Feed the Future Tajikistan Health and Nutrition Activity

FEED THE FUTURE TAJIKISTAN HEALTH AND NUTRITION ACTIVITY

Year 5 Annual Progress Report October 1, 2019–August 30, 2020

Re-submitted September 2, 2020

Table of contents

ACRONYMS AND ABBREVIATIONS ...... 3 ACTIVITY IMPLEMENTATION SUMMARY ...... 4 IR1: Improved quality of health care services for MNCH ...... 6 Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI ...... 6 Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality ...... 12 Outcome 1.3: Stronger facility and provider networks ...... 19 IR2: Increased access to a diverse set of nutrient-rich foods throughout the year ...... 21 Outcome 2.1: Diversified food consumption during the growing season and beyond ...... 21 Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities ...... 25 IR3: Increased practice of healthy behaviors around MNCH ...... 25 Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children six to 24 months of age ...... 25 Outcome 3.2: Improved sanitation and hygiene-related behaviors ...... 31 Outcome 3.3: Increased use of health care services for MNCH, including nutrition, sanitation, and hygiene ...... 36 IR4: Institutionalized evidence-based MNCH services through national-level policies and standards ...... 47 Outcome 4.1: Cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH ...... 47 Outcome 4.2: Evidence-based approaches for MNCH, including nutrition, sanitation, and hygiene, are sustainable ...... 47 MONITORING, EVALUATION, AND LEARNING ...... 48 GENDER ...... 51 STAFFING & MANAGEMENT ...... 51 BUDGET vs. EXPENDITURES ANALYSIS ...... 53 SUB-AWARDS ...... 53 COORDINATION WITH OTHER FTF ACTIVITIES ...... 55 COMMUNICATION AND KNOWLEDGE MANAGEMENT ...... 55 ENVIRONMENTAL COMPLIANCE ...... 58 LIST OF ANNEXES ...... 61

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 2

ACRONYMS AND ABBREVIATIONS

ANC Antenatal Care IT Information Technology BTN Beyond the Numbers IYCF Infant and Young Child CDH Central District Hospital Feeding CE Community Educator MNCH Maternal, Newborn, and CHP Community Health Promoter Child Health CIP Centro Internacional de la MOHSPP Ministry of Health and Social Papa (“International Potato Protection of the Population Center”) PHC Primary Healthcare Center CME Continuing Medical PPE Personal Protective Education Equipment DOH Department of Health QI Quality Improvement DQA Data Quality Assessment SBCC Social and Behavior Change EG Economic Growth (USAID Communication indicator) TAWA Tajikistan Agriculture and EmONC Emergency Obstetric and Water Activity Newborn Care THNA Tajikistan Health and EPC Effective Perinatal Care Nutrition Activity FTF Feed the Future TOT Training of Trainers GMP Growth Monitoring and TWG Technical Working Group Promotion UNICEF United Nations Children’s HCW Health Care Worker Fund HL Health (USAID indicator) USAID United States Agency for HLSC Healthy Lifestyle Center International Development ICATT IMCI Computerized USG United States Government Adaptation and Training Tool VDC Village Development IEC Information, Education, and Committee Communication VIP Ventilated Improved Pit IMAM Integrated Management of WASH Water and Sanitation Acute Malnutrition Hygiene IMCI Integrated Management of WFP World Food Programme Childhood Illness WHO World Health Organization IR Intermediate Result ZOI Zone of Influence

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 3

ACTIVITY IMPLEMENTATION SUMMARY

IntraHealth International and its partner, Abt Associates, are pleased to submit to the Tajikistan Mission of the United States Agency for International Development (USAID) the Quarter Four (Q4, July 1–August 30, 2020) of Year Five (Y5, October 1, 2019–September 28, 2020) quarterly report, which also serves as the Y5 annual progress report for the Feed the Future (FTF) Tajikistan Health and Nutrition Activity (THNA). THNA was implemented in partnership with the Ministry of Health and Social Protection of the Population (MOHSPP) of the Republic of Tajikistan. THNA’s goal was to improve the health status and nutrition of women and children who live in 12 southwestern districts of Khatlon Region, known as FTF’s zone of influence (ZOI). This progress report is consistent with the structure and content of THNA’s approved Y5 workplan.

As activity highlights for Y5, THNA: • Fully completed 31 out of 43 program activities (72%) scheduled for Y5 (Annex 1), with limitations and adaptations due to the COVID-19 pandemic. The remaining activities were partially completed before the COVID-19 pandemic was recognized by the Government of Tajikistan on April 30; • Improved the professional knowledge and skills of a total of 5,998 health care workers (HCWs) and community volunteers (355% of the quarterly target, allowing for double counting) through online and in-person training on nutrition topics; • Reached 169,406 children under five with clinical and community-based nutrition interventions (98% of the annual target despite the COVID-19 pandemic); • Reached 67,203 pregnant women with clinical and community-based nutrition interventions (86% of the annual target due to the COVID-19 pandemic); • Reached 431,005 individuals with food security programs (80% of the annual target due to the COVID-19 pandemic); • Engaged 4,050 school students on the topics of life skills; food security; nutrition; agriculture; and water and sanitation hygiene (WASH) (151% of the annual target despite the COVID-19 pandemic); • Exposed 1,530 community members (85% of the annual target due to the COVID-19 pandemic) to social marketing messages on WASH and ventilated improved pit (VIP) latrines through 40 outreach events; • Conducted a growth monitoring and promotion (GMP) campaign through community volunteers, reaching 94.6% of all children six to 59 months of age and identifying 2.2% of them as having signs of wasting, compared to 6.2% reported in the demographic health survey of 2017; • Helped HCWs identify and refer a total of 5,381 children under five with malnutrition who received treatment at different levels; and • Identified and referred to primary healthcare centers (PHCs) 3,632 pregnant women not registered for antenatal care (ANC), 2,782 children with signs of malnutrition, and 786 children with diarrhea through 194,908 household visits by community health promoters (CHPs) (108% of the annual target despite the COVID-19 pandemic).

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 4

THNA also faced the following challenges due to the COVID-19 pandemic: • Since April, THNA has suspended all in-person clinical trainings by national-level consultants and transitioned to online support for trainers at district nutrition resource centers and for quality improvement (QI) committees. • Since April, THNA has suspended all community-based group activities, allowing volunteers to make household visits only if they observed the rules for physical distancing, handwashing, and wearing face masks. Since May, THNA has suspended all volunteer activities, except for the individual counseling of community members by phone. THNA staff supported community volunteers by phone and Internet-based communication, where available. • On May 1, all THNA staff transitioned to remote work to prevent contracting and spreading COVID-19. Despite this practice, 18 of 55 staff members reported laboratory- confirmed COVID-19 diagnoses or suggestive COVID-19 symptoms, and one staff member died. A total of 37 volunteers reported COVID-19-like symptoms, though official diagnosis was not possible as laboratory tests in rural areas were not available. Three volunteers died. • THNA had to cancel three end-of-project surveys planned for Y5: the Recurring Household Survey, the Recurring Agricultural Practices Survey, and the Rapid Health Facility Assessment.

These and other achievements and challenges are described in detail in this report.

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IR1: Improved quality of health care services for MNCH

Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI

1.1.1. Support a training of trainers (TOT) for 24 district trainers on the newly updated national ANC standards

In Y5, THNA achieved 100% of its annual target by supporting a three-day training of 24 trainers on ANC standards. As a result, participants’ knowledge on pre- and post-training tests improved from an average of 65% to 93% of correct responses. The TOT focused on the revised topics, such as: increasing the number of ANC visits from seven to eight; maintaining regularity in filling out and analyzing gravidograms; ensuring close antenatal follow-up of high-risk pregnant women by doctors; referring pregnant women with acute and chronic internal diseases; and improving counseling on nutrition, breastfeeding, family planning, and newborn care. THNA provided all participants and 24 nutrition resource centers with copies of the updated national ANC standards. This activity is a result of THNA’s Y4 support of the technical working group (TWG) tasked with revising the national ANC standards for PHCs according to the latest World Health Organization (WHO) standards. In turn, during Y5, the 24 districts trainers cascaded 112 in-person training sessions through 12 PHC-based nutrition resource centers, reaching 911 HCWs on the revised ANC standards (Activity 1.1.4).

1.1.2. Support a TOT for 24 trainers from central district hospital (CDH) maternity departments on the newly updated national standard on the management of postpartum bleeding

At the request of the MOHSPP, THNA changed this activity and its targets from providing a TOT for 24 hospital-level trainers to directly training 105 hospital staff on the management of postpartum bleeding. As a result, THNA trained a total of 431 HCWs through in-person trainings and 192 HCWs through online trainings on the management of postpartum bleeding. In Q1, THNA provided two direct trainings on the newly updated national standards on the management of postpartum bleeding. As a result, a total of 44 HCWs, including 37 obstetrician/gynecologists and seven anesthesiologists, from Shahritus, Qabodiyon, Nosiri Khusrav, Dusti, Jaikhun, Jomi, Khuroson, and Yovon CDHs received training. The training participants included trainers from hospital-level nutrition resource centers. An additional topic included indications and contraindications for Caesarean sections. Participant knowledge improved from an average of 20% of correct responses on the pre-training test to 80% on the post-training test. Due to the COVID-19 pandemic, the MOHSPP canceled all direct face-to-face trainings of hospital staff. Instead, THNA supported eight online sessions on the management of postpartum bleeding for 192 HCWs from the 12 FTF districts. Three national trainers conducted the trainings via Skype through the district nutrition resource centers. In Q2–Q3, the local trainers from eight districts conducted 52 cascade trainings on the management of postpartum bleeding and indications for Caesarean section for 387 HCWs, ensuring physical distancing and having no more than eight HCWs at each training session. THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 6

1.1.3. Support district trainers at nutrition resource centers in revising 24 training plans, updating training packages, and improving training skills

In Y5, THNA achieved 100% of its annual target by supporting local trainers in updating 24 training plans and training packages (materials) for nutrition resource centers. THNA provided six capacity-building refresher trainings for 24 district trainers to improve their skills in conducting on-the-job trainings, reporting results, and updating training modules based on revised national standards (three trainings for 21 trainers was the annual target). In Y5, THNA assisted the trainers at 24 nutrition resource centers in compiling visual information materials and updating their electronic libraries. As a result, 24 nutrition resource centers have up-to-date training plans approved by facility managers, which are complemented by revised training packages. The PHC-level training plans cover the following 12 topics: • ANC (revised based on the updated national standards); • Nutrition in pregnancy; • Danger signs in pregnancy; • Breastfeeding; • Care for a healthy newborn aged 0–24 months (revised); • Nutrition for women and children under five; • GMP; • Integrated Management of Childhood Illness/IMCI Computerized Adaptation and Training Tool (IMCI/ICATT); • Malnutrition; • Anemia management and prevention; • The Rohnamo; and • Infection control.

The topic of “Counseling during pregnancy” was included in the “ANC” module, and the topic of “Infant and young child feeding” (IYCF) was included in “Care for a healthy newborn aged 0–24 months.” The hospital-level training plans cover the following 21 topics: • Management of physiological delivery; • Management of postpartum bleeding in the third stage of labor and accounting for blood loss (materials have been updated in the electronic library; • Emergency obstetric and newborn care (EmONC) in hypertension disorders; • Premature delivery; • Anomalies of labor activity; • Infection control and clinical safety (MOHSPP Order #1119); • Nutrition in pregnancy; • Breastfeeding; • IYCF; • Resuscitation of newborns; • GMP; • Hospital-based IMCI; • Danger signs in pregnancy; THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 7

• The Rohnamo; • Kangaroo mother care; • Indications for Caesarean section; • QI and work with indicators; • HIV/AIDS; • Partogram; • Hepatitis B and C; and • COVID-19.

To improve reporting, in Y5, THNA developed an electronic registration form for training participants at nutrition resource centers. As a result, THNA can track continuing medical education (CME) coverage of individual HCWs within a quarter. In response to the COVID-19 pandemic, in Q3, THNA supported nutrition resource centers in developing training modules on COVID-19. At the PHC level, COVID-19 information was integrated into the infection control topic. The trainers revised the following training packages to include COVID-19 information: • Nutrition for children under five; • Nutrition for children under five with malnutrition; and • Nutrition for pregnant women.

New training packages included information on: • The treatment of children with COVID-19; • The treatment of pregnant women with COVID-19; and • Breastfeeding by women with symptoms of COVID-19.

THNA supported six online presentations by national consultants on the newly updated guidelines on IYCF and nutrition in pregnancy during the COVID-19 pandemic. THNA used email, Skype, Zoom, and other means of electronic communication to support HCWs at target facilities.

1.1.4. Support district trainers in training PHC and hospital staff on nutrition topics

In Y5, THNA trained 3,802 HCWs at both the hospital and PHC levels on nutrition topics, allowing for double counting between different quarters. THNA had set its target for Y5 as the number of unique individuals trained; however, the data are collected on the number of training participants, allowing for the double counting of individuals participating in more than one training. Therefore, THNA exceeded its target under the assumption that one HCW participated in no more than two training sessions (1,629 HCWs or 50% of the total number of HCWs being the target).

Due to the COVID-19 pandemic, in Q3, THNA provided 52 online training sessions (Activity 1.3.1). Of these, 17 sessions for 429 participants were nutrition-related.

At the hospital level, nutrition resource centers provided 1,079 CME sessions for 4,691 HCWs including 100% of hospital-based staff and 1,703 HCWs from the rural (“numeric”) hospitals, allowing for double counting between different quarters (Table 1 and Figure 1).

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Table 1. Number of HCWs trained at 12 hospital-level nutrition resource centers, by district, Y5

hun ik Jomi Total Dusti Khusrav Khusrav Balkhi Yovon Yovon

Vakhsh Ja Shahritus Shahritus Levakand Khuroson Khuroson N. Qabodiyon Qabodiyon Kushoniyon

MNCH doctors 107 71 69 84 59 20 57 83 12 63 60 56 741 MNCH nurses/ 125 138 163 198 172 75 195 193 45 99 222 159 1,784 midwives Other HCWs 167 97 44 323 287 240 376 119 132 159 112 110 2,166 Total: 399 306 276 605 518 335 628 395 189 321 394 325 4,691 MNCH: maternal, newborn, and child health Out of the 21 topics offered at the hospital-level nutrition resource centers in Y5, five were nutrition-related: Nutrition in pregnancy, Breastfeeding, IYCF, Hospital-based IMCI, and the Rohnamo. A total of 329 trainings (30%) were on nutrition-related topics, reaching 1,423 participants (1,115 nurses and 308 doctors, allowing for double counting between different quarters).

Figure 1. Number of CME training sessions at the hospital level, by topic, Y5

206 189 Total number of training sessions: 1,079

121

70 66 59 57 41 40 38 32 25 24 22 15 15 14 13 11 11 10 IYCF EmONC HIV/AIDS COVID-19 Rohnamo Partogram Danger signs in pregnancy of newborns labor activity Anomalies of Resuscitation Breastfeeding QI committee QI and indicators of children Hepatitis B and B Hepatitis C Infection control Caesarian section Management of Management Premature delivery Growth monitoring Hospital-based IMCI Hospital-based postpartum bleeding Physiological delivery Nutrition pregnancy in Kangaroo mother care Kangaroo On average, each of the 863 hospital-level HCWs participated in an on-the-job training twice a month. Accordingly, each hospital-level staff person participated in at least one training on each of the 21 topics.

