FEED THE FUTURE TAJIKISTAN HEALTH AND NUTRITION ACTIVITY
Annual Progress Report October 2017 to September 2018
Submitted October 30, 2018
Table of contents
Acronyms and Abbreviations ...... 4
Activity Implementation Summary ...... 5
IR 1: IMPROVED QUALITY OF HEALTH CARE SERVICES FOR MNCH ...... 7 Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI ...... 7 Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality ...... 14 Outcome 1.3: Stronger facility and provider networks ...... 18 1.3.1. Hospital-level activities ...... 18 1.3.2. Primary health care activities ...... 19
IR 2: INCREASED ACCESS TO A DIVERSE SET OF NUTRIENT-RICH FOODS ...... 20 Outcome 2.1: Diversified food consumption during the growing season and beyond ...... 20 Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities ...... 23
IR 3: INCREASED PRACTICE OF HEALTHY BEHAVIORS AROUND MNCH ...... 30 Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children under two ...... 30 Outcome 3.2: Improved sanitation and hygiene-related behaviors ...... 40 Outcome 3.3: Increased use of health services for MNCH, including nutrition, sanitation, and hygiene ...... 46 Community level. Involvement of CHPs on MNCH issues related to nutrition and health ...... 46 Facility level. Improve quality of care through increased use of health care services ...... 50
IR 4: INSTITUTIONALIZE EVIDENCE-BASED MNCH SERVICES...... 54 Outcome 4.1: Ensure cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH ...... 54 Outcome 4.2: Ensure sustainability of evidence-based approaches for MNCH ...... 56 Outcome 4.3. Improving linkages across sectors supporting poverty alleviation, agriculture, nutrition, and health ...... 59
Monitoring and Evaluation ...... 61 Progress towards targets ...... 62 Communications and knowledge management ...... 62
Budget Vs. Expenditure Analysis ...... 66 SUB-GRANTS ...... 67
CHALLENGES ENCOUNTERED AND ACTIONS TO OVERCOME ...... 67
GENDER ...... 68
Management and Staffing ...... 69
PARTNERS...... 69 Collaboration with FTF activities ...... 70 Collaboration with the international community ...... 70
Annexes ...... 72
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ACRONYMS AND ABBREVIATIONS
ANC Antenatal Care MOHSPP Ministry of Health and Social BPS Birth Preparedness School Protection of the Population BTN Beyond the Numbers MOU Memorandum of Understanding CDH Central District Hospital MUAC Mid-Upper Arm Circumference CE Community Educator OB/GYN Obstetrician/Gynecologist CHE Community Health Educator OFSP Orange-Fleshed Sweet Potato CHP Community Health Promoter PHC Primary Healthcare Center CIP Centro Internacional de la Papa QI Quality Improvement (“International Potato Center”) RHC Reproductive Health Center DCC Donors Coordinating Council RHS Recurring Household Survey DOH Department of Health SUN Scaling Up Nutrition DQA Data Quality Assessment TAWA Tajikistan Agriculture and Water EG Economic Growth (USAID Activity indicator) THNA Tajikistan Health and Nutrition EmONC Emergency Obstetric and Activity Newborn Care TOT Training of Trainers EPC Effective Perinatal Care TWG Technical Working Group FTF Feed the Future UNICEF United Nations Children’s Fund GIZ Deutsche Gesellschaft für USAID United States Agency for Internationale Zusammenarbeit International Development (“German Society for USG United States Government International Cooperation”) VDC Village Development Committee GMP Growth Monitoring and VIP Ventilated Improved Pit Promotion WASH Water and Sanitation Hygiene HCW Health care worker WFP World Food Programme HL Health (USAID indicator) WHO World Health Organization HLSC Healthy Life Style Center ZOI Zone of Influence
ICATT IMCI Computerized Adaptation and Training Tool IEC Information, Education, and Communication IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IR Intermediate Result IYCF Infant and Young Child Feeding JICA Japanese International Cooperation Agency KfW Kreditanstalt für Wiederaufbau (“Credit Facility for Redevelopment”) M&E Monitoring and Evaluation MNCH Maternal, Newborn, and Child Health
ACTIVITY IMPLEMENTATION SUMMARY
IntraHealth International and its partner, Abt Associates, are pleased to submit to the Tajikistan Mission of the United States Agency for International Development (USAID) the Year Three (Y3) annual activity report (October 1, 2017–September 30, 2018), combined with the Quarter Four (Q4, July 1–September 30, 2018) activity report for the Feed the Future (FTF) Tajikistan Health and Nutrition Activity (THNA). THNA is being implemented in partnership with the Ministry of Health and Social Protection of the Population (MOHSPP) of the Republic of Tajikistan. THNA’s goal is to improve the health status and nutrition of women and children who live in 12 southwestern districts of Khatlon Region, known as FTF’s zone of influence (ZOI). This progress report is largely consistent with the structure and content of THNA’s approved Y3 workplan (Figure 1).
Figure 1. THNA results framework
Due to its high rates of childhood stunting, Tajikistan was one of 19 focus countries of the U.S. government’s FTF initiative. The 2012 Demographic and Health Survey revealed that 24.6% of children under five in the ZOI were stunted. FTF activities, which have been continuously implemented in the ZOI, including by THNA, contributed to a decrease in the rate of stunting in children under five in the ZOI to 17.6%, according to 2017 Demographic and Health Survey results. Inspired by this achievement, THNA will continue its efforts to improve the nutritional and health status of children and their mothers in the next two years by integrating quality interventions at the community, primary healthcare center (PHC), hospital, regional, and national levels. Project highlights from Y3 include the following: THNA improved nutrition-related professional knowledge and skills of a total of 2,893 health care workers (HCWs) and community volunteers (116% of the annual target).
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THNA improved the capacity of a total of 599 HCWs on maternal, newborn, and child health (MNCH) and nutrition topics. THNA has improved effective perinatal care (EPC) and emergency obstetric and neonatal care (EmONC) in 12 central district hospitals (CDHs) by more than 30% since 2016, as demonstrated by facility scorecards. Implementation of hospital-based integrated management of childhood illness (IMCI) efforts reduced the number of unnecessary hospitalizations by 23% and the number of hospital pediatric deaths by 39%. Government HCWs and community volunteers supported by THNA provided improved services to 52,162 pregnant women (104.3% of the annual target) and 138,911 children under five (99.2% of the annual target). THNA selected and trained a total of 1,391 volunteer community health promoters (CHPs, 150% of the annual target) from the 12 districts over 64 five-day training sessions. CHPs conducted 80,079 individual home visits, providing counseling and education on maternal and child health and nutrition topics, which benefited over 53,000 children under five and 8,846 pregnant women. THNA facilitated the identification of 2,650 children with signs of malnutrition by HCWs, and 808 children by CHPs. CHPs facilitated 199 peer support groups in 158 villages for mothers-in-law, pregnant and lactating women, women of reproductive age, and men. Membership in support groups totaled 1,410 people. CHPs conducted 225 cooking demonstrations in 190 villages, reaching 4,374 community members from 3,864 households with practical information about nutrition for pregnant and lactating women, as well as complementary feeding for children over six months. In families engaged in THNA activities, 56% of children under two received a minimum acceptable diet, compared to the national average of 9%, and 93% of women with children under five achieved minimum dietary diversity, compared to the average of 70% in the FTF districts. Community educators (CEs) reached 185,383 people in individual or small group training sessions on agricultural methodologies and food security. As a result, 148,500 farmers and others (114% of the target) have applied improved agricultural technologies. CEs provided 2,421 action-oriented educational sessions for 21,166 households. As a result, 43% of households plan their family budget, and 54% are saving money. THNA engaged more than 10,400 community members in 232 public outreach events around World Breastfeeding Week, 12 health fairs, 12 farmers’ markets and fairs, nine latrine fairs, and six nutrition awareness events. THNA-supported masons sold 681 ventilated improved pit (VIP) latrines. These and other achievements are described in detail in this report.
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IR 1: IMPROVED QUALITY OF HEALTH CARE SERVICES FOR MNCH
Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI During Y3, THNA continued implementing activities to improve the quality of health services. By enrolling Cohort III facilities, THNA completed its three-year plan of gradual interventions based on identified priorities and the nature of technical assistance required by health facilities. THNA continued its support of the quality improvement (QI) changes in the delivery of MNCH and nutrition services. The QI activities built upon the progress made in Y1 and Y2 in facilities from Cohorts I and II; the remaining facilities from Cohort III were enrolled under the QI action plans. 1.1.1. Hospital-level activities
In Y3, THNA included CDHs from Cohort III in Yovon, Khuroson, and Vakhsh districts into its intensive technical assistance. To improve the quality of care in hospital maternity and pediatric departments, at the beginning of Y3, THNA facilitated the development of QI action plans on the MNCH continuum of care in hospitals from all three cohorts and PHCs (see Activity 1.1.2). As a result, all 12 CDHs developed and approved QI action plans. Implementation of these QI action plans was part of the QI activities supported by THNA in Y3 (see Activity 1.2.1). To support the implementation of the QI action plans, THNA facilitated two-day mentoring and monitoring visits to 12 CDHs by national experts on EPC, for a total of 24 visits in Q1 and Q2. The team of experts included an obstetrician/gynecologist (OB/GYN), a neonatologist, and a midwife, who provided mentoring to 423 HCWs from maternity departments. As a result of THNA’s technical assistance on perinatal care, CDH scores on EPC scorecards improved by 33%, from an average of 1.34 points on a three-point scale in 2016 to 1.99 points in 2018 (Figure 2). Figure 2. CDH scores on EPC scorecards, 2016–2018
*Rapid Health Facility Assessment Definition of scores: According to the World Health Organization (WHO) EPC scorecard, each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0–3: 0 = need for very substantial improvements (totally inadequate care and/or harmful practice with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards); 2 = need for some improvement to reach standard care (suboptimal care but no significant hazards to health or to basic principles of quality care); 3 = good or standard care.
The mentoring and monitoring visits identified the need to improve doctors’ knowledge on some specific topics. To address this need, in Y3, THNA supported four three-day trainings on EPC principles.
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As a result, 81 OB/GYNs from 12 CDHs were trained on the management of complications in pregnancy and childbirth, including preventing and managing premature deliveries, caring for underweight newborns, and using portograms for decision-marking in cases of complications. Due to the shortage of medical staff in hospital maternity departments, THNA was not able to train 100 HCWs as planned. In total, 65 OB/GYNs (100%) from CDHs and 16 OB/GYNs (50%) from “numeric” hospitals were trained on EPC. The knowledge improved, on average, from 50% to 76% based on the number of correct responses on the pre- and post-training tests. Implementation of EPC in maternity departments resulted in an improvement of quality indicators in Q4 of Y3 compared to Q4 of Y2. Scorecards from 12 facilities demonstrated a significant improvement in the incidence rate of two main postpartum complications: the incidence of postpartum hemorrhage decreased from 0.5% to 0.3% of all deliveries, and the number of hemorrhagic shock cases decreased from an average of 4.9 to an average of 1.8 per year (Figures 3 and 4). Figure 3. Incidence of postpartum hemorrhage, % of total number of deliveries
Figure 4. Number of cases of postpartum hemorrhagic shock, 10 CDHs
Note: Levakand and Nosiri Khusrav CDHs had no cases of postpartum hemorrhagic shock in Y2 and Y3; therefore, they are not displayed on the graph. In Q4, mentoring and monitoring visits were followed by a total of 12 supportive supervision visits by a team of national supervisors and THNA staff. A total of 213 HCWs from CDH maternity departments were engaged in evaluation and improvement in the following areas: Status of implementation of EPC principles;
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Progress on implementation of earlier recommendations from previous visits; Medical file maintenance and data collection; Utilization of the MNCH database for data analysis and decision-making; Staff coverage with on-the-job trainings on newborn care, breastfeeding, and nutrition of pregnant and lactating women; Status of the QI plan implementation; Status of the internal monitoring system (plan, indicators, and data analysis). As a result of the improved management of postpartum hemorrhage, the volume of plasma and blood transfusions decreased accordingly, e.g., in Qabodiyon district alone, the volume was reduced from 49 to 11 liters in just one year. These changes in clinical practice also made a financial impact, as they reduced expenses for blood transfusions incurred by the hospital or by the families: the cost is TJS 800 (USD ~90) for each liter of blood/plasma. During supportive supervision visits, an improvement in newborn morbidity and mortality was also noted. Between Y1 and Y3, the contribution of premature infants to neonatal mortality in maternity departments across 12 CDHs dropped from 56% to 49%. With equipment provided by THNA, premature babies are now treated at the CDH, whereas before, they were all transferred to regional facilities. District neonatologists are currently using incubators and the Kangaroo Mother Care method to treat premature newborns, which has had a positive impact on newborn care and outcomes. For example, out of 118 underweight babies in two districts (39 in Balkhi and 79 in Qabodiyon) in Y3, 34 were treated in incubators (of whom, 11 were also treated with the Kangaroo Mother Care method), and the rest (84) did not require special methods of care due to the improved skills of neonatal nurses and the involvement of mothers in care. Another example of the improved capacity of neonatal nurses is in Balkhi district, where there is only one neonatologist for approximately 300 deliveries per month. Out of 39 premature babies in Balkhi, three were born with severe asphyxiation, yet only one of them required a full course of resuscitation from the neonatologist. The others were resuscitated in a timely manner by neonatal nurses in the delivery room, which avoided complications. Keeping the newborn in the “warm chain” is one of the main determinants of newborn survival. With THNA training and support, all staff in maternity departments now understand the importance of maintaining the thermal chain. As a result, the number of cases of hypothermia in newborns decreased more than threefold (Figure 5). Figure 5. Number of cases of hypothermia in newborns, six months prior to measurement
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As a result of QI activities, EmONC in the 12 CDHs improved by 31%, from an average of 1.63 points on the three-point scorecard scale in May 2016 to an average of 2.34 points in September 2018 (Figure 6). Monitoring has shown that every midwife, OB/GYN, and neonatologist has the skills to resuscitate a newborn. Improved skills in newborn resuscitation and the use of a team approach have significantly reduced the mortality and morbidity of newborns. Figure 6. CDH scores on EmONC scorecards, 2016-2018
* Rapid health facility assessment Definition of scores: According to the WHO EPC scorecard, each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0–3: 0 = need for very substantial improvements (totally inadequate care and/or harmful practice with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards); 2 = need for some improvement to reach standard care (suboptimal care but no significant hazards to health or to basic principles of quality care); 3 = good or standard care.
