OPM briefing notes
2010 - 05

Lessons Learned: Developing the Health
Promotion Strategy and Action Plan in Georgia
In 2009 Oxford Policy Management
(OPM) completed technical work to support the Ministry of Labour,
Health and Social Affairs, Georgia, in producing a comprehensive national Health Promotion Strategy
(HPS) along with a prioritised Health
Promotion Action Plan (HPAP). This work was commissioned as part of the European Union support to the Ministry, aimed at facilitating evolution of key evidence-based policies, and enabling the people of Georgia to increase control over their health and its determinants.
This briefing note develops the case for giving support to the Georgian government in elaborating the
HPS. It argues that transparent and participatory processes must be established to assure strong national ownership and consensus over the outputs. The process must also guarantee the skills transfer and capacity building of national stakeholders; and be flexible and highly responsive to the government needs while producing strategies effective, feasible and applicable to the local context.
Georgian public health
Over recent years Georgian efforts to adopt and nurture a democratic market oriented economy have been impressive (Chanturidze et al.
2009). On the down side however, the Georgian health sector still demonstrates system imbalances between curative services and

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prevention, and between clinical services and primary health care
(MoLHSA 2009b). Many Georgians have a predisposition to an unhealthy lifestyle, which is not being adequately addressed (Milner et al. 2009). Such inequalities and imbalances as well as behaviours and lifestyles have not been touched by the positive economic reforms.
The public are generally uninformed of the principles of health promotion and to some extent do not believe that they can make a contribution to their own personal well-being, staying healthy from a preventive perspective. Figure 1 Tannahill’s model of health promotion

The approach in Georgia has generated a high sense of government ownership for decision making on systemic arrangements and service production functions for health promotion.

Methodology and approach

The Ministry is well aware of the problems incumbent upon reducing population vulnerability. In its proactive scrutiny of immediate and longer term needs the Ministry considered that the design of a Health Promotion Strategy, alongside the broad health sector strategy, would contribute to better identification and addressing of key health problems. An action plan would allow consolidation and the direction of available resources towards short term health promotion objectives.

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A widely-accepted Tannahill ‘model of health promotion’ was selected as a basis for the strategy development in Georgia (adapted from Tannahill
1985). The model consists of three overlapping spheres of activity: health education, health protection, and ill-health prevention, as presented in
Figure 1 (Milner et al. 2009).
Health education is a communication activity aimed at enhancing well-being and preventing ill-health through the provision of knowledge and by favourably influencing beliefs, attitudes and the behaviour of people within the community.
Health protection refers to the policies and codes of practice to prevent ill-health or to positively

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enhance well-being, for example,
‘no smoking’ in public places.
Disease / ill-health prevention comprises both the initial occurrence of disease and also its progression and subsequent outcome. The conventional model for health promotion includes primary and secondary disease prevention.
Primary disease prevention seeks to discourage people from adopting unhealthy lifestyles that contribute to disease causation, such as deterring people from starting smoking. Secondary prevention is aimed at controlling identified risk factors and pre-clinical conditions, such as controlling hypertension to prevent coronary heart disease.
The approach in Georgia was comprehensive and interlinked the various aspects of planning into a workable decision making model, presented in the format of the log frames for both the strategy and the action plan. It has been as rigorous as possible in achieving data accuracy and policy transparency. It has generated a high sense of government ownership for decision making on systemic arrangements and service production functions for health promotion. It ensured participation of wide groups of stakeholders, including representatives of public health organisations, relevant line ministries and non governmental organisations. Implementation and lessons learned
1. Establishing a strategy development process
The Ministry was advised by the
OPM team to create a working group responsible for elaboration of the Health Promotion Strategy.
To legitimise the working group, the
Ministry issued an order defining the composition, responsibilities and length of existence of the group.