Restrictions on the number of participants who could be trained at one time due to the COVID- 19 pandemic led to an increase in the total number of training sessions.

In Y5, at the PHC level, nutrition resource centers provided 442 CME sessions for 4,006 HCWs (83%) of PHC staff, allowing for double counting between different quarters (Table 2 and Figure 2).

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Table 2. Number of HCWs trained at 12 PHC-level nutrition resource centers, by district, Y5

Jomi Total Dusti

Balkhi Yovon Yovon

Vakhsh

Jaikhun

Shahritus Levakand Khuroson Khuroson

Qabodiyon Qabodiyon Kushoniyon

Nosiri Khusrav Nosiri

Doctors 176 63 36 12 42 28 34 52 11 55 58 36 603 Nurses/ 301 235 294 258 374 219 240 269 192 438 255 328 3,403 Midwives Total: 477 298 330 270 416 247 274 321 203 493 313 364 4,006

Out of the 12 topics offered at the PHC-level nutrition resource centers in Y5, seven are nutrition- related: ANC, Nutrition in pregnancy, Breastfeeding, Care for a healthy newborn aged 0–24 months, nutrition of women and children under five, IMCI/ICATT, and Malnutrition. Of 442 training sessions, 278 (63%) were on nutrition-related topics, reaching 2,379 participants, allowing for double counting between different quarters (2,068 nurses and 311 doctors). As a result, in Y5, 100% of PHC-based HCWs received training on nutrition-related topics.

Figure 2. Number of CME training sessions at the PHC level, by topic, Y5

Total number of training sessions: 442 112 97

47 45 39 30 20 18 13 11 7 3 ANC GMP Rokhnamo IMCI/ICATT Malnutrition months Breastfeeding Infection control prevention Care for a healthy newborn aged 0-24 children under five Nutrition pregnancy in Nutrition women for and Anemia management and management Anemia Danger signs in pregnancy Starting from Q2, to follow the physical distancing recommendations due to the COVID-19 pandemic, no more than eight HCWs attended each training. The frequency of the training topics depended on the achievement of QI targets on ANC (Activity 1.3.2).

At the request of the Khatlon Department of Health (DOH), the nutrition resource centers trained 918 HCWs through 250 sessions on infection control, which included additional information on COVID-19 prevention: the use of personal protective equipment (PPE), handwashing practices, disinfection measures, and class B waste disposal. To support HCWs during the COVID-19 pandemic, THNA printed and distributed the following MOHSPP-approved materials: general guidelines on managing COVID-19 patients, guidelines on managing pregnancy in women with

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 10

signs of COVID-19, and procedural actions to take during COVID-19. THNA distributed these materials at the hospital and PHC levels.

1.1.5. Support district midwife-coaches in training hospital staff on effective perinatal care (EPC) and EmONC

In Y5, THNA reached 120% of its target by training 143 midwives from central district and rural hospitals on maternal, newborn, and child health (MNCH) topics (120 midwives trained being the target).

THNA supported midwife-coaches in conducting on-the-job trainings on EmONC and MNCH services. To improve the quality of the on-the-job trainings, THNA updated training materials and provided 12 supportive supervision visits by national-level trainers. During the visits, the national-level trainers observed the midwife-coaches at nutrition resource centers as they conducted training sessions with the use of anatomical models.

In addition, in Q3, ten local midwife-coaches conducted 180 in-person training sessions for 656 participants, allowing for double counting (Table 3). To guarantee physical distancing during these in-person trainings, participants were limited to three to four per training, on average. The infection control, COVID-19 prevention, breastfeeding, and family planning topics received additional attention.

Taking part in the trainings, I realized the importance of the mission of the midwife. I also realized that we midwives ourselves can work to improve our knowledge and skills. And this is very important, since the outcome of childbirth in most cases depends on the experience and knowledge of the midwife, and not on the doctor, as we used to think. Zukhra Ruzieva, midwife, Qabodiyon district

In Qabodiyon, Jomi, Jaikhun, and Shahritus districts, newly hired midwives received theoretical knowledge and practical skills trainings from the midwife-coaches before embarking on their duties.

Table 3. Number of training sessions for midwives and number of training participants, by topic, Q3 Topics Number of training Number of sessions participants Active management of the third stage of labor 24 86 Breastfeeding 31 98 Family planning 25 95 Infection prevention and control 12 50 Management of bleeding 26 92 Management of pre/eclampsia 24 73 Nutrition of breastfeeding women 18 72 COVID-19 prevention 20 90 Total: 180 656

1.1.6. Provide support to maintain MNCH databases

In Y5, THNA achieved 100% of the annual target by conducting 12 mentoring and monitoring visits to support the electronic MNCH database at 12 CDHs and PHCs.

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At the hospital level, THNA assisted staff in managing the database and aggregating data for the QI committees’ 2019 reports to facility managers. During the mentoring and monitoring visits, THNA facilitated meetings with the QI committees and hospital administration to prepare reports for the regional DOH and discussed challenges and steps for ensuring that data collection and reporting are sustainable in the future. Challenges included high staff turnover due to migration, the lack of a nationwide database/application specifically for health data collection and reporting, and the rotation of persons responsible for database maintenance. In Q1, THNA facilitated a discussion of these challenges at the quarterly coordination meeting with the DOH and facility managers (Activity 4.2.1).

At the PHC level, THNA was not able to implement the full-fledged MNCH database due to separate information flows from reproductive health centers, IMCI centers, and other PHC providers. Instead, THNA focused specifically on collecting and reporting data on ANC and IMCI indicators and assisting PHC staff with data entry, aggregation, analysis, and interpretation.

In Y5, CDHs successfully submitted their data from the MNCH database. At the PHC level, as part of its annual learning plan, THNA conducted a survey on the barriers to the uptake of the MNCH database (see the Monitoring, Evaluation, and Learning section).

Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality

1.2.1. Support 24 facility-level QI committees

In Y5, THNA achieved 100% of its annual target by training 120 members of QI committees at the hospital and PHC levels on national standards for accreditation through 12 training events and facilitating the development and approval of 24 QI plans. THNA engaged facility managers in the trainings to increase their awareness of and interest in QI and to secure their commitment to its continued implementation. Although THNA had already trained all QI committee members in Y2, many training participants were new due to high staff turnover.

The training sessions included discussing successes and challenges in implementing the 2019 QI plans, updating the QI plans, and selecting indicators for 2020. As a result, QI teams developed 24 facility-specific QI action plans for 2020, which were approved by head doctors and facility managers. According to the results of implementing QI plans in 2019, Jomi CDH was the most successful in improving its QI indictors. In Q2, THNA supported a visit for staff from other districts to the Jomi CDH to learn from its experience.

In Q1, THNA supported the assessment of the 2019 activities of the QI committees, and in Q4, a semi-annual self-assessment for 2020 based on the following criteria (Figures 3 and 4): • Existence of the institutional Order on the establishment of a QI committee and its composition according to standards; • Existence of a proper QI charter; • Existence of properly designed and tracked indicators; and • Progress on the 2019 QI plan (based on % of activities implemented).

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Figure 3. Scoring of hospital-level QI committees, by district 3

2,5 2.4

2 2.1 1,5

0,5

Q1 Y5 Q4 Y5 Average Q1 Y5 Average Q4 Y5

Definition of scores: Each item was evaluated with information gathered by different sources to reach an overall score, ranging from 0 to 3: 0 = need for very substantial improvements; 1 = need for substantial improvement to reach standard; 2 = need for some improvement to reach standard; 3 = good or according to the standard.

Figure 4. Scoring of PHC-level QI committees, by district 3

2,5 2.3 2 1.9 1,5

0,5

Q1 Y5 Q4 Y5 Average Q1 Y5 Average Q4 Y5

The QI committees analyzed their progress and reviewed their activities according to the recommendations after the first assessment in Q1. As a result, QI committees: • Developed criteria for evaluating QI activities; • Regularly discussed QI activity results and shared them at monthly facility staff meetings; and • Evaluated possible risks in the implementation of QI activities and updated QI plans.

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THNA provided technical support to QI committees through 12 mentoring and monitoring visits in Q2 and 12 online meetings in Q3 due to the COVID-19 pandemic (24 mentoring and monitoring visits being the target for three quarters).

In Q3, THNA staff discussed with QI committees the implementation of their QI plans, challenges of the COVID-19 pandemic, and household visits by PHC staff in response to COVID-19. As a result, COVID-19 prevention, patient management protocols, and infection control updates were added to the QI plans for 2020.

Based on the updated QI plans, all 12 CDHs and 12 PHCs made special arrangements for the admission and treatment of COVID-19 patients, as well as updating procedures, including: • Separate wards for pregnant women with signs of COVID-19; • Separate entrances for patients with signs of COVID-19; • Reinforced and frequent disinfection of the facilities; and • A hotline on COVID-19.

In Q3, as part of its QI plan, the PHC in Jaikhun district completed a THNA in-kind grant to provide running water to the facility. Also, as part of their QI plans, the CDHs in Jaikhun, Jomi, Yovon, and Shahritus districts completed renovations in their maternity and pediatric wards.

Effective functioning of QI committees is one of the requirements for future accreditation. Therefore, it is in the interest of facility managers and other staff to set up an active QI committee. As a result of QI activities supported by THNA, over 163,000 people in the 12 FTF districts have access to health services improved through QI interventions.

1.2.2. Organize exchange visits for QI committees at the hospital level

In Y5, THNA achieved 75% of the target by conducting three exchange visits between QI committees for 42 HCWs (60 participants and four exchange visits being the target). THNA organized two exchange visits between hospital-level facilities involving 30 HCWs and one between PHCs involving 12 HCWs. The goal of these exchange visits was to facilitate collaborative improvements in participating facilities.

At the hospital level, during one visit, representatives of the QI committees from 11 CDHs visited the Jomi CDH to learn about its improvements in clinical safety. A second visit to the Dusti CDH was conducted to learn about its improvements in hospital-based IMCI and the management of acute malnutrition.

At the PHC level, the QI committee from the Kushoniyon district PHC visited the PHC in Vakhsh district. The members discussed progress in implementing the 2020 QI plans and collecting data on quality indicators. Also, the Vakhsh district nutrition resource center trainers conducted a training session on the management of anemia in pregnancy to obtain feedback from their colleagues.

I graduated from the medical university in 2009 and worked at a local hospital in Jomi district. Working with THNA completely changed my life. Thanks to the activities of THNA, I have made great strides in my work. I received trainings on all the national standards, such as EPC, ANC, the prevention of infections, and many others. Now I have access to national mentors, whom I can call 24/7. In

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addition, THNA developed my leadership skills. Now, for almost one-and-a-half years, I have been the head of the maternity department at the Central District Hospital in Jomi. We significantly improved the quality of services in our facility, and now the work of our QI committee is the best among 12 district facilities. Sharbonu Sulaimonova, head of the maternity department, Jomi CDH

One exchange visit was canceled by the MOHSPP due to the COVID-19 pandemic. In Q3, THNA facilitated an online meeting between 41 QI committee members from 12 CDHs in lieu of the exchange visit. Meeting participants shared information on COVID-19 management. Some hospitals had to make infrastructure changes to isolate COVID-19 patients, and the QI committees supported those changes.

1.2.3. Train local trainers at the PHC level on supportive supervision around ANC, EPC, and IYCF

In Y5, THNA achieved 100% of its target by facilitating 12 supportive supervision visits on ANC and IYCF) and 12 internal supervisions and self-assessments on the implementation of EPC and hospital IMCI. THNA also supported the training of 16 district-level supervisors at PHCs.

At the PHC level, a total of 182 PHC staff were engaged in 12 supportive supervision visits (Photo 1). At each visit, supervisors discussed the implementation of the approved QI 2020 plans and the results of the internal supervisions. At the internal supervisions, local supervisors used the country-adapted WHO questionnaire (Figure 5).

Photo 1. Supportive supervision visit at a PHC (photo credit: THNA)

The supervisors reviewed the following key areas: • The provision of ANC and IYCF at the PHC level; • The quality of services, which includes the application of diagnostic and treatment standards and evidence-based drug treatment; • ANC and IYCF indicators and scorecards; • Organization and management, including human resources, finance, infrastructure, equipment, supplies, and legal aspects; • Information systems, including the accuracy of information, reporting, and analysis;

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• Training issues; and • Community involvement and patient rights.

Supervisors observed HCWs performing their functions; interviewed HCWs, patients, and managers; and inspected the facilities. At the end of the visit, the supervisors presented and discussed their observations with the HCWs and managers, including the most significant achievements and problems, as well as recommendations for different levels of authority.

Figure 5. ANC scorecards at the PHC level, average across 12 district PHCs, 2016–2020 3,0

2,5 2.33

2,0

1,5 1.34 1,0

0,5

0,0 Jomi Dusti Yovon Balkhi Vakhsh Jaikhun Shahritus Khuroson Levakand N.Khusrav Qabodiyon Kushoniyon Cohort I Cohort II (1) Cohort II (2) Cohort III since Oct 2016 since Feb 2017 since Apr 2017 since Jan 2018

Baseline / 2016 Y5 / 2020 Average 2016 Average Y5/2020 Definition of scores: According to the WHO ANC scorecard, each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0 to 3: 0 = need for very substantial improvements (totally inadequate care and/or harmful practice with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards); 2 = need for some improvement to reach standard care (suboptimal care but no significant hazard to health or of basic principles of quality care); 3 = good or standard care.

At the hospital level, THNA supported 12 internal supervisions and facility self-assessments on the implementation of EPC and hospital-based IMCI. District-level supervisors used national guidelines and assessment tools. The results of the scorecards are presented in Figures 6 and 7. Between Q3 of Y1 (baseline) and Q2 of Y5, hospital EPC scores improved from an average of 1.3 to 2.3 points, in large part due to renovations and upgrades resulting in improved infection control and clinical safety. Average IMCI scores improved between Q3 of Y2 and Q2 of Y5 from 2.9 to 3.41 mostly due to the improved clinical knowledge and skills of the HCWs (Activity 1.1.4). The decline in the IMCI scores in some CDHs was due to the reassignment of pediatrics department space, such as oral rehydration rooms or child playrooms, for other purposes, which is not in compliance with national protocols.

Figure 6. EPC scorecards, average across 12 district CDHs, 2016–2020

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3,0

2,5 2.33

2,0

1,5 1.34 1,0

0,5

0,0 Jomi Dusti Balkhi Jaikhun Kushoniyon Levakand Shahritus Qabodiyon N.Khusrav Yovon Khuroson Vakhsh Cohort I Cohort II (1) Cohort II (2) Cohort III since Oct 2016 since Feb 2017 since Apr 2017 since Jan 2018 Baseline / 2016 Y5 / 2020 Average 2016 Average Y5/2020 Definition of scores: According to the WHO EPC scorecard, each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0 to 3: 0 = need for very substantial improvements (totally inadequate care and/or harmful practice with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards); 2 = need for some improvement to reach standard care (suboptimal care but no significant hazard to health or of basic principles of quality care); 3 = good or standard care.

