Biennial Collaborative Agreement (BCA) 2020-2021

Description of the Biennial Collaborative Agreement

This document constitutes a practical framework for collaboration. It has been drawn up in a process of successive consultations between national health authorities and the Secretariat of the WHO Regional Office for Europe.

The collaboration programme for 2020–2021 has started with the bottom-up GPW 13 outcome prioritization process undertaken by the country in cooperation with the Regional Office. This work was carried out as part of WHO’s transformation in the overall context provided by GPW 13. The objective of the bottom-up planning exercise was to determine the priority health outcomes for WHO collaboration with the country during the period 2019–2023. This document further details the collaboration programme, including the prioritized outcomes, proposed outputs, and product and services deliverables.

The outcomes are the desired changes in the Member State’s capacities that result in increased access to services and that ultimately contribute to sustainable changes in the health of populations. These changes in the health of populations are those that the Member State aims to achieve on the basis of its uptake of the WHO Secretariat’s outputs, and hence they are a joint responsibility of the Member State and the Secretariat.

Achieving the prioritized outcomes as identified in this BCA is therefore the responsibility of both the WHO Secretariat and the Government of Ukraine.

Different modes of delivery are foreseen in the implementation of this BCA, ranging from country-specific (for outputs that are highly specific to the needs and circumstances of individual countries), to intercountry (addressing countries’ common needs using Region-wide approaches) and multicountry (for subregional needs).

Annex 1: GPW 13 results framework

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Health situation analysis

The population of Ukraine is around 42 million people (excluding temporarily occupied Autonomous Republic of Crimea and the city of Sevastopol), mainly urban (69,2%) with 53,7% of female population and overall employment rate of around 56%. The life expectancy is 76,7 years for females and 67 years for males.

Noncommunicable diseases (NCDs) and chronic conditions comprise the bulk of mortality in Ukraine, especially among working age males. In 2017, NCDs were linked to 91% of total deaths. The deaths from five major NCDs (cardiovascular diseases, diabetes, cancers, chronic respiratory diseases and mental health conditions) contribute to almost 84% of all mortality cases in Ukraine. Among these, most of the deaths are caused by cardiovascular diseases (62%) and cancers (14%). Almost 30% of men who died in 2017 from NCDs are in the working age group of 30-65 years. Deaths and injuries from traffic accidents are loss of life and health that can be prevented. In 2015, three quarters of Ukrainians killed in traffic accidents were of working age, and 37,2% were aged 14–35. Notwithstanding high shares in mortality rates, NCDs also account for the bulk of disability (70%) in Ukraine of the 20 million disability-adjusted life-years in 2004. Efforts on combating noncommunicable diseases include increased price and taxes, introduced total ban on advertising, sponsorship and promotion of tobacco products (target 3.a) as well as national strategy adopted in 2018 and strengthening surveillance data and evidence to address NCDs by implementation STEPS survey during 2019.  

While reported cases of communicable diseases, notably HIV/AIDS and multi-drug resistant TB (MDR TB) continue to rise, the Ministry of Health of Ukraine supported by WHO has made significant progress in the implementation of TB control activities, resulting in a decreasing TB notification rate of new and relapse cases from 80.5/100 000 population in 2013 to 62.3/100 000 in 2018. The treatment success rate for MDR TB remains a concern, but Ukraine is increasingly following WHO guidelines. Reported cases of HIV have increased, in part due to significant progress in the number of people tested and diagnosed. HIV treatment coverage has also increased from 66 409 in 2014 to over 113 000 in 2019, with high rates of viral suppression in those treated (94%). Ukraine is increasingly following WHO guidance on hepatitis and using drugs with direct antiviral activity for treatment of hepatitis C and access to these drugs has increased. In November 2019 the National Strategy on HIV, TB and Hepatitis (in line with WHO strategies and guidance) was approved by Cabinet of Ministers demonstrating commitment in line with SDGs to end HIV, TB and hepatitis as public health problems by 2030. As a part of on-going reforms in public health and primary health care, screening for HIV, TB and hepatitis became part of the medical benefits package to be provided by primary health care providers.      

Routine vaccination coverage among young children remains low. According to the statistics of 2017, only 50% of children received all three doses of vaccine against diphtheria-tetanus, only 52% were fully vaccinated against hepatitis B, and less than 50%  against polio; the statistic of 2018 didn't improve significantly among those antigens and figures are 67,5%; 65,2%; 69,2% respectively. During 2017-2019, considerable outbreaks of measles have been reported. Therefore, the targets for Measles and Rubella elimination are not met. Efforts to improve child health (addressed under target 3.2) and tackle vaccine preventable diseases (target 3.b.1.) and key communicable diseases, such as TB, HIV/AIDS and to a lesser extent hepatitis (part of target 3.3), also benefited from increased attention and investment, leading to gradual but steady progress. There is increasing attention on antimicrobial resistance and infection control measures.

