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Ukraine Health System Assessment 2011 better systems, better health UKRAINE HEALTH SYSTEM ASSESSMENT 2011 August 2011 This publication was produced for review by the United States Agency for International Development. It was prepared by Lisa Tarantino, Slavea Chankova, Josh Rosenfeld, and Subrata Routh (Abt Associates Inc.), and Elizabeth Preble for the Health Systems 20/20 Project. Health Systems 20/20 is USAID‘s flagship project for strengthening health systems worldwide. By supporting countries to improve their health financing, governance, operations, and institutional capacities, Health Systems 20/20 helps eliminate barriers to the delivery and use of priority health care, such as HIV/AIDS services, tuberculosis treatment, reproductive health services, and maternal and child health care. August 2011 For additional copies of this report, please email [email protected] or visit our website at www.healthsystems2020.org Cooperative Agreement No.: GHS-A-00-06-00010-00 Submitted to: Robert Emrey, AOTR Health Systems Division Office of Health, Infectious Disease and Nutrition Bureau for Global Health United States Agency for International Development Recommended Citation: Tarantino, Lisa; Slavea Chankova, Elizabeth Preble, Josh Rosenfeld, and Subrata Routh. August 2011. Ukraine Health System Assessment 2011. Bethesda, MD: Health Systems 20/20 Project, Abt Associates Inc. Abt Associates Inc. I 4550 Montgomery Avenue I Suite 800 North I Bethesda, Maryland 20814 I P: 301.347.5000 I F: 301.913.9061 I www.healthsystems2020.org I www.abtassociates.com In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University School of Public Health and Tropical Medicine UKRAINE HEALTH SYSTEM ASSESSMENT 2011 DISCLAIMER The author‘s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government. ABSTRACT In response to a request from the United States Agency for International Development (USAID)/Ukraine Mission, the USAID-funded Health Systems 20/20 Project conducted this assessment in order to identify strengths and weaknesses in the Ukraine health system, focusing on HIV/AIDS, tuberculosis (TB), and family planning; develop recommendations to inform USAID/Ukraine‘s health programming; and review the Government of Ukraine‘s (GOU‘s) draft health reform plan. The Health System Assessment was conducted from January to April 2011. The assessment evaluated key health system functions organized around the six technical building blocks developed by the World Health Organization: governance; health financing; service delivery; human resources; medical product management; and health information systems. The assessment team analyzed the cross-cutting issues that appeared to impact the system most extensively. The team identified a number of strengths and opportunities in the health system in Ukraine as well as four cross-cutting constraints that captured the majority of the key weaknesses across the health system components. The assessment‘s recommendations address the four cross-cutting constraints and highlight opportunities that the GOU, USAID, donor agencies, and other key stakeholders may choose to pursue to strengthen the health system in order to improve the health of all Ukrainians. While the process of decentralization has led to some changes in the financing system, the core of the Ukrainian system remains unreformed since independence from the Soviet Union. Ukraine‘s health system currently faces significant challenges, including increases in non-communicable and infectious diseases, particularly HIV/AIDS and TB, as well as a decline in life expectancy. Poor health status is coupled with a difficult economic environment, a result of the recent global economic downturn. The GOU has embarked on an ambitious health reform plan, articulated in the President of Ukraine‘s Economic Reform Plan (2010) and a number of draft and recently enacted laws. The GOU‘s plan addresses key issues faced by the health system and is based on international best practices. As implementation is now upon the reformers, the GOU is carefully considering the order and methods of enacting the reforms as well as lessons from other countries in the region. CONTENTS Abstract .......................................................................................... 5 Acronyms ...................................................................................... xi Acknowledgments ...................................................................... xiii Executive Summary .................................................................... xv 1. Background ................................................................................ 1 2. Country Overview ..................................................................... 3 2.1 General ...................................................................................................... 3 2.2 Demographic Trends ............................................................................. 5 2.3 Health Status of the Population........................................................... 6 2.4 Tuberculosis ............................................................................................. 9 2.5 Reproductive Health and Family Planning ....................................... 10 2.6 Structure of Health System ................................................................ 11 2.7 Decentralization .................................................................................... 11 2.8 Health System Regulation and Policy Development .................... 12 2.9 Health Reform and Health System Strengthening ........................ 12 2.10 Donor Involvement in the Ukrainian Health System .................. 12 3. Findings .................................................................................... 15 3.1 Governance and Leadership ............................................................... 15 3.2 Health Financing .................................................................................... 25 3.3 Service Delivery .................................................................................... 40 3.4 Human Resources................................................................................. 55 3.5 Medical Product Management ............................................................ 67 3.6 Health Information Systems ............................................................... 75 4. Overarching Findings and Opportunities ............................. 87 4.1 Strengths and Opportunities .............................................................. 87 4.2 Key Challenges ...................................................................................... 88 5. Recommendations .................................................................. 93 5.1 Promote Strong Political Leadership and Governance as Key Ingredients to Successful Reform ...................................................... 93 5.2 Reorient the Health Care System from Inpatient / Specialist Model to Primary Health Care-Focused Model ............................ 94 5.3 Pursue Health Finance Reform as Foundation for Broad-Based Improvements ........................................................................................ 95 5.4 Implement Strategies to Improve Quality of Care ....................... 97 5.5 The Role of International Organizations and Donors ................. 98 5.6 Beyond the Health Sector .................................................................. 99 Annex A: Donor Map of Programs in HIV/AIDS, TB, and Family Planning ......................................................................... 101 UKRAINE HEALTH SYSTEM ASSESSMENT 2011 VII Annex B: Methodology ............................................................. 115 Annex C: Stakeholder Workshop ........................................... 119 Annex D: Contacts List ............................................................. 121 Annex E: Documents Consulted .............................................. 125 LIST OF TABLES Table 2.1. Selected Indicators for Ukraine and Corresponding CIS and EU Averages ................................................................................................... 4 Table 2.2. Ukraine‘s ―Doing Business‖ Rankings ............................................ 5 Table 2.3. Top 12 Causes of Death and DALYS in Ukraine ....................... 6 Table 3.1.1. Legislation and Policies Governing the Health Sector ......... 17 Table 3.1.2. Ukrainian Political Structure and Health Service Delivery System by Level............................................................................................ 18 Table 3.1.3. SWOT Analysis For Governance .............................................. 24 Table 3.2.1. Select Health Expenditure and Economic Indicators, With Regional and Income-Group Comparisons, 2007–2008* .................. 28 Table 3.2.2. Trends in Select Health Expenditure and Economic Indicators, 2004–2009 ................................................................................ 29 Table 3.2.3. National HIV Program Funding Gaps 2009–2016 (US$ million) ................................................................................................. 36 Table 3.2.5. Comparative Analysis of ARV Procurement Prices for the GOU, 2010 ....................................................................................
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