaches to health care provision for PLWHA were proposed: • HIV testing with two rapid tests at all PHC CENTERS and Clinical and Diagnosis Centers (not only in pilot districts). Five hundred thirty-eight (538) health workers (from five districts) have been trained. • Referral of patients with HIV clinical stage І or ІІ from the AIDS Centers to the Clinical and Diagnosis Centers located in the districts. With this in mind, nine offices of specialists in infections were created, and MIS was installed. • MAT Orders on opening new MAT sites in the city (Annex 3) The organization of HIV services for IDPs in Kyiv was analyzed (Annex 4). In order to improve the situation, a draft order of the Health Department on the organization of health care for PLWH was developed (Annex 5). In addition, the HIVRiA Project supports KCSA in the development of the city public health system. The HIVRiA Project conducted an analysis of the existing public health system in the city and recommended the establishment of the city PH Center. The establishment of the Kyiv City PH Center was approved with the KCSA resolution on December 22, 2016. The HIVRiA Project drafted Charter for the city PH Center. In August 2017, the Kyiv City Council endorsed it and KCSA approved the Charter on October 19, 2017. At the request of Odesa OSA, on September 18-19, the USAID HIV Reform in Action (HIVRiA) Project team conducted a Regional Strategic Planning and Monitoring and Evaluation Training in Odesa for the health experts of the Odesa OSA Health Department. The main objective of the training was to build the capacity of health officials in strategic planning and use of M&E tools for the planning and implementation of programs. During the two days of the training, nearly 25 health specialists learnt principles of the targeted programming, strategic planning, and studied regulatory requirements for programming, main M&E principles and tools.

Sub-objective 1.3: Advocacy for improved policy dialogue and to ensure a transparent policy development environment The Project has awarded a grant to the All-Ukrainian Network of People Living with HIV to conduct advocacy activities in support of AIDS programming and funding allocations for HIV. The All-Ukrainian PLWH Network conducted an analysis on the status of AIDS programs’ implementation. The targets of the NAP and regional AIDS programs were analyzed in terms of their compliance with 90-90-90 global targets. To enhance supporting data for effective advocacy the Kyiv School of Economics (KSE) analyzed the linkage between the current structure and levels of funding of national and regional HIV/AIDS programs and their outcomes in terms of the implementation of NAP and selected regional AIDS programs. Additional analysis of AIDS-related death rate dynamics for 2008-2015 at the rayon level demonstrated the following key results: • National figures are driven by a sum of opposite trends in the regions: when the death rate falls in one region, it grows in others. • Six oblasts (Dnipropetrovsk, Kyiv, Poltava, Mykolaiv, Odesa, and Kirovograd) determined the national dynamics, with Dnipropetrovsk being the most influential driver. • The death rate has been growing in the regions surrounding localities that had the highest rates in 2008. • Three dozen administrative units in Ukraine with the highest HIV-related death rates exceed the country median by six to 15 times. • Kryvyi Rih is the most affected administrative unit in the whole country, and the national HIV response over 2008-2015 did not manage to halt HIV-related deaths in this city. Rayon-level data reveal specific administrative units that call for urgent attention, with Kryvyi Rih requiring the immediate response. Growth of AIDS mortality in the rayons surrounding those with the

17 highest death rates, suggests that it is important to pay more attention to HIV-transmission mechanisms and the NAP’s impact on them. Additionally, the HIVRiA Project conducted analysis to understand the landscape of local stakeholders, their incentives, constraints, and relationships (Annex 6). The report will be finalized after adding more information about the prioritization of areas for funding in the field of HIV/ADS response in Ukraine. Under the leadership of the HIVRiA Project, several meetings were organized with the representatives of the GOU, MOH, MOF, MOET, NPHC, donors, and other key national and international organizations with the aim of advocating for increased funding for HIV programs, including extended national ART funding and initiating funding for MAT. Based on the results of the meetings, in October 2016, for the first time in the history of Ukraine, funding was allocated from the state budget for the MAT program. From the 2017 state budget, the MAT program received 13 million UAH. This will help provide therapy for an additional 8,000 people. HIVRiA provided substantial technical assistance in preparing Ukraine’s new application for the Global Fund funding. HIVRiA Project supported the secretariat for the MOH, as well as participated in all key sub-groups, playing a leading role in sub-groups on the resilient and sustainable health systems and financing. The advocacy grant resources were re-focused to support reform discussions with key stakeholders, including the MOH. The plan addressed activities such as restructuring the provision of HIV prevention, treatment, and care, and implementation of a sustainability strategy within the new Global Fund mechanism. In total, the project organized two working groups. These working groups and their subsequent activities fostered general agreement to submit the new proposal in line with the sustainability strategy and transition plan (for step-by-step transition from donor-financed to government-financed services). The advocacy grant focused on the approval of the National Strategy for a Sustainable Response to TB, including Drug-resistant TB, and HIV/AIDS for the Period until 2020 and its action plan, which were approved by the CMU on March 22, 2017. Under the advocacy grant, the project planned to run advocacy campaigns at the regional level. At present, as part of the PH reform, it is relevant to hold regional cluster meetings on the development of the PH system and the establishment of PH centers. In coordination with the MOH, these meetings have been scheduled for November-December 2017 and will help to intensify the PH reform at the local level.

OBJECTIVE 2: IMPROVE AND OPTIMIZE RESOURCE ALLOCATION AND FINANCING FOR THE NATIONAL AND SELECTED REGIONAL HIV/AIDS PROGRAMS TARGETING KEY POPULATIONS

Sub-objective 2.1: Develop evidence pool to create support for funding decisions in HIV response at the national and regional level During Project Year 4, the HIVRiA team made significant progress towards finalizing the Investment Case Phase II Study and completed the draft synthesis report for review by and discussion with national experts. To achieve the objectives of the study, the draft report features: (i) cost analysis, identifying important cost differences for HIV services by service type, facility type, and region, and investigating both overall and per-patient costs; (ii) cost and service quality satisfaction comparison; (iii) interpolation analysis, taking the service coverage and costing data from the cost analysis study and interpolating results to the entire region to estimate the financial HIV burden within each selected oblast; and (iv) optimization analysis to both estimate the incremental costs and present the optimal mix of services, necessary to achieve the 90-90-90 UNAIDS HIV eradication goals. The optimization analysis also informed the training workshop organized by the Project and delivered by the Optima team during Project Year 4. Training workshop attendees, who represented the Ukraine MoH National Public Health Center and the Ukrainian Institute on Public Health Policy,

18 learned how to apply allocative and implementation efficiency forecasting tools to HIVRiA’s Ukraine Investment Case-Phase II study data to identify the most cost-effective and cost-efficient mix of HIV/AIDS services within existing budget constraints and develop funding strategies to maximize program efficiency and sustainability. During the reporting year, the HIVRiA team also finalized and published a study on perceived quality of HIV care across different HIV service providers in three regions of Ukraine. The study contributed to the analysis of linkages between quality and costs of HIV services and was accepted for presentation at the American Evaluation Association Conference (to take place in November 2017 in Washington, D.C.). Based on the findings of the study, in Project Year 5, the HIVRiA team will support the development of regional action plans to optimize investments in HIV programs in Mykolayiv and Poltava oblasts and achieve the greatest long-term impacts.

Sub-objective 2.2: Support the development of HIV strategies and policies at the national and regional level which reflect optimized resource allocation and lead to the most cost-efficient and effective HIVRiA completed a cost-effectiveness analysis of the use of Rapid HIV Tests which will be used to help the MOH optimize provision of tests and budgeting. The team’s analysis quantifies the cost of identifying one HIV positive case and fills a critical information gap. The study results reflect recommendations to scale-up usage of Rapid HIV Testing to facilitate HIV-case detection and reach the first 90 of UNAIDS 90-90-90 targets (Annex 8), as well as more effective resource allocation. As a continuation of this activity and to support the development of HIV strategies and policies, HIVRiA Team developed and tested an Electronic Tool on Forecasting Regional Programmatic and Financial Needs for Rapid HIV Tests provision at the regional level (Annex 9). In early July, the team held the first round of regional consultation workshops on projecting regional financial needs for Rapid HIV Test provision. Representatives of OSA’s Health Departments, regional AIDS centers, and pilots from seven project regions participated and received training on using the tool for program and financial forecasting of HIV Rapid Test procurement at regional level and prepared drafts of financial projections and developed needs for Rapid HIV Test provision for 2018. Using the electronic tools, the participants calculated financial and program needs for Rapid HIV Test provision for 2018 and developed regional annual operational procurement plans for HIV Rapid Testing provision for 2018 (Annex 10). This tool supports the regional level to project financial needs to purchase Rapid HIV Tests based on their regional epidemiologic situation and incorporates strategic 90-90-90 targets to achieve an optimal HIV response for a specific region. The tool will strengthen the processes of evidence-based planning and decision-making and enhance transparency and accountability in decision making and program planning at the regional level. Since May 2017, the HIVRiA Project boosted activities within NASA e-tool development and institutionalization. The team, jointly with NPHC, piloted the NASA e-tool in the Cherkasy and Poltava regions (Annex 11). Based on two piloting reports developed with recommendations for tool functionality improvements, the HIVRiA team prepared guidelines for reporting HIV expenditures based on adapted NASA and online tool (Annex 12). During a stakeholder meeting in early October 2017, participants discussed the current functionality and future plans for institutionalizing the NASA tool. The action plan was developed with defined key steps, timelines and responsibilities for the future period (Annex 13). To develop the performance-based financing (PBF) mechanism within the primary health care system, the project agreed on five priority areas: immunization, hypertension, HIV infection, tuberculosis, and diabetes. Within each area, a specific indicator was defined as a key performance indicator (with approximately 10 indicators in total). For defining key performance indicators, an appropriate data from national and international data sources was collected (Annex 14). The project held a series of presentations on this list of indicators with national and regional representatives. Additionally, there was prepared a review of international best practices in PBF implementing with a detailed description of country experiences from the United Kingdom, Estonia, Turkey, Haiti, and Rwanda (Annex 15). To strengthen the knowledge and capacity of Kyiv City authorities and PHC centers representatives in managing decentralized HIV budgeting and funding, the HIVRiA Project team held a two-day workshop in collaboration with representatives of Harvard University’s faculty. Additionally, the

19 representatives from pilot PHC centers in Balta and Tsarychanka were enrolled in this capacity building activity. To provide technical assistance to the MOH and the NPHC in costing and projecting financial needs for implementing Test and START approach in Ukraine with further usage during the next NAP preparation process, the HIVRiA Project started estimating costs for implementing Test and START in 2018-2020 in Ukraine. The technical experts’ consultation meeting was held on February 28, 2017, to initiate dialogue among partners and stakeholders about the most important factors and parameters that would impact the national HIV/AIDS response and should be accounted for while planning Test and START implementation. The scope and types of cost (indirect, overhead, etc.) were discussed with the partners to be accounted in calculations. HIVRiA Project prepared preliminary costs and projected program targets and financial needs for implementing Test and START Strategy in 2018-2020 in Ukraine. It is planned to discuss the costing approach and preliminary estimates on costs of Test and START strategy implementation with the national stakeholders including MOH and the NPHC in November (Annex 16). The Project also provides technical assistance in developing effective financing mechanisms for funding the newly formed public health system and essential public health services, including HIV prevention and other critical services. The Project team conducted a series of meetings with public health specialists and stakeholders to discuss public health financing scenarios and algorithms. Based on these discussions, the Project provided recommendations for changes to budget code legislation related to public health subvention and programming. Three typical algorithms for public health were identified and presented to the national stakeholders including MOH and regional authorities (Annex 17). Additionally, the Project team jointly with partners develop a draft of the PHC Operational Manual that includes the separate chapter devoted to the performance of public health programs. As a part of building a sustainable model to provide critical services to KPs and PLWH at the local level, the HIVRiA team developed models for costing of HIV counseling and testing services and MAT for PHC centers (Annex 18). During two regional workshops for pilot regions conducted in October 2017, participants from regional health departments, primary healthcare centers, TB and narcological dispensaries, and partner NGOs calculated costs for these HIV-related services provided by PHC facilities in their regions (Annex 19). Costing of these services would be used by the participants within the process of advocacy for funding allocation and quick provision due to the changing of the main components in calculations such as salaries, prices of utilities etc.

Sub-objective 2.3: Strengthen capacity of national and regional partners in finance planning, budget preparation and execution to match the needs to optimized HIV/AIDS service-delivery operations The flagship course on Health Systems Reforms and Sustainable Financing introduces a practical and comprehensive framework for understanding health systems. It also provides a structured approach to developing reform policies to improve systems performance. The course is based on the ‘control knob’ framework developed by a group at the Harvard School of Public Health. The principal goal of the course is to provide intensive, state-of-the-art knowledge and training on options for health sector development, including lessons learned and best practices from country experiences. The USAID HIVRiA Project is implementing this activity through a grant mechanism through the Kyiv School of Economics (KSE) and National Academy of Public Administration under the President of Ukraine (NAPA). The project aims to facilitate the institutionalization of the short-term Health Systems Reforms and Sustainable Financing course, developed and implemented by incorporating lessons into the Ukrainian post-graduate curriculum, including usage of modern methods of pedagogy, such as case studies, group work, and discussion. During the reporting period, these educational institutions are finalizing the process of course adaptation and obtained all needed approvals of Academic and/or Faculty Council to initiate beginning of the course from the fall semester (Annex 20). To adopt ProZorro electronic procurement system for practices at the regional levels the Project held a series of activities. The training on how to use the ProZorro procurement platform was conducted for representatives of Project partner regions to optimize resource use in public HIV-care facilities. Additionally, feasibility assessments for implementing ProZorro for the procurement of HIV

20 commodities was conducted in two regions: Kyiv city and Odesa region. Based on the assessment, recommendations on options for use ProZorro to procure commodities by AIDS Centers in these regions were produced. Via targeting two institutions (Poltava Regional AIDS Center and Poltava Narcological Clinic) experts of Transparency International Ukraine (TI-Ukraine) for the first time provided full scale procurement process review and advisory support to improve the institutions’ procurement process using ProZorro. The procurement results obtained through the ProZorro system and already-conducted procurement in AIDS Center and Narcological Clinic were analyzed to identify problems and provide recommendations to improve the institutions’ processes using the ProZorro system. Analysis of past procurements identified the following issues: legislative violations, abuse by the customer, and unintentional mistakes. Two promotional videos on using ProZorro for HIV-related commodities and other healthcare products were finalized and launched (‘Anatomy of ProZorro’ https://www.youtube.com/watch?v=hPESicFVfsc and ‘DOZORRO - the weapon of the activist’ https://www.facebook.com/dozorro.org/videos/982856921844791/). Analysis revealed that the number of unique visitors to ProZorro and DoZorro increased after the launch of the videos (28% ProZorro and 20% DoZorro). The project conducted several presentations on successful procurements of HIV-related healthcare commodities at national and international events, conferences, and round tables. Between September and March 2017, representatives of Transparency International Ukraine also conducted four presentations at large national events in Kyiv, including Forum “Farmbudget-2017”; III All Ukrainian “Move towards ProZorro in the field of health care; and “END TB: Search for new solutions in the face of new challenges. At each event, specific success/failure stories of centers for HIV/AIDS prevention, TB dispensaries, and penitentiaries were discussed during the group work sections. OBJECTIVE 3: OPTIMIZE AND STRENGTHEN HUMAN RESOURCES FOR HEALTH (HRH) FOR THE DELIVERY AND SCALE-UP OF GENDER-SENSITIVE HIV/AIDS SERVICES TARGETING KEY POPULATIONS

Sub-objective 3.1: Strengthen evidence base data for HIV workforce planning and development In Year 4, the HIVRiA team completed the development of the model for estimating HRH requirements to achieve the 90-90-90 targets using the Test and START Approach. This model was built using a range of parameters and assumptions related to (i) HIV service package components; (ii) service standards/chronometric data; (iii) frequency of service provision per client per year; (iv) share of services provided by group of health cadre; (v) service coverage targets; (vi) working days per annum; and (vii) percentage of time spent on provision of HIV services by type of facility. The HRH model is fully outlined in the HRH Requirements Projection Model Technical Description document (Annex 21). Using this model, the HIVRiA team carried out empirical HIV and human resource capacity data analysis and developed three regional analytical notes with Test and START HRH estimates for Mykolayiv, Odesa, and Poltava oblasts (Annex 22, 23). These estimates as well as the key gap analysis findings and recommendations were presented and discussed with chief doctors and managers of municipal healthcare facilities and health administrations from the three oblasts. The model also informed the development and finalization of a tool for facility-level human resources projections (Annex 24), which was piloted at Poltava Oblast AIDS Center. The HIVRiA team utilized the completed HRH Requirements Projection Modeling tool to deliver a training and to strengthen the capacities of national and regional specialists in estimating workforce demand for Test and START approach implementation (Annex 25).

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Sub-objective 3.2: Support the introduction of systemic and operational changes in HRH for the provision of sustainable and integrated HIV/AIDS services at the national and regional levels In Year 4, the HIVRiA team organized three regional stakeholder consultations in Mykolayiv, Odesa, and Poltava oblasts to identify key priority areas for addressing the projected HRH needs (as reflected in the Project-developed analytical notes), review recommendations for HRH planning based on 90-90-90 programmatic targets, and elaborate HRH rationalization options (Annex 26). These agreed priority areas and related HRH rationalization options will inform both immediate regional actions and the development of the forthcoming national and regional AIDS programs. As one solution to address projected HRH needs, the HIVRiA team also developed and disseminated practical guidelines for the roll-out and implementation of task-shifting mechanisms for HCT, ART, and OST services designed to support chief physicians of health facilities and answer their “how to” questions. Further, in support of the National HRH Strategy implementation process and to strengthen the platforms for national HRH dialogue and leadership, the HIVRiA team assisted NPHC in setting up a formal HRH for HIV Intersectoral Working Group, developing HRH for HIV IWG Provisions, and updating the membership in the group. This work also included collecting inputs from key stakeholders to draft the Annual HRH for HIV Operational Plan. The HRH for HIV IWG will now focus on critical HRH issues that can be addressed on the national level, identifying bottlenecks, elaborating solutions and working with MOH and other bodies to enact improvements in the HRH for HIV policies and practices. Finally, the HIVRiA team worked with the e-Health component partners to ensure that effective IT solutions developed for the Ukrainian Ministry of Health include a functional HRIS module, which at minimum meets WHO-recommended dataset requirements for national health workforce registries. To achieve this aim, the HIVRiA team established a technical working group for drafting detailed requirements for the e-Health-based HRIS module and endorsing them with the MOH. With the draft finalized in the reporting year (Annex 27), the development and roll-out of the HRIS will be completed in Project Year 5. The e-Health-based HRIS will provide analysts with access to up-to-date, accurate, and standardized health workforce data, offering essential information on health care personnel and allowing for strategic decision-making and evidence-based HRH planning on national and sub- national levels.

