JSI Research & Training Institute, Inc. (JSI) * Helen Keller International (HKI) * International Food Policy Research Institute (IFPRI) * Save the Children (SC) * The Manoff Group (TMG)

Quarterly Report October 1, 2013 – December 31, 2013 Cooperative Agreement Number: AID-OAA-A-11-00031 February 14, 2014

The Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) Project is supported by the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-OAA-A-11-00031. SPRING is managed by JSI Research & Training Institute, Inc. SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Contents

I. Quarter 1 Report Highlights ...... 1 II. PY3 Activity Matrix ...... 2 III. PY2 Activity Matrix ...... 12 IV. Country Updates ...... 15 A. SPRING/Bangladesh Program Implementation ...... 15 B. SPRING/Haiti Program Implementation ...... 22 C. SPRING/Nigeria Program Implementation ...... 29 D. SPRING/Uganda Program Implementation ...... 32 V. Knowledge Management ...... 49 VI. Operations, Finance, and Management ...... 51 VII. Monitoring and Evaluation ...... 54 Appendix 1: Quarter 1 Travel ...... 69 Appendix 2: Performance Monitoring Plan and Progress Tracking ...... 72 Appendix 3: SPRING Website Activity and Outreach ...... 74

iii SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

iv SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

I. Quarter 1 Report Highlights

During the first quarter (Q1) of project year three (PY3), SPRING solidified the project’s technical agenda, expanded the scope of operations to new locations, grew in staff at headquarters and country offices, and revamped the project management structure.

This report details progress during the October-December 2013 period and is organized as follows: • Section II contains a table, “PY3 Activity Matrix,” reporting on SPRING’s portfolio of core-funded initiatives by the PY3 work plan focus areas: (1) anemia, (2) social and behavior change communications, (3) nutrition systems, (4) agriculture and nutrition, (5) the Sahel, and (6) general technical assistance. • Section III is a similar table, “PY2 Activity Matrix,” reporting on seven activities which carried over into this quarter from PY2. • Section IV contains detailed reports from SPRING’s four Mission-funded country programs in Bangladesh, Haiti, Nigeria, and Uganda. These reports offer narratives, photos, and data detailing each country’s current progress. • Section V covers SPRING’s knowledge management activities. • Section VI addresses the project’s operations and management and provides a quarterly financial report of expenditures (by activity, month, and funding source) and obligations. • Section VII and three appendices provide monitoring and evaluation (M&E) information for the quarter, covering both core and country achievements, according to the indicators from SPRING’s performance monitoring plan (PMP).

Numbers alone cannot tell the whole story, of course, but in Q1 SPRING carried out 33 assignments in 11 countries; trained nearly 400 people; reached over half a million people through social and behavior change communication (SBCC) activities; produced 19 documents, tools, and reports; conducted three webinars; increased social media presence by 40%; and received over 10,000 unique page views to SPRING webpages. The project continues to grow in size, scope, and reach, and looks forward to continuing to do so in support of the imminent launch of USAID’s new nutrition strategy.

1 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

II. PY3 Activity Matrix

Initiative Initiative Name Activity Updates and Status Number FOCUS AREA 1: ANEMIA 1.1 Demonstrated effectiveness of In October 2013 SPRING held a National Anemia Stakeholders Workshop in Uganda in targeted, integrated anemia partnership with the Ministry of Health (MOH) to discuss and develop consensus programming process in 2 countries around the factors that contributed to the 2001-11 reduction in the prevalence of anemia. The workshop brought together over 100 actors from the various sectors and provided them an opportunity to review the evidence around the coverage of anemia prevention and control programs in Uganda in the past decade. During the workshop stakeholders also began the development of an action plan on “key intervention” areas based on available evidence and local knowledge and experiences as discussed around contextual factors in a transparent and informed manner. Following the workshop, a National Anemia Technical Working group was revitalized and tasked with revising the Anemia Policy of 2002 and tracking the progress of the action plan developed during the Stakeholders’ Workshop. The Commissioner of Community Health was appointed as the chair to the working group and to the Ministry of Health’s nutrition unit as the Secretariat.

Manisha Tharaney and Laird Ruth also traveled to Uganda this quarter to participate in the second National Micronutrient Technical Working Group meeting. The workshop was attended by 36 participants that ranged from MOH, academia, UN agencies, USAID and its in-country partners, and other local and international NGOs.

In Q2 of PY3, SPRING will continue to support the MOH in monitoring the progress around commitments made in the action plan, as well as the Anemia Consultative Group in developing a policy around Delayed Cord Clamping, as this was identified as a key action in the Anemia Action. SPRING will finalize the formative research protocol and tools for the MNP program in Uganda. Next quarter, SPRING will initiate dialogue with the MOH, the Scaling Up Nutrition (SUN) focal person, and USAID focal

2 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

persons in Sierra Leone to identify their technical needs around anemia. Finally, the Multi-Stakeholder Action Plan will be finalized in Q2.

1.2 Increased access to anemia-related SPRING is collaborating with the SUN secretariat in PY3 to develop a template for a technical resources and data at global Country Anemia Dashboard to provide information to policy makers and program and country level managers on the multiple causes of anemia in an organized manner. In December 2013, SPRING and USAID held a call with the SUN secretariat to discuss the outline of the dashboards. The dashboards will be modeled after the Countdown to 2015 Maternal, Newborn and Child Health country profiles. The dashboards will present the status of key national level anemia-related indicators, as well as information on the anemia- related policy and programming in a country. The dashboards will be used to compare anemia prevention and control program progress and commitments across countries. The templates will be populated by a research analyst from the SPRING project with data from DHS, MICS, and other surveys under the guidance of the consultants in the next quarter.

1.3 Increased commitment and buy-in to SPRING supported the organization of the Multisectoral Anemia Partners Meeting that targeted anemia programming at was held in partnership with USAID and the Anemia Task Force Secretariat on October country and global levels 18, 2013. The objectives of the meeting were to share frameworks and evidence to guide integrated approaches to anemia prevention and control; to share/explore best practices and lessons learned in multisectoral anemia programming in selected countries; to identify opportunities for integrating anemia prevention and control activities into existing programs and to identify opportunities for further integration at global and country level. The workshop was attended by over 75 participants representing USAID and various partner agencies.

In addition, SPRING actively engaged in supporting the planning and organization of the Micronutrient Forum (MN) to be held in Ethiopia in June 2014. SPRING reviewed 63 abstracts submitted to the organizers of the MN Forum and made recommendations for the abstracts to be presented as posters or oral presentations. SPRING developed a concept note to support two symposia - one on HCES and another on anemia at the MN forum. In Q2, SPRING will finalize the anemia symposium for the MN forum.

3 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

FOCUS AREA 2: SOCIAL AND BEHAVIOR CHANGE COMMUNICATIONS FOR MIYCN 2.1 Enhanced evidence for promising In India, SPRING worked with Digital Green (DG) to outline and design the toolkit which SBCC delivery strategies will correspond with an ongoing virtual training institute initiative. SPRING also worked closely with IFPRI to finalize data collection protocols and tools for the feasibility study, tracked data collection progress, and participated as interviewees. The results of the feasibility study have been undergoing analysis by IFPRI in this last quarter and results are expected by the end of Q2.

In collaboration with partners, provide technical support to scale up of the SPRING/DG model in India, secure funding to conduct an impact evaluation of the SPRING/DG model in India, and provide technical support in the design and implementation of the impact evaluation (if funded): At the start of Q1, SPRING worked closely with IFPRI, DG, and other partners to develop a letter of interest for funding for an impact evaluation under Grand Challenges India led by the Department of Biotechnology (DBT) of India, its Biotechnology Industry Research Assistance Council (BIRAC), and the Bill & Melinda Gates Foundation. In December, SPRING was notified that the LOI was considered for submission of a proposal for the smaller Intervention Development Grant (IDG) rather than a larger Transition to Scale and Impact grant and the partners were requested to submit a proposal to test the feasibility of the innovative intervention to better understand the agriculture-nutrition-health linkages. SPRING remains engaged with DG to provide technical support for scale-up of the model in Keonjhar and plans to travel to India in Q2 to assist with nutrition trainings for local staff.

Support adaptation, implementation, and evaluation of the SPRING/DG model in one additional country context - Bangladesh (contingent upon Bangladesh Mission approval): Given the uncertainty and risk due to the political situation during Q1 in Bangladesh, all travel was on hold which stalled the design of implementation plans to incorporate the SPRING/DG model within the SPRING program in Bangladesh. This work is expected to move forward towards the end of Q2 and during Q3.

Evaluate the impact of the UNICEF Community-IYCF counseling package in Nigeria

4 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

(Year 1 of 3): During this quarter, SPRING initiated a partnership with UNICEF/New York to evaluate and document the effectiveness of UNICEF’s Community IYCF Counseling Package in Nigeria. While in country in November, SPRING Technical Director, Toby Stillman, held two meetings with UNICEF/Nigeria and SPRING/Nigeria staff to discuss plans for the collaboration and evaluation. SPRING/HQ and UNICEF/New York had a subsequent call in December to plan for a scoping visit, brainstorm possible Principal Investigators for the evaluation, and discuss the Memorandum of Understanding (MOU). The scoping visit has been planned for mid-February. In the meantime, progress has been made on a concept note and draft protocol, which is expected to be submitted to USAID at the end of Q2.

Finalize and disseminate results of the SBCC literature review: SPRING concluded a literature review exploring the effectiveness of various SBCC delivery platforms in increasing uptake of high impact MIYCN practices. The need for further analysis of findings and extensive revision has delayed submission. A near final draft was shared with SPRING’s AOR and approved for very limited distribution to the Working Group for the SBCC Symposium being planned collaboratively by USAID (with SPRING) and GAIN.

Document and disseminate evidence related to optimal dietary practices of pregnant and lactating women and women of reproductive age: This quarter SPRING received a draft of the first of two reviews – focused on programmatic experience in addressing dietary needs of women of reproductive age. SPRING is currently reviewing the draft. SPRING also finalized contractual arrangements with the Consultant Laura Caulfield of Johns Hopkins School of Public Health for the review of published literature on efforts to address dietary needs of women of reproductive age. 2.2 Explore the potential of SBCC Please refer to Initiative 4.1 under the Improving Nutrition through Agriculture focus approaches in promoting the area for information on this activity. adoption of nutrition-sensitive behaviors 2.3 Enhanced communication and Lead or provide substantial technical input to key SBCC-related networks: SPRING co- exchange of knowledge at country hosted the MIYCN-FP Working Group meeting on October 22nd, held at MCHIP’s office and global levels and is preparing to host the next meeting of the working group in Q2 at JSI. SPRING is also contributing to the development of an illustrative MIYCN-FP Behavior Chart

5 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

(outlining the behaviors, audiences, determinants, and potential activities for behaviors that integrate MIYCN and FP) that will be a deliverable of that working group in the coming year. The team continues to participate in other SBCC related working group calls and efforts including the SBC Task Force and CORE SBCC Working Group.

Support a global SBCC Symposium and conduct one web-based knowledge learning exchange: During Q1, USAID approached SPRING to be its implementing partner in a collaborative effort with GAIN to convene a working group of SBCC thought leaders and nutrition thought leaders to develop a strategic research and implementation agenda for the next 10 years. In December SPRING began participating in weekly coordination calls with GAIN and USAID, refined the terms of reference for the expert working group, and supported recruitment of working group members. In Q2 participation in calls will continue, and SPRING will take the lead in planning and hosting a day-long strategy session for the working group.

SPRING has continued to consult with USAID on the direction of an e-learning initiative by providing an addendum to the Landscape Analysis submitted in PY2 further outlining potential directions for the e-learning approach and then submitting suggested topics for one e-learning webinar for PY3. In Q2, the topic for the webinar will be finalized and curriculum development will be initiated.

Provide focused TA for the development of a multi-sector SBCC strategy in Uganda and up to one additional country: Marcia Griffiths and Ashley Aakesson traveled to Uganda in October 2013 to initiate support to the Office of the Prime Minister in the development of the Social Change and Mobilization Sub-strategy of the National Nutrition SBCC and Advocacy Strategy and assist with recruiting an SBCC Project Officer who will be seconded to the OPM for 12 months starting in January 2014. In November and December Ms. Griffiths and Ms. Aakesson began drafting a review of Social Change and Mobilization experience in Uganda as well as the sub-strategy document. In Q2, Ms. Griffiths and Ms. Aakesson will travel to Uganda for a partners meeting to review the draft sub-strategy and agree on a process for pulling together and finalizing the National SBCC and Advocacy Strategy. They will work with Kenneth Mulondo, the SBCC Project Officer, to develop a work plan for his secondment to OPM.

6 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

FOCUS AREA 3: NUTRITION SYSTEM STRENGTHENING 3.1 Increased USAID and global SPRING held initial internal meetings during Q1 to plan for the launch of this new understanding of a nutrition “system” activity area. As a first step, Dr. Jessica Fanzo, of the Institute of Human Nutrition at (in particular the interface between Columbia University, was invited to speak on “Strengthening the engagement of food health and food systems) and its and health systems to improve nutrition security: Innovative and equitable solutions to relevance for programming address malnutrition” (presentation was in January 2014).

In PY2, SPRING developed a draft tool to assess characteristics of a country’s nutrition workforce and applied it in Haiti. In Q1 of PY3, SPRING continued revising the tool for application in at least one more country. The work in the second country will be used to finalize and disseminate generic guidance as a blueprint for interested countries to use this tool autonomously. The guidance will provide detailed information on how to map the workforce, how to analyze data collected, and how to summarize and disseminate findings. The guidance will also provide suggestions for countries to plan and produce workers for promotional-preventive nutrition actions using a “needs-based” approach.

In an effort to document experiences and evidence on the most effective ways to roll- out or scale-up trainings related to nutrition counseling skills, SPRING is conducting operations research to evaluate the success of SPRING/Haiti's on-the-job training (OJT) methodology for improved nutrition counseling and support at the facility level. During Q1 of PY3, SPRING/HQ along with SPRING/Haiti finalized the protocol, requested approval from JSI's and Haiti's Institutional Review Boards (IRB), and pre-tested the data collection tools for interviews and observations of client-provider interactions. A small team of data collectors (Ministry of Health departmental Nutrition Focal Points) will be trained and data will be collected in SPRING/Haiti's seven new PY3 health facilities in January 2014. Tools for the research were based on the standardized toolkit of Nutrition Assessment, Counseling, and Support (NACS) facility assessment tools developed by SPRING in PY2 and described below under PY2 activity 3.3.

In Q1 of PY3, USAID provisionally approved the first phase report of the results of the SPRING Early Life Nutrition Linkages to Noncommunicable Disease (ENL-NCD) Model. Final approval and dissemination will occur after SPRING meets with Dr. Ariel Pablos-

7 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Méndez in February 2014. Two additional NCD profiles were submitted for approval to USAID in Q1, for Haiti and Uganda. 3.2 Increased application of evidence in During Q1, SPRING developed a draft outline of this activity to assist with planning and nutrition scale-up processes potential dissemination strategies. Three dissemination options (report, infographic, and video) were developed for presentation to USAID for discussion (meeting held in January 2014). After determining the scope and focus of the research questions, potential information sources, and a dissemination plan, implementation of the activity will begin.

The SPRING Pathways to Better Nutrition (PBN) Case Studies team successfully gained IRB approval and conducted baseline national-level data collection during Q1 in Kampala, Uganda. With the guidance and approval of the Office of the Prime Minister, and in collaboration with REACH, UNICEF, and Tufts University, the PBN team traveled to Uganda and conducted over 20 interviews with stakeholders from the SUN stakeholder groups and accessed necessary budget data to begin analysis for the two- year study. In addition, global level interviews in preparation for the Nepal case study were initiated and steps were taken toward IRB submission in Nepal. FOCUS AREA 4: IMPROVING NUTRITION THROUGH AGRICULTURE 4.1 Increased access to evidence SPRING completed a literature review on social and behavior change theory and supporting measurable outcomes practice from multiple disciplines and sectors, as well as identified common elements of conceptual frameworks and design monitoring and evaluation tools. This was a key first step to inform the development of the outline of an "ag-friendly" toolkit for improving nutrition-sensitive behaviors in agriculture projects. SPRING also compiled a list of specific nutrition-sensitive behaviors to inform a white paper and external stakeholder consultation process which will provide the conceptual framework and context for the toolkit.

The draft landscape analysis completed for the AgN-GLEEs helped SPRING to identify projects which have been integrating nutrition by training agriculture frontline workers to deliver nutrition-specific SBCC messages. In Q2, the team will develop protocols for two field studies/briefs that will survey the processes and approaches supporting this

8 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

common strategy, including collecting data in at least one country, likely Ethiopia.

SPRING held meetings with members of USAID’s WASH team to better understand the potential gaps that SPRING may fill in this field. SPRING is now identifying potential areas of collaboration with WASHPlus and following up to better understand better practices in order to share key examples of successful integration of WASH in projects that support nutrition outcomes. 4.2 Increased capacity to apply evidence- SPRING drafted a series of four desk briefs in Q1, the first of which describes the based knowledge and practice pathways and principles that served as the conceptual frameworks for the Landscape Analyses underlying the AgN-GLEEs. The additional three briefs each highlighted one of the pathways and used vignettes to illustrate how current Feed the Future activities feature each pathway. Initial consultations were held with USAID to determine and define the scope of SPRING’s assistance to Feed the Future Missions in developing, clarifying, and/or defining appropriate nutrition-sensitive indicators.

Collection criteria for identification and summation of key context assessment tools were established and progress toward collecting these has begun. Over 50 prospective context assessment guides/tools have already been reviewed for potential inclusion in the proposed interactive context assessment toolkit. In Q2, a consultant will be hired to support the completion of this work.

No technical assistance (TA) to USAID missions took place in Q1. However, a visit to Ethiopia by SPRING staff produced a preliminary set of possible TA activities that are currently under Mission review and may begin in Q2.

