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27
Inka Píbilová
Impacts of Czech cancer-fighting projects
in Georgia and Serbia: lessons for the
Visegrad Four*
Abstract:...
28 Inka Píbilová
The following article looks at the examples of two cancer-fighting projects
funded as part of Czech devel...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 29
Czech Republic is 78 per cent. This is close to the ...
30 Inka Píbilová
Georgia7
in 2013 and another one in Serbia8
in 2015. This article considers
the key evaluation findings r...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 31
Graph 1. The cancer-fighting project approach
3
diag...
32 Inka Píbilová
Actual impacts on women with cancer: saving lives
or contributing to hopelessness?
The external evaluatio...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 33
the city of Kragujevac and women without health insu...
34 Inka Píbilová
Table 1. Key aspects influencing the Czech cancer-fighting projects10
Aspect/Area Georgia Serbia
External...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 35
Aspect/Area Georgia Serbia
Medical staff
involved
Fr...
36 Inka Píbilová
Table 1 indicates that Serbia provided a far better enabling environment
for cancer prevention than Georg...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 37
only contribute to improving cancer awareness and ea...
38 Inka Píbilová
applicable to all Czech civil society organizations (CSOs) associated with
the development and humanitari...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 39
reputable Masaryk Memorial Cancer Institute plan to ...
40 Inka Píbilová
ministry, the Czech embassy in Belgrade reportedly continues to highlight
the need for cancer screening o...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 41
staff as well. Further, it is not clear either if th...
42 Inka Píbilová
onwards. This was recommended so that training sessions for Serbian
oncologists or for cancer patient ass...
Impacts of Czech cancer-fighting projects in Georgia and Serbia... 43
limited staffing capacities, the unavailability of e...
44 Inka Píbilová
Specific policy demands, backed with credible evidence, need to be
formulated by project implementers and...
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Impacts of Czech cancer-fighting projects in Georgia and Serbia: lessons for the Visegrad Four

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The goal of the article is to offer lessons learned on how to share what can be considered “transition experience” with countries in the Western Balkans and Eastern Partnership among others, in order to have a real impact on people’s lives. The author concludes that the Czech Republic, and other Visegrad countries, should share transition experience in areas where they have achieved evident progress and gained significant know-how which they are able to share. At the same time, such experience sharing has to be needs-based and complementary to other development efforts in partner countries. Based on the international recognition of the progress of the Czech Republic and on the evidence from two evaluations discussed in the article, women’s cancer prevention and treatment seem to be a great example of a well-chosen transition experience shared with the Czech partner countries of Georgia and Serbia. Yet, for similar projects in the future, it is necessary to reflect on the key local influencing factors; to understand exactly how each project will work and remain flexible throughout the project cycle; to focus on actual impacts and to accept accountability, and finally to practice evidence-based, consistent, long-term advocacy to achieve systemic changes.
Published in the peer-reviewed journal International Issues & Slovak Foreign Policy Affairs, Vol. XXV No. 3-4 | 2016, titled "Is there a shared transitional experience?"

Published in: Healthcare
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Impacts of Czech cancer-fighting projects in Georgia and Serbia: lessons for the Visegrad Four

  1. 1. 27 Inka Píbilová Impacts of Czech cancer-fighting projects in Georgia and Serbia: lessons for the Visegrad Four* Abstract: The goal of the article is to offer lessons learned on how to share what can be considered “transition experience” with countries in the Western Balkans and Eastern Partnership among others, in order to have a real impact on people’s lives. The author concludes that the Czech Republic, and other Visegrad countries, should share transition experience in areas where they have achieved evident progress and gained significant know-how which they are able to share. At the same time, such experience sharing has to be needs-based and complementary to other development efforts in partner countries. Based on the international recognition of the progress of the Czech Republic and on the evidence from two evaluations discussed in the article, women’s cancer prevention and treatment seem to be a great example of a well-chosen transition experience shared with the Czech partner countries of Georgia and Serbia. Yet, for similar projects in the future, it is necessary to reflect on the key local influencing factors; to understand exactly how each project will work and remain flexible throughout the project cycle; to focus on actual impacts and to accept accountability, and finally to practice evidence-based, consistent, long-term advocacy to achieve systemic changes. Píbilová, I., “Impacts of Czech cancer-fighting projects in Georgia and Serbia: lessons for the Visegrad Four,” International Issues Slovak Foreign Policy Affairs Vol. XXV, No. 3–4, 2016, pp. 27–44. * I would like to express my gratitude to all the evaluation actors who shared their views and relevant documents about the long-term impacts of these projects and their evaluations in September and October 2016 (see the list of institutions in the next footnote). I am also very appreciative of comments made in relation to this article by Eva Sabolova (Datatree), Daniel Svoboda (Development Worldwide), Marie Kórner (4G Eval), MUDr Václav Pecha and Ondřej Štefek (Naviga 4).