Sub-objective 3.3: Strengthen capacity of Ukrainian institutions in HRH policy development and implementation During the reporting period, O.O. Bohomolets National Medical University (NMU), in partnership with the National Public Health Center and Ukrainian Training Center for Family Medicine (UTCFM) and University of San Francisco California (UCSF) developed and conducted first pilot short-term training course on "Modern Aspects of Public Health". As a result, 29 participants received certificates upon successful completion of the course and now are equipped with modern approaches and tools on how to utilize public health approaches in Ukraine. The short-term training course on Public Health was designed as a four-week course (156 academic hours) that includes the following topics: introduction to public health, biostatistics and epidemiology, HIV surveillance, M&E, policy, and programming. To ensure that course will have examples of triangulation it was proposed to include HIV example’s, including one on MSM epidemiology situation with ARV treatment and other STD, etc. All participants and lectors expressed great appreciation for the program and provided positive feedback. During the coming Year 5, the Project team will continue working with the National Medical University and UTCFM, as well as NPHC to help implement the course and build the capacity of existing faculty to provide trainings for the health workforce. An increased professional capacity in Ukraine for public health supports an integrated HIV response in line with public health principles and approaches. In Project Year 4, the HIVRiA team also collaborated with NMU, UTCFM, and NPHC (who led the supervision process) and conducted a second short-term training course, “Modern Aspects of Public Health”, for professionals who will serve at newly organized national and regional centers of public

22 health. Participants from six regions attended the course: Odesa, Rivne, Zakarpattya, Chernivtsi, Kherson oblasts and Kyiv City. Completion of this milestone enabled HIVRiA to significantly strengthen the capacities of 28 physicians, health finance specialists, and communication specialists in public health issues and to gain new knowledge and skills for practical implementation (Annex 28). The impact of this project initiative manifests through these regions becoming the first to reorganize their health care systems and establish regional public health centers in their respective oblasts.

4. REGIONAL PILOTS. BUILDING A SUSTAINABLE MODEL FOR THE PROVISION OF CRITICAL SERVICES TO KEY POPULATIONS AND PEOPLE LIVING WITH HIV AT THE LOCAL LEVEL During PY3 and PY4, local pilot projects titled ‘Building a sustainable model for the provision of critical services to key populations and people living with HIV at the local level’ (Pilot) have been implemented in seven high-burden regions. Pilots cover 15 geographical locations: Kryvyi Rih, Kryvyi Rih rayon (Dnipropetrovsk oblast), Poltava, Poltava rayon, Kremenchuk (Poltava oblast), Bilhorod-Dnistrovskyi, Bilhorod-Dnistrovskyi rayon, Odesa City (Odesa oblast), Kherson (Kherson oblast), Pervomaisk, Pervomaisk rayon (Mykolaiv oblast), Kaniv, Kaniv rayon (Cherkasy oblast), and five districts in the Kyiv City. The HIVRiA Project staff leads implementation of the pilot in the rayons with the support of competitively selected local NGOs and local healthcare providers, and in close collaboration with USAID RESPOND Project and GFATM PRs (Alliance, Network, and UCDC). Pilot timeframe: December 2015 – December 2017 The pilots at the local level helped to achieve a significant increase in the sustainability of HIV services through local government strengthening, elimination of policy barriers in services provision, mobilization of local financial resources, budgeting and costing of critical HIV services, decentralization of HIV testing services (involvement of PHC in testing), provision of ART (opening of new ART sites), opening of new MAT sites, promotion of the provision of MAT upon prescription and piloting of the MAT co-payment model, introduction of social order, training of local change agents and service providers. Cooperation at the oblast level has helped to roll out some of the pilot best practices in the entire oblast. Local baseline situational analyses Based on the pilot results, 7 rayon/city level HIV Situation Analyses were prepared (Annex 29). This is the first time they were conducted at the local level and included not only the epidemiological status and description of HIV response interventions, but also the analysis of the provision of services like the patient pathway and the cascade of services, and practical recommendations. HIV Situation Analyses were used for pilot planning and implementation, as well as generating evidence for local decision making. Increased local financial resources Pilots advocacy campaign focused on additional funds to be allocated for the purchase of rapid tests and on the need for social services. The table below shows the funds allocated from the local budget for 2017. 2017 Pilot Amount, Administrative Specifications Thousands of Area UAH 5,090,000 UAH for HIV/AIDS and TB response; 65,000 UAH for additional HIV RT procurement for PHC Kryvyi Rih city 5155.00 CENTERS Kryvyi Rih 20,000 UAH for HIV social services contracting; rayon 46.00 26,000 UAH for HIV RT procurement and vacutainer

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321,800 UAH HIV Program (including 50,000 UAH for the purchase of test kits for rapid testing for key populations); Kherson city 446.80 125,000 UAH for HIV social services 41,753,000.66 for HIV Program (including 6,653,180 UAH for the purchase of rapid test kits + ELISA for key populations); Kyiv city 42182.57 429,570 UAH for HIV social services 980,700 local budget for HIV services; 50,000 UAH for HIV social services; 4,300 UAH for the purchase of test kits for rapid testing for Poltava city 1035.00 key populations Poltava rayon 83.00 83,000 local budget for HIV services 183,429 HIV Program 120,000 UAH for HIV social services; 32,686 UAH for the purchase of rapid test kits for key populations; 132,449 UAH for purchase of medicines for the treatment of opportunistic infections; 16,857 UAH for treatment in inpatient department; 8,210 UAH for purchase of infant food for children born by Kremenchuk 493.20 HIV-infected mothers 385,000 UAH for HIV Program (including 50,000 UAH for the purchase of rapid test kits for key populations and 10,000 Pervomaisk UAH for testing supplies); city 463.00 78,000 UAH for HIV social services 198,000 UAH for HIV Program (including 20,000 UAH for the Pervomaisk purchase of rapid test kits); rayon 244.80 48,800 UAH for HIV social services 101,300 UAH for the purchase of test kits for rapid testing; Bilhorod- 50,000 UAH for HIV social services; Dnistrovsky city 163.30 10,000 UAH for MAT co-payment. Bilhorod- 201,090 UAH for HIV Program (54,500 UAH for the purchase Dnistrovsky of rapid test kits for key populations and 50,000 UAH for HIV rayon 201,09 social services) 100,000 UAH - additional funds for HIV social services, based on current changes to the Kaniv City and Rayon Program "Care" and was not planned in original proposal; 15,000 UAH for the purchase of test kits for rapid testing for key populations; Kaniv city 432.37 19,000 UAH for the position of social worker at the Kaniv PHC Center of the intergrated care; 20,000 UAH of additional funds for MAT co-payment from Kaniv City budget; 300,000 UAH for co-financing of repairing of the facilities in CDH and PHC CENTERS from Kaniv City and Rayon budget; 99,500 UAH for the equipment for the HCT cabinets for ambulatories at villages: Mezhyrich, Liplyavo, Stepantsi, Martynivka and Prokhorivka - through additional funds for support for PHC service by Kaniv rayon Council. 58.000 UAH for the equipment purchasing, through Kaniv Kaniv rayon 424.79 City AIDS Program.

HIV testing services decentralization The pilot strategy, based on UNAIDS and WHO recommendations, envisaged the implementation of HIV rapid testing at the local level through the involvement of new service providers. Special

24 attention was paid to the scale-up of the HIV testing at the PHC level. The implementation of the strategy included five stages: 1) analysis of the situation and development of proposals; 2) development and approval of local policies (local orders, amendments in the HCF TOR, etc.) (Annex 30); 3) raising local funds for rapid testing and necessary equipment; 4) training of doctors and nurses; 5) introduction of testing. This approach maximizes the sustainability of services after the completion of pilots. HIV testing training was provided for 1102 persons. Thanks to pilots, the number of PHC outpatient facilities providing HIV testing has increased from 25 in 2015 to 225, as of October 2017. Table: number of PHC outpatient facilities providing HIV testing Pilot Administrative Area 2015 2016 2017 (as of October 1, 2017)

Kryvyi Rih city 15 25 38 Kryvyi Rih rayon 2 2 11 Kherson city 8 8 8 Kyiv city 0 0 143 Poltava city 0 8 6 Poltava rayon 0 2 2 Kremenchuk 0 0 5 Pervomaisk city 0 1 6 Pervomaisk rayon 0 0 6 Odesa city 0 0 11 Bilhorod-Dnistrovsky city 0 1 3 Bilhorod-Dnistrovsky rayon 0 2 9 Kaniv city 0 1 1 Kaniv rayon 0 0 6 TOTAL 25 50 225

Integrated care services package Based on results and recommendations of rayon/city level HIV Situation Analyses, the HIVRiA Project made efforts to integrate HIV services in specialized HCFs, in particular, the scale-up of HIV testing, the opening of new ART sites, the integration of DOT, and the opening of new MAT sites. The table shows the efforts of pilots to integrate services into a specialized health network, according to work plans. Provision of ART and HIV testing DOT MAT number of patients Bilhorod-Dnistrovsky rayon CRH and Starokozache RH, and Starokozache RH: 2 DOT sites at 2 testing algorithm outpatient facilities introduced – 2 RT under Starokozache RH, 4 DOT sites at 4 outpatient facilities under CRH (since May 2017)

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Bilhorod-Dnistrovsky city CMH: testing New MAT site is to algorithm introduced – be open in Q4 of 2RT 2017 Odessa city New site with MAT upon prescription is to be open in Q4 of 2017 Pervomaisk rayon CRH: testing 2 outpatient facilities algorithm introduced – start ART from October 2RT 2017 Pervomaisk city CMH: testing 1 outpatient facilities algorithm introduced – start ART from October 2RT 2017 Kherson city Oblast drug treatment Oblast drug treatment Oblast AIDS Center clinic: HIV testing clinic: ART introduced (TB/HIV co-infection, introduced (one patient so far) STI and Hep) Kherson municipal hospital named after Ye. Karabelesh - 3 patients (11 patients are ready to start), Kherson municipal hospital named after А. and О. Тropin - 15 patients (14 patients are ready to start), Kherson municipal hospital named after O.Luchanskyi - 5 patients (9 patients are ready to start). Kiev city Territorial medical  Territorial medical We open 4 MAT association “TB”: HIV association “TB” and sites (they will also testing introduced. Sociotherapy clinic – serve as integrated provided ART in care sites) at PHC Clinical and Diagnosis inpatient units – if such centers: patients were available. Center in Obolon Local protocols  PHCC No. 2 district: HIV testing introduced. Darnytsia introduced.  Will be provided district; through the offices of  PHCC No.1 Clinical and Diagnosis specialists in infections Obolon district; Center in Podil district: at Clinical and  PHCC No. 2 HIV testing Diagnosis Centers Solomianskyi introduced. (including prescription district; of ART and PLWH  PHCC No.3 oversight). Clinical and Diagnosis Shevchenkivskyi Center in district.

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Solomianskyi district:  Clinical and Diagnosis HIV testing Center in Obolon district introduced.  Clinical and Diagnosis Center in Darnytsia Clinical and Diagnosis district Center in  Clinical and Diagnosis Shevchenkivskyi Center in Shevchenkivskyi district district: HIV testing  Affiliate No. 1 of the introduced. Clinical and Diagnosis Center in Clinical and Diagnosis Shevchenkivskyi district Center No.1 in  Affiliate No. 2 of the Darnytsia district: HIV Clinical and Diagnosis testing introduced. Center in Shevchenkivskyi district Clinical and Diagnosis  Affiliate No. 3 of the Center No.2 in Clinical and Diagnosis Darnytsia district: HIV Center in Shevchenkivskyi district testing introduced  Affiliate No. 4 of the Clinical and Diagnosis Center in Shevchenkivskyi district  Affiliate No. 3 of the Clinical and Diagnosis Center in Solomianskyi district  Clinical and Diagnosis Center in Podil district Kryvyi Rih city Kryvyi Rih TB clinic Kryvyi Rih TB clinic We open 4 MAT No.2: testing algorithm No.2 sites (they will also introduced – 2RT Kryvyi Rih mental clinic serve as integrated care sites) at PHC Kryvyi Rih STI clinic: - the service existed, is centers testing algorithm provided for patients introduced – 2RT who need ART. To be offered by 4 Kryvyi Rih mental MAT /integrated care clinic: testing sites at PHC centers. algorithm introduced – 2RT Kryvyi Rih rayon Kryvyi Rih CRH: To be offered by an We open 1 MAT testing algorithm MAT /integrated care sites (it will also introduced – 2RT sites at the PHCC. serve as integrated (Rossozynsk, care site) at the Suprunovskaya PHCC outpatient clinic) Poltava city Private Clinic “100% Because of Project Wasn’t the pilot task. of Life”: testing efforts, DOT provision algorithm introduced – was expanded at PHC 2RT ( Center No. 2 and the number of patients was Private Clinic “100% increased. of Life”: through Private Clinic “100% of MAT co-payment Life”:

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TB prevention by mechanism – 5 isoniazid. patients Poltava rayon 2 PHC facilities initiate HIV testing with 2 rapid tests. Kremenchug city Kremenchuk PHC Opening of MAT site Center and rayon in Pridneprovskaya PHC facilities Hospital is planned (outpatient) initiate for the 1st of HIV testing with 2 December 2017. rapid tests. Kaniv city

Kaniv central rayon TB treatment was New MAT site in clinic (PHC facility that organized at Kaniv Kaniv Central covers Kaniv city) – central PHC clinic and District Hospital, as testing algorithm after TA from the of 09.30.2017, – site introduced – 2RT Project will be able to provides MAT provide HIV + patients services to 14 with better services patients. and Infection Control.

Scaling up the provision of MAT upon prescription and piloting the co-payment model In order to measure the willingness of current and potential MAT clients, social surveys were conducted in each pilot. Overall, the survey proved that MAT clients had a positive attitude toward the co-payment model when drugs are provided upon prescription and additional services are provided at one site. Each pilot analyzed the need for MAT courses, developed proposals for different co-payment models (Annex 31), costed MAT services, analyzed retail and wholesale prices for opioid agonists, and checked effective local policies for their compliance with the national legislation. In Pervomaisk (Annex 31-1) and Kryvyi Rih (Annex 31-2), the "prescription" MAT co-payment model was selected for piloting. Under this model, MAT drug prescriptions are issued to clients who buy drugs from a pharmacy at their own expense. In this case, the client visits the MAT site three times a month, during which he/she sees a drug treatment specialist and receives a prescription. Health services are provided by the staff of the MAT site located at the HCF and are paid for by the local budget. For the patient, benefits of the "prescription" model include convenient treatment (there is no need for a daily visit to the MAT site, freedom of movement, place of residence, working schedule and employment in general, etc.). The HCF benefits from saving budget funds (no need to buy drugs, reduced cost of the site maintenance and staff), reducing the workload for MAT site staff, and not needing to change its policy. For the implementation of the "prescription" model, a number of local policies were developed, agreed, and approved. As of October 1, 2017, 24 MAT program clients in Pervomaisk and 33 clients in Kryvyi Rih are buying drugs upon prescription in the pharmacy. It should be noted that the MAT co-payment practice is being rolled-out to other rayons of the Mykolaiv oblast, thus, 168 clients receive prescriptions for MAT drugs to be purchased from pharmacies in six HCFs (Mykolaiv oblast drug treatment clinic, Pervomaisk CMH, Novyi Buh CRH, Vitovka CRH, Mykolaiv CRH, Ochakiv CRH). The general dynamics of the MAT “prescription” model scale-up and co-payment piloting is shown on the graph.

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Cumulative MAT Scale-up in 7 pilot administrative areas 400 377 1950 350 1900 1850 300 1800 235 250 1750 200 1700 150 1650 1600 100 68 1550 35 50 1500 0 0 12 0 57 0 1450 2015 2016 2017 Total # on MAT New MAT site Prescription form Co-payment option

Social order for direct financing of services provided by NGOs According to the legislation, the social order is funded from the local budgets. Each pilot region and city decided independently which program would include the social order. In many pilots, as a result of the advocacy efforts, the decision was made to include a social order in a social welfare program; in some pilots, it was decided to include a social order in the HIV program. As part of the social order implementation under the pilots, the HIVRiA provided the following: training for the representatives of the social welfare departments of the pilot regions; assistance in preparing an analytical statement setting forth the priorities of a social order and draft local social order policies; and assistance in costing selected social services as a subject of social order (meetings in pilot rayons and cities). Justification was prepared for each social service: specification and cost per client. The number of clients and estimated amount of funds from the local budget were identified. The social order is currently being implemented in line with plans and services procured. The results of the social order implementation are presented in the table below. Budget Pilot Target allocated Target Service delivery Administrative Social Service Coverage, # for 2017, audience timeframe Area of people UAH Kryvyi Rih Linkage to care and October - rayon 10000 retention PLWH 20 December 2017

PWIDs CSWs June-December Kherson city 20000 Case management MSMs 73 2017 Linkage to care and June-December Kherson city 30000 retention PLHIV 38 2017 June-December Kherson city 75000 Palliative care PLHIV 75 2017 October - Kyiv city 429570 Palliative care PLHIV 70 December 2017

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1) students of secondary technical schools, colleges and vocational technical schools; 2) 1) primary prevention 500 students of HIV; 2) service of vocational social prevention of technical August - Poltava city 50000 human trafficking schools 1500 December 2017 PLWH and 1) social support / people patronage; 2) short- vulnerable to June - Kremenchuk 119954 term counseling HIV 203 December 2017 HIV+ Short-term Pregnant July - December Pervomaisk city 2300 counseling Women 6 2017 PLWH + July - December Pervomaisk city 64000 Social support PLWH/TB 58 2017 Representation of July - December Pervomaisk city 11700 interests PLWH 50 2017 Pervomaisk January - rayon 48800 Social support PLWH 90 December 2017 Bilhorod- June 23 - Dnistrovsky city 50000 Case management PWIDs 175 December 2017 Secondary prevention - motivation of PWID to pass HCT and TB diagnostic in local PHC clinics, condoms distribution, educational information August - Kaniv city 50000 materials. PWIDs 65 December 2017

Linkage to care and retention for PLWHA to decrease the level of self-stigmatization September- Kaniv rayon 50000 and discrimination. PLWH 40 December 2017

Capacity Strengthening The pilot teams analyzed the HR capacity and prepared lists of PHC and SHC workers who need additional training. The HIVRiA Project organized the training for the health workers on such topics as HIV testing, ART, MAT, stigma, and discrimination. The training outcomes are shown in the table below.

