Presentation at the Regional stock taking meeting on the implementation of the Investment Approach in EECA: Moving from analysis to action and investing for sustainable impact (23-25 February 2016, Vienna, Austria)

1. Building the sustainable
response to TB and HIV/AIDS in
Ukraine: from Scenarios to the
Strategy.
Nechosina Elena,
Technical Advisor of MOH Multisectoral working group
on sustainability issues
Regional stock taking meeting on the implementation of the
Investment Approach in EECA: Moving from analysis to action and
investing for sustainable impact
23-25 February 2016, Vienna, Austria

3. Parties to the process:
 Ministry of Health (MOH)

Multisectoral working group on sustainability issues under MOH
(representatives of government bodies, international and
national organisatons)
 Policy subgroups (on HIV/AIDS and TB)
 Technical and experts assistance: UNAIDS, UNODC, USAID
Project HIV Reforms in Action, USAID Project Strengthening
Tuberculosis Control in Ukraine.

4. «Scenarios constructor set»
Tool for managerial decisions

5. Approaches:
 «Good – money relationships» between
ordering party, payer, service provider
and service recipient.
 Ukrainian context: reforms and
competitive priorities
 «Scenarios constructor set»

7. Reforms in Ukraine
Key reforms which
considered in the scenarios:
-Decentralisation
-Health system reform
-Social services reform
-Budget reform
As a forecasting and uncertainty
factors (when reforms will be
implemented, which model will be
implemented).

8. Ukraine today
State
Health sector
HIV/AIDS
Anti-
terrorism
operation
Internally
displacement
people
Energetic crisis
Unemployment
Corruption
Competitive
priorities and limited
resources: in the
state, in the health
sector and in
HIV/AIDS sphere
In the condition of limited resources priorities should be reviewed and
efforts should be focused.
Diabetic
Oncology
Ineffective
health
system
ART OST
Preventi
on

9. “Scenarios constructor set”
 Is this service separate/ “autonomus’?
 Or service can be simplified and included to other
service as an element?
 Health service?
 Social service?
 Other?
 State budget? Oblast budget?
 Rayon budget? Budget of community?
Step 1. Service or
element?
Step 2. Type of service
(branch)?
Step 3. Level ob
budget?
Step 4. “State guarantee” or
«good will»?
Algorithm of questions and options of managerial decisions.
• Allocated budget funds for the service?
• Service “competitive” with other services of branch?
• Or service funded from budget of community if it have own
resources and “good will”?
Step 5. Procurement
procedures?
• Competition (state purchase, social order, health service
contract)
• Direct funding of institutions/ organisation?
Developed with support of

10. Step 1. Identify, is it separate service
or element of service
If -
Option 1. Separate/ autonomus service – follow to Step 2.
If -
Option 2. Not a separate service, is an element of other service -
 Identify the main service – health care or social service or other
 Make sure that this element is covered in the standard/ regulation of main
service
 Make sure that this element is covered on unit cost of main service (staff,
consumables etc)
Comments: Important for some services (Needle and syringes programs, condom
programs, IEC, Care and support for PLHA ), in case of decision to simplify/
reduce the service.

11. Step 2. Identify type of service (branch)
– health care service, social service or
other service
If
Option 1. Health care service
Option 2. Social service
Option 3. Other type of service (according the appropriate laws)
1) Make sure that the appropriate regulations/ standards of service
exist (including the requirements for the service providers).
1A) If not, initiate developing/ approving the standards.
2) Apply rules of the type/ branch
3) Follow to Step 3.
If
Option 4. New unknown/ unnamed service
Initiate development of new Law (or amendment to existing laws)
Comments: new type of public health service was suggested according the
trends of health system reform.