Figure 7. Hospital IMCI scorecards, average across 12 district CDHs, 2016–2020 5,0

4,0 3.4 3,0 2.9 2,0

1,0

Baseline / 2016 Y5 / 2020 Average 2016 Average Y5/2020 Definition of scores: According to the WHO Hospital IMCI scorecard, each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0 to 5: 0 = need for structural changes (totally inadequate care and/or harmful practice with severe hazards to the health of mothers and / or newborns); 1 = need for substantial improvement in management of all of the illnesses and related departments; 2 = need for substantial improvement in management of the majority of illnesses and related departments to reach standard care (suboptimal care with significant health hazards); 3 = need for considerable level of improvement; 4 = need for some improvement to reach standard care (suboptimal care but no significant hazard to health or of basic principles of quality care); 5 = good or standard care.

1.2.4. Facilitate supportive supervision visits on infection control and clinical safety at district-level PHCs

In Y5, THNA achieved 100% of the target by having 12 QI action plans at the PHC level include activities on infection control. THNA achieved this target by providing 12 supportive supervision visits on infection control and clinical safety to district-level PHCs.

The goals of the supportive supervision visits included assisting in the implementation of infection control as part of the QI action plans and facilitating facility self-assessments on infection control

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 17

in accordance with national standards. Supportive supervision demonstrated that all facilities had developed and implemented QI plans on infection control and clinical safety, which included staff training, knowledge testing, and quarterly self-assessments by each department.

At the PHC level (reproductive health and family medicine centers), between Y3 and Y5, the average score improved by only 4 percentage points (Figures 8 and 9). Supportive supervision visits indicated positive changes in HCWs’ attitudes and behavior toward clinical safety. However, progress at PHCs is limited because their infrastructure needs are even more desperate than those of the hospitals. In Y4–Y5, THNA supported seven PHC facilities with their water supply and constructed 114 VIP latrines at PHCs.

Figure 8. Infection control and clinical safety at reproductive health centers, % of standards met, by year, by district 50% 43% 40% 39% 30%

20%

10%

0% A. Jomi Dusti J. Balkhi Jaikhun Kushoniyon Levakand Shahritus Qabodiyon N.Khusrav Khuroson Vakhsh Yovon Cohort I Cohort II (1) Cohort II (2) Cohort III since Oct 2016 since Feb 2017 since Apr 2017 since Jan 2018

Y3 Y5 Average Y3 Average Y5

Figure 9. Infection control and clinical safety at family medicine centers, % of standards met, by year, by district 50%

40% 37%

30% 33%

20%

10%

0% A. Jomi Dusti J. Balkhi Jaikhun KushoniyonLevakand Shahritus Qabodiyon N.Khusrav Khuroson Vakhsh Yovon Cohort I Cohort II (1) Cohort II (2) Cohort III since Oct 2016 since Feb 2017 since Apr 2017 since Jan 2018

Y3 Y5 Average Y3 Average Y5

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 18

In Q3–Q4, THNA’s partner facilities received online support from THNA and national supervisors in response to the COVID-19 pandemic, including information on: • Additional disinfection procedures; • Increased frequency of handwashing and the provision of additional handwashing stations where possible; • Screening of all arrivals for fever and clinical symptoms prior to entry into CDH maternity and pediatric departments; • Use of PPE with newly arrived patients, especially those with COVID-19 symptoms; and • Obligatory wearing of face masks for all staff and patients.

In Q3–Q4, THNA assisted other international partners in providing THNA partner facilities at the PHC and hospital levels with disinfectants and PPE. At the hospital level, facilities received medical masks, antiseptics, jumpsuits, liquid soap, and chlorine. At the PHC level, facilities received jumpsuits, respirators, shoe covers, protective glasses, gloves, and antiseptics. In Q4, THNA also provided an in-kind sub-grant to the DOH with PPE for the Bokhtar city ambulance station (jumpsuits and goggles) for 70 HCWs. A total of 2,103 frontline HCWs received PPE.

Outcome 1.3: Stronger facility and provider networks

1.3.1. Support biweekly online conferences between national-level supervisors and district facilities

In Y5, THNA achieved 105% of its annual target by supporting 24 facilities (12 CDHs and 12 district PHC facilities) with mentoring support by 36 national-level mentors from tertiary-level facilities through 253 biweekly online conferences (240 conferences being the target).

In Q1, the main topics for support at the hospital level were the updated clinical standards on the management of postpartum hemorrhage and recommendations on Caesarean section. At the PHC level, the main topics were the GMP campaign and the referral of children identified as malnourished. Several complicated clinical cases of eclampsia (from Qabodiyon district) and a premature delivery case (from Jomi district) were discussed online.

In Q2, the main topics of the conferences were: • Implementation of the QI action plans; • Cases of complicated deliveries; • Internal supervision; • Management of pregnant women with severe anemia; and • Implementation of the EmONC guidelines.

In Q3, the topics of the online conferences included: • Management of postpartum hemorrhage; • Indications for Caesarean section; • Audit of critical cases in the maternities; • Nutrition of children under five during the COVID-19 pandemic; • Nutrition of children under five with malnutrition during the COVID-19 pandemic; • Treatment of children with signs of COVID-19; • Treatment of pregnant women with signs of COVID-19;

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 19

• Nutrition of pregnant women during the COVID-19 pandemic; and • Breastfeeding by women with symptoms of COVID-19.

In Q3, in response to the COVID-19 pandemic, THNA supported national consultants in strengthening their online communication with the FTF districts and facilities. The consultants regularly conducted online trainings and conferences on all professional topics, including those focusing on the prevention and treatment of COVID-19 (Table 4).

Table 4. Online events, by type and topic, and number of participants, Q3 of Y5 Non-COVID- COVID-19- Number of Number of 19-related related participants participants events Online trainings 13 285 19 315 Peer learning conferences 8 312 12 448

1.3.2. Organize the final roundtable on the Beyond the Numbers (BTN) approach

THNA achieved its target by organizing the final BTN online roundtable for 56 participants from 11 districts in Q3 (48 participants being the target). The event was held online due to the COVID- 19 pandemic. Facilities in Nosiri Khusrav district are not equipped for emergency surgical interventions, and they did not participate in the BTN discussions over the years.

At the roundtable, each team presented what they saw as their achievements, which included: • A twofold reduction in the incidence of postpartum hemorrhage over the past three years; • A decreased incidence of intrapartum complications that depend on the use of partograms, from 25% to 12% of all complications observed; • Improvements in the quality of EmONC; • Implementation of the CME system; and • Consideration and discussion of all mistakes made at the facility level to avoid them in the future.

After the roundtable, the teams held an additional eight online BTN meetings to discuss critical situations that had occurred in maternity wards. The online format of the BTN meetings may ensure their sustainability in the future.

By participating in discussions of critical situations that have occurred in other maternities, we learn ourselves and help our colleagues. We analyze what we would do if this were to happen in our facility or share our experience if such an incident has already occurred in our hospital and we have learned lessons. We are not embarrassed to discuss our mistakes, as this helps us improve the quality of our work. An obstetrician/gynecologist, Qabodiyon district

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 20

IR2: Increased access to a diverse set of nutrient-rich foods throughout the year

Outcome 2.1: Diversified food consumption during the growing season and beyond

2.1.1. Train 50 new community educators (CEs) from Y4 on three remaining seasonal topics

In Y5, THNA reached 116% of its target by training and certifying 58 CEs—47 recruited in Y4 and 11 others—on three topics: (1) poultry and dairy production, (2) household budgeting and family entrepreneurship, and (3) home garden management. Knowledge of the training participants improved from 60-78% of correct responses on pre-training tests to 82–98% of correct responses on post-training tests (Table 5). THNA provided all trained CEs with social and behavior change communication (SBCC) materials on each topic. Healthy lifestyle center (HLSC) representatives participated in the trainings and familiarized themselves with the content of CE activities.

Table 5. Average pre- and post-training test results, CE training, % of correct responses, Q1–Q2, Y5 Training topics Pre-test Post-test Day 1: Poultry production 60% 89% Oct. 2019 Day 2: Dairy production 78% 98% Day 1: Household budgeting 71% 95% Nov. 2019 Day 2: Family entrepreneurship 61% 82% Day 1: Home garden management 68% 87% Jan. 2020 Day 2: Home garden management 64% 94%

2.1.2. Provide CE-led practical trainings for households on four seasonal topics

In Y5, THNA reached 91% of its annual target by reaching 162,989 community members (out of 180,000 planned, allowing for double counting) with 233,414 person-sessions1 on seasonal agricultural topics. On average, each CE reached 143 individuals every month, and everyone received a training or a counseling session on one or two topics. Between May and August, THNA suspended all CE activities due to the COVID-19 pandemic.

CEs from 491 THNA villages provided practical trainings to 80,416 households on the topics of poultry production (47,230 person-sessions) dairy production (25,203 person-sessions), economic empowerment (household budgeting and entrepreneurship; 46,875 person- sessions), home garden management (69,207 person-sessions), winter food storage (28,141 person-sessions), and post-harvest technologies (16,758 person-sessions; Photo 2). CEs reached these households through individual home visits or by bringing several households together.

To support CEs’ effective work in the communities, THNA provided the CEs with 15,000 copies of the brochures on household budgeting, crop rotation, and poultry care (a total of 45,000 brochures), as well as 14,880 copies of the brochures on composting. During the monthly

1 A “person-session” refers to each session, allowing for double counting. For example, if the same ten people participated in two sessions, there would be ten total people trained, but 20 person-sessions.

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 21

peer learning meetings, CEs received refresher trainings on this topic. The brochures were used as demonstration materials during CE training sessions in the communities.

Photo 2. CE practical session on drying vegetables (photo credit: THNA)

In February, THNA organized a GMP campaign for children six to 59 months of age. In addition to CHPs, THNA engaged 486 CEs in the GMP campaign (Activity 3.3.2). THNA trained CEs on the use of mid-upper arm circumference (MUAC) tapes.

In the past, we used a lot of chemical fertilizers to get a higher yield, but after the trainings provided by THNA, we are more aware about their negative effects. For the past two years, I am maintaining two compost pits in my backyard. With the use of compost, I get a better yield and products free from chemicals. I have also observed other benefits of it. There is less waste now, and I no longer spend money on fertilizers. During educational sessions in my community, I share this practical experience with my neighbors. Ayrushan Ergasheva, a CE from Chkalov village, Takhti sangin jamoat, Qabodiyon district

I have been working as a CE for three years and have participated in all monthly peer learning meetings. Many of my neighbors listened to the new information I was giving, but they were not necessarily ready to change their practices. However, their opinion changed last year when they saw that I had received a good harvest from the early autumn carrots following crop rotation, composting, and proper irrigation. When they found out that I received good income from its sale, more than 30 families started following my practices this year. They planted autumn carrots early and got a good harvest. Carrots planted in autumn can be harvested a month earlier and cost double the standard price at the market. Now my neighbors often turn to me for advice. Avvalmurod Akuziev, a CE from Yangiabad 1 village, H. Kholmatov jamoat, Shahritus district

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 22

In Q3–Q4, THNA canceled all CE-led practical trainings for households on seasonal topics due to the COVID-19 pandemic. In April and March, at the monthly individual meetings with volunteers, THNA trained CEs and CHPs alike on COVID-19 prevention and provided them with SBCC materials on COVID-19. THNA advised CEs to stay home in self-isolation to reduce the risk of contracting and spreading COVID-19 and to communicate with members of their communities via phone. THNA staff provided mentoring and supervision to community volunteers via phone and Internet-based communications (Skype, Viber, WhatsApp, and Imo). The goals of these calls were to support volunteers in self-isolation, to understand their health status and the epidemiological situation in their communities, and to provide advice and answer questions. THNA staff also delivered key messages to volunteers on the following topics: • COVID-19 prevention; • Stress management in self-isolation; • Child care during self-isolation; and • Breastfeeding by women with symptoms of COVID-19. This year, I got a better harvest of tomatoes than last year. However, due to the limited access to the market, I was unable to sell some of the tomatoes on time. This was not an issue though since THNA taught us how to cook and preserve various tomato products. I cooked and canned over 200 jars of tomato sauce, lecho, tomato juice, salted tomato, and tomato with cucumbers and sweet peppers. Now I do not worry about my family’s food diversity in the winter. I also exchanged experiences via phone with my neighbors. I express my deep gratitude to the project. Gulnora Khuramova, CE, Qabodiyon district

2.1.3. Facilitate monthly peer learning sessions for CEs

In Y5, THNA achieved 78% of its annual target by bringing together 491 CEs in 154 peer learning sessions (198 sessions for 492 CEs being the annual target; Photo 3). THNA also achieved 100% of another target by engaging 24 HLSC representatives in CE monthly meetings. At these meetings, CEs shared their experiences through groupwork, presentations, role-plays, games, and other interactive exercises. In Q1–Q2, THNA continued testing CEs on topics relevant to their work to identify gaps in their knowledge. These gaps were then addressed through refresher trainings at the meetings. Based on the results of the knowledge tests, THNA emphasized family entrepreneurship and budgeting, poultry management, botulism prevention, irrigation, crop rotation, composting, and poultry management in its refresher trainings. HLSC staff contributed to refresher trainings at monthly CE meetings.

Beginning in March, ТНNА canceled its monthly volunteer group meetings due to COVID-19. Instead of group peer learning meetings, in March and April, THNA conducted individual meetings between its staff and CEs. At these individual meetings, THNA provided information on preventing infectious diseases, including COVID-19, such as physical distancing measures, the use of face masks, and especially hand hygiene. THNA provided volunteers with COVID- 19 prevention and SBCC materials, hand sanitizers, and face masks and collected volunteer reports. HLSC staff conducted a portion of the trainings at these meetings. Beginning in May, THNA provided mentoring and supervision to community volunteers via phone and Internet- based communications (Skype, Viber, WhatsApp, and Imo).

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 23

Photo 3. CEs at a monthly peer learning session (photo credit: THNA)

Some highlights of CEs’ activities over Y5 include: • The level of trust and respect for CEs increased among community members due to the CEs’ sharing of COVID-19 information. Almost 60% of CEs are government employees, such as teachers, heads of villages, and HCWs. Thus, rather than self- isolate, they were able to make household visits on behalf of the government to disseminate information on COVID-19 prevention. THNA was able to distribute to CEs SBCC materials on COVID-19 prevention early, and they were thus able to share the information with their neighbors in a timely manner—assisting their communities at a critical time and raising their profile among the population. • CEs were able to apply their prior knowledge of the prevention of infectious diseases, especially handwashing with soap, to help their communities during the COVID-19 pandemic. • CEs effectively collaborated with CHPs, the heads of villages, HCWs, and others on a variety of activities, from COVID-19 prevention, to the GMP campaign, to cooking demonstrations and WASH events in the communities and at schools. • Four CEs from Kushoniyon, Levakand, Vakhsh, and Qabodiyon districts sewed a total of more than 1,000 face masks and distributed them free of charge to members of their communities. • CEs reported that many people in self-isolation were engaged in canning and food preservation at home—skills that CEs had been promoting in communities to improve food security.

