How can a decade of projects bringing health to rural communities in Georgia continue to make a difference today? WDF went there to find out.
06 November 2023 Andreea Enea
This autumn, WDF's Board of Directors had this chance to experience the progress made by the six projects supported by our Foundation in Georgia.
For more than a decade, these projects have been serving rural and socially vulnerable communities affected by diabetes – and visiting the heart of rural Georgia to hear directly from them has proved to be eye-opening, in many ways.
Despite intensive urbanisation, 40% of the Georgian population is still rural, with 17.5% living below the national poverty line. This population is more vulnerable to diabetes and other non-communicable diseases (NCDs) because people live in low-resource settings where access and quality of care are significantly more limited than in and around Tbilisi, the capital.
For the past ten years, the government has made efforts to broaden access to state-funded care through a universal healthcare insurance program. However, systemic barriers such as a lack of basic equipment, training, and insufficient healthcare professionals to deliver early prevention and management for such diseases persist.
Another challenge is that most healthcare facilities and providers are privatised, with about 80% of care delivered by the private sector. The only exception is rural ambulatories.
Access to comprehensive diabetes care, including treatment of complications, is still unevenly distributed across the country and is largely available at private-for-profit facilities. Moreover, there is a shortage of nurses and specialists to treat children with type 1 diabetes outside the capital.
With unequal access to basic healthcare services and high out-of-pocket expenditure, many Georgians with diabetes are vulnerable to related complications.
It is NCDs like diabetes that take a toll on the Georgian health system. According to the 2021 International Diabetes Federation report, there is a 6.8% diabetes prevalence in adults, while the number of undiagnosed people stays high. NCDs account for most morbidity and 93% of the mortality, and are attributed to widespread unhealthy behaviours: sedentarism, high salt intake (one of the highest rates in the WHO Europe region), delayed access to care and low quality of services, particularly in some regions.
The complexity of such challenges and limitations required a sensible approach and one sustainable enough to advance access to healthcare for those who needed it the most.
WDF took this road in 2012 with small-scale projects implemented in parallel. Thanks to the synergy between committed partners like the Welfare Foundation and Georgia Red Cross Society (GRCS), these projects have grown into larger collaborations with the valuable involvement of the Ministry of Health and other partners with the same mission.
The projects encompass a wide spectrum of initiatives – from community-based interventions to improve access to care in rural areas, to outreach activities like mobile units for screening and prevention, patient support groups and awareness-raising campaigns.
But each project tells its own story of change.
To see how a decade of partnerships and local empowerment have impacted a country, WDF listened to the voices of the communities – from trained doctors and nurses, local champions and self-support groups, to children and parents who have been part of the projects and now, in one way or another, are giving back.
The first stop was the Lions Eye Diabetes Clinic, which together with the NGO Welfare Foundation, both partners of WDF, led a comprehensive diabetes and diabetes eye care project serving marginalised groups in six regions.
The project (WDF18-1589) aimed to prevent diabetes complications and improve access to quality care by establishing ten regional eye care clinics and a mobile unit to reach remote areas and promote early detection. It ignited Georgia’s first national diabetes register while strengthening the capacity of local organisations and encouraging the formation of self-support groups at a community level have sustained the project’s positive outcomes.
A unique approach was having the participation of the Armenian EyeCare Project (AECP). The WDF partner from Armenia provided modern training on diabetes eye complications to healthcare professionals in Georgia who lacked access to this knowledge.
‘They [AECP] shared their experience and showed us how necessary it is to introduce telemedicine and artificial intelligence for timely diagnosis and detection of diabetic retinopathy’, shares Dr Nino Karanadze, director and co-founder of the clinic. ‘The training framework that they followed saved us a lot of time’.
The clinic offers preferential care for socially vulnerable people such as pensioners, war veterans, families with many children, orphans, refugees, and persons experiencing homelessness. 'Their first visit or examination is always a charitable service, as they do not have the means to access high-tech eye examinations.'
Mette Skar, senior programme manager at WDF, agrees that synergy between partners not only amplifies the immediate impact of such efforts but lays the foundation for the future.
‘Everyone had the opportunity to see how regional cross-fertilisation can bring new skills and strengthen capacities even across borders.’
Such positive outcomes have been largely sustained because they were locally owned and built on prior successes, advancing from local initiatives to nationwide engagement.