In the implementation of the 2030 Agenda, Ukraine builds on earlier successes on Millennium Development Goals (MDGs). In 2017 Ukraine has issued the first Sustainable Development Goals (SDGs) national report taking into account the principle of ‘leave no one behind’ and using a wide range of informational, statistical and analytical materials. In August 2019 the Government adopted a new resolution governing the data collection to monitor SDGs indicators and provide a solid base for further planning of Ukraine’s development.

In 2015, the Government of Ukraine initiated a massive reform of its entire health system, to move towards universal health coverage (UHC) (SDG targets 3.8, 3.b and 3.c) and improve the health outcomes of the population. A comprehensive reform strategy has been put forward with four key areas including (1) health service and delivery; (2) health financing; (3) quality governance of the sector; and (4) ensuring essential health system inputs. On 30 March 2018, the Government of Ukraine established a new single purchasing agency, the NHSU, and approved the regulations required for the functioning of the agency. In 2018-2019, the healthcare reform was launched with the introduction of contracting and new provider payment methods at primary healthcare level, based on the principle that “money follows patient”. In April 2020, the plan is to launch the next stage of reforms with a focus on outpatient specialist and inpatient care. Case-based payments will be introduced for hospital services, shifting the focus from inputs to outputs. This, in turn, will facilitate the restructuring of the oversized hospital infrastructure. However, in addition to financial incentives, to address the issue of outdated service delivery model focused on specialized inpatient care, regional hospital masterplans have to be developed and licensing and accreditation have to be strengthened. Government Financial Guarantees include: primary care, emergency care, pediatric care, delivery, specialized outpatient and in-patient care, rehabilitation and palliative care. As part of the medical guarantees programme for 2020, cardiovascular diseases, maternity and neonatal care, and cancer are included as priority conditions.  As a part of on-going reforms in public health and primary health care, screening for HIV, TB and hepatitis became part of the medical guarantees to be provided by primary health care providers.      

To improve access to essential medicines, vaccines and diagnostics the government provides public centralized procurements through transparent mechanisms by engagement of international specialized organizations since 2015 which are to be transferred to the central procurement agency “Medical Procurements of Ukraine” created in 2018. In parallel, to ensure access to safe, effective, quality and affordable essential medicines the reimbursement program “Affordable Medicines” has been launched in 2019 and implemented by the NHSU using electronic prescriptions for treatment of patients with cardiovascular diseases, type II diabetes and bronchial asthma (target 3.8, 3.b.3).  

Against this positive development, humanitarian and health-related needs in Donbas, particularly along the contact line, are steadily increasing and the already overstretched health system can hardly respond to the needs of its citizens. More than 3.4 million people are in need of health-related humanitarian assistance, including 1.4 million Internally Displaced People (IDP) and 2 million people living close to the contact-line. Since 2014 at least 145 health facilities have been damaged or destroyed by shelling making it impossible to ensure proper management of health staff and medical services. Emergency medical and trauma care, psychosocial support integrated into primary health care services, and regular deliveries of essential emergency medical supplies will continue to be among the priorities. The country highly recognized health security and the need of strengthening capacity, make a more resilient health system to be adequately prepared to emergencies to ensure appropriate response to health threats (target 3.d, 3.d.1, 11.a). Overall challenges remain related to slow economic growth; rising health care cost partly due to changing epidemiological patterns, deteriorating infrastructure; governance practices and inefficient institutions; and an outdated health information system.  

The WHO Director-General, Dr Tedros Adhanom Ghebreyesus, declared the novel coronavirus (2019-nCoV) outbreak a public health emergency of international concern (PHEIC) on 30 January 2020. The first case in Ukraine was detected on February 29. Since early March, with strong support from WHO, the Ministry of Health has been issuing and constantly updating public health measures and technical guidance to the public, other government agencies, private companies and health care providers. To manage the outbreak in Ukraine the following areas need particular attention: strong public information campaign, coordinated approach among different levels of the government, good cooperation and information exchange among various ministries and government agencies involved in the response, technical guidance to providers on patient pathways for those with COVID-19 symptoms, adequate capacity of service providers particularly in infection prevention control, testing strategy and supplies, and ensuring continuation of essential health services, including immunization of children, deliveries and other urgent procedures.