Along with these achievements, challenges remain that are not related to staff knowledge or to the availability of equipment. For example, the negative trends observed in Vakhsh district (Figs. 1, 2, 3, and 4) can be explained by poor management, and a lack of leadership and motivation. All medical facilities in all districts also lack local protocols, thus THNA will focus on developing those in Y4. To improve the quality of data, in Y3, THNA provided 36 supportive supervision visits, led by a database consultant and THNA staff, to 12 facilities. In addition, in Q2, THNA supported a refresher training for 16 staff from 12 CDH maternity departments on data collection and use for decision-making. As a result, since April 2018, all CDH maternity departments have submitted MNCH data along with their analysis to the regional Department of Health (DOH). THNA also maintains its own database to track facility scorecard data. Although midwives can be very effective in supporting and counseling pregnant women, in THNA target facilities, they played a limited role in MNCH and EmONC efforts due to lack of knowledge. To increase their capacity, THNA in partnership with the Scientific Research Institute of Obstetrics, Gynecology and Perinatology developed training materials and provided 15 supportive supervision visits and on-the- job trainings for 85 midwives in Qabodiyon, Shahritus, Nosiri Khusrav, Jaikhun, and Yovon maternity departments using a peer-to-peer approach. Pre- and post-training tests showed an increase in midwives’ knowledge and skills on important elements of MNCH and EmONC, from an average score of 29% to 75% (Figure 7).
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Strengthening the capacity of midwives is very important in improving care for mothers, especially in reducing the incidence of postpartum hemorrhage and providing adequate emergency care for newborns during the “golden minute.” Sh. Buzmakov, chief physician, Balkhi CDH To broaden its efforts in strengthening the capacity of midwives, THNA will focus on training midwives from maternity departments of “numeric” hospitals in Y4. Figure 7. Results of pre- and post-training tests among midwives of CDH maternity departments
In Y3, THNA planned to provide in-kind sub-grants to Cohort III facilities to address their basic equipment needs. THNA, however, canceled these plans because Kreditanstalt für Wiederaufbau (KfW) had equipped facilities in Yovon and Khuroson districts in 2017, and there was lack of leadership and motivation to change demonstrated at the Vakhsh CDH. THNA is supporting the MOHSPP technical working group (TWG) on neonatal standards. Implementation and approval of neonatal standards has been delayed, as the clinical guidelines on Kangaroo Mother Care are still being finalized. In Q3, Kangaroo Mother Care guidelines and ten neonatal standards were submitted to the MOHSPP and WHO for review. THNA expects the MOHSPP to approve the guidelines and standards early in Y4. A training of trainers (TOT) on Kangaroo Mother Care, followed by on-the-job training in CDH maternity departments, has been postponed to Q1 of Y4. 1.1.2. Primary health care activities
In Y3, THNA continued its efforts at the PHC level to improve the quality and accessibility of health care services in communities and establish an effective continuum of care. Based on successful experiences at the hospital level, THNA facilitated the development of QI action plans with Cohort III facilities on improving the quality of health care at the PHC level and increasing the utilization of PHC services by communities. THNA strengthens the continuum of care through linkages among households, PHCs, and hospitals, assuring that appropriate care is available at each level. To link PHC and hospital MNCH services, THNA advocated for PHC and hospital practitioners to participate in QI committees. As a result, PHC managers approved 12 QI action plans on the integrated MNCH continuum of care, which included PHC services. In Y3, THNA’s continued technical support included: coaching HCWs and facility managers; providing direct technical guidance on developing internal indicators to monitor progress; building the capacity
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of HCWs through on-the-job trainings and supportive supervision visits by national experts; and promoting the utilization of birth preparedness schools (BPSs). To improve the quality of antenatal services at the PHC level, THNA trained 60 HCWs (40 doctors and 20 nurses) on antenatal care (ANC). The training curriculum was designed according to the national protocol on nutrition in pregnancy, integrated into the ANC national standards. Practical exercises included cooking demonstrations for HCWs. As a result, HCWs’ knowledge of ANC improved from 32% to 72%, based on the pre- and post-training test scores. Since the start of THNA, a total of 200 HCWs have been trained on ANC. Medicine is moving ahead quickly. We, who are in the middle of nowhere, in kishlaks, are falling behind this progress. Your project is helping us to catch up. You provide us with new knowledge, equip our hospitals with new equipment. This is very important for saving people’s lives. Interview with an OB/GYN from Firuza jamoat, Nosiri Khusrav district, at mid-term review To strengthen the knowledge gained from the ANC trainings, THNA conducted 24 mentoring and monitoring visits to 286 HCWs from PHCs and reproductive health centers (RHCs) in the 12 districts of Khatlon Region. The focus was on improving the quality of ANC during uncomplicated pregnancies. THNA analyzed the ANC data and produced QI scorecards for each facility (Figure 8). The mentoring and monitoring visits covered the following areas: • ANC quality at PHCs and RHCs; • Record-keeping according to the ANC national standards; • Assessment of ANC indicators; • Interviews with pregnant women and women who had recently delivered to assess the quality of nutrition counseling and other services; • Assessment of compliance with the national standard on infection control; • Assessment of the BPSs; • Technical support to establish a QI committee, identify improvement objectives, and develop a workplan.
Figure 8. Progress of QI indicators on ANC, average across 12 district PHCs, Y2–Y3
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The most significant achievements were in the proportion of pregnant women who were registered for ANC in the first trimester; who received nutrition counseling; and who received folic acid supplements in the first trimester. Eclampsia screening has not improved due to infrastructural and supply challenges: there are no private facilities to collect urine, and no urine quick tests for the protein. Although the proportion of women receiving appropriate anemia treatment has increased, less than a third of women who require the treatment receive it. Mentoring and monitoring visits revealed that for the last five or six years, PHC staff did not get new knowledge on updated ANC national standards nor did they receive the standards themselves. More detailed analysis at the facility level is presented in Annex I. Over one year, Levakand and Nosiri Khusrav districts demonstrated an increase in early ANC registration from 56% to 88% and an increase in nutrition counseling from 50% to 90%. In Jomi, Levakand, Jaikhun, and Nosiri Khusrav districts, folic acid supplementation more than doubled, from about 30% to 65%. At the same time, many districts demonstrated a regress on pre-eclampsia screening, particularly Yovon from 35% to 30%, and Kushoniyon from 34% to 30%. In Y3, THNA conducted 12 supportive supervision visits to district-level PHCs on growth monitoring of children under five. In partnership with the World Food Programme (WFP), THNA provided 259 mid- upper arm circumference (MUAC) tapes to HCWs. As a result, a total of 46,166 children were screened and 2,650 of them (17.4%) aged 6 to 59 months were identified as showing signs of malnutrition (Table 1). Each child with signs of hypotrophy was registered with a PHC facility and received follow-up services, which THNA and district IMCI centers verified through 12 monitoring visits to district PHCs. One challenge identified through those visits was the effective referral of children to CHPs for follow- up upon discharge from PHC or hospital care. THNA will address this challenge in Y4 through joint facility and community efforts in building a continuum care. Table 1. Number of children with signs of malnutrition, by district District # of children -2Z -3Z -4Z Vakhsh 282 267 13 2 Levakand 43 40 3 0 Kushoniyon 21 20 1 0 Yovon 612 580 28 4 Khuroson 112 112 0 0 Jomi 126 114 9 3 Balkhi 249 232 15 2 Dusti 218 214 3 1 Qabodiyon 287 282 4 1 Shahritus 439 373 57 9 Nosiri Khusrav 28 28 0 0 Jaikhun 233 229 4 0 Total: 2,650 2,491 137 22
THNA delayed some procurement and in-kind sub-grants in Y3, which also affected program activities. These included in-kind sub-grants to PHCs to establish nutrition resource centers, and the introduction of the hospital-based MNCH and nutrition database at the PHC level. As the nutrition resource centers were equipped only at the end of Q4, introduction of the MNCH database and refresher trainings have been rescheduled for Q1 of Y4. Despite the delay, THNA supported QI committees on data collection and analysis. In Y3, quantitative and qualitative indicators were introduced to managers and QI committees in Cohort III, and PHC data were collected from all 12 districts (Annex I).
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Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality 1.2.1. Hospital-level activities During Y3, THNA finalized the establishment of 24 QI committees: one at the hospital level and another at the PHC level, in all 12 FTF districts (see Activities 1.1.1 and 1.1.2). To support QI committees in improving the quality of health care services, in collaboration with Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), THNA revised and updated the QI training package it developed in Y1. To strengthen the capacity of QI committees, THNA conducted 36 mentoring visits following up on the implementation of the QI action plans. These visits included on-the-job QI trainings for 102 HCWs at CDHs. Topics included: principles of quality management, the function and responsibilities of the QI committee, the cycle of continuous QI, establishment of an internal monitoring system, and leadership. As a result of the training, the teams developed QI plans for CDHs in 2018 (see Activity 1.1.1). During the support visits, THNA assisted QI committees in developing their monitoring tools and calendar plans, identifying challenges in data collection, and finding ways to improve by designing local protocols.
Twice in Y3, THNA conducted assessments of QI indicators in four districts (Figure 9). The data demonstrated that within six months, documentation of labor and child delivery improved from an average of 24% to 46% of the maximum achievable score; handwashing practices of observed staff improved from 25% to 51%; fetal auscultation by observed midwives improved from 26% to 54%; and staff readiness to provide EmONC improved from 30% to 54%. In Q4, THNA provided four mentoring visits to all facilities and analyzed their data with the QI teams. Figure 9. QI indicators achieved by maternity departments of four CDHs and their averages (%)
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In Q2, THNA conducted a five-day training for 20 pediatricians from CDHs on infection control. The results demonstrated an improvement in knowledge, from an average of 49% correct responses on the pre-tests to 83% on the post-tests. Training topics included proper glove use, handwashing, clean water storage, preparation and use of antiseptics, handling sharps, and hazardous waste disposal. As a result of continuous THNA support over the past three years, CDHs demonstrated an improvement in infection control and clinical safety from an average of 48% of the maximum score in August 2017 to 59% in June 2018 (Figure 10). The greatest results were achieved in improving the disinfection, washing, sorting, packaging, and sterilizing of medical instruments. As part of their efforts to improve waste management, seven facilities (in Kushoniyon, Jaikhun, Dusti, Yovon, Jomi, Shahritus, and Nosiri Khusrav districts) installed incinerators and established proper disposal pits for biohazardous material. In Y3, together with the MOHSPP and the Sanitation and Epidemiology Service, THNA conducted 16 mentoring and monitoring visits to 12 CDHs, engaging 110 HCWs. The purpose was to assess the implementation of the infection control and clinical safety guidelines and to provide on-the-job trainings. Figure 10. Assessment of infection control and clinical safety indicators at 12 CDHs
Monitoring tasks included: • Improving the quality of health care for patients; • Preventing nosocomial infections; • Minimizing the risk of transmitting blood-borne infections (e.g., HIV and Hepatitis B and C) to HCWs; • Improving the quality and safety management system; and • Conducting practical on-the-job trainings. Mentoring and monitoring visits revealed that many HCWs still do not comply with the guidelines on waste disposal. The reasons for the non-compliance are the guidelines being confusing, poor enforcement of the guidelines, and staff turnover. THNA developed a list of recommendations for effective infection control. THNA supported the development of two procedures/internal protocols
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on safe injections and handling of medical instruments, according to MOHSPP Order #1119, in the form of easy-to-follow, step-by-step instructions. In Y4, THNA will print and distribute these two procedures for implementation by QI committees. CDHs face serious challenges with infection control, as most pediatric departments have no running water. THNA encouraged managers from CDHs to improve the water supply at hospitals. As a result, CDHs in Kushoniyon, Shahritus, and Jomi districts mobilized their own or their local government’s resources to improve the water supply at their pediatric facilities. In Y4, THNA will support Dusti CDH in improving the water supply in its pediatric department. In Q4, THNA with a team of national-level supervisors analyzed the scorecards on EPC and hospital IMCI to judge the scorecard-based competition between facilities. Criteria for selecting the winners included having an efficiently functioning MNCH database, as well as high scores achieved on EPC, hospital-based IMCI, and infection control indicators. Based on the results, the winners were the Jomi, Yovon, and Shahritus CDHs. The prizes will be awarded in Y4 as in-kind sub-grants to respond to facility needs. The in-kind sub-grant for effective implementation of infection control guidelines to decrease septic complications among newborns and postpartum women was delayed until Y4. The in-kind sub-grant to improve hospital laboratory services was canceled, as there is no national strategy in this area. Lab services are provided for a fee, hospitals cannot guarantee supplies for lab equipment, and there is lack of laboratory staff in remote locations. Considering these circumstances, THNA felt it would irresponsible to provide equipment, which would not benefit women or children. During Y3, none of the three TWGs supported under IR4 completed its work (see Activity 4.1). Therefore, THNA could not support TOTs for 40 hospital-level staff on new or updated clinical practice guidelines. This activity has been postponed until Y4, and THNA made an agreement with the Japanese International Cooperation Agency (JICA) and GIZ on cost-sharing. Writing an article on trainings conducted for HCWs will be completed in Y4. 1.2.2. Primary health care activities To strengthen the capacity of QI committee members in 12 PHCs, in Y3, THNA conducted QI trainings for 61 HCWs from district family medicine centers. The topics were similar to those of the hospital-level training (see Activity 1.2.1). As a result, QI teams developed action plans and internal indicators for PHCs for 2018 (see Activity 1.1.2). In Y3, THNA supported infant and young child feeding (IYCF), growth monitoring and promotion (GMP), and integrated management of acute malnutrition (IMAM) trainings for PHC staff (see Activity 3.3); therefore, QI committees were enabled to carry out internal monitoring and data analysis. In Q4, THNA in collaboration with the Institute of Pediatrics and Pediatric Surgery conducted 12 supportive supervision visits to PHCs to improve IYCF, as well as nutrition for pregnant and lactating women. During supportive supervision visits, 191 HCWs were tested and 120 women with children up to two years old were interviewed on the principles of nutrition and the treatment of children with nutritional problems (Figure 11). Surprisingly, the results demonstrated that on average, a higher proportion of women had knowledge of IYCF topics (63%) than did the HCWs (54%). This finding may be explained by THNA’s behavior change communication interventions around nutrition at the community level (see Activities under Outcome 3.1). In Y4, THNA will address this disparity in knowledge by training PHC providers on nutrition topics.