HIV testing topic ART topic MAT topic Stigma and Original in Original in Ukrainian Original in discrimination Ukrainian as as Ukrainian as topics Pilot «Консультування Цикл тематичного Тренінг «Замісна Original in Administrative та тестування удосконалення підтримувальна Ukrainian as Area (КіТ) на ВІЛ з «Сучасні технології терапія хворих з Формування використанням протидії опіоїдною толерантного швидких тестів», розповсюдження залежністю», ставлення у including ВІЛ/СНІД та including медичних

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Навчальний наркозалежності: Навчальний цикл працівників до цикл роль первинної тематичного людей, які живуть тематичного медичної допомоги удосконалення з ВІЛ, та удосконалення на засадах «Замісна представників «Консультування сімейної підтримувальна груп найвищого і тестування на медицини» терапія хворих з ризику ВІЛ-інфекцію» опіоїдною залежністю» Dnipro city 0 0 1 0 Kryvyi Rih city 126 13 30 19 Kryvyi Rih rayon 44 1 4 3 Kherson city 88 2 3 11 Kyiv city 535 0 25 23 Poltava city 40 0 0 9 Poltava rayon 14 0 0 4 Kremenchuk 62 0 3 11 Pervomaisk city 34 1 5 15 Pervomaisk rayon 25 3 0 7 Odesa city 62 0 4 5 Bilhorod- Dnistrovsky city 3 0 4 13 Bilhorod- Dnistrovsky rayon 15 2 0 3 Kaniv city 34 2 0 13 Kaniv rayon 20 0 0 3 Total 1102 24 79 139

Generally, the analysis of participants pre- and post-training evaluation demonstrated 34% increase. The analysis by separate topics are demonstrated below in Figures 1-4.

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Pre-test Post-test Changes

68.07% Which human body cells are 96.90% susceptible to HIV? 28.83% 47.33% What does HIV testing and counseling 89.02% mean? 41.69% 68.74% What does HIV positive test result 94.46% mean? 25.72% 62.32% What does HIV negative test result 94.96% mean? 32.64% 89.75% What biological materials have the 98.15% highest HIV content? 8.41% 24.88% 92.53% Mark populations at high risk of HIV: 67.64% 89.89% 97.07% What are the HIV transmission routes? 7.17% 41.14% Name the stage of the HIV epidemic in 93.88% Ukraine: 52.74% 17.73% The blood of what populations must be 83.19% tested for HIV? 65.46% 71.99% What is the purpose of pre-test 93.76% counseling? 21.77% 83.69% The efficient work of a consultant is 96.26% determined by the following tools: 12.56% 18.58% 84.87% Identify the purpose of HIV screening: 66.29% 37.01% Name the sequence of actions of those 93.38% exposed to HIV at workplace: 56.36% 33.19% What are the modern screening 91.07% approaches? 57.88% 60.63% What is the purpose of post-test 94.22% counseling? 33.60% Figure 1. Pre- and post- training participants’ evaluation results for HIV testing topic training.

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Pre-test Post-test Changes

43% OVERALL 72% 29% 8% Does Ukraine’s legislation specify the role of the … 50% 42% 75% What do you mean by the PHC integrated… 79% 4% 0% Name treatment stages in the MAT program 8% 8% 58% Basic clinical and pharmacological effects of… 67% 8% 38% What does medication-assisted therapy (MAT) mean? 63% 25% 63% HIV laboratory testing for HIV+ patients is… 88% 25% 50% HIV-related stigma is 83% 33% 38% Specify the meaning of the "counseling supervision" 79% 42% 0% Specify HIV counseling and testing principles 17% 17% 88% The purpose of HIV counseling and testing is 92% 4% 75% HIV counseling and testing is 88% 13% 17% HIV most at-risk populations are 50% 33% 50% According to WHO/UNAIDS definition, what kind of… 96% 46% 4% For HIV stage III, the following diseases are common 63% 58% 58% Other viruses and HIV 75% 17% 13% How can antiretroviral drugs be grouped in terms… 54% 42% 13% HIV stage I is known for the following pathologies 71% 58% 17% Pneumocystic pneumonia can be diagnosed by 58% 42% 83% When should post-exposure prophylaxis (PEP) be… 96% 13% 54% What does the viral load mean? 100% 46% 50% How is HIV transmitted? 63% 13% 29% In what body fluids is HIV concentration the highest? 83% 54% 33% At what stage of treatment of HIV positive people is… 58% 25% 96% What is the modern definition of HIV as a disease? 100% 4% 8% What cells, besides T-helpers, are affected by HIV? 58% 50% 92% What clinical manifestations are characteristic of… 96% 4% 58% Name HIV at-risk populations 83% 25% 92% The source of HIV infection is 100% 8% 0% Is the patient's consent needed for HIV testing? 79% 79% 29% What world countries have the largest HIV positive… 63% 33%

Figure 2. Pre- and post-training participants’ evaluation results for ART topic training.

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Pre-test Post-test Changes

41% OVERALL 91% 50%

20% What licenses does a facility need to have 79% to issue prescriptions using Form 3? 59%

65% Can a family doctor provide MAT for drug 86% users? 21%

22% What doctors can issue prescriptions using 94% Form 3? 72%

51% Can MAT be prescribed for pregnant drug 100% users? 49%

55% What basic MAT drugs used in Ukraine do 100% you know? 45%

32% Please name the MOH order regulating the 89% use of drugs in healthcare facilities 57% Figure 3. Pre- and post-training participants’ evaluation results for MAT topic training.

80% 73% 70%

60% 57%

50%

40%

30%

20%

10%

0% Pre test Post test Figure 4. Pre- and post- training participants’ evaluation results for MAT topic training.

Pilot outcomes and best practices Pilot conferences will be conducted in seven regions in November-December 2017. In Year 5, HIVRiA will scale these pilots to all other rayons/cities within the seven oblasts. Pilot results will be analyzed in Year 5 and final reports developed. Based on pilot results, the project will develop two sets of guidelines and training materials. One training guide will describe how to develop and implement a sustainable model for the provision of HIV services, including how to fund critical

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services for key populations (KP) and people living with HIV (PLWH). The second set of training materials will be based on how to plan for, cost, and manage social contracts for HIV services by NGOs. Both the sustainability and social contracts training materials will be designed for use by local administrations and will be disseminated at the regional and national levels. These activities help integrate priority services for PLWH within the routine purview of the regional and local governments and supports sustainability and continuity of HIV services over time.

CROSS-CUTTING ACTIVITIES Gender Equality/Women’s Empowerment issues 1. HIV Reform in action Project conducted series of trainings for health care providers from pilot regions to reduce level of stigma and discrimination towards KP’s. Training methodology that we proposed was based on the materials from sister USAID Project RESPECT and was focus on communication and consultation skills (HCT methodology), including practice under trainer’s supervision; HIV legislation and clinical protocols overview; stigma index overview, including specifics of such KP’s as MSM, female PWID and pregnant women, HIV+ children. Each topic has number of practical exercise and modeling role situation from their day to day work and discussion of cases that may occur. Training questioner show that after the training health care providers show around 15% less stigmatize attitude towards KP’s, around 20-30 % of knowledge increasing on HIV. And what is more important number of trainees who pass this training where engage in HIV service delivery and reported that this training helps them to change their behavior and attitude to their patients. 2. The HIVRiA Project developed and shared the HIV Legal Environment Assessment (LEA) Report among key national and regional stakeholders. Report was made based on UNDP operation guide to conducting national legal assessment for HIV and includes analysis of legal environment for main KP’s to HIV, including not only MSM, but also LGBT community in general with specific emphasis on transgenders as new group that was included in UNAIDS Comprehensive HV Protocol in 2014. It is worth to say that it’s first national assessment that covers legal issues of all KP’s to HIV with gender-sensitive approach. Each part of the report includes clear recommendations on how to improve policies, laws, and regulations and may be serve as road map to advocate for legal changes in Ukrainian HIV-related policy. 3. The HIVRiA Project developed and shared the HIV Legal Environment Assessment (LEA) Report among key national and regional stakeholders. Report was made based on UNDP operation guide to conducting national legal assessment for HIV and includes analysis of legal environment for main KP’s to HIV, including not only MSM, but also LGBT community in general with specific emphasis on transgenders as new group that was included in Comprehensive HIV Protocol in 2014. It is worth to say that it’s first national assessment that covers legal issues of all KP’s to HIV with gender-sensitive approach. Each part of the report includes clear recommendations on how to improve policies, laws, and regulations and may be serve as road map to advocate for legal changes in Ukrainian HIV-related policy.

Institutionalization and Grants Management Table. List of sub-grants operated during the Y4Q4 (July 1 – September 30, 2017) Grant No Sub-grantee Title of project Period of performance STATUS name

09 HRH- NGO DEVELOPMENT Apr 01, 2016 – Dec 25, 2016 03/April 01, Ukrainian Center OF PUBLIC Mod 2: Close out process 2016 of Family HEALTH Apr 01, 2016 - March 31, 2017 Medicine (UCFM) CERTIFICATE Mod 3: PROGRAM April 01, 2016 – May 31, 2017

11 CO “All-Ukrainian CREATING THE Aug 01, 2016 – Mar 31, 2017 Administration of Advocacy/ Network of CONDITIONS FOR Mod 2: on-going grant August 01, PLWHA” A SUSTAINABLE Aug 01, 2016 – June 30, 2017 project. 2016 RESPONSE TO Mod 3:

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Grant No Sub-grantee Title of project Period of performance STATUS name

THE HIV July 01, 2017 – September 30, EPIDEMIC 2017

Mod 4: October 01, 2017 - 31 December 2017 12/02 – SD All Ukrainian OVERCOMING May 16, 2016 – Sep 26, 2016 Close out process /May 16, Charitable STIGMA AND 2016 Organization DISCRIMINATION, Mod 1 “Tochka Opory” INCREASING May 16, 2016 – Oct 15, 2016 GENDER SENSITIVITY TO SCALE UP ACCESS OF KPS TO HIV SERVICES: “FRIENDLY DOCTOR” 12/03 – NGO “Club Eney” OVERCOMING May 16 – Sep 26, 2016 Close out process SD/May 16, STIGMA AND Mod 1 2016 DISCRIMINATION, May 16– Sep 30, 2016 and INCREASING redesign of Milestones GENDER Description SENSITIVITY TO Mod 2 SCALE UP May 16 – Oct 07, 2016 ACCESS OF KPS Mod 3 TO HIV May 16 – Oct 31, 2016 SERVICES: Mod 4 EUROPEAN November 01 – November 30, CHOICE – 2016 “BUILDING STIGMA AND DISCRIMINATION FREE SERVICES” 12/04 – NGO "Initiative for OVERCOMING May 23, 2016 – Dec 23, 2016 Close out process SD/May 16, Life", Mykolayiv STIGMA AND 2016 DISCRIMINATION, INCREASING GENDER SENSITIVITY TO SCALE UP ACCESS OF KAPS TO HIV SERVICES: ANTI- DISCRIMINATION EDUCATION OF PROFESSIONAL COMMUNITIES 13 Region- Charity PILOT A 01 April 2016 – 30 September Administration of 02/April 01, Organization SUSTAINABLE 2017 on-going grant 2016 Mykolaiv's MODEL FOR THE project. Regional Fund PROVISION OF "Healthy Nation" CRITICAL Mod 2: No-cost extension SERVICES TO October 01, 2017, - December package KEY 20, 2017 prepared, POPULATIONS approved AND PEOPLE internally in LIVING WITH HIV HIVRIA Project AT THE RAYON and approved LEVEL IN USAID

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Grant No Sub-grantee Title of project Period of performance STATUS name

MYKOLAYIV OBLAST 14 Region- Kherson NGO PILOT A 01 April 2016 – 30 September Administration of 03/April 01, “Association XXI SUSTAINABLE 2017 on-going grant 2016 Stolittya” MODEL FOR THE project. PROVISION OF CRITICAL Mod 2: No-cost extension SERVICES TO October 01, 2017, - December package KEY 10, 2017 prepared, POPULATIONS approved AND PEOPLE internally in LIVING WITH HIV HIVRIA Project AT THE RAYON and approved LEVEL IN USAID KHERSON OBLAST 15 Region- Odesa Charity PILOT A 01 April 2016 – 30 September Administration of 04/April 01, Fund “Way to SUSTAINABLE 2017 on-going grant 2016 Home” MODEL FOR THE project. PROVISION OF CRITICAL Mod 3: No-cost extension SERVICES TO October 01, 2017, - December package KEY 20, 2017 prepared, POPULATIONS approved AND PEOPLE internally in LIVING WITH HIV HIVRIA Project AT THE RAYON and approved LEVEL IN ODESA USAID OBLAST 16 Region- the Cherkasy PILOT A 01 April 2016 – 30 September Administration of 05/April 01, NGO for PLWHA SUSTAINABLE 2017 on-going grant 2016 “Heart to Heart” MODEL FOR THE project. PROVISION OF No-cost extension CRITICAL Mod 2: package SERVICES TO October 01, 2017, - December prepared, KEY 25, 2017 approved POPULATIONS internally in AND PEOPLE HIVRIA Project LIVING WITH HIV and approved AT THE RAYON USAID LEVEL IN CHERKASY OBLAST 17 Region- Kyiv city Branch PILOT A 16 May 2016 – 30 September Administration of 06/May 16, of Network of SUSTAINABLE 2017 on-going grant 2016 PLWH MODEL FOR THE Mod 2: project. PROVISION OF 16 May 2016 - December 31, CRITICAL 2017 SERVICES TO KEY POPULATIONS AND PEOPLE LIVING WITH HIV IN KYIV CITY 03 HF-01/ AUCO “Ukrainian PREPARATION OF October 01, 2015 to May 31, Close out October -1, Institute on Public DATA FOR 2016 process. 2015 Health Policy” ECONOMIC Mod 1 by Aug 31, 2016 (UIPHP) ANALYSIS OF Mod 2 by November 30, 2016 HIV/TB Mod 3 by February 28, 2017 RESPONSE Mod 4 by May 31 PROGRAMS

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Grant No Sub-grantee Title of project Period of performance STATUS name

National Academy ADAPTATION AND June 19, 2017 – December 25, Administration of for Public INSTITUTIONALIZ 2017 on-going grant 18/1 HF 02/ Administration ATION OF THE project. June 19, under the HEALTH FINANCE 2017 President of AND ECONOMICS Ukraine (NAPA CURRICULUM Kyiv Institute of ADAPTATION AND Initial meeting Economics INSTITUTIONALIZ conducted; ATION OF THE Grant started. HEALTH FINANCE Administration of 18/2 HF 02 AND ECONOMICS on-going grant CURRICULUM project. Kyiv School of Data Collection for June 29, 2017 – September 30, Grant Award Economics (KSE) Capitation Rate 2017 approved by Development USAID and signed; Initial meeting conducted; Mod 1: Grant started. October 01, 2017 – December 31, 2017 Administration of on-going grant project. No-cost extension package prepared, approved internally in HIVRIA Project RFA 2017- and approved 20 USAID CO “All-Ukrainian Support the June 28, 2017 – July 28, 2017 Administration of Network of Ministry of Health on-going grant PLWHA” (MoH) in Mod 3: project. developing and July 29, 2017 - August 31, 2107 No-cost extension implementing Mod 4: package effective IT September 01, 2017 - prepared, solutions” (e- September 30, 2017 approved Health) internally in HIVRIA Project and approved USAID Close out RFA 2017 procedure started – 21 CO “All-Ukrainian Support the September 18, 2017 – RFA issued Network of Ministry of Health December 15, 2017 Applications PLWHA” (MoH) in collected and developing and evaluated. implementing Grantee selected. effective IT Grant negotiation solutions” (e- conducted Health) – 2nd stage Grant funding approved internally Approval package prepared and submitted to USAID RFA 2017 Grant Award – 22 approved by

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Grant No Sub-grantee Title of project Period of performance STATUS name

USAID and signed; Initial meeting conducted; Grant started. Administration of on-going grant project.

Note. For the List of sub-grants issued and extended under award during the reporting period (October 1, 2016 – September 30, 2017) please refer to the Annex to the Annual Report.

