1. Підсумкова конференція проекту “Разом до здоров’я” 2005-2011 рр. Successful strategies, public health impact, lessons learned and remaining challenges Laurentiu Stan JSI Research and Training Institute, Inc.

2. www.tfh.jsi.com 2 The Together for Health (TfH) Project Background

3. www.tfh.jsi.com 3 Six-year project (Oct. 2005 – Nov. 2011) – $12.3 million Implemented by JSI Research & Training Institute Inc. in collaboration with: –The Academy for Educational Development –Harvard School of Public Health Goal: Abortions, unintended pregnancies Sexually transmitted infections …by improved provision & access to quality FP/RH services, in public and private sectors Together for Health (TfH)

4. www.tfh.jsi.com 4 FP/RH Service Provision in Ukraine at baseline Numerous health professionals (> 12,200 ObGyn’s) and health facilities FP/RH service provision: mainly by Ob-Gyn’s through a vertical network of FP centers and WCC GOU concerned of needs for health reforms : –Emerging primary health care –Decentralization towards regional level and below Over-reliance on traditional methods & abortions Providers & population perpetuated misconceptions about contraception, especially hormonals Low access to modern contraceptives (no donations, reduced GOU procurements) & geographic inequalities

5. www.tfh.jsi.com 5 Suboptimal access to information on FP/RH in the health sector for its clients Source: UDHS, 2007

6. www.tfh.jsi.com 6 TfH Objectives & Intended Results 1.Increase health providers’ knowledge & skills (clinical and counseling)  training 2.Improve clients’ knowledge and attitudes regarding FP/RH services & supplies  IEC/BCC interventions 3.Improve availability, accessibility & affordability of contraceptives  commodities 4.Strengthen capacity of public & private sectors to support policies & systems for improved RH  policy

7. www.tfh.jsi.com 7 TfH Coverage by 2011 ( 15 out of 27 regions - 65% of Ukrainian population )

8. www.tfh.jsi.com 8 ….State Program Reproductive Health of the Nation (SPRHN) TfH Implementation Strategies (1) - Working under the Umbrella of…. To support its FP/RH objectives and activities, at the national and oblast levels.

9. www.tfh.jsi.com 9 TfH Implementation Strategies (2) - Comprehensive approach, branding of the FP program/interventions Change Behavior of Population/ Clients Capacity Building of Health Providers Contraceptive Availability in Pharmacies and Public Sector “Ask the doctor about FP methods” “Have you asked the doctor about FP methods?”

10. www.tfh.jsi.com 10 The Together for Health (TfH) Public Health Impact

11. www.tfh.jsi.com 11 Building capacity for quality service provision in Primary Health Care over 9,000 health professionals trained since 2006 ~ 2/3 were PHC providers (FDs and non-Ob-Gyns’) Source: TfH, 2011

12. www.tfh.jsi.com 12 Improved availability of FP services and supplies at the community level Increased availability of free contraceptives at health facilities Source: TfH, 2011

13. www.tfh.jsi.com 13 Percent reduction of abortion rates in project-assisted regions, 2005-2010 Source: Ukraine MOH, 2005-2010

14. www.tfh.jsi.com 14 Average annual reduction of abortion rates in project assisted regions Regions Baseline Year Years in the TfH-exposed cohort Lviv20064 years Kharkiv20064 years Vinnitsa20064 years Volyn20064 years Dnipropetrovsk20064 years Poltava20064 years Odessa20073 years Donetsk20073 years Zaporizhzhya20073 years Rivne20073 years Khmelnytsk20073 years Ivano-Frankivsk20082 years Cherkassy20082 years AR Crimea20091 year Sevastopol20091 year

15. www.tfh.jsi.com 15 Contraception, steadily replacing abortion Source: Support for Market Development, 2005 – 2011 Ukraine MOH, 2005 – 2010

16. www.tfh.jsi.com 16 Contraception, steadily replacing abortion with positive demographic changes (Ab. decrease; contraceptive increase; birth rates increase) Dnipropetrovsk - 25% Ab. Rate decline + 8% Birth Rate increase Khmelnytsky - 16% Ab. Rate decline + 7% Birth Rate increase Source: Ukraine MOH, 2005-2010

17. www.tfh.jsi.com 17 Decline of incidence of child abandonment (ICA) higher in the TfH-assisted regions Source: Ukraine MOH, 2005-2010

18. www.tfh.jsi.com 18 The Together for Health (TfH) Key Lessons Learned

19. www.tfh.jsi.com 19 Importance of FP/RH in the Gov’t health agenda dictates allocations at national & regional levels Proportion of expenditures vs. alloted (FP Objective) Central budget; TfH vs. non-TfH Regions (Local budgets) Cumulative data 2008-2010 Source: MOH/TfH, 2011 Source: TfH, 2011

