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

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).

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.

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.

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).

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).

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.

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.

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).

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

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.

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

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).

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.

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_
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).

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.

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

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.

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_
georgia_summary_of_the_complex.html (accessed October 11, 2016).

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