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 24

• Before the COVID-19 pandemic, CEs were able to conduct some educational sessions for men at mosques after prayer, which had been challenging in previous years.

The challenges included: • Since the government did not officially recognize the COVID-19 pandemic in its early stages, most community members did not initially follow the necessary preventative measures like self-isolation, physical distancing, wearing masks, etc. • Due to several mudslides in April, some villages lost their harvest, which negatively affected food security and income. • Family budgeting became increasingly difficult, as many households were unable to save money due to decreased incomes/rising prices during the COVID-19 pandemic. • The use of household backyard gardens was limited, as many areas have no irrigation. Water shortages in some villages make the improvement of irrigation practices impossible. • In some areas, high groundwater levels due to clogged drainage systems negatively affected crop yield—CEs discussed organizing community work with village development committees (VDCs) to clean the drainage canals. • Poultry vaccination was lacking due to the high price of vaccines, as well as the lack of a veterinarian in most villages—CEs discussed options for pooling the resources of several households or even several villages together to purchase vaccines.

Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities

In Q1, THNA saw the results of its collaboration with Centro Internacional de la Papa (CIP) in Y4 through the harvest of sweet potatoes provided to THNA-targeted schools in the summer of 2019 (Activity 3.1.2). The yield of sweet potatoes from the school gardens was over 2,000 kg. CIP completed its project in September 2019, and the FTF Tajikistan Agriculture and Water Activity (TAWA) has also been completed. THNA, however, promoted TAWA’s crops, such as bok choy, broccoli, and mung beans through cooking demonstrations in Q1 and Q2. In Q3– Q4, THNA suspended all community group events, including cooking demonstrations, because of the COVID-19 pandemic.

IR3: Increased practice of healthy behaviors around MNCH

Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children six to 24 months of age

3.1.1. Train Department of Education (DOE) staff and teachers from the three additional schools over a two-day training on THNA’s peer education curriculum

In Y5, THNA achieved 100% of its annual target by training ten DOE staff and teachers from three additional schools on THNA’s peer education curriculum (Photo 4). In Y5, THNA worked with a total of 12 schools, one in each target district.

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 25

In Q1, THNA selected three schools from the remaining districts to participate in project activities: school #38 in Khuroson district, school #5 in Shahritus district, and school #12 in Nosiri Khusrav district. All schools met the specified criteria for selection: include grades 1 through 11 (primary through high school); have a school garden; have a reliable water supply; have a school canteen supported by the World Food Programme (WFP); have a headmaster and teacher who support the THNA initiative; and have an experienced gardener working in the school garden. Each school nominated two teachers to lead THNA activities.

In Q1, THNA conducted a two-day training for ten participants: six schoolteachers, three representatives of the district departments of education, and one representative from the regional DOE. The training covered THNA’s extracurricular program for school peer educators on nutrition, WASH, agriculture, and other life skills. The regional DOE representative experienced with the THNA curriculum co-facilitated the training with THNA staff. Training participants received 100 sets of training materials, informational banners, and stationery to work effectively with peer educators.

Photo 4. Training of DOE staff and schoolteachers (photo credit: THNA)

Although I have been working as a teacher for more than 25 years, I still learned about new topics at this training, such as nutrition, budgeting, some agricultural aspects, sanitation and hygiene. At the same time, it was clear that these topics are interconnected by the common theme of health. I will gladly present this knowledge to schoolchildren. Amriddin Toshmatov, a teacher at school #12, Nosiri Khusrav district

3.1.2. Support teachers at three schools on establishing and running peer education activities

In Y5, THNA reached 151% of its target by engaging 4,050 students (180 peer educators and 3,870 other students) in 12 schools in practical trainings on WASH, nutrition, agriculture, and life skills. The annual target was a total 2,680 individuals: 180 peer educators and 2,500 school

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 26

students. In May 2020, there were no peer education activities, as schools were out of session due to the COVID-19 pandemic, and June and July are the months of regular school recess.

In Y5, THNA provided 65 supportive supervision visits to 12 target schools, 25 of which were to the three newly selected schools. During the visits, THNA staff attended the sessions facilitated by the teachers and peer educators to observe, help, and provide recommendations.

In Q1, THNA provided three newly selected schools with visual aids on irrigation, crop rotation, crop families, composting, sources of vitamin A, safe water storage, iodized salt, and the five routes by which intestinal infections are spread, in addition to a nutrition map and nutrition pyramid. These three schools also received 15 types of agricultural tools for their school gardens. In Q1, THNA provided all 12 schools with an in-kind sub-grant of 11 types of kitchen utensils. The students used them during practical sessions on cooking demonstrations at schools.

3.1.3. Provide practical sessions to children by CEs and CHPs

In Y5, THNA achieved 128% of its annual target by providing 2,468 person-sessions for school students grades 8–11 on WASH, nutrition, agricultural, and exclusive breastfeeding topics (1,920 person-sessions being the annual target). CEs and CHPs reached 12 secondary schools and one boarding school in Yovon district, with a total of 80 practical sessions.

Photo 5. School students conducting a cooking demonstration session (photo credit: THNA)

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In Y5, with support from the peer educators, CHPs conducted 40 cooking demonstration sessions involving 1,166 school students (Photo 5). The CHPs also used these cooking demonstrations to provide short educational sessions on hygiene and kitchen safety. They demonstrated seasonal recipes from the THNA recipe book, introducing new vegetables, such as broccoli and bok choy. Special attention was paid to recipes with meat as one of the main sources of iron. CHPs also conducted seven sessions on exclusive breastfeeding, with the involvement of 315 school students in grades 8–11. CEs conducted 33 educational sessions for 987 school students on crop rotation and irrigation. School WASH events are described under Activity 3.2.1.

In our family, the vegetable salad usually consists of tomatoes and cucumbers. It was new for me to learn about bok choy and broccoli. I had never tried them before. At the cooking demonstration, we prepared salads using these vegetables. I very much liked the taste and learned about their benefits. I will now suggest these vegetables to my family. Mohira Shaydolova, a 10th grade school student from school #12, Nosiri Khusrav district

I really enjoyed participating in the breastfeeding session, it was the first time I received scientific information on breastfeeding. I learned about the composition of breast milk and the importance of breastfeeding for the baby. Such information is very important for every family. In our family, my nephew receives sweetened water in addition to breast milk, which can be the cause of diarrhea or other infectious diseases. Therefore, I will make sure that the child no longer receives sweetened water. Abdulaziz Sultonov, 10th grade student, school #5, Shahritus district

In Q1, seven target schools harvested 2,050 kg of sweet potatoes (Table 6; Photo 6). This was a result of receiving 5,076 sweet potato cuttings from CIP in Q3 of Y4. The harvest was used to diversify school meals for elementary school students. In Qabodiyon district, the crop failed due to the poor condition of the cuttings received.

Table 6. Sweet potato harvest, Q1, Y5 District Jamoat Village Sweet potato Sweet potato & school # cuttings harvest, kg Balkhi Navobod Komsomol #35 1,000 450 Dusti G. Gulmurod Pasariq #11 576 200 Jaikhun Istiqlol Telman #7 1,000 500 Jomi Yakkatut Jovid #16 500 200 Kushoniyon Bohtariyon N. Karaboev #19 1,000 400 Levakand Guliston Botrobod #4 500 300 Qabodiyon N. Niyozov Chorbog #9 500 0 Total: 5,076 2,050

I like conducting educational sessions for my peers. The project equipped us with the necessary materials for high-quality training. We always use them for explaining the topic, group work, and practical exercises. I like the big banners on the walls in our classroom that help us

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 28

visualize the necessary information. They also serve as an outline of the topic. Dildora Ochildieva, a 10th grade school student from school # 5, Shahritus district

Photo 6. Sweet potato harvest from school garden (photo credit: THNA)

3.1.4. Conduct monthly cooking demonstrations for community members, led by CHPs

In Y5, THNA achieved 111% of its annual target by bringing together 47,756 participants (of the target of 43,200, allowing for double counting) for 3,461 cooking demonstrations (96% of the target of 3,600) in 491 communities. Beginning in April, THNA suspended all community cooking demonstrations led by CHPs due to the COVID-19 pandemic.

For the cooking demonstrations, CHPs continued using THNA’s recipe book. Each demonstration focused on one or two recipes for specific target groups (children six to eight months, nine to 11 months, 12 to 23 months, or pregnant and breastfeeding women). CHPs used these cooking demonstrations as platforms for small group educational sessions on nutrition and WASH topics. The average number of participants in the cooking demonstrations was 14.

In Y5, THNA facilitated 24 exchange visits (67% of the target of 36 visits over three quarters) between CHPs from different communities. The purpose of these visits was to improve CHPs’ cooking demonstration skills. As a result, 154 CHPs (77% of the target of 200 CHPs) participated in the exchange visits to other villages. In Q3, THNA did not facilitate exchange visits, as cooking demonstrations were suspended.

To foster the sustainability of CHP activities, THNA engaged HLSC staff in 12 target districts in cooking demonstrations. This engagement provided HLSC staff with an opportunity to

THNA Year 5 Annual Progress Report: October 1, 2019–August 30, 2020 29

participate in CHP activities, familiarize themselves with the methodology, and ensure that the CHPs’ work will be sustainable under future HLSC leadership.

In addition to cooking demonstrations in the communities, in Y5, CHPs conducted 40 cooking demonstrations at THNA partner schools for 1,166 school students (Activity 3.1.3), reaching 162% of the annual target.

3.1.5. Facilitate peer support group meetings for community members, led by CHPs

In Y5, THNA achieved 127% of its annual target by facilitating 4,009 peer support group meetings (3,150 group meetings being the target) in 491 communities for 36,158 participants (164% of the 22,000 targets, allowing for double counting). Beginning in April, THNA suspended all support group meetings due to the COVID-19 pandemic.

The goals of these peer support group meetings are to diversify the foods consumed by pregnant and breastfeeding women and children over six months of age, as well as to promote ANC and exclusive and continuous breastfeeding. These peer support groups brought together participants with different life experiences and challenges, with the goal of sharing best practices for improving nutrition in women and children. Each group met at least once a month to discuss a nutrition-related topic proposed by CHPs or by group members. This format allowed for both the sharing of experiences among peers and for educational sessions by CHPs. An average number of participants per group was nine.

Volunteers facilitating peer support group meetings received supportive supervision from THNA staff. Supportive supervision was available through observation of peer support group meetings by district coordinators or their assistants and by technical staff, individual discussions with volunteers, and group discussions at monthly CHP peer learning sessions.

I am the mother of twins. Even breastfeeding mothers with one child complain that their milk is not enough for their baby. That is why babies are given formula in the first months of life. But my experience is different. With the support and advice of my mother-in-law, who is a member of a support group, I received useful information on the importance of breastfeeding and was able to give breast milk to both of my babies for up to six months. Now I share my experience with other mothers, and I believe that every mother's milk is enough for her baby. Kimkhoh Kholmurodova, a mother from Tutak village, Yovon district.

3.1.6. Conduct 108 community events on exclusive and continuous breastfeeding

In Y5, THNA conducted 72 community events on exclusive and continuous breastfeeding (67% of the target for three quarters) for 1,704 pregnant and breastfeeding women and their family members (85% of the target of 2,000 participants).

In Q1, THNA developed a standard program of community events on breastfeeding, which includes information sessions, role-plays, quizzes, and information materials on the topic. CHPs are responsible for convening community members and running these events, with assistance from THNA staff. CHPs received program materials from district coordinators in advance. To encourage community member participation, THNA provided small incentives, such as child bowls and spoons for complementary feeding of children over six months.

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Starting in April, THNA suspended all community events on exclusive and continuous breastfeeding due to the COVID-19 pandemic. Through regular phone calls with volunteers, THNA staff delivered an adapted version of the WHO’s messages on breastfeeding by women with symptoms of COVID-19, which included the following information:

• If the mother has a confirmed or suspected case of COVID-19, and if her condition allows her to breastfeed, she should continue breastfeeding • The mother should wear a face mask and wash hands with soap before breastfeeding and when caring for the child; and • The risk of contracting a serious case of COVID-19 is minimal in young children, and it is outweighed by the risk of discontinued breastfeeding.

Volunteers disseminated these key messages through phone calls to HCWs, village development committee (VDC) members, relatives, friends, and neighbors.

At the breastfeeding event, I learned that using bottles for feeding has a negative effect on a child’s health. The volunteer demonstrated how bottles and nipples could become a source of infection and lead to diarrhea, malnutrition, and anemia. This demonstration convinced me that breastfeeding is always safer and better for babies. Olufta Boboeva, a mother from Qumshokh village, K. Kholmatov jamoat, Shahritus district.

Outcome 3.2: Improved sanitation and hygiene-related behaviors

3.2.1. Conduct 60 community WASH events and 12 school WASH events in 12 districts

In Y5, THNA reached 85% of its annual target by exposing 1,530 community members (out of the 1,800 planned) to SBCC messages on WASH and social marketing messages on the VIP latrine. To achieve this result, THNA organized 40 community WASH events (67% of the 60 planned) under the slogan “Be part of the solution, not the pollution” (Table 7; Photos 7 and 8). THNA was not able to reach its targets because in Q3–Q4, THNA canceled all public community events due to the COVID-19 pandemic.

In addition, THNA achieved 110% of its annual target by reaching 2,955 school students (2,680 being the annual target) with SBCC messages through 12 school WASH events (Table 8). Starting in May 2020, THNA canceled all school-based activities due to the COVID-19 pandemic.

For community WASH events, community volunteers and THNA identified the communities with the most cases of diarrhea and childhood malnutrition. In the following months, these communities became the sites of community WASH events. In those communities, the volunteers identified model households with proper latrines, safely stored water, clean yards, and garbage disposed through composting. At these households, CHPs organized community WASH events for at least 30 participants and disseminated messages on safe water, proper sanitation, and hygiene. Participants of the events included women of reproductive age, mothers-in-law, schoolchildren, husbands, PHC staff, and HLSC representatives. By engaging children, who performed dramatic sketches and dances, recited poems, and participated in quizzes for small prizes (hand soap), THNA encouraged communities to adopt healthy WASH practices.