In support of Feed the Future's Learning and Evidence Exchange agenda, SPRING hosted three agriculture-nutrition webinars in Q1 with a combined attendance of over 223 people that helped SPRING increase its targeted Agriculture-Nutrition dissemination list to close to 1,000 individuals. In addition, SPRING hosted an online discussion forum through the Agrilinks AgN-GLEE Group that garnered 382 page views and partnered with the USAID KDAD project in a post-webinar #AgEvents Twitter chat that included an additional 15 organizations sharing 22 resources on low-cost video for agriculture.

9 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

4.3 Improved enabling environment for SPRING started mapping USAID’s centrally-funded nutrition-sensitive nutrition-sensitive investments/activities in close collaboration with a BFS staff-person. A mock-up of what approaches/interventions a database of this information could look like (hosted on the SPRING website) was developed and shared with BFS and GH colleagues. Interviews of USAID staff for data collection will be completed during Q2.

SPRING solidified the timeline for the consultant developing a review of literature and research related to the food system, with completion of this output during PY3. The chapter for Advances in Food and Nutrition Research is underway. FOCUS AREA 5: THE SAHEL 5.1 Develop a strategy, targeted SPRING conducted several scoping visits to both Niger and Burkina Faso. Immediately messaging, and corresponding following the REGIS-ER award to NCBA CLUSA on November 15, 2013, SPRING began communication and training tools to actively engaging with them, other key stakeholders in both countries, and USAID, to increase adoption of key MIYCN refine SPRING’s objectives. During the TDY in November, SPRING collected information practices and services in Burkina Faso about existing nutrition, food security, and resilience programing, as well as materials, and Niger (REGIS-ER) messages, and methods to support the design and initial execution of the SBCC work, which will ultimately support the development of the REGIS-ER project’s nutrition and hygiene-related SBCC strategy and activities. The SPRING-supported SBCC landscape analysis, which will be finalized in Q2 and is already guiding SPRING’s inputs and feedback on the REGIS-ER PY1 work plan, and the proposed design of an overarching REGIS-ER SBCC strategy focusing on MIYCN and hygiene in this resilience context.

SPRING is currently finalizing a two-year work plan and corresponding budget, defining both long-term and short-term technical assistance needs and an STTA plan based on these objectives. Active recruitment is underway. FOCUS AREA 6: GENERAL TECHNICAL ASSISTANCE 6.3 General Technical Assistance SPRING completed an assessment for USAID/Tajikistan to better understand and document Feed the Future implementing partners’ approaches, effectiveness, and consistency in messaging across all elements of the Feed the Future initiative, including agriculture, nutrition, water, and policy. The assessment included an analysis of media, information communications technologies (ICT), and behavior change messaging

10 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

approaches across the portfolio. During Q1, SPRING finalized a desk review, which synthesizes the communications-related findings from project documents and interviews and identifies the various communication channels that activities use to reach target beneficiaries and how nutrition messages are structured through those channels. Key findings and recommendations from the desk review helped to shape follow-on actions, including a field visit in October 2013 for SPRING to meet with implementing partners, visit the zone of influence and structure the scope of work with a national consulting firm hired to undertake additional field-based qualitative surveys. SPRING’s national consultant partner, M-Vector, carried out a survey to determine the extent to which health and nutrition messages delivered through a range of channels, especially via television and radio, have been reaching beneficiary populations. They also researched cost information for television and radio spots for project implementers and determined how media organizations in Khatlon sustain their programming. A draft of their report was completed in Q1 and includes a summary of SPRING’s findings on use of mass media for communication in the Zone of Influence. Finally, SPRING led a two-day workshop in December 2013 for Feed the Future project staff across the portfolio. The workshop served to increase participants’ knowledge and understanding of behavior change by building skills and sharing better practices. A workshop report was also completed during the quarter. Next quarter SPRING will submit the final report.

11 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

III. PY2 Activity Matrix

Seven activities from SPRING’s PY2 work plan carried over into PY3; this section updates the status of that work. Activity Activity Name Activity Updates and Status Number 3.1 Analysis of IFA provision and consumption At the end of PY2, SPRING submitted a package of technical briefs to USAID on across high-burden countries the distribution and consumption of iron-folic acid (IFA) through antenatal care programs in 21 countries, as well as one overview brief. In December 2013, SPRING received feedback on all briefs from USAID, and resubmitted the Kenya and Rwanda documents, addressing USAID’s comments. Further comments were received on the revised Kenya and Rwanda briefs, which now serve as a “model” for all briefs going forward. SPRING intends to finalize all 21 briefs plus the overview during Q2 PY3. Additionally, a journal article summarizing the findings of the IFA analyses across countries was developed, which will be completed and submitted to Public Health Nutrition in Q2 of PY3. 3.3 TA to strengthen HIV/Nutrition assessment Based on SPRING’s experiences evaluating NACS through facility assessments in and integration of services Haiti and Uganda, the project developed a compendium of tools that could be used in a variety of settings to assess NACS implementation. These tools will be useful to SPRING whenever future NACS assessments are called for, and they may also eventually be of interest to the broader nutrition community. The suite of tools and related documents (overview, key indicators, interview guides, checklists, observation guides, etc.) was submitted to USAID on October 11, 2013, and brief verbal feedback from USAID was received. SPRING will follow up with USAID in Q2 of PY3 to ensure that we are able to finalize the toolkit and determine next steps. 4.2 Develop and test strategies to streamline The Qualitative Study on Motivation to Produce, Sell, and Consume Homestead the integration of nutrition and hygiene Food Production Goods provided insight into the factors that motivate interventions within Ag projects households in Bangladesh to grow nutrient-dense foods, consume the nutritious foods that they produce rather than sell them, and when people go to the market to purchase foods of higher nutritional value. Tom Schaetzel presented

12 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

the results and proposed recommendations with SPRING in September 2013. With the study report completed this quarter, several findings emerged: men have a vague notion of what nutritious foods actually are, but are committed to buy the right foods for their wives and children. There is also social pressure associated with buying certain foods considered to be “cheap” foods, such as green leafy vegetables, which have a negative association regardless of their nutritional value. Sweets are usually bought for children as they are easy to buy (widely available and cheap), provide immediate happiness for the child, and reward the father as he’s perceived as a “good father.” Recommendations for further engaging men will build on these ideas of rewards and happiness. Findings also show that couples have well defined roles in term of decision- making in production, consumption, as well as selling and buying; women are in charge of all homestead food production and are highly motivated when seeds are provided and when methods are taught by demonstrations. Conclusions and recommendations from this research will be the foundation of further SBCC activities in Bangladesh, in particular building the communication components targeting men’s and couple’s decisions related to food production and consumption, and market purchases.

Final reports of the findings are under review and will be available in Q2. 4.3 TA to strengthen use of HCES to design, In October 2013, SPRING participated in a two-day workshop for the ECSA estimate impact, and monitor nutrition Technical Working Group on Monitoring and Evaluation in Kampala, Uganda to discuss and explore opportunities to introduce a fortification monitoring module into current or planned surveys and to agree on standard indicators. Though the workshop was a fortification-specific application of Household Consumption and Expenditure Surveys (HCES), it gave explicit recognition of the need to repurpose HCES to make them more attuned to countries’ food and nutrition information requirements and more relevant in helping improve our understanding of the food-nutrition-agriculture nexus in many countries. SPRING also gave two presentations on the application of HCES in estimating food fortification vehicle coverage and intake at the Smarter Futures/Flour Fortification Cost and Economic Benefit Training Workshop in Dar es Salaam, Tanzania in December 2013. In addition, a SPRING paper (in collaboration with HKI/Africa partners) on

13 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

the current status and challenges of food fortification in Africa was published in Sight and Life Magazine.

Initial analysis of a variety of nutrition indicators at the household/individual and national/subnational levels was conducted using the 2011/12 Bangladesh Integrated Household Survey. A comparative analysis to be conducted next quarter will include the Bangladesh 2010 Household Income and Expenditure Survey and provide insights into how to improve the HCES as a tool for understanding food and nutrition issues, in Bangladesh and other countries. An abstract for this work, another HCES paper, and an HCES panel were submitted to the Micronutrient Forum (Ethiopia, June 2014). 4.4 Research study on integration During Q1, Aaron Buchsbaum and Jody Harris designed a series of qualitative interview questionnaires to facilitate a five-day qualitative interview training in Burkina Faso from October 21-26, 2013. These efforts supported IFPRI-led research examining the importance of cross-sector coordination in implementing agriculture-nutrition projects, and looked specifically at communication structures in Helen Keller International's 'Enhanced Homestead Food Production' activity (2009-2012). During Q2, SPRING will analyze the field interviews and finalize the first draft of the report. 6.1 TA to strengthen complementary feeding SPRING completed the internal strategy paper, and it is currently under review. programs in selected SPRING countries In Q2 of PY3, the paper will be used for further discussions with USAID and help to define SPRING’s work in this area. 6.3 Definition of theoretical impact pathway of This deliverable was submitted to USAID on November 5, 2013. SPRING is MCH practices awaiting USAID’s comments.

14 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

IV. Country Updates

A. SPRING/Bangladesh Program Implementation

I. Introduction

SPRING/Bangladesh doubled its population coverage going into PY3 but is maintaining its same geographic coverage through 40 upazilas, or subdistricts. Ongoing violence and political instability have unfortunately marred the project’s ability to fully execute its work over this performance period. Supportive supervision visits and activities requiring medium- to long-distance travel were particularly impacted during this period. SPRING/Bangladesh was nonetheless able to continue its work at the community level; it was only in a small number of upazilas that SPRING’s work at that level was disrupted. Despite the political instability, SPRING/Bangladesh was able to successfully establish all of its new PY3 farmer field schools (FFS) and distribute winter seeds in time to all FFS participants. Moving into 2014, the political situation remains unclear and increasingly unstable, and SPRING/Bangladesh will closely monitor the situation and do its best to maintain the highest degree of efficiency in its work. Any significant disruptions or delays will be brought to the attention of USAID in a timely fashion. II. Key programmatic activities performed and achievements

In Q1 of PY3, SPRING/Bangladesh established 2,560 FFS groups, which in turn have reached 48,347 pregnant and lactating women (PLW), thereby doubling SPRING’s year-over-year population coverage. As a result, there are now cumulatively over 76,842 FFS participants with SPRING-supported home gardens among 3,861 FFS.

SPRING/Bangladesh will continue its engagement with its five Bangladeshi implementing partner nongovernmental organizations (IPNGOs) to cover activities occurring in 40 upazilas. For PY3, SPRING will have 30 upazila coordinators, 24 field supervisors, and 320 union facilitators to provide support to its activities, as well as to provide follow-up support to phased out, or “graduated,” FFS. Achievements are described under each Strategy. Strategy 1: Strengthen Policy, Advocacy, and Stewardship for Nutrition

Participation in National and International Stakeholder Groups

In Q1 of PY3, SPRING/Bangladesh participated in the development of the basic nutrition curriculum, a process that was led by the Government of Bangladesh’s Institute for Public Health and Nutrition (IPHN) and the National Nutrition Service (NNS), with technical leadership from FANTA-III. SPRING/Bangladesh, along with many other NGOs and projects, provided technical input to this important national document and will be adopting the curriculum as part of its training package for frontline health workers in PY3.

15 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

National and International Public Service Events On October 5, Bangladesh celebrated the National Vitamin A Plus Campaign across Bangladesh as part of ongoing national efforts to raise awareness about diseases that result from vitamin A deficiency, such as night blindness. SPRING/Bangladesh worked closely with the Ministry of Health and Family Welfare (MOHFW) to maximize awareness and ensure effective implementation at the district level and did so by planning activities and events in all 40 project upazilas.

SPRING/Bangladesh supported upazila-level health and family planning departments by providing outreach services to communities; helping with intensive community mobilization, including making public service announcements, providing visual aids such as roadside banners, and inviting mothers from SPRING/Bangladesh’s FFS.

SPRING/Bangladesh celebrated International Hand Washing Day by conducting extra hand washing sessions with FFS members and demonstrating the construction and use of tippy taps to encourage FFS participants to install the devices in their households.

Vitamin A Plus Campaign inauguration by the Upazila Health & Family Planning Officer in Barisal Division, October 2013 Strategy 2: Promote Communications and Innovative Approaches to Social and Behavior Change

The Aquaculture for Income and Nutrition (AIN) project, implemented by World Fish, included and conducted hand washing sessions, and included tippy tap instructions in their manual as a part of the nutrition training, with technical assistance from SPRING/Bangladesh.

In PY3, SPRING/Bangladesh developed a draft SBCC strategy as a guideline for its activities. The strategy is now in its final phase and is being harmonized with SPRING’s revised PMP. The SBCC strategy should be completed at the beginning of Q2 of PY3.

SPRING/Bangladesh is an active member of the Behavior Change Communication (BCC) Working Group, coordinated through the Bangladesh Knowledge Management Initiative (BKMI) on behalf of the

16 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

MOHFW’s Education Information Department. The group is preparing a National BCC Strategy that came out of the Nutrition Advocacy and Nutrition Stakeholders Forum which was conducted by the UN, the GOB, along with national and international NGOs. These types of central-level workshops and meetings provide an excellent opportunity to receive updates on various nutritional issues, and for the SPRING/Bangladesh team to share its thoughts and experiences regarding maternal and child nutrition, especially on ENA. Strategy 3: Enhance Systems and Capacity for Delivery of Quality Nutrition Services

Monitored quality of nutrition activities of trained officers Nutrition activities, especially the implementation of FFS activities, were closely monitored in spite of the ongoing hartals and blockades during the quarter. Upazila coordinators and IPNGO field supervisors paid regular visits to FFS sessions, FFS households, community clinics, and the union health and family welfare centers, as well as to the courtyard group sessions conducted by the trained DAE extension officers.

During this quarter, SPRING/Bangladesh supported the NNS in monitoring the status of nutrition corners. SPRING/Bangladesh staff members visited all the upazilas’ health complexes in its 40 upazilas and submitted their report to the NNS based on their monitoring observations. The concept of a “nutrition corner” was introduced in 2013 by the GOB (DGHS) through IPHN under the Health, Population, and Nutrition Sector Development Program (HPNSDP). The objective of the nutrition corners is to integrate nutrition services into an already established IMCI corner, which has now been renamed the “IMCI-Nutrition Corner.” SPRING plans to support health officials by providing effective counseling to mothers and caregivers after the establishment of these nutrition corners.

SPRING/Bangladesh assisted the NNS in monitoring community clinics in order to support the reporting system to be run by the Community Health Care Providers (CHCP). Accordingly, SPRING staff visited 1,005 community clinics in 40 upazilas and provided summary reports to the NNS based on their monitoring observations. During those visits, SPRING/Bangladesh provided support to the CHCPs, both in terms of reporting systems, as well as on technical issues, notably through nutrition-related reporting content.

SPRING/Bangladesh has continued routine supportive supervision visits in Barisal and Khulna. These visits were conducted with the supervisory level health workers, and mainly to the community clinics and the union health and family welfare centers. Due to hartals and the blockades, it was difficult to travel long distances and therefore, supportive supervision visits from the division or district level officials were limited.

17 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Strengthened capacity of frontline health workers and community support group members

Due to the adverse political situation, SPRING/Bangladesh was unable conduct the refresher trainings planned for frontline health workers and community support group members. Furthermore, as the supportive supervision visits were limited, notably those involving senior level health workers, it was not possible to determine training needs or the specific training content needed. Nonetheless, SPRING/Bangladesh continued to mentor the health workers and the community support group members during their monitoring visits. Should the political situation stabilize and provide a more conducive environment for travel, SPRING hopes more of these necessary visits and travel can take place in Q2.

A frontline health worker providing nutrition information to PLW at Nadra Kalarhut Community Clinic, Monirampur District, Khulna Division (October 2013)

Strategy 4: Foster Integration of Agriculture and Nutrition

Farmer field schools

Between October and December 2013, SPRING/Bangladesh distributed seeds for the winter planting season to 24,010 beneficiaries across 1,149 FFS established in PY2 as well as to the 48,347 beneficiaries across 2,560 FFS established during this quarter. Each household received 4-6 varieties of nutrient-dense summer and/or winter vegetables for cultivation in home gardens. These agricultural inputs are used in conjunction with the FFS participatory learning methodology, which also includes information on women's nutrition, hygiene actions (including tippy tap preparation), and composting.

18 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Home gardens established among households with pregnant women and children under the age of two

During this quarter 48,347 PLW and women with children under two were recruited into FFS. FFS participants received training on topics including land preparation and composting, exclusive breastfeeding for children under six months, complementary feeding for 6 - 24 month-old children, and women's nutrition.

Small-scale poultry rearing and fish culture to create access to animal protein for resource-poor households through FFS

All of the cumulative 76,842 PLW in 3,861 FFS participated in the training sessions on poultry rearing and fish culture modules, aimed at ensuring better access to animal protein in the complementary food given to children, as well as in the mother’s diet. With the improved production technology training provided by SPRING/Bangladesh, around 27,748 participants (out of 28,495) have started to rear indigenous chickens on a small scale, resulting in better egg production. This figure includes PY1 and PY2 FFS participants, as the poultry module for PY3 will be started in Q2. Through SPRING’s work on aquaculture, 9,709 beneficiaries (out of 14,793 pond holders) are engaged in rearing fish and now aim to eat nutrient-dense small indigenous fish, such as mola. They also sell the larger fish in the market to generate income for their families.

