2.1 Evaluative Question 1
Since 1995, what has the European Commission put in place, in terms of global policies, strategies, and programmes (Cotonou agreement, TACIS, MEDA, ...) to operationalise its engagements with the ICPD Plan of Action and ICPD+5? To what extent are the EC policies, strategies and programmes coherent with ICPD?
This Evaluative Question is being answered via Brussels-based interviews, document analysis, etc. The Preparatory Phase concluded that the EC’s population policy focus has shifted from concern with rapid population growth as a deterrent to economic development to concern with the right to adequate sexual and reproductive health. In addition to its focus on women, the EC has actively targeted adolescents. This evolving population policy has been externally coherent with shifts in the stance of other policy institutions. Moreover, the internal coherence of EC population policy has improved over time. There is little sign from policy documents, however, that the EC has sought to exploit synergies with other areas of EC assistance (apart from health and support to refugees / internally displaced persons). Nor has there been adequate consideration of strategic linkages between population policy and policies in other areas.
In view of needs in poor countries and the scarcity of resources, the relevance of EC population assistance appears to be assured. The Preparatory Phase did not reach a judgment on whether EC assistance has been effective in pursuing policy goals. The validity of the efficiency criterion is diminishing with the move towards a human- rights based approach, however, as poor reproductive and sexual health particularly affect vulnerable groups, and as the unit costs of most interventions are low, the EC’s population activities may be very efficient means of addressing inequities. The Preparatory Phase also did not reach a conclusion regarding sustainability; however, it is widely known that available international financing falls far short of needs and governments are reluctant to commit resources.
The evaluation team has found that the Commission’s record-keeping and accounting systems for population projects have been over-stretched as a result of the multiplication of sectors, budget lines, and directorates, as well no doubt as by rapid staff turnover. The team noted that steps are underway in Brussels to unify databases.
Most generally, the Preparatory Phase of this evaluation found that there are opportunities for the EC to enhance its impact in the population field and, by exploiting synergies with other sectors, to bolster the relevance and effectiveness of its overall development approaches. In order to translate these preliminary indications into practical steps and actions, the Preparatory Phase recommended that the Commission proceed with the Completion Phase of this thematic evaluation on
2.2 Evaluative question 2
To what extent did EC third country co-operation strategies (especially CSPs, NIPs, etc.) reflect an overall population and development sector approach, and respond to the needs of the Cairo Plan?
At the level of countries: Were country strategies internally coherent from the standpoint of population and were population components coherent with the global development policy of the EU?
General overview of EC assistance
Over the decade 1992-2002, the EC allocated about Euro 340 million to Georgia (see Table 6 at the end of the Report). The EC’s strategy in Georgia has evolved significantly in response to the changing economic and political climate. Initially, country strategy concentrated on transition towards democracy and the market economy, stressing technical assistance as the main strategic instrument. The main problems encountered were (i) the difficulty of effectively mobilising, under very difficult political circumstances, the good intentions and accurate understanding of problems expressed by the GoG and (ii) dealing with the adverse on-the-ground situation of conflict, IDPs, poor governance, corruption, and weak civil society institutions. These factors have led to a shift to the overall objective of poverty reduction. Coupled with this is a desire to more effectively implicate NGOs and local communities in implementation of the strategy. The evolution of EC strategy has been gradual, in response to lessons learned in Georgia and elsewhere. At the same time, it has been dramatic, involving a marked shift towards the social sector.
Prior to 2000
Prior to institution of the Country Strategy Paper (CSP) system in 2000, it is possible to judge EC aims from those of the Tacis National Programme 2000-01: (i) support for institutional, legal, and administrative reform, (ii) support to private sector development, and (iii) development of infrastructure networks.
CSP 2002-06
As a result of limited progress, the first Georgia Country Strategy Paper (CSP 2002- 06) adopted on 27 December 2001 re-oriented EC strategy towards the following three priority areas: (i) support for institutional, legal, and administrative reform), (ii) support for addressing the social consequences of transition, and (iii) development of infrastructure. Replacement of private sector development with social consequences of transition was a response to the perceived lack of progress towards improving the life of ordinary Georgians.