  2. 2. 28 Inka Píbilová The following article looks at the examples of two cancer-fighting projects funded as part of Czech development cooperation between the years 2010 and 2013. To find out about the long-term “real impacts” of these projects, I contacted the key stakeholders in September 2016.1 While the projects were not officially labeled as “transition projects,” I believe that they offer valuable lessons on what we might consider to be “transition experience” and how this can be shared with countries in the Western Balkans and the Eastern Partnership among others in order to make a real impact on people’s lives. These examples also show how important it is to tailor projects to local circumstances and to reassess what should be “transferred” and how, so as not to do more harm than good. Cancer prevention and treatment – potentially an area in which the Czech transition experience can be shared Early detection of cancer increases the likelihood of survival if the patient receives good and timely treatment.2 According to a recent EUROCARE-5 study (2014),3 the five-year relative survival rate for breast cancer in the 1 Written responses and relevant documents were received by October 14, 2016 from the Czech Ministry of Foreign Affairs and the Czech Development Agency in collaboration with the Czech embassy in Georgia, Caritas CR (the Czech implementer of the two projects), Oasa Sigurnosti Kragujevac (the Serbian implementer), Kragujevac municipality (Serbia), the EU Delegation in Serbia and Tanadgoma (the Georgian implementer). Responses were also received from the health ministries in Georgia and Serbia, the National Screening Center, the National Center for Disease Control and Public Health (both in Tbilisi, Georgia) but not from one of the Georgian implementers nor from the Czech embassy in Serbia. 2 “Health policy studies – cancer care: assuring quality to improve survival. Country note: Czech Republic,” OECD, 2013, p. 1–2. Available online: http://www.oecd.org/els/health- systems/Cancer-Care-Czech-Republic-2013.pdf (accessed on October 5, 2016). 3 J. Gregor, T. Pavlík, O. Májek, L. Šnajdrová, L. Dušek, Survival rates of Czech cancer patients have improved. Brno: Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, April 13, 2014. Available online: http://www.onconet.cz/ index-en.php?pg=newsaid=975#references; and http://www.onconet.cz/index-en. php?pg=newsaid=980 (accessed on October 5, 2016); J. Mužík, L. Šnajdrová, J. Gregor, Epidemiology of breast cancer in the Czech Republic, Epidemiology of breast cancer in the Czech Republic, Brno: Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, December 15, 2015. Available online: http://www.mamo.cz/index-en. php?pg=professionals--breast-cancer-epidemiology (accessed on October 5, 2016); and R. De Angelis, M. Sant, M.P. Coleman, S. Francisci, P. Baili, D. Pierannunzio, et al. EUROCARE-5 Working Group, Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE-5-a population-based study, Lancet Oncol 2014; 15(1), pp. 23–34.
  3. 3. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 29 Czech Republic is 78 per cent. This is close to the European average of 81.8 per cent and exceeds that of other European “post-communist countries” that average only 73.7 per cent. The GLOBOCAN 2012 data confirm this progress.4 Similar trends have also been identified for cervical and other types of cancer.5 The EUROCARE-5 study further argues that this success can be largely attributed to the breast cancer screening program launched in the Czech Republic in 2002 and covered by national health insurance. The Organization for Economic Co-operation and Development (OECD) viewed the new clinical guidelines, quality assurance and health information infrastructure positively but highlighted the need for further improvements. Since 2008 Czech development cooperation has included women’s cancer prevention among its health priorities. This is despite the sensitivity regarding the issue and the small number of donors engaged in the sector, due to the fact that cancer is associated with suffering and the perception that positive outcomes are less likely. Moreover, the Czech public see issues such as peace and security as a higher priority than health issues.6 Therefore sharing transition experience in cancer prevention can be seen as a bold choice for Czech development cooperation. So far, three cancer prevention projects have been implemented in Georgia and Serbia as part of Czech bilateral development cooperation. The Czech Ministry of Foreign Affairs commissioned external evaluations of a project in 4 L. Dušek, J. Mužík, D. Malúšková, L. Šnajdrová, Epidemiology of breast cancer: international comparison, Brno: Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, 2015. Available online: http://www.mamo.cz/index- en.php?pg=professionals--breast-cancer-epidemiology--international-comparison (accessed on October 5, 2016). 5 “Health policy studies …,” op. cit. 6 “Special Eurobarometer 441, EU development cooperation and aid,” European Commission, November – December 2015. Available online: https://ec.europa.eu/ europeaid/sites/devco/files/eb-eu-development-cooperation-and-aid-czech-republic- 122015_en.pdf (accessed on October 10, 2016). Sharing transition experience in cancer prevention can be seen as a bold choice for Czech development cooperation.