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Figure 11. Knowledge of nutrition
In Q4, THNA’s local trainers conducted cascade trainings for 161 PHC staff on IYCF and on nutrition for pregnant and lactating women in four districts: Vakhsh (42 HCWs), Khuroson (25 HCWs), Balkhi (70 HCWs), and Levakand (24 HCWs trained). To strengthen the capacity of QI committee members, in Y3, THNA provided 12 joint supervision visits to local QI committees to determine the quality of home visits by family nurses in the 12 districts. The home visits identified certain areas in which improvement is urgently needed. For example: Only three out of eight family nurses at the Kushoniyon and Qabodiyon health centers could provide counseling on complementary feeding; and Only 38 out of 100 children aged 12 to 24 months had their height and weight measured during a home visit by an HCW. During these visits, QI committees received technical support on implementing their action plans, collecting data, achieving QI targets, and counseling parents based on the results of child growth and development monitoring. Unfortunately, progress in implementing QI activities and achieving results has been slow. Reasons for the slow progress include a lack of family doctors (as in Nosiri Khusrav district) or their heavy workload; the lack of continuing medical education and on-the-job training opportunities for staff in remote areas; and the lack of basic equipment and supplies, such as family doctors’ kits, scales, and stadiometers. THNA made recommendations to managers and QI committee members on building the capacity of their staff using 12 established nutrition resource centers at district-level PHCs, with continuing medical education materials and on-the-job trainings for HCWs at remote facilities. THNA combined infection control trainings for PHCs with 12 mentoring and monitoring visits. The mentoring and monitoring visits on infection control followed the same methodology as the visits to CDHs and provided 153 PHC staff with on-the-job trainings (see Activity 1.2.1). PHCs achieved an average of only 39% of the maximum assessment scores (Figure 12). Furthermore, systemic challenges prevent PHCs from reaching at least 50% of the infection control standards. Some facilities (e.g., in Dusti district) date as far back as 1936 and cannot be rehabilitated. In most districts, PHCs lack running water, have no space for cleaning and storing instruments, and lack basic waste management systems.
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Figure 12. Infection control and clinical safety indicators at the PHC level
Mentoring and monitoring visits and on-the-job trainings resulted in the following recommendations from the national experts: Establish and follow a schedule for cleaning the premises; Conduct regular testing of staff on infection control knowledge and proper skills, such as handwashing, waste disposal, sterilization, safe injections, etc.; and Implement a facility self-assessment based on national infection control standards. The in-kind sub-grant for effective implementation of infection control guidelines has been delayed until Y4. In Y3, THNA planned to replicate the “mothers’ rooms” established in Y2. Twice during Y3 (in Q1 and Q4), THNA assessed the existing four mothers’ rooms, finding that they were not being used effectively and that video equipment was not being used for the intended purpose of patient education. There were only 757 visits to the four mothers’ rooms over the 12-month period, with as few as 27 visits in Shahritus district. After an attempt to revive these rooms in Q2–Q4, THNA decided not to replicate this model in other districts. Outcome 1.3: Stronger facility and provider networks 1.3.1. Hospital-level activities In Y3, THNA continued strengthening the network of HCWs both horizontally and vertically. THNA supported a total of 288 regular, biweekly online conferences between national mentors and district facilities to provide continuous and sustained supportive supervision to HCWs in 12 CDHs. In addition, in complicated emergency cases, HCWs initiated a number of unscheduled online consultations with their mentors using videoconferencing equipment provided by THNA. For example, a 28-year old pregnant woman was hospitalized with eclampsia and acute renal failure in the maternity department of the Jaikhun district hospital. She was not fit to be transported to the tertiary-level facility, so Scientific Research Institute of Obstetrics, Gynecology and Perinatology experts provided online support to the medical team in Jaikhun. As a result, both the mother and child survived. Based on the positive experience with online conferencing, in Q4, THNA procured furniture and equipment for 12 nutrition resource/training centers at the hospital level, which will open in Y4.
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To promote the sharing of experience between HCWs from all 12 CDHs, THNA supports a variety exchange visits. In Y3, THNA facilitated four exchange visits on breastfeeding, nutrition, and care for underweight children, engaging 85 HCWs. Implementing a “Beyond the Numbers” (BTN) approach, THNA trained 20 hospital staff from Cohort III facilities. In addition, THNA supported three BTN cross- visits, engaging 91 HCWs to share best practices among all facilities from Cohorts I, II, III. Two activities, a regional-level conference on the progress of BTN activities and scaling up supportive supervision activities to “numeric” hospitals, were postponed to Y4. In Y3, THNA was not able to support the training of 40 HCWs on EmONC because a total of 96 HCWs had already been trained in Y1 and Y2. As almost all staff from maternity departments and intensive care units from all 12 CDHs have been covered by EmONC trainings, the MOHSPP excluded the FTF ZOI from this training program. 1.3.2. Primary health care activities In Q4, THNA equipped 12 nutrition resource/training centers at the PHC level on the premises provided by the facilities. As a result, in Y4, these nutrition resource/training centers will build the capacity of more than 300 PHC-level HCWs from 12 districts. The centers will establish an electronic network among participating facilities to exchange information and provide practical online trainings. Nutrition resource/training centers are based at the same PHC facilities where BPSs were developed by the Mercy Corps’s MCH project. This strategic placement of the centers allows THNA to provide technical assistance to 12 BPSs at PHCs on nutrition during pregnancy and the lactation period. BPSs were also included in ANC mentoring and monitoring visits (see Activity 1.1.2). At the beginning of Y3, 286 PHC staff received consultations from THNA on implementing their QI plans. To follow up on the progress, the following indicators were developed: Number of pregnant women participating in BPS classes; Number of deliveries accompanied by partners; Number of children under six months exclusively breastfed. As part of strengthening PHC nutrition services, THNA supported a nutrition competition and exhibition among the PHC facilities from all 12 districts, under the slogan “Healthy Food for a Healthy Generation.” The competition raised significant PHC provider interest in learning more about nutrition. Over six months, between February and July, national and regional mentors provided 24 mentoring visits to PHC teams to implement nutrition-related QI changes. As a result, 150 PHC HCWs from 12 districts participated in the competition. At the final event, on August 10, 12 PHC teams presented their work, which consisted of: A presentation of a nutrition corner by each district (including information on healthy food, nutrition in pregnancy and during lactation, breastfeeding, complementary feeding, and supplementary feeding); A presentation of recipes with calculations of nutrient and caloric intake; and Role-plays on the topics of: o Nutrition in pregnancy; o Complementary feeding; o Nutrition for children between one and two years of age; o Nutrition for children between three and five years of age.
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This event concluded the Exclusive Breastfeeding Week in Khatlon Region supported by THNA (see Activity 3.1.4). Balkhi, Vakhsh, and Yovon district PHCs were the winners of the competition. As a result of the competition, 36 recipes for women and children under two were developed. All 12 PHCs received audiovisual equipment to show educational videos in their facilities’ waiting areas to increase nutrition awareness among their patients. The nutrition competition will be replicated in other regions with support from other donors. In Y4, THNA will run a nutrition competition among rural PHCs to engage more HCWs.
IR 2: INCREASED ACCESS TO A DIVERSE SET OF NUTRIENT-RICH FOODS
Outcome 2.1: Diversified food consumption during the growing season and beyond
2.1.1. Capacity development of THNA and TAWA staff on nutrition-related topics on a regular basis by international nutrition specialist In Y3, THNA’s international nutrition advisor provided seven capacity development sessions on nutrition-related topics for THNA and Tajikistan Agriculture and Water Activity (TAWA) program staff. As a result, staff knowledge on IYCF practices, maternal nutrition, food diversity, child health, and the establishment of peer support groups for caregivers improved. An electronic manual on the WHO’s essential nutrition actions was shared with program staff to reference recommendations on nutrition interventions. Also, 32 THNA and TAWA staff were trained to conduct cooking demonstrations that were later cascaded to CHPs. In Q4, the nutrition advisor provided a refresher training for THNA program staff on the effects of food security, water and sanitation hygiene (WASH) practices, health care access, and caregivers’ knowledge and behaviors on a child’s nutritional status. In addition, the nutrition advisor mentored the new THNA nutrition officer. 2.1.2. Orientation training for 280 CEs on the new CHP/CE approach (Jomi, Khuroson, Dusti, Balkhi, Levakand, and Kushoniyon districts) From January to March, THNA conducted orientation trainings for 500 CEs from 12 FTF districts on their roles within the new CHP/CE model. The purpose was to familiarize new CEs, who had been community health educators (CHEs) for some years, with the new THNA approach. THNA exceeded its original target of training 280 CEs in six districts. To be able to demonstrate tangible results by the end of the project, THNA decided to engage all 12 FTF districts into the new CHP/CE model in Y3, instead of just six districts. As a result, THNA successfully implemented the new community volunteer model with agricultural and health-related topics divided between CEs and CHPs, respectively, in the whole ZOI. 2.1.3. Improve household food storage for winter (“consumption”) In June, THNA conducted a two-day TOT for 12 THNA district coordinators on post-harvest methodologies. The TOT combined theoretical knowledge of drying fruits and vegetables and storing legumes and cereals with practical exercises on canning fruits and vegetables. District coordinators, in turn, cascaded their knowledge to 429 CEs (405 CEs in Q4) through 23 trainings on post-harvest methodologies in 12 districts. As a result, in Q4, CEs conducted 1,416 action-oriented educational sessions on food canning and preservation to 17,688 beneficiaries/10,526 households with pregnant and lactating women and children under five.
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THNA also received from TAWA and distributed informational materials and videos on fruit and vegetable storage. THNA provided community volunteers and village development committees (VDCs) with these materials on CD/DVDs. This activity was modified from what was outlined in the Y3 workplan. Originally, THNA planned to hire a short-term national consultant to identify and pilot a winter food storage technology in three jamoats. Instead, throughout Y3, THNA relied on its manual on food storage developed in Y2.
2.1.4. Increasing men’s knowledge of the importance of nutrition of adolescent girls, pregnant and lactating women, and children under two by involving a prominent person in the community In December, THNA conducted a one-day training for 12 district coordinators on the Khutbah manual. This manual covers maternal and child health, as well as nutrition, from an Islamic standpoint. The original plan was for district coordinators to cascade this training to religious leaders who would, in turn, disseminate key maternal and child health messages to men during daily prayers. Unfortunately, the regional government strongly discouraged THNA from direct activities with religious leaders for political reasons. For the same reason, THNA also canceled its plan of holding a roundtable with religious leaders and other stakeholders on the Khutbah manual. Instead, THNA disseminated Khutbah messages through two men’s peer support groups (see Activity 3.1.3), in which religious leaders also participated. 2.1.5. Behavior change communication on diversified food consumption for pregnant and lactating women, children under two, and adolescent girls Distributing information, education, and communication (IEC) materials to the communities THNA provided 500 newly selected CEs and 1,389 CHPs with a package of IEC materials approved by the MOHSPP to work with in their communities. In Y3, THNA community volunteers distributed over 110,000 copies of 16 types of print materials on nutrition, WASH, danger signs during pregnancy, and food security in both Tajik and Uzbek. In addition to printed materials, CHPs and CEs also received 1,333 copies of IYCF counseling cards, 1,782 sets of food diversity cards, and 3,659 copies of DVDs with animated films and videos on WASH and nutrition. Volunteers used these materials to deliver key messages to beneficiaries during educational sessions, household visits, cooking demonstrations, farmers’ markets, latrine fairs, and health fairs.
In addition to community volunteers, THNA disseminated IEC materials through information boards in 265 health facilities. THNA also provided IEC materials to VDCs, WASH subcommittees, peer facilitators in two schools, and PHC staff in four mothers’ rooms. Conducting community outreach events To promote nutritional diversity for pregnant and lactating women, children under two, and adolescent girls, in Q3–Q4, THNA conducted a total of 225 cooking demonstrations in 190 villages in 12 districts (see also Activity 3.1.5). Cooking demonstrations covered preparation of specific nutritious dishes, food hygiene, seasonality of fruits and vegetables, and storage of nutrient-rich foods during the lean period. Discussions also focused on the benefits of vitamins A and C, folate, iron, calcium, and zinc, and food groups rich in specific nutrients. Cooking demonstrations also promoted TAWA’s crops (broccoli, bok choy, and mung beans) as important additions to women’s and children’s diets.
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Volunteers engaged 4,374 community members from 3,864 households (Table 2) in these outreach events. As a result, knowledge of sources of vitamin A among women with children under five in the households engaged in THNA activities improved from just 25% of correct responses in 2016 to 53% in 2018, as demonstrated by the Recurring Household Surveys (RHSs, Figure 13). As THNA focused on the less-known sources of vitamin A, such as liver, eggs, and apricots, the largest increase in knowledge was demonstrated in these categories over the past year.
Table 2. Cooking demonstrations by location and number of participants
# of pregnant Total # of Total # of # District # of villages # of events women participants households
1 Balkhi 9 19 59 300 258 2 Dusti 19 20 69 397 338 3 Jaikhun 21 31 137 661 606 4 Jomi 10 10 23 187 174 5 Khuroson 20 23 35 330 301 6 Kushoniyon 30 34 104 771 678 7 Levakand 8 8 12 144 124 Nosiri 8 3 3 9 71 68 Khusrav 9 Shahritus 4 5 18 138 136 10 Vakhsh 39 40 91 787 638 11 Yovon 26 31 121 568 524 12 Qabodiyon 1 1 0 20 19 Total: 190 225 678 4,374 3,864
Figure 13. RHS results on knowledge of sources of vitamin A among women with children under five in the households engaged in THNA activities, 2016–2018
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Another result of these community education efforts is that 93% of women with children under five engaged in THNA activities achieved minimum dietary diversity, compared to 84% a year ago (Figure 14). The average for FTF districts according to the 2017 Demographic and Health Survey was 70%. Figure 14. RHS results of the minimum dietary diversity* of women with children under five engaged in THNA activities, 2017–2018
*Achieving minimum dietary diversity means a woman consumes food from five or more of ten food groups. THNA was not able to cover all 500 targeted villages with cooking demonstrations in Y3 for the following reasons: (1) CHPs were fully recruited and trained only in May, therefore most cooking demonstrations began only in June; (2) given the busy THNA schedule, four months between June and September were not enough to cover all 500 villages; and (3) district coordinators in Dusti and Qabodiyon districts had to be replaced and trained on cooking demonstrations, therefore volunteers in those districts were limited in training and support from their coordinators. In Y4, with support from district coordinators and their assistants, CHPs will organize one cooking demonstration in each one of 500 villages every month, for a total of 6,000 cooking demonstrations during the year.