The CSP 2002-06 identified poverty reduction as the main goal of cooperation. It aligned itself with the interim Poverty Reduction Strategy Programme published by GoG in late 2000, which in turn identified improvement in conditions in the social
sector (health and education) as a key strategic direction. With regard to health, the goal was given as increasing the share of GDP devoted to health care from 0.9% of GDP in 1999 to 7%, with emphasis given to improving health care financing.
The National Indicative Programme (NIP) 2002-03 associated with CSP 2002-06 identified two actions related to health. The first (Euro 1.3 million) addressed Priority (i) above and consisted of technical assistance to the MoLHSA. Extreme inequality in health care availability was noted, reference was made to the 1999 Health Care Policy adopted by GoG, and the need to coordinate with the World Bank’s Health Care 1 soft loan was emphasised. Expected results were an improved legislative and regulatory framework for access to PHC by the poorest strata of society, especially outside Tbilisi. Under Priority (ii), the NIP 2002-03 called for expenditure of Euro 7.5 million to rehabilitate PHC delivery points not covered by other programmes (e.g., World Bank), especially in the most impoverished areas.
Revision and draft CSP 2003-06
In response to continued lack of progress and irregularities in the cooperation programme, including grave security problems, a revision of the country strategy was undertaken in 2002, resulting in the revised CSP 2003-06 (still in draft). The new strategic priorities are (i) promoting rule of law, good governance, and respect for human rights and institutions, (ii) reducing poverty, targeting assistance to the most vulnerable groups, especially in rural areas, and (iii) enhancing stability and security through confidence building measures aiming at the prevention and settlement of internal conflicts and actions in favour of affected populations. This striking change of priorities reflects a high-level judgement that previous approaches in Georgia were not working. In effect, the new draft CSP warns that the lack of policy will on the part of GoG is not going unnoticed and that credible reform steps are crucial. Assistance will only be continued, the CSP seems to say between the lines, if it is coherent with the political situation: “There is evidence that influential forces in Georgia, in and outside the Government, do not adequately support reform. The resolution of internal conflicts also appears as a major condition for sustainable economic and social development.” (p. 4).
All of the CSPs reviewed make reference to phenomena such as IDPs, emigration, breakdown of social protection, the poor public health situation, etc. They would benefit, however, from consideration of the broad population theme taken as a whole – depopulation, aging exacerbated by emigration of the young, rising mortality, and sub-replacement fertility as a consequence of high risk and low household income -- as a major contextual variable for development strategy.
Activities related to population / ICPD
ICPD Programme of Action-related components of EC country strategy in Georgia over 1994-2002 consisted of
- Small NGO projects implemented under the TACIS-LIEN programme. - Targeted social assistance, mainly to the elderly and to disadvantaged
- ECHO humanitarian emergency assistance to internally displaced persons (IDPs), which included a significant component of financing the rehabilitation and operation of health facilities.
All of these activities were coherent with EC development policies and commitments to ICPD goals. They do not, however, add up to a comprehensive effort to take ICPD into account at the country level. This observation must be placed in the context of the shifts in EC strategy described above and limited engagement with the social sector prior to the present. Moreover, GoG policy itself, while consistent with ICPD, continues to be heavily oriented towards a limited basket of ICPD priorities, namely safe motherhood and mother and child health.
The major emerging area of EC support is Tacis support for health sector reform emphasising access to primary health care for the poor.
This activity, as it moves forward, offers a significant opportunity for the EC to increase the ICPD component of country assistance.
Tacis-LIEN. In the mid-to late 1990s, the Tacis-LIEN programme supported 7-8 small (ca. Euro 100,000 – 300,000) NGO-implemented activities in Georgia with an explicit social focus towards disadvantaged groups. The overall objective was strengthening of civil society, with social reintegration of deprived and marginalized groups the project purpose and improved delivery of social services to target groups one of the anticipated results (see Table 7 at end of Report for the logical framework). One of these projects, implemented by Family Planning Association of Georgia in collaboration with International Planned Parenthood Federation (IPPF), rehabilitated, equipped, and supported the operation of RH/FP clinics in Aspindza and Akhaltsekhe (South Georgia) as well as Tbilisi (a clinic targeted at IDPs). The total amount committed was ca. Euro 200,000.