For example, the eye clinics were integrated into facilities providing diabetes and diabetic foot care originating from a prior project (WDF14-923) led by the Welfare Foundation. This has been the first-ever attempt to screen for complications, bringing together a multitude of stakeholders to enhance prevention and care for rural communities and reduce the incidence of diabetes-related amputations. This, too, built on the results of the first project funded by WDF in Georgia (WDF12-720) led by the same partner.
The delegation saw how these efforts continue to help make a difference for Georgian people with diabetes or complications, during a visit to the Gormedi Outpatient Clinic in Gori – one of the foot care clinics opened ten years ago that serves the conflict-affected population and internally displaced persons.
‘Our doctors and nurses had the chance to participate in diverse capacity-building initiatives’, explains Dr Nana Koberidze, Head of the clinic and coordinator of the projects.
‘Many did not have such opportunities for decades as the system of continuous medical education is non-functional in Georgia. As a result, they managed to provide better quality services and free consultations; the number of patients increased, particularly those with fewer complications.’, Dr Nana Koberidze adds.
Capacity strengthening is not the only focus of the projects in Georgia.
Empowering patients to access essential health services and improve their quality of life through community-level initiatives is a core part of achieving sustainability of the outcomes.
According to UNHCR, over 288,000 persons – mostly ethnic Georgians – are internally displaced or affected by the protracted conflict at the northern border. The number places Georgia in the top five countries with the highest number of internally displaced persons (IDPs) in Europe and Central Asia by the end of 2022.
The Georgian government has supplied temporary or long-term housing solutions to people in affected villages like Ditsi, in the Gori district.
In a health post in Ditsi, the delegation met the staff and patient-support groups trained under WDF-supported projects. Among them was Zurab Maisuradze, an energetic 71-year-old patient with diabetes who took part in a WDF project ten years ago.
‘I was diagnosed with diabetes by my doctor in 2008, soon after the Russo-Georgian war, but I thought the symptoms were related to mental health’, Zurab tells the visitors.
‘After being diagnosed, I became interested in learning more about diabetes management. At the same time, I found out that other people with diabetes from my community needed support, so I trained as a peer educator as part of the project’.
Zurab is also the leader of a self-support group formed in 2013. The members share information, strips and needles for glucose monitoring and even medicine, ‘when somebody is in great need and is unable to buy it’, he explains. ‘Diabetes management became easier and our quality of life improved as we already knew how to support each other’.
In 2018, however, things took a turn for the worse. ‘I felt tingling and pain in my feet, but I did not pay much attention to it in the beginning’, he remembers, ‘but I soon noticed ulcers on my skin’. Due to his experience as a peer educator, Zurab suspected it was related to diabetes. The nurse at the health centre had training in podiatry and managed his foot ulcers.
When the nurse had to leave Georgia, Zurab lost access to proper treatment and his diabetic foot problems reappeared. He was referred to the Gormedi clinic where he was treated by doctors trained under the WDF-supported projects.
‘The collaboration with partners in other regions has been intensive and beneficial’, says Dr Nana Koberidze, highlighting the impact of the training in diabetes-related complications. ‘It promoted successful networking between us, which continues even today’.
The focus of all WDF partnerships in Georgia has been to prevent NCDs and elevate care through community-centric approaches including for underserved Armenian, Azari, and Georgian communities living in rural areas where access to care is a critical challenge.
A notable example is the ‘Improved control of diabetes in remote areas in Kvemo Kartli region’ project (WDF17-1471), completed in 2021. Led by the Georgia Red Cross Society (GRCS), it strengthened the vital collaboration between authorities, healthcare professionals and volunteers. This was founded on an earlier pilot (WDF13-800) led by the same partner to elevate prevention, detection and care for communities in poverty in the Gardabani district.
At the heart of it all is an inspiring community of volunteers.
Over 1,200 Red Cross and local volunteers (including patients, nurses and teachers) are involved in community outreach for prevention and screening, with tens of thousands of people being already screened for diabetes and risk factors and referred to relevant clinics.
Among them is Marina Ananyan, 56, a community volunteer and self-support group leader involved in training volunteers and disseminating health information to villagers.
‘I found out about the GRCS activities and the project from my son, who was driving their mobile unit’, she tells the visitors, as people were lining up to check their blood glucose in a Red Cross van in a village close to the Armenia-Azerbaijan border.
‘After hearing his stories, I wanted to be part of them, and I became a volunteer’.
Marina joined the training and after learning about the symptoms, she got screened and diagnosed with diabetes. Since then, she has led a self-support group created in 2018 and became a community leader supporting her peers even after the project ended.