Other THNA community outreach events, such as farmers’ markets and fairs (see Activity 2.2.2) and TAWA’s open field days (see Activity 2.2.3), are described below in this report.
Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities
2.2.1. Improve participants’ ability to grow nutritious food (“availability”) Home garden management In Q2, THNA conducted a two-day TOT on home garden management for 12 district coordinators. The curriculum covered soil structure, organic fertilizers, composting, land preparation for planting vegetables and fruit trees, the selection of high-nutrient crops, and crop rotation. A special session was devoted to irrigation technologies that save water and soil nutrients. In turn, in Q2, district coordinators
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provided 26 cascade trainings to 500 CEs on home garden management. CEs started to work with their communities using their new knowledge and skills. In Y3, CEs conducted a total of 15 educational sessions for 3,910 households on home garden management. CEs themselves served as examples in their communities, demonstrating crop rotation practices; the use of organic fertilizers, such as compost; and the planting of new crops, such as broccoli. As a result, 61.9% of respondents in THNA’s Economic Growth Survey in September indicated they had used new technologies in their home gardening, compared to 48.4% a year ago. This percentage translates into 49,500 households (or 148,500 beneficiaries) using improved agricultural technologies in the THNA districts. Home cheese production To diversify food consumption in target households, THNA in partnership with TAWA promoted the production of semi-solid and solid cheese at home as an alternative to purchasing them at market price. In Q3, TAWA’s consultant trained 19 THNA staff, including 12 district coordinators, in a one-day training on the safe production of cheese at home, with different types of coagulants and varying flavors and salt content. In Q4, district coordinators trained 435 CEs (81 male and 354 female) on preparing semi- solid cheese using affordable and locally available ingredients: cow’s milk and white vinegar (Table 3). Cheese is then promoted as a nutritious addition to the diets of children under five and pregnant and lactating women who require additional protein and calcium. Furthermore, the whey from cheese production is used for making cookies and even hair conditioner.
Table 3. Number of CEs from 12 districts trained on cheese-making District Dates Male Female Total 1 Balkhi August 14–16 4 53 57 2 Dusti August 24 5 18 23 3 Jaikhun August 17 & 23 11 28 39 4 Jomi August 15–16 20 25 45 5 Khuroson August 16–17 12 21 33 6 Kushoniyon August 15–16 8 58 66 7 Levakand August 15–16 0 8 8 8 Nosiri Khusrav August 7–8 0 9 9 9 Qabodiyon September 5 2 27 29 10 Shahritus August 7–8 0 19 19 11 Vakhsh August 15–17 2 54 56 12 Yovon August 23–24 17 34 51 Total: 81 354 435
Anecdotes, shared by CEs, from the first cheese-making experience in the communities One CE who had no cow bartered with what he did have, hay, to obtain milk from a neighbor to make cheese. A mother made cheese for her child’s birthday instead of a birthday cake, and they all enjoyed it. During Eid Qurbon (August 21), cheese was a new food item served on the holiday table.
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In August and September, CEs provided 483 action-oriented educational sessions on cheese-making to a total of 5,891 community members (1,647 men and 4,242 women) from 3,910 households. These sessions benefited 618 pregnant women and 5,281 children under five. Poultry production As another way to improve the nutritional status of women and children, THNA promoted poultry production at the household level. In Q2, THNA conducted a two-day TOT on poultry care and vaccination for 12 district coordinators. The topics included the selection of poultry, requirements for a chicken coop, feeding, vaccination, and hygiene. In addition to poultry meat and eggs, which provide rich nutrients to mothers and children, poultry is an additional source of income for households. In Q2, district coordinators provided one-day cascade trainings for 500 CEs on poultry care and vaccination. In turn, in Y3, CEs conducted 525 educational sessions on poultry care and vaccination for 5,711 community members/3,338 households. According to THNA’s Economic Growth Survey in September 2018, 27.2% of the people who had received the training began home poultry production. Greenhouse promotion To improve beneficiaries’ ability to grow fresh vegetables throughout the year, THNA selected 20 active VDCs in Balkhi district for a pilot program on promoting greenhouses. In Q2, THNA cooperated with TAWA to provide a workshop for the selected VDC members on the greenhouse production of tomatoes, broccoli, sweet peppers, and herbs during winter. The training included a field trip to TAWA- supported greenhouses in Balkhi district. VDC members, in turn, conducted 42 practical sessions (30 of them in Q4) for 488 households (320 of them in Q4) on greenhouse management in Balkhi district. As a result, small greenhouses are increasingly used to grow different kind of greens, as well as early tomato and sweet pepper seedlings. In large greenhouses, early tomatoes and cucumbers were grown (Photo 1). Within two quarters, 17 households (five of them in Q4) installed greenhouses in their gardens (Table 4).
Table 4. List of households that installed greenhouses, Balkhi district Jamoat Village # Greenhouse installers Size Halevard Molotov 1 Rahima Mirzoeva Small 2 Tuti Rezvonshoeva Small 3 Sarvinoz Ayubova Small 4 Muhiddin Nozimov Large 5 Tutigul Rahimova Large 6 Shakarmoh Makhmudova Small 7 Idimoh Rahimova Small Lohuti 8 Nematjon Sharipov Large 9 Muhabatsho Gulov Large 10 Zarobiddin Kenjaev Large Dustov 11 Fotima Qalandarova Small 12 Gulbarg Murodova Small Navobod Pushkin 13 Rajabmoh Sadulloeva Small 14 Zulayho Nazarova Small 15 Ashurmoh Sattorova Large 16 Sangali Sattorov Large 17 Gulnazar Pirnazarova Large
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Photo 1. Large greenhouse, April 2018, Balkhi district (photo credit: THNA)
In Y3, THNA coordinated the selection of new crops with TAWA. THNA advocated for broccoli and okra, as they are rich in vitamins A and C, and in antioxidants, and encouraged TAWA to boost the availability of these crops. 2.2.2. Improve participants’ ability to buy nutritious food (“access to markets”) Training on household budgeting and family entrepreneurship Figure 15. RHS results on household budgeting in households engaged in THNA activities, 2016–2018
To improve the ability of households to purchase nutritious foods, in Q1, THNA provided a two-day TOT on household budgeting and family entrepreneurship for 12 district coordinators. The topic included: Planning and balancing the family budget; Planning agricultural production;
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Categorizing and scheduling revenues and expenditures; Setting and achieving financial goals; and Saving for health care and the improvement of sanitation conditions. In Q2, district coordinators conducted 26 trainings for 500 CEs on household budgeting and family entrepreneurship. In turn, CEs provided 2,421 action-oriented educational sessions for 21,166 households. As a result, according to THNA’s RHS in June 2018, 43% of households do plan their family budget, and 54% are saving money (Figure 15). Installing information boards To improve the ability of farmers from remote villages to market their products, in Q4, THNA piloted information boards at five sites in three districts (Table 5). The sites were chosen due to their location in a district center or at a daily or weekly market. The goal was to give farmers a public place to inform wholesale buyers or resellers about their products and how to contact them for purchase. The farmers in THNA target villages were notified about these boards through jamoats, CEs, and VDCs. THNA’s monitoring demonstrated, however, that the use of these boards did not receive much traction (Photos 2 and 3). Therefore, THNA did not proceed with installing all 15 boards, as originally planned.
Table 5. Locations of information boards for farmers # District Jamoat Village Place of installation 1 Dusti Nuri Vakhsh Eshbek Sattor Regular market 2 Dusti 20 solagii istiqloliyati Tojikiston Garauti Thursday market 3 Dusti 20 solagii istiqloliyati Tojikiston District center Jamoat 4 Balkhi Guliston Orzu Sunday market 5 Yovon Hayoti nav Alisher Navoi Sunday market
Photos 2 and 3. Information boards, Balkhi and Dusti districts (photo credit: THNA)
Farmers’ markets and fairs To promote new and nutritious crops together with health and nutrition behavior change messages, in Y3, THNA organized 12 farmers’ markets and fairs in 12 districts (four of them in Q4). These events brought together 1,887 community members (~500 in Q4). TAWA contributed by inviting their farmers,
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who eagerly showcased their new crops. Representatives of USAID and the DOH, local authorities, and staff of district healthy life style centers (HLSCs) and village PHCs attended the events.
Photo 4. USAID staff with community members at the farmers’ market and fair, Balkhi district (photo credit: THNA)
Key messages of the farmers’ markets and fairs included: • The first 1,000 days in a child’s life are “golden”; • Exclusive breastfeeding for children up to six months; • Complementary child feeding (presented through cooking demonstrations); • Seasonal dietary diversity and nutrition for children between six and 59 months of age; • Dietary diversity and nutrition for pregnant and lactating women, and adolescent girls; • Introduction of new high-nutrient crops (broccoli, okra, and sweet potatoes); and • The benefits of dairy and chicken products. Participants returned home with new knowledge and inexpensive fresh fruits, vegetables, and meat and dairy products purchased at the fairs.
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2.2.3. Coordinate with FTF partners on joint activities in the field Coordination with TAWA In Y3, THNA held 10 coordination meetings with TAWA. The focus of coordination was on farmers’ markets and fairs, supplying crops to two pilot schools in Jomi and Dusti (see Activities 3.1.1 and 3.1.2), a TOT on cheese-making, and THNA’s participation in TAWA’s open field days. THNA, in turn, supported two of TAWA’s open field days in Jomi and Balkhi districts in Q2. At these events, THNA promoted the nutritional value of spring crops for women of reproductive age, for pregnant and lactating women, and for age-appropriate complementary feeding of children. In addition, THNA distributed brochures on nutrition in pregnancy and complementary feeding of children. In Q3, THNA’s CEs joined TAWA’s trainings on fruit and vegetable drying technologies. To promote TAWA’s crops, THNA developed broccoli and bok choy recipes for children under two years and women of reproductive age, which CHPs presented during their cooking demonstrations (see Activity 2.1.5). CEs also promoted these crops, and they were included in THNA’s recipe book to be published in Y4. THNA also coordinated with TAWA in joint activities at two schools promoting nutritious crops (see Activity 3.1.2). Coordination with Centro Internacional de la Papa (CIP) In Y3, THNA also closely collaborated with CIP on the promotion of orange-fleshed sweet potato (OFSP). CIP supplied two farmers in Jaikhun district, who are also THNA CEs, with sweet potato cuttings and conducted educational sessions on the production of OFSP and its varieties, which are rich in beta- carotene. Land preparation and planting was held from June 1–2 and involved approximately 15 households at each farm. The planting area totaled at 112 m2, and 528 sweet potato cuttings were planted (Photos 5 and 6). CIP provided the farmers with phenological calendars, which provide guidance on fertilization and other necessary care. The mentored farmers spread their knowledge of best land management practices for OFSP and other vegetables throughout their communities. Harvesting OFSP is planned for the end of October or the beginning of November. THNA also coordinated with CIP on joint activities at two schools promoting OFSP (see Activity 3.1.2).
Photos 5 and 6. After planting (left photo, June 2018) and growing (right photo, September 2018) of OFSP (photo credit: THNA)
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IR 3: INCREASED PRACTICE OF HEALTHY BEHAVIORS AROUND MNCH
Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children under two
3.1.1. Launch nutrition promotion activity at secondary schools in Dusti and Jomi districts In Y3, THNA continued its cooperation with the regional Department of Education based on the memorandum of understanding (MOU) signed earlier by Mercy Corps to implement the Aflateen+ program. Under this MOU, THNA obtained approval from the Department of Education to pilot a peer education program on life skills, health, and nutrition for adolescents in School #11 in Dusti district and School #16 in Jomi district during the 2017– 2018 school year. To develop this program, THNA used relevant materials earlier approved by the MOHSPP and the Ministry of Education and Science. As a result, in Q1, THNA put together four training modules from a combination of Aflateen+ and WASH (Mercy Corps/USAID), as well as healthy lifestyle (UNICEF) materials (Table 6). Table 6. Peer education modules Nutrition WASH Life skills Gardening 1 The concept of Personal hygiene Life fulfilment, life Land preparation and nutrition and its skills, and health crop rotation components 2 Food groups and Clean water: water Budgeting and saving Irrigation problems related to purification and nutrition disinfection 3 Practical work: Environmental Planning and Food storage cooking healthy food cleanliness and proper budgeting disposal of waste
The schools assigned one teacher each to be responsible for supporting the students in organizing the adolescent clubs. The teacher assisted in selecting 30 students from the eighth to tenth grades to become peer educators.
3.1.2. Conduct educational sessions on healthy food choices, food preservation and storage, and planning of family budget with school students
In Q2, THNA trained the 30 peer facilitators and two teachers on facilitation and communication skills. Training included interactive methodology, listening and counseling skills, and peer mobilization skills, among other topics. After the initial training, THNA continue to train the students and teachers on 12 specific topics related to nutrition, WASH, gardening, and life skills (Table 6 above). In turn, peer educators cascaded these trainings through nine sessions on each of the 12 topics at each school, for a total of 216 peer training sessions. Over 360 students were engaged in peer education activities at the two schools (Table 7).
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Table 7. Peer coverage by 30 school educators Topic # of sessions # of students Nutrition The concept of nutrition and its components 18 364 Food groups and problems related to nutrition 18 359 Practical session: cooking healthy food 18 357 WASH Personal hygiene 18 361 Clean water: water purification and disinfection 18 353 Environmental cleanliness and proper disposal of waste 18 367 Life skills Life fulfilment, life skills, and health 18 363 Budgeting and saving 18 365 Planning and budgeting 18 358 Gardening Land preparation and crop rotation 18 361 Irrigation 18 357 Food storage 18 364 Total: 216 Over 360
Through regular visits, THNA provided supportive supervision to peer educators and school teachers through regular supervision visits. Student facilitators were mentored so they could provide effective educational sessions for their peers. Facilitators were observed becoming more active and engaged in school events, as well as in school gardening activities. In Y4, THNA is planning to replicate this experience in seven additional schools in seven districts.