2010 - 05

Table 1 Criteria for selecting key health promotion priorities
1 Linkage to major causes of death and morbidity in Georgia
2 Evidence of lifestyle and risk factor problems in Georgia
3 The contribution to disability-adjusted life years (DALY)
4 
The probability that unhealthy behaviours and risk factors can be modified and changed
5 Areas of intervention to have the potential for significant outcomes

Table 2 Strategic priorities for health promotion, Georgia, 2009–2015
1 Controlling tobacco use
2 Promoting healthier eating including childhood / maternal nutrition
3 Promoting physical activity
4 Reducing alcohol and drug misuse
5 Promoting mental health
6 Reducing injuries
7 Reducing infections including sexually-transmitted diseases and HIV
8 
Encouraging citizen participation in screening initiatives aimed at early detection and identification of cardiovascular co-morbidities and cancer

Table 3 Format for presenting the Health Promotion Strategy
(2010–2015) log frame by key health priorities
Outcomes

Outputs

Activities

Output measures Outcome measures STRATEGIC OBJECTIVE N1

Table 4 Format for presenting the Action Plan (2010–2011) by area of intervention
Activities

Outputs

Timing

Resources required Responsible for implementation Funding source AREA OF INTERVENTION
Objective 1.n
Activity 1
Activity n

Wider consultations with the representatives of other line ministries and non governmental organisations were organised to assure early notification and the participation of diverse representatives in the strategy development process. The
Ministry and the working group led workshops for strategic and operational planning thus ensuring government leadership and national

ownership over the outputs. By establishing a process, the transfer of knowledge, skills and experience to the national actors was facilitated and provided the background for an intensive implementation process.
2. Achieving consensuses on the key requirements of the strategy
Prior to initiating the strategic planning process, the working group discussed the key requirements of

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Figure 2 Framework on linking the Health Promotion Strategy and the
Action Plan strategic and operational priorities
Action Plan for implementation of the Georgia national Health Promotion Strategy
Settings for health promotion intervention

Areas for health promotion intervention

Lifestyles
Tobacco use and exposure

Creating an information base for action, including research

Community

Nutrition status

Developing capacity for health promotion, including that of key partners and institutions

Children fully immunised

Developing integrated tools for health promotion at various levels and settings

Schools

Physical activity levels
Alcohol and drug use

Advocating for health promotion interventions Healthcare

Implementing awareness raising campaigns Developing, updating and reinforcing health promotion regulation Status of people with mental health disorders

Burden of disease and injury

Preventative behaviour for infectious diseases

Workplace

Putting community at the centre of health promotion

Injury preventative behaviour

Developing multi-sectoral response Population habits for screening

the Health Promotion Strategy. The government’s expectations of the strategy included:
•  hat it would cover a five-year
T
period, and take into consideration the current context beyond the health sector per se, and trends in health care / public health policy;
•  pecific terms of defining the
S
strategic directions that would lead to the changes in population behaviour and therefore to the nation’s health status;
•  ealistic expectations, so as
R
to ensure that the behaviours identified for change would be feasible within the social and cultural contexts in which people live (Slavin and Swann 2004/5);
•  hat it would be accompanied
T
with explicit methodology for approaching the requirements; and
•  hat it would be attached with
T

a specific and detailed Action
Plan and a clear and realistic logical framework for monitoring performance against the defined indicators. By establishing a process, the transfer of knowledge, skills and experience to the national actors was facilitated and provided the background for an intensive implementation process. 3. Defining the vision for the strategy
The working group, with the support of the OPM team elaborated the
Vision and Aim for the Health
Promotion Strategy. ‘Our vision is for the people of Georgia to attain the best possible health throughout their

lives’. ‘Our aim is to enable people in Georgia to increase control over their health and its determinants, and thereby improve their health’.
(The Georgian Health Promotion
Strategy uses the full World
Health Organisation aim for health promotion – the process of enabling people in Georgia to increase control over their health and its determinants, and thereby improve their health.)
4. Defining key strategic priorities
Table 1 presents the criteria that have been used by the Health
Promotion Strategy working group for selecting key health promotion priorities. On the basis of analysis of the five criteria, considerations on best international practice for planning

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health promotion strategies, and intensive consultation among national and international stakeholders, eight public health topics were chosen and adopted as the strategic priorities for health promotion in Georgia (Table 2).
For each strategic area the report presented (i) the evidence; (ii) expected outputs and outcomes; and (iii) specific activities targeting individual, community, institutional, system and legislative interventions.