20. www.tfh.jsi.com 20 Partnership and coordination with various stakeholders National level institutions - to foster nationwide dissemination and programs’ sustainability Local level counterparts (governmental & NGOs) - to coordinate efforts and maximize results (e.g. best reach the most vulnerable groups) Private sector partners - to ensure coordinated messages, dissemination to non-project areas, and for leveraging additional resources Higher educational institutions - to ensure institutionalization of FP/RH education for doctors and nurses. THREE EXAMPLES SELECTED FURTHER 

21. www.tfh.jsi.com 21 USAID’s TfH Partnership with national level institutions and authorities Professor Nina Goyda, Pro-Rector Sustainable policy development: programs, protocols, guidelines (SPRHN approval and implementation) Nationwide dissemination—reaching additional beneficiaries from ALL regions Facilitation of communication between providers – regional authorities – national level health authorities Institutionalization of project-developed approaches: service provision systems, curricula, M&E tools, etc. Ensure coordination of messages when reaching various types of professionals: university professors, doctors, health managers and administrators

22. www.tfh.jsi.com 22 USAID TfH’s Partnership & coordination with Regional level NGOs to reach certain targeted groups/communities Maria Didenko, board member of NGO "Youth center for development", BCC trainer At local level, NGOs and non-health structures are key partners to reach target population groups However, NGOs experience with FP/RH and health providers is still in its infancy NGOs can serve a networking forum with other NGOs active in social areas and on HIV/AIDS prevention Social services for youth and the Department of education are key partners with experience in reaching certain vulnerable groups/target communities

23. www.tfh.jsi.com 23 USAID’s TFH Partnership & coordination with private sector Bayer Health Care Dr. Vladislav Golovinov Product Manager, Business Unit Women's Healthcare Development and dissemination of evidence-based information and resources for health professionals Awareness raising and educational campaigns for youth Continuous medical education events (CMEs) Worldwide partnership to assist governments and health ministries to provide access to subsidized contraceptives to vulnerable groups

24. www.tfh.jsi.com 24 Create the momentum and build upon it Substantial experience accumulated during the TfH implementation- basis for further improvements To achieve change there is a need for a range of actions with continuous investment /TA ~ ”reinvent ourselves” Providers’ capacity building Behavior change of population Policy / SPRHN Advocacy for adopting new approaches to sustain current public health achievements

25. www.tfh.jsi.com 25 Main challenges ahead in improving FP/RH in Ukraine

26. www.tfh.jsi.com 26 Ukraine, still high abortion-related Maternal Mortality Ukraine DHS,2007 : “…almost half of the women undergoing one abortion reported having had 2-3 during their lifetime” Source: Ukraine MOH, 2005 - 2010  Enhanced focus on behavior change and on standards of abortion procedures

27. www.tfh.jsi.com 27 Need to deeper focus on rural population Ukraine DHS, 2007: “…women who live in the capital and large cities have lower first abortion rates than those in smaller cities or towns” (Levchuck, 2009) Ukraine MOH data from 2009: “… percentage of live births to mothers aged 19 years old and younger is almost double in rural areas (12.8%) than in urban areas (6.7%)” (Tefft, 2011)

28. www.tfh.jsi.com 28 Population ability to pay for contraceptives is much lower than in 2005 (Source: Support for Market Development and Statistic Committee) Minimum wage could buy: 66 cycles of lowest priced OCs in 2005 44 cycles of lowest priced OCs in 2010

29. www.tfh.jsi.com 29 Advocacy for improved funding for FP/RH within governmental programs Need for a renewed call to action for “revival” of the SPRHN and Regional FP/RH programs Inclusion of FP/RH interventions within the governmental and donors‘ initiatives: –Presidential Initiative “New Life” –Government efforts to reform the health system –UN/WHO lead “Beyond the numbers” initiative

30. www.tfh.jsi.com 30 Building Partnerships HEALTH MANAGERS COMMUNITIES HEALTH PROFESSIONALS ACADEMIC INSTITUTIONS HEALTH MANAGERS Health professionals Policy makers POLICY MAKERS Academic institutions

31. Підсумкова конференція проекту “Разом до здоров’я” 2005-2011 рр. ДЯКУЄМО! Ця презентація була розроблена завдяки щедрій підтримці американського народу з допомогою Агентства США з Міжнародного Розвитку. Відповідальність за зміст цієї презентації несе Корпорація Інститут Дослідництва та Тренінгів JSI; інформація, яка відображена в цій презентації не завжди поділяє погляди Агентства США з Міжнародного Розвитку або уряду Сполучених Штатів.