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Table 7 Number of WASH events and their coverage, by district, Y5 # District # of events # of house- Total # of # of women # of men holds participants 1 Balkhi 6 243 237 213 24 2 Dusti 3 114 128 118 10 3 Jomi 3 120 106 77 29 4 Jaikhun 3 122 98 93 5 5 Kushoniyon 6 236 223 194 29 6 Khuroson 3 124 116 106 10 7 Levakand 2 104 81 63 18 8 N. Khusrav 2 128 84 81 3 9 Qabodiyon 3 118 102 101 1 10 Shahritus 3 121 116 110 6 11 Vakhsh 3 107 119 100 19 12 Yovon 3 174 120 108 12 Total: 40 1,711 1,530 1,364 166

Photo 7. A community WASH event, Yovon district (photo credit: THNA)

Within THNA, we have conducted many activities and events on sanitation and personal hygiene. Communities actively participated, but the people might not have been convinced that clean hands could save a person from infectious diseases. However, during the COVID- 19 pandemic, national TV channels repeated that the cheapest, easiest, and most effective way of preventing COVID-19 is proper handwashing with soap. After seeing this information on TV, the villagers thanked THNA for teaching them about personal hygiene and proper handwashing early on before the pandemic. We as community volunteers continued household visits, conducted individual sessions, and distributed information materials and key massages on WASH and COVID-19 prevention. Ruzigul Sherova, CHP, Yovon district

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Table 8. WASH events at schools, Y5 # District and school # Girls Boys Total 1 Balkhi, school #35 139 166 305 2 Dusti, school #11 59 49 108 3 Jaikhun, school #7 138 204 342 4 Jomi, school #16 149 168 317 5 Khuroson, school #38 61 87 148 6 Kushoniyon, school #19 148 164 312 7 Levakand, school #4 102 123 225 8 Nosiri Khusrav, school #12 66 59 125 9 Qabodiyon, school # 9 226 127 353 10 Shahritus, school # 5 36 64 100 11 Vakhsh, school # 15 126 109 235 12 Yovon, school #49 206 179 385 Total: 1,456 1,499 2,955

Photo 8. A WASH event at a school (photo credit: THNA)

At schools, the students organized the WASH events themselves, with support from CHPs, HLSC staff, and school administration. These events provided participants with messages on safe water, safe latrines, proper sanitation, and hygiene. They included dramatic sketches, recitations of poems on WASH topics, quizzes, song and dance performances, and drawing competitions on the topic of “Why we get sick.” Active participants received hygiene packages as incentives.

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3.2.2. Support a peer exchange visit for 20 community masons

In Y5, THNA met its target of having 20 community masons share experiences in the production and marketing of sanitation products for VIP latrines. In Q2, THNA organized a one-day peer exchange visit to one of the most successful and skilled masons in Kushoniyon district. Masons shared their experiences in the production and marketing of VIP latrines (Photo 9).

Photo 9. Peer exchange visit by community masons to Kushoniyon district (photo credit: THNA)

During the exchange, the skilled community mason outlined the important steps for promoting a successful sanitation business and covered the following topics: • Market assessment; • Demand creation and activation; • Reaching potential low-income customers; • Creating new molds; • Automation of the business; • Supply chains and business models; • Innovative options for supply-side financing; and • Product innovation.

As a result, 20 masons received practical tips from their already successful peers on how to run or improve their own businesses. This exchange visit focused on the differences between various types of concrete rings and latrines; their functionality, advantages, and disadvantages; factors in selecting a latrine type; and construction methods. Exchange visits may lead to changes that enable a new practice. Today, we discussed that to satisfy customer needs, we need to use not just one mold but many molds of different sizes. I produce concrete rings 40 cm in height, but sometimes customers need 80 cm or 1 m. After the exchange visit, I rented a mold 80 cm in height to attract more consumers. Rajab Kholiqov, community mason, Vakhsh district

3.2.3. Conduct a social marketing campaign for VIP latrines

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In Y5, THNA reached 30% of its target by facilitating 298 household referrals by community volunteers to community masons for VIP latrine construction (1,000 referrals being the target). The volunteers cited the lack of financial resources in households as the main barrier to successfully marketing VIP latrines in the communities. The volunteers also referenced the global COVID-19 pandemic as negatively affecting income in their communities, which depends on labor migration. With many countries and businesses shut down, remittances were significantly reduced. The households that might have been interested in improving their latrines could not afford to do so.

After the exchange visit, the masons made plans to produce concrete rings and slabs at customers’ sites instead of transporting them from the masons’ shops. Another cost-saving idea is to rent the molds to the customers to allow them to produce the rings and slabs themselves.

In Q2, THNA placed information about the benefits of VIP latrines and contact information for community masons on the doors of 114 latrines built at rural PHCs.

In Q2, local THNA partners completed the construction of 42 VIP latrines at the rural PHC facilities remaining from Y4 (Photo 10). In addition, following advice from USAID’s environmental officer, THNA provided its partners with door springs for installation on all 114 VIP latrines built at rural PHCs.

Photo 10. Community masons’ contact information posted to the door of a rural PHC facility latrine (left) and installation of a door spring (right) (photo credit: THNA)

The village of Kalfi Sabad is one of the biggest villages in the jamoat of Sitorai Surkh. The PHC of Kalfi Sabad serves many households. Earlier, when the latrines were not there, community members did not have the courage or opportunity to attend some events, especially pregnant women. This is partly because this lack of latrines had been a big barrier for us. Now this problem is greatly mitigated. The construction of this latrine in our PHC has solved one of the deep-rooted problems we have been facing. Now the constructed VIP latrine is serving almost

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310 households, especially females. A more dependent or incontinent patient may have his/her toileting needs met. Jumagul Rustamova, nurse at Kalfi Sabad PHC, Yovon district

Outcome 3.3: Increased use of health care services for MNCH, including nutrition, sanitation, and hygiene

Community Level

3.3.1. Train 150 new CHPs to replace dropouts

In Y5, THNA, achieved 95% of its target by selecting, training, and certifying 143 new CHPs from 12 districts to replace dropouts (150 new CHPs being the target). By the end of Y5, THNA had 1,272 active CHPs.

In Q1, in close partnership with district HLSCs, rural PHCs, and VDCs, THNA selected 143 new CHPs. New CHPs were selected to ensure that most THNA communities would be engaged through the end of the project. HLSC staff played an active role in meeting with local communities, explaining the role of volunteers, interviewing candidates, and recommending finalists to community members.

Photo 11. New CHPs graduating after the basic five-day curriculum training, Khuroson district (photo credit: THNA)

THNA, together with district trainers from among HLSC and PHC staff, reviewed and updated the basic five-day training curriculum for CHPs. The curriculum now includes a practical training on cooking demonstrations. District trainers with support from THNA trained new CHPs in seven groups, with an average of 20 participants per group. District trainers were primarily responsible for these trainings to ensure their ability to train health volunteers

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beyond the end of the THNA project. The trainers measured the change in participants’ knowledge through pre- and post-training tests. These tests demonstrated an improvement in participant knowledge from an average of 52% to 87% of correct responses. Participants who achieved at least an 80% score on the post-training tests received a CHP certificate (Photo 11).

THNA provided new CHPs with a basic package of materials, including a branded tote bag and apron, a MUAC tape, a THNA recipe book, a United Nations Children’s Fund (UNICEF) flipbook on exclusive and continuous breastfeeding, a set of food diversity cards, a DVD with THNA videos, and a set of other counseling aids on the health and nutrition of women and children.

3.3.2. Provide household visits by CHPs

In Y5, despite the COVID-19 pandemic, THNA achieved 108% of its target by reaching 194,908 households through CHP home visits, educational sessions, and other activities (180,000 household visits being the target, allowing for double counting). As a result of their home visits, CHPs identified and referred 3,632 pregnant women not registered for ANC, 2,782 children with signs of malnutrition, and 786 children with diarrhea to PHCs. Volunteers and district coordinators followed up with PHCs on each child with signs of malnutrition to ensure linkage to services, confirm the accuracy of the numbers, and ensure that appropriate services were provided.

CHPs provided THNA with complete information on children with signs of malnutrition, as well as the numbers of children with diarrhea and of pregnant women referred to PHCs. CHPs reconciled their referrals with HCWs at rural PHC facilities. THNA district coordinators reconciled this referral information with district-level PHCs during monthly meetings with HCWs or district IMCI centers.

GMP campaign by community volunteers

In February, CHPs together with CEs and rural HCWs conducted a GMP campaign among children under five through household visits in 481 villages. THNA proposed this campaign to the MOHSPP and DOH in December 2019 in response to questionable results of the GMP campaign conducted by HCWs in November–December 2019. As a result, community volunteers screened a total of 111,313 children (94.6% of all children six to 59 months of age registered with PHCs) with MUAC tapes (Photo 12). The volunteers identified 2,437 children with signs of malnutrition (wasting), which puts the estimated prevalence of wasting in THNA communities in 2020 at 2.2%. THNA district coordinators provided the list of children with signs of malnutrition to district-level PHC managers and IMCI centers for care and treatment. After verification of MUAC screening results by HCWs through weight and height measurements, a total of 1,610 children were confirmed as malnourished, which puts the estimated prevalence of wasting in THNA communities even lower, at 1.4%, compared to 6.2% reported in the 2017 demographic and health survey.

Photo 12. A CHP measures the arm of a child with a MUAC tape, Vakhsh district (photo credit: THNA)

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The GMP campaign, in which I participated, once again made me think that I am doing the right thing. When I measured children’s arms, I found children with signs of malnutrition. I talked to their parents and answered their questions on the causes and consequences of malnutrition the best I could. I was very proud because the parents respected me as they would have respected a health worker. I am glad to be a volunteer and make my contribution to the healthy development of the children in my village. Dilorom Bobonazarova, CHPs, Qushachinor village, Qabodiyon district

During their home visits, in Q1–Q3 (through April), CHPs provided individual and small group counseling sessions on exclusive breastfeeding (95,977 person-sessions), complementary feeding for children over six months (85,895 person-sessions), nutrition for pregnant women (62,841 person-sessions), WASH (110,371 person-sessions), diarrhea (31,413 person- sessions), danger signs in pregnancy (42,309 person-sessions), iodine and its deficit (42,362 person-sessions), anemia (36,714 person-sessions), and immunization (26,214 person- sessions). The reason for the large number of WASH sessions was to disseminate and reinforce COVID-19 prevention messaging through Q2–Q3. These activities reached 33,717 pregnant women and 121,139 children under five.

Each CHP visited an average of 22 households per month, in a catchment area of approximately 100 households per CHP. CHPs specifically targeted households with children under two years of age and children with malnutrition or other known medical conditions, as referred by PHCs; low-income households and incomplete families; households with pregnant women; and households with newlyweds. During their visits, CHPs provided counseling and disseminated information materials on exclusive and continuous breastfeeding,

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complementary feeding for children over six months, and health and nutrition for pregnant and breastfeeding women. CHPs used visual aids for counseling, such as UNICEF’s flipbook on IYCF, food diversity cards, and THNA’s recipe book. Other counseling topics included danger signs in pregnancy, safe drinking water, and other WASH topics. To screen children six months to five years of age for malnutrition, CHPs used MUAC tapes. CHPs also marketed VIP latrines (Activity 3.2.3).

From May to September, THNA suspended all in-person activities by CHPs, substituting them with phone-based counseling for community members. THNA did not collect reports from CHPs during these months. THNA advised CHPs to stay home and self-isolate to reduce the risk of contracting and/or spreading COVID-19. During this period, most volunteers stayed home, and THNA staff supported them through phone calls and Internet-based communications, such as Skype, Viber, WhatsApp, and Imo when available. THNA staff regularly called volunteers to support them in self-isolation, to understand their health status and the epidemiological situation in their communities, to answer their questions, and to provide additional key messages. New SBCC messages covered the following topics: • COVID-19 signs, symptoms, and prevention; • Breastfeeding during the COVID-19 pandemic; • Accessing health services during the COVID-19 pandemic; • Stress management in self-isolation; • Prevention and treatment of diarrhea in children.

THNA staff encouraged CHPs to share key messages with their household members and, when possible, through phone calls with other community members. Some CHPs who are government employees (teachers, VDC members, cleaners at health facilities, etc.) disseminated key messages to their community members as part of their household visits on COVID-19 prevention and routine work activities.

3.3.3. Conduct 24 local health fairs in remote rural communities

In Y5, THNA reached 67% of the annual target by conducting 16 local health fairs in remote communities (24 health fairs being the target for three quarters). THNA achieved 117% of another target by reaching 1,394 community members with MNCH messages and health services (1,200 community members being the annual target). THNA did not organize health fairs in Q3–Q4 due to the COVID-19 pandemic. More community members attended each health fair than expected (almost 90 vs. the 50 planned).

THNA facilitated visits to remote villages by family practitioners, specialists (obstetrician/gynecologists, pediatricians, and ultrasound diagnosticians), and lab technicians. As a result, THNA provided access to MNCH and other services to: • 788 women of reproductive age, of whom 370 were pregnant (40 newly identified and registered); • 522 children (231 boys and 291 girls); and • 84 older women.

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Five children were identified as malnourished and received consultation and referral. Urine protein (a sign of preeclampsia) was found in 144 pregnant women, who were referred for follow-up ANC services.

A health fair is not only for the provision of medical services to the population but also one of the ways to disseminate useful information and engage the community in healthy lifestyles. The health fair provides an opportunity for people in remote villages where there are no medical facilities to receive the necessary information that is beneficial to their life and health. Said Kholov, director of HLSC, Levakand district

3.3.4. Build HLSC technical and managerial capacity to support community volunteers

In Y5, THNA achieved 100% of its target by improving the technical and managerial capacity of 25 HLSC staff to support community volunteers (25 HLSC staff being the target). In Q1–Q3 (though April), two HLSC staff in each of the 12 FTF districts and the director of the regional HLSC engaged in the evaluation, analysis, and planning of community volunteer activities through monthly THNA staff meetings; contributed to CE and CHP trainings as co-trainers; helped facilitate monthly peer learning sessions and provided refresher trainings on nutrition, health, and WASH topics; and helped organize community WASH and breastfeeding events, as well as cooking demonstrations and peer support groups (Table 9).

Table 9. HLSC engagement in THNA activities in Y5 Activity Level of HLSC Frequency of engagement 2.1.1. Train 50 new CEs from Y4 on three Regional, district October and December remaining seasonal topics 2019, January 2020 2.1.3. Facilitate monthly peer learning sessions for Regional, district October 2019 – April CEs 2020 3.1.4. Conduct monthly cooking demonstrations District October 2019 – March for community members, led by CHPs 2020 3.1.5. Facilitate peer support group meetings for District October 2019 – March community members, led by CHPs 2020 3.1.6. Conduct 108 community events on exclusive District October 2019 – March and continuous breastfeeding 2020 3.2.1. Conduct 60 community WASH events and 12 District October 2019 – March school WASH events in 12 districts 2020 3.3.1. Train 150 new CHPs to replace dropouts Regional, district October 2019 3.3.3. Conduct 24 local health fairs in remote rural District October 2019 – March communities 2020 3.3.4. Build HLSC technical and managerial capacity Regional, district October 2019 – April to support community volunteers 2020 3.3.5. Facilitate monthly peer learning sessions for District October 2019 – April CHPs 2020 3.3.6. Train CHPs on additional SBCC topics District October 2019 – April 2020

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3.3.5. Facilitate monthly peer learning sessions for CHPs

In Y5, THNA achieved 75% of its annual target by facilitating 190 monthly peer learning sessions (of the target of 252 sessions) for 1,286 CHPs (643 CHPs every month, on average), 290 local HCWs, 25 HLSC representatives, and other active partners. Beginning in May, THNA suspended monthly meetings with volunteers, replacing them with telephone support by THNA staff.