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GPW 13 prioritized outcomes and links to Health 2020 and the 2030 Agenda in Ukraine

Since 2015, Ukraine has made laudable steps reforming its health system to ensure progress universal health coverage (UHC). The reforms which have been implemented over the past four years aim to achieve equal access to essential health services with a focus on primary health care, including financial risk protection, access to affordable, safe, effective medicines and vaccines (GPW13 targets 1-5, 31, 34, 35; SDGs targets 3.8, 3.c, 3.b.3, 3.7, 5.1, 17.18). However, many challenges remain and require concerted actions towards the designation of a high-quality, affordable, equitable health service delivery system at all levels of healthcare system that is focused on the best interests of patients.

Besides health threats such as drug-resistant tuberculosis, HIV, hepatitis and antimicrobial resistance, the response to the needs of people suffering from (multiple) chronic illnesses is at the top of the service delivery reform agenda. Chronic illnesses have multiple impacts: they represent a considerable restraint on life-quality, productivity and the functional state of people who suffer from them, they contribute significantly to morbidity and mortality rates, resulting in increased health and social costs.  

Ukraine has also implemented a number of measures towards strengthening public health system, population health improvement, and protection of individuals and population from exposure to risk factors. It has also adopted health-in-all-policies approach (GPW13 4.2; SDGs 17.18). The governmental action plan on public health system development prioritised objectives with special focus on prevention and control of vaccine-preventable diseases (GPW13 10, 34, 40; SDGs 3.3, 3.8.1, 3.b.1), key communicable diseases, such as HIV/AIDS, viral hepatitis and tuberculosis, to address antimicrobial resistance (GPW13 36, 38, 39, 41, 42; SDGs 3.3, 3.8, 3.b.3), to tackle noncommunicable diseases and risk factors (tobacco, alcohol, nutrition, physical activity – GPW13 21-31, 33; SDGs 2.2, 3.3-3.6) as well as on actions towards strengthening epidemiological surveillance, preparedness to health emergencies, in particular regarding highly pathogenic disease outbreaks, rapid detection, identification and response to health threats by increased preparedness and implementation of the International Health Regulations (GPW13 9, 10; SDGs 3.d, 16.4, 16.7).  

WHO in close collaboration with humanitarian actors and the government will continue to address the humanitarian situation in Donbas, particularly along the contact line, to ensure meaningful access to health care services for the conflict-affected population residing near the contact line and in non-Government Controlled Areas (NGCA) by implementing practical measures to address challenges in terms of distance, cost of travel and accessibility for disabled internally displaced persons (IDPs) (GPW13 1, 2, 4-5, 9, 28, 36, 39, 41, 45-46; SDGs 3.8, 3.d, 3.3, 3.4, 3.9, 6.1, 6.2, 16.7, 16.8). WHO supports coordination and leads the Health Cluster in Ukraine, as well provides policy advice, strategic guidance in key communicable and noncommunicable diseases, through the Health Cluster Working Groups on HIV and TB; and the Mental Health and Psychosocial Support. In addition the support is ongoing in GCA to improve health services as well bridge the humanitarian and development actions.  

The economic, social and environmental determinants of health need an inter-sectorial approach within the SDGs framework. Ukraine, like other UN member states, has joined the global process of sustainable development. To establish the strategic framework for Ukraine's national development for the period up to 2030, an inclusive process of adapting the Sustainable Development Goals has been initiated on the basis of the principle "Leave no one behind". This will enable Ukraine to build upon the achievements and more systematically address health challenges, such as premature mortality from noncommunicable diseases (target 3.4, 3.5 and 3.a, but also 2.1 and 2.2), communicable disease (targets 3.3, 3.8, 3.b.3) and road traffic injuries (target 3.6), in the coming decades. It will also empower the country to strengthen health systems, including access to affordable medicines, availability of the health workforce, emergency preparedness and sustainable financing for health. This will contribute to achieving health targets 3.8, 3.b and 3.d, as well as targets related to ending poverty (SDG 1). The aspects of strengthening national institutions, partnership for development (both national and international) and aid effectiveness, and intersectorial actions are essential to ensure improvement.  

This BCA enables Ukraine to progress towards UHC, health protection and health promotion in line with movement towards achieving SDGs targets to ensure healthy lives and promote well-being for all at all ages, but also address other goals on gender equality, food security, water and sanitation, climate change, air quality, inequalities and partnerships.

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Linkage of the BCA with national and international strategic frameworks for Ukraine

This BCA for Ukraine supports the realization of Ukraine’s national health policies and plans, such as legal frameworks and health-related concept papers “On the development of Public Health System in Ukraine”, “On New Health Financing Mechanism”, “On Affordable Medicines” as well as supportive to health sector ongoing reforms and policies on decentralization – the concept of local self-governance reform and territorial organization of power; environment – the concept of adaptation to climate changes. The BCA follows the vision of the Cabinet of Ministers action programme and other strategic documents. The BCA actions will provide necessary impetus to strengthen the performance of the Ukrainian health system and improve health outcomes of the Ukrainian population.  