Following a mid-term evaluation in 2000, the Tacis-LIEN programme was phased out, apparently in large part because of the evaluation’s finding that management and administration procedures were inefficient. This must be seen as a disappointment at the country level, as project evaluations in Georgia were generally favourable. Coherence of the projects with EC country strategies and global development goals was not questioned. However,
- coherence with other Tacis projects was limited,
- Tacis-LIEN interventions were small, scattered, and unfocused, raising issues of impact and sustainability, and
- LIEN procedures were judged to be too complicated, with the effect of reducing efficiency.
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EC Food Security Programme (FSP). Starting in 2000, the EC FSP financed a programme to provide (through the MoLHSA) social assistance to targeted members of the elderly population; in addition, institutions caring for children without parents were supported, as were families with many children and disabled persons including
the blind. The establishment of a social safety net for the elderly (see logical framework given as Table 8 at the end of the Report) is consistent with ICPD, with EC development objectives, and with country strategy. As shown in Table 9, social protection financed through FSP is in fact much more significant than the traditional food security activities per se that are implemented by the Ministry of Agriculture.
European Community Humanitarian Office (ECHO). In the early and mid-years of the period covered by this evaluation, ECHO was active across a wide range of activities dealing with alleviating the plight of IDPs, including providing health care which, in turn, included a modest amount of RH/FP and a more significant MCH / Safe Motherhood component. These activities were concentrated mostly in Zugdidi, Samagrelo region. Other regions covered included Abkhazia, South Ossetia, Adjara, Imereti, and Tbilisi. International partners included Medecins sans Frontiers, Feed the Children, International Federation of Red Cross Societies, International Committee for the Red Cross, CARE, Oxfam, WomanAid International, and others; in addition, the World Food Programme was involved. In Zugdidi, emergency assistance in the health area was implemented by Technical Assistance to Georgia (TAG), a local NGO, in collaboration with Save the Children. The Republican hospital in Zugdidi, including the maternity department (which also provides limited RH/FP services through a Women’s Cabinet) was renovated, and a polyclinic reserved for IDPs was established. 15 village ambulatories were renovated and provided with drugs; in addition, staff was trained. Most clients benefiting from these facilities are IDPs.
Overall answer to Evaluative Question 2
EC assistance in support of ICPD goals was scattered over the evaluation period. RH/FP projects in the context of Tacis-LIEN focused on strengthening civil society and socializing marginalised groups, not on broad ICPD goals. While internally coherent and coherent with EC policy, these projects did not attain the level of a strategic approach to population, nor does population broadly speaking play a large role in CSPs. ECHO humanitarian assistance in rehabilitating health centres offering RH/FP and safe motherhood services was a major ICPD-related intervention, as was EC FSP-financed targeted social assistance for the elderly. However, both are meant to deal with emergency situations, not to provide long-term strategic support for development. Work on primary health care reform begun during the evaluation period and currently being expanded offers the opportunity for a more coherent approach to ICPD issues.
2.3 Evaluative question 3
Reproductive health: How far have EC supported actions in this field addressed specific objectives related to Chapter 7 of the ICPD and those of Regulation 1484/97?
Health (including primary health and health sector), morbidity, and mortality incl. HIV/AIDS: To what extent have EC supported actions addressed specific objectives related to Chapter 8 of the ICPD and those of Regulation 550/97? What has been done?
Reproductive health.
Within Tacis-LIEN and ECHO humanitarian support, EC support for ICPD Chapter 7 key actions consisted of
- support for RH/FP through clinic renovation, - staff training,
- provision of medicines
- provision of information, education, and communication to clinic clients
Through PHC ongoing reform, the EC is supporting - Improved access to RH/FP
- Putting-in-place of qualified human resources at health facilities
- Increased awareness and demand on RH-related issues among the public The latter activity is, however, in its very early stages. Moreover, as mentioned above, FP is not incorporated into the Basic Benefit Package that is at the heart of the PHC reform. It would appear that the EC should be more active in urging the GoG, especially as the PHC reform project advances, to take a broader view of ICPD concerns.
