POLICY Project
CORE PACKAGE FINAL REPORT:
Setting Priorities and Overcoming
Operational Policy Barriers to
Achieve Reproductive Health
Goals in Ukraine
POLICY Project
March 2004
Setting Priorities and Overcoming Operational Policy Barriers to Achieve Reproductive Health Goals in Ukraine
POLICY Project
March 2004
Setting Priorities and Overcoming Operational Policy Barriers to Achieve Reproductive Health Goals in Ukraine
Nicole Judice
POLICY Project
The POLICY Project is funded by the U.S. Agency for International Development (USAID) under Contract No. HRN-C-00-00-00006-00. POLICY is implemented by the Futures Group in collaboration with the Centre for Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). The views expressed in this paper do not necessarily reflect those of USAID.
Contents
I.Introduction1
II.Analytic Frameworks3
III.Context, Policy Issue, and Stakeholders6
IV.Operational Policy Barriers and the POLICY Project’s Response11
V.Priority Setting in Kamianets-Podilsky: Policy Implementation
Problems and the POLICY Project’s Response (November 2001
to December 2002)18
VI.Policy Changes and Decisions Achieved with Technical Assistance
from POLICY21
VII.POLICY’s Impact and Future Perspectives27
Appendix 1. Efficiency Study Methodology: At-a-Glance31
References32
1
Ukraine Core Package Final Report
I.Introduction
I.Introduction
In Ukraine, a decline in fertility and a perceived “demographic crisis” have spurred strong interest in both increasing the birth rate and improving maternal and child health (MCH) services. At the same time, however, Ukraine has paid only sporadic attention to family planning. Despite evidence of improvements in the contraceptive prevalence rate and the abortion rate, induced abortion remains a major method of fertility control in Ukraine. According to the 2001 Ukraine Reproductive Health Survey, the abortion ratio in 1999 was 1.1, indicating approximately equal numbers of abortions and live births.[1] The exploding incidence and prevalence rates of sexually transmitted infections (STIs), particularly syphilis and HIV/AIDS, areprovide additional proof of the need for that greater attention to reproductive health issues is needed. Considering these problems, Ukrainian women and men—--—more than ever—--require access to high-quality family planning (FP), and reproductive health (RH) services.
To address this need, on March 26, 2001, Ukraine’s president adopted the National Reproductive Health Program 2001–2005 (NRHP), the country’s first performance-based reproductive health program. An intergovernmental and multisectoral RH Policy Development Group (PDG) (discussed in more detail below) developed the program, with technical support from the USAID-funded POLICY Project (POLICY). While the program constituted a step forward in improving the policy environment for family planning and reproductive health in Ukraine, policymakers and other stakeholders shortly realized that, in view of significant barriers, the NRHP’s highly ambitious agenda could not be successfully implemented.
In addition, the NRHP received little funding from the national government, and local RH budgets were insufficient to implement the program in its entirety. If local governments were allowed to use their resources more efficiently and provided with information and assistance to determine the most effective and highest-priority RH interventions for their community, greater resources would be available to implement the NRHP. Thus, it is critical that program managers and health authorities at the oblast and city levels set priorities specific to their jurisdictions. The PDG requested that POLICY assist a local government as a model to identify RH priorities for the city and to develop a city RH plan or program.
In response, through a targeted package of activities, POLICY assisted major stakeholders in analyzing the operational policy barriers to implementing the NRHP.[2] POLICY also provided technical assistance (TA) from September 2001 to November 2003 to help the PDG identify and document operational policy barriers to efficient resource allocation and use in two typical Ukrainian cities (Kamianets-Podilsky and Svitlovodsk) and to help RH stakeholders in Kamianets-Podilsky set priorities and include them in an RH implementation plan.[3]
POLICY assistance contributed to the following policy development and decisions:[4]
- Four Ukrainian cities and the PDG submitted an unprecedented request to the Cabinet of Ministers in January 2003 for flexibility to operate independently of national budgeting norms in order to serve as pilot sites for new health financing schemes. POLICY provided data and technical assistance to support theis effort.
- The city administration and Ccity Ccouncil in Kamianets-Podilsky increased resources for RH in city facilities starting in December 2003 following POLICY’s assistance to the city to assess RH priority areas.
- The city of Kamianets-Podilsky developed and adopted athe City Health Reform Plan in December 2002 with technical assistance from POLICY.
- The PDG developed a “National Reproductive Health Policy Guide,”, which serves as a critical source of information about important RH policies and programs, specifies how to implement them, and raises awareness of recent research findings and programs related to RH. POLICY provided technical assistance to the PDG and the Ministry of Health (MOH) during this process, and collected information to contribute to the Gguide.
Purpose
This paper documents the role of the POLICY Project in achieving the recent policy changes and decisions described above. The paper first outlines the two frameworks used to facilitate the policy analysis and dialogue that led to these policy changes. The next section describes theUkraine’s socioeconomic and FP/RH context in Ukraine, the policy environment for RH, how healthcare is financed, and the policy stakeholders and process involved in making policy changes and decisions. The main body of the paper focuses on each policy decision and POLICY’s technical assistance that helped achieve the various policy actions. In summary, the paper presents POLICY’s approach to strengthening implementation of the NRHP by using a strategy that emphasized policy analysis, research, multisectoral policy dialogue, and capacity building, all of which led to several interrelated policy changes and improved financing for reproductive health services.