Capacity Building During Y4, capacity building activities concentrated mainly on non-governmental actors – both pilot- implementing organizations in Project regions and selected grantee NGOs implementing activities in line with Project objectives at the national and regional level. Having added two more NGOs in Y4 - Kherson (Association “21st Century”) and Pervomaysk (“Zdorova natsiya”), during the reporting period the Project has worked with all seven non- governmental organizations implementing pilot projects in the target regions, by offering them custom capacity building support. Four organizations - Krivyi Rig branch of PLWH Network, NGO Svitlo Nadii from Poltava, Zdorova Natsiya from Pervomaisk and Association 21st Century from Kherson - have completed CYPRESS cycles, culminating in creation of Performance Improvement Plans, with certain actions to mitigate gaps in prioritized organizational domains which needed improvement to achieve greater efficiency. In Y4, the Project provided targeted technical assistance to support implementation of Performance Improvement Plans’ for these organizations. Thus, individual strategic planning sessions were conducted with five organizations where the Project Capacity Building Advisor provided TA for development of strategic and relevant operational plans of these organizations (Krivyi Rig branch of PLWH Network, Cherkassy NGO “Vid sertsya do sertsya”, Zdorova Natsiya, Pervomaisk, Kherson Association 21 Century and Kyiv branch of PLWH network, NGO “100% of Life”). Other interventions included individual field and on-line consultations on operational and project planning, development of middle and top-level managers’ capacity, fundraising opportunities, etc. that led to organizational improvements, particularly in strategy/vision, HR and time management, and overall planning in these organizations. For example, in Poltava, the Project supported a series of on-the-job trainings and consultations for middle-level managers at the NGO Svitlo Nadii, in the framework of one of the PIP priority tasks to improve the capacity of midlevel managers. The project identified managers’ needs, and formulated and implemented a yearlong training program. On-the-job trainings and individual coaching proved to be successful approaches that allowed managers to develop solutions to daily challenging situations they encounter in their work. Other implementing partners received capacity building training based on initial needs assessments or existing capacity building plans and included tailored CB solutions. For a consortium of organizations in the Odesa region responding to a need for strong advocacy at regional and municipal levels, the Project provided legal assistance to incorporate organizational statutes officially. (These organizations included the NGOs Way Home and Veselka and the Odesa Collegium of Doctors.) The Kyiv branch of PLWH network, NGO “100% of Life”, received assistance in conducting an annual performance evaluation of its key personnel (senior and midlevel managers) and formulating recommendations for individual performance development areas, as well improvements for the system itself. The Project’s work with pilot implementing partners also included trainings on identified systemic gaps in knowledge and skills. This work strengthened capacity of partners by developing a cohort of professionals who can then train other professionals in similar fields. The Project has conducted two

39 more trainings in Y4, one of which covered topics such as health regulations, budgeting in health care, central executive authorities and agencies’ structure; and main legislative documents regulating health care in Ukraine, reforms in health care and decentralization. The training allowed participants representing CSOs to develop a more substantial understanding of the peculiarities of state administrations and the functions of self-governed bodies. Increased knowledge in these areas contributed to more harmonious implementation of pilot activities and better relations with regional stakeholders. Another training supported development of practical skills in strategic and operational management, HR management, delegation of responsibilities, electronic tools of planning and reporting, time management, internal communication. Participants discussed current practices of pilot-implementing organizations and formulating recommendations to improve organizational management. The project’s overall aim is to strengthen the organizational capacity of pilot-implementing partners, enabling them to replicate pilot concepts and develop their own capacity to provide technical assistance in the future. In Y4, the Project also provided TA in organizing a series of trainings on HIV testing using rapid tests in the framework of pilots: curricula were reviewed and updated, competent trainers selected, training planning, and reporting tools finalized. In parallel with implementers of pilot activities, Project’s grantees in various domains have also benefitted from CB support for their institutional strengthening. The "Ukrainian Family Health Training Center", Club Eney and Tochka Opory (Fulcrum) formulated goals of further developments and analyzed factors impeding their best performance, having completed individual Performance Improvement Plans. Thus, one of the priority tasks in Club Eney’s PIP was to formulate a communication strategy to rasie its visibility and improving its image. When working on the communication strategy, the organization realized the need to create an overall strategy for the organization. Club Eney has requested further TA to conduct a strategic planning session, which resulted in creation of a strategic plan for the development of the organization’s vision and mission. The All-Ukrainian Network of PLWH’s requested technical assistance for recommendations on its concept of community medical clinics “100% of Life” network. The Project has undertaken this task in cooperation with Deloitte Ukraine by assessing business processes. HIVRiA will present the results of this study in a joint report to the Network in Q1 of YR 5. In YR 4, the Project has re-evaluated partner performance, based on the CYPRESS methodology and Performance Improvement Plan results, and relevant changes in the institutional capacity of three organizations that completed their PIPs in 2015-2016: Krivyi Rig Branch of the PLWH Network, Ukrainian Institute of Social Studies named after O. Yaremenko and Poltava NGO Svitlo Nadii. Even though the organizations have not always achieved the desired improvement in scoring, and % of completed actions of PIPs varied from 18.75 to 75 % for different orgnisations, participants remarked that this process taught them to be more realistic in evaluating their potential, putting issues of organizational development on agenda and actually including them into their operational plans. Organizations have identified management weaknesses that they will address with HIVRiA through enhanced capacity building; some organizations have included capacity building as one of the strategic areas of their overall strategic plans. In YR 5, three more organizations will benefit from reassessment according to CYPRESS methodology. In terms of strengthening CB cooperation with governmental partners in YR 4, the Project has supported the Public Health Center of the MOH in developing institutional capacity. A series of meetings/interviews were held with the management of the Center dedicated on strategic development of the Center during a preparation stage, to be culminated in the strategic development workshop for MOH Public Health Centre. A strategic development workshop, organized and planned for July 13-15, 2017, was delayed due to conflicting priorities. In September, due to top management change uncertainty in the PHC, the event was postponed for YR 5, pending the decision on the Center's Director and Deputies. Similarly, organizational needs assessment for Kyiv Public Health Center has not been initiated in YR 4 due to delays in organization and official incorporation of the Kyiv PH Center by Kyiv City authorities. This activity will begin in YR5. Regarding provision of targeted capacity building interventions and trainings for change agents, during YR 4, the project identified and invited them to participate in several activities aimed at developing their individual capacity: trainings, round tables, seminars, courses, etc. In May 2017, the project organized a study tour to the US “Building the National Public Health System Responding

40 to the Population’s Priority Health Needs”, in partnership with University of California San Francisco (UCSF) and Californian public health departments at the city and state levels. The study tour was designed to generate a critical mass of reform-oriented change agents and advocates for public health and financing reforms, as well as the Ukraine HIV Fast-Track Initiative. A group of 10 national and Kyiv municipal policymakers and public health leaders representing the Ministry of Health, Parliament, Kyiv city health authorities, national and Kyiv public health centers, learned about the United States’ public health system through active conversations with public health professionals and discussed innovative approaches to bolster Ukraine’s public health reform strategy. After a week of site visits, the Project team and Deloitte facilitated a comprehensive strategy session, where participants synthesized lessons learned and discussed specific action plans to implement best practices within Ukraine. The tour resulted in strengthened capacity of national and Kiev city policy makers to support public health system reforms, design public health services that respond to priority needs, and determine how to fund these services through national and regional governments. High-level meeting which was scheduled for Y4Q4 and was supposed to be conducted in cooperation with MOH was cancelled due to changed circumstances and priorities of MOH.

Gender and Stigma Sensitization During Year 4 of the Project, the team provided TA to the LGBT community, including supervision and final reporting on the small grant for LGBT activists in Zaporizhzhya under Grant program of IX National LGBT Conference focused on promoting a stigma-free attitude toward community members. The project also provided TA to the Country Coordination Mechanism (CCM) Secretariat on a procedure to choose a candidate from the LGBT community for the first time so that interests of the LGBT constituency are represented. Regarding the selection process to CCM, the project delegated Ms. Makovetska to participate in the steering committee, ensure inclusiveness and transparency, and uphold the eligibility criteria of the candidate-selection process. In collaboration with the USAID Project RESPECT, the HIVRiA team conduct three trainings on “Tolerant attitudes towards people living with HIV and most-at-risk among health workers” for 73 physicians and nurses from the pilot regions of Bilhorod-Dnistrovskyi and Odesa, Pervomaysk, Kherson, Kryvy Rih, Poltava and Kremenchuk site, Kaniv rayon, and four rayons of Kyiv city, including new rayons. To optimize both partners’ efforts, HIVRiA based its trainings on RESPECT’s curriculum for post-graduate courses, adapted to PHC needs, and provided information on stigma and discrimination and the principle of HCT. These efforts will form tolerant behavior towards key populations. In addition to assistance mention above, the Project arranged for two three-day trainings for LGBT activists on involving the LGBT community to ensure a sustainable HIV response in Ukraine (Annex 34). During the trainings a number of topics were covered, e.g. primary principles of the Global Fund: community engagement, human rights and gender (CRG); constituency representation in CCM and advocacy in the name of community; and how to use the mechanisms of local state authorities’ consultative and advisory bodies to advocate for services for KPs. All participants mentioned that the information was new and necessary for them. Activists also reported that they feel more confident when working with local authorities because they were equipped with a toolkit of mechanisms and had reviewed the legislation to which they may refer while advocating for funds in local budgets.

Communication and Knowledge Management During the reporting period, the HIVRiA Project generated and published 149 news items on its website http://www.hivreforminaction.org/ in English and Ukrainian, with a target of 70 news items for Y4. At the end of the reporting period, the website attracted 18,444 unique visitors for Q1-4 Y4: 2,667 unique visitors in Q1, 5,284 unique visitors in Q2, 4,089 visitors in Q3, and 6,404 unique visitors in Q4. The project’s Facebook page (www.facebook.com/HIVReformUA) is dedicated to HIV reform in Ukraine and HIVRiA’s activities. At the end of the reporting period, the project’s Facebook page gained 193 new followers. This showed a 50.1% growth in the number of followers since the beginning of the reporting period (457 followers at the beginning of the reporting period vs. 690 followers at the end of Q4Y4, with a target of 650 followers for Y4). There were nine to 11 publications

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(posts) posted on the Facebook page per week. The average coverage of publications per week at the end of the reporting period is 2,726 readers. In Y4, the HIVRiA Project issued five editions of its newsletter (electronic and print) in both English and Ukrainian and distributed them among 600 HIVRiA key national, regional, local, and international stakeholders (Annex 35). One hundred thirty-eight media publications (media hits) occurred within the reporting year Y4, with a target of 40 articles for Y4. The publications presented information on the project’s activities to a wide range of audiences and were mostly dedicated to the progress of pilots in the seven project regions (Cherkasy, Dnipropetrovsk, Odesa, Mykolaiv, Poltava, and Kherson oblasts, and Kyiv City) regarding health reform and public health. Knowledge of HIVRiA’s impact continues to spread among HIV/AIDS stakeholders at the national, regional, and district levels as the project leads in the provision of the technical assistance to support the national HIV reform. During the reporting period, the Project developed, published, and distributed the following publications among stakeholders:  The policy brief on “Analysis of the Workload, Motivators and Incentives of Medical Personnel for the Provision of HIV Services in Seven Regions of Ukraine - Summary of Key Findings”  “The Strategy for Development and Planning of Human Resources for Health for HIV in Ukraine for the Period Until 2020”  “The Analysis of the Workload, Motivators, and Incentives of Medical Personnel for Provision of HIV Services in Seven Regions of Ukraine”  “Perceived quality of HIV care across different service providers: Understanding what drives client satisfaction with HIV/AIDS services in three oblasts of Ukraine” (in English);  “Legal Environment Assessment for HIV in Ukraine” (in English and Ukrainian); On November 21-23, 2016, the HIVRiA Project participated in the Third National HIV/AIDS Conference in Ukraine “Together for Every Life: Fast Track to 90-90-90” with ten project implementation lessons in the following spheres: MAT co-financing, HR capacity building for Fast Track, Public Health, HIV legal environment, and models of financing and decentralization for sustainability of services. The Project also provided a set of recommendations for the development of the conference concept and agenda through participation in the conference’s organizing committee. The Project participated in the conference information fair with the following:  two posters (Finance, Policy, and HR);  four information leaflets (Public Health Strengthening, HIV Legal Environment Assessment, Prospects of MAT co-financing, based on results of studies in seven regions; Analysis of the Workload, Motivators and Incentives of Medical Personnel, based on results of research in seven regions);  two publications (HRH Strategy and Analysis of the Workload, Motivators and Incentives of Medical Personnel (Summary)). On March 23, 2017, the HIVRiA Project participated in the International Conference “HR Policy in Health Care in Terms of Threats to Ukraine’s National Security." From May 24-26, 2017, the HIVRiA Project took part in the national conference "Topical Issues of Public Health System Development in Ukraine" in Uzghorod and provided technical support. HIVRiA presented the following topics to the national and international participants to increase awareness about the public health system reform in Ukraine: the new public health system and response to the health challenges at the local, national, and global levels; the HR forecasting tool for specialists of the regional public health centers; terms of reference and structure of potential regional public health centers; and the regional public health system.

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SECTION 2. HEALTH SYSTEM FINANCING REFORM SUPPORT

OBJECTIVE 2: IMPROVE AND OPTIMIZE RESOURCE ALLOCATION AND FINANCING FOR THE NATIONAL AND SELECTED REGIONAL HIV/AIDS PROGRAMS TARGETING KEY POPULATIONS

Sub-objective 2.4: Build the capacity of the national and selected regional/local GoU entities to design and establish a national purchasing agency HIVRiA rapidly initiated activities to support the health system financing reform. In support of MOH efforts to establish a national purchasing agency, HIVRiA brought health financing and health insurance experts to provide recommendations for the process of establishing the National Health Service and to draft the health insurance law. The technical note developed, ‘Establishment of a Health Care Purchasing Entity’, included an extensive list of recommendations on the draft health insurance law that was later refined into the draft law on medical guarantees No. 6327. The HIVRiA Project selected a team of legal specialists to support the MOH in legal issues crucial to implementing the reform. In addition, two consultants, a regional health reform coordinator, and a health financing reform coordinator were selected and placed at the MOH, providing short-term technical assistance (STTA). At the request of the MOH, HIVRiA supported MOH and NAMS in piloting a new payment mechanism. To fulfill Government Resolution #425, as of June 14, 2017, the orders were prepared and their endorsement secured from the Ministry of Health, Ministry of Finance, Ministry of Economic Development and Trade, Ministry of Justice, Antimonopoly Committee and NAMS. Order title No. and No. and Annex No. date of the date of joint order registration of the MOH in the and NAMS Ministry of Justice 1 On approval of model contracts for the provision August 14, Not Annex 37 of health services to the population for the 2017, No required implementation of the pilot project to change the 938/56 mechanism of financing the provision of health services in some research facilities of the National Academy of Medical Sciences 2 On the procedure for the referral of August 28, September http://zakon2.rada.g patients based on their health indications to 2017, No. 20, 2017, ov.ua/laws/show/z11 pilot project healthcare facilities, and for the 967/58 No. 60-17 provision of tertiary (highly specialized) health 1160/31028 care in such facilities 3 On the list of tertiary (highly specialized) August 28, September http://zakon2.rada.g healthcare services provided by pilot project 2017, No. 20,2017,No. ov.ua/laws/show/z11 facilities 967/58 1161/31029 61-17/paran4#n4 4 On calculation of fees for tertiary (highly September Work in Annex 38 specialized) healthcare services provided by 20, 2017 progress pilot-project facilities No.1123/64 5 On approval of fees for tertiary (highly September Work in Annex 39 specialized) healthcare services provided by 28, 2017, progress pilot-project facilities No. 1189 6 On the model agreement on the provision of October 23, Not Annex 40 health care to the population between the health 2017 No. required departments, general departments (offices) of 1925/71 the oblast, Kyiv city state administrations, and facilities of the pilot project on changing the mechanism of financing the provision of health services in some research facilities of the National Academy of Medical Sciences

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Legal support for implementation of the National List of Essential Medicines as a basis for public procurement in Ukraine was provided: In mid-2015, Ukraine began work to reform the National List of Essential Medicines in Ukraine (hereinafter - the National List). The World Health Organization's international practice of creating the Model List of Essential Medicines provides an example used by many developing countries. The purpose of this workstream is the development and legal support of the process of harmonization of draft regulatory and legal acts in the central executive bodies concerned, which are necessary for comprehensive functioning of the updated model of the National List. The approved model for defining the National List is constantly under review to incorporate international experience and realities of the Ukrainian health care system. Currently, several draft legal acts have been developed: 1) the Resolution of the Cabinet of Ministers of Ukraine “On Amendments to Resolution of the Cabinet of Ministers of Ukraine No. 333 as of March 25, 2009” (amendments to the current version of the National List); 2) the Order of the Ministry of Health of Ukraine “On Approval of the Procedure for Determining the Need to Purchase Medicines by Healthcare Establishments and Institutions Financed Completely or in Part from State and Local Budgets”; 3) the Order of the Ministry of Health of Ukraine “On Approval of the Regulation on the Use of the National List of Essential Medicines in the Process of Providing the Population with Medicines in Healthcare Institutions and Facilities Fully or Partially Financed from State and Local Budgets” (specifics of medical use of certain drugs included in the National List); 4) amendments to the Order of the Ministry of Health of Ukraine No. 84 as of February 11, 2016, “On Approval of the Regulation on the National List of Essential Medicines and the Regulation on the Expert Committee for the Selection and Use of Essential Medicines”; the Order of the Ministry of Health of Ukraine No. 1050 as of October 7, 2016; and “On Approval of the Regulation on the Selection of Medicinal Products for Inclusion in the National List of Essential Medicines". The above regulatory legal acts required legal support to review and incorporate them into the legislative documentation of the relevant executive bodies. The draft resolution “On Amending of Resolution No. 333 as of March 25, 2009 of the Cabinet of Ministers of Ukraine also needed amendments to align with the legal document “National List of Essential Medicines in the Process of Providing the Population with Medicines in Healthcare Institutions and Facilities Fully or Partially Financed from State and Local Budgets”.

Sub-objective 2.5: Support the MOH and relevant Parliamentary Committees to define and develop a basic benefits package of service, in consultation with civil society and patient organizations HIVRiA provided recommendations for the provisional list of services developed as part of the PHC basic benefit package. As the WHO Ukraine office is leading the process of basic benefit package (BBP) development, the HIVRiA Project initiated and hosted two coordination meetings with WHO representatives. A status-update meeting was arranged with a WHO expert from the UK. Attendees agreed that WHO will share the draft of a white paper on BBP development with partners for input.