Primary health care, safe motherhood, and child survival.
All of the Tacis-LIEN and ECHO activities described above supported a broad and comprehensive range of activities envisaged by Chapter 8 of the ICPD regarding PHC, safe motherhood, and child survival. These include antenatal care, safe delivery, vaccinations, and health care of children under the age of 3. Interviews with MoLHSA officials and document review clearly indicate that these are priority areas and expanded EC support will be forthcoming as the PHC project financed by EC / WB / DFID moves forward.
HIV/AIDS.
The EC has done little in the area of HIV/AIDS. However, the GoG application for $12 million from the Global Fund to Combat AIDS, Tuberculosis and Malaria has recently been approved, presaging a major expansion of activities.
The Tacis-LIEN and ECHO interventions represent small “one-off” projects and emergency assistance, not a broad sectoral intervention. While consistent with broad development goals, GoG policies, and interventions in other areas, they cannot be considered to have made a substantial or sustainable contribution towards ICPD goals. Tacis-LIEN was geared primarily towards strengthening civil society and only secondarily towards vulnerable populations; ECHO interventions were by definition emergency activities not designed to be long-term in nature. Aggregate trends in basic indicators such as maternal mortality were adverse throughout the evaluation period, although project personnel reported improvements on a highly localised level (lower incidence of abortion, more pro-active attitudes towards health, etc.). None of these improvements appear to have been sustainable once project interventions ceased. Sustained improvements in health are unlikely without the recovery of household incomes.
Overall assessment of Evaluative Question 3
In terms of the range of activities supported, the EC programme has been satisfactory. Commitment to ICPD goals requires, however, that the EC seek, through policy dialogue and technical assistance, to broaden Government’s approach to emphasis RH/FP in addition to safe motherhood and mother and child health. ECHO interventions in the area of RH/FP have served their immediate goal of humanitarian assistance well, but have not contributed much to a long-term resolution of unmet ICPD needs. Trends in health indices over the evaluation period have been adverse.
2.4 Evaluative question 4
Refugees, internally displaced persons, and distress migration: How far have EC supported actions addressed specific objectives related to the relevant subsections of Chapters 9 and 10 of the ICPD for all countries, and of Regulation 2130/2001 for Asian and Latin American countries?
What has been done?
Through ECHO, the EC supported emergency health care activities related to IDPs as described above. The ICPD activities from Chapters 9 and 10 undertaken have consisted of work to provide
- access to adequate accommodation (through rehabilitation activities, including rehabilitation of infrastructure),
- education;
- health services, including family planning; and other necessary social services.
In view of the fluid political situation, there have been no activities undertaken to promote return or resettlement or to search for durable solutions or address root causes of displacement. Absent a political breakthrough, there appears to be little chance that the situation on the ground will change. A large proportion of IDPs in Georgia have essentially settled in the zone of displacement; in the far west of the country, IDP families move fluidly across the border with the breakaway Abkhazia region. There is an urgent need to forge a durable link between IDPs and general development activities.
The acute humanitarian emergency having passed, ECHO’s mandate in Georgia has ended. Some activities have been taken over with new financial resources; however, most have not. For example, in one ECHO-financed clinic visited by the team, a community-based health care finance scheme has resulted in a steady supply of basic medicines. In other clinics visited by the team, the shelves are empty. ECHO activities in favour of IDPs in Georgia assuredly pass the standard tests of relevance, effectiveness, efficiency, impact, and “connectedness” employed by ECHO itself in its evaluations. Whether they were linked to longer term development is to be questioned, however, because the humanitarian situation is frozen in a low-level equilibrium trap – not sufficiently acute to warrant continued ECHO involvement, but not resolved either.
Overall assessment of Evaluative Question 4
The EC has engaged in a broad range of activities related to IDPs in Georgia, including provision of health services that are at the core of ICPD. It has done little in the area of return because of the political situation.
2.5 Evaluative question 5
Population composition (incl. age structure, indigenous populations, and people with disabilities) and distribution (incl. internal migration apart from displaced