We teach our peers to wash hands with soap, not to eat Rollton, and to grow crops at home, not just in the school garden. We are proud to be trainers. Interview with a school student at mid-term review
After a training on crop rotation, I gave advice to my father in our home garden, and he followed it. I would like to grow strawberries in our home garden and sell them at the market. Interview with a school student at mid-term review
Before, I brushed my teeth only once a day. After a training on personal hygiene, I now brush my teeth twice a day. Interview with a school student at mid-term review
In March, to facilitate practical work on the land, THNA provided each school with 16 types of agricultural tools through small in-kind sub-grants. With these tools, the students prepared plots and planted different crops provided by TAWA and CIP, as well as by the schools themselves.
In collaboration with TAWA, in April, THNA led the students in planting 400 tomato and 400 sweet pepper seedlings. The harvest was in July, and school administrations preserved the vegetables in the form of a paste for winter storage. By the end of the academic year (Q3), the broccoli and cauliflower planted in Q2 was harvested and used in school kitchens to feed children in grades 1–4. The harvest was 300 kg of cauliflower and 80 kg of broccoli in Dusti district, and 220 kg of cauliflower and 100 kg of broccoli in Jomi district. A total of 385 children in Jomi district and 312 children in Dusti district received
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nutritious food for one month. These vegetables complemented WFP’s school feeding program for the youngest school-aged children. THNA also provided logistical and technical support for joint activities with CIP at schools. CIP has supplied a total of 514 sweet potato cuttings to plant on 0.01 hectares of land at both schools. CIP also conducted trainings on how to produce OFSP and provided schools with phenological calendars. Following CIP recommendations, schoolchildren irrigated and fertilized the sweet potato crops. THNA plans to conduct cooking demonstrations on OFSP after it is harvested at each school at the end of October or the beginning of November. Nutrition awareness events on adolescent health, nutrition, and hygiene
Photo 7. International Day of the Girl Child, School #11 in Dusti. Demonstration of preparing a smoothie (photo credit: THNA) To increase the awareness of child and adolescent health, nutrition, and hygiene, in Y3, THNA organized the following community events at pilot schools: Two events devoted to International Day of the Girl Child (October 11) at both schools (also see Activity 3.2.4); One event dedicated to International Women’s Day (March 8) at the Dusti district school; Two events dedicated to International Day for Protection of Children (June 1) at both schools.
The students, their parents and teachers, as well as representatives from the regional Department of Education and Science and from district HLSCs attended these events. In total, THNA brought together 831 participants at school community events in Jomi and 1,044 participants in Dusti.
3.1.3. Promote maternal health during pregnancy, the consumption of diverse food groups, and IYCF and WASH practices
Peer support groups Men and older women (mothers-in-law) are the decision-makers in Tajik families. The participation of younger women (kelins, daughters-in-law) in THNA activities, such as cooking demonstrations, small group training sessions, peer support groups or home visits, depends on these family decision-makers. Therefore, THNA began by first engaging mothers-in-law and men in its activities. In Y3, CHPs established a total of 199 peer support groups in 158 villages across the 12 ZOI districts: 141 support groups for mothers-in-law, two for men, and 56 for pregnant and lactating women and women of reproductive age (Table 8). These groups meet monthly to discuss exclusive breastfeeding, complementary feeding for children over six months of age, nutrition for pregnant and lactating women, and other related topics for the specific group or community. Membership in support groups
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totaled 1,410 people. THNA staff provided supportive supervision and mentoring visits to assist CHPs and district coordinators in forming and facilitating peer support groups.
Table 8. Number of active peer support groups and their members, by district and type of beneficiary # of groups # of groups for # of groups Total # of SG Total # of # District for mothers- PLW/WRA* for men members SGs in-law 1 Khuroson 0 12 0 67 12 2 Jomi 35 35 0 654 70 3 Dusti 3 5 0 87 9 4 Kushoniyon 2 3 1 35 5 5 Levakand 2 2 0 28 4 6 Vakhsh 3 8 0 46 11 7 Yovon 0 26 1 169 27 8 Jaikhun 2 4 0 38 6 9 Balkhi 9 25 0 141 34 10 Qabodiyon 0 10 0 67 10 11 Shahritus 0 7 0 44 7 12 Nosiri Khusrav 0 4 0 34 4 Total: 56 141 2 1,410 199 *PLW = pregnant and lactating women; WRA = women of reproductive age; SG = support group Engaging men in peer support groups around MNCH and nutrition has been a challenge, as men do not see these issues as one of their priorities. They, however, are key decision-makers in allocating family resources, including for food and health care. In Y4, THNA will invite heads of VDCs (raisi mahalla), who are men and oftentimes community religious leaders to monthly volunteer peer learning meetings. In turn, THNA will expect these raisi mahalla to mobilize other men in their communities around MNCH issues. Educational sessions by CHPs Besides support group meetings, CHPs provide regular action-oriented educational sessions in their communities on maternal health and IYCF practices for women of reproductive age and pregnant and lactating women. CHPs conducted 2,035 educational sessions on breastfeeding and 4,457 sessions on complementary feeding, reaching a total of 114,226 participants across 12 districts (25,404 male and 88,822 female). CHPs also addressed these topics at peer support group meetings and at cooking demonstrations. Home visits by CHPs In Y3, during their 80,079 home visits (47,399 in Q4), CHPs provided pregnant women with individual counseling and referral services. The CHPs’ goals are to identify pregnant women in the first trimester of pregnancy, counsel them and members of the household on the importance of prenatal care, inform them of the danger signs during pregnancy, and inform the HCWs at PHCs of a pregnant woman identified in the community. In Y4, THNA will monitor the effectiveness of this community work through referral coupons provided by CHPs to their beneficiaries.
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At a home visit, one woman complained to me about weakness and dizziness. The conversation that followed suggested to me that she might be pregnant. I advised her about the importance of antenatal care and the danger signs in pregnancy. The woman promptly visited the clinic and was prescribed treatment for anemia. Several days later, she met me and thanked for the timely advice. Interview with a volunteer from Vakhshi village at mid-term review 3.1.4. Promote IYCF practices and exclusive breastfeeding for children under six months
Media campaign on exclusive breastfeeding In Q2, THNA critically assessed the coverage of the target communities by mass media, such as national and local TV stations, newspapers, radio, and the Internet. This assessment demonstrated that the target population has little access to mass media other than national TV; moreover, national TV channels charge a high price for any advertisements, including those that are non-commercial. The cost of achieving any impact on the target communities through national TV channels is beyond THNA’s scope and budget. Therefore, in Y3, THNA focused on individual and small group interventions by CHPs and CEs to raise awareness and change attitudes and practices around IYCF and exclusive breastfeeding for children under six months.
In Q3, THNA supported a media training in Khatlon Region for 15 local TV, radio, and print media journalists. The training focused on FTF goals and activities, including maternal and child nutrition. The training was organized by the Internews Network, which is implementing USAID’s Access to Information project. THNA contributed to the training program with: A presentation and discussion on mother and child nutrition, exclusive breastfeeding, vitamins, micronutrients, and complementary feeding; and A cooking demonstration in Levakand district to present CHP/CE activities and to promote complementary feeding. As a result, during and after the training, participating journalists published several blog posts (see the Communications and knowledge management section below).
World Breastfeeding Week
THNA supported the regional DOH’s celebrations around World Breastfeeding Week (which in Tajikistan, is traditionally celebrated over ten days, from August 1–10). THNA organized 232 community events in 220 target villages (Table 9) of all 12 FTF districts during the entire month of August. CHPs supported rural PHCs in conducting these local events. CHPs disseminated key messages around exclusive breastfeeding through role-plays, poem recitations, discussions, demonstrations of breastfeeding techniques, and sharing real-life stories of rural women. The majority of participants were pregnant and lactating women, women of reproductive age, adolescent girls, and mothers-in-law. These events reached a total of 5,375 participants from 4,786 households. Providing support to CHPs and coordinating so many events was a significant challenge for THNA.
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Table 9. World Breastfeeding Week events by location and number of participants # of # of villages Total # of Total # of # District # of events pregnant reached participants households women 1 Balkhi 23 26 119 399 347 2 Dusti 10 11 69 263 236 3 Jaikhun 6 6 28 88 77 4 Jomi 22 28 310 788 703 5 Khuroson 13 14 112 339 296 6 Kushoniyon 33 34 262 804 737 7 Levakand 6 6 29 122 102 8 Nosiri Khusrav 6 6 55 152 129 9 Qabodiyon 15 15 76 307 267 10 Shahritus 15 15 113 368 335 11 Vakhsh 30 30 154 557 492 12 Yovon 41 41 382 1,188 1,065 Total: 220 232 1,709 5,375 4,786
Photo 8. A community event around World Breastfeeding Week, Kushoniyon district (photo credit: THNA)
Home visits by CHPs In Y3, during their household visits, CHPs provided individual counseling or small group educational sessions on breastfeeding for 8,846 pregnant women and 21,625 mothers with children under five.
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All mothers were encouraged to exclusively breastfeed for the first six months. In addition, 6,753 pregnant women and 9,594 women with children under five received advice on complementary feeding. Over 53,000 children under five benefited from these CHP services provided to women with young children, their mothers-in-law, and other household members. In addition, CHPs referred women and children to health services related to breastfeeding and other issues of postnatal care, child nutrition, child growth monitoring, immunizations, signs of malnutrition (reaching 808 children, see also Activity 3.3.1), or other specific health conditions, such as diarrhea or fever. We learned the importance of timely registration with the doctor. I go for appointments together with my daughter-in-law to hear the doctor’s recommendations and ensure they are followed. Interview with a mother-in-law at mid-term review International Day for Protection of Children In partnership with the regional HLSC, THNA organized celebrations for International Day for Protection of Children (June 1) in all 12 districts, reaching a total of 521 participants (Photo 9). Photo 9. Celebration of International Day for Protection of Children, Yovon district (photo credit: THNA)
The objectives were to promote optimal IYCF practices and adequate adolescent nutrition to protect children from diseases and to enable them to attain their highest physical, mental, and economic potential. The program included information on child rights, exclusive breastfeeding, questions and answers with participants, and THNA’s jingle (song) about breastfeeding, complementary feeding, and hygiene.
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3.1.5. Promote timely, adequate, affordable, and age-appropriate complementary food for children aged six to 24 months Cooking demonstrations To support CHPs in their action-oriented, community-level educational sessions, in Q2, THNA developed a cooking demonstration manual to ensure the quality of cooking demonstrations. The manual highlights WHO’s Five Keys to Safer Food. In Q2, a one-day TOT on conducting cooking demonstrations was held for five district trainers, eight TAWA staff, and 23 THNA program staff for their further cascade trainings for CHPs. In Q3–Q4, THNA’s district coordinators trained a total of 1,153 CHPs (1,091 women and 62 men) on cooking demonstrations through 46 cascade trainings in 12 districts. The last five trainings for 80 CHPs were conducted in Qabodiyon district in September. The cascade trainings highlighted food safety practices and recipes for complementary food for children over six months and for pregnant women. Photo 10. Cooking demonstration at the farmers’ market and fair, Balkhi district (photo credit: THNA)
In Y3, THNA developed and tested 21 recipes, of which 12 recipes are for complementary feeding of children over six months, and nine recipes are for pregnant and lactating women. The recipes use locally
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available ingredients. The recipes were developed and tested with the involvement of adolescent girls, women of reproductive age, and elderly women in THNA target communities. THNA is preparing a recipe book in Tajik for publication early in Y4. The recipe book is organized by season and child age category for complementary feeding and will assist CHPs in preparing and conducting effective cooking demonstration sessions. Of the total 225 cooking demonstrations (Table 2, Activity 2.1.5), CHPs organized 13 cooking demonstration sessions specifically on age-appropriate, nutritious complementary food for children over six months. These cooking demonstrations engaged 286 caregivers, including 13 men and 273 women, of which 30 were pregnant women over 18 years. The rationale for promoting complementary feeding “at six months” was to ensure that caregivers were aware of the importance of starting age- appropriate complementary feeding at that age, when breastmilk is no longer sufficient to meet all of the nutritional requirements of the child. In Q3–Q4, THNA provided 37 CHPs from 12 districts with 13 supportive supervision sessions on cooking demonstrations. To increase CHPs’ proficiency, THNA will continue to mentor them on their facilitation and organizational skills.
During a home visit I saw a woman feeding her seven-month-old granddaughter with sweet tea from a bottle. I explained to her [the principles of] breastfeeding and complementary feeding and the causes of stunting. I showed to her how to make purée with potatoes and apples for babies over six months. That woman was very grateful and said she would participate in other educational sessions. Interview with a volunteer from Sovkhoz Kirov-2 at mid-term review Monthly campaigns on complementary feeding THNA disseminated key messages on complementary feeding through performance and other forms of engagement during monthly events, such as 12 farmers’ markets and fairs (also see Activity 2.2.2). On International Day for Protection of Children, THNA organized educational sessions for 491 women and 30 men in 12 districts. All of these events featured locally available ingredients and promoted complementary food for children over six months of age. The recipes included apple, carrot, and pumpkin purées. These crops are available in the kitchen gardens of targeted households. As part of its promotional methodology on IYCF, THNA produced a song (jingle) as an effective way of raising awareness at public events. The song promotes exclusive breastfeeding for infants under six months, timely complementary feeding starting at six months, and continued breastfeeding for up to 24 months. The song was recorded in April and widely used at all public THNA events. The jingle was also recorded on CDs along with other materials and disseminated to all THNA volunteers. Food diversity cards In Q2, THNA completed testing of dietary diversity cards. In Q3, 2,000 sets of 60 cards were printed and disseminated to volunteers through monthly peer learning meetings. CEs and CHPs use these food diversity cards during their small group and individual counseling sessions on complementary feeding for children aged six to 24 months; on dietary diversity for pregnant and lactating women and for adolescent girls; vitamin sources; iron-rich foods, etc. We also do household visits, but the people like your visits much more because you have [cooking] demonstrations, show videos, and give out informational materials. As people say, it’s better to see once than to hear twice. Interview with the deputy chief of the Hukumat, Yovon district
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The efforts to promote food diversity and complementary feeding for children over six months resulted in improved food intake by children six to 24 months of age in THNA’s target communities (Figure 16). According to 2018 RHS results, 56% of children in families engaged in THNA activities received a minimum acceptable diet, compared to the national average of 9% reported in the 2017 Demographic and Health Survey. Figure 16. RHS results on food intake of children six to 24 months in families engaged in THNA activities
An unexpected RHS finding is the declining prevalence of exclusive breastfeeding and the increasing prevalence of continuous breastfeeding by women with children under two engaged in THNA activities (Figure 17). This trend may be the result of a lack of focus on exclusive breastfeeding and an emphasis on complementary feeding in THNA activities over the past year. In Y4, THNA will attempt to correct these trends by emphasizing the importance of exclusive breastfeeding in its community-based activities. Figure 17. RHS results on the prevalence of exclusive breastfeeding and continuous breastfeeding, 2016– 2018
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3.1.6. Promotion of iodized salt in the ZOI
In Q1, THNA received 5,000 iodine test kits from UNICEF. A total of 2,000 kits were distributed to 860 CEs and CHEs in all 12 districts, and 3,000 kits were distributed to 341 CHPs in three districts (Jomi, Khuroson, and Dusti) in January. All volunteers were trained on the use of the iodine testing kits and were mobilized to use them in households and at retail points (including markets, shops, and canteens). In addition, adhesive posters promoting iodized salt were distributed to all targeted communities to be displayed near shops and schools and at PHCs and jamoats, etc. According to CE and CHP reports, the salt in 90,463 households and retailers in 12 districts was tested, and iodine was present in only 57,494 samples (63.5%). The iodine test kits that THNA received from UNICEF and distributed to volunteers expired in February 2018. Since then, no additional testing kits have been made available.