Given the large number of CHPs (1,288 in Q1 of Y5), in Q1–Q2, THNA engaged half of them through monthly peer learning session to ensure the bimonthly participation of all CHPs. To facilitate collaboration between CHPs and rural PHCs, THNA invited rural HCWs to the monthly CHP learning sessions. THNA also increasingly engaged HLSC staff in facilitating these sessions. Meeting agendas covered: the peer exchange of successes, challenges, lessons learned, and best practices; tests to identify knowledge gaps; short refresher trainings to fill the knowledge gaps or learn about new topics; analysis of the results of the CHPs’ work over the previous month; recognition of the highest-achieving CHPs; and the collection of data reports for the current month. At these meetings, CHPs shared their experiences through group work, presentations, role-plays, games, and other interactive exercises. THNA staff recognized an improvement in the CHPs’ skills in facilitation and presentation, measuring with the MUAC tape, and identifying children with malnutrition.

In Q1–Q2, THNA tested volunteers’ knowledge on important topics of their work, with an average of 88% of correct responses to the test questions. To close the gaps in knowledge, THNA provided volunteers with refresher trainings on: (1) exclusive breastfeeding during child growth spurts, (2) nutrition of pregnant women in the third trimester, (3) identifying swelling as one of the danger signs during pregnancy, (4) anemia among pregnant women, and (5) helminthiasis. For this purpose, THNA developed additional key messages (Activity 3.3.6), which were tested and presented to CHPs during the meetings. At the end of January, THNA held a refresher training for all volunteers (CHPs and CEs alike) on the use of MUAC tapes to prepare the volunteers for the child GMP campaign in February (Photo 13).

At the peer learning sessions, 781 CHPs received small prizes based on their work results, such as the number of people reached by activities or the number of children with malnutrition identified. THNA provided all CHPs with information, education, and communication (IEC) materials on anemia, diarrhea and rehydration treatment, helminths, handwashing, water storage, infections, VIP latrines/sanitation and hygiene, danger signs in pregnancy, the healthy food map, iodized salt, the WHO’s “Five Keys to Safer Food,” and vitamin A, as well as MUAC tapes, brochures, recipe books, and video materials. The learning sessions included practical exercises on the use of these IEC materials.

In March and April, following recommendations made by the MOHSPP and USAID, ТНNА canceled regular monthly group meetings with volunteers, replacing them with individual meetings with volunteers by district coordinators and THNA staff. THNA provided volunteers with COVID-19 prevention and SBCC materials, hand sanitizers, and face masks and collected volunteer reports for March and April. THNA encouraged volunteers to continue their household visits in April to disseminate COVID-19 prevention and SBCC information, but to postpone any group activities, such as peer support group meetings, cooking demonstrations, WASH and exclusive breastfeeding events, and health fairs.

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Highlights of CHP activities in Y5 include the following: • During the GMP campaign in February, CHPs effectively identified, referred, and followed up not only with children with signs of malnutrition but also pregnant women with danger signs or who had not been registered for ANC. • Community members recognized the value of CHP activities, particularly around WASH and hand hygiene, which are part of COVID-19 prevention. Healthy WASH practices became more prevalent: there are more washstands with soap in households, and more VIP latrines have been constructed by community members. • CHPs and community members made face masks and distributed them to HCWs and other community members. For instance, one CHP in Kushoniyon district sewed 100 face masks and gave them as a gift to her community. The district coordinator in Qabodiyon district and her daughters-in-law sewed 1,000 masks and distributed them in the communities. A community volunteer in Yovon district made 200 masks and donated them to schoolchildren. • In June and July, CHPs in Balkhi district participated in the COVID-19 prevention SBCC campaign organized by the HLSC at the central market of Balkhi district. During several events, CHPs assisted HLSC staff in educating the public about COVID-19 prevention measures, such as physical distancing, proper hand hygiene, and the use of face masks. The district HLSC’s engagement of the CHPs demonstrated that the government entity recognized the CHPs’ knowledge and skills in health promotion. In Q4, similar campaigns with CHP engagement were organized by the HLSCs in Khuroson and Qabodiyon districts. • CHPs in two villages in Balkhi district closely collaborated with the deputy manager of the district PHC. The CHPs informed the PHC about the epidemiolocal situation in their villages and provided lists of families with signs of COVID-19. Due to the collaboration between the PHC, the WFP, and the CHPs, the villages received 41 washstands. • Pregnant women in Yovon district approached CHPs for ANC registration and counseling, and the CHPs referred them to the appropriate health facilities. During the COVID-19 pandemic, CHPs did not actively identify pregnant women through household visits, but referred them to health facilities through phone calls. • There was improved engagement and support for CHPs from CEs, HCWs, VDCs, and HLSCs as part of the joint action plan.

The main challenges faced by CHPs include the following: • The summer diarrheal season started, and CHPs had to reinforce key messages on diarrhea prevention and management in children through phone calls to community members rather than in-person meetings. However, volunteers did observe a decline in cases of diarrhea in Q4. • Some community members prematurely abandoned COVID-19 prevention measures, such as physical distancing and the use of face masks. CHPs and HCWs had to take extra steps to reinforce prevention measures in the communities, including sewing and distributing face masks and providing phone counseling to overcome the challenges of self-isolation.

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• Food security risks increased for some vulnerable community members due to high food prices and harvest losses in some villages (caused by natural disasters, such as floods, mudslides, and locusts). • Turnover of HCWs in some villages remained an issue: it takes time and effort to establish relationships between CHPs and new HCWs, and some villages have no HCWs.

Photo 13. Community volunteers at monthly meeting, January 2020, Vakhsh district (photo credit: THNA)

3.3.6. Train CHPs on additional SBCC topics

In Y5, THNA reached 107% of its target by training 1,286 CHPs on additional SBCC topics, specifically the nutrition of pregnant women, exclusive breastfeeding, anemia in pregnant women, intestinal parasites, and deworming (1,200 CHPs trained being the target). THNA provided CHPs with IEC materials and key messages at monthly meetings. The messages were pretested in the field before disseminating them to the communities through CHPs. The nutrition and exclusive breastfeeding messages were presented as vignettes and were discussed in small groups and through role-plays. CHPs discussed communication channels for delivering the messages, such as peer support groups, community breastfeeding events, cooking demonstrations, health fairs, and individual counseling/group sessions during home visits.

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In Q2, before the Government of Tajikistan had officially recognized the pandemic, THNA adopted and shared WHO- and UNICEF-developed materials on COVID-19 prevention with CHPs and CEs. The key messages and print materials were distributed at individual meetings with volunteers (Activity 3.3.5). In addition to COVID-19 prevention, key topics included breastfeeding during COVID-19, the importance of accessing medical services for mothers and children during the pandemic, and stress management for mothers and children.

In Q4 (July and August), THNA adapted additional key messages provided by WHO, UNICEF, and the International Federation of the Red Cross and Red Crescent Societies on coping with stress in adults, children, and adolescents during self-isolation, as well as COVID-19 prevention in school settings. THNA distributed these key messages to volunteers through phone calls and encouraged the volunteers to share these messages through remote communication (phone, Viber, WhatsApp, and Imo) to their community members.

3.3.7. Incentives for volunteers

In Q1, THNA finalized the results of the volunteer competition that had started in Q4 of Y4. A total of 104 volunteers (66 CHPs and 38 CEs) were recognized as the first-, second-, or third- place winners of the essay, photo, or video competition in each of the 12 districts. An additional 45 volunteers (29 CHPs and 16 CEs) were recognized in special categories as “the best field worker,” “children’s friend,” “the best health worker assistant,” “the best agriculture promoter,” “the best cook,” and “the best facilitator,” among others. The winners received diplomas and prizes. All participants regardless of their result received letters of appreciation from THNA and pins with the logo of the volunteer competition. THNA displayed banners and posters with the 12 best photographs and essays at the monthly volunteer peer learning sessions. Volunteers and HLSC and PHC representatives had the opportunity to appreciate the winning works. The winners presented their works and discussed what changes volunteer work had brought to their communities and their own lives.

I am very proud that the project appreciated my work, which I sent for the competition. I sent over ten photos of my activities in the village. Although the competition is over, I will continue taking pictures, writing stories about my villagers, and sharing them with other volunteers. Everyone should know who a volunteer is and what we are doing for the health of mothers and babies in our communities. It will convince other people to become volunteers. Oimgul Zikrilloeva, a CHP from Ayni village, Navobod jamoat, Balkhi district

To keep community volunteers (both CEs and CHPs) and local partners motivated, THNA provided them with different material incentives. In Q1–Q2, a total of 1,868 umbrellas, 1,757 electric air pots, and 1,883 plastic food containers were distributed to community volunteers, HCWs, and HLSC representatives as incentives.

In Q1–Q2, at the monthly meetings, THNA rewarded those volunteers who demonstrated the greatest achievement based on their monthly service reports. A total of 765 volunteers were rewarded with small kitchen utensils to be used in cooking demonstrations.

In Q3–Q4, THNA was not able to provide incentives to volunteers because of the COVID-19 pandemic.

Facility Level

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3.3.8. Conduct a TOT for district trainers on an updated IMCI/integrated management of acute malnutrition (IMAM) protocol

In Y5, THNA reached 88% of the annual target by supporting a TOT in Q3 for 21 district trainers on the updated IMCI/IMAM protocol (24 district-level trainers being the target). Three participants could not participate due to their duties in the red zone of COVID-19 care.

The results of the training pre- and post-tests showed an improvement in knowledge, from 41% to 86% of correct responses.

3.3.9. Support cascade trainings at nutrition resource centers for HCWs on the updated IMCI/IMAM and IMCI/ICATT protocols

In Y5, THNA reached 141% of its target by training and certifying 85 HCWs on IMCI through ICATT (60 HCWs being the target). In addition, THNA reached 537% of another target by supporting cascade trainings to 322 HCWs (232 nurses and 90 doctors) on the updated IMCI/IMAM protocol (60 HCWs being the target for three quarters).

In Q3, 21 local trainers who had been trained on the updated IMCI/IMAM protocol (Activity 3.3.8) cascaded 160 in-person trainings to 322 HCWs, while observing COVID-19 physical distancing recommendations. THNA also supported the training and certification of 85 HCWs (27 family doctors and 58 family nurses) on IMCI/ICATT at district-level IMCI centers (Table 10).

Table 10. Number of HCWs trained on IMCI through ICATT, by district, Q1–Q3

Jomi Dusti Balkhi Jaikhun Kushoniyon Levakand Shahritus Qabodiyon N. Khusrav Khuroson Yovon Vakhsh Total Number of HCWs trained through IMCI centers with 5 6 6 7 7 10 6 5 7 10 10 6 85 certification

Following the training, the regional IMCI center conducted 12 mentoring and monitoring visits to health facilities to assess the knowledge of certified HCWs. Results demonstrated that family nurses trained on IMCI can independently monitor children’s development and can recognize danger signs and refer patients in a timely manner and that the quality of counseling on the nutrition and care of children up to five years of age has improved.

3.3.10. Support a semi-annual GMP campaign by local PHC providers and the referral of children under five with malnutrition for treatment

In Y5, THNA reached its target by supporting the fourth semi-annual GMP campaign by PHC staff among children under five in the 12 FTF districts in November–December (Photos 12 and 13). As a result of the GMP campaign, HCWs identified 1,347 children with severe and moderate acute malnutrition, as well as 2,171 children with mild malnutrition (weight-to- height measurement <-1Z).

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Prior to the GMP campaign, THNA provided refresher trainings through nutrition resource centers to 185 HCWs on weight and height measurement and the use of the MUAC tape.

In addition to the GMP campaign, HCWs identified children with malnutrition through their routine screening and referred them to district IMCI centers. In Q1–Q3, a total of 5,381 children under five were registered with IMCI centers with different levels of malnutrition (Table 11). Children with a Z-score of -1Z received counseling on nutrition and active home visits; children with a Z-score of -2Z in Shahritus, Dusti, and Balkhi districts received therapeutic nutrition at the PHC level; and in other districts, children with Z-scores below -2Z received therapeutic nutrition at the hospital level.

Table 11. Number of children with malnutrition registered with district IMCI centers, by Z-score, by district, Y5 Y5 Q1 Y5 Q2 Y5 Q3

Total Total children Total children children identified identified FTF districts -1Z -2Z -3Z -1Z -2Z -3Z identified -1Z -2Z -3Z with with with malnutrition malnutrition malnutrition

Jomi 65 43 18 4 60 46 14 0 209 121 78 10 Dusti 1,002 409 593 0 25 18 7 0 156 15 121 20 Balkhi 140 1 138 1 150 118 32 0 96 10 70 16 Jaikhun 102 56 35 11 102 85 17 0 37 18 16 3 Kushoniyon 67 42 25 0 182 136 46 0 5 2 2 1 Levakand 88 58 30 0 10 10 0 0 14 9 2 3 Shahritus 1,407 1303 95 9 57 37 20 0 57 7 46 4 Qabodiyon 98 15 81 2 90 21 67 2 60 35 22 3 N. Khusrav 9 3 3 3 23 16 7 0 20 17 3 0 Khuroson 48 15 28 5 117 82 26 9 17 5 2 10 Yovon 171 49 119 3 219 82 121 16 67 23 25 19 Vakhsh 321 177 143 1 68 38 30 0 22 6 13 3 Total 3,518 2,171 1,308 39 1,103 689 387 27 760 268 400 92 % of total 62% 37% 1% 62% 35% 2% 35% 53% 12%

3.3.11. Monitor follow-up at the PHC and hospital level of children with signs of malnutrition identified by CHPs

In Y5, THNA continued monitoring the collaboration and case cross-referrals between PHCs and CHPs. Reports on children with malnutrition identified and referred by CHPs were presented during routine PHC meetings.

In Y5, CHPs identified a total of 2,693 children under five with signs of malnutrition with the use of the MUAC tape: 2,437 through the GMP campaign (Activity 3.3.2) and 256 through their regular household visits. Of these, 346 children (12.8%) were confirmed as “newly diagnosed” with malnutrition and treated; 1,384 (51.4%) had already been registered with a PHC as malnourished; 843 (31.3%) were not confirmed as malnourished; and 120 (4.5%) were lost to follow-up due to lack of contact information.

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In turn, HCWs provided CHPs with information on 216 children with malnutrition who had been discharged from hospitals for community follow-up.

IR4: Institutionalized evidence-based MNCH services through national-level policies and standards

Outcome 4.1: Cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH

4.1.1. Support the MOHSPP TWG on updating the hospital-based IMCI training package

In Y5, THNA together with UNICEF, the WHO, and the WFP supported the MOHSPP in updating the training package on hospital-based IMCI. In Q2, the MOHSPP approved the updated IMCI protocol. THNA provided a TOT on the training package in Q3 (Activity 3.3.8).

4.1.2. Develop a national nutrition pyramid for children and adolescents

In Q1–Q2, THNA supported the MOHSPP TWG in developing the national nutrition pyramid for children and adolescents. Due to the COVID-19 pandemic, the TWG was not able to complete its work or have the pyramid approved by the MOHSPP.

4.1.3. Support the National Nutrition Forum in October 2019

In Y5, THNA achieved 128% of its target by supporting 32 participants from the FTF districts in attending the Third National Nutrition Forum in Dushanbe (25 participants being the target). THNA supported the MOHSPP in organizing the National Nutrition Forum entitled, “Nutrition in the framework of the National Development Strategy for the period of 2030.” THNA contributed to the Forum’s program with a project presentation, an exhibition from three FTF districts, and printed materials about the importance of MNCH and nutrition for the future sustainable development of Tajikistan.