Picture 3: Under the supervision of a SPRING/Bangladesh union facilitator, women prepare their home gardens with winter agricultural inputs in Kashimnogar Union in Khulna Division (October 2013)

19 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Strategy 5: Engage in Strategic Partnerships with the Public and Private Sectors

Engagement with the public and private sectors

In Q1, SPRING/Bangladesh initiated or continued with 10 major partnerships, including: the GOB's National Nutrition Strategy, RCHCIB, DGHS, DGFP, DAE, the Agricultural Information Services, the USAID- funded Aquaculture Project, SHIKHA, the USAID NGO Health Service Delivery Project (NHSDP), and the USAID Horticulture Project. These strategic partnerships allow SPRING/Bangladesh to leverage existing resources, expand its reach, and strengthen its technical capacity. By partnering with other projects and NGOs, SPRING/Bangladesh has been able to implement activities in a more cost-effective manner and has allowed for a greater ability to reach more of its target population.

Increased coordination among nutrition programs at the upazila and district levels

The upazila SPRING/Bangladesh staff, IPNGO staff, and representatives from the divisional teams continued to attend the district-level meetings organized by DGHS, the DAE, and other collaborative partners. There have also been district-level monthly meetings organized between SPRING/Bangladesh, IPNGOs, and government counterparts. Strategy 6: Expand Learning for Designing, Planning, and Managing Effective Nutrition Programs

Networking, qualitative research, and temporary duty visits

SPRING/Bangladesh attends monthly DGFP, DGHS, and DAE health and family planning coordination meetings in all 40 intervention upazilas and remains an active participant in Dhaka with the National Nutrition Working Group, CSA-SUN, RCHCIB, and the NGO coordination meetings.

Tim Williams, SPRING/Bangladesh Senior Strategic Information Advisor, traveled to Bangladesh from September 29 - October 10, 2013. The purpose of this travel was to review the SPRING/Bangladesh PMP indicators and targets, and make revisions as necessary. The secondary purpose was to work with SPRING/Bangladesh staff, particularly the newly hired Strategic Information Officer and the incoming Country Manager, to ensure that SPRING’s SI systems are functioning well and collecting/utilizing appropriate information to meet reporting and project management needs. III. Strategic Information

During the first quarter of PY3, SPRING/Bangladesh has progressed well in spite of consistent political unrest. A total of 2,560 FFS were established though which 48,347 new participants (all PLW), along with approximately 36,968 children under two, were reached with ENA/EHA messages. As part of SPRING’s regular activities, some 646,393 contacts were made through the health system, through Sub-Assistant Agriculture Officers (SAAOs) and FFS. This represents 22% of the annual target for 2014.

20 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Graph 1: Annual Target vs. Quarterly Achievement: Contacts

SPRING/Bangladesh has an established M&E system which has been in place since the beginning of the project. A total of seven monitoring tools (e.g., data collection forms/questionnaires, including supportive supervision) have been used to collect data from the field level with the help of Union Facilitators, Implementing Partner’s Program Focal Persons, Upazila Coordinators, and the divisional M&E Specialists on a regular basis. Recently, SPRING/Bangladesh revised its monitoring forms to better capture this information, including: 1) number of individuals who have received USG assisted short-term agriculture sector productivity or food security training; 2) number of farmers and others who applied new technologies or management practices as a result of USG assistance; and, 3) number of hectares under the improved technologies or management practices as a result of USG assistance. These changes were made based on internal project monitoring recommendations as well as a request from USAID to report on a few of these aspects from this quarter, as part of FTF reporting requirements. Furthermore, SPRING/Bangladesh has been assessing the feasibility of using mobile technology as a way to get data directly from the field level to make the M&E system more effective and robust. IV. Activities Planned for Next Quarter

SPRING/Bangladesh will be reprinting the infant and young child feeding (IYCF) brochure for health workers in Q2, which was originally produced by IPHN in partnership with Alive & Thrive. SPRING/Bangladesh participated in the technical update of this second version and has agreed to reprint and distribute that brochure to GOB health workers. The redesign has been completed and printing should occur next quarter.

SPRING/Bangladesh will work in Q2 to finalize its SBCC strategy and PMP. These two documents will be crucial in guiding SPRING’s work and will be linked together. Valuable input from USAID has been incorporated and a final draft of these documents will be shared with USAID at the beginning of Q2 of PY3.

Finally, next quarter, SPRING/Bangladesh expects to see the completion of its qualitative research, managed centrally by SPRING/DC. The results of this research will be shared with the broader nutrition

21 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

community in Bangladesh and should help to provide interesting opportunities for further research and refinement of BCC materials and messaging. V. Administration and Management

Q1 of PY3 was particularly busy concerning administration and management. All procedures related to the relocation of the recently hired SPRING/Bangladesh Country Manager, Aaron Hawkins, were completed during the period. The Divisional Manager for Khulna was recruited, and the selected candidate will begin January 1, 2014. Additionally, recruitment for upazila coordinators for both divisions began in Quarter 1 and will continue into Q2.

The Khulna office moved to a new location during this period, due to the safety needs of staff. Further, to ensure the safety and security of the office, a local security company was contracted to ensure security service on a 24 hour basis.

Upon receipt of USAID approval, SPRING/Bangladesh procured and distributed nine varieties of seeds of for its 72,357 beneficiaries (24,010 in PY2 and 48,347 in PY3) for the winter planting season. Further, a Memorandum of Understanding (MOU) was made between seed vendors and SPRING/Bangladesh to ensure that the seeds are received on time, at the same price, and with a quality guarantee in the upcoming summer season.

B. SPRING/Haiti Program Implementation

I. Introduction

In PY2, SPRING/Haiti provided technical assistance to five health facilities in the West, Artibonite, and North departments to strengthen nutrition assessment, counseling, and support (NACS) services. These facilities supported in PY2 have already been trained on improving IYCF counseling. In Q1 of PY3, SPRING/Haiti expanded its support to seven additional health facilities, focusing on building capacity in NACS and IYCF counseling. SPRING/Haiti now supports twelve health facilities in the West, Artibonite, North, Center, and Northeast departments. II. Key programmatic activities performed and achievements

Achievements are described under each Strategy. Strategy 1: Strengthen Policy, Advocacy, and Stewardship for Nutrition

Provide leadership and advocacy in Nutrition Cluster meetings

On October 25th and December 20th, SPRING/Haiti participated in the monthly Technical Cluster Meetings facilitated by Ministère de la Santé Publique et de la Population (MSPP). The objectives of the meetings were to share the information about what each MOH Nutrition partners is doing in the field, to present nutrition data and the perspectives for the next month. SPRING/Haiti presented its activities with PY2 and PY3 target sites this year, with a focus on the joint IYCF/NACS TOT for the PY3 sites in November 2013, the NACS TOT for the PY2 sites in December 2013, and the cascade training by the master trainers planned to begin in January 2014 in all twelve sites.

22 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Conduct coordination meetings of key stakeholders at the department level

Departmental level meetings were not scheduled to take place this quarter. SPRING/Haiti is making arrangements to meet with the Nutrition Security Program (NSP) and World Food Program (WFP) during the planned departmental visits in January 2014, while conducting the baseline assessment in the new PY3 target sites.

Provide support to the MSPP in revising national guidelines

Upon the request from MSPP-Unité de Coordination du Programme National d’Alimentation et de Nutrition (UCPNANu), SPRING/Haiti has worked with UCPNANu to finalize a comprehensive supervision tool for health workers. This tools draws on existing materials developed by MSPP, SPRING, MEASURE Evaluation, FANTA, and UNICEF. SPRING/Haiti assisted MSPP in organizing a two-day stakeholder workshop with key nutrition partners to review existing tools, and provide feedback for the development of the comprehensive supervision tool. This meeting was held on October 22-23, 2013.

During the meeting, four working groups composed of MSPP/UCPNANu, MSPP/ Unité de Planification et d’Evaluation (UEP), and partners drafted a section of the proposed consolidated supportive supervision tool. Based on the results of the working groups, SPRING/Haiti drafted and submitted the first version of the tool to MSPP and partners. The SPRING/Haiti team is currently drafting the second version to incorporate feedback, and will submit to MSPP in Q2. MSPP’s goal is to roll-out the comprehensive supportive supervision tool nationwide. SPRING/Haiti is also drafting a two-pager on the stakeholder workshop to be shared in January 2014.

In addition, MSPP-UCPNANu requested that SPRING/Haiti review counseling cards number 26 of the “Bonjan fason pou bay yon tibebe mange depi l fèk fèt jouk li rive 24 mwa.” SPRING/Haiti submitted a revised version to MSPP-UCPNANu in December 2013 and is awaiting approval.

Collaborate with MSPP and FANTA to finalize NACS tools and approach

The NACS training package was validated by the MSPP this quarter. The package was developed by FANTA in collaboration with MSPP-UCPNANu, and was edited and finalized in collaboration with SPRING/Haiti. SPRING/Haiti and FANTA held several working sessions throughout the quarter to review and edit the tools.

SPRING/Haiti used the package during both training of trainers (TOTs) conducted this quarter: the joint IYCF/NACS TOT for the new PY3 target sites in November 2013, and the NACS TOT for the PY2 target sites in December 2013. Suggested edits compiled during both TOTs were submitted to FANTA to be incorporated prior to the final printing. One-hundred copies of the ‘’Manuel de Référence NACS: Pour les prestataires de services des établissements de santé en Haiti”, and the “Guide du facilitateur pour la formation du personnel de santé dans les établissements sanitaire” will be provided to SPRING/Haiti for dissemination.

23 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Strategy 2: Promote Innovation and Innovative Approaches to Social and Behavioral Change (SBC)

Support national-level IYCN materials

As planned, SPRING/Haiti provided the MSPP-UCPNANu, departmental staff, NSP, and the health facilities trainers with the “Latch, 1, 2, 3” video on early initiation of breastfeeding, as well as three videos on breastfeeding that will be used in conjunction with the IYCF cascade training. Trainers were provided with technical support on how to use the video effectively during training sessions and when conducting sessions for pregnant women. In total 18 copies of each video were distributed to the MSPP- UCPNANu, departmental staff, NSP, and the health facilities trainers.

Joint IYCF/NACS TOT – November 27, 2013 - Petit-Goave - Demonstration of a good counseling session Photo credit: Nicole Racine Strategy 3: Enhance Systems and Capacity for Delivery of Quality Nutrition Services

Conduct TOT and support cascade training for the NACS package and on-the-job training IYCF Counseling package

This quarter, SPRING/Haiti successfully held the five-and-a-half-day IYCF/NACS training for the seven PY3 target facilities, and the four-day NACS TOT for the five PY2 target facilities that had already completed the IYCF training in June 2013. The NACS training manual was designed to be used in conjunction with the IYCF on-the-job training (OJT) for health workers. The counseling package with and elaborates on the FANTA/NACS counseling tool “Bonjan abitid nan manje ak lijyen”. As shown in Table 1, a total of 50 master trainers were trained this quarter: 31 in November (26 women, 5 men) and 19 trainers in December (18 women, 1 man). Cascade trainings have been planned in all health facilities, and OJT will commence in January and February 2014. SPRING/Haiti plans to support and supervise the master trainers as they roll out the cascade trainings.

24 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table 1: Trainings supported by SPRING/Haiti in Q1 People Trained Start Title/Name of Health Comments Date Training Total Male Female Workers OJT on NACS 5 ½-day training organized by and IYCF SPRING/Haiti and MSPP. Training 11/25/13 counseling for 31 5 26 31 was for Master Trainers from the health seven new PY3 facilities. workers 4-day training organized by OJT on NACS SPRING/Haiti, FANTA and MSPP. 12/16/13 for health 19 1 18 19 Training for Master Trainer from workers the PY3 facilities. Total 50 6 44 50

Joint IYCF/NACS - November 27, 2013 - Practicing NACS anthropometric measurements - Children from Hôpital Notre-Dame de Petit-Goave. One facilitator observing trainers. Photo credit: Nicole Racine

25 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Conduct reinforcement visits

To encourage and improve the quality of nutrition services, SPRING/Haiti will begin reinforcement visits (RV) in February 2014, following the completion of at least half of the OJT IYCF cascade training in the facilities that have been supported by SPRING since PY2. Three RVs will be conducted in each target facility during PY3.

Contribute to design and rollout of NACS QI approach in partnership with MSPP, HEALTHQUAL, and CDC

SPRING/Haiti, HEALTHQUAL, and CDC met in November 2013 to discuss the Joint Action Plan, the PY2 Health Facility Profiles, and the upcoming baseline assessment in the new PY3 health facilities. The Joint Action Plan for NACS quality improvement (QI) approach, PY2 Health Facility Profiles, and the list of 12 SPRING target facilities are being finalized and will be submitted to HEALTHQUAL in January 2014.

Establish relationship with community-based support services

In October 2013, SPRING/Haiti met with its community-based partner, NSP. The goal of this meeting was to discuss the complementarity of services at the health facility and the community level, and the importance of establishing linkages with community-based support services to strengthen the impact of NACS at the facility level. The need to follow up on cases of malnutrition once discharged from the health facilities to avoid recurrence of malnutrition and the need to strengthen the referral and counter- referral systems were discussed.

Five key personnel from NSP participated in the joint IYCF/NACS TOT in November 2013. NSP is currently using the MSPP-SPRING/Haiti’s counseling cards ‘’Bonjan fason pou bay yon tibebe manje depi l fèk fèt jouk li rive 24 mwa’’ to train their leader mothers. The SPRING/Haiti-NSP MOU drafted by SPRING/Haiti is currently under review, and will be finalized in Q2.

Equip health facilities with NACS equipment and supplies

Upon completion of the baseline assessment in the new PY3 target sites, SPRING/Haiti will meet with both UNICEF and WFP to discuss the procurement of anthropometric equipment needed for quality nutrition assessment and ensure continuous supply of therapeutic food. This meeting is planned for January 2014. Strategy 4: Expand evidence-based learning for designing, planning, and managing effective nutrition programs

Conduct operational research on the on-the-job training approach to rolling out the IYCF Counseling package

SPRING initiated discussion and planning around quantitative and qualitative operations research (OR). The OR will compare the advantages and disadvantages of the OJT training approach with typical four to five-day training. The protocol was developed and submitted to Haiti’s National Bio-Ethic Committee, and data collection will begin in January 2014.

26 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

I. Strategic Information

SPRING/Haiti encompasses three types of activities, 1) gathering of data for performance M&E, 2) developing and implementing research to enhance the evidence base on what works and what doesn’t, and 3) disseminating and sharing lessons learned.

As mentioned above, SPRING/Haiti finalized plans for baseline data collection in SPRING’s seven new PY3 facilities for both the evaluation of project activities and for the OJT OR. SPRING/Haiti revised and updated the project M&E tools and prepared a baseline survey for the seven new SPRING/Haiti- supported health facilities. This included conducting a pre-test and requesting approval from Haiti’s National Bio-Ethics Committee.

In addition, data were routinely collected on project activities and target facilities, which are reported in SPRING/Haiti’s PMP. Data on USAID/Haiti’s Partner Indicators are presented below. For this quarter, only data from PY2 facilities are reported since SPRING/Haiti has only just begun work in PY3 facilities. Once the PY3 baseline is completed in January 2014, SPRING/Haiti will calculate targets for the health facilities, update the PMP, and submit a revised PMP to USAID/Haiti.

In order to feed into the health component of the Mission Annual Report (PPR), USAID conducted a Data Quality Assessment (DQA) to assess the quality of the training data reported by SPRING/Haiti to USAID during PY2.

Table 2: SPRING/Haiti’s contribution to USAID/Haiti’s Partner Indicators FY FY 2014 FY FY FY 2014 Indicator FY 2014 Indicator label 2014 SAPR 2014 2014 APR No. Q1 Q2 Results Q3 Q4 Results Number of HIV-positive clinically C2.3.D malnourished clients who received 3,975

therapeutic or supplementary food

Number of eligible clients who received food and/or other nutrition services By Age: <18 3,602 C5.1.D By Age: 18+(including pregnant women)

By: Pregnant Women or Lactating Women

Number of health care workers who successfully completed an in-service training 50

H2.3.D program within the reporting period By Type of Training: Male Circumcision NA NA NA NA NA NA By Type of Training: Pediatric Treatment NA NA NA NA NA NA

27 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

II. Activities Planned for Next Quarter

- Support master trainers during cascade trainings in all target facilities - Provide leadership and advocacy in Nutrition Cluster meetings - Meet with MSPP/UCPNANu to discuss the SUN activity and the PY3 baseline assessment - Conduct coordination meetings of key stakeholders at departmental level - Establish relationship with partner in community-based support services, NSP - Contribute to the design and roll out of the NACS QI approach with MSPP, HEALTHQUAL, and CDC - Meet with HEALTHQUAL to finalize the Joint Action Plan and train HEALTHQUAL coaches and QI teams on nutrition - Conduct baseline in new PY3 target facilities - Submit targets and revised PMP to USAID/Haiti (post- PY3 baseline assessment) - Meet with UNICEF and WFP to streamline RUTF supplies.

Joint IYCF/NACS TOT - Nov 27, 2013 - Practicing NACS anthropometric measurements - Child and mother from Hôpital Notre-Dame de Petit-Goave. Photo credit: Nicole Racine

III. Administration and Management

Administration and management throughout this quarter consisted of productive meetings, program coordination, international travel, and a smooth transition in management.

Ms. Anuradha Narayan, Deputy Director for SPRING/DC, traveled to Haiti from October 7-11, 2013 to provide technical and management support to the SPRING/Haiti team. The main purpose of the visit was to work with the SPRING/Haiti team in Haiti to plan out PY3 activities, strengthen management and operations to meet PY3 deliverables, and ensure that communication and reporting channels were

28 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

strengthened. Ms. Narayan has also met with USAID/Haiti, MSPP, FANTA, and Partners of the Americas to discuss the collaboration with these partners.

In November 2013, USAID’s PROMIS TA team, met with SPRING/Haiti to review SPRING/Haiti’s PEPFAR Expenditure Analysis spreadsheet and provide technical assistance on how data must be uploaded to the PROMIS site. SPRING/Haiti successfully submitted the Expenditure Analysis on November 15, 2013.