Sub-objective 2.6: Support MOH and selected local authorities in the design and establishment of a performance-based payment system under ‘money-follows-the client’ approach 2.6.1. Support for Capitation Rate Development To conduct capitation rate development, the Project announced a grant and selected the Kyiv School of Economics as a grantee for relevant data collection and aggregation. Utilization and cost data- collection tools were developed. After defining the sample of regions and primary health care facilities, KSE began collection of utilization and cost data (Annex 41). A preliminary capitation rate for 2018 was calculated based on population, utilization, budget, tariff, and cost data from 10 regions and 100 primary health care facilities. In early November 2017, the project expects to present

44 capitation rates for 2018 to the MOH and other stakeholders for further implication of 2018 budget development process (Annex 42). 2.6.2. Primary Health Care Provider Autonomy

During the reporting period, the HIVRiA Project initiated technical assistance to two selected PHC centers in Balta and Tsarychanka hromadas focusing on operational and financial management in the capitation payment model. This pilot is aiming to create a successful, easily replicable example for other hromadas. Technical assistance covered the following components: 1. Legal support to Balta and Tsarychanka local authorities as well as PHC administration to change legal status of PHC centers into autonomous non-for-profit organizations with independent operational and financial management. As a result, detailed roadmaps were developed for each PHC center to become autonomous organizations (Annex 43). Each PHC center obtained a permit from local authorities to become a non-profit organization. It is anticipated that the legal status change will be completed within 3-6 months; 2. For each select hromada, the HIVRiA Project conducted IT environment and capacity assessments focusing on capacity to implement a medical information system (MIS) for the PHC network, further integrating it into the national e-Health system (Annex 44). As a result of the assessment, each pilot PHC received a comparison analysis of e-Health-compliant MIS available on the Ukrainian market, as well as a detailed list of technical recommendations for e-Health compliance. 3. The HIVRiA Project conducted two communication events for medical personnel of PHC centers to explain principles of health care reform, specifically PHC reform, and communicate pilot project objectives. More than 160 staff members of two PHC centers as well as local authorities' representatives attended the events. 4. The HIVRiA Project conducted training for PHC centers of the pilot hromadas on operational and financial management under the capitation model. A three-day training module was developed covering key topics of provider autonomy such as legislation and organization; strategic planning, facility operations, human resources, PHC group practice management and quality management. Core management teams of PHC centers, as well as local administration representatives attended the training. The HIVRiA Project also provides technical assistance to the MOH on developing an operational manual to develop primary care service provision at the local level. The projects facilitates the PHC working group for the guideline development. The manual will serve as a practical guide for PHC managers, doctors, and local authorities for effective transformation of a local primary health care provision. An informational booklet containing key concepts of the guideline was developed and the Acting Minister of Health presented it at the Lviv Publishers’ Forum for a broad community. (Annex 45). 2.6.3. Hospital Districts The Project provides technical assistance to regional administrations as well as hospital councils to develop strategic plans for hospital districts. In particular, the Project develops a specific tool based on the latest approaches for hospital districts strategic planning. The tool is designed to assist hospital councils in data management and use to generate well-informed integrated strategic plan which will depict a clear direction of development for each hospital within a hospital district. Within this activity, in August, the Project conducted a situational analysis mission, including Deloitte US experts, aiming at collecting up-to-date information with regard to hospital districts, data availability and readiness for strategic planning. Within the scope of the mission, a working visit to Poltava oblast was conducted where the Poltava oblast administration’s health department as well as hospital district representatives shared their experience in forming hospital districts and hospitals councils, their previous experience in hospital district strategic planning, lessons learned, and challenges faced. Based on the mission results, the Project team has developed a draft of a training manual and tools on hospital district strategic planning intended to be delivered in a workshop format to select leaders of hospital councils. These materials were developed by using latest international best practices and approaches adapted to the Ukrainian context (Annex 46).

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In September 2017, the project tested training materials in workshops designed to better customize materials and suggested approaches for strategic planning to the Ukrainian context and make the workshop more applied and hands-on for beneficiaries. Training materials were tested in Khmelnytskiy and Cherkaska oblasts, selected in collaboration with the MOH. Participants represented oblast health administrations, heads of the hospitals within formed hospital districts, members of hospital districts councils, and local authorities (hromadas). As a result of the testing workshops, local participants developed a list of key issues that regions are currently facing and that need to be addressed or clarified at national level before rolling out the hospital district strategic planning process. To address this issues and provide more clear guidelines to hospital district planners, the HIVRiA Project provided support to amend MOH Order #165, as of February 20, 2017, on standard regulations for hospital districts (http://www.moz.gov.ua/ua/portal/dn_20170220_165.html). As a part of this activity, the Project will keep on working with the MOH to clarify these issues so that regions can proceed with strategic planning for hospital districts and scale up this initiative across Ukraine. The project team also continues to finalize the strategic planning materials and tools that will be tested in one pilot district before the nation-wide dissemination.

Sub-objective 2.7: Support the National Purchasing Agency and MOH in developing and implementing effective IT solutions to launch, manage and administer health system financing reforms To effectively launch the healthcare reform, the Government of Ukraine is introducing a new e-Health system for clinical and financial data processing in the healthcare system. The HIVRIA Project supports the MOH to develop innovative IT solutions capable of supporting capitation and reimbursement processes. For this objective, the project awarded the CSO “All-Ukrainian Network of PLWHA” with grant funding in the amount of 3,598,404UAH, equivalent to $138,400. Under the award, the project expected the grantee to achieve the following objectives: 1. Develop a minimum viable product (MVP) for the e-health system, as a coded, tested, and usable piece of software capable of supporting capitation and reimbursement processes, designed by the MOH within the context of planned reforms. 2. Prepare a legal basis for smooth transition of developed products and relevant rights to the Government of Ukraine. 3. Ensure maximum data security for future scaling of an MVP and development of a universal, fully functional e-Health system in Ukraine. The HIVRiA Project effectively supported the e-Health Project Office of the MOH in areas of project management, methodology, and quality review and will continue to support the overall success of the project. This approach was possible due to establishment of an effective e-health team including HIVRiA Project local staff, STTA experts from Deloitte US and Deloitte Ukraine. The local teams handle day- to-day project progress and issues, while the US team lends its expertise and supervises project status and deliverables, facilitating resolution of major project issues and performing overall project coordination. HIVRiA supported development of core registries and started public pilot successfully with registration of medical facilities, doctors, and patients, and completion of patient declarations. The IT solution contains enhanced security mechanisms to protect sensitive data, and the security component is to be further developed and tested during the next stages. Security code analysis and security architecture review began with support from Deloitte Ukraine’s cybersecurity team. The Project also provided legal support for drafting the MOH order that allows official initiation of testing the components of the eHealth system. This order was adopted by MOH in September (http://www.moz.gov.ua/ua/portal/dn_20170907_1060.html). As the result, current pilot of eHealth MVP solution can fully support the capitation process with required reporting and integration with external medical information systems. Since the launch of the full capitation component, there are 503 medical facilities, 800 doctors and 148 patients already registered in the eHealth system.

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Legal experts from Deloitte Ukraine supported the process of transferring intellectual rights for the eHealth MVP solution over to the SOE that is going to maintain and support it, in production mode as well as legal support to launch the SOE is provided. As a result, the HIVRiA team has already commenced: • legal due diligence and preparation of legal documents required for the transfer of the product from TI-Ukraine to the newly established SOE as a representative of the MOH; • legal due diligence of the protection of personal data in the eHealth system; • legal due diligence of current waivers and personal data protection procedures for their compliance with the requirements of the law in Ukraine; • drafting of MOH essential orders, and a charter of the SOE. At the MOH request, HIVRiA initiated support for the next stages of eHealth MVP development, specifically to enable the drug reimbursement module. To support this area, on September 18, 2017, the “All-Ukrainian Network of PLWH” received a grant for $145,090. This component will provide the possibility to register pharmacies, access a dashboard for reimbursement, register medicines eligible for reimbursement, generate reports on dispensed medicines, create e-prescriptions, and dispense medicines based on e-prescription. During analysis of electronic reimbursement implementation within the eHealth system, the recommendations on amendments to the legislative regulations were provided, including developing legislative regulatory documents for electronic prescription. In order to assist MOH to align eHealth development with the health reform milestones, HIVRiA, with support from the Deloitte US team conducted a two-day strategic session on health-reform goals and eHealth main objectives (Annex 47). Over 50 representatives of national and international organizations involved in eHealth development discussed the key objectives of healthcare reform and introduction of eHealth as a modern electronic system for improved healthcare management.

Cross cutting: Strategic Communication and Knowledge Management Communication During Y4, the Project launched a range of activities to establish a sustainable internal communication system for the MOH and high-quality external communications to support health reform. The Project conducted a communications landscape assessment (Annex 48) as a first step in identifying gaps and major areas of MOH communication efforts. In May 2017, the Project held a strategic workshop on Communications for the MOH Communications Department. Major communications topics, key messages, and the list of activities were identified and became one the key parts of the future communication strategy of the MOH. In August 2017, the Project conducted a stakeholder mapping brainstorm session with the MOH Communications team (Annex 49) gathered more than 50 stakeholders to discuss stakeholder mapping and inform MOH Communication Strategy. In September 2017, the Project developed an outline of the new communications strategy (Annex 50) that will be discussed with MOH leaders in Q1Y5 to finalize the document. We recognize that visually engaging communication is critical to success in health-reform promotion. The Project developed and approved with the Minister of Health the MOH Brand Identity Concept (Annex 51). In Q1Y5, the Project will finalize the Brandbook of MOH with all tools and components on basis of mentioned Concept. It will make all MOH external communications recognizable, understandable, and accessible. The new MOH website will become a key source of information for the people and professional community. The Project conducted a Communications Task Force Workshop for the MOH website team and supported three advisors to develop high-quality content with a new philosophy of MOH website and efficient web communications. The Project developed an outline of the MOH Website Content Guidebook (Annex 52), which will be finalized in Q1Y5. The Project supported development, printing, and dissemination of 1 million copies of MOH Health Reform Newsletter. This newsletter was delivered to all health facilities in Ukraine. For a month, the newsletter was distributed on trains in Ukrzaliznytsya.

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During reporting period, the Project provided input on organizational design for the Communications Department of the MOH (Annex 53). This draft design can be modified according to the new approaches to administrative reform taking place in the MOH. The Project is working with the administrative reform team to finalize this design. Development of a tool-kit for internal communication of MOH is postponed until the administrative reform of the MOH is completed. MOH Thematic working groups As a result of the e-Health strategic session, HIVRiA recommendations and facilitation, the MOH launched thematic working groups working on core health reform components. The MOH coordination team nominated thematic group team leaders and provided milestones for each group (Annex 40). HIVRIA project staff leads three thematic WGs and actively participates in most of the others. Weekly meetings with Team-leads are held and they document and report on progress against key milestones, provide weekly reports. The project follows implementation of health reform activities and helps MOH manage risks working closely with all thematic group leaders. Knowledge Hub During the reporting period, the Project expanded capacity-building efforts to create a concept for the Knowledge Hub (KH), an on-line platform to respond to emerging technical needs and improve access for partner organizations and institutions to high-quality technical support and expertise. Knowledge Hub is a central repository containing products generated by the Project, a pool of experts trained in the use of these products, and an infrastructure allowing easy access to project resources. The hub will also serve as a clearinghouse for clients’ TA requests. A Needs Assessment Report has been prepared, analyzing and assessing demand for TA services from partners and providing profiles of stakeholders interested in receiving TA and the type of products that will interest them (Annex 54). The assessment is followed by a roadmap that will lay out the HIVRiA-stakeholder TA partnership. Preparatory work including inventory of research products and infrastructure development of the platform itself will continue into Y5, with KH planform launched in January 2018.

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PROJECT MANAGEMENT ISSUES The expansion the Objective 2 component in Y4Q2 to “Support Health Systems Financing Reforms” posed the greatest project management challenge in Y4. With the project expansion, the HIVRiA team had to quickly adapt, expand, and deliver results to complete the ambitious revised workplan. Existing HIVRiA staff took on additional roles/responsibilities in this new component and, at times, had to support the project in areas outside of their original technical roles. The operations team worked to quickly recruit and onboard new staff to support the component; however, finding highly- specialized and qualified candidates continued to remain a challenge and delayed HIVRiA’s originally planned recruitment schedule. In the interim, Communications Specialist, Technical DCOP, Objective 2 Lead and COP were crucial in providing surge support for health reform activities. The DCOP, and Director of Finance also assumed additional technical and supervisory roles for the new component while staff were being onboarded and trained. To support the new component, HIVRiA hired 5 full-time staff and 15 short-term resources, with 7 additional resources currently in the process of being hired. Multiple Deloitte US technical advisors were deployed to provide technical support and to coach and train new resources, in addition to advancing workplan activities. By utilizing existing HIVRiA staff in the interim and Deloitte US technical advisors, HIVRiA was able to effectively mitigate project management risks/issues and deliver results in Y4.

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RELEVANT INDICATORS FOR REPORTING PERIOD Section 1a. HIV REFORM SUPPORT

FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t

Purpose Indicators (indirect)

Project is reporting data on national spending on HIV/AIDS for year 2015. Data source: GAM Report 2017. According to the most recent NASA and GAM reporting, in 2015 $27,812,234.41 were spend from Public sources, $2,444,213.66 from Private sources and $65,269,348.16 from International Sources. 68% of all AIDS spending in 2015 were Domestic and from International sources. international HIV/AIDS $72,879, $116,979, $110,133, $85,236, $95,525, Actual AIDS spending by spending categories: 204 1 spending by USD ($) Jan-12 358 440 679 N/A 796 1. Treatment, care and support – financing sources (2010) (2012) (2013) (2014) (2015) $47,571,645; (PEPFAR – 2. Prevention of vertical transmission CO_FIN_NAT) of HIV – $2,756,498; 3. Prevention – $16,419,547; 4. Programmes for children and adolescents – $1,806,424; 5. Social protection – $986,874; 6. Community mobilization – $2,228; 7. Governance and sustainability – $25,042,486; 8. Critical enablers – $660,767;

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t 9. TB / HIV co–infection, diagnosis and treatment – $279,328. For more detailed disaggregation please refer to the Annex XX (2015 gam 8-1 en-ukraine)

To calculate data for this indicator, information from NAP 2014-2018 and Budget Passport for NAP was used. According to NAP, total sum of 1,269,528.97 thousand of UAH was planned to allocate in year Percentage of 2017. Among total sum, it was planned to the actual annual allocate 1,122,393.88 thousand of UAH from the budget State Budget. Actual State Budget allocations allocations for for year 2017, according to Passport of NAP NAP in the State program (approved by joint MOH and MF Order Budget Law of 2 % 36.1% Jan-13 36.1% 42.93% 39.85% N/A 75.86% #580/544 as of June 31, 2017) amounts to 851 Ukraine as a 477.4 thousands of UAH. portion of the originally This data does not include input from: approved  External donors such as PEPFAR, allocations in the USAID, CDC, Global Fund, NAP because their contribution is not a part of the State Budget.  Regional (oblast, rayon, city) budgets, because this information was not submitted to PHC timely and completely. Percentage and 0.98% 4.15% To calculate actual results for this indicator, the dollar value of % and 0.18% 0.8% 0.14% latest available NASA data was used (year funds spent for dollar $312,332. $1,154,59 3 $9,247 Jan-12 $16,433.9 $398,131.2 N/A 2015). Total HIV-related spending in Ukraine priority services (UAH) 4 7.7 (2010) (2012) (2013) (including all regional and national expenses) in targeting KPs value (2014) year 2015 amounted to $95,525,796 (exchange from the 51

FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t state/local rate 1USD = 21.845 UAH). Among those budget out of the expenses, total HIV-related  $9.064 were allocated Prevention, expenditures promotion of testing and linkage to from the care programmes for gay men and state/local other men who have sex with men budget in (MSM), selected regions. (PEPFAR)  $1,041.81 Prevention, promotion of testing and linkage to care programmes for sex workers and their clients,  $1,139,866.56 to Prevention, promotion of testing and linkage to care programmes for persons who inject drugs,  $6,371.21 to Prevention, promotion of testing and linkage to care programmes for prisoners

 $7,309.06 Prevention programmes for vulnerable and accessible populations from state/local budget out of $27,812,234.4 HIV-related expenditures from state/local budget. It should be noted that expenses on ARV and VCT were not disaggregated by KP/General population due to NASA methodology. Hence, data on ARV and VCT were not included into the reporting indicator.

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t Percentage of adults and children known to be alive and on As of the most recent data in Ukraine GAM 85.5 4 treatment 12 % 85.4% Jan-15 - 85.4% 85.5% 85.92% report 2017 the 12-months retention rate for % months after patient cohort initiated ART in 2015 was 85.92% initiation of antiretroviral therapy As of September 1, 2017, according to reports Percentage of 68,313 / issued by PHC, 84,570 PLHIV were receiving adults and 65,775 / ART. 30.6% 115,9 children currently 55,784 / 55,784 / 25.8% 84,570 / 5 # / % Jan-14 40 / Percentage of adults and children who meet the receiving 23.8% 23.8% (increase (increase 35.5% N/A eligibility criteria of antiretroviral therapy antiretroviral d by 2%) d by prescription and who currently receive it, amount therapy (ART) 4.8%) to 35.5% (of the estimated size of PLHIV population)

Number of As of September 1, 2017, according to reports people who inject issued by PHC, 9 806 PWID were on MAT. 8,525 / 7,784 / 8,385 8,881 9,806 6 drugs (PWID) on # and % Jan-14 6.5% According to the latest KP size estimation, MAT 2.75% 2.51% medication 2.7% 2.86% 2.8% coverage for PWID is 2.8% that is quite lower assisted therapy than expected in the reporting period. Percentage of HIV-infected 55.1% As of January 1, 2017, according to the reports individuals with 62.2% Or issued by PHC, the number of newly detected 7 late diagnosis % 53.6% Jan-13 53.6% 53.43% 40% 55.6% 45.1% HIV cases was 14 334, among them – 7 961 stage III-IV 43.8% (55.6%) with stage III-IV. among all new diagnoses

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t Number and percentage of 111,6 As of September 1, 2017, according to the HIV-positive 43,790 / 50,402 / 47,811 / 43,344 / 60 / 41,576 / 8 # and % Jan-14 reports issued by PHC, 41,576 HIV-positive patients who 78.5% 79% 72.7% 63.45% 96.3 49.1% patients or 49.1% received ART funded by GoU. receive ART % funded by GoU

Outcome indicators

Stage The GoU adopts On March 22, 2017, the Cabinet of Ministers of national (1- Ukraine (CMU) adopted the Strategy for a HIV/AIDS initiated, sustainable response to TB, including drug- Sustainability 2-drafted, resistant TB, and HIV/AIDS for the period until 9 1 Oct-15 - - 1, 2, 3 4 4 strategy for the 3- 2020, and approval of its action plan phase-out of the adopted, (http://www.kmu.gov.ua/control/ru/cardnpd?doc Global Fund by 4- id=249913834). The Strategy is currently 2017. implemen implementing. ted)

Stage National Public (1- Health Strategy initiated, On November 30, 2016, the Government of reflects HIV/AIDS 1 2-drafted, Ukraine (GOU) has approved the Public Health strategic 1 Oct-15 - - 1, 2 3 4 0 3- System Development Concept of Ukraine, and priorities and ‘90- adopted, its implementation plan. 90-90 UNAIDS 4- Strategy’ goals. implemen ted)

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t

During reporting period, 1 RAPs was developed and approved by RCCs:  Kyiv city HIV Program for 2017- 2021 (December 08, 2016) 4 LAPs:  Bilhorod-Dnistrovsky rayon HIV Program (October 28, 2016) Number of RAPs  Bilhorod-Dnistrivsky ciry HIV and LAPs with Program (October 30, 2016) 1 budgets # 0 Oct-14 - 14 3 1 5  Kryvyj Rih city Program “Zdorovia 1 prepared in Natcii” for 2017-2021 (December selected regions 21, 2016)  Kryvyj Rih rayon Program “Zdorovia Natcii” (December 24, 2016) Additionally, 4 addendums to existed local Programs (Pervomaisk rayon = December 23, 2016 and February 22, 2017, Poltava city – January 31, 2017, Pervomaisk city – February 23, 2017).