  4. 4. 30 Inka Píbilová Georgia7 in 2013 and another one in Serbia8 in 2015. This article considers the key evaluation findings regarding the project’s impacts on the lives of rural women. Conclusions are then drawn about the lessons learned that can be applied to other transition projects. Czech cancer-fighting projects in Georgia and Serbia: the general approach The purpose of the Georgia project was to improve the survival rates of patients with breast or cervical cancer (or tuberculosis), while the Serbian one was aimed more generally at improving the prevention of breast cancer among Serbian women. The two projects followed a similar logic. After an initial awareness raising campaign among rural women, breast and cervical cancer screenings were conducted in mobile units in villages. A few days later, the women received their results and those who had tested positive were invited for follow-up examinations at a  local health center or clinic. Patients with a  confirmed diagnosis were advised to follow a  specific treatment and referred to appropriate health facilities. Where feasible, their primary health service providers then followed up on the treatment. Progress was monitored by project medical staff and recorded in the project database. However, there were gaps in the data as some patients did not report back. The approach is illustrated in Graph 1. 7 I. Pibilova, V. Pecha, E. Margvelashvili, O.Štefek, P. Krucký, “Promotion of prevention and early detection of breast and cervical cancer among women in the regions of Samegrelo and Shida Kartli II in Georgia” (implemented in 2011–2013, evaluated in 2013), see the project description available online: http://czechaid.cz/en/, and the full evaluation report available at http://www.mzv.cz/file/1038491/evalrep_georgia2013_en_final. pdf (both links accessed on October 5, 2016). 8 I. Pibilova, V. Pecha, T. Menicanin, L. Bumbálek, “Promoting cancer prevention among women in the Šumadija region,” Serbia (2010–2012, evaluated in 2015), see the project description available online: http://czechaid.cz/en/ and the full evaluation report available  online:  http://www.mzv.cz/jnp/en/foreign_relations/development_ cooperation_and_humanitarian/bilateral_development_cooperation/evaluation/ serbia_report_on_the_evaluation_of_a.html (both links accessed on October 5, 2016).
  5. 5. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 31 Graph 1. The cancer-fighting project approach 3 diagnosis were advised to follow a specific treatment and referred to appropriate health facilities. Where feasible, their primary health service providers then followed up on the treatment. Progress was monitored by project medical staff and recorded in the project database. However, there were gaps in the data as some patients did not report back. The approach is illustrated in Graph 1. Graph 1. The cancer-fighting project approach During the two projects, Czech health experts shared their experiences of prevention and screening. The Czech implementer also shared experience regarding project management and related issues. I believe all these areas can be seen as “transition experience.” The projects were identified and formulated by the Czech Development Agency (CzDA). The CzDA selected implementers via a public tender, which meant that no major modifications to the project design were allowed. The CzDA and Czech embassy monitored implementation. The total project budget ranged from 10.5 million Czech crowns (389,000 euros)9 (Serbia) to 11 9 The exchange rate of approx. 27 CZK per 1 EUR was applied, in line with the October 2016 rate of the Czech National Bank. Source: http://www.cnb.cz/cs/index.html (accessed on October 13, 2016). During the two projects, Czech health experts shared their experiences of prevention and screening. The Czech implementer also shared experience regarding project management and related issues. I believe all these areas can be seen as “transition experience.” The projects were identified and formulated by the Czech Development Agency (CzDA). The CzDA selected implementers via a public tender, which meant that no major modifications to the project design were allowed. The CzDA and Czech embassy monitored implementation. The total project budget ranged from 10.5 million Czech crowns (389,000 euros)9 (Serbia) to 11 million Czech crowns (407,000 euros) (Georgia) over three years. Expenses were fully covered by the CzDA. 9 The exchange rate of approx. 27 CZK per 1 EUR was applied, in line with the October 2016 rate of the Czech National Bank. Source: http://www.cnb.cz/cs/index.html (accessed on October 13, 2016).
