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One of the major risks to long-term growth of Georgian economy and poverty alleviation is the deteriorating human capital stock as a result of unequal access to health care and low quality of social services. It is estimated, that the public spending on health constitutes less than 20% of total health expenditure, rest 80% being direct out of pocket payments. Universal access to a basic package of services has become a major objective for Georgian health sector reform.

The priority for ongoing reform of Georgian health care system is the establishment and further development of the Primary Health Care (PHC). At the end of 2000, the Government of Georgia (GoG) adopted a concept of primary health care development that envisages the formation of a health care model that effectively and reliably provides the entire population of the country with high quality, cost effective and equitable medical services and is physically available and affordable. The PHC system development program has become an integral part of the GoG’s Poverty Reduction Strategy, illustrating the government’s commitment towards the PHC sector.

The World Health Organization (WHO) defines primary health care as the principal vehicle for the delivery of health care at the most local level of a country's health system. It is essential health care made accessible at a cost the country and community can afford with methods that are practical, scientifically sound and socially acceptable. Everyone in the community should have access to it, and everyone should be involved in it. Beside an appropriate treatment of common diseases and injuries, provision of essential drugs, maternal and child health, and prevention and control locally endemic diseases and immunization, it should also include at least education of the community on prevalent health problems and methods of preventing them, promotion of proper nutrition, safe water and sanitation.

In the long run, strengthening of PHC services in Georgia is expected to have a beneficial impact on the health status of the population, increase degree of satisfaction that health care produces among the citizens, and protect the individuals against the serious financial burden that disease can produce.

GoG has undertaken significant health sector reforms in the last eight years. These reforms have changed the role of the Ministry of Labor, Health and Social Affairs (MoLHSA) from a direct provider of health services to policy-maker, planner, and regulator of health services. In addition, the GoG has developed and approved a Primary Health Care (PHC) Strategy for the country, which serves as a guiding document for the development of PHC and General Practice/Family Medicine (GP/FM) in the country. The PHC Strategy calls for major changes in the institutional establishment and functional performance. It is however, important to do this within a sector-wide context. The basic health package should not be seen as an island in the health sector. It must be linked with other services and other levels of care.

The reorientation of primary health care service appeared on the top of the Governments agenda recently, generated tremendous support from a number of multi-lateral and bi-lateral donor agencies such as World Bank, European Union (EU), British Department for International Development (DFID) and others. This in itself created a need of effective coordination and harmonization of various donor financed activities.

To address this co-ordination challenge and ensure country ownership, the Ministry of Labour, Health and Social Affairs (MoLHSA) decided that all future interventions in the PHC sector must be better coordinated and lead by the Ministry. Memorandum of understanding has been signed between the Government of Georgia / MoLHSA, European Union (TACIS), DFID, and World Bank. “The Parties” agreed co-operate to develop an enabling co-ordination framework and strategies to further establish and develop the Primary Health Care System in Georgia. This shall strengthen the co-ordination of the state and the international initiatives for the efficient and effective utilization of all resources. To achieve this objectives the Ministry of Labour, Health and Social Affairs with aid of donor organizations sets up Primary Health Care Co-ordination Board (PHC CB) and it’s supporting Management Committee (PHC MC). Both of these bodies have been established more than a year ago.

Purpose of the PHC Coordination Board is to:
•    Lead the PHC Program of Work;
•    Act as the overall governing body of the PHC Program and the PHC Management Committee ;
•    Define, evaluate and/or approve the Mission, Goals, Strategy, Global Project Design, Overall Resource Requirements, Concurrent & Final Program Performance;
The PHC Management Committee is under the direction of the Board and is charged with day to day implementation the PHC program.
It should be mentioned, that the establishment of PHC CB and MC was not a purely technical decision. Already during the First Health Reform Project, financed by the WB loan and started in 1996, a Project Coordination Unit (PCU) within Ministry of Health has been established for the same purpose. Later on PCU has been renamed and reorganized to Georgian Health and Social Projects Implementation Centre (HSPIC) with respective changes in the scope of work of the unit. HSPIC became a public (governmental) agency, with it’s executive director appointed by the President. By the time of PHC project launching, HSPIC has already gained an experience in managing health and social reform projects of other than WB donors also (such as Global Fund to Fight AIDS, Tuberculosis and Malaria). So the tasks of newly established PHC CB and MC where in a certain degree overlapping with the ones of HSPIC.

Overall PHC development program includes the following components:
•    Rehabilitation of the PHC infrastructure, including PHC clinics, referral laboratories and perinatal referral pilot clinic.
•    Development of human resources (HR) for PHC;
•    Support for health care financing reforms and policy development.
•    Development and strengthening of health management information system (HMIS).
•    Implementation of the information, education and communication (IEC) campaign.
•    Enhancement of capacity of the Ministry of Labor. Health and Social Affairs (MoLHSA) to manage the PHC sub-sector.

In order to fine-tune the implementation plans, ensure proper sequencing of the activities, avoid unnecessary duplication of efforts and wastage of scarce resources, as well as identify all the possible gaps, series of thematic stakeholder workshops have been called by the PHC MC during last moths. As a result consolidated process charts have been developed for each sub-component of the PHC development program, outlining the scope of responsibility of each stakeholder and timing of respective activities.
Based on these charts and stakeholder discussions, the Master Terms of Reference for Primary Health Care Program, outlining high-level goals, objectives, activities, deliverables, plans, constraints, risks, reporting needs, key evaluation considerations, strategic approach and inter-dependencies has been drafted by the PHC MC and is to be approved by the PHC Board in September later this year.