Outcome 4.2: Evidence-based approaches for MNCH, including nutrition, sanitation, and hygiene, are sustainable

4.2.1. Coordinate the implementation of the joint action plan among PHCs, CHPs, and VDCs through quarterly DOH-level meetings with PHC managers and other key stakeholders

In Y5, THNA achieved 33% of its target for three quarters by holding one quarterly DOH-level coordination meeting with PHC managers and other stakeholders, out of three planned. As a result of this meeting, community volunteers together with HCWs implemented a GMP campaign (Activity 3.3.2); 42 rural PHCs completed the construction of VIP latrines remaining from Y4; and seven out of nine health facilities completed their water improvement projects supported through in-kind grants from THNA. In Q2–Q4, because of the COVID-19 pandemic, no coordination meetings were held.

4.2.2. Regularly present data from the MNCH databases to the DOH and MOHSPP

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In Y5, 12 CDHs with support from THNA submitted their quarterly reports to the DOH using the data from the MNCH database. Also, THNA presented data to the DOH and MOHSPP on the successful implementation of online trainings and sessions during the COVID-19 pandemic.

4.2.3. Support national-level participation in international Scaling Up Nutrition (SUN) events

In Q1, THNA supported a member of the Tajikistan SUN secretariat, Dr. Sherali Rahmatullaev, to attend the 2019 SUN Movement Global Gathering in Kathmandu, Nepal in November 2019. The five-person Government of Tajikistan delegation shared the country’s experiences of and insights into how nutrition, and multi-stakeholder partnerships, can accelerate the achievement of the United Nations Sustainable Development Goals in the country. The overall theme of this global gathering was “Nourishing People and Planet Together,” which acknowledges that globalization, urbanization, inequities, humanitarian crises, and climate shocks are driving unprecedented negative changes to people’s nutrition around the world.

4.2.4. Support the MOHSPP in health financing reform in 12 FTF districts

In Y5, the MOHSPP made no requests to support activities related to financial reforms in the FTF districts.

4.2.5. Organize the final THNA close-out event to share project results at the national level In July, THNA organized two final close-out events for local and international partners, USAID, and implementing partner staff (IntraHealth International and Abt Associates) to share project results. An event on July 28 held in Tajik and Russian combined in-person participation by 52 MOHSPP and DOH representatives, trainers from nutrition resource centers, and THNA clinical staff in an auditorium in Dushanbe, 40 THNA staff in the Dushanbe and Bokhtar city offices, staff from 12 CDHs and 12 district PHCs in 24 nutrition resource centers, and approximately 20 different partners – all joined through Zoom videoconferencing, for a total of over 120 participants. Presenters included the US Ambassador to the Republic of Tajikistan with opening online remarks, the chief pediatrician of the DOH, trainers from hospital- and PHC-level resource centers, and THNA community agricultural and health volunteers. On July 29, THNA organized an exclusively online event in English for over 40 participants from among IntraHealth and Abt US-based staff, USAID staff and international partners in Tajikistan. THNA staff made the same presentations and answered questions from the online audience.

Conference presentations are included as Annex 2 to this report.

MONITORING, EVALUATION, AND LEARNING

In Y5, THNA’s activities on monitoring, evaluation, and learning included: • Running regular DQAs on volunteer-reported data demonstrating an average 94% accuracy rate between January and April 2020;

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• Presenting THNA’s first peer-reviewed publication at the FTF’s 7th Annual Scientific Symposium on Agriculture in Kathmandu, Nepal; and • Developing and implementing THNA’s annual learning plan, based on USAID’s principles of collaborating, learning, and adapting, on: (1) barriers to MNCH database uptake at the PHC level; and (2) CHP best practices in identifying and referring children under five with signs of malnutrition, as well as unregistered pregnancies.

In Y5, THNA faced the following challenges due to the COVID-19 pandemic: • THNA did not achieve its quarterly and annual targets on some indicators; and • THNA canceled the sixth round of the Recurring Household Survey, the fourth round of the Recurring Agricultural Practice Survey, and the final Rapid Health Facility Assessment. As a result, the achievements on some indicators will not be available for Y5, and some THNA results presented in the final project are based on 2019 survey data. Data Quality Assessment (DQA) In Q1, instead of a DQA in the field, THNA screened the quality of volunteer reports submitted electronically by district coordinators. Over three months, THNA screened approximately 5,000 cumulative volunteer reports submitted by district coordinators.

Figure 10. DQA, Q2–Q3 Data discrepency, Jan. – Apr. 2020, average % 9% 6% 6% 5%

91% 94% 94% 95%

January February March April Reported correctly In Q2–Q3, THNA conducted a DQA by verifying 245 reports with source data. Results of the assessment show that the data reported are 94% correct (Figure 10). Approximately 6% of data sources filled by volunteers in Y5 had errors.

FTF’s 7th Annual Scientific Symposium in Nepal Based on the results of five rounds of the Recurring Household Survey, THNA presented a poster at the 7th Annual Scientific Symposium that was held in Kathmandu, Nepal from December 10 to 12, 2019.

Learning Plan

In Q2, THNA completed implementation of its Learning Plan by conducting and incorporating into the project work the results of two qualitative surveys on:

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1. CHP best practices in identifying and referring children under five with signs of malnutrition and unregistered pregnant women; and 2. Barriers to implementing the MNCH database at the PHC level. The CHP survey included 20 volunteers, of whom ten had identified and referred large numbers of pregnant women and children with signs of malnutrition and ten who had identified very few or no women and children in need of referral. Both groups received similar questions that addressed the barriers that CHPs face in making these identifications and referrals. The results demonstrated that: • CHPs vary greatly in their communication and counseling skills; • CHPs do not regularly cover all households in their villages because the workload is higher than 100 households per CHP; and • The GMP campaign to measure all children is a great tool for screening all households over a short period of time. To address these issues, future projects and HLSCs should: carefully select CHPs with good communication skills and provide more training on counseling skills; consider recruiting and training more volunteers to cover all households or potentially reduce the workload per CHP; and add biannual GMP campaigns to its regular work.

The HCW survey engaged six PHC providers and managers in Balkhi, Dusti, Khuroson, and Vakhsh districts to identify barriers to the uptake of THNA’s MNCH database. The results demonstrated that: • Most PHC providers were not aware of the existence of the database because those who had been introduced and trained on its use are no longer employed; • Those who were aware of the database did not see any value in its use for their own reporting or care purposes; • PHCs do not collect data from the reproductive health or IMCI centers and cannot collate them into one database; and • PHC management and the DOH do not require that the database be used. To address these issues, future projects and the DOH should train current staff on the use of the MNCH database and demonstrate how data are used for decision-making, QI, and facility planning and budgeting. Moreover, data collection needs to be streamlined by the government and cannot be the sole effort of a technical assistance project, particularly if such technical assistance is not expected by government partners. Lastly, facility and DOH management teams need to be sensitized to the use of data for decision-making before staff are required to collect the data.

COVID-19 challenges

In Y5, THNA did not achieve its quarterly and annual targets for some indicators due to the COVID-19 pandemic and the suspension or cancellation of activities. In Q3, THNA was planning to conduct the sixth round of the Recurring Household Survey, the fourth round of the Recurring Agricultural Practice Survey, and the final Rapid Health Facility Assessment. Due

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to the COVID-19 pandemic, THNA canceled these final assessments. As a result, achievements on two FTF indicators, EG.3.2-24 and EG.3.3-10, will not be available for Y5.

Overall, of the 13 FTF indicators, THNA did not achieve its annual targets on seven, five of which were due to the cancellation of volunteers’ community work and two of which were due to canceled final assessments.

GENDER

THNA implemented its nutrition strategy by targeting women of reproductive age who are at increased risk of having micronutrient deficiencies and raising malnourished children. THNA focused on individuals and families by supporting direct, targeted interventions, such as individual counseling and peer support groups, which facilitate transformative learning. THNA incorporated gender-sensitive approaches into its nutrition-specific interventions, in line with the nutrition strategy and in accordance with the results of the nutrition behavior study. This integration included strengthening THNA’s targeted approach to women by encouraging opportunities for improving livelihoods and savings through the agricultural sector and by focusing on men as household providers and purchasers of nutrient-rich food. In general, husbands and mothers-in-law make decisions about the health care-seeking behaviors of women with young children. THNA strived to strengthen its work with men as family decision-makers through peer support groups. In Y5, THNA encouraged CHPs to promote exclusive breastfeeding concepts to male family members through different means, including peer support groups. By the end of Y5, at least 30 peer support groups for men were functioning in THNA communities. In addition, to improve family resources for MNCH services and encourage health care-seeking behaviors, in Y5, THNA through 486 CEs conducted small sessions on household budgeting and family entrepreneurship, which reached 25,203 community members (allowing for double counting). In Y5, THNA trained 180 peer educators (108 of whom are girls, 60%) on issues related to home budgeting and hygiene. Peer educators, in turn, provided educational sessions on those topics, which reached 3,842 students (1,901 of whom were girls, 49%). In Y5, THNA provided access to MNCH services for 1,394 community members through 16 health fairs at the community level. Among the beneficiaries, a total of 872 were women (63%). In Q3–Q4, due to the COVID-19 pandemic, THNA suspended all community group activities, such as peer support groups and cooking demonstrations. However, community volunteers continued household visits in April, delivering key messages and identifying pregnant women not yet registered for ANC. In May–August, volunteers provided individual counseling to women over the phone, with specific emphases on health-seeking behaviors for pregnant women, continuing breastfeeding by women with symptoms of COVID-19, the need for family planning services in the COVID-19 pandemic environment, and child care in self-isolation.

STAFFING & MANAGEMENT

THNA was led in country by IntraHealth International’s chief of party, Roman Yorick, who was supported by the deputy chief of party from Abt Associates, Gulnora Razykova.

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In Q4, THNA had a total of 55 staff members, including 50 IntraHealth International and five Abt Associates staff. Of the staff members, 32 were located in the regional office in Bokhtar city. A communications specialist left THNA in March; management decided not to fill this vacancy due to COVID-19’s limitations on program activities and THNA nearing its completion.

Starting May 1, both the Dushanbe and Bokhtar city THNA offices transitioned to remote work due to the COVID-19 pandemic. In May–August, 18 THNA staff reported laboratory- confirmed COVID-19 diagnoses or suspected COVID-19 symptoms. One staff member and three community volunteers died of COVID-19 or other conditions complicated by COVID- 19.

Most THNA staff had their contracts extended from August 1 through September 15, 2020.

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BUDGET vs. EXPENDITURES ANALYSIS

A breakdown of expenditures through July 31, 2020, against the current obligation is presented in Table 12. The breakdown of expenditures by program element/funding stream is presented in Table 13.

Table 12. Project-to-date obligation and burn rate Approved Actual Cooperative Actual Spent to Remaining Budget Category Year 5, Burn rate Agreement July 31, 2020 Budget Quarter 4 Budget Personnel & Consultants $2 627 610 $ 50 146 $2 723 187 -$95 577 104% Fringe Benefits $986 498 $ 23 336 $898 751 $87 747 91% Travel $500 989 $ 40 $450 716 $50 273 90% Equipment $7 500 $ - $8 596 -$1 096 115% Contractual $4 611 358 $ 27 287 $4 501 836 $109 522 98% Other Direct Costs $2 349 738 $ 56 605 $2 223 214 $126 524 95% Total Direct Cost $11 083 693 $157 414 $10 806 300 $277 393 97% Indirect Cost $2 075 138 $ 29 326 $1 898 040 $177 098 91% Total $13 158 832 $186 740 $12 704 340 $454 491 97%

Table 13. Quarterly expenditures by funding stream Year 5 Program element Quarter 4 4.5.2.8: Nutrition sensitive agriculture (ES-GFSI) $46 478 3.1.6 Maternal Child Health (GH-C) $103 046 3.1.9 Nutrition (GH-C-GFSI) $37 216 Total $186 740 SUB-AWARDS

In Y5, THNA disbursed $157,106 worth of medical, training, and office equipment; furniture; construction materials; and printed information and communication materials in the form of sub-grants to the DOH and its facilities. This amount constitutes 15% of the total $1 million budgeted for sub-grants within THNA. By the end of Y5, THNA had disbursed a total of $998,633 (99.86%) in sub-grants.

Sub-grant of water pumps and water tanks for 12 PHC facilities

In Q1, THNA provided water pumps and tanks, as well as the materials for constructing water towers at nine medical facilities in Khatlon Region. The total cost of this in-kind sub-grant to the DOH was $46,712.81.

Furniture and information technology (IT) equipment for HLSCs of the 12 FTF districts and the regional HLSC and for nutrition resource centers and IMCI centers of the 12 FTF districts and regional IMCI center

In Q2, THNA provided furniture and IT equipment (a laptop, printer, and Wi-Fi router) to the HLSCs of the 12 FTF districts and the regional HLSC, as well as Wi-Fi routers to the nutrition

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resource and IMCI centers of the 12 FTF districts and the regional IMCI center. The total cost of this in-kind sub-grant to the DOH was $11,346.64.

Additional materials for completing construction of VIP latrines

In Q2, THNA provided door springs, mosquito nets, and buckets to the Shahritus CDH, to 112 PHCs, and to six secondary schools of Khatlon Region under sub-awards #3391-012, #3391- 017, #3391-021, and #3391-027 to complete the construction of VIP latrines. The total cost of this in-kind sub-grant to the DOH was $1,405.74.

PPE (jumpsuits and goggles)

In Q4, THNA provided the ambulance center of Bokhtar city with PPE (jumpsuits and goggles) for use during the COVID-19 pandemic. The total cost of this in-kind sub-grant to the DOH was $2,871.00.

Also, in Q1 of Y5, THNA completed the following in-kind sub-grants initiated in Y4:

Sub-grant of blueprints for construction projects in Khatlon Region

THNA provided blueprints to the DOH for water tower construction and water tank installations; for construction of eight-person gender-specific VIP latrines; and for providing water supply and sewage systems to the pediatric and maternity departments of Dusti CDH The total cost of this in-kind sub-grant to the DOH was $1,731.57.

Sub-grant of agricultural tool sets for schools

THNA provided sets of agricultural tools to three secondary schools in Khuroson, Shahritus, and Nosiri Khusrav districts of Khatlon Region. The total cost of this in-kind sub-grant to the DOH was $1,336.95.

Sub-grant of kits for family doctors at district PHCs

THNA provided 270 kits for family doctors. The total cost of this in-kind sub-grant to the DOH was $32,544.90.

Sub-grant of kits for family nurses

THNA provided 800 kits for family nurses. The total cost of this in-kind sub-grant to the DOH was $23,995.20.

Sub-grant of materials for installing VIP latrines in 100 selected medical centers

THNA provided materials for constructing one-person VIP latrines in 38 PHCs and an eight- person VIP latrine in the Shahritus CDH. The cost of in-kind sub-grant to the DOH was $29,687.76.

Sub-grant of kitchen utensils provided to 12 schools in Khatlon Region

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THNA provided kitchen utensils to support peer education activities at schools in the 12 districts of Khatlon Region. The cost of this in-kind sub-grant to the DOH was $1,439.28.