  6. 6. 32 Inka Píbilová Actual impacts on women with cancer: saving lives or contributing to hopelessness? The external evaluations revealed dramatic differences in the impact the projects had on the lives of women diagnosed with cancer. In Georgia, according to the implementers, 65 per cent of the 31 cancer cases and 4 per cent of the 48 cases of pre-cancerosis diagnosed through the project were treated. This was above the national treatment rate (25 per cent) but still alarmingly low. During the project, at least five patients died; some received partially inappropriate or insufficient treatment, which probably led to cancer relapse. Ultimately the evaluation team estimated that out of the 79 women diagnosed with either pre-cancerosis or cancer through the Czech project, only a  handful underwent appropriate treatment and had an increased chance of survival. The rest had little hope as the treatment was not accessible due to financial reasons and the distance to health facilities. Furthermore, some patients had difficulty accepting their diagnosis. However, the complete set of statistics is still not available. It is not clear if the remaining cancer patients started treatment following the steps advised by the evaluation or if they utilized the national health insurance re-launched in mid-2013. Nor is it clear whether women in the target areas started to focus more on prevention and continued to attend screenings after the project ended. To sum up, the Georgian project achieved some positive results, but the long- term impact on women’s lives is unclear. In Serbia the available evidence shows that almost 100 per cent of women diagnosed with pre-cancerosis (100 cases) or cancer (12 cases) were treated at local secondary and tertiary level health facilities thanks to the personal intervention of the local doctors who screened these patients in the mobile units. The project further contributed to equal access to health care by putting marginalized women in touch with treatment facilities and ensuring that they followed their treatment plans. Thus even socially excluded Roma women from In Serbia almost 100 per cent of women diagnosed with pre- cancerosis or cancer were treated at local secondary and tertiary level health facilities thanks to the personal intervention of the local doctors who screened these patients in the mobile units.
  7. 7. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 33 the city of Kragujevac and women without health insurance working in rural agricultural areas benefited. Their immediate health expenses were covered by a project surplus that arose because of the favorable currency exchange rate; further treatment was covered by the national health insurance once their positive diagnosis had been confirmed. A patient in a rather late stage of cancer who had refused treatment was identified by the evaluation team six months after project completion. She was put in touch with a local cancer patients association to help her deal with her fears of painful treatment and suffering. Her current status is not known. The project led to behavioral changes among women in target rural areas – some continued to undergo screening after the project had ended and paid for it out of their own pockets, knowing that early detection increases survival chances. Furthermore, greater public awareness of the need to undergo screening before cancer symptoms appear, positive experiences of screening and successful treatment as well as increased medical staff capabilities to conduct screening and understand the issues rural women face have likely contributed to an above-average participation rate in the recently launched national cervical screening in Kragujevac. These are long- term changes which were probably partly achieved with the contribution of the project. Influencing factors and accountability At first sight, it looks as if the Georgian project was a tremendous failure and the Serbian one an enormous success. Yet, subjecting the two projects to an objective comparison is rather difficult. Each country is at a completely different stage of development, and a  number of factors outside the implementers’ influence played an important role. In addition, there is a lack of data to enable cause and effect to be fully determined. The evaluation team identified the following aspects that influenced projects’ outputs, outcomes, impacts and sustainability.
  8. 8. 34 Inka Píbilová Table 1. Key aspects influencing the Czech cancer-fighting projects10 Aspect/Area Georgia Serbia External factors Health care system Constant major challenges affecting the accessibility of health facilities, needs major reform Relatively stable and accessible, needs improvements Patients’ health care financing Most citizens did not have health insurance during the project, national health insurance was introduced only in mid-2013 and the extent of coverage is unclear Most patients have national health insurance, yet some citizens are excluded, including some project beneficiaries; reform is needed National cancer screening programs Implemented during the project, but only in some cities, the launch in rural areas was delayed, so there was a gap after the project ended Started just after the project finished, thus allowing for regular follow-ups for women whose cancer awareness had been raised Project design Identified and formulated by CZDA (staff supported by an external health expert) CZDA (only staff) Funding 10.9 mil CZK, 100 per cent awarded based on a public tender (thus limited project design flexibility) 10.5 mil CZK, 100 per cent awarded based on a public tender (thus limited project design flexibility) Implemented by Caritas CR (coordination in Georgia, but frequent changes of project manager) Caritas CR (coordination from Prague, change of two project managers) Local partners Two non-government organizations (NGOs) as official local partners, namely Tanadgoma and the Cancer Prevention Centre (consistent project management), no formal agreement between the implementer and the local health facilities, Tanadgoma was based at a local hospital where some project beneficiaries received treatment One local NGO as an official partner, namely Oaza Sigurnosti Kragujevac (consistent project management), the local health center and Kragujevac municipality; a Memorandum of Understanding (MoU) between the implementer and the center 10 Adopted from I. Píbilová, V. Pecha, L. Bumbálek, T. Menicanin, “Report on the evaluation of a  project under the Czech Republic’s development cooperation in the health sector. Promoting cancer prevention among women in the Šumadija region,” Serbia (2010–2012), Naviga 4, MFA CR, 2015. Available online: http://www.mzv.cz/jnp/en/foreign_relations/ development_cooperation_and_humanitarian/bilateral_development_cooperation/ evaluation/serbia_report_on_the_evaluation_of_a.html (accessed on October 5, 2016).
