1. Together for Health is funded by the United States Agency for International Development and implemented by JSI Research & Training Institute, Inc. in collaboration with the Academy for Educational Development and Harvard School of Public Health Building a Sustainable Family Planning Program in a Pronatalist Environment: Ukraine Experience Laurentiu Stan, MD, MPH, TfH Project Director Natalia Zaglada, MD, TfH Policy Coordinator Asta-Maria Kenney, Senior Advisor, JSI

2. Presenter Disclosures No relationships to disclose LAURENTIU STAN

3. Project seeks to help Ukrainians shift from abortion to contraception by improving access to quality FP/RH services; Funded by USAID and implemented by JSI Six years: 2005 – 2011; $12.3 million; Policy development is only one piece of TfH’s broad service delivery agenda. Together for Health (TfH)

4. Ukraine

5. Health System in Ukraine Middle-income country, 47 million people, transitioning from a Soviet past; Health system little changed from Soviet times—under-funded, over-regulated; Too many health facilities and specialists: 12,000 ob-gyns, 6,000 family doctors, more than 2,000 hospitals; Increasing decentralization—27 regions; Two streams of revenue: central and regional budgets.

6. Context for Family Planning in Ukraine Abortion rates – remain 2-3 times the level in the European Union; 24% of MWRA rely on condoms; 18% use IUDs—only 5% use pills, compared with 46% in Western Europe; Low fertility, declining population and strongly pronatalist policy; Contraception seen by many as a population control measure.

7. National RH Programs in Ukraine Two MCH/RH Programs 1995—2005, but no funds allocated to FP; Tradition of using government health Programs to procure equipment, vehicles, curative pharmaceuticals, etc.— not for public health or preventive interventions; With the old MCH/RH Program expiring in 2005, TfH saw an opportunity for change.

8. Steps of the Policy Process 1.Develop national program 2. Develop regional prog. 3. Mobilize money 4. Implement !

9. Step 1: Developing a National Program TfH vision in 2005 was: –Developing a broad RH program—not only FP—following the framework of WHO’s 2004 RH Strategy for European Region; –Prioritizing poor and vulnerable populations; –Adopting preventive approaches; –Funding for FP from Government of Ukraine; –Giving regions a key role in implementing the Program, to support decentralization.

10. “Advocacy Package” Developed to Reposition FP for Policy Makers Shift perceptions on FP away from a “population control measure” towards: –FP promotes health and is a human right –FP prevents abortion—rather than reducing fertility –Governments all over the world invest in FP, including contraceptive procurement; Advocacy Package - helpful with Ministries of Finance and Economics; and later useful for regional-level advocacy; Package later adapted for the Eastern Europe/Eurasia region;

11. Key Argument FP prevents abortion—rather than reducing fertility; example of Romania/Georgia/CAR

12. State Program RH of the Nation (SPRHN) Adopted SPRHN 2006-2015 adopted by Cabinet of Ministers in December, 2006; Program follows WHO/Euro’s RH strategy and builds on MDGs (5 objectives): –Safe Motherhood –Adolescent RH –Family Planning –“Preserving RH” (prevention/treatment of cancers) –Program management; Prioritizes vulnerable populations, like PLWH, low income, youth; Adopts multisectoral approach;

13. SPRHN 2006-2015 Adopted (Cont.) Includes groundbreaking public health concepts: –In-service training to accelerate expansion of the network of FP providers beyond Ob-Gyns—to include family doctors, midwives and others –Behavior change communications (BCC) –Procurement of contraceptives –Program management Authorizes ~$100 million for MCH/FP/RH from central and regional governments, including $12.5 mill. for FP, of which $9.5 mill. for contraceptive procurement.

14. Step 2: Developing Regional Programs Something new for the regions; TfH developed guidelines and a computerized spreadsheet: “Technical and Financial Guidelines for Developing Oblast FP/RH Programs,” which follows Ukrainian law; Ministry of Health (MOH) and TfH conducted a national SPRHN launch conference where regions were shown how to use the guidelines; MOH followed up with a letter to governors to encourage local health administrations to develop RH programs; TfH gave grants to NGOs for advocacy at regional level.

15. 21 Regional RH Programs Adopted

16. A year after SPRHN launch, 21 of 27 regions had adopted local FP/RH Programs following the SPRHN framework—using TfH guidelines; More than $100 mill. authorized up to 2015; All except one region included FP—a First!—authorizing about $18 million: –Contraceptive procurement ($14.5 million) –Equipment and refurbishment –Information systems –Public education.

17. Step 3: Mobilizing the Money Use a “double advocacy” approach (like “dual protection”!) –Authorization of Program funds is not enough; –Funds need to be mobilized annually; TfH provides technical assistance during annual development of health budgets;

18. Step 3: Mobilizing the Money (cont.) To support the annual allocations: Advocacy Package used in regions; TfH used USAID-donated condoms as an incentive for local funding for contraceptive procurement; NGOs advocated for RH Program funding in some regions.

19. Step 4: Implementing the Program Major challenges: –Efficient contraceptive procurements; –Financing in-service training and BCC activities under Ukrainian Budget Code provisions; –Strengthening Program management— TfH supporting development and implementation of computerized M&E system; SPRHN Coordination Committees established at nat’l and regional levels; TfH funds being used to fill the gaps to allow activities to move forward;

20. Launch of the SPRHN National M&E Guidelines/Electronic Tool (September 2009) M eeting of the Vinnytsya Oblast RH Program Coordinating Committee (August 2008)

21. Step 4: Implementing the Program (cont.) ENORMOUS PROGRESS has been made: For the first time, a national program authorizes FP funding and government funds have actually been spent for FP; For the first time, some funds being used for public health activities like training and BCC; Contraceptive procurement processes are improving; Local counterparts are working more transparently while implementing SPRHN.

22. Results: SPRHN Expenditures for FP and Contraceptive Procurement (USD) YEAR CENTRAL BUDGETLOCAL BUDGETS TOTAL FPContraceptive Procurement TOTAL FPContraceptive Procurement 2008$540,400$182,000 $1,134,800$372,200 2009$105,000 $258,100$172,000 TOTAL $645,400$1,392,900

23. Lessons Learned A national program like SPRHN can be an important vehicle to build a sustainable policy environment for FP/RH services; Reforms are needed to fulfill this vision in Ukraine: –To build management capacity and facilitate implementation –To allow more effective & efficient use of funds –To help health managers see the potential of the Program; Technical assistance for implementation of a national program can promote good governance and help combat corruption.

24. Thank You! ДЯКУЄМО! This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc. and do not necessarily reflect the views of USAID or the United States Government.