During the reporting period, 7 pilot projects on alternative approaches to deliver/finance HIV Number of pilots services were launched on 14 geographical on alternative locations and 7 (10 locations) of them continue 1 approaches to implementation of the alternative approaches to # 0 Oct-14 - 0 6 7 7 2 deliver/finance deliver/finance HIV services (social services) HIV services through resource allocation for services from implemented local state budgets:  Pervomaisk city & rayon  Kherson city

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t  Bilgorod-Dnistrovsky city  Poltava city and Kremenchug city;  Kaniv city and rayon;  Kryvyy Rih rayon;  Kyiv city During the reporting period, the activities on piloting were initiated and as result 7 pilot regions (or 8 administrative areas) implemented of the alternative resource allocation and financing options for HIV Number of services: alternative resource  Pervomaisk city (social services in field 1 allocation and of HIV response, MAT co-payment) # 0 Oct-14 - 0 6 7 7 3 financing options  Kherson city for HIV services  Bilgorod-Dnistrovsky city& rayon implemented in  Poltava city (on MAT services) selected regions  Kremenchug city  Kaniv city& rayon (MAT site, social services contracting)  Kyiv city (social services contracting)  Kryvyj Rih rayon (social services contracting) Number of change In Project Y4, the list of the national/ regional/ agents/champion local change agents/champions was updated. s enrolled and 1 trained who put # 0 Oct-13 -0 9 22 30 42 During the reporting period, 42 change agents 4 the new were trained and started to put into practice skills/tools / new skills obtained during training sessions approaches into supported by the Project. practice

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t

Key Output indicators

During the reporting period, more than 22 regulatory documents were developed/reviewed due to the Project’s evidence-based recommendations and endorsed/applied by GoU at different levels:  National public health concept endorsed by CMU (November 30, 2016)  Local policies and orders to pilot MAT co- Number of payment model (Pervomaysk, Odesa city regulatory and Bilhorod-Dnistrovskyi city) documents  Kyiv City AIDS Program (December 08, developed/ 2016) reviewed due to  KCSA resolution about Kyiv City PHC the Project`s 1 establishment (December 22, 2016). evidence-based # 0 Oct-13 0 19 16 17 22 5  MOU between KCSA and Kyiv Pilot NGO recommendation (February 16, 2017) s that are  Strategy for a sustainable response to TB, endorsed/ including drug-resistant TB, and applied by GoU HIV/AIDS for the period until 2020, and (national/regional approval of its action plan endorsed by /local) CMU (March 22, 2017)  4 Local AIDS Programs (Bilhorod- Dnistrovsky rayon HIV Program (October 28, 2016), Bilhorod-Dnistrivsky ciry HIV Program (October 30, 2016), Kryvyj Rih city Program “Zdorovia Natcii” for 2017- 2021 (December 21, 2016), Kryvyj Rih rayon Program “Zdorovia Natcii” (December 24, 2016)

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t  Joint order of MOH and MSP  Draft order of the Health Department on the organization of health care for PLWH  Kyiv City Order on opening new MAT sites  Orders on MAT co-payment implementation  Kyiv City PH Center establishment documents  Local orders and protocols for HTS and MAT Number of certification programs/course During the reporting period, the Project s on public successfully works on developing and health, institualization of HIV/Healthcare-related healthcare courses into the higher educational curricula in 1 budgeting/analysi # 0 Oct-14 - - 2 1 2 Ukraine: 6 s developed and  Certificate training course “Modern introduced in the Aspects of Public Health” teaching  Course “Economics and Financing of programs of the HealthCare” (August 29, 2017) educational institution

Number of person-courses During Y4, total number of 1510 participants completing in- (representatives from national and local state 1 service training # 0 Oct-13 8 401 504 930 1510 institutions, NGO sector, and academic 7 within the institutions) completed trainings, workshops and reporting period technical seminars. (PEPFAR)

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FY Baseli FY 2014 FY 2015 FY 2016 2017 FY 2017 Unit of Indicator Baseline ne Comments Measure PY1 PY2 PY3 PY4 PY4 Date Results Results Results Targe Results t Number and percentage of partner organizations 1 provided with # and % N/A - - - - 85% 80% 8 capacity building activities and improved their score Percentage of improvement in For grantee organizations which have received self-assessment support in 2015, Yaremenko Institute has 1 scores of partner % N/A - - N/D N/D 80 80 completed its Performance Improvement Plan in 9 organizations October 2015, hence, re-assessment was provided with conducted after October 2016. capacity building activities The Strategy for Development and Planning of National 5-year Human Resources for Health in HIV in Ukraine Qualitativ plan for HRH for the Period until 2020 has been endorsed on e scale planning and September 9, 2016 by the Program Committee 2 (see management 0 Oct-13 0 1, 2, 3 3 4 4 of the National TB and HIV/AIDS Council of 0 operation strategy aligned Ukraine. al with NAP is definition) During Y4 HRH Annual Operational Plan for introduced 2017 was developed and used by created ISHRWG on regular basis.

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Section 1b. HEALTH SYSTEM FINANCING REFORM SUPPORT

Unit of FY 2017 FY 2017 Comments Indicator Baseline Baseline Date Measure PY4 Target PY4 Results

Specific impact indicators (standard the U.S. Foreign Assistance indicators)

TA provided in strengthening the Universal Health Coverage (UHC) 21 # NA JAN 2017 2 2 essential package of health services implementation score (EPHS)

The Project intensively contributed to Strengthening integration of Health developing and functionality of eHealth 22 Yes/No NA JAN 2017 Yes YES Information Systems (HIS) data system in Ukraine. The Project also initiated

Training for PHC centers managers and doctors on “Management of health care Number of government officials receiving 23 # NA JAN 2017 15 18 institutions under the PHC reform” USG-supported anti-corruption training covered also topics on anti-corruption topics

Outcome indicators

1. Legal framework for implementation A legal and organizational framework for 3-point of health financing reform developed 24 effective operation of the National NA NA 1, 2 2 score Purchasing Agency developed 2. Recommended regulatory changes partially adopted

# of primary health care providers N/A to the reporting period 25 introduced operational management # 0 MAR 2017 0 0 under capitation model # of regional administrations equipped N/A to the reporting period 26 with toolkits for hospital district strategic # 0 MAR 2017 TBD N/A planning Key output indicators

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Unit of FY 2017 FY 2017 Comments Indicator Baseline Baseline Date Measure PY4 Target PY4 Results

Number of regulatory documents Specification provided in the report text developed/ reviewed due to the Project`s (Section “Health Reform Support”) 27 evidence-based recommendations that # 0 MAR 2017 2 12 are endorsed/ applied by GoU (national/regional/local) Due to the planned activities 7 different Number of tools, guidelines, strategies 28 # 0 MAR 2017 7 7 tools/guidelines/strategies were developed developed during the reporting period.

Number of events supported by Project: During the reporting period, more than  Communication events 10 various events were conducted with Project’s support. Among them are 29  Workshops/Stakeholders # 0 MAR 2017 3 10 meetings related to PHC autonomy activities,  Trainings Hospital Strategic planning, MOH  Etc. Communication and eHealth. On September 19-21, 2017, the Project Number of in-person-courses completing held Training for PHC centers managers 30 in-service training within the reporting # 0 MAR 2017 15 18 and doctors on “Management of health period care institutions under the PHC reform”, Odesa

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EVALUATION OF ACTIVITY WITH RESPECT TO ENVIRONMENTAL IMPACT Regarding Initial Environmental Examination (IEE) conditions 3.1.5, 3.1.6 of the Cooperative Agreement, project activities for the reporting period did not have adverse impacts on human health. Certain activities, which are linked to IEE 4.1.2, 4.1.4 were continued (Legal Environmental Assessment, TA to Public Health Department of MOH and Kyiv City SA to establish Kyiv City Public Health Center and prepare Kyiv City Fast Track HIV/AIDS Program) and potential positive impact on health of target population (PLHIV, KPs) is expected in long-term period. Activities on Kyiv City RAP development were successfully conducted in Q4Y3-Q1Y4 (IEE 4.1.5), thus positive impact on health of target population (PLWH, KPs) is anticipated.

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PROJECT ACTIVITY MONITORING MATRIX

SECTION 1. HIV REFORM SUPPORT This report illustrates progress by symbols in color code:  Dark green: Completed,  Light green: Ongoing,  Yellow: Delayed,  Orange: Cancelled  Red: Not completed. In Y4, of total 113 tasks:  89 tasks were completed,  12 tasks are ongoing,  0 tasks were not initiated,  7 tasks were delayed,  5 tasks were canceled.

Y4 Tasks completeness ratio – 78.7 % Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV Objective 1: Enhance national leadership and capacity for evidence-based and gender-sensitive HIV policy programming and implementation Sub-objective 1.1: Support national government institutions in AIDS policy development, programming and implementation National public 1.1.1. Strengthening Provide TA to MOH PH National public health # of concepts 1 X X X health concept MOH capacity in TWG in finalizing PH concept finalized and approved by and national public health concept and endorsed CMU implementation policy development, implementation road road map reflects including HIV/AIDS map. HIV/AIDS programming strategic priorities Completed

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Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV HIV surveillance, 1.1.2. Technical Develop Terms of TORs developed #TORs 3 X X X programming and assistance in Reference for HIV units developed monitoring organizational of NPHC functions development of HIV established and related units of the operational at the NPHC NPHC Completed National partners 1.1.3. TA to develop Prepare analytical report Consensus reached by # of analytical 1 X X equipped with regulations and design based on the national partners on report data for informed and test co-payment international experience the need to implement prepared decision making scheme related to ART of the implementation of co-payment scheme regarding provision ART co-payment related to ART introduction of mechanism provision ART co-payment mechanism in Ukraine Completed Present report results to # of 1 X Х stakeholders stakeholders meetings conducted Completed Social service 1.1.4. Project Support TWG under Joint order of MOH # of orders 1 Х Х X Х provision and continues supporting MOH to develop the and MSP endorsed by endorsed social contracting MOH and MSP in order for the approval of the TWG protocol endorsed developing social the Procedure for by MOH and MSP services and social planning and provision joint TWG contracting of social services for mechanism at the local prevention, care and

level. support to families (individuals) affected by HIV/AIDS and TB. Completed National HIV 1.1.5. Create Provide TA to UCDC/ Comprehensive HIV # of 1 X X X X management conditions to scale up NPHС in preparing HIV management guide is comprehensiv guidelines access to treatment for management guide prepared, adopted by e HIV reflecting new KPs (continued from Y3) MOH and management WHO disseminated in the guidelines recommendations regions. adopted Ongoing

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Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV endorsed by the Conduct 2 workshops Regional # of 2 X X national MOH for presenting and implementers’ workshops discussion with regional feedback reflected in partners the final draft of HIV management HIV management guide guide Completed National and 1.1.6. Support Continue supporting AIDS Program # of functional 1 X X regional functionality of the functionality of the AIDS Dashboard is AIDS Program stakeholders AIDS Program Program Dashboard operational and Dashboards (MOH, NPHС, Dashboard (updating/upgrading updated with 2016 oblast functionality, when data administrations, necessary) health care providers, NGOs and patients) are equipped with the visual evidence- based data on RAP implementation and results.

Completed Sub-objective 1.2: Strengthen capacity of local government entities in implementing regional AIDS programs with emphasis on key affected population Kyiv City AIDS 1.2.1. Support Kyiv Support in developing Kyiv City AIDS # of RAPs 1 X X X Program reflects City State Kyiv City AIDS Program Program developed endorsed FTCI targets Administration in the (Municipal AIDS Plan) and funds allocated implementation of the and annual budgets «Fast Track Initiative» based on FTCI targets in the Kyiv City Completed MAT and harm Develop plan for MAT Procurement plan # of local 1 Х Х Х reduction and harm reduction developed based on orders commodities are commodity procurement a municipal program prepared procured to in Kyiv City ensure the implementation of the Fast Track targets in Kyiv Completed

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Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV HIV+ IDPs’ Policies to facilitate Policy to ensure # of local 1 Х Х Х access to access of HIV+ IDPs to access of HIV + IDPs orders treatment and treatment and care to treatment and care prepared care scaled up services developed developed Completed HIV+ non-official Policy on how to ensure Policy to ensure # of local 1 Х Х Х Kyiv City that HIV+ non-official access of HIV + non- orders residents get residents have access official residents to HIV prepared access to HIV to HIV services services developed services developed Completed HIV Services Jointly with KCSA, Pilot work plan # of local 1 Х X Sustainability Pilot identify additional updated memorandum launched in two districts for launching signed more districts of HIV Services Kyiv Sustainability Pilot (see. Sub-objective 1.3) Completed Kyiv municipal 1.2.2. Provide TA to PH system analysis KCSA received # of analytical 1 Х public health KCSA to set up city prepared for the city of recommendations and notes center established public health centers: Kyiv guidance on the prepared working meetings held, establishment of the TOR drafted public health center Completed Provide legal support for Package of documents # of local 1 Х Х Х the registration of a new prepared orders structure within the prepared State Registration Service Prepare draft decisions of the oblast council on public health reform Completed Sub-objective 1.3: Conduct advocacy, Improve dialogue and ensure transparent policy development environment Available data 1.3.1. Craft Conduct analysis to Study incentives and # of analytical 1 X X and information of informational understand the constraints of the local reports effectiveness of packages for landscape of local and national prepared funding of stakeholders on the stakeholders, their stakeholders in National AIDS long-term costs of HIV incentives and advocating for funding program and effective constraints and relations of AIDS programs and synthesized and strategies to halt the among one another HIV reform in general used to optimize epidemic. resource allocation Completed 66

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV Analyze the current Narrative report about # of analytical 1 X X status of financing and current status of reports implementation of the financing of HIV/AIDS prepared national and 3 regional activities from national HIV/AIDS programs and regional budgets Completed Analyze targets of the Narrative report with # of analytical 1 X X national and regional the analysis of targets reports HIV programs in terms of the national and prepared of their compliance with regional (covering all 90-90-90 targets focal regions) HIV programs in terms of their compliance with 90-90-90 targets Completed Conduct series of Working group # of working 3 X X X working group meetings meetings to discuss groups with Ministry of Health, results of the analysis conducted UCDC, Ministry of Finance to discuss results of the analysis and develop consensus on adequate financing of HIV/AIDS programs. Completed Revised AIDS 1.3.2. Conduct Conduct series of Consensus achieved # of working 3 X X plan and/or advocacy activities consultations with the with stakeholders on groups annual budgets aimed at the revision CMU, MOH, MOF and whether national AIDS conducted reflect updated of targets of the NAP other national program needs to be ART targets (for with a focus on stakeholders regarding changed Fast Track and scale-up of ART and changes to current 90-90-90) MAT/OST coverage HIV/AIDS programs based on UNAIDS Fast Track Strategy

Completed Conduct press- Conduct press- # of press 3 X X X conferences advocating conference advocating events for the revision of for the revision of conducted targets of the NAP with targets of the NAP with a focus on scale-up of a focus on scale-up of ART and MAT/OST ART and MAT/OST Ongoing 67

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV coverage based on 90- coverage based on 90- 90-90 targets 90-90 targets Adequate funding 1.3.3. Conduct high Organize and facilitate High level meetings at # of high level 1 X of national AIDS level meetings to inter-sectorial working the national level to meetings program secured agree on funding group (MOH, MOF, secure funding for HIV allocations for the UCDC, MPs) to review

national HIV program strategies for financing for 2017-2018, and National HIV/AIDS scale-up program Completed Documented evidence National 1 X X of securing state budget with funding for HIV adequate programs provided funding of the national AIDS program Completed National 1.3.4. Develop and Conduct series of Sustainability Strategy, # of strategic 1 X X HIV/AIDS conduct advocacy consultations with the including documents sustainability activities aimed at the Cabinet of Ministers, implementation plan, related to strategy and adoption of the HIV/TB MOH regarding adoption endorsed by CMU HIV/AIDS implementation Transition and of the sustainability Sustainability plan prepared and Sustainability Strategy strategy Strategy endorsed by CMU and implementation Advocate for and adopted by plan support the adoption of CMU. the Sustainability Strategy by CMU Completed Local budgets 1.3.5. Conduct Round tables, press Advocacy events at # of regions, 3 X X reflect funding regional level events events and advocacy the regional level, to where there is disbursed for all with OSAs, regional meetings with key secure funding for HIV documented appropriate MPs and other key stakeholders (AIDS activities completed evidence of services stakeholders to draw centers, OSA, NGOs) securing attention to HIV aimed at securing local funding for program funding and funding conducted regional HIV ensure allocation of programs oblast resources for RAPs Ongoing Objective 2: Improve and optimize resource allocation and financing for the national and selected regional HIV/AIDS programs targeting key populations Sub-objective 2.1: Develop evidence pool to create support for funding decisions in HIV response at the national and regional level Recommendation 2.1.1. Use Investment Identify & present a set Recommendations # of Study 1 X Overall the delay of s developed for Case II study results in of (most cost-effective) developed for national Reports Delayed the activity 68