  9. 9. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 35 Aspect/Area Georgia Serbia Medical staff involved From Tbilisi with the exception of one doctor from the region concerned From the local health center Advocacy to national authorities The health ministry and other key institutions were officially involved, the results were presented at the regional level, but not reflected at the national level; there was no institutional ownership The health ministry was informed only after the project started, it was not involved in its formulation and implementation, the results were presented at the regional level, but not reflected at the national level; there was no institutional ownership Efficiency Low screening costs, inconsistent documentation, high administration costs, planning, monitoring and evaluation by the CzDA health expert Low screening costs, reasonable documentation and administration costs, no internal assessment or evaluation, monitoring by the implementer and the CzDA Project implementation and follow-up Effectiveness Weak, fewer women screened than planned (3,244 instead of 8,500), still a high incidence rate of 1.18 per cent in 2011 and 0.58 per cent in 2012 of the total number of women screened (2013 data were not available), mainly early cancer stages detected Strong, more women screened than planned (4,292 instead of 4,000), i.e. 52 per cent of the rural population concerned, a high incidence rate of 0.33 per cent of the total number of women screened, mainly early cancer stages detected Impacts Most of the women diagnosed with cancer were not treated due to psychosocial reasons, finances and poor accessibility of treatment, women are not aware of their rights and mostly do not attend regular screenings Most women diagnosed with cancer were treated in local hospitals (a few with the project support), some patients continue attending regular screenings, others are not aware of their screening rights Sustainability Responsibility for rural screening unclear, even though women demand it Responsibility for rural screening unclear, medical staff involved in continued screening of rural women in the city, women trust them more than before and some come, some villages still demanded rural screening in 2015
  10. 10. 36 Inka Píbilová Table 1 indicates that Serbia provided a far better enabling environment for cancer prevention than Georgia. The Serbian health system has been more stable. Most patients had national health insurance and were able to benefit from it. National screening programs were launched in time to build on the project’s results and responded to the increased demand for screening. In Georgia the re-launch of national health insurance gave some hope to cancer patients, yet government funds were limited and there was low awareness among the public and medical staff about what it covered. There is no evidence that any project beneficiaries were treated towards or after the end of the project, i.e. after national health insurance was introduced in Georgia. Besides the external conditions mentioned above, the evaluations identified a number of internal influencing factors. A dedicated project team made up of the local Serbian NGO partner and gynecologists from the local health center in Kragujevac, Serbia, and involving the local primary, secondary and tertiary level health facilities contributed tremendously to getting most cancer patients treated, despite treatment not being part of the project design nor budgeted for. Crucially patients in Serbia knew the doctors who would further screen them and treat them because they had met them during initial field screening. In Georgia, on the other hand, the project medical staff were mainly brought in from Tbilisi, about six to eight hours away from most project areas. Some patients reported that getting treatment in Tbilisi was too expensive and that local treatment was either not accessible or not trusted. The health practitioners in the villages were genuinely concerned about women suffering from cancer but did not have the power to help them receive appropriate treatment. Thus women with diagnoses of pre-cancerosis or cancer tended not to receive help, even though treatment would not have been expensive. For detailed findings and conclusions, see the evaluation reports.11 Some project stakeholders argue that the CzDA and the implementers did not have the financial resources and capacity to influence the institutions and authorities concerned with developing the health services sector and could 11 I. Píbilová, V. Pecha, E. Margvelashvili, O. Štefek, P. Krucký, “Project evaluation report, official development cooperation project of the Czech Republic with Georgia. Promotion of prevention and early detection of breast and cervical cancer among women in the regions of Samegrelo and Shida Kartli II in Georgia,” Naviga4, MFA CR, 2013. Available online:http://www.mzv.cz/file/1038491/evalrep_georgia2013_en_final.pdf(accessed on October 5, 2016); and I. Píbilová, V. Pecha, l. Bumbálek, T. Menicanin, op. cit.