Sub-grant of print materials for district and regional HLSCs

THNA provided print brochures, posters, and banners to support the district and regional HLSCs. The cost of this in-kind sub-grant to the DOH is $4,033.30.

COORDINATION WITH OTHER FTF ACTIVITIES

In Y5, THNA coordinated its activities with the WHO, UNICEF, WFP, and other development partners and donors. Together with UNICEF and the WHO, THNA supported the TWG at the MOHSPP on developing the nutrition pyramid (Activity 4.1.2). Together with the WFP and UNICEF, THNA monitored children with malnutrition in the 12 districts at the hospital, PHC, and community levels. In Q3–Q4, THNA coordinated its efforts with the WHO, UNICEF, and other development partners and donors to disseminate SBCC materials on COVID-19 prevention, as well as PPE for frontline HCWs.

COMMUNICATION AND KNOWLEDGE MANAGEMENT

In Y5, THNA disseminated SBCC and IEC materials, as well as clinical practice guidelines, including those on COVID-19 prevention and treatment.

IEC materials for community volunteers THNA disseminated the following IEC materials. • 12,100 copies each of posters on the danger signs for mothers and children and rehydration were produced, as well as the healthy nutrition map and vitamin A banners that were redesigned as posters; • 14,380 copies each of brochures on diarrhea and helminths, 24,200 copies of posters on the benefits of iodized salt, and 24,500 copies of the WHO’s “Five Keys to Safer Food” manual were produced for CHP/CEs and teachers to use for educational sessions at 12 district schools; for 108 community events on exclusive breastfeeding; for household visits; and for 24 community health fairs; • 1,080 copies of brochures on sanitation and marketing were produced, as well as 34,100 flyers on the same topic; • 13,180 copies each of posters on handwashing, infection prevention (the “5 Fs”), and safe drinking water were produced for 73 WASH events (60 in the community and 13 in schools), as well as 13,600 copies of brochures on anemia prevention for 108 exclusive breastfeeding community events in the 12 districts; • 2,000 copies of the brochure on instructions for using the MUAC tape were produced for the GMP campaign in the 12 districts; • 1,500 copies of the recipe book for women of reproductive age and children aged six to 24 months were produced and presented to teachers at 12 district schools to

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support peer education activities and were also disseminated to district coordinators, their assistants, and new CHP/CEs to use in cooking demonstrations; • 15,000 copies each of new posters on women’s anemia and the causes of worms among children were developed, tested, and printed for all 12 districts as part of SBCC activities, as well as another 15,000 copies of new brochures on composting as part of household budgeting and hygiene activities; • 2,000 DVDs were produced and distributed to CHPs/CEs to support the integration of nutrition messages into agriculture-focused programs during Y5. The volunteers are using these DVDs during trainings, household visits, and community events. The DVDs include 15 videos and one mp3 audio file on the following topics:

o Iodized salt promotion (a THNA-produced informational video) o Complementary feeding (four THNA-produced tutorial videos) o Nutrition for pregnant women and adolescent girls (four THNA-produced tutorial videos)

o The value of breastmilk (an mp3 jingle/song) o Safe toilets and drinking water (THNA-produced animated videos) o Cattle hygiene, farming, and breastfeeding (animated videos from partner organizations); • 25 copies of banners (1 x 1.2 m2) on the benefits of breastfeeding were provided to CEs and teachers at 12 district schools to use in educational sessions; • 15,000 copies each of brochures in Tajik on household budgeting and crop rotation, as well as 15,000 copies of the poultry care guidebook were printed and presented to CEs for further dissemination and use in educational sessions; and to support teachers in 12 district schools in running peer education activities, as well as for distribution at WASH events in the 12 districts; • 45 banners (1 x 1.2 m2) on crop rotation; irrigation; crop families; vitamin A; the nutrition pyramid; the healthy nutrition map; the storage, safety, and usage of drinking water (three banners per topic); as well as infection prevention (the “5 Fs”) and the benefits of iodized salt (12 banners per topic) were provided to CEs and teachers in 12 district schools to use in educational sessions; • Two copies each of banners (2 x 3 m2) on the storage, safety, and usage of drinking water and the benefits of iodized salt were produced for 73 WASH events (60 in the community and 13 in schools), as well as two copies of banners (2 x 3 m2) on breastfeeding benefits for 108 community events on exclusive breastfeeding in the 12 districts; • UNICEF brochures on food for pregnant women (25,400 copies), exclusive breastfeeding (26,780 copies), and complementary feeding (37,500 copies) were produced for CHPs and CEs to use in educational sessions, during monthly cooking demonstrations in the communities, and at 12 schools (reaching 43,200 participants who attended 3,600 cooking demonstrations until the end of Q3 of Y5);

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• 14,680 copies of brochures on “breastfeeding is the basis of life” and 13,480 copies of posters on breastfeeding benefits were produced for CHPs and CEs; • 1,000 copies of the WHO’s poster “Recommendations for citizens on reducing the risk of coronavirus infection”; • 10,000 copies of the WHO’s booklet “Keep yourself healthy”; • 23,000 copies of UNICEF’s posters and 10,000 copies of the booklet “Protect yourself and others from COVID-19”; • 2,000 copies of the collection of THNA success stories over five years in Tajik; • 350 copies of THNA technical briefs on the clinical QI collaborative and community volunteer SBCC interventions; and • 1,820 certificates of appreciation for THNA partners, HCWs, and community volunteers.

In Q1, THNA provided the following print materials to the regional and 12 district HLSCs through an in-kind sub-grant to the regional DOH: • 7,000 copies each of UNICEF brochures on food for pregnant women, exclusive breastfeeding, and complementary feeding; • 7,000 copies each of posters and brochures on handwashing, diarrhea, helminths, anemia, danger signs for mothers and children, sanitation and marketing, infection prevention (the “5 Fs”), and safe drinking water, as well as the WHO’s “Five Keys to Safer Food” manual; • 5,000 copies of the poultry care guidebook; • 120 copies of UNICEF’s instruction brochure on the IYCF flipbook; and • 52 banners (1 x 1.2 m2) on water storage, the nutrition pyramid, the healthy nutrition map, and vitamin A (13 banners per topic).

Clinical practice guidelines for health facilities The following clinical practice materials were also produced: • 1,000 copies of the MOHSPP’s guidelines for the prevention, diagnosis, and treatment of COVID-19; • 500 copies of the MOHSPP’s guidelines for the assessment, diagnosis, and treatment of COVID-19 (2nd edition from May 4, 2020, for the hospital level); • 500 copies of the MOHSPP’s procedures for the management of patients with signs of COVID-19 at the hospital level; • 1,200 copies of the MOHSPP’s procedures #1 and #2 for the management of patients with signs of COVID-19 at the PHC level; • 1,200 copies of the MOHSPP’s procedures for the management of patients with signs of COVID-19 at home;

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• 1,200 copies of the MOHSPP’s standard operating procedures for the prevention of COVID-19 at the PHC level; • 5,000 copies of guidelines on promoting, protecting, and supporting exclusive breastfeeding; and • 120 photo albums for trainers at nutrition resource centers.

Media publications

The following success stories, articles, and technical briefs were also produced: • A success story entitled, “Improving access to water, sanitation and hygiene in communities” on the VIP latrines installed at six schools and 114 PHCs was approved and published by USAID. • An article entitled, “The Future of Health in Tajikistan starts with Community Health Volunteers” on the role of community health volunteers was published on the IntraHealth International website. • An article entitled, “Tajik Community Health Volunteers Improve Nutrition, Maternal Health, and Agriculture for Thousands” on recruiting and training 1,300 health volunteers and 500 agriculture volunteers who provide families with health advice, agricultural skills, and necessary referrals was published on the IntraHealth International website. This article was written based on technical briefs summarizing the approaches and results of four years of work. • Another technical brief summarizing the approaches and results of four years of work entitled, “Collaborative Quality Improvement of Maternal, Newborn, and Child Health Services in Tajikistan” was published on the IntraHealth International website. • A success story entitled, “Community Health Workers are Tackling Malnourishment in Remote Tajikistan” was approved by USAID and published by IntraHealth International. • A success story entitled, “From Fearful to Confident” about a doctor from rural Khatlon Region who has become a THNA trainer at one of the nutrition resource centers was published by USAID. • An end-of project press release was published by USAID.

ENVIRONMENTAL COMPLIANCE

In Q1, THNA provided one in-kind sub-grant of water pumps and water tanks for 12 PHC facilities (described above in the sub-grants section of this report), to which a Negative Determination with Conditions apply with environmental impact mitigation and monitoring plans completed and submitted to USAID in Y4.

Under the sub-grant to install VIP latrines in 100 selected medical centers (Activity 7.11. in the Y4 plan), THNA provided the last set of construction elements for underground structures (concrete rings and slabs) and materials for above-ground parts of VIP latrines (doors, cement blocks, cement, sand, and other construction materials) to 38 PHCs in rural areas of Khatlon

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Region (see ERC-002-4 and ERC-002-5). Also under this sub-grant, THNA provided construction materials (cement blocks, cement, sand, doors, formwork boards, and other construction materials) and the blueprint for the construction of eight-person VIP latrines at Shahritus district CDH (see ERC-015).

In accordance with requirements under Section A11, Environmental Compliance of the cooperative agreement, in Y5, THNA completed and submitted to USAID 14 progress reports on Environmental Review Checklists (ERCs, Table 14).

Table 14. Environmental compliance progress reports submitted to USAID in Y5 Activity Date ERC approved Date progress report approved 7.8. Sub-grant to provide water supply for the maternity and pediatric departments Feb. 27, 2019 Nov. 12, 2019 of Dusti CDH, ERC-001 7.11. Sub-grant to install VIP latrines in 100 selected medical centers 25 sites, ERC-002-1 Feb. 1, 2019 Dec. 13, 2019 25 sites, ERC-002-2 Apr. 10, 2019 Jan. 7, 2020 25 sites, ERC-002-3 May 21, 2019 Feb. 11, 2020 25 sites, ERC-002-4 Jul. 30, 2019 Mar. 28, 2020 14 sites, ERC-002-5 Aug. 26, 2019 Shahritus district, ERC-015 Aug. 29, 2019 Mar. 27, 2020 7.17. Sub-grant to install VIP latrines and water reservoirs in six schools in Khatlon Mar. 29, 2019 Feb. 11, 2020 Region, ERC-003 7.13. Sub-grant of water pumps and water tanks for 12 PHC facilities Khuroson district, PHC, ERC-005 May 30, 2019 Site visit planned before approval Qabodiyon district, rural PHC, ERC-007 Jun. 4, 2019 Site visit planned before approval Yovon district, CDH, ERC-013 Jul. 1, 2019 Site visit planned before approval Yovon district PHC, ERC-006 Jun. 4, 2019 Feb. 21, 2020 Levakand district, rural PHC, ERC-010 Jun. 13, 2019 Feb. 21, 2020 Khuroson district, CDH, ERC-012 Jul. 1, 2019 Mar. 16, 2020 Jaikhun district, PHC, ERC-004 May 28, 2019 Jul. 21, 2020 Jomi district, PHC, ERC-009 Jun. 12, 2019 Not available Kushoniyon district PHC, ERC-014 Jun. 26, 2019 Not available

By the end of Y5, two WASH projects remain incomplete by local recipients of in-kind sub- grants at the PHCs of Jomi and Kushoniyon districts (ERC-009 and ERC-014, respectively). THNA provided these facilities with building materials: the 10 m3 water storage tank, all materials for the construction of a 12.5 m-high water tower, a water pump, and engineering blueprints. All construction works had to be carried out by health facilities, as no construction

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activities are allowed under Section C24, Limiting Construction Activities, of THNA’s cooperative agreement.

Because construction activities relied on partners’ financial resources, the construction process was suspended due to the MOHSPP’s instructions to spend all available funds for the procurement of medical supplies for COVID-19, such as PPE for HCWs and disinfectants.

The Kushoniyon district PHC is nearing completion of its construction. Remaining tasks include completing the painting of the tower, insulating and painting the tank, and connecting the tank to the water supply system of the PHC. In the Jomi district PHC, the foundation of the tower is not yet completed due to management issues. Thus, these two WASH projects under Activity 7.13 will remain incomplete at the end of THNA.

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LIST OF ANNEXES

Annex 1. Activity implementation progress

Annex 2. Presentations from THNA final conference

Annex 3. THNA progress toward Y5 targets

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Annex 3. THNA progress toward Y5 targets Progress Purpose FY20 Quarterly achievements FY20 Q-ly toward / Indicator target target Q1 Q2 Q3 Q4 annual Output target HL.9-4: Number of individuals receiving Output nutrition-related 2,868 3,414 2,584 480* (IR 1, 2, 2,500 833 374% professional training (344%) (410%) (310%) (58%) & 3) through USG-supported programs HL.9-1: Number of children Output under five reached by USG- 71,910 65,473 32,023 (IR 2 & 173,000 57,666 * 98% supported nutrition (125%) (91%) (56%) 3) programs HL.9.2: Number of children under two (0-23 months) Output reached with community- 22,065 23,045 5,249 (IR 2 & 64,000 21,333 * 79% level nutrition interventions 103% 108% (25%) 3) through USG-supported programs EG.3.2-24: Number of individuals in the agriculture Output system who have applied 240,000 n/a n/a n/a n/a ** n/a (IR 2) improved management practices or technologies with USG assistance HL.6-1: Estimated potential Output beneficiary population for 17,413 7,426 11,554 (IR 2 & maternal, newborn and 36,000 12,000 * 101% (145%) (62%) (96%) 3) child survival program: number of live births HL.6.3-63: Number of newborns who received Output 17,413 7,426 11,554 postnatal care within two 28,000 9,333 * 130% (IR 1) (187%) (80%) (124%) days of childbirth in USG- supported programs Output HL.9.3-1: Number of (linked pregnant women reached 24,207 24,825 18,171 to with nutrition interventions 78,000 26,000 * 86% (93%) (95%) (70%) Result 1, through USG-supported 2, & 3) programs HL.6.6-1: Number of cases Output 2,436 2,126 7,853 of diarrhea treated in USG- 20,000 6,667 * 62% (IR 3) (37%) (32%) (118%) assisted programs HL.6.2-1: Number of women Output 17,431 7,449 11,571 giving birth who received 35,000 11,667 * 104% (IR 1) (149%) (64%) (99%) uterotonics in the third

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stage of labor through USG- supported programs HL.8.2-2: Number of people Output gaining access to a basic 10,702 29,274 33,000 11,000 * * 121% (IR 3) sanitation service as a result (97%) (277%) of USG assistance EG.3.3-10: Percentage of female participants of USG Output nutrition-sensitive 92% n/a n/a n/a n/a ** n/a (IR 2) agriculture activities consuming a diet of minimum diversity Output EG.3.2: Number of 159,963 188,857 82,185 (IR 2 & individuals participating in 540,000 180,000 * 80% (89%) (105%) (46%) 3) USG food security programs * No activities planned in the Annual workplan. ** Annual surveys not implemented due to the COVID-19 pandemic

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