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV national partners pilot regions to inform services for financing at and regional partners prepared and associated with 1) on most cost- MOH the regional level (based on most cost-effective disseminated collected data quality effective recommendations on on the region’s HIV interventions and issues, 2) interventions and how to shape the most epidemiological profile). modes of HIV service methodological modes of HIV cost-effective mix of provision changes, 3) study service provision. HIV services (with team changes. Action plan biggest long-term developed for impact on HIV/AIDS). optimized allocation of resources for HIV services in a pilot region Action plan developed # of 1 X X Activity is shifted to optimizing resource comprehensiv Y5 allocation for HIV e action plans services, based on results of IC Study Delayed Organize a stakeholder Stakeholder meeting # of 1 X Planned on the week meeting to present study held for presenting and stakeholder of November 13-17 results and discuss its operationalizing study meetings implications for further results. NAP development Delayed Sub-objective 2.2: Support the development of HIV strategies and policies at the national and regional level which reflect optimized resource allocation and lead to the most cost-efficient and effective. Cost-effective 2.2.1. Developing Provide TA to the MOH Policy paper with # of policy 1 X The study report was approach for operational plans for for updating standards recommendations papers/ finalized and policy scaling-up usage scaling up rapid HIV regulating Rapid HIV developed for MOH recommendati paper is expected by of rapid tests in test usage in Testing provision ons developed the end of October prevention prevention programs in programs is the pilot regions in adopted by MOH Ukraine Ongoing Regions received Assist MOH and GF Working meetings held # of working 2 X X optimized model PRs in estimating with regional partners meetings (procurement and financial needs for on projecting financial supply) for HIV scaled-up Rapid HIV needs for Rapid HIV diagnosis Test provision tests provision Completed

69

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV Financial projections # of 1 X X developed for Rapid projections HIV tests provision developed (across financial sources) Completed Design Rapid HIV tests Regional operational # of 2 X procurement plans for procurement plans procurement regions developed for HIV plans rapid testing provision submitted for approval by regional authorities Completed HIV expenditure 2.2.2. Build capacity Support the Piloting completed in # of piloting 2 X monitoring within GoU for data implementation of NASA Kyiv City and reports and (NASA) is fully and analysis (NASA online tool pilots in Kyiv Dnipropetrovsk region recommendati institutionalized at institutionalization) City and Dnipropetrovsk ons prepared the national and region regional levels Completed Develop combined Guidelines developed # of guidelines 1 X guidelines for reporting and submitted for developed about HIV expenditures approval by based on adapted UCDC/MOH. NASA and using NASA online tool Completed Provide trainings for Trainings held for # of people 40 X X Activity planned in regional partners on regional partners on trained Y5 using NASA online tool using combined NASA and NASA tool guidelines Cancelled PBF framework 2.2.3. Develop Elaborate and present (Draft) PBF framework # of PBF 1 X X X Initially, it was mechanisms and innovative financing for field-testing and mechanisms designed guidelines planned to introduce supporting and budgeting approval by the MOH and submitted for prepared PBF approach contracting tools mechanisms to and MOF performance- consideration and together with new for HIV services improve allocative and based funding approval by the MOH, financial provision technical efficiencies in framework mechanism MOF mechanisms. Based designed, tested HIV programs in primary HC settings on international TA it Piloting performance- was concluded that based funding Cancelled piloting PBF model 70

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV and submitted to framework mechanism during 6-months MOH, MOF in primary HC settings period (starting from for HIV services in 1 January 1, 2018) is

region conducted (Kiev not efficient. city or Poltava region) International best experience suggests that applicable timeframe to pilot PBF model is up to 2 years (Annex 15) Working group meeting Stakeholder working # of working 2 Х Х held with stakeholders group meetings groups (representatives of organized to discuss conducted MOF, MOH, etc.) to PBF policy discuss PBF policy recommendations recommendations Ongoing Provide assistance to Joint PBF Principles # of policy 1 Х MOH, MOF in approving and Practices policy papers a Joint PBF Principles paper by the MOH and developed and Practices policy MOF elaborated paper Cancelled National workshop held Joint workshops held # of 1 Х on PBF Principles and with the MOH and workshops Practices (including for MOF on PBF conducted HIV services) Cancelled Capacity of 2.2.4. Training in Pilot PHC contracts in Training provided for # of people 20 X national and managing Kyiv City, including HIV Kyiv City authorities on trained regional health decentralized HIV services feasible for designing and costing specialists/ budgeting and funding PHC provision a typical PHC contract economists in (for Kyiv City) healthcare budgeting/analysi s is improved Completed Key Test & 2.2.5. Provide TA to Break down Test and Summary prepared of # of 1 X X START MOH to cost Test and START Strategy into a the Test and START summaries interventions START Strategy set of service packages Strategy implications prepared costed and to be costed. specifying the types of Completed

71

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV financial needs interventions to be projected costed

Hold consultations with Round of consultations # of working 2 X The second national stakeholders to held with national meetings consultation meeting discuss and approve stakeholders. is planned in general principles and November 2017 important parameters for costing Test and START Strategy components. Ongoing Cost Test and START A comprehensive # of 1 X The activity is in Y5 activities (services) account developed of comprehensiv WP costed Test & START e reports interventions, prepared specifying direct, indirect/overhead cost and estimated uncertainty Ongoing MOH provided 2.2.6. Build capacity Develop, in collaboration Typical algorithms # of algorithms 3 Х Х Х with guidelines for within GoU for public with WHO, algorithms developed for PH care with reference financing and health financing and for PH services services provision, costs budgeting public budgeting, including provision, specifying including for HIV- developed for health programs HIV programs types of services, related services agreed list of providers, modes of PH

payment for services, interventions. scope and timing of interventions Completed Set up a Working Group Working group # of 3 Х Х (MOH, MOF, UCDC) for meetings held for recommendati developing PH financing developing PH ons on PH and budgeting financing and financing and methodology budgeting budgeting methodology. developed by the Working Group. Completed Develop guidelines for Guidelines developed # of guidelines 1 Х The finalization of budgeting PH programs for budgeting PH for regional Ongoing the guidelines for 72

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV programs at the authorities on budgeting PH regional level PH program programs was budgeting postponed to the developed moment of implementation of the related changes in Budget Code Sub-objective 2.3: Strengthen capacity of national and regional partners in finance planning, budget preparation and execution to match the needs to optimized HIV/AIDS service-delivery operations Capacity of 2.3.1. Implement and Designing a course(s) Model course # of study 1 X X Ukraine institutionalize national on health developed and used course plans educational health system and systems/health financing as a framework for developed institutions health financing based on the Harvard spinoff courses by (NAPA, KSE, training course(s) Flagship Course NAPA, KSE, KMBS KMBS) is strengthened in teaching Health systems/health financing Ongoing Capacity of Harvard faculty provides Distance learning and # of curricula 1 X X X national and local faculty coaching workshops organized implemented regional health and course supervision for NAPA, KSE, KMBS and specialists/ through organizing supervised in economists in distance learning and national health workshops for NAPA, educational systems/health KSE, KMBS to institutions financing is institutionalize training improved course by incorporating it into curricula Ongoing Conduct health Course conducted # of people 20 X This activity was systems/health financing trained delayed because of training course for education year national and regional timeline in Ukraine specialists which starts from September, thus activities on curricular Delayed institutionalization

73

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV were not able to be initiated earlier. Electronic public 2.3.2. Advocacy and Conduct feasibility Prepare # of reports 1 X X procurement TA to the MOH and assessment for recommendations on prepared system (ProZorro) oblasts to procure implementing ProZorro options for use successfully MAT and prevention for the procurement of ProZorro to procure tested for HIV commodities HIV commodities commodities by commodities selected AIDS centers procurement in one high-burden region Practical experience on the use of ProZorro system is gained and disseminated Completed 2.3.3. TA on the Pilot ProZorro for HIV Practical experience # of sites 1 X X process of ProZorro commodities in 1 region on the use of the where procurement to system is gained and ProZorro selected AIDS centers disseminated implemented and/or OSA provided Completed Conduct trainings for 7 Trainings held for # of people 20 X X regions on electronic representatives of 7 trained procurement (ProZorro) pilot regions on electronic procurement Completed 2.3.4. Support and Run ProZorro advocacy Media-products # of media- 1 X advocate usage of campaigns for (promotional video, products ProZorro procurement procurement of other materials) on prepared and system for HIV-related HIV/AIDS commodities ProZorro use for HIV- presented pharmaceuticals related commodities and/or medical and other healthcare commodities at products regional level Completed Presentation of the # of report(s) 1 X successful cases of prepared on procurement of HIV- successful related and other implementatio Completed 74

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV healthcare n of commodities procurement via ProZorro Objective 3: Optimize and strengthen human resources for health (HRH) for the delivery and scale-up of gender-sensitive HIV/AIDS services targeting key populations Sub-objective 3.1: Strengthen evidence base for HIV workforce planning and development Strengthened 3.1.1. Empirical Human resources Empirical data analysis # of analytical 3 X X evidence base for analysis of human requirements for Test carried out and 3 notes on Test HRH decision- resources and START estimated regional Test and and START making, through requirements for Test for at least 3 regions START projections HR projections greater quantity and START conducted developed. prepared Completed and diversity of available HIV Facility-level human Site defined and # of sites 1 X X workforce data at resources projections mapping of HIV where facility- developed for at least 1 service provider level the central and pilot site /geographical facilities conducted; projections regional levels or facility-level site/ Test and START were

facility-level developed Human resources requirements for projection/s/ achieving Test developed and START objectives identified at regional level Completed Sub-objective 3.2: Support the introduction of systemic and operational changes in HRH for provision of sustainable and integrated HIV/AIDS services at the national and regional levels Regional 3.2.1. Participate in At least 3 regional HRH Develop and # of 3 Х X X authorities receive regional HRH planning operational disseminate region- recommendati region-specific process consultations conducted specific ons developed empirical with technical staff and recommendations for and analysis-based decision makers at HRH planning disseminated recommendations Oblast Health for new Administrations and approaches to AIDS Centers. HRH planning based on new programmatic targets and scenarios Completed

75

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV A training conducted One training # of people 20 X with participation of implemented, with trained national and regional national and regional- stakeholders on level participants estimating workforce attending demand for Test and START (participants from national institutions [UCDC/NPHC] and from pilot regions [Deputy Chief Doctors and M&E personnel of AIDS Centers, technical and decision-making staff of Oblast Health Administrations]) Completed Methodology 3.2.2. Collaborate with Methodology guidelines Methodology # of 1 X X X guidelines for the and provide support to for the roll-out of task- guidelines developed methodology roll-out of task- regional health shifting mechanisms and institutionalized guidelines shifting administrations to developed based on through the approval developed mechanisms endorse task-shifting piloting and evaluation of MOH/ Ukrainian developed mechanisms in selected pilot regions Center for Scientific Medical Information. Completed Upgraded and 3.2.3. In collaboration Develop an upgraded, Revised ToR for HRIS # of HRIS 1 X X X It is anticipated that comprehensive with developers of HIV fully-functional and developed and modules of the Workforce HRIS is MIS (ACCESS) and comprehensive HRIS submitted to HIV MIS HIV MIS Registry will be developed and MOH, develop and and ensure integration developers; HRIS developed and operational by the integrated into integrate the HR with HIV MIS module developed and integrated end of May 2018. MIS module into MIS (developed and rolled- integrated into HIV out by ACCESS Project) MIS Ongoing Sub-objective 3.3: Strengthen capacity of Ukrainian institutions in HRH policy, planning and development Increased 3.3.1. Support newly Develop Analyze existing HR # of 2 X X X X capacity, established NPHC and recommendations and framework and institutional ownership and Kyiv City PHC in propose tools for develop new/revised policies and accountability for establishing HR and establishing HR and HR policies and tools tools HRH policy talent development talent development for adoption at the developed development and function/ policy Completed

76

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV implementation function and policy framework for National National and Kyiv City within GOU framework and Kyiv city PHCs PHCs Local educational 3.3.2. Public health Certificate course Certificate course # of certificate 1 X institution(s) certificate program developed and developed and courses improve(s) developed at National introduced in the implemented developed and capacity to Medical University with teaching program of the introduced in develop Public broad involvement of National Medical the curricula of Health workforce national stakeholders University as a pilot the National in areas of public model of training. Medical health policy, HIV University surveillance, programming and monitoring Completed Certificate course in PH At least 24 persons # of people 24 X and epidemiology completed certificate trained (including HIV course in PH epidemiology and control) piloted and implemented Completed Recommendations for Recommendations Set of 1 X further implementation developed and recommendati of the course provided provided ons provided to NMU and Public Health Department of MOH Completed Conduct training for National level # of people 25 X X national and regional (National PH Center trained public health specialists and PH Department) and Kyiv City public health center staff trained Completed 4. Regional Pilots: Building a sustainable model for the provision of critical services to Key Populations and People Living with HIV at the local level 4.1 Regional Pilots – Implementing basic package of HIV services in PHC and ambulatory care Implement 4.1. Support public Prepare policy Policy framework # of regions 7 Х Х Х provider-initiated authorities in framework: developed to introduce where policy testing for HIV implementing the  Develop a minimum package of framework to (PIT) counseling basic package (rapid, services (testing- introduce a Completed 77

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV (pre- and post- testing, behavioral protocol for behavioral counselling- minimum testing; enrolment changes, and referral) referral of referral) at primary and package of in HIV prevention, of services at primary patients with specialized HCFs services was treatment and and specialized (TB, HIV to AIDS developed care programs, STI and drug Centers; etc.) at local level treatment) HCFs Develop/amend local Support public health care facility authorities in protocols, scope of work implementing the of health care providers, basic package (rapid etc. testing + behavioral changes+ referral) of services at primary and specialized (TB, STI and drug treatment) HCFs Expanded TA for the development Expanded integrated # of HCFs with 13 Х Х Х integrated care of an expanded package services package integrated services package of integrated services developed and service implemented at (ART, MAT, HIV implemented at package selected sites in prevention, TB, STI, selected sites implemented pilot rayons etc.) at the local level Completed Costing of health Costing of specific Costing of HIV # of HC 7 X X services in the health services and services provision facilities where field of HIV, packages of services, completed HIV-service according to the specifically basic costs are standard package (rapid testing, calculated indicators of post-test counseling, CMH, CRH and referral to the Trust specialized Office) in the field of HIV institutions for each HCF (Objective 2 personnel) Completed Funds for critical TA and advocacy for the Local councils adopted # of local 7 X X X regional level HIV use of health resolutions on the budgets with services allocated subventions for critical allocation of resources adequate from health HIV services for the provision of HIV funding of HIV subventions services services Local authorities allocate funds for Completed 78

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV HIV testing from local budgets Health care Train rayon/city health Health care providers # of people 700 X X X X providers are able care providers based on trained on provider- trained to deliver HIV test identified needs initiated HIV testing results, refer to and counselling treatment, care and prevention Completed Train supervisors of Supervision team # of people 20 X X rayon/city health care trained on provider- trained providers based on initiated HIV testing identified needs and counselling Completed 4.2. Regional Pilots – MAT co-payment model MAT co-financing 4.2. Develop and pilot Develop and present MAT co-financing # of models 3 X X X model developed, an MAT co-payment different MAT co- models/options at the prepared including policy model financing local level prepared mechanisms models/options (Objective 1&2 Unit cost of MAT personnel) Completed service per one Cost different MAT co- Costing of different # of models 3 X X X program financing MAT co-financing with calculated participant in models/options models/options unit costs different (Objective 2 personnel) completed healthcare Completed facilities identified; Prepare and introduce Policy barriers at the # of local 7 X X local policies and orders local level for the orders MAT co-financing to pilot MAT co-payment introduction of MAT prepared mechanism model (Objective 1&2 co-financing removed implemented in 3 personnel) Completed pilot regions Provide TA for Resources allocated # of sites with 5 X X administrations in from local budgets for allocated Increased number opening new MAT sites the opening of new funds on OST of PWIDs on MAT where MAT co-payment MAT sites model is supposed to be implemented Completed Implement Organize advocacy # of events 7 X X communication strategy activities for decision- conducted for MAT scale-up at the makers in support of Completed

79

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV local level (Objective 1& the integrated service Communications delivery model and personnel) MAT pilot Decision makers Train rayon/city health Health care providers # of people 40 X X support MAT care providers on trained on MAT trained scale-up OST/MAT Completed 4.3 Regional Pilots – Social Contracting NGO’s are 4.3 Assist public ТА to local Local needs # of analytical 7 X X X contracted to authorities with administrations on social assessment of the notes provide implementing the contracting population in social prepared preventive and/or social contracting services completed support services model for direct through social funding of services contracting or provided by NGOs other mechanisms Completed Annual social # of regions 7 X X X contracting plan where social approved and contracting published engaged Completed Social contracting X X X X TOR developed Completed Social contract X X X X competition organized and conducted Completed Develop local case Case management # of local 1 X X X management models for PLWH guidelines mechanisms linking focused on ART prepared health care provider adherence, PWIDs services to NGO and TB patients outreach implemented Ongoing 4.4 Regional Pilots – Capacity Building Capacity of 7 non- 4.4. Build capacity of Conduct 2 social Local pilot # of people 40 Х X governmental local implementers of contracting trainings for implementation teams trained organizations as the pilot projects local pilot are equipped with future TA (NGO) ty of local implementation teams knowledge and skills Completed 80

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV providers implementers of the to implement pilot strengthened pilot projects (NGO) in tasks selected oblasts