  11. 11. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 37 only contribute to improving cancer awareness and early diagnosis during the three-year project. This meant that the cancer treatment and survival of cancer patients was beyond their control. While these limitations were certainly valid, the evaluators and some other stakeholders thought the Georgian project should have put in place risk mitigation strategies and strived to achieve the project’s overall objective: “to increase the probability of surviving breast and cervical cancer (and TBC) among the target population in the Samegrelo and Shida Kartli regions.” Such strategies could have included establishing formal partnerships with local health centers (for screening and treatment) or municipalities (for co- financing the treatment) before the project started. Patients could have been informed about the screening and treatment options and prices at reliable health centers and then been actively referred to these institutions. It could have been advocated to the authorities that rural women need to be included in national screening programs and that they need to know what treatment costs can be covered by the national health insurance. The CzDA and the implementer argued that this was beyond their capacities and outside their remit. Yet, such strategies would have been in line with the focus on results and joint risk management required by the Czech Republic’s development effectiveness commitments, and set out in the Paris Declaration (2005), Accra Agenda for Action (2008)12 and Busan Partnership Agreement (2011).13 Moreover, accountability for impacts and their sustainability is also stipulated in the FoRS Code on Effectiveness14 , 12 “ParisDeclaration,”OECD,2005;and“AccraAgendaforAction”,OECD,2008.Availableonline: http://www.oecd.org/dac/effectiveness/parisdeclarationandaccraagendaforaction. htm (accessed on October 10, 2016). 13 “TheBusanPartnershipforEffectiveDevelopmentCo-operation”,OECD,2011.Availableonline: http://www.oecd.org/dac/effectiveness/thehighlevelforaonaideffectivenessahistory. htm (accessed on October 10, 2016). 14 “FoRS Code on Effectiveness”, FoRS, 2011. Available online: http://www.fors.cz/user_ files/fors_code_on_effectiveness_en.pdf (accessed on October 10, 2016). The principle on accountability for impacts and their sustainability states that “FoRS Members and observers are accountable for positive and negative, intended or unintended impacts of their development interventions and other activities on the situation of target groups and other development actors. They assume their part of accountability for sustainability of positive impacts and they are interested in the changes in lives or attitudes of target groups even after they had finished their projects. They enhance sustainable development of local communities by helping to reduce damages to the environment and by promoting preserving of biodiversity.” The FoRS Code specifically considers the following indicator key – “FoRS Members and observers are accountable for the impacts of their activities; they use the evaluation results and solve actively the incidental negative impacts of
  12. 12. 38 Inka Píbilová applicable to all Czech civil society organizations (CSOs) associated with the development and humanitarian CSO platform – the Czech Forum for Development Cooperation (FoRS). The FoRS Code reflects the Istanbul Principles15 agreed globally by CSOs and is thus applicable to Georgian and Serbian CSOs as well. Therefore the Czech government and the implementing CSOs should have actively addressed the negative impacts already identified during project implementation. Actual impacts on cancer prevention and treatment in Georgia and Serbia The CzDA noted that the 2013 evaluation confirmed the urgent need to cooperate with Georgia in the health sector over the long-term. Just after the project was completed, the CzDA utilized an opportunity to improve radiotherapy. The Georgian institutions favored a  more expensive, linear accelerator to the cobalt radiotherapy machine suggested by evaluators for the Samegrelo region. As this was beyond the financial capabilities of Czech development cooperation, the CzDA arranged a new energy source for an existing radiotherapy machine in Tbilisi. As a result, the number of treated persons reportedly increased. Further, as recommended by the evaluation, the CzDA has launched a  holistic approach to the fight against cancer and included aspects of cancer treatment in its new, complex cancer-fighting project in Georgia (2014–2017):16 it supports the oncohematology department for children. The CzDA also stated that it had started working on the Georgian cancer registry and planned to cooperate on the development of cancer treatment guidelines. Furthermore, there were plans to facilitate treatment and provide psychosocial support to cancer patients. Representatives from the highly their actions.” Its “serious infringement … can lead to the exclusion of the concerned organization from the FoRS platform.” 15 “Istanbul Principles,” Open forum for CSO development effectiveness, September 30, 2010. Available online: http://cso-effectiveness.org/-istanbul-principles,067-. html?lang=en (accessed on October 10, 2016). 16 “Support of early diagnosis, prevention and treatment of oncological diseases,” project ID: CzDA-GE-2010-5-12191. Available online in English: http://czechaid.cz/en/projekty/ support-of-early-diagnosis-prevention-and-treatment-of-oncological-diseases/ and Czech: http://czechaid.cz/projekty/podpora-prevence-vcasne-diagnostiky-a-lecby-onkologickych- onemocneni/ (accessed on October 10, 2016).
  13. 13. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 39 reputable Masaryk Memorial Cancer Institute plan to visit Georgia in early 2017 to address these issues. All these activities have been conducted in coordination with the Ministry of Labor, Health and Social Affairs of Georgia and the Georgian National Center for Disease Control and Public Health. The project will complement a  parallel project by the European School of Oncology on the professionalization of clinical oncologists. So far, there is no evidence about the actual impact of the new approach on the lives of cancer patients or people at risk. There is also no evidence of the impacts of any experience sharing, policy or advocacy on the Georgian health system (e.g. better utilization of national health insurance, modification of the National Screening Program, etc.). On the other hand, no subsequent cooperation related to cancer has taken place in Serbia as the Czech Republic planned to phase out from the health sector in this country in 2016 anyway. The Czech foreign ministry reported that the project had become a major inspiration for the nationwide cancer screening of women. It is not clear how – the Serbian implementer reported it had not been approached by any authority wishing to share its project experience. Moreover, “the (national) screening results were less successful than those of the project” according to the Czech ministry and the Georgian National Cancer Screening Office.17 The Czech foreign ministry further highlighted that the Serbian health ministry was more aware of the importance of cancer prevention. Cancer screening was one of the points the Czech health minister discussed with his Serbian counterpart during his visit to Serbia in 2015. The Czech ambassador also reminded the mayor of Kragujevac in 2015 about the project’s legacy and highlighted the need to continue activities aimed at better prevention and early diagnosis. Financial constraints were mentioned as a major limiting factor, even though some sources claimed that funding was available from the Serbian Institute for Public Health. According to the Czech foreign 17 National Cancer Screening Office website: http://www.skriningsrbija.rs/eng/statistics/ (accessed on October 15, 2016). As recommended by the evaluation, the CzDA has launched a holistic approach to the fight against cancer and included aspects of cancer treatment in Georgia.