Outcome 3.2: Improved sanitation and hygiene-related behaviors
3.2.1 Form WASH subcommittees within health sections of VDCs in Jomi, Kushoniyon, Khuroson, Levakand, Dusti, and Balkhi districts
In Y3, THNA facilitated the establishment of 33 WASH subcommittees in six districts. Each WASH subcommittee consists of five members, including the head of mahalla (VDC) and a CHP. The goal of these subcommittees is to encourage communities to change their hygiene and sanitation attitudes and practices and to encourage them to solve sanitation problems themselves. In Y3, THNA conducted the following trainings for WASH subcommittees: Eight one-day community mobilization trainings to develop and implement local activities to solve village and household sanitation problems. Eight essential hygiene and sanitation action trainings to educate WASH subcommittee members about the links between WASH, nutrition, health, and disease prevention. Fundraising training to enable WASH subcommittees to write small project proposals. As a result, ten VDCs submitted their project proposals to THNA, of which five will be supported through in-kind grants in Y4. Four proposals concern providing safe water to schools, and one concerns providing water to a village. All proposals have significant cost-share contribution from local communities. WASH subcommittees, with the support of THNA, put together special information boards in six villages. These boards, among other information, include the committee’s six-month workplan. According to these workplans, hashars (joint voluntary work efforts that benefit a community) were organized in all six districts to keep the surroundings clean, with the goal of reducing the prevalence of environmental enteropathy, especially among children under five. Some successful mobilization efforts included the following: In Levakand district, members of the village of Botrobod, which comprises approximately 300 households, repaired the main water pump. The CHP and WASH subcommittee collected TJS 2,500 from community members to provide adequate access to water to more than 2,000 people. In the village of Zagertut in Levakand district, the WASH subcommittee constructed a safe latrine with assistance from community members. The community also installed a large water
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tank near the latrine to allow for washing hands with soap. The tank is located in a public place and is accessible to all passersby. The CHP is responsible for further promotion of handwashing in the community. A CHP from Rohi-Lenin village in Kushoniyon district, upon her return from the Haj, spoke to neighbors about the importance of sanitation and hygiene in Islam. WASH subcommittees in Qushlich, Hisorobod, and Iftikhor villages of Khuroson district mobilized their communities for cleaning days. You gave very good information to my daughter-in-law. She started to clean up, wash the dishes, and boil the water. She now keeps the children clean and says microbes cause illness. I am grateful to you because if I make comments to her, she gets offended. If a volunteer teaches her, she then does everything herself. Interview with a mother-in-law at mid-term review
My grandson at 10 months weighed 6 kilos. He was always sick with diarrhea and vomiting. All our money went to the hospital, and he was thin. After training sessions, we started using boiled water, boiling the bottle and the nipple, and covering them with cloth. It has been a month since my grandson has had diarrhea or vomiting and started to gain some weight. Interview with a mother-in- law at mid-term review
Earlier we thought that one piece of soap was enough for the household. Now we understand it’s not enough and are buying and using more soap. Interview with a mother-in-law at mid-term review 3.2.2 Coordination and collaboration with governmental structures on promotion of WASH Photo 11. A practical activity at a WASH outreach event, Jaikhun district (photo credit: THNA)
In Y3, THNA organized a roundtable on WASH between THNA-supported VIP latrine masons and different regional authorities, including the DOH and its agencies, the tax committee, TajikStandart, and a microloan organization Mehnatobod, for a total of 36 participants. The goals were to improve home latrines in the region and to remove bureaucratic obstacles faced by latrine masons. As a result,
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Mehnatobod offered masons a low-interest microloan to expand their production. Similar loans from Mehnatobod are also available to households to improve their latrines. Working with local authorities at the community level, in Y3, THNA conducted 30 WASH outreach events in 30 villages for a total of 574 participants (Photo 11). The events were dedicated to communal hygiene, with the slogan “Our Health is in Our Hygiene.” Each event addressed the following topics: Proper garbage disposal; Disease prevention through handwashing with soap; The financial, agricultural, and hygienic benefits of compost; Nutrition, hygiene, and sanitation in child development and environmental enteropathy; and Communal hygiene and access to handwashing facilities, water, and soap. 3.2.3. Capacity-building of community masons for construction of VIP latrines In Q1, THNA organized seven one-day entrepreneurship trainings on latrine production for 40 community masons from nine districts. Local masons received knowledge on business planning and management, sales and marketing, sanitation product construction and services, cost calculations, financial planning, legal issues, and taxation procedures. To cover the remaining districts with mason services, in Q2, THNA provided a two-day skills training on the construction of VIP latrines and on business management to 16 newly selected community masons from seven districts. In this training, the masons learned how to construct the concrete slabs and rings for VIP latrines (a safe toilet that helps prevent the spread infectious diseases), calculate expenses for materials, advertise, ensure a profit margin, manage their business, and develop their workplan for one season. Regulatory requirements were also part of the training. In Q4, THNA purchased and donated iron molds for rings and slabs to 15 new community masons. An additional set of molds went to an experienced mason in Jomi district. In Y4, THNA expects masons to produce more concrete rings and slabs to make VIP latrines more accessible in communities. In Y4, THNA also plans to support construction of demonstration VIP latrines by community masons in 100 village-level PHCs. In Y3, THNA conducted nine latrine fairs (two in Q4) in eight districts: Balkhi, Shahritus, Yovon, Dusti, Qabodiyon, Khuroson, Nosiri Khusrav, and Jaikhun. A total of 2,599 community members (845 in Q4, Table 10) participated in nine events. To spark community interest in the latrine fairs, THNA engaged Alovuddin Abdulloev’s comedy group from Bokhtar city. The actors performed comic sketches around sanitation and hygiene (Photo 12). Other activities at the fairs included children’s drawing competitions; reciting of poems on sanitation, water, and hygiene; and role-plays by community volunteers. Latrine fairs also served as a marketplace for masons who build VIP latrines. In Y3, communities improved over 681 latrines, and in addition to those produced by masons whose data THNA can track, some individuals in the communities constructed VIP latrines of their own. In Y3, the masons sold 2,093 concrete rings and 681 slabs (Figure 18), for a total of 681 complete latrines. Differences between districts in terms of units sold are mainly explained by the number of masons; the technologies they use (mixing concrete with a machine or by hand); their entrepreneurial abilities; and the purchasing capacity of local communities.
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Table 10. Latrine fairs by date, location, number, and gender of participants # of Date District Jamoat Village male female participants 01/23 Balkhi Madaniyat Qzilabayraq 300 100 200 02/16 Shahritus Kh. Kholmatov Sverdlov 195 70 125 03/02 Yovon H. Huseinov Dastgiraki poyon 259 50 209 03/28 Dusti Dehkonobod Rohinav 150 50 100 04/24 Qabodiyon Shahrak Center 350 150 200 05/14 Khuroson Hiloli Mehnat 350 100 250 06/06 Khuroson Center School #1 150 50 100 07/19 N. Khusrav Istiqlol H. Olimov 450 100 350 07/15 Jaikhun Qumsangir Mehnatobod 395 195 200 Total: 2,599 865 1,734
Photo 12. Group photo of community volunteers and children at a latrine fair, Nosiri Khusrav district, July 2018 (photo credit: THNA)
In Y3, CHPs addressed hygiene practices through household visits. CHPs provided 4,276 small group educational sessions for 50,212 community members from 31,524 households on personal and environmental hygiene, safe water, and VIP latrines. From their household visits, CHPs reported that 35,661 households (39.4%) have handwashing basins, 37,090 households (41.0%) use compost, and 21,528 households (23.8%) have improved latrines. For all WASH-related activities, THNA used IEC materials previously developed and approved by USAID. In Y3, THNA did not develop any new WASH materials.
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Figure 18. Sales of VIP latrine components in 12 THNA districts, Y3
3.2.4. International marketing days
On International Day of the Girl Child (October 11), THNA organized awareness-raising events on nutrition in two pilot schools in Jomi and Dusti districts (also see Activity 3.1.2). More than 1,200 people participated, including students, teachers, parents, and other community members. The slogan for the events was “Healthy Nutrition of Adolescents is the Basis for Mothers’ and Children’s Development.” Messages included the prevention of malnutrition in adolescents, the consequences of early marriage, gender inequality, gender-based violence, discrimination of women, and illiteracy. Students participated in a cooking demonstration, poem recitation, and a theatrical performance. Around Global Handwashing Day (October 15), THNA conducted outreach events in each of the 12 ZOI districts under the slogan, “Our Hands—Our Health” (Photos 13 and 14). CEs led the organization of the event, with project staff providing guidance on community mobilization. During the event, communities were encouraged to practice effective handwashing habits and to place handwashing facilities with soap in key areas of the home. Additional information about the dangers of poor handwashing practices was presented, and the event reached almost 700 participants. Around World Toilet Day (November 19), THNA conducted outreach events in all 12 ZOI districts under the slogan, “A Safe Toilet is a Guarantee of Everybody’s Health.” The VIP latrine was promoted as an alternative to current local latrines, which spread infection and pollute underground water. Key messages were delivered to participants through presentations, Q&A sessions, discussions, animated videos by THNA, role-plays, quizzes, and poems read by schoolchildren. CEs and VDC members in villages, who organized the events, offered examples from their own life experience, which resonated especially with participants. A total of 1,200 participants received soap to promote hygiene and prevent infectious diseases.
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Photos 13 and 14. Global Handwashing Day in Dusti and Kushoniyon districts (photo credit: THNA)
As a result of WASH activities, from the RHS in June 2018, data collectors observed soap at handwashing stations in 70% of households. Furthermore, the soap was much more likely to be present if the respondent had reported her participation in a THNA WASH activity (Figure 19). Figure 19. RHS results on WASH practices in households engaged in THNA activities, 2016–2018
*The lower presence of soap at mostly outdoor washing stations in the two fall observations may be explained by the fact that soap is kept indoors during the rainy season.
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Outcome 3.3: Increased use of health services for MNCH, including nutrition, sanitation, and hygiene
Community level. Involvement of CHPs on MNCH issues related to nutrition and health
3.3.1. Regular screening of households for malnourished children under two and referral to PHCs for registration and counseling
In Q3–Q4, via MUAC measurements, CHPs identified 808 children with suspected signs of malnutrition and referred them to PHCs (Table 11). THNA verified these numbers with health facilities through referral coupons provided to caregivers and collected at the local PHC. Not all of these children came for PHC appointments, and only a small proportion were confirmed as malnourished among those who visited PHCs. This was the CHPs’ first experience identifying and referring children with signs of malnutrition, and the process is yet to be streamlined. Differences between the districts in terms of number of malnourished children identified may be explained by a number of factors and may not necessarily reflect the actual incidence or prevalence of child malnutrition. These factors may include the level of CHPs’ engagement, the number of CHPs in each district, the quality of their training and experience with MUAC tapes, and others. THNA will continue monitoring this indicator and will follow up with each case of child malnutrition identified by CHPs in Y4.