In December 2013, Dr. Herby Verna, SPRING/Haiti Country Manager, resigned from his role as SPRING/Haiti Country Manager. In consultation with USAID, it was agreed that Ms. Nicole Racine, SPRING/Haiti Program Manager, would take on in-country representation for SPRING/Haiti. On December 19-21, 2013, Ms. Kristen Kappos, SPRING/HQ Project Officer, traveled to Haiti to ensure the new management structure was put in place, meet with SPRING/Haiti staff to review modifications to respective job descriptions, and facilitate the transition to the new management structure. During her TDY, she and Ms. Racine met with Dr. Olbeg Désinor, USAID Activity Manager for SPRING/Haiti, for an in- briefing. Dr. Désinor was supportive of the management transition.

Early next quarter, SPRING will update the TRAINET to include the joint IYCF/NACS TOT for the PY3 target sites from November 25 – 30, 2013 and the NACS TOT for the PY2 sites from December 16 to 19, 2013.

C. SPRING/Nigeria Program Implementation

I. Introduction

The objective of the SPRING/Nigeria activities is to facilitate the improvement of the nutritional wellbeing of children under five years. Working through partners under the Umbrella Grant Mechanism (UGM) Orphans and Vulnerable Children (OVC) Project, SPRING will roll out IYCF training in 10 states in PY4. Through a series of stakeholder meetings, SPRING/Nigeria has initiated work with UMG partners, namely STEER and SMILE, to assess their needs, determine the most appropriate mechanisms for providing technical support, and harmonize/align work plans to the extent possible. In PY3, SPRING is focusing on the rollout of the IYCF counseling package to five states: Bauchi, Benue, Edo, Federal Capital Territory (FCT), and Kaduna.

II. Key programmatic activities performed and achievements

Achievements are described under each Strategy.

Strategy 1: Strengthen the capacity of local, nongovernmental, and governmental agencies to improve supply and delivery of nutrition services

Roll out community IYCF counseling through UGM partners

Representatives from the USAID-funded STEER, SMILE, and SPRING projects convened a Partners Technical Planning meeting in Abuja from November 20 to 22, 2013, to discuss the roll out of the Nigeria IYCF Counseling Package. Twenty-four stakeholders attended, representing SPRING; UGM lead partners

29 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

SMILE and STEER; State Ministries of Health from Kaduna, Bauchi, Benue, FCT and Edo; FMOH; and NPHCDA.

The planning meeting was facilitated by Mr. Tobias Stillman, SPRING/DC Technical Director, and Mr. Babajide Adebisi, SPRING/Nigeria Country Manager. The opening remarks were delivered by Ms. Roselyn Gabriel, IYCF Coordinator of the FMOH, and a goodwill message was given by Ms. Philomena Irene, USAID/Nigeria Senior Program Manager.

The meeting objectives included establishing a partnership framework and modalities for implementing the IYCF counseling package, as well as developing a work plan for partner activities in the five states, in collaboration with UGM and MOH partners.

At the end of the meeting the following next steps were identified: • Develop terms of reference for coordination forums (state and LGA levels) • Develop an M&E plan and supervisory checklists (state, LGA, and local levels) • Conduct an assessment of health facilities to identify those that meet the inclusion criteria • Consolidate state work plans into a composite C-IYCF work plan.

SPRING-UGM Partners Technical Planning Meeting. Abuja, Nigeria. November, 2013. Strategy 2: Design and advocate for policies, systems, structures, and social change campaigns enabling the provision of quality nutrition services and adoption of IYCF practices

Mapping IYCF stakeholders and implementing partners

In Q1, SPRING/Nigeria initiated and supported the FMOH to develop a mapping tool for assessing IYCF implementation and partners’ involvement across the country. The development of the mapping tool is the first step in a larger mapping exercise, which will contribute to a national database for IYCF roll-out

30 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

in the country. The tool will also provide relevant data for advocacy and the opportunity to review implementation strategies periodically. III. Strategic Information

SPRING/Nigeria, in coordination with UGM partners and the relevant State Ministry of Health (SMOH), conducted an assessment of the primary health care centers and secondary health facilities in Bauchi, Benue, and Kaduna between December 2 to 13, 2013. The assessment mapped the health facilities in the UGM-selected local government areas (LGAs) to verify their suitability for the roll-out of IYCF activities in the selected states. Following the assessment, SMOH, SPRING/Nigeria, SMILE, and STEER began the process of selecting target health facilities. SPRING/Nigeria mediated discussions between the SMOH, State Primary Health Care Development Agency (SPHCDA), and the UGM partners on anticipated IYCF activities during the exercise. As a result, the SMOH was included in the planning activities and communication, and moreover, the partnership between the stakeholders was enhanced. Considerable progress was made in the selection of health facilities for IYCF roll-out in the LGAs of the STEER states (Bauchi and Kaduna), with the creation of a database which identifies facilities based on the inclusion criteria. This database will help the partners make planning decisions and will contribute to a baseline for project evaluation in the future.

SPRING/Nigeria participated in the Managing for Results (MFR) training course, which was organised by Nigeria Monitoring and Evaluation Management Services (NMEMS) II and USAID. The purpose of the 2013 MFR training was to expose participants to the concepts and principles of MFR, especially focusing on the results framework, performance data and indicators, and data quality assessment. IV. Activities Planned for Next Quarter

The activities planned for the next quarter are dependent on the finalization and approval of the revised work plan. The activities regarding the Nigeria IYCF Counselling Package will be further defined through the finalization of terms of reference between partners, and the consolidation of state work plans into a composite IYCF work plan. The planned activities include conducting a five-day training of trainers for STEER and SMILE; printing of C-IYCF and F-IYCF Counseling Materials for training rollout and distribution; supporting a quarterly LGA nutrition focal person's meeting in 5 UGM states; and, conducting the training of civil society organization (CSO) and LGA Program Officers in STEER- and SMILE-supported states. V. Administration and Management

SPRING/Nigeria participated in the USAID Annual Performance Report (APR) guidance review meeting on October 10, 2013. SPRING/Nigeria presented its 2013 Annual Progress Report narrative to USAID/Nigeria, with other USG IPs in Nigeria in attendance. This report was reviewed by a committee with representation from USAID and CDC.

On November 13, SPRING/Bangladesh welcomed Ms. Elizabeth Kolmstetter and Mr. Dennis Diamond, visitors from USAID/Washington’s Office of Human Resources. The guests met representatives from the FCT Primary Health Care Development Board (PHCDB), including the Executive Secretary and State Nutrition Officer, and were given a briefing on current IYCF activities in FCT as well as an introduction to the function and mission of the PHCDB. Additionally, a field visit was conducted to an IYCF support group in the Byazhin Community, Bwari Area Council of FCT. About 300 participants were in attendance,

31 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

including representatives from the FCT PHCDB Team, USAID/Washington, USAID/Nigeria, SPRING/Nigeria, the Bwari Area Council, traditional rulers, support group members, and other engaged community members. This visit provided attendees the chance to observe a support group’s meeting, which focuses on one IYCF component.

D. SPRING/Uganda Program Implementation

I. Introduction

SPRING/Uganda is focused on strengthening health facility and district systems for provision and uptake of preventive and treatment nutrition services using the NACS framework; developing SBCC and community mobilization materials; supporting food fortification through the National Working Group on Food Fortification (NWGFF), Uganda National Bureau of Standards (UNBS), and the Ugandan MOH; and increasing support for nutrition at national, regional, district and lower local government levels through advocacy and coordination initiatives. SPRING/Uganda, upon request from the Government of Uganda (GOU) through the Office of the Prime Minister (OPM), is supporting the Uganda Nutrition Action Plan (UNAP) 2011-2016 Secretariat in the development of the Social Change and Mobilization Sub-strategy of the National Nutrition SBCC and Advocacy Strategy.

The implementation and monitoring of Partnership for HIV Free Survival (PHFS) activities, which began in March 2013, continued in the districts of Namutumba, Ntungamo, and Kisoro in Q1 of PY3. The activities were implemented and monitored through joint efforts with the MOH, District Health Offices (DHO), USAID IPs (ASSIST, STAR-EC and STAR-SW), and the 12 Phase I health facilities of Namutumba Health Center (HC) III, Magada HCIII, Ivukula HC III and Nsinze HC IV in Namutumba; Itojo Hospital, Kitwe HC IV, Ruhama HC III and Rubaare HCIV in Ntungamo; Kisoro Hospital, Busanza HC IV, Muramba HC III, and Rubuguri HC IV in Kisoro. II. Key programmatic activities performed and achievements

Achievements are described under each Intermediate Result. Intermediate Result 1: Increased Demand for Undernutrition Prevention and Treatment Services

Strengthening Capacity of Village Health Teams and Other Community-Level Resources for SBCC

In Q1, SPRING/Uganda made significant progress in developing its innovative behavior change approach to engage community resource persons, particularly village health team (VHT) members as change agents for nutrition-enhancing behaviors. Working with Fenon Entertainment Limited, SPRING/Uganda created twelve videos that target the following high-impact behaviors: exclusive breastfeeding, taking a sick child to the health facility, and feeding a sick and recovering child. The videos were produced through filming testimonials by mothers (“Great Mothers”), fathers (“Fabulous Fathers”), and grandmothers (“Wise Women”) in the Southwest (SW) through either focus group discussions or one- on-one interviews. The testimonials were filmed using projective techniques or indirect measures of emotional expressions in order to understand how the audiences felt about the wellness of their child. The videos were edited in December, 2013 and will be pre-tested using trained VHTs to record the videos as job aids in Q2. VHTs will screen the testimonials to the target populations in Kisoro and

32 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Ntungamo, and facilitate discussion on the doable actions that the audience can adopt for good nutrition practices.

Team from Fenon Entertainment setting mobile studio for filming the participants in Kisoro. Photo by Moses Ssebale, SPRING/Uganda

Operational Research on Improved Intake, Compliance, and Adherence to Iron-Folic Acid by Pregnant Women

In an effort to improve the uptake of IFA supplements in the SW, SPRING/Uganda has monitored cases of 19 pregnant women in Ibanda and Itojo hospitals since June 2013. During home visits in July 2013, key nutrition and health messages regarding adherence and compliance to IFA intake were given. In December 2013, follow-up visits to 14 of 19 women were conducted to identify the key achievements attained, challenges faced, and lessons learned in promoting IFA intake and compliance among pregnant women. One key finding was that all women were given IFA supplements, although none of them completed the recommended dosage. A report presenting the key findings will be available in Q2.

33 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Arineitwe Sylvia, 26 years, Kitwe Cell Ibanda Town Council

Sylvia, a mother of two, was enrolled in IFA intake four months into her pregnancy (first antenatal visit). She attended four ANC visits and reported that IFA supplements were given at each visit. Sylvia reported that with the project’s initiative she learned more about the relevance of taking the IFA tablets during pregnancy. “I only thought that they were given to me to take just like any other tablets and to keep me in good health without knowledge of their major importance, but with your advice I now understand that the tablets help to prevent anemia during pregnancy and help to keep enough reserves for the body after delivery.” Concerning the side effects of the supplements, Sylvia said that at first she had some nausea which later disappeared. In August she gave birth to a 3.2 kilogram boy who she has exclusively breastfed.

Development and Support of National Social Mobilization Strategy

SPRING is providing TA in the development of a multi-sector SBCC strategy in Uganda. Marcia Griffiths, SPRING Senior Consultant, and Ashley Aakesson, SPRING Technical Advisor for Nutrition SBCC, traveled to Uganda in October 2013 to initiate support to the OPM in the development of the Social Change and Mobilization Sub-strategy of the National Nutrition SBCC and Advocacy Strategy, and assist with recruiting an SBCC Project Officer who will be seconded to the OPM for 12 months starting in January 2014. In November and December, Ms. Griffiths and Ms. Aakesson began drafting a review of Social Change and Mobilization experience in Uganda as well as the sub-strategy document. In Q2, Ms. Griffiths and Ms. Aakesson will travel to Uganda for a partners meeting to review the draft sub-strategy and agree on a process for pulling together and finalizing the National SBCC and Advocacy Strategy. They will work with Kenneth Mulondo, the SBCC Project Officer, to develop a work plan for his secondment to OPM. Intermediate Result 2: Increased Access and Availability of Targeted Nutrition Interventions for Vulnerable Groups

Procurement and Distribution of Anthropometric Equipment

In Q1, SPRING/Uganda continued to procure and distribute anthropometric equipment to target health facilities. Following the training of health workers at Mbarara Regional Referral Hospital (RRH), Kabale RRH and Ishaka Adventist Hospital, SPRING/Uganda provided each hospital with four medical weighing scales for adults, four seca salter scales for children, four roller height measures, and MUAC tapes for

34 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

children, adolescents, and adults. Continuing Medical Education sessions (CMEs) on how to properly use and maintain the equipment were held with health workers in each of the hospitals before the equipment was distributed. It is hoped that the knowledge and skills obtained from the training will improve nutrition assessment of clients seen in each hospital. Monitoring of the equipment and continued coaching of the health workers will be done during routine visits throughout PY3.

Integration of Nutrition Services into Ongoing Community Services in Kisoro, Ntungamo, and Namutumba Districts

In PY3, SPRING/Uganda mapped NGOs/CBOs and other groups involved in economic strengthening and other livelihood support activities in the Kisoro, Ntungamo, and Namutumba districts with the aim of integrating nutrition into their services. In PY3, SPRING/Uganda is committed to working with at least four NGOs/CBOs implementing agriculture, food security and/or economic strengthening in Kisoro and Ntungamo districts. This quarter, SPRING/Uganda Nutrition Specialists identified potential NGOs/CBOs, final selections will be completed in Q2.

Piloting Home Fortification Using MNPs for Children 6-23 Months in Namutumba District

SPRING/Uganda and SPRING/DC, in collaboration with the MOH, WFP, UNICEF, Uganda Health Marketing Group, and CDC, continued to develop a roadmap on the implementation of MNPs, and outline the role of each partner. In Q1, a second workshop was held to finalize the rollout of the MNP program. The purpose of the meeting was: • To share program experiences from other countries on MNPs • To provide an update on the current status of the MNP pilot program, especially the formative research component • To define the roles of partners in implementing the MNP pilot program based on the National Implementation Framework • To finalize the program design of the MNP program The workshop was attended by 36 participants from the MOH, academia, UN agencies, USAID and its partners in country, and other local and international NGOs.

Documentation of DNCC, SNCC, and Other Nutrition Interventions in Uganda

The SPRING/Uganda documentation activity on the process of District Nutrition Coordination Committee (DNCC) and Sub County Nutrition Coordination Committee (SNCC) work planning and implementation in Kisoro, Ntungamo and Namutumba districts, will take place in Q2 and Q3. In conjunction with SPRING/DC, SPRING/Uganda has supported the case study evaluation done through the OPM at the national and district levels. SPRING/Uganda staff joined SPRING/DC staff in conducting national-level interviews during Q1 of PY3. District-level work will take place in Q2 and Q3 with continued support by SPRING/Uganda staff. Intermediate Result 3: Improved Quality of Nutrition Services at National, Facility and Community Level

Capacity Building of Service Providers on Nutrition Service Delivery and Food Fortification

35 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

SPRING/Uganda conducted several training and coaching sessions on nutrition service delivery and food fortification this quarter; descriptions of these sessions are below.

Nutrition Service Delivery in the SW

In Q1, trainings of health workers on integrating NACS into routine service delivery were conducted in three hospitals: Kabale RRH in Kabale district, Mbarara RRH in Mbarara district, and Ishaka Adventist Hospital in Bushenyi district. The service providers developed action plans for implementing priority improvement areas, which were determined during the training.

SPRING/Uganda, in collaboration with district and health facility teams, conducted coaching and mentorship sessions with health workers in different contact points in the targeted health facilities in the SW this quarter. Twenty-one of 39 health facilities in Kisoro and Ntungamo were reached. Specifically, the following health facilities were reached through coaching and mentorship: Rukoni HC III, Bwongyera HCIII, Rugarama HC III, Kitondo HC III, Ngoma HC III, Itojo Hospital, Ntungamo HC IV, Nyakyera HCIII, Ruhaama HC III and Butare HC III in Ntungamo district; and Kisoro Hospital, Mutolere Hospital, Muramba, Rubuguri, Busanza, Chahafi, Kagezi, Kagano, Nyarubuye, Nyarusiza, and Nyabihuniko HC IIIs in Kisoro district. Additional health facilities reached this quarter included Ibanda Hospital in Ibanda district, Kitagata Hospital in Sheema district, and Kabale RRH in Kabale district. In total, 101 health workers in these health facilities were mentored on nutrition assessment using weighing scales, MUAC tapes and height/length boards; nutrition support services including provision of IFA supplements for pregnant women and people living with HIV (PLHIV); conducting nutrition education sessions; collecting data using NACS score cards and other HMIS registers as necessary; treatment of acute malnutrition according to MOH Integrated Management of Acute Malnutrition (IMAM) guidelines; and logistics management for RUTAFA.

To complement the NACS training and coaching of health workers, CMEs were conducted in selected health facilities. Site-level CMEs on strengthening the capacity of health workers on management of acute malnutrition using the MOH’s IMAM guidelines were conducted in Kitagata and Ibanda Hospitals and reached 25 health workers. As a result of the sessions, the health workers will be in position to scale up outpatient therapeutic care (OTC) services beyond HIV. Sessions on logistics management for RUTAFA were conducted for 51 health workers in Ntungamo HCIV (9), Itojo Hospital (31) and Rwashamaire HC IV (11) in Ntungamo district; and for 86 health workers in Kisoro Hospital, Busanza HCIV, Muramba HC III, Mutolere Hospital, Chahafi HCIV, Kagezi HC III, Kagano HC III, Rubuguri HC IV, Bukimbiri HC III, Gateriteri HC III, and Rutaka HC III in Kisoro district.

