1. EU and Wider Neighborhood Ukraine

2. EU and Wider Neighborhood Health Gap Main problem –premature adult morbidity and mortality Economic issue –loss of prime labor force –Cost of health services Social issue –Unequal opportunities because of poor health –Poor health leads to poverty –Poverty leads to poor health

3. EU and Wider Neighborhood Shrinking Populations

4. EU and Wider Neighborhood Health Gap

12. Infant mortality follows EU trend –though on higher level More recently accuracy of data has been questioned –survey data in several CIS countries significantly higher –but no survey data available for Ukraine Commitment to Millennium Development Goals –MCH but no premature adult mortality

13. EU and Wider Neighborhood Health Gap: Behavioral Risk Factors We really do not know –little and fragmented info on knowledge, behaviors, attitudes Makes it difficult –to recognize the problem –design and monitor impact of policy interventions

14. EU and Wider Neighborhood Health Gap

15. EU and Wider Neighborhood Infectious diseases: international PH issues Endemic outbreaks of vaccine preventable and waterborne diseases HIV/AIDS –In Ukraine: between 50,000 and 400,000 HIV positive TB STIs

16. EU and Wider Neighborhood International Public Health Issues

19. EU and Wider Neighborhood Health Financing Gap Public financing of health lower than expected High level of out-of- pocket payments –informal and formal People can not access health services –in Ukraine 30% of population reports no access (2001) Leads to poverty and ill health vicious circle

20. EU and Wider Neighborhood Health Care Services: Structural Imbalances

21. EU and Wider Neighborhood Health Care Services Structural Imbalances

22. EU and Wider Neighborhood Health Care Services: Structural Imbalances

23. EU and Wider Neighborhood Ukraine response to health sector challenges (1) Health system has been resisting reform so far –Para 49 in Constitution guarantees free health care and forbids optimization of health services Strategic health reform documents –“Concept of the Development of Health Care in Ukraine” President’s Decree 2000 –“The Health of Nation,” Government program, 2002; based on WHO Health for All strategy –But no effective implementation, decision making barriers, strategies not funded

24. EU and Wider Neighborhood Ukraine response to health sector challenges (2) Emerging health system reform directions –Family Doctor based PHC services –Health financing system reform, attempts to introduce social health insurance Joint Government, WB, GFATM effort to tackle HIV/AIDS and TB epidemic –annually 1 million workers seek temporary employment abroad

25. EU and Wider Neighborhood Ukraine – evidence on EU convergence “European Way” – overarching development objective declared by the President of Ukraine Public health, safety, occupational health –Sanitary Epidemiology Service – largely unchanged Soviet model, incremental changes planned Pharmaceutical industry –domestic industry supplies60% of local market, first manufacturers GMP certified Medical training and qualifications –undergraduate and graduate training still far from Europe –still 138 recognized specialties

26. EU and Wider Neighborhood World Bank Program in Ukraine Tuberculosis and AIDS Project; 2003; cost US$ 77M (WB loan US$ 60 M) –TB (US$ 28.7 M) training, diagnosis, treatment, public awareness, monitoring and evaluation; –HIV/AIDS component (US$ 32.2 M) treatment protocols, training, harm reduction, public awareness, strengthening regional capacity Prisons component (US$ 12.7 M) both HIV/AIDS and TB; –Implemented in parallel and complementary to the GFATM grant of US$ 90 M Policy dialogue under Programmatic Adjustment Loan Program (PAL 2 2003) –Health financing reform –PHC reform

27. EU and Wider Neighborhood World Bank Program in Russia Health Reform Pilot Project; 1997; (cost $83.2 mill (WB loan $66 million) –Kaluga oblast reform (Restructuring delivery system and provider incentives; Maternal and Child health and Family Planning) –Tver oblast reform (Restructuring cardiovascular health services; Family medicine; Restructuring provider incentives) –National Training Program in Family Medicine Health Reform Implementation Project; 2003; cost $41 mill (WB loan $30 mill) –Rationalization of health services –Strengthening financial and economic management –Improving policy and governance

28. EU and Wider Neighborhood World Bank Program in Russia Tuberculosis and AIDS Control Project; 2003; cost $286 mill (WB loan $150 mill) –Control of TB ($217M) policies, strategies and protocols; strengthening surveillance, monitoring, quality control; improvement of TB case detection and diagnosis; improvement of TB treatment) –Control of HIV/AIDS ($65.3) policies, strategies and public information; surveillance and monitoring; targeted prevention of HIV/AIDS and STIs in high risk groups; prevention of mother-to- child transmission) Health policy analysis and dialogue –studies, advisory services

29. EU and Wider Neighborhood World Bank Program in Moldova Tuberculosis and AIDS Project; 2003; cost US$ 15M (WB grant US$5 M, GFATM grant US$ 9.5M) –HIV/AIDS/STI component (US$ 6.9M): strategic planning and institution building, surveillance system, training, laboratory capacity; prevention and harm reduction programs among high risk groups; treatment and care for PLWHA; –TB (US$ 6.8M) policies, strategies and protocols; surveillance, monitoring, quality control; improvement of TB case detection and diagnosis; improvement of TB treatment Health Investment Fund Project; 2000; cost US$ 20M (WB credit US$ 10M; Netherlands US$ 8.4M) –Policy and institutional strengthening of MOH (US$ 1.7 M) –Health Investment Fund (US$ 17.7M) – emergency and primary health care; hospital capacity rationalization