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Harmonization of the international Donor Assistance for the Development of Primary Health Care in Georgia - Hopes, Expectations and Reality

Research Proposal                                                                

George Khechinashvili



Background                                

The past two decades have witnessed an upsurge in the number of external agencies involved in the health sectors of developing countries. Concomitantly, there has been an increase in the volume of resources transferred through multilateral, bilateral and non-governmental organizations to these health systems. Notwithstanding the beneficial impact of increased resources, recipients and donors are increasingly concerned about the effects of this trend. 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. Donors, as well as recipients are concerned about aid efficiency and effectiveness. Both recipients and donors are looking for ways of better managing the aid coordination and harmonization. Although there has been considerable experience with coordination strategies, most writing has considered external assistance in general, rather than the health sector in particular. There has been little analysis of the manner in which recipient ministries of health manage donors and the influx of resources. Sector wide approaches (SWAPs) are a new development in the organization of aid to developing countries where donors and lenders collectively contribute to funding the entire health sector.
Donors are embracing sector wide approaches enthusiastically, and they have been introduced in the health sector in several countries, but the realities have been little tested. Yet, there are some inherited risks and problems associated with SWAp; Donors will not be able to attribute funds, causing problems in evaluation and reporting, there will be dilution of dedicated training, there is a lack of confidence in government financial management and procurement systems, etc
The shift from project-based delivery of development assistance to SWAps has implications for the accountability relationships between all of these parties:
•    Accountability between the donor agency and its own government and public;
•    Accountability between the donor agency and the developing country government;
•    Accountability between the developing country government and its citizens.
Involvement in SWAps is forcing donor agencies to find new ways of accounting for their performance to their home governments and their publics.

In Georgia reorientation of primary health care (PHC) service has been taking place for several years and is supported by various international organizations. In a large extent, due to lack of co-ordination, assistance from such organizations has been less effective than hoped in meeting stated goals.
In 2003, PHC Development Program was initiated by the Ministry of Labour, Health and Social Affairs (MoLHSA), supported by the World Bank, DFID, EU and other bilateral development agencies or international NGOs. To address the aid harmonization challenge, MoLHSA decided that all future interventions in the PHC sector must be consistent with the National Strategic Health Plan and Health Policy, and must be better coordinated through the PHC Coordination Board and the PHC Management Committee, established within MoLHSA. Memorandum of understanding has been signed by the MoLHSA and donor representatives. Parties have agreed that the PHC Co-ordination Board and it’s supporting Management Committee should be the central coordination point for the PHC program.




Objectives

Overall objective of this project is to identify provisions and tools for effective coordination of international development assistance targeted at reforming country health sector.
Specific objectives are to:
•    Explore donor agency regulations with regard to aid harmonization and SWAp;
•    Identify government institutions and professionals attitudes towards SWAp;
•    Identify mechanisms, that are used for aid coordination (e.g. agreed strategic direction, geographical zoning, sub-sector specialization, donor consortia, project co-financing, harmonization of procedures;
•    Observe coordination arrangements from the initial stage and it’s development and dynamics throughout the PHC development project implementation;
•    Evaluate impact of the SWAp on project implementation with regard to avoiding duplication of efforts and controversies in implementation strategies, filling the possible gaps in program planning, etc.
 

Methodology and Implementation Plan


The study will be based on review of documents and interviews with key government and donor informants with the emphasis on interrelationship between national and international policies, exploring interests of different stakeholders.
Triangulation of qualitative and quantitative research methods will be deployed to address the project objectives.
Initially systematic literature search (electronic databases, manual search using snowball technique) and review will be performed to explore international experience on SWAp implementation in practice, evaluation, definitions and distinctions between coordination, harmonization and SWAp.  
Together with literature review, content, context, structure and actors of the Georgian PHC development program, as well as initial provisions for aid coordination will be described in the first report.
Based on the literature review, study tools and instruments (questionnaires, interview structures, FGD guides, etc.) will be developed.
Stakeholder analysis of parties involved in PHC Development Program implementation will be performed. For the presentation of stakeholder analysis data, matrix will be prepared. Stakeholders will be grouped in three major groups: 1). government agencies, 2).multi- and bi-lateral donors, and 3). international NGOs.   
Development of coordination provisions will be observed and described during PHC program implementation. Special attention would be drawn on ways of solving controversies and disagreement.
Obstacles, advantages and disadvantages of coordination, associated risks and their mitigation techniques, sources of resistance, communication channels used by the stakeholders will be identified.


Expected results

Strengths and weaknesses of the dominant mechanisms used to coordinate health sector aid will be described, assessed and compared with each other.
Results of the study and lessons learned might be used nationally for better coordination of international development assistance in the future during implementation of the health, as well as other sector project.
Taking into account country specifics, results of this study also would be useful to be considered in the future for better coordination of  activities while planning and implementing the programs and projects supported by the international development community in other developing countries.