36 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Trainees holding a group discussion on how to break the intergenerational cycle of malnutrition. Photo by Sheilla Kobusinge, SPRING/Uganda

Nutrition Service Delivery in Namutumba (Funding Source: Partnership for HIV Free Survival)

Through PHFS, SPRING/Uganda worked with the Namutumba DHO MOH, STAR-EC, and ASSIST to train six facility-based health workers, ten HIV care linkage facilitators, and two nursing assistants in integrated IYCF, and eMTCT. This training was conducted by accredited IYCF (3), Quality Improvement (1) and eMTCT (1) national and district facilitators, aimed at imparting skills for supporting HIV-positive mothers in exclusive breastfeeding to exposed babies for the first six months, initiating complementary feeding at six months, and continuing breastfeeding up to one year while ensuring all the exposed infants get ART treatment at birth and thereafter periodically as per MOH guidelines. This training was conducted from November 25 to 29, 2013, to continuously counsel and educate HIV-positive mothers on nutrition practices. The training outcomes indicated that the service providers had gained improved understanding on how IYCF is linked to eMTCT, skills on how to counsel mothers and caretakers on IYCF practices and how to continuously use quality improvement approaches to enhance the quality and documentation of IYCF counseling and other treatment services offered to mother-baby pairs. Continuous coaching of the service providers on monthly basis was encouraged.

In Namutumba, SPRING/Uganda provided TA through PHFS to STAR-EC/mothers2mothers (m2m) by training 30 mentor mothers on MIYCN. This training was held on December 16-20, 2013 in Jinja, Uganda and was a continuation of the previous training in September 2013, in which SPRING/Uganda trained staff of m2m as NACS trainers. Through these joint trainings, m2m and SPRING/Uganda are collaborating to develop mentor mothers who have adequate skills to provide home-based care with strong components of MIYCN. The mentor mothers are important service providers for HIV-positive clients in East Central (including Namutumba) and improving their ability to provide targeted maternal and child nutrition support. In Namutumba, SPRING/Uganda will continue working with m2m leadership

37 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

in coaching the trained mentor mothers in providing targeted nutrition support to HIV-positive mothers and exposed infants, as per PHFS guidelines. In collaboration with Namutumba District Health Department, STAR-EC, and ASSIST, SPRING/Uganda provided TA in coaching health service providers in Phase I facilities in the district. This included bi- monthly coaching sessions to strengthen capacity of health workers in Namutumba HCIII, Magada HC II, and Ivukula HC III in the integration of NACS into routine HIV care and documentation of eMTCT services offered to mother-baby pairs. A total of eight heath service providers were coached in Ivukula HC II, 11 in Magada HC III and eight in Namutumba HC III.

Following the training of selected health service providers on integrated IYCF and eMTCT in November 2013, SPRING/Uganda Nutrition Specialists and District Nutrition Focal Person visited and coached 14 health workers in Ivukula HC III (4), Magada HC III (6) and Nsinze HC IV (4). The objective was to improve the health workers’ ability to counsel and provide health education on IYCF and eMTCT, and to document all services provided to clients. SPRING/Uganda and DHO representatives conducted 10 additional visits in all the four Phase 1 health facilities this quarter. These visits were used to monitor the implementation of the planned activities, identify gaps in nutrition and HIV service delivery, and generate possible solutions to be monitored for improvement. Together with the health service providers, quality improvement journals were updated and achievements were summarized in the form of run charts.

Food Fortification

As part of the continued support to UNBS in strengthening the capacity of industries to produce fortified foods as per the fortification standards, SPRING/Uganda provided logistical assistance to UNBS to train technicians from key industries across the country. The on-site training sessions were conducted between November 22, 2013 and December 22, 2013. UNBS trained 136 technical representatives from 14 industries currently fortifying maize flour (4), edible cooking oil (4), and wheat flour (8) on good manufacturing practices, QC, and QA (see Table 1 for details).

38 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table 1: Details of food processing industries trained on GMP, QC, and QA by UNBS in November and December 2013

Food vehicle Name of Industry Number of participants Maize Reco in Kasese 16

Maganjo Grain Milling Limited, Kawempe 5 Total 21 Edible cooking oil Mukwano Industries Limited, Kampala 18 Mukono Industries in Mukono 11 Mt Meru in Lira 8

Bidco in Jinja 11

Total 48 Wheat Panjaba Kampala 6 Kengrow in Mbale 7 PanAfric Kampala 15

Maganjo Kawempe 7

Bakhresa Nakawa 14

Engano Nakawa 7 Ntake Nalukolongo 5 Unga Millers Nakawa 6 Total 67 Grand total 14 Trainings for nutrition service delivery in the SW, PHFS, and food fortification are summarized in Table 2 on the following page.

39 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table 2: Trainings supported by SPRING/Uganda in Q1

People trained Start Date Town/City Title of Training Comments Total Male Female SPRING/Uganda supported the participants and trainers with training materials and allowances. Health service providers attended from ANC, Nutrition, Maternity and YCC 9/30/2013 Kabale NACS training 16 3 13 contact points, including 6 nursing officers, 3 enrolled nurses, 3 enrolled midwives, 1 store assistant, 1 community linkage coordinator, 1 nursing assistant and 1 senior health inspector. SPRING/Uganda supported the participants and trainers with training materials and 10/28/2013 Mbarara NACS training 18 2 16 allowances, tea breaks, and lunch. In the training, there were 16 health workers with one store keeper from Mbarara RRH and the District Nutrition Focal Person.

SPRING/Uganda supported participants and trainers with training materials and allowances. The training consisted of 19 health workers from Ishaka Adventist Hospital, 1 11/25/2013 Bushenyi NACS training 36 10 26 health worker from each of the following health facilities; Bushenyi HC IV, Kabushaho HC IV, Kabushaho HC IV, Kyabugimbi HC IV, Kyabujimbi HCIV, Kyeizoba HC III, Kyeizoba HC III, Kyeizoba HC III, Kyeizoba HC III, and 8 project staff from SCORE.

All Major People trained included lab technicians, machine operators, production officers, quality Fortification GMP 11/22/2013 towns in controllers of 15 industries. Total number trained were 21 for maize, 48 for oil, and 67 for and QA/QC Uganda wheat industries.

The training was aimed at equipping participants with knowledge and skills in eMTCT to IYCF and eMTCT 11/25/2013 Namutumba 18 6 12 adequately support HIV-positive pregnant and lactating mothers to access comprehensive training care. QI training for The training was organized by SPRING/Uganda and facilitated by USAID’s ASSIST project. 11/11/2013 Mbarara district QI team 29 20 9 The training was intended to equip participants with skills in quality improvement. and SPRING staff

CMEs on Kitagata and 10/1/2013 management of 25 The CME was about capacity building for health workers to manage malnutrition in OTC. Ibanda acute malnutrition

CME on logistics The CME was conducted using the CME module, which has topics on logistics 10/1/2013 Ntungamo management for 51 management systems and which features tools like order forms and a dispensing log. A RUTF practical session was conducted on how to fill out the forms.

40 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Nutrition Logistics and Supply Improvements at District and Facility Levels

In Q1, SPRING/Uganda continued to work with Production for Improved Nutrition (PIN) to scale up RUTAFA for the management of acute malnutrition through OTC in HC IIIs and IVs in Kisoro, Ntungamo, and Namutumba districts. Following numerous challenges by the lower HCs in accessing RUTAFA, a new system was rolled out by PIN and SPRING/Uganda. This system allows the lower high volume HCs supported by SPRING/Uganda to request RUTAFA directly from the DHO. SPRING/Uganda and the Kisoro district nutritionist and district Logistics Officer, coached and trained all HC IVs and high volume health center IIIs on how to requisition RUTAFA from the DHO in Kisoro. The District Logistics Officer was part of the coaching team to help understand the new system and develop an effective and sustainable reporting system. The health workers were trained on ordering and managing the RUTAFA correctly, as well as preparing a monthly OTC report. The training was conducted in a form of a CME in each of the eligible health centers. The manual was extracted from the NACS training manual by MOH (Session 4.3 Supplies and Logistics Management) in addition to the guidelines shared by PIN. As part of the coaching, a RUTAFA requisitioning schedule was developed for each of the facilities. This new system is functioning and the prepared hospitals and four of the five health centers trained have made requisitions to the DHO, except for Bukimbiri HCIII. Challenges in the new system include the lack of transportation for deliveries, and submitting timely requests. More follow up is needed to continue mentoring the health workers on generating reports and the importance of correct and timely documentation.

Intermediate Result 4: Social and Policy Environment Creating an Enabling Environment for Improved Nutrition Service Delivery and Food Fortification

A number of new initiatives need to be a part of institutional arrangements to accelerate uptake and increase changes of sustainability. SPRING/Uganda began to support activities that will accelerate the uptake of interventions, especially those promoted through short-term initiatives. In Q1, the focus was on Anemia Control, PHFS, and Food Fortification.

Anemia Control

On October 2-3, 2013, SPRING/Uganda, in partnership with the MOH, held a National Anemia Stakeholders Workshop to discuss and develop consensus around the factors that contributed to the reduction in the prevalence of anemia between 2001 and 2011 in Uganda. The objectives of the workshop were the following: - To systematically review the progress made in maternal and child anemia programs in Uganda, by examining the strength of the evidence, contextual factors and specific practices that have influenced the progress made; - To summarize and gain consensus on the nature, extent, and limitations of the evidence; and - To develop consensus on the status of the current programs and their delivery systems based on their implementation pathways and management at scale.

During the workshop, stakeholders developed an action plan on “key intervention” areas based on available evidence and local knowledge and experiences as discussed around contextual factors in a transparent and informed manner.

41

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

The workshop brought together over 100 actors from the various sectors and provided an opportunity to review the evidence around the coverage of anemia prevention and control programs in Uganda in the past decade. Following the workshop, a National Anemia Technical Working Group was revitalized and tasked with revising the Anemia Policy of 2002 and tracking the progress of the action plan developed during the Stakeholders’ Workshop. The Commissioner of Community Health was appointed Chair of the group and MOH nutrition unit as the Secretariat.

Stakeholders at the National Anemia Meeting, October 3, 2013 (Photo by Nancy Adero, SPRING/Uganda)

eMTCT Nutrition Services (Funding Source: Partnership for HIV Free Survival)

As part of institutionalizing PHFS and spreading best practices, SPRING/Uganda worked with the district health department to organize a district-based learning session in Namutumba. The session was held on October 14, 2013, and attended by 30 participants (10 female, 20 male). The purpose was to review performance, share best practices between all the stakeholders within the district, and develop a way forward to improve implementation of the partnership in the phase I facilities. Action plans for spreading best practices for PHFS in Namutumba were developed. Representatives from health facilities and district quality improvement team (DQI) were identified to participate in the national PHFS learning session on October 16-18, 2013.

Following the district level learning session, SPRING/Uganda facilitated 131 health workers and DQI members for the National PHFS learning session in Kampala. The learning session was organized by MOH with support from ASSIST, SPRING, FANTA and TASO. The goal of the session was to share changes tested, challenges faced, and lessons learned in the process of implementing PHFS in the six districts of

42

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Kisoro, Ntungamo, Namutumba, Tororo, Manafwa, and Jinja. The specific objectives of the learning session included:

• To introduce gender integration in PMTCT care to site teams • To enable site teams to share changes they have tested to improve the focus areas of retention of mother-baby pairs, data quality, routine visits • To share the draft change package • To build competence in prioritization and the use of data • To generate a list of changes tested which can be shared in the spread phase and through coaching visits • To support sites to develop action plans for other key focus areas such as DBS testing, retesting of HIV-negative women, IYCF counseling, maternal counseling and nutrition assessment using the prioritization matrix and their dashboards.

The participating health service providers and DQI members prioritized focus areas for improving retention of mother-baby pairs, provision of standard package for routine visits, data quality, and DBS testing at six weeks. Additionally, gaps in male involvement in eMTCT were identified. A key area for improvement was the current knowledge around ANC, which will be addressed through increased community sensitization and repackaging health talks to accommodate interests and roles of male partners. The participants committed to continue implementing quality improvement projects to improve mother-baby pair retention in care, specifically by keeping the baby and mother’s care cards together in one place and completing the cards immediately after the consultation. Other strategies for improving the quality of standard care services (ART for the mother, CTX/NVP for the mother, IYCF counselling and nutrition assessment) included seeing mothers and their babies on the same day, training expert clients to provide supporting at triage, and creating one point for provision of the standard care. Changes to improve testing of exposed infants at the special visits (six weeks, post- breastfeeding cessation, and 18 months) were also discussed and prioritized.

The district and facility representatives recognized the value of the learning and documentation session and declared to implement all the prioritized actions in their respective facilities. Jointly with ASSIST, monthly coaching is conducted in each of the sites to support them in implementing their priority actions. The next national learning session will be held at the end of February 2014.

Food Fortification

To strengthen efforts for institutionalizing a mandatory food fortification program in Uganda, SPRING/Uganda has been working with the Food Fortification Secretariat in the MOH to a plan series of advocacy meetings with government and private institutions. These meetings will guide them in methods for supporting food fortification efforts in the country, specifically by increasing the demand for adequately fortified foods.

The first meeting was convened by the Secretariat on November 29, 2013. The meeting was attended by 16 representatives from the Ugandan police force, Ugandan prisons, hospitals, schools, Ministry of Education and Sports, MOH, and the private sector including traders. The private sector was urged to increase involvement by organizing small and large scale industries to fortify foods. The representatives

43

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

appreciated the efforts by the government to institutionalize food fortification and pledged their commitment to support the efforts. Additional related meetings will be held next quarter in order to create awareness and obtain commitment among more stakeholders within the public and private sectors. SPRING/Uganda will continue providing technical and logistical support to the Fortification Secretariat in organizing these meetings.

On November 11, 2013, SPRING/Uganda Food Fortification team met with UNBS to discuss methods for improving documentation and coordination of the QC and QA support provided to food processing industries. Shared responsibility between UNBS, MOH, NDA, and UBOS was recommended, in order to ensure food fortification efforts in each department is well documented and coordinated. SPRING/Uganda is to working with the MOH to increase control and oversight of the program from UNBS. The need to revise the regulation manuals, training curriculum reporting format and to establish more laboratory facilities in the regions to decongest the Central Laboratory was identified.

One of the key strategies for passing nutrition messages to the community, district, subcounty, and national leaders, is through designated celebrations and national-level meetings. On World AIDS Day in Namutumba, organized in Nsinze Subcounty, 356 people (158 males, 198 females) received HIV testing and counseling and information on preparing balanced meals for themselves and children. Larger audiences within the district were reached through community dialogues, radio spots, and talk shows. With the theme of “Re-engaging Communities for Effective HIV Prevention” and the slogan of “Accelerating Community Action Towards Zero New Infections,” the district and its partners provided messages for supporting communities to adopt HIV preventive and treatment services for mothers and exposed children. SPRING/Uganda worked with health workers to ensure nutrition and feeding educational sessions were held during the celebrations. Consequently, two testimonials from clients were received and they served as a powerful tool for sharing messages to all HIV infected mothers. Over 450 participants were reached in Kisoro district during similar World AIDS Day celebrations held in December 2013.

In December 2013, SPRING/Uganda participated in the National Nutrition Forum convened by the UNAP Secretariat in the OPM. The forum was organized to share progress on the implementation of UNAP 2011-2016 since it was launched in October 2011.

SPRING/Uganda contributed to a USAID pamphlet on nutrition projects in Uganda, and held a booth to showcase project activities and achievements. SPRING/Uganda also supported the attendance of district officials from Bushenyi, Kisoro, Ntungamo, and Namutumba districts.

Review and Development of Nutrition-Related Policies and Guidelines

SPRING/Uganda participated in official government-convened meetings to update tools and guidelines relevant for nutrition. A key milestone was the review of nutrition tools to be used at health facilities as part of the HMIS. For the first time in Uganda, the HMIS will include tools that routinely capture nutrition information. The new HMIS tools will ensure that nutrition status is tracked through the facility, district, and national HMIS. SPRING/Uganda participated in the development of the tools at all levels. These are expected to be released during the second quarter.

44

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

The MOH revised the training manual for NACS. SPRING/Uganda participated in the development and the pretest, and is using the manual to build the capacity of health workers in its 10 supported districts.

SPRING/Uganda is continuing to support the revision of guidelines for the control of anemia, ensuring that the multisectoral nature of anemia control it taken into account. This is being achieved through support to the Anemia Working Group, which was formed after a SPRING-sponsored national work shop in October 2013.

Dissemination and Advocacy for Use of Nutrition Policies, Guidelines, Job Aids, and M&E Tools SPRING/Uganda will disseminate official documents completed by the GOU. The MOH was not able to complete and release any of the above for this quarter, and therefore this activity has been postponed to Q2 and Q3.

Strengthen the Capacity and Sustainability of the National Fortification Efforts

SPRING/Uganda worked with the East, Central, and Southern African-Health Community (ECSA-HC) in collaboration with USAID/East Africa, to organize a workshop in Kampala on October 7-8, 2013. The goal of the workshop was to create awareness on using Household Consumption and Expenditure Surveys to inform food and nutrition policies. Specific objectives included:

1. To ensure that participants recognize the need for fortification M&E and the role of the HCES 2. To understand how HCES data might be used in a fortification monitoring module 3. To identify ways in which HCES might be strengthened as tools for designing monitoring and evaluating fortification programs

The meeting was attended by 35 participants, mainly government officials from the Bureau of Standards and Statistics responsible for fortification and M&E, representatives from international organizations, and six ECSA member state representatives (Tanzania, Malawi, Uganda, Kenya, Swaziland and Zambia). The meeting helped participants develop country-specific plans on how to use HCES in the design and M&E of fortification programs. As a result, Uganda planned for a fortification M&E workshop to develop its own M&E framework for food fortification.