Asked if she feels that her work is making an impact, Marina believes so. Having access to knowledge and various programs has empowered her not only to manage her diabetes but also to provide support to others. ‘Being a volunteer creates trust and respect among my peers and this motivates me to continue to be part of the volunteering community’.
Meeting the communities left a strong impression on the visitors, including Tine Gammeltoft, member of the WDF Board. ‘Seeing the remarkable work of the volunteers providing support and building local alliances reminds us that strong partnerships and community bonds are key to empowerment and strengthened care’.
After seeing how far our partnerships have progressed, a question remained: where is this road leading?
Simon Gabritchidze, manager of several WDF projects in Georgia, has been instrumental in broadening their sustainable impact. He is also one of the key conveners of the NCD Alliance Georgia, a network organisation of partners who have successfully collaborated in past projects and the implementing partner of the latest project in Georgia (WDF22-1882).
‘By joining forces with other NGOs in the field, we realised that we would have a stronger voice and we would be better placed to advocate and bring about changes to improve prevention and care for diabetes and NCDs in Georgia’, he explains.
The latest project in Georgia, which is among the five projects funded by WDF in 2023, aims to be a holistic response to the health and educational needs of children with diabetes (CwD) and has the strong involvement of the Ministry of Health.
The ambition is to open diabetes clinics in all twelve regions of Georgia by focusing on capacity building of doctors and nurses and working with the government to achieve positive changes in state-supported programs.
Moreover, rural areas suffer from a shortage of paediatric endocrinologists, low awareness of diabetes management and low readiness of schools and kindergartens to manage CwD. The project aims to create safer school environments and greater public awareness of the rights, stigma and challenges that children and their parents face.
Back in Tbilisi, the delegation had the chance to sit with families taking part in the project.
George, a teenager living with type 1 diabetes, expressed his love for video games and his aspiration to become a game designer with a life-affirming confidence.
‘Despite the daily struggles of lacking access to adequate diabetes care and the visible concerns of his mother, he dared to dream of a bright future; diabetes could not hold him back’, remembers Tina Abild Olesen, Vice-chair of the WDF Board.
The parents’ perspective reflects another side of the story, marked by struggles in managing their children’s diabetes daily.
‘It is the lack of education on diabetes management and lack of support systems that gives the parents a challenging time in managing their children’s diabetes’. The parents are left feeling alone with a huge responsibility, explains Mette Skar, WDF manager of projects in Georgia.
To address the root of the problem, the new WDF-supported project is prioritising patient and peer education, ensuring better guidelines for paediatric endocrinology.
An empowered community can have a major role in sustaining such changes. This is what the ‘Parents’ organisation for type 1 diabetes’, strongly involved in the project, is striving for.
‘At the age of 10, my son had severe symptoms’, recalls Lali Chachua, 45, economist, part of the organisation. ‘My family doctor suspected diabetes and immediately sent me to an endocrinologist’. After spending days in a diabetes clinic, Lali left with little information about the management of her son's disease.
‘The organisation has done a lot for my son and other children, ensuring continuous glucose monitoring, raising awareness to reduce stereotypes and discussing problems and solutions with the authorities’, adds Lali, including taking action when children’s rights are violated in school environments.
Visiting Georgia for the first time in years reflected the lasting changes that a decade of alliances has brought about in many ways. It showed that:
Collaborations across regions can strengthen the sustainability of partnerships and healthcare capacity to serve patients, especially vulnerable communities, long after completion
A community-centric approach where people are empowered to improve their well-being can have a positive ripple effect within their diverse communities, creating alliances and thus elevating the lasting impact of the programmes
A multi-stakeholder network of partners that puts patients at the core of the programmes can catalyse lasting change at a more systemic level.
‘Georgia has pockets of excellent peer and community-based initiatives’, remarks Dr Kaushik Ramaiya, member of the WDF Board. ‘With more support to elevate primary care and nurse training, a lot can be achieved at a minimal cost’.
Meeting the diverse partners involved in the projects also paves the way for bigger steps going forward, such as consolidating the collaboration with the Ministry of Health, supporting the reform of primary care, increasing the number of trained nurses, and facilitating more knowledge exchange.
In retrospect, it is through local empowerment, multi-stakeholder partnerships and community bonds that the projects can drive such transformational impact, which can change not only individuals and organisations but, hopefully, the country itself.
Photos by: Davit Mirvelashvili