Table 11. Number of children identified by CHPs as malnourished and referred to PHCs, by district # District # of children 1 Balkhi 32 2 Dusti 71 3 Jaikhun 0 4 Jomi 11 5 Khuroson 20 6 Kushoniyon 348 7 Levakand 22 8 Nosiri Khusrav 33 9 Qabodiyon 83 10 Shahritus 112 11 Vakhsh 2 12 Yovon 74 Total: 808
After the start of your project, I have much better statistics. Your volunteers are going around the village measuring children. They are trusted, and families let them in their homes. Not every husband or mother-in-law would let me talk with his wife or mother-in-law because I am a man. Now I know all children in the village who are stunted or underweight, and I can pay special attention to those families. Interview with a doctor from Haqiqat village, Khuroson district, at mid-term review
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3.3.2. Implement a follow-up mechanism for the identification and treatment of malnourished children under two and pregnant women
In Q3, THNA designed a referral mechanism, including referral coupons, which was introduced to CHPs during their monthly peer learning sessions. Referral involves the following steps: 1. A CHP identifies a malnourished child using the MUAC tape; 2. The CHP counsels the mother or other caregiver about the urgent need to visit the closest PHC; 3. The CHP completes and provides a referral form; 4. The CHP notifies local HCWs and THNA staff by phone about the suspected case of child malnutrition; 5. Upon the child’s visit to the PHC, the HCW registers, examines, treats, or refers the case to the next level; 6. The PHC provider completes his/her part of the referral form, confirming or dismissing the case of malnutrition. The HCW keeps the provider’s coupon and gives it to the district trainer (HLSC or PHC staff) at the end of the month at the district medical council meeting (medsovet); 7. When the child is discharged home, the PHC provider informs the local CHP by phone about the need to follow up with the family; 8. The CHP visits the household to assist the family in following the doctor’s recommendations on improving the child’s nutrition. THNA will review this procedure in Y4 and revise it, if necessary. 3.3.3. Training of CHPs on advocating for the use of PHC services for MNCH The importance of referrals to PHCs is reinforced in monthly peer learning sessions and in the joint action plan for CHPs and PHCs (see Activity 3.3.6). CHPs have been trained on the notion that they are not medical workers, and they cannot make diagnoses or prescribe treatment. However, to improve MNCH, they should provide timely advice to families when a visit to the PHC is granted. 3.3.4. Conduct awareness-raising health fairs in communities on recognizing danger signs in pregnancy From June to August, THNA conducted 12 health fairs on the topics of danger signs in pregnancy and exclusive breastfeeding in the 12 districts (Table 12). Key messages included recognizing the danger signs during pregnancy, the importance of ANC, nutrition for pregnant and lactating women, iodine deficiency, exclusive breastfeeding, and hygiene. Specific villages were selected based on their remoteness (long distance from the center of the district), their low rates of ANC, and their high rates of home deliveries. Participants included pregnant and lactating women, women of reproductive age, their husbands, and their mothers-in-law; in total, 568 people participated. Your project helped 23 health centers in our district. I personally know seven of your volunteers. They are our eyes and ears. In our jamoat, we have migrants from Garm and Komsomolabad. They have tough traditions; they are hiding their pregnant women. But volunteers are able to get into the homes and find pregnant women in early terms. If they cannot convince the women to get registered, they inform us, and we send our nurses. Interview with a family doctor from Sino jamoat, Kushoniyon district, at mid-term review
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Table 12. Health fair by location, number of participants, and target group. Total # of # of # District Jamoat Village participants PLW* 1 Balkhi Madaniyat Madaniyat 38 12 2 Dusti Dehkonobod Dehkonobod 55 33 3 Jaikhun Qumsangir Tojikiston 27 14 4 Jomi Yakkatut N. Makhsum 40 10 5 Khuroson Fakhrobod Fakhrobod 55 32 6 Kushoniyon Navbahor Vahdat 87 41 7 Levakand Guliston Oqgaza 38 25 8 Nosiri Khusrav Istiqlol Oltinsoy 36 22 9 Qabodiyon E. Niyozov Chorbog 43 30 10 Shahritus Nazarov Dehqon 52 31 11 Vakhsh Tojikobod Sokhtmon 49 23 12 Yovon Dahana Gharav 48 25 Total: 568 298 *PLW = pregnant and lactating women
Photo 15. Testing the salt for iodine during the health fair in Levakand district (photo credit: THNA)
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3.3.5. Eighteen PHC/HLSC staff selected to conduct trainings for CHPs In response to a DOH Order, 31 PHC/HLSC staff from the 12 districts were assigned as district trainers. In Q1 and Q2, they participated in a three- or five-day TOT on the CHP model, consisting of more than ten topics. As a result of the TOT, THNA selected 18 of the best district trainers, and 16 of them are currently active to support and mentor CHPs. An additional 17 district trainers will be trained in Y4 to fill the current gap. 3.3.6. Joint review of the CHP referral system involving staff and PHC workers In Q3, THNA facilitated a meeting at the DOH to review the joint activity plan for local PHCs, CHPs, and VDCs, and the DOH approved the plan in May. Managers of 12 district-level PHCs and HLSCs participated in this meeting with the head of the DOH and THNA leadership. District PHC managers very positively received the joint activity plan, which is based on the concept that CHPs help identify, refer, and follow up with households on MNCH issues. The referral mechanisms were also discussed (see Activity 3.3.2). THNA followed up on this meeting by presenting the joint activity plan and the referral mechanism at the monthly medical council meetings (medsovet) in 12 districts. PHC managers from all levels pledged their support for joint PHC, CHP, and VDC activities. 3.3.7. Mentoring of CHPs by HCWs District trainers in 12 districts mentored CHPs during small group educational sessions and cooking demonstrations in the community. District trainers supported CHPs by answering their questions and providing counseling. 3.3.8. Regular monthly meetings (of PHCs, HLSCs, CHPs, and VDCs) to discuss the results and reports provided by the CHPs In Y3, THNA coordinated monthly peer learning meetings with CHPs. In total, THNA held 142 CHP peer learning meetings (see Activity 4.2.1). Representatives of PHCs and HLSCs (district trainers) participated in all of these meetings, and VDC representatives were invited in September. Joint meetings between community volunteers and other local stakeholders were shown to be effective and will continue in Y4. THNA also facilitated discussions on CHP activities, their coordination with PHCs, and their results, at regular monthly meetings of district medical councils (medsovet) in 12 districts. In addition, THNA presented CHP activities at quarterly meetings with managers of district PHCs, regional HLSCs, and RHCs at the DOH. In Y4, THNA will continue coordinating community-based volunteer activities with health authorities and providers at different levels. 3.3.11. Conduct nutrition awareness/counseling campaigns involving national and local nutrition specialists and CHPs To increase the awareness of caregivers about the need for child growth monitoring, in Q4, THNA conducted six nutrition awareness/counseling events in Levakand, Kushoniyon, Vakhsh, Balkhi, Jomi, and Yovon districts. These events reached 371 people in total (Table 13). The majority of participants at the events were mothers with children under five, pregnant women, women of reproductive age, and their husbands and mothers-in-law. During the events, CHPs and HCWs demonstrated how, when, and why children under five should be measured by HCWs. MUAC measurements, dietary diversity for children aged six months to two years, and the use of the Instructions for the Lives of Mothers and Children MNCH Handbook (Rohnamo) were discussed.
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Table 13. Nutrition awareness events by location, number of participants, and target group. Total # of # of Date District Jamoat Village participants WCU5* September 6 Levakand Vahdat Zaghirti 48 28 September 7 Kushoniyon Istiqlol Davlatov 52 39 September 11 Vakhsh Tojikobod Proletar 74 49 September 11 Balkhi Halevard Ghalaba 69 4411 September 11 Jomi Yakkatut Pushkin 53 31 September 12 Yovon H. Huseinov Zulmobod 75 51 Total: 371 242 *WCU5 = women with children under five
Facility level. Improve quality of care through increased use of health care services
3.3.9. Malnutrition management—capacity-building of PHCs
In Y3, joint activities with UNICEF and WFP on IMAM resulted in the integration, revision, and approval of guidelines on IMAM. To strengthen local training capacity on IMAM, THNA supported the training of six Khatlon regional trainers in a five-day TOT in Dushanbe on IMAM for future cascade trainings in the 12 FTF districts. THNA is supporting implementation of IMAM in pediatric departments of CDHs and “numeric” hospitals in all 12 districts and in rural PHCs in three districts. The reason for this strategy is that therapeutic nutrition is supplied for inpatient treatment in the pediatric departments of all 12 CDHs and 17 numeric hospitals, while for outpatient treatment, it is available only in Balkhi, Shahritus, and Dusti districts. Photo 16. Training on IMAM for pediatricians from “numeric” hospitals, Bokhtar city, July 23–27, 2018 (photo credit: THNA) Following the TOT, THNA conducted four two-day trainings on IMAM for 73 PHC nurses from Shahritus district. With these trainings completed, 100% of all PHC HCWs in the district, including physicians, have now been trained. The five-day curriculum intended for physicians was shortened to two days for nurses. The focus was on the proper screening and early detection of children under five with signs of or at risk of malnutrition. Practical sessions were devoted to counseling skills on nutrition through role-plays, the use of the Z-table, preparation of treatment formulas provided by UNICEF and WFP (Photo 16), case registration, and reporting. To facilitate screening for childhood malnutrition and referral for treatment at the community and PHC levels, WFP provided over 2,000 MUAC tapes to HCWs from PHC facilities (see Activity 1.1.2) and to CHPs. To improve HCWs’ identification of children with malnutrition, their counseling skills, and their
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understanding of follow-up mechanisms, THNA conducted a three-day TOT on GMP for 20 regional PHC providers from 12 pilot facilities. The training agenda included child development, early signs of malnutrition, referral protocols, and nutrition counseling. All participants received MUAC tapes, the IMAM protocol, and updated guidelines on diagnosing and preventing malnutrition in children. The training included practical exercises, such as cooking demonstrations of complementary food for children six to 12 months of age. As a result, the pre- and post-training test demonstrated an improvement in participants’ knowledge from 35% to 93% of correct responses. Following the TOT on GMP, THNA conducted three cascade trainings on GMP for 64 PHC staff from rural medical facilities in Jomi, Kushoniyon, Levakand, and Vakhsh districts. The pre- and post-training test results demonstrated knowledge improvement from 18% to 85% of correct responses. The training focused on the correct assessment of anthropometric indicators (weight/height) and child development, danger signs of severe malnutrition (Kwashiorkor) and stunting, and case registration and reporting. Practical exercises improved participants’ counseling and cooking demonstration skills. In Y3, THNA trained a total of 95 medical staff from 12 PHCs (55 family doctors and 40 nurses) on IYCF. The main topics included: nutrition of pregnant and lactating women, proper counseling of mothers on nutrition and care for newborns, exclusive breastfeeding, and complementary feeding. As a result, participants’ knowledge improved from 45% to 85% of correct responses based on pre- and post- tests. Practical exercises included correct weight and height measurement and cooking demonstrations of complementary food for children aged six to 12 months. In Q4, following the development of the comprehensive training package on nutrition (see Activity 4.3.1), to strengthen the pool of local trainers, THNA conducted a four-day TOT for 16 regional trainers from PHC facilities and four THNA staff. The TOT covered nutrition of infants, young children, and pregnant and lactating women; the causes of malnutrition; the long-term effects of malnutrition and micronutrient deficiency; and many others. As a result, participants’ knowledge improved from an average of 47% to 97% based on pre- and post-training tests. In Y4, the trainers will conduct cascade trainings for doctors and nurses at the rural PHC level. As part of the joint action plan for CHPs, PHCs, and VDCs, THNA tested a procedure for CHPs to follow up on children with malnutrition at the community level (see Activities 3.3.2 and 3.3.6). In Q4, THNA provided seven mentoring visits to PHC staff to assess the referral and follow-up of children with malnutrition. Supportive supervision visits to ensure the quality of continuous care and treatment of infants and young children with severe acute malnutrition at the PHC level was postponed until Y4 due to the delay in the approval of the IMAM protocol, TOT, and cascade trainings. In Y3, THNA continued distributing the MNCH Handbook (Rohnamo) and provided 12 one-day on-the- job trainings for 240 PHC staff. A total of 25,000 handbooks were distributed to PHC staff for further dissemination to pregnant women and mothers with babies under six months. The MNCH Handbook was developed by the MOHSPP in 2016 as a tool to improve HCWs’ counseling skills on complementary feeding and child growth monitoring and to increase community awareness about child nutrition and development. In Y3, THNA established 12 resource centers at the district PHC level on nutrition/the IMCI computerized adaptation and training tool (ICATT)/IMCI, and in Y4 will establish 12 more resource centers at the CDH level (see Activity 1.3.1 and 1.3.2). THNA will strengthen the capacity of these centers by providing on-the-job training and by installing ICATT/IMCI software and the MNCH database at the PHC level. The newly developed and reviewed IMCI record forms have been submitted to the MOHSPP for approval. Once approved, THNA will print and distribute the forms to all health facilities in FTF districts using the capacity of the 12 resource centers.
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3.3.10. Malnutrition management—capacity-building of hospital pediatric staff In Q4, following the TOT at the national level, THNA provided support to UNICEF in conducting a five- day training for 35 pediatricians and nurses from “numeric” hospitals on IMAM. The results of the pre- and post-training tests demonstrated an improvement in knowledge, from an average of 49% to 83% of correct responses. In turn, UNICEF trained CDH staff.
Figure 20. Scorecards on hospital-based IMCI
Figure 21. Indicators on emergency care and treatment of pneumonia and diarrhea in CDHs, 2017–2018
For the Hospital IMCI scorecard, each item is evaluated with the information gathered by different sources to reach an overall score, ranging from 0 to 5: 0 = need for structural changes (totally inadequate care and/or harmful practice with severe hazards to the health of mothers and/or newborns). 1 = need for substantial improvement in the management of all of the illnesses and related departments; 2 = need for substantial improvement in the management of the majority of illnesses and related departments to reach standard care (suboptimal care with significant health hazards); 3 = need for a considerable level of improvement; 4 = need for some improvement to reach standard care (suboptimal care but no significant hazards to health or to basic principles of quality care); 5 = good or standard care.
To strengthen the knowledge of hospital staff after UNICEF’s training on IMAM, THNA conducted three trainings on IYCF and child nutrition for 60 hospital-level staff from all 12 FTF districts. The main topics
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included counseling on breastfeeding, complementary feeding, care for newborns and older children, nutrition disorders in mothers and children, parent education on child care, and nutrition. Practical exercises included cooking demonstrations of complementary food for children aged six to 12 months. As a result, the knowledge of participants improved from an average of 26% to 78%, based on the pre- and post-training tests. Building on the successful implementation of hospital-based IMCI over the past two years, in Y3, THNA supported two trainings for 47 pediatricians from CDHs and “numeric” hospitals on the WHO Pocket Book on Hospital IMCI. All participants received pocket books and demonstrated improved knowledge from an average of 37% to 77%, based on pre- and post-training test results. In Y3, THNA provided 24 supportive supervision visits by national experts to pediatric departments of 12 CDHs, engaging a total of 519 HCWs. The data collected with the use of MOHSPP-approved tools demonstrate progress in implementation of the hospital-based IMCI program from an average of 2.1 points on the scorecard in Y1 to 3.6 points in Q4 of Y3 (Figure 20).