II.Analytical Frameworks
II.Analytic Frameworks
POLICY used two frameworks to support the PDG’s work in Ukraine. The first framework was developed by POLICY to identify and analyze operational policy barriers. With technical assistance from POLICY, Tthe PDG used theat framework, with technical assistance from POLICY, and identified 22 operational policy barriers to implementing the NRHP in Ukraine. The PDG then analyzed these barriers and revised and drafted policies to address them operational policy barriers. One of the barriers addressed by the PDG was addressed was that local government and stakeholders’are not sufficientlylack of informationed about RH problems and issues, and that policymakers’ failure to did not use up-to-date information on RH for planning purposes. Thus, POLICY introduced the second framework described below to facilitatguide RH stakeholders through the process of setting priorities among RH interventions and services. ColumbiaUniversity developed theis latter framework, and POLICY previously used it with some success in Nepal.
POLICY Framework for Addressing Operational Policy Barriers.
Operational policies are important elements in how a health system operates and are linked to the following four levels of operations: national laws and policies, public and private sector regulations, health systems management, and RH service delivery (see Figure 1). “Operational barriers can be traced to these four levels, and many barriers are affected by policies at multiple levels” (Cross, Hardee, and Jewell, 2001).
FIGURE Figure 1.
Conceptual Framework for Identifying Operational Policies
The framework for identifying and overcoming operational policy barriers involves the following four steps as undertaken under the direction of the PDG in January 2001 to address the operational policy barriers to implementing the NRHP:
- Understanding the public sector;
- Setting up a collaborative system for identifying barriers;
- Conducting analyses to identify the policy roots of the barriers; and
- Following through with the recommendations of the analysis to remove the policy barriers.
Using this framework, the PDG identified the 22 barriers to implementing the NRHP. Building on that exercise and based on the PDG’s request, POLICY used the framework to conduct research on three operational policy barriers related to the waste of government resources in the health sector: (1) inefficiencies in resource use at the facility level,;(2) inflexibility in city budget allocations,; and(3) the “shadow economy” in healthcare.
Columbia Framework for Priority Setting.
The priority-setting approach used in Kamianets-Podilsky was based on ColumbiaUniversity’s “Setting Priorities in International Reproductive Health Programs: A Practical Framework” (the Columbia Framework), which provides a systematic process for assessing RH interventions and program options and determining priorities for action. The framework considers six criteria for setting priorities: (1) magnitude of the RH problem, (2) efficacy of RH interventions, (3) cost of the RH interventions, (4) program requirements, (5) capacity of the health system, and (6) cultural and social acceptability of the RH interventions. Policymakers and program managers can rate each intervention according to the six criteria and determine the most desirable choices among interventions. Site-specific information is required only for the last two factorscriteria. Information on the other factorscriteria can be obtained on the global or regional level if local data are not available.
III.Context, Policy Issue, and Stakeholders
III.Context, Policy Issue, and Stakeholders
Socioeconomic and Family Planning/Reproductive Health Context
. Formerly part of the Soviet Union, Ukraine was—--in economic terms—--—second only to Russia as the strongest republic in the Soviet Union and, over the past four years, has experienced significant economic growth. Yet, the gross domestic product per capita totaled $4,350 in 2003 compared with around $6,598 for Central and Eastern Europe and the Commonwealth of Independent States (Human Development ReportUNDP, 2003). Moreover, nearly 30 percent of Ukraine’s population is estimated to live in poverty. Given that households have to pay for most drugs and supplies used throughout the course of their healthcare, the population living below the poverty line is at a significant disadvantage in gaining access to high-quality FP/RH care.
As in many other former Soviet countries, reproductive health and other health services in Ukraine are widely considered entitlements. While the constitution declares that all health services are free for the population, in reality, most clients are required to make charitable contributions to the health facility and to purchase most drugs and even supplies for their care. In addition, many clients pay their healthcare workers under the table. As a result, some of the neediest in the population may be less inclined to seek RH care or may receive less-than-adequate care if they are unable to make under-the-table payments to providers.
Ukraine has been experiencing what some call an “acute demographic crisis.” Since the early 1990s, Ukraine’s population has been shrinking as a result of a falling birth rate, increased mortality, and migration.[5] Ukraine’s 1993 population of 50.9 million decreased to approximately 48.05 million in 2003. Already low fertility rates further declined from 1.83 in 1991 to an estimated 1.34 in 2003. The decline in fertility and perceived “demographic crisis” have spurred greater interest in both increasing the birth rate and improving maternal and child healthMCH services. At the same time, however, Ukraine has paid only sporadic attention to family planning. The exploding incidence and prevalence rates of sexually transmitted infections (STIs), particularly syphilis and HIV/AIDS, arprovide additional proof of the need for that greater attention to RH issues is needed. Ukraine is the first European country to exceed an HIV prevalence rate of 1 percent of the adult population and is said to have one of the “fastest-growing epidemics in the world” (UNAIDS, 2002).