The BCA will support the continued implementation of the reforms and continued strengthening and modernization of Ukraine’s health system in accordance with its laws. The adoption of key legislative acts by Verkhovna Rada (the Parliament) in 2017, as well as several governmental decrees have opened the process of re-shaping the Ukrainian health care system. Thus, on 19 October 2017, Verkhovna Rada of Ukraine gave a start to the reform by adopting the Law of Ukraine On Government Financial Guarantees of Public Medical Services (Law 2168) and amended the National Budget, and on 14 November adopted the Law of Ukraine On Improving Affordability and Quality of Medical Services in Rural Areas. This set of documents created a strong legal and political framework to implement new health financing arrangements. The BCA activities will support the continued implementation of these laws as well as contribute to the implementation of the number of national programs, strategies and plans: the Medical Guarantees Programme, National NCDs Action Plan for achieving SDGs up to 2030; National Action Plan on AMR control; National Strategy on HIV/AIDS, TB and viral hepatitis for the period up to 2030; State Strategy of the development of TB medical care; State Strategy for the Implementation of the State Policy on Providing the Population with Medical Products for the period up to 2025 and Action Plan of its implementation; the State Drug Policy for 2019-2020; Concept on Mental Health for the period up to 2030; Concept on Emergencies Medical Service development; Strategy for medical education development; State Strategy on Regional development by 2020; Strategy and Action Plan on immunization up to 2022; Biosafety and Biosecurity Strategy based on “One Health” approach for the period up to 2025; Action Plan to reduce the level of exposure from radon and its decay products, minimize long-term risks from radon exposure in residential, non-residential premises and workplaces.

This BCA aims to support Government policy priorities in health, based on the country disease burden, regional and global evidence of what works, health system challenges and opportunities, and considering obligations under the EU-Ukraine Association Agreement. Ukraine has an opportunity to utilize the European Union standards harmonization (including in public health and security, access and quality of medicines, mobility of human resources, taxes on tobacco and alcohol products, food safety standards etc.) for health improvement. The BCA-supported activities are in line with WHO European Programme of Work, Roadmap to implement the 2030 Agenda for Sustainable Development, building on experience of Health 2020, and a number of key global or regional strategies. These include global health sector strategies for HIV, Sexually transmitted infections (STIs) and viral hepatitis 2016-2021, Action plans for the health sector response to HIV, viral hepatitis and tuberculosis in the WHO European Region, End-TB Strategy 2016-2035, European Vaccine Action Plan 2015-2020, Investing in Children: the European Child and Adolescent Health and Development Strategy 2015-2020, Regional Strategy on Sexual and Reproductive Health 2016-2020, European Mental Health Action Plan 2014-2020, Global Action Plan on Prevention and Control of Noncommunicable Diseases 2013-2020, Strategy and Action Plan for Healthy Aging in Europe 2012-2020, Roadmap of actions to strengthen implementation of WHO Framework Convention on Tobacco Control in the European Region 2015–2025, European action plan to reduce the harmful use of alcohol 2012–2020, European Food and Nutrition Action Plan 2015–2020, The European Action Plan for Strengthening Public Health Services, Global Action Plan on Antimicrobial Resistance, Global Strategy on Woman and Child Health, international treaties (Convention on the Rights of Persons with Disabilities, Framework Convention on Tobacco Control, International Health Regulations 2005), Action plan for health employment and inclusive economic growth (2017–2021) as a mechanism for coordinating and advancing the intersectoral implementation of the Commission’s recommendations and immediate actions in support of WHO’s Global Strategy on Human Resources for Health: Workforce 2030, Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), Global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls, and against children, Global Plan for the Decade of Action for Road Safety 2011−2020, United Nations Decade of Action on Nutrition (2016–2025), WHO Ministerial Conferences outcome documents, resolutions, norms and standards, and the list of the Ministry of Health priority areas for intervention, as set forth in the ministry’s strategic development plan.

Ukraine is eligible to receive funds under the Pandemic Influenza Preparedness (PIP) Framework Partnership Contribution as an international arrangement adopted by the World Health Assembly in May 2011 to improve global pandemic influenza preparedness and response. Ukraine joined the International Health Partnership UHC2030 in 2019. The BCA 2018-2019 has integrated the health-related key SDG targets and indicators and supports the implementation of the Ukraine UNPF 2018-2022.

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Programmatic priorities for collaboration

The collaboration programme for 2020–2021, as detailed in Annex 2, is grounded in the above analysis and was mutually agreed on and selected in response to public health concerns and ongoing efforts to improve the health status of the population of Ukraine. It seeks to facilitate strategic collaboration and enable WHO to make a unique contribution.

Annex 2

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