The consultation process generated familiarity with the strategy and action plan and obtained engagement and contribution with the implementation process.
5. Format for presenting the
Strategy and Action Plan
The Ministry, the Health Promotion
Strategy working group and the wider group of health promotion stakeholders representing various ministries and NGOs placed particular importance on the format for presenting the Strategy. A log frame was designed to observe an intuitive flow between the strategic objectives, outcomes, outputs, activities, and output and outcome measures. Table 3 presents these format headings for the Health
Promotion Strategy log frame.
The Health Promotion Strategy log frame was included as an annex in the monitoring and evaluation (M&E) framework. The M&E framework presented output indicators for each strategic objective, data collection tool and timing.
The format for presenting the Action
Plan was even more detailed in terms of the activities per area of intervention and the objectives, together with outputs, timing,

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resources required, responsible bodies for implementation and the funding sources. Table 4 presents the format for the Action Plan.
6. Ensuring linkages between the
Strategy and the Action Plan
The priorities for the Health
Promotion Strategy and the
Action Plan were selected from different categories. The Strategy emphasised important health topics and lifestyles; whereas the priorities for the Action Plan were selected from the areas of intervention as per key health system functions. The rational behind this was to narrow the broad strategic priorities into realistic and feasible actions. The need to develop the framework that would link the priorities of the Strategy and the Action Plan became apparent. Figure 2 presents the framework for bridging the priority areas distinct to the Health
Promotion Strategy and the Action
Plan, leading to the overall objective of decreasing the burden of disease and injuries, and improving the health status of the population of
Georgia.
7. Institutionalisation and sustainability
Soon after completion, the Health
Promotion Strategy and the
Action Plan were adopted by the
Government of Georgia. The long consultation process had been initiated with the respective line ministries to generate familiarity with the Health Promotion Strategy
/ Action Plan and to obtain their engagement and contribution to the strategy implementation process.
A number of aid partners working in health promotion expressed their willingness to align responsibilities and resources with the national
Health Promotion Strategy.
Implementation of the Health
Promotion Strategy and Action Plan started in January 2010.

References and resources
Tata Chanturidze, Tako Ugulava, Antonio
Durán, Tim Ensor and Erica Richardson
(2009) ‘Georgia: Health System Review’.
Health Systems in Transition, European
Observatory for Health Systems and
Policies, 11(8): 1–116.
Philip Milner, Tata Chanturidze and
Jeff Levett (2009) ‘Health Promotion
Strategy for Georgia, 2010–2015’, Policy
Management Consulting Group (PMCG)
/ Oxford Policy Management (OPM):
Tbilisi.
MoLHSA (2009a) Georgia Health System
Performance Assessment 2008, Full
Report, Ministry of Labour, Health and Social Affairs: http://www.who.it/ document/E92961.pdf MoLHSA (2009b) State Health Care
Programmes and Budget, 2009–2010,
Georgia, Ministry of Labour, Health and
Social Affairs.
Hazel Slavin and Ken Swann (2004/5)
‘Principles for a Health Promotion
Strategy 2006–2008, MoLHSA Georgia’, strategy developed with MoLHSA / OPM,
Dec. 2004, revised Dec. 2005.
Andrew Tannahill (1985) ‘What is Health
Promotion?’ Health Education Journal;
44(4): 167–8.

Tata Chanturidze
Consultant
Health care policy, Health care design tata.chanturidze@opml.co.uk OPM briefing notes
ISSN 2042-0595 (Online)
Editor: Adam Swallow.
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