Coordination of International Donor Assistance – Global trends and good practices

Coordination of international donor assistance on a country level remains one of the biggest challenges worldwide. The international development community has come a long way in understanding what makes aid more effective. The way the donors provide their aid matters a lot. All the major donor agencies have given sustained and systematic attention to “harmonization friendly” changes within their practices, operational policies and procedures with those of partner country systems to improve the effectiveness of development assistance.
This is particularly pertinent where the effort lacks adequate coordination, which too often results in project proliferation and duplication, disruption of normal accountability line, fragmentation, unrealistic demands, and ultimately a loss of control over the health development process.

Several mechanisms have been suggested in order to promote effective delivery of the aid. It has been suggested, that in good country environments, where there are genuine reformers, donors should integrate their support in the recipient’s development strategy, budget, and service delivery system. Donor financial assistance and knowledge transfers should be harmonized with the recipient’s priorities and focus on outcomes and results.

Other options for coordinating donor assistance are geographical zoning, assigning lead agency, sub-sector specialization of activities by the donor agencies involved, etc.

Aid differs in important ways from domestically financed services. The beneficiaries and financers live in different countries. This geographical and political separation between beneficiaries in the recipient country and tax-payers in the donor country breaks the normal performance feedback loop. Beneficiaries in recipient country cannot reward or punish the policymakers responsible for the performance in donor countries:

In recent years, donors have given a renewed emphasis to the importance of their relationships with partner governments and, in particular, to placing nationally designed country strategies at the heart of the development process. Ministers, Heads of Aid Agencies and other Senior Officials representing 28 aid recipient countries and more than 40 multilateral and bilateral development institutions endorsed the Rome Declaration on Harmonization in February 2003.

The nine principles underlying this new approach to partnership are developed by the Development Assistance Committee (DAC) of the Organization for Economic Co-operation and Development (OECD). These are:

1. Donors should support country-owned, country-led poverty reduction strategies, or equivalent national frameworks, and base their programming on the needs and priorities identified in these.
2. Development assistance should be provided in ways that build, and do not inadvertently undermine, partner countries’ sustainable capacity to develop, implement and account for these policies to their people and legislature.
3. Co-ordination of donor practices enhances the effectiveness of aid, particularly for aid dependent countries. Aid co-ordination should, whenever possible, be led by partner governments.
4. Reliance on partner government systems, where these provide reasonable assurance that co-operation resources are used for agreed purposes, is likely to enhance achievement of sustainable improvements in government performance.
5. Partner countries and donors have a shared interest in ensuring that public funds are used appropriately.
6. Donors should work closely with partner countries to address weaknesses in institutional capacity or other constraints that prevent reasonable assurance on use of co-operation resources.
7. The development of appropriate partner country systems will often be a medium term process. Until donors can rely on these, they should simplify and harmonize their own procedures to reduce the burden placed on partner countries.
8. No single approach is suitable for all countries. The manner in which harmonization is implemented needs to be adapted to local circumstances and institutional capacities.
9. Assistance to empower civil society and support effective organizations representing the private sector also can enhance improvements in partner government performance.

Donors’ ability to adopt many of these guiding principles, and the good practices that follow from them, depends on the commitment and capacity of partner governments to improve donor co-ordination and aid effectiveness. Donors have legitimate concerns regarding good
management and the impact of their aid. This can create a tension between the good practices of promoting ownership and partnership with partner governments and the desire of donors to ensure that aid is used for its intended purposes and helps promote reform.

One year experience and current status of PHC reform in Georgia – problems and proposed strategy

More than one year elapsed since launching of the PHC reform in Georgia. Nevertheless, tangible, visible outputs are still to be seen. This delay in initiating activities only in part might be attributed to the recent political changes in Georgian Government and resulting total staff turnover within the MoLHSA.
Inappropriate coordination arrangements in place are the prime cause of the delay. First of all, problems are not defined and objectives are not set up systematically, based on the coherence of the logic. Many activities (components and workstreams) are still split between implementers, causing duplication and wastage of resources. Activity plans do not follow horizontal and vertical intervention logic and are not properly distributed among stakeholders. Gaps in activities to achieve stated goals are not defined properly. Sequencing and division of responsibilities are not ensured either. Practice of blaming each other in delays and resulting vicious circles are common. Common performance monitoring and evaluation indicators do not exist.
Each Implementing organization maintains its office including administrative and technical staff, resulting in very high transaction costs.

Overall logframe for the PHC program, which would clearly outline the hierarchy of goals and objectives, horizontal and vertical logic behind, objectively verifiable indicators of success and important assumptions beyond the influence of the program is still not available. In order to fill this gap, it is proposed to hire a consultant, which jointly with the PHC MC and other stakeholders will be responsible for development of the logframe, as a guiding document for implementation, monitoring and evaluation of the PHC reform in Georgia. Re-distribution of activities between implementers will be also greatly facilitated by doing so.

KEY REFERENCES:

1.    Harmonising Donor Practices for Effective Aid Delivery. A DAC reference document, OECD 2003;
2.    Rome Declaration on Harmonization, February 2003;
3.    Primary Health Care – Master Terms of Reference. (Draft) March 2004, Georgia.
4.    Roberts MJ, Hsiao W, Berman p, Reich MR. Getting Health Reform Right – a guide to improving performance and equity. Oxford University Press 2004.
5.    The Role and Effectiveness opf Development Assistance. Lessons from the World Bank Experience. The World Bank, Washington DC.