Following the HCES meeting in Kampala, and to advocate for the institutionalization of a national fortification program in Uganda, SPRING/Uganda provided technical and logistical support for the consultative meetings on M&E framework for fortification. Held on October 11, 2013, the meeting aimed at consultatively developing an operational M&E framework suitable for all stakeholders involved in national food fortification program. A total of 21 participants from MOH, UNBS, UBOS, Makerere University, NDA, SPRING/Uganda, the Private Sector Foundation Uganda, food processing industries, GAIN/Geneva, Flour Fortification Initiative (FFI), and Project Healthy Children/Malawi, attended the meeting. The participants identified activity indicators, data sources and collection methods and developed a draft document that SPRING/Uganda was tasked to edit and lay into a framework. SPRING/Uganda has finalized the draft framework and submitted it to the Fortification Secretariat for review. Upon finalization of the review, SPRING/Uganda will support the Secretariat organize an M&E technical working group and present the draft framework for their input in the next quarter. The project is committed to providing TA to the Secretariat until the Monitoring, Evaluation and Surveillance (MES) system for food fortification is operational. It is anticipated that after the review of the draft framework, process data collection tools and database will be developed. The Secretariat will remain the main 45

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

custodian of the data and UNBS, food processing industries, Uganda Revenue Authority (URA) and other parastatals will regularly feed them with data.

III. Strategic Information

Monitoring Performance on PHFS Indicators

PHFS monitors its set of indicators using a dashboard. Table 3 displays an aggregated dashboard from the four health facilities in Namutumba district for October and November, 2013. Data from December is not yet available.

Table 3: Aggregated Dashboard Indicators Oct Nov 2 % Pregnant women with known HIV status 94.7 57.1 3 % Pregnant women who were counseled, tested and given results 94.6 32.6 4 % Pregnant women initiated on ART 100 100 5 % HIV-negative mothers retested for HIV after every 3 months during pregnancy 10.2 5.6 6 % HIV-exposed infants tested for HIV at 6 weeks (1st PCR) 56.3 55 7 % Exposed infants whose DNA PCR results were given to caregiver 37.5 50 8 % HIV-exposed babies whose mothers were put on ART 91.7 100 9 % HIV-positive mothers who receive IYCF counseling at each visit 50.9 79 10 % HIV-positive mothers who receive maternal nutrition counseling 55.4 86.6 11 % exposed mothers initiating BF within 1 hour of birth 100 100 12 % exposed infants reporting to be adhering to recommended IYCF practices 83 89 13 % HIV-positive pregnant and lactating mothers who at each visit receive NACS 79.8 86.2 14 % Exposed infants who receive nutrition assessment every month 95.7 88.4 15 % HIV-positive mothers malnourished during the reporting period* 0 0 % Exposed infants undernourished & receive RUTF support at any point during the 16 0 0 reporting period % HIV-positive mothers undernourished & receive RUTF support during the 17 0 0 reporting period 18 % Mother-baby pairs who keep their scheduled appointments* 68.3 73.9 19 % Exposed infants malnourished at any point during the reporting period* 0.7 0 % HIV-exposed infants in PMTCT programs that are alive at 18 months of age and 20 25 3.6 HIV positive* Color codes cut offs (%): Red <60, Yellow 60-89 & Green 90+ Indicators with a star (*) Red 10+, Yellow 5-9 & Green <5.

In Q1, SPRING/Uganda continued to generate and provide progress reports to the MOH, FANTA, and USAID. SPRING/Uganda updated the PMP, the GIS shape files and program maps, and participated in the work planning process. Continuous monitoring of project activities has been ongoing. SPRING/Uganda embarked on developing and operationalizing a robust M&E system, which is now in the last stages of development. The system will help streamline SI reporting needs and data management. While this system is under development, the team has continued with data collection for monitoring purposes. SPRING/Uganda participated in 35 meetings across a variety of topics and conducted eight trainings, mainly in the areas of IYCF and NACS, training over 100 people across nine districts. 46

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

SPRING/Uganda supported the MOH to develop an M&E framework for food fortification in collaboration with UNBS, UBOS, Makerere University, National Drug authority, and private sector actors. A draft M&E framework for fortification in Uganda has been developed and is under review by MOH.

SPRING/Uganda worked towards strengthening monitoring and documentation of PHFS in this quarter. SPRING/Uganda actively participated as part of the M&E task force in the development of PHFS baseline assessment tools, and funded the baseline assessment data collection in Kisoro, Ntungamo and Namutumba. On October 7-11, 2013, an orientation of district health team and SPRING/Uganda program staff on baseline data collection in East Central and Southwest was held, while the data collection was conducted in October 14-18, 2013 in all the three districts.

SPRING/Uganda continued with joint monthly data collection in October and November in order to check progress in implementation of priority planned activities for PHFS for each month.

Together with the Namutumba district DNCC focal person and DHO, SPRING/Uganda participated in a meeting organized by WHO and the MOH, to adapt assessment tools for scaling up the ANI project. The meeting was held on December 16-18, 2013 in Colline Hotel Mukono. At the end of this two-day meeting, an agreement was made to finalize the adoption of an existing M&E framework and tools for use in conducting the baseline assessment to inform the formulation of food-based dietary guidelines for Uganda. Since WHO support in Namutumba is focused on improving complementary feeding practices, it will complement the nutrition support provided by SPRING/Uganda to the district. Therefore, it is important that SPRING/Uganda continues its role on the technical team working with the MOH and WHO in conducting the baseline assessment.

During this quarter, SPRING/Uganda finalized a draft report of findings from the first round of the household survey for all SPRING districts, and revised survey plans to adjust for the potential of additional child age groups in future rounds of data collection. In Q2, the LQAS results from the first round will be analyzed at the sub-county level for inclusion into the performance reporting and program monitoring. IV. Activities Planned for Next Quarter

1. Support the MOH and the UBS in coordinating an advocacy and sensitization meeting for institutionalizing food fortification in Uganda, including conducting public institutions’ readiness for mandatory fortification assessment in Uganda. 2. Provide TA to the MOH for: implementation of the work plan for the NWGFF, the Anemia Working Group, PHFS coordination meetings and activities, NACS working group, Technical Working Group on Micronutrient Powders, and Resource Center with regard to the new HMIS tools. 3. Pre-testing of SBCC and CM video campaign materials in Kisoro and Ntungamo districts. 4. Train facilitators of VHTs on how to effectively mobilize and facilitate nutrition enhancing discussions with communities using video testimonials developed by SPRING/Uganda. 5. Implementation of SBCC and CM campaign to promote key nutrition behaviors in six sub- counties of Itojo, Ruhama and Bwongyera in Ntungamo district, and sub-counties of

47

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Muramba, Nyarusiza and Chahi in Kisoro district, using video as a tool and community mobilization activities. 6. Conduct training of health workers in integrating NACS into routine health service delivery in SW Uganda and Namutumba (as part of PHFS), and in support of nutrition interventions in SW Uganda. 7. Support regional and district QI teams in coaching health workers on NACS in PHFS and former NuLife-supported health facilities in SW Uganda and Namutumba. 8. Implement PHFS Baseline Assessment for Phase 11 facilities (all facilities implementing ‘treatment for life’ in Kisoro, Ntungamo and Namutumba). 9. Provide TA to UNAP secretariat in the development of social mobilization and SBCC sub- strategy for UNAP, including consultative meetings with partners. 10. Conduct baseline assessments for Phase 11 of the PHFS, Data Quality Checks. 11. Work with the MOH and MNP working group to prepare for Formative Research for use of MNP as part of improved complementary feeding interventions. V. Administration and Management

To accommodate the increasing operational needs for the project, key administrative activities, especially regarding human resources, were important activities this quarter. Recruitment of staff continued through the quarter and almost all positions have now been filled. SPRING/Uganda hired the following positions in Q1: Program Officer-Fortification and Micronutrients, Nutrition Advisor, Procurement & Logistics Assistant, and two Assistant Accountants. The sub-offices in Kisoro, Ntungamo, and Namutumba are fully functional.

48

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

V. Knowledge Management

This quarter, the KM team finalized a number of PY2 deliverables, hosted three successful webinars, provided support for SPRING’s participation at the 20th Annual International Congress on Nutrition (IUNS), and finalized the PY2 annual report. The KM team officially welcomed a new member in Q1, Alexis Strader, who has an MBA/MA in International Service, a BA from University of North Carolina, and has previously worked with World Vision and Population Services International in Mali. The KM team will share her services with other JSI projects, and she will dedicate 50% of her time to SPRING. Production Updates

The KM team supported SPRING’s major presence at the global IUNS conference in Granada, Spain, in September, including preparing posters for staff presenters and contributing to SPRING’s exhibition booth, by providing display materials, a video compilation highlighting the project’s work, and other promotional materials. The KM team managed the production and finalization of fourteen deliverables this quarter: • 11 poster presentations for IUNS • The PY2 Annual Report • A technical report, Phase I Report of the Early Life Nutrition Linkages to Noncommunicable Disease (ENL-NCD) Model Maternal Interventions to Improve Birthweight and Gestational Age, Bangladesh, was submitted to USAID in October • A poster presentation, Using the DHS Reproductive Calendar to Estimate the Effect of Family Planning Use on Birth Weight, was presented at the American Evaluation Association meeting in October. Online Content

The KM Team developed five blogs this quarter: • Webinar to Highlight How Extension, Technology, and Behavior Change Combine to Improve Agriculture and Nutrition Authors: John Nicholson, SPRING Knowledge Management Manager, JSI Research and Training Institute, and Kristina Beall, SPRING SBCC Project Officer, The Manoff Group Posted on the USAID Impact Blog • JSI @ APHA 2013: Local Research, Global Impact Author: Alexis D’Agostino, Monitoring & Evaluation Analyst, the USAID SPRING Project, JSI Posted on JSI’s The Pump • New application of demographic and health survey in nutrition modeling Author: Alexis D’Agostino, Monitoring & Evaluation Analyst, the USAID SPRING Project, JSI Posted on JSI’s The Pump • Inspired by World Food Day with a success story from Bhola, Bangladesh Author: Mohammad Mazharul Islam, SPRING Upazila Coordinator, Daulatkhan, Barisal Division Posted on JSI’s The Pump • Breastfeeding Support in Bangladesh: Close To Mothers Author: Tonima Sharmin 49

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Posted on the SPRING website

Website Update

During this quarter, the KM Team continued to build and refine the website. Major website additions include the addition of the Nutrition Systems page, new profiles on the leadership page, many more news items, and resources from events, including the Multisectoral Anemia Partners Meeting and a webinar on the SPRING/Digital Green collaboration. SPRING had 10,876 page views from 3,010 unique visitors from 121 countries. Over one-third of the site's visits were from Africa and Asia. There have been 630 downloads from the site during this quarter. Please see Appendix 3 for more information on website analytics. VI. Social Media

SPRING has made significant progress in furthering its efforts to use social media to heighten project visibility. The SPRING Facebook page now has 185 likes, up from 156 last quarter. SPRING's Twitter account now has 457 followers and posts three to five tweets per day, having garnered 113 followers in this quarter. SPRING will continue to use both Facebook and Twitter in highlighting SPRING’s work. Please see Appendix 3 for more information on social media analytics and dissemination.

Next Quarter

In the next quarter the SPRING KM team will: • Finalize the publications that are in progress • Provide country support on an “as-needed” basis • Host one to two webinars.

50

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

VI. Operations, Finance, and Management

This quarter, SPRING finalized and received approval for the PY3 core work plan, completed several PY2 activities, and began work on PY3 deliverables. The quarter began with an increase in funding for SPRING activities from Core and Field support, including the addition of the Agriculture and Nutrition portfolio through the Bureau for Food Security (BFS), increased funding in Bangladesh, and the submission of a concept note to USAID/Ethiopia.

With Christian Winger’s resignation early in quarter 1, Carolyn Hart stepped in as interim Project Director and submitted her approval request to serve as permanent SPRING Project Director. In anticipation of her approval, SPRING spent much of the first quarter focused on reviewing the project’s management structure, as well as the supporting processes and operations systems to accommodate for the change in personnel. In addition, SPRING reorganized project staffing, identified personnel gaps, and defined needs for the successful implementation of the PY3 work plan. Also of note is that SPRING is developing a series of tracking tools to monitor progress of activities and status of deliverables, to include a web-based tracking sheet that will streamline the quarterly reporting process. The Project Management Team is also working with the USAID team to define meeting requirements, times, and action item tracking.

SPRING also finalized and posted the position for Country Support Team Lead to support the SPRING Country Initiatives portfolio, the Project Officer position to support the Core activity in the Sahel region of Africa, and a Program Coordinator position to assist with the ever-growing needs of the project. As SPRING expands, we continue to refine our internal processes and protocols, increase transparency amongst all partners, and fine tune our internal communication. SPRING is in the process of implementing more robust Consultant Policy and Guidelines and Short-term Technical Assistance Guidelines, and refining previous processes based on lessons learned from the last year.

Financially, SPRING continues to increase funding and expenditures. Q1 of PY3 continues SPRING’s upward trend of expenditures and expansion of activities across all funding sources.

Next Quarter

In the next quarter SPRING will: • Hire and orient identified new staff (Country Support Team Lead, Country Program Officer, and Program Coordinator) • Recruit for a IYCN/SBCC Technical Advisor • Roll out the web-based Activity Project Tracking System.

51

SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

VII. Monitoring and Evaluation

SPRING is committed to increasing evidence-based decisionmaking and establishing a culture of information use both within core and country work, as well as in the countries where SPRING works. Rigorous M&E is an integral component of SPRING project management and implementation.

SPRING tracks performance and effectiveness using a package of linked MS Excel worksheets that aggregate data on indicators from SPRING’s performance monitoring plan (PMP). This serves as an early warning system and enables constructive and participatory discussions and planning of program design and implementation at all levels.

An updated version of the PMP which includes these achievements is included in Appendix 2. In the section that follows, SPRING provides a more detailed explanation of the main achievements reported in the PMP. These include achivements of core and country teams.

Country- and region-specific situational/landscape analyses carried out by SPRING (PMP Indicator 1.1)

During this quarter one landscape analysis was underway: the analysis of anemia and anemia programs among women of reproductive age and children in Uganda.

People trained in child health and nutrition through USG-supported health area programs (PMP Indicator 1.2)

During Q1, a total of 151 people were trained in Haiti and Uganda over the course of nine trainings. In Haiti, SPRING provided IYCF and NACS training to master trainers in conjunction with FANTA and the Ministry of Health (MSPP). In Uganda, SPRING conducted trainings on NACS, quality improvement, logistics management of RUTF, quality assurance of fortified foods, and management of acute malnutrition. Figure 4 and Table A provide more information on the numbers trained and on each individual training respectively.

Figure 4. Numbers of people trained and trainings in Haiti and Uganda*

*NOTE: No trainings were conducted in Bangladesh or Nigeria during Q1.

54 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table A. List of trainings conducted # OF PEOPLE TRAINED LOC. TITLE BY GENDER COMMENTS/DESCRIPTION TOTAL MALE FEMALE TOT on IYCF This was a 5 ½-day training of trainers (TOT) organized by SPRING and MSPP for master and HIV trainers from the seven PY3 facilities. Average score for the pre-test was 23/40; average Haiti 31 5 26 Nutrition score for the post test was 33.5/40. Twenty-four participants out of 31 scored 80% or (NACS) more.

TOT On IYCF This was a four-day NACS TOT organized by SPRING/Haiti, FANTA, and MSPP for Master and HIV Trainers from the PY2 facilities. Average score for the pre-test was 13.2/20, average Haiti 19 1 18 Nutrition score for the post test was 17.4/20. Sixteen out of nineteen participants scored 80% or (NACS) more.

SPRING supported participants and trainers with training materials and allowances. The training consisted of 19 health workers from Ishaka Adventist Hospital, 1 health worker Uganda NACS training 36 10 26 from each of the following health facilities; Bushenyi health center IV, Kabushaho HC IV, Kabushaho HC IV, Kyabugimbi HC IV, Kyabujimbi HCIV, Kyeizoba HC III, Kyeizoba HCIII, Kyeizoba HCIII, Kyeizoba HC III, and 8 SCORE project staff members.

SPRING facilitated the participants and trainers with training materials and allowances, Uganda NACS training 18 2 16 tea breaks, and lunch. In the training there were 16 health workers, 1 storekeeper from Mbarara regional referral hospital, and the Mbarara District Nutrition Focal Person.

Fortification Good Trainees included lab technicians, machine operators, production officers, quality Uganda Manufacturing 136 N/A* N/A* controllers of 15 industries. Total number trained were 21 for maize, 48 for oil, and 67 Practices and for wheat. QA/QC

55 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table A. List of trainings conducted # OF PEOPLE TRAINED LOC. TITLE BY GENDER COMMENTS/DESCRIPTION TOTAL MALE FEMALE This training was aimed at equipping participants with knowledge and skills in eMTCT to IYCF and Uganda 18 6 12 enable them adequately support HIV-positive pregnant and lactating mothers to access eMTCT training comprehensive care. QI training for district QI team The training was organized by SPRING and facilitated by USAID|ASSIST. The training was Uganda 29 20 9 and SPRING intended to equip participants with skills in quality improvement. staff Management of This training was considered Continuing Medical Education (CME). It was aimed at Uganda acute 25 N/A* N/A* capacity building for health workers on the management of acute malnutrition in malnutrition Outpatient Therapeutic Care (OTC). Logistics This was also CME, focusing on logistics management systems and tools such as order Uganda management 51 N/A* N/A* forms and a dispensing log. A practical session was conducted on how to properly fill out for RUTF the forms. * Note: Number of trainees by gender will be available in Q2.