Policy Environment for Reproductive Health
. In 1998, POLICY began its work in Ukraine by conducting an overall FP/RH assessment through a key informant study to identify decision- makers, their political priorities, and their knowledge of FP/RH issues. The study revealed that health and RH were not high priorities in the broad policy environment, which encompasses many competing social and economic development concerns. However, policymakers interviewed for the study concluded that Ukraine’s RH situation was grave and deteriorating. At the time the study was conducted, nongovernmental organizations (NGOs) had limited opportunities to participate in decision making, and RH stakeholders did not have the advantage of an official, multisectoral coordination body for developing FP/RH policies.
The POLICY team found that the key informant study raised the awareness and attention of policymakers to RH issues and concluded that conditions were favorable for assigning a higher priority to RH. As a result of discussions during the key informant study, the multisectoral Policy Development Group (PDG) formed in Kyiv with POLICY support and Ministry of Health ( MOH) leadership. In March 1999, the PDG held its first meeting and determined its purpose: To raise awareness of reproductive health issues and to develop programs and policies to improve the situation and create a successor program to the National Family Planning Program (NFPP). The PDG’s meeting and statement of purpose constituted a major step in promoting a participatory policy process and a more supportive policy environment for FP/RH in Ukraine.
Since then, the PDG has remained active in the RH policy arena. In 2000, with assistance from POLICY, the PDG developed Ukraine’s first performance-based National Reproductive Health Program and budget, which was adopted by President Leonid Kuchma in March 2001. While the NRHP’s adoption was considered a great achievement, PDG members realized that it was just the first step in improving the quality and efficiency of RH services. The greater challenge has been to ensure the program’s successful implementation by identifying and removing operational policy barriers. Since January 2001, the PDG has met monthly to identify and address the most crucial operational policy barriers to providing access to high-quality RH services. Section IV presentdiscusses, in greater detail, the PDG’s work since January 2001.
Healthcare Financing in Ukraine
. Since 2001 and the introduction of per capita financing, the national government has allocated funds to cities and raions based on population size. At the municipal level, where the majority of clients receive health services, average per capita spending on healthcare from municipalities throughout Ukraineconstitutetotals 70 Ukrainian hryvnas annually.[6], [7] In many parts of Ukraine, city residents are not the only clients who patronize municipal facilities. For example, in Kamianets-Podilsky, the city estimated that, in first-quarter 2002, 13 percent of its clients were tax-paying residents of the raion (includes rural residents as well as residents of other cities). The municipal facility does not receive any extra funds to treat nonresident clients and must use the scarce resources intended for serving city residents only.
Although budget funds are now distributed to cities and oblasts in accordance with a per capita formula, outdated norms continue to influence the distribution of funds to healthcare facilities. Two MOH orders contribute to funding inefficiencies: MOH Order #33, “On staff Staff norms Norms and typical Typical staff Staff numbers Numbers in health Health care Care facilitiesFacilities,” enacted on February 23, 2000, and MOH Order #74, “On reference Reference norms Norms on inpatient Inpatient care Care needs Needs for child Child careCare, care Care for pregnant Pregnant and postpartum Postpartum womenWomen, and gynecological Gynecological careCare,” enacted on March 24, 1998.
Orders #33 and #74 are based primarily on the number of beds for inpatient services (e.g., one obstetric/gynecologic position per 15 obstetric/gynecologic beds) and the number of patient visits for outpatient services. When operating in accordance with the orders, healthcare facility managers lack the authority to make decisions about the facility’s staffing or bed needs. Instead, MOH Order #33 mandates that the number of staff must be calculated in terms of the number of beds in the facility, and MOH Order #74 mandates a specific number of beds per population (five obstetrical beds per 10,000 population). If the health facility manager adjusts the number of beds or staff to match actual need and the number of beds or staff falls below the amount mandated in the orders, the facility may receive reduced funding in the following year. As a result, healthcare facilities or service providers operate without any economic incentive to provide high-quality services or improve performance in a manner that may result in fewer facility visits or shorter inpatient stays.
Given Ukraine’s significant healthcare budget deficit, it is even more crucial that resources in the RH sector are used efficiently. Without addressing waste of resources in the overall health system, chronic problems in RH and healthcare cannot be solved solely by increasing resources. Insufficient funding reflects not only lower allocations from the government than necessary but also inefficient practices and policies in how the scarce resources are used. As noted, “The existing approaches to distributing funds within the health sector turn the problem of financial deficit into one that cannot be resolved even if the general economic situation in the country improves” (Lekhan et al., 2002).
In view of ongoing resource scarcity, one way that local governments can begin to implement the NRHP is to allocate funds efficiently to the most effective RH interventions. Thus, Ukraine there ifaces a critical need for program managers and health authorities at the oblast and city levels to set priorities specific to their jurisdictions. But, to set priorities and develop feasible implementation plans, oblasts and cities need information about relative costs and impacts, political viability, and the burden of disease/problem that pertains to each intervention under consideration. Such information is sparse in Ukraine, and many oblastand city and oblast health administrations are not prepared to conduct the planning exercises driven by that information.