  14. 14. 40 Inka Píbilová ministry, the Czech embassy in Belgrade reportedly continues to highlight the need for cancer screening on relevant occasions. Nevertheless, it is not apparent if the advocacy focuses on policy changes to cover the screening of uninsured women and to replicate the field screening piloted by the project to reach out to marginalized women at high risk of cancer, as recommended by the evaluation. It was reported that the project evaluation and subsequent advocacy had not reached important stakeholders, including the biggest donor in the health sector – the European Union – or the National Health Insurance Fund of the Republic of Serbia, or the (expert) public.18 As was the case in Georgia, there is no valid evidence that Czech advocacy activities have had an impact on the Serbian health system. Furthermore, there is no information on whether any experts or twinning arrangements have been requested by the Serbian authorities in the areas suggested by the evaluation (e.g. oncology data management, revision of screening procedures, training in tailor-made treatments, or strengthening cancer patient associations). No expert assignment has been approved, according to the web of the Czech Development Agency.19 It is also not clear to what extent the Temporary Expert Assignment Program is actively being promoted among the organizations involved in earlier development projects, including cancer prevention, to generate interest in the Czech “transition experience.” Contribution to changes in the Czech development cooperation system The external evaluations are also expected to provide advice on systemic changes to Czech development cooperation. Some of the recommended changes were indeed introduced. Yet, it is not possible to assess the extent to which the above evaluations were the drivers of such changes, as similar changes were proposed in other evaluations and by CzDA 18 An evaluation summary was provided in Serbian by the evaluation team to the Czech foreign ministry, responsible for the dissemination of the evaluation report. The summary is available online at http://www.mzv.cz/jnp/en/foreign_relations/development_ cooperation_and_humanitarian/bilateral_development_cooperation/evaluation/ serbia_report_on_the_evaluation_of_a.html (accessed October 11, 2016). 19 “Temporary Expert Assignment Program,” CzDA. Available online: http://czechaid.cz/ temata/dvoustranne-projekty-v-zahranici-v-ramci-specifickych-programu-cra/program- vysilani-expertu/ (accessed October 11, 2016).
  15. 15. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 41 staff as well. Further, it is not clear either if these changes led to greater effectiveness in development or improved the lives of people living in poverty and marginalization; yet, they can be perceived as the first steps in this direction. For example, the CzDA confirmed that an itemized budget template made it easier to assess cost-efficiency. In addition, sustainability has been included among the selection criteria for new projects, yet the recommendation for sustainability plans, set out at the very beginning, has not yet been fully reflected. TheCzDAreportedthatithasstrengthened its stakeholder mapping and has been striving to involve key actors, state and non-state, during the whole project cycle. Yet, the level of such engagement and the form of on-going advocacy to increase impacts and sustainability (Memoranda of Understanding with commitments of local authorities to co-funding and sustaining project benefits, evidence-based policy briefs, meetings with ministries, conferences, etc.) were not specified in the official documents. As recommended in 2013, the CzDA confirmed that it had piloted results-oriented monitoring the very same year and noted that it had been conducting thorough monitoring along with the Czech embassies. It also organized a meeting of development attachés on project cycle management, and monitoring in particular, in June 2016, as recommended in the 2015 evaluation. Data are not available on whether the improved monitoring led to better informed decisions during the project life cycles. In fact, the experience of the development project implementers shows that monitoring is still focused on activities rather than results. Besides the grants, it is not clear if the agency updates the logical frameworks of its projects (usually implemented via tenders) on the basis of the latest monitoring nor to what extent it conducts internal evaluations as suggested. The available evidence shows that projects managed by the agency are generally not evaluated, despite the fact that mid-term evaluations in particular have the potential to identify areas for change in time, i.e. before the projects end. This is highly applicable to the current cancer project in Georgia. Finally, rather than transferring temporary Czech experts’, the Czech foreign ministry is considering mutual exchanges of experts from 2017 Visegrad countries should share transition experience in areas where they have achieved evident progress and gained significant know-how.