Conduct experience # of working 1 X sharing session on MAT meetings co-financing models/options Completed Conduct 2 workshops # of working 2 X X for representatives of meetings different rayons to share best practices and identify support focus points Completed 4.5 Regional Pilots – Monitoring Regional pilots 4.5 Monitoring Coordinate and monitor Monitoring visits to # of monitoring 42 X X X X implemented implementation of the pilot implementation each implementing visits under Project pilots in selected regions partner conducted supervision and mentoring Completed Prepare and Local report on # of reports 7 X disseminate local implementation of the reports pilot project developed Completed Cross-Cutting Capacity Building Capacity building CB 1.1. Support Conduct needs Needs assessment # of capacity 1 X X This activity has support to organizational assessment and and performance goal- development been started in 2017 governmental transformation of performance goal- setting completed assessments with several partners at UCDC into the national setting of the NPHC conducted meetings with PHC national and public health institution Director and her regional level to ensure HIV deputies on strategic provided in order surveillance, development of the to identify programming, and Center as a policies, monitoring functions preparation for the financing, and continue strategic strategic staffing development for delivering workshop. This optimal HIV Delayed workshop which has 81

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV services to KP been scheduled for and PLWH Q4 (initially planned for July) was cancelled due to conflicting priorities. In September, due to top management change uncertainty in NPHC, event did not happen and moved to later time, pending the decision on the Centre’s Director/Deputies. Provide TA to national CYPRESS workshops # of capacity 3 X X Provision of TA level unit of public health conducted, action plan development should have been based on assessment developed, according interventions based on needs results to the needs identified conducted assessment and based on goals set during the assessment Strategic implemented development workshop which did Delayed not happen CB 1.2. Support Conduct needs Organizational needs # of capacity 1 X X This initiative has not organizational assessment and provide assessment for Kyiv development been initiated in Y4 development of Kyiv TA to Kyiv PH Centre Public Health Center interventions due to delays in public health Centre based on assessment completed and action conducted organization and results plan developed based on official incorporation assessment of Kyiv PH Center by implemented Kyiv City authorities. Delayed Capacity of non- CB2. Capacity building Conduct needs Assessment # of capacity 1 X X X X governmental support to NGOs – assessment and completed, action plan development organizations implementers of pilot performance goal- developed and being plans based strengthened to projects to enable setting with two implemented on enable them them supporting organizations: Zdorova assessment supporting regional Natsiya (Pervomaysk) implemented regional administrations in and Association 21 administrations in century (Kherson) Completed 82

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV further replication further replication of of pilot concepts pilot concepts and providing expertise on selected focus areas after the Project completion Provide necessary Targeted capacity # of pilot 7 X X X X targeted CB building interventions organizations interventions based on provided which received performance capacity improvement plans building prepared in YR 3 interventions Completed Conduct 2 trainings to Trainings conducted # of people 40 X X address existing trained systemic gaps relevant to all organizations: - Government functions rules and regulations at the national and regional level; - Project management and communication. Completed CB3. Strengthen non- Continue supporting Y3 Targeted capacity # of grantees 4 X X X X governmental partners grantees as future TA building interventions which received as future TA providers providers by providing and trainings provided capacity in order to provide necessary targeted CB to Family Medicine building expertise on selected interventions based on Training Center, Club support focus areas performance Eney, Ukrainian improvement plans Institute of Social prepared Research, and Fulcrum NGOs Completed CB4. Monitoring action Implement performance Organizations’ # of 6 X X X X plans of non- improvement plan in performance improvement governmental partners areas specific to improvement plans plans being (see CB 2 and 3), being implemented implemented Completed 83

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV providing organizational mentoring/coaching, development as necessary Conduct second Assessment # of 3 X X assessment using conducted and self- organizations CYPRESS methodology assessment scoring with improved with partner received scoring organizations provided with capacity building activities Completed Change agents’ CB5. In coordination Provide targeted Targeted capacity # of people 30 skills and with the Project’s capacity building building interventions who received knowledge Communication interventions/ trainings and trainings provided targeted improved in order Specialist and according to the needs capacity to generate Objective Leads, build and type of change building broader support capacity of change agents: interventions for proposed agents systemic changes at the national and local level Completed Study tour for change # of study 1 X X agents to the United tours States conducted Completed Meetings conducted # of change 30 X X Over the year between change agents agents change agents were and guest speakers that participated invited and are experts on the participated in a subjects of high- number of activities relevance to change aimed at developing agents their individuals’ capacity: trainings, round tables, seminars, courses, etc. High-level meeting which was scheduled for Q4 and was supposed to Cancelled be conducted in 84

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV cooperation with MOH was cancelled due to changed circumstances and priorities of MOH. Gender and Stigma Sensitization Joint activities GS1. Support activities Project will support the Set of # of sets of 1 X with other partner through Policy, Health participation of regional recommendations on recommendati projects at the Financing and HRH representatives from responding to gender- ons presented national level Objectives that will pilot regions in the MSM sensitive problems and at the LGBT coordinated and have impact on KP and LGBT XI National needs of KPs Conference streamlined to communities Conference and\ or elaborated and\or other address KP other nationwide events events needs to discuss main problems of KPs in access to health, and develop recommendations for both NGO and GOU and HCFs Completed GS2. Organize LGBT Convene and facilitate Coordination meetings # of meetings 4 X X X X stakeholders meetings LGBT stakeholder conducted and conducted with the aim to meetings recommendations coordinate advocacy disseminated among and programmatic relevant stakeholders activities to ensure complementarity of donor support in the field of stigma and discrimination-free service provision to KPs at the national level Completed Inclusive and GS3. Implement and Conduct trainings for 3 trainings conducted # of people 70 X X friendly services utilize gender, stigma, primary health care trained to KPs are and discrimination workers on gender provided in curriculum from issues (related to Ob. 1 primary health RESPECT project to – integration of care. train primary health Completed 85

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV care workers on preventive services in all communication and levels of care) counseling skills Evidence base for GS4. Implementation Implementation of the Information campaign # of grant 1 X X gender and of grant on information grant introduced under 3 reports stigma-related campaign for PHC pilots of the project issues in access physicians on tolerant to HIV care and and stigma-free treatment attitude towards KPs presented Completed Communication and Knowledge Management Accountability and CM1. Maintain the Project news posted # of news on 70 X X X X transparency Project's website and on the website the website through provide information to communication national and regional with HIV/AIDS stakeholders stakeholders supported Completed CM2. Publish media Media hits and # of media hits 40 X X X X hits and interviews interviews on and interviews with leading health HIV/AIDS reform experts on HIV/AIDS published reform Completed CM3. Provide routine Newsletter is # of 6 X X X X information through published newsletters Project Newsletters per year (Ukr/Eng) Completed Core Health Care CM4. Maintain Provide information on Facebook page is # of FB 650 X X X X Reform topics, Facebook page HIV reform in Ukraine maintained and followers including public number of followers is health and HIV increased visualized through social media Completed Evidence-based CM5. Develop Policy Policy briefs on Policy, # of Policy 4 X X X X best practices in briefs/memoranda/leafl Finance and HR briefs public health/HIV ets) on priority public published for decision published disseminated for health/HIV topics makers, health care decision makers, providers, donors to health care advocate for HIV Completed 86

Quarters Expected result/ Indicators Year 4 Activity Sub - Activity Key milestone output Status Comments outcome (output) Target I II III IV providers, donors services sustainability to advocate for in the regions HIV services sustainability in the regions Project CM6. Support Set of recommendations Project implementation # of Project 4 X implementation organization and for the development of lessons are presented implementatio lessons learned provide co-funding for the Conference Concept at the Conference n lessons shared with the National HIV and Agenda. presented at national and Conference organized the regional partners by NPHC/MOH Conference and key stakeholders Completed

87

SECTION 2. HEALTH SYSTEM FINANCING REFORM SUPPORT UNDER OBJECTIVE 2. This report illustrates progress by symbols in color code:  Dark green: Completed,  Light green: Ongoing,  Yellow: Delayed,  Orange: Cancelled  Red: Not completed. In Y4, of total 41 tasks:  27 tasks were completed,  11 tasks are ongoing,  3 tasks were not initiated,  0 tasks were delayed,  0 tasks were canceled.

Y4 Tasks completeness ratio – 65.8 % Indicators Year 4 Expected result/ outcome Activity Sub - Activity Key milestone Status Comments (output) Target Objective 2: Improve and optimize resource allocation and financing for the national and selected regional hiv/aids programs targeting key populations Sub-objective 2.4: Build the capacity of the national and selected regional/lpcal GoU entities to design and establish a national purchasing agency Legal framework for 2.4.1. Provide legal Provide legal support to Amendments to # of 2 implementation of health support to MOH in MOH in developing regulatory framework recommended financing reform developed health reform amendments to the made regulatory implementation legislation for health changes Regulatory framework financing reform adopted for creating NHS Provide legal support to developed and develop required approved decrees (MOH orders, decrees) to launch the NHS Completed

88

2.4.2. Provide Provide technical Technical assistance technical assistance to assistance to health in health financing MOH to successfully financing working group policy and the reform implement critical at the MOH action plan provided health reforms Completed Sub-objective 2.5: Support the Ministry of Health (MoH) and relevant Parliamentary Committees to define, develop, implement and update a basic benefits package of service, in consultation with civil society and patient organizations Recommendations on draft 2.5.1. Provide Participate and provide Recommendations on # of benefit package developed feedback in input in stakeholder draft benefit package recommendati and provided to the MOH consultation with consultation related to are developed and on provided stakeholders related to development of the provided to the MOH development of the basic benefit package primary care basic benefit package Completed Completed Sub-objective 2.6. Support MoH and selected oblast/ local authorities in the design and establishment of a performance-based payment system under ‘money- follows-the client’ approach 2.6.1. Support for Capitation Rate Development Preliminary capitation rate for 2.6.1.1. Develop Support data collection Data collection tools in # of tools 1 primary care services utilization and cost and analysis to inform Excel are developed developed Completed calculated. data collection tools Utilization and Unit Cost for services included in and templates of services Basic Benefit Package 2.6.1.2. Select a Interview MoH staff to Sample of Primary # of samples 1 sample of primary care assist in the Care centers is prepared centers identification of centers selected Completed that represent healthcare delivery system in Ukraine 2.6.1.3. Collect data Collect data to inform Data is collected from Data collected 1 on utilization of Utilization and Unit Cost sample clinics on primary health care of services utilization of primary data at PHC in the care and cost of Completed Compile cost of services sample clinics services data at sample PHC centers 2.6.1.5. Tweak the Utilize cost and Preliminary capitation # of analytical 1 preliminary Capitation utilization data to rate is established note with Postponed to rates to sync with the conduct calculations for preliminary Ongoing November due to overall healthcare refined capitation rate capitation rate MOH schedule budget and any cost 89

management Conduct additional Additional revisions to estimation strategies including calculations to further preliminary capitation developed establishing withholds, revise capitation rate rate are calculated risk corridors, etc 2.6.2. Healthcare Provider Autonomy Pilot on operational 2.6.2.1. Provide Advocacy in Selected pilot PHC # of pilot PHC 2 management under technical assistance to collaboration with MOH providers are agreed providers capitation model initiated in 2 selected primary to identify which pilot with MOH and local selected PHC sites health care providers PHC providers should authorities Completed in operational be included

management under capitation model Legal roadmap for transition Legal support to Action plan (roadmap) # of action 2 PHC providers to non-profit selected PHC providers and regulatory plans/ enterprises completed to become non-for-profit documentation to roadmaps enterprises (legal status, transform PHC prepared Completed

payment method, HR, providers to non-profit contracting issue etc.) enterprises are prepared Communication with Communication events # of 2 PHC staff on reform, with PHC staff on communicatio new model of PHC reform, new model of n event Completed operational and benefits PHC operational and conducted benefits are conducted TA in operational and Training on resource # of people 20 financial management management and trained under capitation model budgeting under Completed including facility and capitation model of group practice payments is conducted administration Human resource needs for Conduct assessment of HR needs assessment # of PHCs with 2 pilot PHC providers identified clinical and is conducted and HR HR plans administrative staff plan is developed approved Ongoing needs for PHC Prepare HR plan

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Assessments on MIS Support PHC in Needs assessment is # needs 2 implementation conducted implementing local MIS conducted and MIS assessments Completed under E-health system implementation plan is conducted prepared Local citizens have relevant Communication Press and public # of events 2 information about PHC activities to inform local events to inform local conducted reform in pilot region communities on PHC communities are Ongoing reform and new mode of conducted PHC operations Training initiated at pilot PHC 2.6.2.2. Initiate Training and training Training is initiated at # of trainings 1 centers in areas related to development of a manual designed and pilot PHC centers initiated contract negotiations, training manual that implemented Completed contract development, would be used with management of PHC group other PHC clinics practice, and HR throughout Ukraine 2.6.3. Hospital districts Regional administrations 2.6.3.1. Conduct Work with MOH to Set of tools and a road # of the 1 equipped with toolkits for technical assistance to develop a set of tools map for consolidation roadmaps/ Ongoing hospital district strategic regional and data needs that are of hospitals into a action plans planning administrations in necessary for hospital district is developed developing strategic developing the strategic developed # of tools plans for hospital plans 1 developed Ongoing districts Prepare and conduct 2-day workshop on # number of 1 cluster workshops for hospital district events regional administrations strategic planning is conducted presenting the tool and conducted Ongoing a roadmap to conduct a hospital district strategic planning. Sub-objective 2.7. Support the MoH in developing and implementing effective IT solutions to launch, manage and administer health system financing reforms. MVP is developed consisting 2.7.1. Develop Project Define and map MVP Project # of complete 1 of 4 components: MPI, Management Plan required activities to Management Plan is project plans physician registry, facility (project plan) to manage MVP developed developed registry, and declaration support development development Completed registry of Minimal Viable Product (MVP)

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2.7.2. Utilize SMEs to Advise MVP project SME advise is # of hours 20 advise and manage e- team in terms of: testing, provided to MVP SMEs spend health project team cybersecurity; disaster development group advising MVP Ongoing recovery; and building in team controls for certification process and audit MVP technical 2.7.3. Develop Develop requirements Requirements for each # of registries, 4 documentation and business requirements for MVP for each registry: of four registries are which have process documentation components patient, provider, facility, defined defined Completed developed declarations requirements

Develop requirements Requirements for MVP # of registries, 4 for reporting from MVP reporting from each of which have the 4 registries are defined defined requirements Completed on how to report from the MVP 2.7.4. Develop Develop guide for Guide for electronic # of guides / 1 communication electronic and manual and manual data entry guidelines The activity will be strategy for registration data entry, as well as is developed and developed Not initiated initiated after to support physicians submission guidance for submitted to finalization of MVP with collecting and physicians physicians components submitting data from

patients and for Develop information Information leaflet for # of 1 leaflet for patients information patients to understand patients is developed explaining what is leaflets why they need to have expected from then and developed Not initiated a contract with a detailing how to register physician and what is with the physician expected from them 2.7.5. Define Develop document Set of specifications # of 1 specifications of NHS outlining NHS portal for NHS portal are specifications portal in collaboration specifications defined in set defined Completed with MOH to support collaboration with future development MOH 2.7.6. Advise on Provide guidance and Business processes # of business 4 development of the SME support to develop for 4 directions are processes Completed following business business processes on developed developed

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reimbursement, processes: refund registration and reimbursement, declaration, and registration and actualization of declaration, and registries actualization of registries Strategic planning sessions 2.7.7. Manage MOH Facilitate requirement Final e-Health # of 1 held for MOH for stakeholders to ensure gathering sessions with requirements are documents development of effective e- eHealth requirements, end users and user- gathered from the end with the health solution to launch, specifications, and acceptance sessions to users requirements Completed manage, and administer legal environment confirm e-health developed health system reforms requirements are approach defined Cross-cutting: Communication and Knowledge Management Communication The Communication CM1. Support of MOH Provide Assessment Assessment of current # of analytical 1 Department of MoH is to establish report on current communication reports with designed Communication communication processes is recommendati Department processes with relevant conducted and the ons prepared Completed recommendations report with the relevant recommendations is prepared Assess current capacity Recommendations for # of 1 in the area of training to bridge the recommendati communications and skill gaps is developed on prepared identify the skills/needs The functional design for the future of Communication Communications department is Department Completed developed, presented Develop to decision makers of recommendations for MoH and finalized the new Communication Department structure and support Prepare the capacity Capacity development # capacity 1 development plan plan is developed and development Ongoing endorsed by decision plans prepared makers

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and implemented Design capacity building Key communication # of trainings 2 trainings for staff is trained to conducted Completed Communication strengthen their department staff capacity MoH Communication CM2. Support MoH Communication Strategy Communication # of 1 Strategy is developed and and facilitate developed and Strategy and Communicatio approved Communication presented to MOH Communication plan n Strategy Completed Strategy and decision makers are developed and developed

Communication plan agreed with MOH development MoH is equipped by tool-set CM3. Support MoH to Develop tool-kit, Tool-kit and guidelines # of tool-set / 1 for internal communication develop internal procedures and are developed and guidelines Development of a communication system guidelines for Internal presented to MOH developed Ongoing tool-kit for internal

Communications communication of MOH is postponed

until the Develop a On-boarding tool-kit is # of tool-kits 1 administrative reform Communication on- developed developed Ongoing of the MOH is boarding tool-kit completed Content management CM4. Support website Update a Guideline for MoH # of guidelines 1 guideline for website of MoH content management Guideline/procedures for website is developed developed is developed guideline for MoH MoH website content Completed management and support its implementation Brand book for MoH is CM5. Support MoH in Development of MoH MOH brand book is # of brand 1 developed Brand book Brand book developed books development to developed Completed

improve visual communication Key Messages Survey for CM6. Support the Key Conduct Key Messages Key Messages Survey # of analytical 1 Health Care Reform is Messages Survey for Survey for Health Care is completed and the reports with Not The activity finalized Health Care Reform Reform report is finalized recommendati Initiated postponed to late on prepared Autumn Knowledge Hub

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Knowledge hub is designed CM7. Design and Conduct needs The report on needs # of 1 support assessment for assessment is assessment implementation of knowledge repository prepared reports with Completed Knowledge Hub in content and structure recommendati support of health on prepared reform implementation Present Concept for the # of concept 1 recommendations to the Knowledge Hub is developed and key stakeholders for the developed and agreed Ongoing Knowledge Hub platform presented to key stakeholders Develop a roadmap and Action plan for # of action 1 an action plan for its Knowledge Hub plans/roadmap implementation implementation is s developed Completed developed and final for its implementing

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