56 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Figure 5 displays the number of people trained by SPRING in each quarter, as well as the cumulative total number trained. The majority of trainings occurred in Bangladesh, and therefore the total number trained is heavily influenced by activity in the country. Because SPRING/Bangladesh decided to shift their focus to needs-based refresher trainings, it did not conduct any training in Q1 but anticipates ramping up refresher training in Q2.

Figure 5. Total number of people trained by SPRING and cumulative total, by quarter

Instances of technical assistance provided to SPRING-supported countries (PMP Indicator 1.6)

Technical assistance (TA) is defined as support provided by SPRING (including SPRING staff and consultants) to country programs during TDY trips. Appendix 1: Quarter 1 Travel provides detail on each TDY trip and denotes whether each trip included TA. Throughout the quarter, there were 22 instances of TA. This included trips to (among other things): initiate work in the Sahel region; provide operational support to field offices during transitional times; facilitate and impart knowledge at workshops; and create national strategies for anemia, social and behavioral change, and micronutrient powder roll-out in Uganda.

57 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Geographic reach of SPRING country activities (PMP Indicators 1.3.1 and 1.3.2)

The tables below outline the reach and coverage of SPRING activities in the four main countries where SPRING operates. Table B shows the number of geographic units (i.e. upazilas, departments, LGAs, districts) where SPRING operates vs. targets and the total number of such units in the country.

Table B. Geographic coverage of SPRING country activities SUB-NATIONAL GEOGRAPHIC UNITS COUNTRY Number reached in Number reached in quarter/year as a percent of… Number targeted for PY3 Number in country quarter Number targeted for PY3 Number in country Bangladesh 40 40 486 100% 8% (upazilas) Haiti 5 5 10 100% 30% (departments) Nigeria 4 35 774 11% 1% (LGAs) Uganda 9 19 112 90% 8% (districts)

Facilities and services reached by SPRING country activities (PMP Indicators 1.3 and 1.4)

Table C shows the number of service sites and institutions receiving SPRING support. In all four SPRING countries, health facilities were supported by the project through trainings and tools. In Bangladesh, in addition to 1,480 health facilities 3,709 farmer field schools were supported by SPRING, totaling to 5,189 service sites. SPRING/Nigeria supported 99 support groups in addition to 30 health facilities, for a total of 129 service sites. Table D describes support to institutions in brief detail.

Table C. Service sites and institutions reached by SPRING country activities NUMBER OF SERVICE SITES NUMBER OF INSTITUTIONS COUNTRY REACHED SUPPORTED Bangladesh 5,189 6 Haiti 12 2 Nigeria 129 6 Uganda 47 11

58 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table D. Institutions receiving support from SPRING country activities Institutions (government or NGO) receiving Description of activities Country SPRING support Bangladesh Directorate General of Health Services SPRING attends monthly DGFP, DGHS and DAE health and family planning (DGHS) coordination meetings in all 40 intervention upazilas and remains an active participant in Dhaka with the National Nutrition Working Group, CSA-SUN, RCHCIB, and the NGO coordination meetings. Bangladesh Directorate General of Family Planning See above (DGFP)

Bangladesh Directorate of Agriculture Extension (DAE) See above

Bangladesh Agriculture Information Services See above. Uses their multiple media platforms to disseminate "small do-able" actions that lead to improved nutrition. Bangladesh Government of Bangladesh’s Institute for While FANTA-III provided technical leadership, SPRING, along with many other Public Health and Nutrition (IPHN) and the NGOs and projects, provided technical input on a national nutrition curriculum and National Nutrition Service (NNS)/ will be adapting the curriculum as part of its training package for frontline health Revitalization of Community Clinic Health workers in PY3. Care Initiatives Bangladesh Aquaculture for Income and Nutrition (AIN) The AIN project, implemented by World Fish, included and conducted hand washing sessions and included Tippy Tap instructions in their manual as a part of the nutrition training, with technical assistance from SPRING. Haiti Ministry of Health (MOH) Supported the MOH through its support to health facilities, and in revising its IYCF counseling cards for SBCC. Haiti National Security Program from Partners of Participated in a training of trainers for community health workers (CHWs) and the Americas leader mother capacity building organized by SPRING/Haiti.

59 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table D. Institutions receiving support from SPRING country activities Institutions (government or NGO) receiving Description of activities Country SPRING support Nigeria Oyo State MOH SPRING disseminated and shared the IYCF training packages developed by SPRING Ondo State MOH with the representatives of Ministry of Health during the MNCHW Partners Review Osun State MOH and Planning Meeting in Ibadan. Ogun State MOH Lagos State MOH Ekiti State MOH Uganda Uganda National Bureau of Standards (UNBS) SPRING supported UNBS to organize a meeting for industries aimed at improved reporting for GMP, QA/QC, and also training industries on good manufacturing practices, dosing, verification, and calibration Uganda Office of the Prime Minister (OPM) SPRING supported OPM to organize the Nutrition Forum and continuity of DNCC activities at district level. Uganda MOH SPRING organized meetings in conjunction with the MOH on fortification industrialization, the National Anemia Stakeholders Meeting, and National Working Group on Anemia. Uganda Kisoro District Local Government SPRING supported health facilities in the district local governments by conducting Ntungamo District Local Government routine mentorship and coaching for health workers, participating in district Namatumba District Local Government planning meetings in Ntungamo, Kisoro, and Kabale districts, and participating in Strengthening Decentralization for Sustainability (SDS) meetings to review Bushenyi District Local Government progress made on planned activities for the previous quarters and planned Mbarara District Local Government activities for the next quarter. SPRING also participated in district health Ibanda District Local Government management meetings organized by the districts. Kabale District Local Government Kanungu District Local Government Runkungiri District Local Government Sheema District Local Government

60 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Population reached by SPRING country activities (PMP Indicator 1.3.3)

Table E shows the number of people reached through counseling or community events supported by SPRING. In all four SPRING countries, health facilities were supported by the project through trainings and tools.

Table E. Number of people reached by SPRING country activities ESTIMATED NUMBER OF PEOPLE REACHED LOCATION BY GENDER COMMENTS/DESCRIPTION TOTAL CHILDREN <5 MALE FEMALE Bangladesh 48,000 0 36,968 23,181 Delivered messages on agriculture, poultry, fish culture, and ENHA through farmer field schools. Bangladesh 452,176 0 452,176 318,521 Frontline health workers provided one-on-one counseling on ENHA at health facilities. Nigeria 2,750 1,000 1,700 0 Provided a community orientation/sensitization to IYCF in Bwari Council, FCT. Nigeria 3,565 1,000 2,000 0 Provided a community orientation/sensitization to IYCF in Abaji Area Council, FCT. Nigeria 792 245 547 0 C-IYCF groups provided group counseling to support pregnant women and other community members. Uganda 83 11 72 0 As part of the Great Mothers and Health Children video campaign, community events were run in Kisoro and Ntungamo districts. Uganda 1,286 514 772 0 During the World AIDS Day celebration in Namutumba, HIV counseling and testing services, food demonstrations and nutritional advice were given, men received safe male circumcision and testimonials on HIV were arranged. Uganda 5,000 0 0 0 SPRING, in conjunction with the local government, supported a marathon in Bushenyi district where mother- baby pairs received nutrition assessments. Uganda 420 0 420 0 HIV-positive pregnant and lactating women received nutritional status assessments in facility-based group counseling sessions. Uganda 420 0 420 0 In one-on-one counseling sessions, HIV+ pregnant and lactating women received nutrition advice, including IYCF in the context of HIV and maternal nutrition.

61 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Figure 6 summarizes the number of people reached in each quarter, as well as over the course of the SPRING project. Similar to the number of people trained, these numbers are in large part due to activities in Bangladesh. However, although the number of trainings per quarter fluctuated from quarter to quarter, the number of people reached per quarter has consistently increased.

Figure 6. Number of people reached by SPRING and cumulative total, by quarter

62 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Number of country, regional, and global meetings conducted or attended (PMP Indicator 2.1.1)

SPRING was active in the global dialogue on nutrition during the past quarter, participating in 13 major meetings and conferences, presenting at six of those meetings, and hosting five of them. The topics were wide-ranging, covering anemia, behavior change communication capacity building, food security, and scaling up nutrition. Descriptions of each meeting are in Table F below.

Table F. Country, regional, and global meetings conducted or attended by SPRING SPRING SPRING Date Title (Location) hosted/ SPRING staff attending Description presented organized 12/17/13 WEBINAR; Seeds of Change: Yes Kristina Beall, John No A webinar hosted on Dec 17th to learn more about Leveraging Community Video Nicholson, Peggy Koniz- the Digital Green community-led video approach, for Agriculture and Nutrition Booher, Aaron Buchsbaum, and how nutrition can be integrated into this unique Behavior Change in South Alexis Strader, Carolyn agricultural extension platform. Asia and Sub-Saharan Africa Hart, Sam Clark, Lidan Du, Anu Narayan, Ashley Aakesson, among others.

12/11/13 Tajikistan Communications Yes Alyssa Klein, Judiann Yes A workshop for Mission and Feed the Future to Workshop McNulty (Consultant) implementing partner staff to consider how their 12/13/13 projects could better communicate with beneficiaries, each other, funders, and the government and how they could better work together to improve communications strategies and reach goals. 12/05/13 Food Security Discussion: No Alexis Strader, Victor Pinga No After a review of final evaluation reports of Food for to Promising Practices by PVOs Peace-funded development assistance projects, the 12/06/13 that Contributed to a TOPS program team of technical specialists has Reduction in Child Stunting identified a variety of promising practices among projects that demonstrated a measurable decline in stunting. This meeting was to discuss these promising practices for further dialogue among the food security community.

63 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table F. Country, regional, and global meetings conducted or attended by SPRING SPRING SPRING Date Title (Location) hosted/ SPRING staff attending Description presented organized 11/18/13 Food Security and Nutrition No Sarah Titus, Peggy Koniz- Yes The goal of the meeting was to support the TOPS to (FSN) Network Regional Booher community of practice by providing opportunities for 11/20/13 Knowledge Sharing Meeting food security practitioners to identify needs, build collaboration, and create mechanisms for continued communication and learning. Ms. Titus presented on SPRING's approach to integrating agriculture and nutrition using the key programing principles and agriculture-nutrition pathways framework. 11/13/13 Second International No Heather Danton Yes The goal of this two-day forum was to set objectives to Conference on Nutrition of the ICN2, a high-level ministerial conference 11/15/13 (ICN2) which will propose a flexible policy framework to address today’s major nutrition challenges and identify priorities for enhanced international cooperation on nutrition. 11/03/13 American Public Health No Alexis D'Agostino, Manisha Yes Alexis D'Agostino and Manisha Tharaney presented to Association (APHA) Tharaney, Timothy SPRING work at the annual APHA conference. The 11/06/13 Conference Williams presentations covered SPRING's work in IFA system analysis and workforce analysis, respectively. 10/31/13 UNICEF Meeting on Yes Toby Stillman, Peggy Koniz- No UNICEF came to SPRING to present their Breastfeeding Advocacy Booher, Kristina Beall, Anu Breastfeeding Advocacy Initiative and request Initiative Narayan, Sascha Lamstein, support from SPRING. Ashley Aakesson

10/24/13 Forum on Stunting Reduction No Anu Narayan, Victor Pinga No Alive & Thrive and the Government of Ethiopia co- to hosted a Forum on Stunting Reduction: Nutrition & 10/25/13 Beyond for Solutions. The purpose of the Forum was to explore approaches to stunting reduction with a focus on practical guidance for the design, implementation, and evaluation of stunting reduction programs.

64 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table F. Country, regional, and global meetings conducted or attended by SPRING SPRING SPRING Date Title (Location) hosted/ SPRING staff attending Description presented organized 10/22/13 MIYCN-FP Working Group Yes Kristina Beall, Peggy Koniz- Yes Regular meeting of the MIYCN-FP Working group co- Meeting Booher, Agnes Guyon chaired by SPRING and MCHIP, including representatives from about 20 organizations working at the intersection of nutrition and family planning. 10/16/13 American Evaluation No Alexis D'Agostino Yes Alexis D'Agostino presented a poster on use of the to Association (AEA) Conference DHS reproductive calendar to estimate the effect of 10/19/13 family planning use on birth spacing in Bangladesh at the annual AEA conference meeting. 10/18/13 Multisectoral Anemia Yes Manisha Tharaney, Jessica Yes SPRING, in collaboration with the USAID-led Partners Meeting Tilahun, Jolene Wun, Multisectoral Anemia Task Force Secretariat, hosted Samantha Clark, Sarah a Multisectoral Anemia Partners Meeting designed Thornton, Ryan to bring together practitioners, partners, and Macabasco, Daniel Cothran government representatives to identify ways to work together across sectors within countries to address the multiple causes of maternal and child anemia. 10/10/13 USAID/World Bank-SASKI No Kristina Beall, Peggy Koniz- No Co-hosted by USAID and the World Bank-SASKI this Agriculture Seminar: Digital Booher agriculture seminar featured the work of Digital Green: An Update from the green presented by DG CEO Rikin Gandhi. USAID has Pioneer in Low Cost Video for provided several low cost video workshops for Agriculture and Nutrition in implementing partners in Africa based on this India and Africa approach and World Bank's livelihood projects in India are using Digital Green's video-methodology for agriculture and nutrition extension. 10/02/13 Uganda National Anemia Yes Manisha Tharaney, Jack Yes The meeting drew 110 participants from a wide to Stakeholders Meeting Fiedler, Jolene Wun range of stakeholders, including Ugandan national 10/03/13 ministry and district-level representatives; USG implementing partners, and civil society. By the end of the meeting, a sector-by-sector action plan identifying the priority actions that should be taken to reduce anemia was developed.

65 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Number of networks or community of practice groups that SPRING leads or participates in (PMP Indicator 2.1.2)

SPRING HQ staff continue to participate in the 26 networks/communities of practice mentioned in previous quarters.

Research and evaluation activities conducted by SPRING (Indicator 2.2.1)

During this quarter 16 research and evaluation activities were underway or completed:

• Landscape analysis of anemia and anemia programs among women of reproductive age and children in Uganda • Digital Green Pilot and Feasibility Study in India • Evaluation of the UNICEF Community-IYCF package in Nigeria • SBCC Literature Review on platforms for increasing high-impact MIYCN practices • Literature review of optimal dietary practices of pregnant and lactating women and women of reproductive age • Literature review of social and behavior change theory and practice from multiple disciplines and sectors • Review of context assessment guide/tools for Agriculture/Nutrition • Nutrition mapping exercise of USAID centrally-funded investments • Literature review of the food system environment • Review of drivers and barriers to scaling up key nutrition interventions • Operations research to evaluate a new approach to improve nutrition workforce capacity in Haiti • Multi-country analysis of IFA provision and consumption across high-burden countries • Qualitative study on motivation to produce, sell, and consume homestead food production goods in Bangladesh • Qualitative study on importance of cross-sector coordination in implementing agriculture/nutrition projects in Burkina Faso • Analysis and documentation country-level efforts to reduce undernutrition over time ("Pathways to Better Nutrition" Case Studies) • Research on IFA and IYCF behaviors following counseling visits in Southwest Uganda.

66 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Documents (reports, tools, statements) produced by SPRING (PMP Indicator 2.2.3)

By the end of this quarter, SPRING had completed the content for 20 products which were submitted to USAID. These are listed in Table G, below.