  16. 16. 42 Inka Píbilová onwards. This was recommended so that training sessions for Serbian oncologists or for cancer patient associations could be conducted in Serbia as well as at health institutions in the Czech Republic. Conclusions and lessons learned International recognition of the Czech Republic’s progress and evidence from the two evaluations discussed above suggest that the prevention and treatment of women’s cancer seem to be a good example of a well-chosen transition experience shared with the Czech partner countries of Georgia and Serbia. Examples of the Czech “transition experience” that can be shared include screening procedures, oncology data management, tailor-made treatments and cancer patient associations. Once this transition experience has been shared, it is worth developing a case study including lessons learned for other countries and regions. On the basis of the two projects considered in the article, the author believes that the Czech Republic, and other Visegrad countries for that matter, should share transition experience in areas where they have achieved evident progress and gained significant know-how which can be shared. At the same time, such experience sharing has to be conducted on a needs-basis and complementary to other development efforts in partner countries. In order to achieve real, lasting positive impacts, though, a  number of lessons need to be taken into account for project management and advocacy: 1. Prepare for key influencing factors: Any development or transition project or program needs to take into account country-specific influencing factors. First of all a thorough risk analysis needs to be undertaken as part of project planning/formulation. Subsequently risk mitigation strategies and a sustainability plan should be set (including e.g. a request for co-funding by municipalities or the active involvement of local health facilities, as in the case of the projects elaborated above). Finally, if tailored to local needs and circumstances, the project plan would likely modify the general approach and specify what should be “transferred” and how. Conclusions about project feasibility can be made ahead of project approval and unrealistic project proposals can be avoided. Such project planning requires time and the presence of planners in the field, which is often not the case due to the CzDA’s
  17. 17. Impacts of Czech cancer-fighting projects in Georgia and Serbia... 43 limited staffing capacities, the unavailability of external subject matter specialists and limited funds. Yet, in the long-term, this approach could prevent the inefficient and ineffective use of funds as well as negative impacts. 2. Understand exactly how the project works and remain flexible: It needs to be acknowledged that development or transition projects, especially when piloting new methodologies or when implemented in a challenging, ever-changing environment, may not work out the way they were planned. Rather than simply assessing the non-achievement of indicators, it is worth analyzing what exactly works, how and why, and what decisions should be made to enhance the results and long- term positive impacts. The first step is to conduct ongoing monitoring in the field and mid-term evaluations and acknowledge “failures” or emerging challenges. The second is to modify project activities. While public tenders cannot be altered, the overall CzDA projects (and NGO projects implemented via a grant mechanism) can and should be if needed. Without such flexibility it is highly unlikely that complex projects or programs will get everything right from the very beginning and contribute to significant positive impacts. 3. Focus on actual impacts and accept accountability: There is a lack of evidence of the projects discussed above and their evaluations having any long-term impact on the health systems in Georgia or Serbia (changes in legislation, utilization of national health insurance, etc.) and ultimately on the ordinary citizens (the “final beneficiaries”). The question of “where does our accountability for results and impacts end” is a highly relevant one for government, civil society organizations and the private sector for that matter too. Complex development and transition projects should be long-term, and their results and wider impacts especially on vulnerable people should be regularly evaluated (after pilot phases, mid-term, at the end, ex-post) and actions should be taken to achieve positive changes in people’s lives. Without these “real life” impacts, any project or change in policy, system or procedure remains insignificant. In fact, they may even do more harm than good. 4. Evidence-based, consistent, long-term advocacy to achieve systemic changes: Both the projects had enough evidence to address issues on the systemic level. They advocated systemic changes, yet these tended to be one-off advocacy events. Advocacy needs to go beyond the sharing of experiences with ministries and other key institutions.
  18. 18. 44 Inka Píbilová Specific policy demands, backed with credible evidence, need to be formulated by project implementers and consistently advocated to achieve real change. Moreover, my own experience shows that joint advocacy with other key donors or relevant local institutions can be very powerful.20 Development attachés (Czech diplomats with a  development portfolio) and project coordinators who have been in partner countries for the long- term could ensure a presence in the field and significantly contribute to the project planning, monitoring, evaluation and coordination of advocacy efforts as proposed in the four points above. Together with the local partners, they are the “champions” of Czech development cooperation in the field. 20 See evidence e.g. in I. Pibilova et al, “Georgia – report from the complex evaluation of the Czech Republic development cooperation supporting human rights, democracy and societal transformation human rights, democracy and societal transformation,” MFA CR, 2014. Available online: http://www.mzv.cz/jnp/en/foreign_relations/development_ cooperation_and_humanitarian/bilateral_development_cooperation/evaluation/ georgia_summary_of_the_complex.html (accessed October 11, 2016).

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