12. Step 3. Identify level of service
delivering (subsidiary principle, taking
into account the decentralization
reforms)
Option 1. National level – unlikely.
Option 2. Oblast level (tertiary health care )
Option 3. Rayon level (secondary health care)
Option 4. Level of community (basic) (primary health
care and social services)
Comments: after changing of Constitution, than changing of related
laws (first of all, on Self-government, Budget Code)

13. Step 4. Identify the manner
of budget allocation
Option 1. «State guarantees» - separate budget line, subvention (for
example – diabetes, emergency ambulance etc.)
Option 2. «Common pool» of branch - subvention and budget of branch (for
example, health care subvention from state budget to local budgets)
Option 3. «Good will» - right of local authorities to fund any programs/
services by own resources.
 Identify sphere/ branch of budget expendetures
 Identify Key Spending Units
 Identify amount of funds and scope of procurement

Follow to Step 5.
Comments: Take into account that state guarantees can be implemented in the
volume according the funds available (principle of balanced budget)

14. Example: «State Guarantees» and
«Common Pool» in health care
subvention (oblast level)
«Common pool» -
expenditure for all
health care branch
(including HIV and
TB)
«State guarantees» - directed funds for
emergency ambulance, mountainous
regions, diabetes, hemodialysis, cash
payments to HIV-positive children
Formula of health subvention amount

15. Step 5. Identify procedures
of service purchasing
Option 1. Competition (state purchase, social
order, health service contract, “money follow
client” other)
Option 2. Direct funding entities/ organisation

16. Developing the scenarios of
services

17. “Constructor set” in using:
 «Constructor set» was presented on
meeting of MOH Sustainability working
group (august 2015) and was
recommended for the scenarios
developing.
 Scenarios of 7 HIV services and 4 TB
services was developed using the
“scenario constructor”

18. Example: Prevention services for PWID, CSW, MSM
(united scenario)
State of the art
Type of service: not identified, separate. Ordering party = payer: Alliance (GF project)
Centralized procurement of consumables, grants for service delivery
Scenario А
Social service
• Type of service: socail
service, separate.
• Ordering party = payer:
Local departments of social
protection.
• Manner of budget
allocation: based on needs
assesment (“good will”)
• Type of service: element of
health care (consumables).
• Ordering party = payer:
local health department.
• Manner of budget
allocation: “blend pool” of
health care subvention).
• Type of service: new,
public health
• Details – should be
identified in future legislation
on public health.
Scenario B
Element of health care
Scenario C
New service, “public health”
Source: insert source information here
OR OR

19. EXAMPLE: OST, state of the art

20. EXAMPLE: OST
Scenarios

21. EXAMPLE: OST
Scenarios

22. Example: OST
State of the art
Type of service: health care, separate. Ordering party: Health department
Centralized purchasing the OST: Payer: Alliance, with agreement of MOH (GF project)
Service delivery Payer: local health care departments. Payer: Alliance (GF)
Scenario А
Centralized purchasing the
OST drugs
• Actual option, if the money
in state budget will be
allocated:
• Payer – MOH, state budget,
• Service delivery – Health
Department, local budget.
• B1) Purchasing the OST
drugs for all providers.
Separately – purchasing the
services
• Partial payment by patient
(or other party), partial –
from the budget
• Full payment by client
Scenario B1 and B2
Purchasing the service and
OST from the one budget
Scenario C
Partial payment by client
Scenario D
Full payment by client
e
For all scenarios:
Type of services: health care, separate.
Ordering party: health department
• B2) OST drugs included to
service cost
OR
AND
AND AND

23. Scenarios consolidation:
 All suggested scenarios were analyzed
(December 2015)
 The services which can be implemented with
the same scenarios were consolidated (for
example, purchasing ART and TB treatment,
services for KAP)
 Consolidated scenarios were included to the
draft of Strategy and plan.

24. Strategy for a sustainable response
to TB, including drug-resistant TB,
and HIV/AIDS for the period until
2020
(will be approved by the Cabinet
of Ministry Decree)

25. Strategy for the sustainable
response to TB and HIV/AIDS.
 The goal of the Strategy is to create
over a medium term an appropriate
organizational and legal conditions for a
sustainable response to TB, including
drug-resistant TB, and HIV/AIDS under
the implementation of new global public
health strategies (90-90-90, Fast Track,
The Global Plan to Stop TB).

26. Key aspects of Strategy:
 Correspondence with reform process in the
state
 Renewal the public policy according the new
global strategies
 Targets prioritization for the resource
diversification (shared responsibilities –
budget, donors funds, client payments)
 Initiating the new type of services – public
health services