Table G. Documents completed and finalized TITLE OF DOCUMENT TYPE AUTHOR(S)

COMPLETED (CONTENT COMPLETED AND SUBMITTED TO USAID, IF REQUIRED) Side-by-Side Summary of Two “Packages” for Informational Peggy Koniz-Booher, Community-Based Infant and Young Child Feeding product Kristina Beall, Sascha Counseling Lamstein, Toby Stillman

mNutrition Strategy Briefs/other report Andrea Spray, Daniel Cothran, Mike Frost, and Kristina Beall

Workforce Mapping Tool Tool Manisha Tharaney, Meghan Anson, Riitta-Liisa Kolehmainen-Aitken

Country Profile of NR-NCDs: Uganda (resubmission Briefs/other report Amanda Pomeroy, Alexis with major revisions) D’Agostino

Country Profile of NR-NCDs: Haiti (resubmission Briefs/other report Amanda Pomeroy, Alexis with major revisions) D’Agostino

Phase I Report of the Early Life Nutrition Linkages Briefs/other report Amanda Pomeroy, Marc to Non-Communicable Disease (ENL-NCD) Model Cunningham, Alexis (resubmission with major revisions) D’Agostino, Warren Stevens, and Jolene Wun

Social and Behavior Change Communication Briefs/other report Sascha Lamstein, Peggy Pathways for Maternal, Infant, and Young Child Koniz-Booher, Kristina Nutrition Practices Beall, and Ashley Aakesson

Improving Nutrition through Agriculture: Briefs/other report Anna Herforth and Jody Understanding and Applying Primary Pathways Harris and Principles

Improving Nutrition through Agriculture: Briefs/other report Ag/Nut team Understanding the Food Production Pathway

Improving Nutrition through Agriculture: Briefs/other report Ag/Nut team Understanding the Agricultural Income-to- Nutrition Pathway

67 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Table G. Documents completed and finalized TITLE OF DOCUMENT TYPE AUTHOR(S) Improving Nutrition through Agriculture: The Role Briefs/other report Ag/Nut team of Women's Empowerment

Addendum to the Nutrition SBCC eLearning Briefs/other report SBCC Team Landscape Report

Nutrition SBCC eLearning Curriculum Concepts Briefs/other report SBCC Team Brief

Agriculture and Nutrition Global Learning and Briefs/other report Ag/Nut team Evidence Exchange (AgN-GLEE) Final Report

SPRING PY2 Annual Report Briefs/other report SPRING Project

Using the DHS Reproductive Calendar to Estimate Presentation Alexis D’Agostino the Effect of Family Planning Use on Birth Weight

SPRING Nutrition Brief: A Rapid, Initial Assessment Briefs/other report John L. Fiedler, Alexis of the Distribution and Consumption of IFA Tablets D'Agostino, Celeste through Antenatal Care - Rwanda (resubmission Sununtanasuk with major revisions)

SPRING Nutrition Brief: A Rapid, Initial Assessment Briefs/other report John L. Fiedler, Alexis of the Distribution and Consumption of IFA Tablets D'Agostino, Celeste through Antenatal Care - Kenya (resubmission with Sununtanasuk major revisions)

Toolkit for Evaluating Capacity for and Tools Sascha Lamstein, Simon Implementation of Nutrition Assessment, Sadler, Timothy Williams, Counseling, and Support Services at Health Manisha Tharaney, Kristen Facilities Kappos, Peggy Koniz- Booher, Toby Stillman Part I: Introduction, Background and General Guidance on Priority Measurement Points for NACS

Part II: Tools for the NACS Health Facility Assessment

FINALIZED AND POSTED ON SPRING WEBSITE Building on Uganda 's Progress in Reducing Presentation Manisha Tharaney Anemia: From Evidence to Action

68 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Appendix 1: Quarter 1 Travel

DATES Technical Traveler Country assistance Purpose START END provided? To review the SPRING/Bangladesh PMP indicators and targets, and make revisions as necessary. The secondary purpose was to work with SPRING/Bangladesh staff, particularly the newly hired 9/26/2013 10/10/2013 Tim Williams Bangladesh Yes Strategic Information Officer and the incoming Country Manager, to ensure that SPRING’s SI systems are functioning well and collecting/utilizing appropriate information to meet reporting and project management needs. To prepare for and participate in the National Anemia 9/27/2013 10/11/2013 John Fiedler Uganda Yes Stakeholders Meeting, led by SPRING/Uganda in partnership with the MOH. To prepare and participate in the national M&E 9/27/2013 10/11/2013 Manisha Tharaney Uganda Yes meeting on food fortification led by SPRING/Uganda. To participate and co-facilitate an M&E meeting around food 9/27/2013 10/11/2013 Jolene Wun Uganda Yes fortification held by ECSA-HC. To meet with USAID and local consultant for Feed the Future 10/4/2013 10/12/2013 Heather Danton Tajikistan No SBCC and mass media messaging research project. With the transition of leadership and growth of the team in Haiti, the main purpose of the visit is to work with the SPRING team in 10/7/2013 10/11/2013 Anu Narayan Haiti Yes Haiti to plan out PY3 activities, strengthen management and operations to meet PY3 deliverables and ensure that communication and reporting channels are strengthened. To initiate support to the Uganda OPM in the development of 10/15/2013 10/23/2013 Ashley Aakesson Uganda Yes the Social Change and Mobilization Sub-strategy of the National 10/15/2013 10/23/2013 Marcia Griffiths Uganda Yes Nutrition SBCC and Advocacy Strategy. Represent SPRING in the Alive & Thrive Forum on Stunting 10/23/2013 11/06/2013 Anu Narayan Ethiopia No Reduction: Nutrition & Beyond for Solutions held on 24-25 October in Addis Ababa; collect data for technical brief series, 10/23/2013 11/06/2013 Victor Pinga Ethiopia No and determine future technical assistance needs.

69 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

DATES Technical Traveler Country assistance Purpose START END provided? Burkina 10/26/2013 10/31/2013 Aaron Buchsbaum No Faso To conduct training for qualitative interview team, and provide Burkina initial supervision of data collection. 10/26/2013 10/31/2013 Joby Harris Yes Faso 10/26/2013 11/2/2013 Laird Ruth Uganda Yes To prepare for and participate in a National Stakeholder’s 10/26/2013 11/2/2013 Manisha Tharaney Uganda Yes Meeting on the roll out of MNPs in Uganda. Burkina To participate in and present at the Food Security and Nutrition 11/16/2013 11/21/2013 Sarah Titus Yes Faso Knowledge Sharing Workshop in West Africa and also to establish and/or strengthen connections with food Burkina security/resilience program implementers to prepare for REGIS 11/16/2013 11/21/2013 Peggy Koniz Booher Yes Faso SBCC work. To continue to collect information about existing nutrition, food security and resilience programing, as well as materials, 11/21/2013 11/26/2013 Peggy Koniz-Booher Niger Yes messages and methods to support the design and initial execution of the SBCC work under the SPRING Sahel Program, which will ultimately support the development of the REGIS-ER 11/21/2013 11/26/2013 Waverly Rennie Niger Yes project’s nutrition and hygiene –related SBCC strategy and activities. The objective of the TDY is to provide interim technical and operational support to the SPRING/Uganda team while the SPRING/Uganda Program Manager is on a six-week leave of 10/21/2013 11/8/2013 Kristen Kappos Uganda Yes absence. Coverage is required and timely, given SPRING/Uganda is entering the new fiscal year and there is considerable planning needed to realize the activities in the PY3 work plan. 11/10/2013 11/22/2013 Amanda Pomeroy Uganda Yes To conduct national-level key informant and budget interviews for the Pathways to Better Nutrition (PBN) Case Studies activity, 11/10/2013 11/22/2013 Lidan Du Uganda No and provide technical assistance to the Uganda strategic 11/10/2013 11/22/2013 Alexis D’Agostino Uganda Yes information team. 11/12/2013 11/15/2013 Heather Danton Italy No To attend the preparatory meeting for the International

70 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

DATES Technical Traveler Country assistance Purpose START END provided? Conference on Nutrition 2 in Rome, Italy and to speak on a panel related to agriculture and nutrition. To convene key stakeholders from the Federal and State 11/16/2013 11/27/2013 Bridget Rogers Nigeria Yes Ministries of Health, SMILE, STEER, etc. for a three-day workshop to feed into a detailed implementation plan for rollout of the 11/16/2013 11/27/2013 Toby Stillman Nigeria Yes Facility and Community IYCF packages in five Nigerian states. The overall objective of this TDY was to provide M&E-related support to the SPRING/Haiti team. This included finalizing the plans for and supporting the collection of baseline data in new 11/18/2013 11/24/2013 Sascha Lamstein Haiti Yes health facilities; finalizing plans for conducting Reinforcement Visits (RVs); supporting the collaboration with HEALTHQUAL/CDC for QI activities; and providing general M&E support to ensure that the project’s data collection efforts for the PMP are sound. To provide follow-up support in the administration, operations, 12/1/2013 12/14/2013 Alan Rogosch Uganda Yes and management to SPRING/Uganda through TA related to in- country operations and the provision of targeted training. 12/8/2013 12/16/2013 Alyssa Klein Tajikistan Yes To host a two-day workshop for USAID/Tajikistan and Feed the Future implementing partner staff and support national 12/8/2013 12/16/2013 Judiann McNulty Tajikistan Yes consulting firm, M-Vector, to complete their work. To participate and present at the Smarter Futures/Flour 12/09/2013 12/14/2013 Celeste Sununtnasuk Tanzania Yes Fortification Initiative Cost and Economic Benefit Workshop. 12/19/2013 12/21/2013 Kristen Kappos Haiti Yes Provide management support to the SPRING/Haiti team. 12/09/2013 12/18/2013 Peggy Koniz-Booher Niger Yes To provide technical support to the REGIS-ER Project team in the development of the nutrition-related SBCC work plan and M&E 12/09/2013 12/18/2013 Waverly Rennie Niger Yes indicators for REGIS-ER and continue ongoing SPRING Sahel SBCC activities.

71 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Appendix 2: Performance Monitoring Plan and Progress Tracking

Achievements No. Indicator PY3 Q1 Q2 Q3 Q4 Strategic Objective: Policies and Programs to scale up effective nutrition services improved*

Number of children under five reached by USG- 1 355,489 supported nutrition programs

Number of children under five who received 2 0 vitamin A from USG-supported programs IR 1: Country-specific approaches to scale up nutrition programs improved* Number of situational analysis/ landscape analysis 1.1 1 carried out by SPRING

Number of people trained in child health and 1.2 nutrition through USG-supported health area 363 programs

Number of facilities or services (e.g., health 1.3 facilities, farmer field schools, others) reached 5,377 with SPRING support Number of institutions reached with SPRING 1.4 25 support Number of health facilities with established 1.5 Measured and reported on an annual basis. capacity to manage acute under-nutrition

Number of instances of technical assistance 1.6 23 provided to SPRING-supported countries

Sub-Result 1.1: Country-specific SBCC programs strengthened

Estimated number of contacts made through 1.1.1 513,700 SBCC activities Number of people accessing nutrition e-learning 1.1.2 N/A N/A N/A N/A module

See also indicators 1.2, 1.3, 1.4, 1.6

Sub-Result 1.2: Country-specific approaches to improve dietary quality and diversity (including

72 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Achievements No. Indicator PY3 Q1 Q2 Q3 Q4 micronutrient adequacy) advanced See indicators 1.2, 1.3, 1.4, 1.6 Sub-Result 1.3: Country-specific scale-up of evidence based nutrition interventions supported Number of geographic units reached by SPRING 1.3.1 58 activities

Percent of geographic units in the country 1.3.2 See Section VII, Table B reached by SPRING activities Percent of target population reached on SPRING - 1.3.3 Measured and reported on an annual basis. supported geographic units See also indicators 1.2, 1.3, 1.4, 1.6 IR 2: Global evidence base, advocacy platforms, and policies for nutrition expanded Number and type of dissemination activities 2.1 8 supported by SPRING Sub-Result 2.1: Policy and advocacy efforts to support food and nutrition policies and programming strengthened Number of country, regional, and global meetings 2.1.1 13 conducted or attended

Number of networks or community of practice 2.1.2 26 groups that SPRING leads or participates in Sub-Result 2.2: Evidence base learning, monitoring and evaluation for effective approaches to scale- up nutrition services expanded Number of research and evaluation activities 2.2.1 16 conducted by SPRING Number of instances where standard nutrition 2.2.2 Measured and reported on an annual basis. metrics are improved based on SPRING inputs 19 Number of documents (reports, tools, statements) 2.2.3 completed, produced by SPRING 1 finalized 2.2.4 Number of unique visits to SPRING website 3,010

73 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Appendix 3: SPRING Website Activity and Outreach

Users Accessing the SPRING Website

• SPRING had a total of 5,294 visits from October 1, 2013 to December 31, 2013 from 3,010 absolute unique visitors (a 1% increase over PY2 Q4). Absolute unique visitors are unduplicated visitors—each visitor is counted only once. • In total, SPRING had 10,876 unique page views during PY3 Q1. • Approximately 30% of all SPRING Q1 visits included three or more pageviews. o Average pageviews per visit during Q1 was 2.6. • Approximately 95% of all SPRING Q1 visits lasted over 3 minutes. o Average time on site during Q1 was 4 minutes, 21 seconds. • Users who are familiar with the SPRING website explore content more extensively. Returning visitors to SPRING interact with the content for a longer period of time, spending more time on the website (average: 5 minutes, 45 seconds) and viewing more pages (average: 2.84) per visit than new visitors (average: 3 minutes, 3 seconds and 2.37 page views per visit). • Approximately 46% of users accessed the SPRING website from outside of the United States. • Visitors accessed the SPRING website from 121 countries with over 16% of all visits coming from Africa and approximately 18% of visits coming from Asia.

Top 10 Countries Visits from Africa, by Region – PY3 Q1

Visits to SPRING – PY3 Q1 %

1. United States Eastern Africa 63

2. Bangladesh Western Africa 30

3. Uganda Southern Africa 5

4. India Northern Africa 1

5. Nigeria Middle Africa >1

6. United Kingdom

7. Canada

8. Ethiopia

9. Kenya

10. Burkina Faso

74 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Top 5 SPRING Webpages (PY3 Q1, excluding SPRING homepage)

1. Events 2. About Us 3. News 4. Publications 5. Technical Areas

Downloads

• A total of 630 documents were downloaded from the SPRING website during PY3 Q1. o Top 5 downloads for this reporting period included: 1. The Multisectoral Anemia Partners Meeting Participant Guide (44) 2. The Multisectoral Anemia Partners Meeting Agenda (35) 3. Guatemala Integration Lab presentation (30) 4. Building on Uganda's Progress in Reducing Anemia: From Evidence to Action (29) 5. Uganda NACS Assessment (29)

Number of Downloads, by Quarter 655 663 700 630 600 533

500

400

300

200

100

0 FY 2013 Q2 FY 2013 Q3 FY 2013 Q4 FY 2014 Q1

Downloads

75 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Outreach/Traffic to SPRING (PY3 Q1)

Traffic Sources - FY 2014 Q1

3% 9% Search Engines

Direct Traffic 14%

46% Social Media (Faceb Twitter & LinkedIn) Sites that link to SP

Email 28%

• Sites that link to SPRING drove approximately 9% of all traffic to the website. The following websites were among those that linked to the SPRING website:

o www.agrilinks.org o www.digitalgreen.org o www.fsnnetwork.org o www.usaid.gov o www.K4health.org o www.fantaproject.org

• 45% of the traffic to the SPRING website is driven by search engines, however many of these searchers are already aware of SPRING. The following is a list of the top search terms that generated traffic to the SPRING website: 1. http://spring-nutrition.org/ 2. spring Bangladesh 3. spring usaid 4. spring nutrition 5. spring jsi

• 14% of all visits to the SPRING website in Q1 were generated through social media.

76 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Number of SPRING Twitter Followers 450 390 400 351 350 317 277 300 250 200 # of Follo 150 100 50

0 • During PY3 Q1, the number of SPRING Twitter followers increased by 41% from 277 followers to 390

Languages

• 5% of all visits (260) to SPRING during this reporting period were from users with browsers set to a language other than English. o The most common browser language was French (79), followed by Spanish (69), Chinese (18) and German (13).

Awareness Day Outreach

• World Food Day, October 16, 2013 SPRING/Bangladesh published a blog (see above) and SPRING’s Knowledge Management team posted on Buzzfeed.com: World Food Day Buzzfeed • Universal Children’s Day, November 20, 2013 Two items were created to raise awareness for Universal Children’s Day: an Animated short which had a total of 165 views, and a Resource Compilation posted on the SPRING website.

Vimeo

There are currently 33 videos posted on the SPRING website (via Vimeo), with 69 plays and 3,048 loads during PY3 Q1. A load is counted each time the video player loads on any page, either on Vimeo.com or wherever a video is embedded. A play is counted each time someone pushes the play button on a video. Below are the top ten most loaded videos.

77 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

Rank Video Loads

1 Agriculture and Nutrition Global Learning and Evidence Exchange: An 300 Overview 2 Susan Bradley Explains the Rationale of Joint Planning for 288 Agriculture/Nutrition Programs

3 AgN-GLEE - Africa Feedback: USAID Ethiopia 287

4 Susan Bradley on Women's Agriculture- and Nutrition-Related Decision 284 Making 5 Yaajeende Project, Senegal 280 6 Susan Bradley Gives Overview of the AgN-GLEE-Africa Event 274

7 Yaajeende Project (APS), Senegal 269 8 Webinar Recording: Multisectoral Anemia Partners Meeting 262

9 AgN-GLEE - Asia Feedback: USAID/Bangladesh 135

10 AgN-GLEE - LAC Feedback: USAID Brazil 134

Webinars

Three webinars were conducted during PY3 Q1, including: 1. Multisectoral Anemia Partners Meeting Webinar (the live event was webcast as a webinar simultaneously during the event) Date: Oct. 18, 2013 Total Unique Attendees: 13 2. Digital Green SBCC Approach Date: December 17, 2013 Total Unique Attendees: 146

Development Experience Clearinghouse Submissions

Between October 1, 2013, and December 30, 2013, SPRING submitted a total of 24 documents to the Development Experience Clearinghouse (DEC). These documents are delineated below.

Annual Report

• SPRING Year One Annual Report • SPRING Project Year 2 Annual Report

Concept Notes

78 SPRING PY3 Quarterly Report, October 1, 2013 – December 31, 2013

• Concept Note 1: Examining social and behavior change communication (SBCC) strategies to incorporate nutrition, hygiene, or health into agricultural programs • Concept Note 2: Evaluating an “enhanced” mHealth component for maternal, infant, young child nutrition (MIYCN) programs • Concept Note 3: Studying the integration of maternal, infant, and young child nutrition (MIYCN) with agriculture, water, sanitation, and hygiene (WASH), or HIV programs • Concept Note 6: Improving the nutrient content of crops to improve micronutrient intake levels for farmers and their families • Concept Note 7: Examining and comparing nutrient intake adequacy in SPRING countries Meeting Reports • "Noncommunicable Diseases Consultation: Meeting Summary and Notes" • National Stakeholder's Meeting on NACS in Haiti (English)

Research Reports

• Research Prioritization Summary Report • Report on Findings from an Assessment of the Integration of Nutrition into HIV Programs in Selected Facilities and Communities in Haiti

Training Materials

• The Community Infant and Young Child Feeding Counselling Package Facilitator's Guide (Nigeria) • The Community Infant and Young Child Feeding Counselling Package Participant Materials (Nigeria) • The Community Infant and Young Child Feeding Counselling Package Key Messages (Nigeria) • The Community Infant and Young Child Feeding Counselling Package Training Aids

Technical Reports

• Nutrition-Related Noncommunicable Disease (N-RNCD) Country Profiles (Combined) • Assessment of Nutrition Assessment, Counseling, and Support (NACS) Services in Southwest Uganda • Nutrition-Related Noncommunicable Disease (N-RNCD) Regional Profile Africa • Nutrition-Related Noncommunicable Disease (N-RNCD) Regional Profile South and Southeast Asia • Phase I Report of the Early Life Nutrition Linkages to Noncommunicable Disease (ENL-NCD) Model

Translations

• National Stakeholder's Meeting on NACS in Haiti (French)

Work Plans

• SPRING Bangladesh Work Plan PY3 • SPRING Haiti Work Plan PY3 • SPRING/Uganda Work Plan PY3

79