A detailed analysis of the scorecards shows significant improvements in emergency care and the treatment of pneumonia and diarrhea in children (Figure 21). In implementing hospital-based IMCI, THNA pursued two objectives: (1) to reduce unjustified hospitalization, and (2) to reduce pediatric hospital mortality. An assessment of patient charts demonstrated that hospitalizations for uncomplicated respiratory conditions and diarrhea have been reduced, which is reflected in the lower total number of hospitalizations (Figure 22). During the same period, hospitals demonstrated a reduction in pediatric hospital mortality, which is more significant than the reduction in hospitalizations. While the number of hospitalizations decreased by 23%, the total number of hospital pediatric deaths decreased by 39%. This success indicates not only an improvement in hospitals’ management of children’s illnesses but also an improvement in timely diagnoses and referrals by PHC staff. Figure 22. Hospitalizations in pediatric departments and children’s mortality in CDHs (averaged over nine months per year, 2016–2018 )
To support collaboration on QI issues, in Y3, THNA facilitated a cross-visit to share best practices on hospital-based IMCI. In collaboration with national experts, THNA organized 24 pediatricians from all FTF districts to visit the Yovon CDH. The pediatric department in Yovon CDH has been implementing
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IMCI practices since 2013 and has demonstrated significant improvements (Figure 20). National experts presented the outcomes of their mentoring and monitoring visits to the Yovon hospital. As a result of the cross-visit, each team revised the QI plans for their own pediatric departments. To summarize the implementation of hospital-based IMCI and to discuss achievements and challenges, in Q4, THNA together with the MOHSPP and DOH organized a roundtable. This roundtable resulted in the following recommendations: 1. Sign an order by heads of CDHs on the implementation of the WHO IMCI pocket book and appointment of staff responsible; 2. Develop action plans for the implementation of the WHO IMCI pocket book; 3. Carry out routine maintenance in pediatric wards; 4. Train staff on the emergency assessment of pediatric conditions upon admission; and 5. Organize proper pediatric examinations in the emergency room. 3.3.11. Conduct nutrition awareness/counseling campaigns involving national and local nutrition specialists and CHPs This activity has been postponed to Y4, as CHPs were recruited and trained only in Q3. 3.3.12. Provide assistance through allocating sub-grants on running and use of room for oral rehydration, at least five rooms in every district (every FTF ZOI district) In Y3, THNA finalized its assessment and agreed with local health facilities to support a total of 36 oral rehydration rooms: one at a district-level health center and another two at the village level in each district. Facilities allocated and renovated space when necessary. THNA will equip the oral rehydration rooms in Y4. 3.3.13. Deliver IEC materials—job-aids, leaflets, and videos on nutrition during pregnancy and lactation—to medical staff In Y3, during trainings on IYCF, GMP, and IMAM, THNA distributed 200 counseling guides on nutrition for children under five and 150 booklets on complementary feeding. In addition, 164 participants of various clinical trainings from PHCs received materials on nutrition for pregnant and lactating women. During the nutrition competition among PHC facilities, THNA distributed 300 leaflets of three types on nutrition to HCWs.
IR 4: INSTITUTIONALIZE EVIDENCE-BASED MNCH SERVICES
Outcome 4.1: Ensure cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH
4.1.1. Printing and extensive distribution of existing materials on nutrition
In Q3, THNA printed 2,500 copies of UNICEF’s illustrated flip-book for counseling on breastfeeding and young child nutrition. Of these, 2,000 copies have been distributed to CHPs at their monthly peer learning sessions, along with 2,000 THNA-branded bags and aprons. THNA provided another 200 copies of the counseling flip-book to PHC staff during IYCF and IMAM trainings.
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In Q3 and Q4, THNA printed 200 copies of the new guidelines on IMAM and the WHO IMCI pocket book and distributed them during trainings, mentoring and monitoring visits, and supportive supervision visits. In Q4, THNA printed 29 banners on breastfeeding, as well as 10,000 copies of each booklet on breastfeeding, complementary feeding, and nutrition in pregnancy. THNA distributed these materials to 541 rural medical facilities, 12 maternity and 12 pediatric departments in CDHs, 12 district-level PHCs, and 12 RHCs in conjunction with World Breastfeeding Week celebrations. 4.1.2. Establishment of and technical support to nutrition corners at the health facility level
After the establishment in Y2 of nutrition corners at maternity departments of CPHs, in Y3, THNA supported the development of nutrition corners (information boards) in 12 district PHC facilities. The objective was to provide pregnant and lactating women with information on exclusive breastfeeding and complementary feeding through a variety of print and electronic materials, many of which THNA provided to PHCs. In Q4, national and regional nutrition experts assessed the nutrition information presented in the 12 corners during the nutrition competition. At the final ceremony, all participating PHCs received TV sets to show video information materials in the patient waiting areas. 4.1.3. Active mentoring by THNA staff of four key staff at DOH, involvement in national-level events, and development of their capacity for management
In Y3, THNA supported the participation of two DOH staff in the joint annual review of the implementation of the national health strategy. THNA further mentored the DOH staff by training one of them as a trainer on the new IMAM protocol and two of them on data collection and analysis. The head of the DOH reviewed and signed an order on the joint PHC, CHP, and VDC action plan. The DOH chaired a meeting with HLSC and PHC managers on the joint plan (see Activity 3.3.6). As a result, health facilities demonstrated support for CHP activities at the community level. The DOH head and his deputy actively participated in joint monitoring efforts and provided feedback on project activities during meetings with medical staff. The DOH issued the necessary orders to enable HCWs to participate in THNA’s training activities. 4.1.5. Work with the Donors Coordinating Council (DCC) on raising the government of Tajikistan’s awareness of nutrition issues and supporting the 2nd annual nutrition forum
THNA is actively engaged with the DCC, participating in all of its meetings. However, the 2nd annual national nutrition forum in 2018 was canceled due to lack of support from the MOHSPP. 4.1.6. Support a series of short-term consultants in support of MOHSPP priorities
One international short-term technical assistance consultant reviewed the CHP strategy in Q4 and assisted in the development of the Y4 workplan. 4.1.7. Support World Breastfeeding Week
To support World Breastfeeding Week (traditionally held over ten days in Tajikistan), THNA provided information materials to PHC and hospital facilities in all 12 FTF districts. Visual materials included 29 banners on exclusive breastfeeding and 30,000 copies of print materials on breastfeeding for community members. As part of World Breastfeeding Week, in collaboration with the regional RHC, THNA organized breastfeeding campaigns in Shahritus, Jomi, and Balkhi districts, for a total of 1,474 beneficiaries
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received breastfeeding and nutrition counseling in the three districts. THNA also organized the final event of the nutrition competition during World Breastfeeding Week (see Activity 1.3.2). 4.1.8. Support Scaling Up Nutrition (SUN) activities
In Y3, THNA continued supporting the multisectoral coordination council for the SUN Global Movement. In Y3, THNA provided its IEC materials on nutrition to the SUN secretariat in Tajikistan to develop a national nutrition communication strategy. In addition, THNA participated in a workshop organized by UNICEF on the development of this strategy. IntraHealth is also contributing to the development of the nutrition communication strategy as part of a project funded by GIZ. 4.1.9. Training of media personnel, including editors, on maternal and child nutrition The training of media personnel and the competition for media to promote improved nutrition are described under Activity 3.1.5, Media Engagement.
Outcome 4.2: Ensure sustainability of evidence-based approaches for MNCH 4.2.1. Establishment of the CHP model In Y3, THNA established a new community-based volunteer model by dividing the responsibilities of the former CHEs between the new CHPs and CEs (who are often former CHEs). In the new model, CHPs are responsible for health, nutrition, and WASH topics, while CEs are responsible for agricultural topics. In Q1, THNA presented this new CHP/CE volunteer model to the regional DOH. The head of the DOH assigned his deputy as the primary focal point to supervise THNA’s implementation. THNA and the DOH signed an MOU articulating the responsibilities of both parties. To ensure the future sustainability of the CHP/CE model within the government health care system, in Q1, THNA together with district governments (Khukumats) and district PHCs selected 34 district trainers from among staff of district PHCs and HLSCs. Of these, 31 were trained on the CHP/CE model over a five-day TOT. The TOT covered exclusive and continuing breastfeeding, complementary feeding, WASH topics, danger signs during pregnancy, and nutrition for pregnant and lactating women. In Q2 and Q3, 14 district trainers provided five-day initial trainings for 1,369 CHPs. To date, 17 district trainers remain active. In Q2, THNA together with district trainers and VDCs selected almost 1,400 CHPs and 500 CEs from 500 target villages in all 12 districts. Originally, THNA had planned to institute the CHP/CE model in just six districts in Y3, but scaled up the model to cover all 12 districts to be able to achieve tangible results by the end of the project. THNA facilitated meetings between newly selected volunteers to discuss their divided and shared responsibilities, and how these differ from the former CHE model. In Q2 and Q3, THNA trained 1,391 CHPs (Table 14) over 64 initial five-day trainings. THNA printed CHP reporting forms and introduced and distributed them to all CHPs as part of their initial five-day training. Reporting forms are likely to evolve according to project needs and will be revised in Y4. THNA experienced some challenges in conducting the large number of five-day trainings in this short time period. THNA staff supported national and regional trainers in training the CHPs.
To strengthen collaboration among CHPs, clinical staff, and community leaders, in Q3, THNA introduced a joint plan of action approved by the DOH. THNA together with district trainers facilitated 40 meetings between CHPs, VDCs, and rural PHCs to inform them about the new community model for health and nutrition. Through these meetings, THNA sought VDCs’ support for CHP community activities, such as
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peer support groups, cooking demonstrations, and home visits. District trainers disseminated the joint plan of action to 350 rural PHCs. Table 14. Number of CHPs trained, by location and month District # of CHPs trained Total villages Jan. Feb. Mar. Apr. May Balkhi 60 - - 24 100 52 176 Dusti 29 108 - - - - 108 Jaikhun 43 - - 21 91 - 112 Jomi 51 - 150 - - - 150 Khuroson 49 - - 63 20 - 83 Kushoniyon 80 - - 27 130 - 157 Levakand 11 - - - 23 - 23 N. Khusrav 10 - - 20 39 - 59 Qabodiyon 30 - - 22 88 22 132 Shahritus 21 - - - 86 - 86 Vakhsh 60 - - 23 92 47 162 Yovon 56 - - 26 93 24 143 Total: 500 108 150 226 762 145 1,391
Photo 17. Newly trained and certified CHPs, Balkhi district (photo credit: THNA)
THNA transformed its “monthly reporting days” into monthly peer learning sessions for volunteers. In addition to refresher training by THNA staff and district trainers, the agendas of these sessions included the exchange of practical experience among volunteers, role-plays to develop counseling skills, knowledge tests to identify topics for refresher trainings, activity plans for the upcoming months, and reporting on the work completed within the past month. In Y3, THNA facilitated 255 peer learning sessions for CEs and CHPs. Given the large number of CHPs, THNA rotates their participation in the peer learning sessions on a bimonthly basis in most districts.
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THNA’s district coordinators collect reports from volunteers during their peer learning sessions. Learning sessions provide an opportunity for THNA staff and volunteers to clarify reporting questions, correct errors, and improve volunteers’ reporting skills by learning from each other. District coordinators enter consolidated data into an online KoBoCollect database and into Excel spreadsheets. All data are then consolidated into the THNA Microsoft Access database. THNA staff and district coordinators monitor the data quality. To streamline data entry and consolidation, in Q4, THNA adapted IntraHealth’s online human resource information system (iHRIS) database, which has already been used to monitor community volunteer services in other IntraHealth projects around the world. In Y4, iHRIS will replace the KoBoCollect, Excel, and Access spreadsheets/databases. To motivate CHPs and CEs to achieve targets and improve their knowledge, practical skills, and reporting, THNA introduced service excellence awards to three CHPs and CEs at every monthly peer learning session. In Y3, 108 CEs and 132 CHPs were recognized for their achievements and received small awards. In Y4, THNA is planning a larger cross-district best volunteer competition, with awards based not only on knowledge but also on performance and results achieved in the communities. In Y3, THNA provided every CHP and CE with an incentive in the form of a large blanket. A total of 2,134 blankets were procured, and 1,000 of them were distributed in Q4. The rest will be distributed early in Y4. Another incentive for community volunteers were THNA-branded bags for information materials and aprons for cooking demonstrations distributed to 1,834 CEs and CHPs. As expected, THNA experienced some volunteer attrition: 164 CHPs (11.8%) and 89 CEs (17.8%) dropped out (Figure 23). At the end of Y3, district coordinators initiated the selection of new volunteers by VDCs, jamoats, PHCs, and other community activists. Newly selected CHPs will be trained in Q1 of Y4. Figure 23. CHP attrition in Y3, by district
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4.2.2. Regular coordination meetings with the Khatlon HLSC The THNA field leadership in Khatlon met regularly with the HLSC to coordinate joint activities. These meetings included coordinating CHP trainings conducted by district trainers, disseminating joint plans of action, and organizing monthly volunteer peer learning sessions and health fairs (see Activity 3.3.4) in the 12 districts. At these events, HLSC staff and PHC HCWs addressed questions from volunteers and other community members on health and nutrition. The head of the Khatlon HLSC committed to supporting THNA in obtaining permission to use HLSC air time on the local TV station to broadcast THNA video materials; however, no actions have been taken regarding this activity as of the end of Y3.
Outcome 4.3. Improving linkages across sectors supporting poverty alleviation, agriculture, nutrition, and health
4.3.1. Development of joint plans as a concrete and sustainable way for PHCs and CHPs to implement joint actions In Q3, THNA piloted one-day meetings for 60 PHC HCWs and CHPs in Jomi, Dusti, and Khuroson districts. The main purpose was to brainstorm and develop draft joint action plans between CHPs and PHC HCWs to achieve mutual goals with respect to MNCH and nutrition at the community level. As part of the meetings, participants identified their greatest challenges affecting MNCH and nutrition: • Following national standards for ANC; • Ensuring proper nutrition of women and children and monitoring the growth and development of children under five; • Caring for newborns and infants; • Promoting community sanitation and hygiene to reduce the incidence of infectious diseases; and • Encouraging participation in support groups for families and women with children under six months of age As a result of these meetings, THNA facilitated the development of a joint PHC, CHP, and VDC action plan and a referral mechanism between CHPs and PHCs at the community level (see also Activities 3.3.2 and 3.3.6). The DOH approved this plan and THNA presented it to PHCs, the regional HLSC, and RHCs. In Q4, THNA introduced the joint action plan to local stakeholders (PHC providers and VDC members) throughout the 12 districts at meetings in local PHCs. A total of 379 PHCs received and discussed the joint plans with CHPs and VDCs. 4.3.2. Collaborate with UNICEF on implementation of the Instructions for the Lives of Mothers and Children MNCH Handbook (Rohnamo) with an ANC supplement and have CHPs follow-up on how it is being used by mothers In Y3, THNA continued its collaboration with UNICEF on implementing the Instructions for the Lives of Mothers and Children MNCH Handbook (Rohnamo) in 12 districts at the hospital and PHC level. THNA provided 12 one-day on-the-job trainings for 240 staff on Rohnamo (see Activity 3.3). A total of 1,391 CHPs received training on Rohnamo and the handbook itself to distribute at the household level to mothers with children under two and to pregnant women. 4.3.3. Host a DCC meeting to discuss nutrition awareness activities In Q2, THNA hosted a DCC meeting on health. The meeting followed the Joint Annual Review and was devoted to developing the new National Health Strategy 2021–2030. Following the meeting, THNA
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provided its input into the development of the donor and activity mapping framework as a mechanism for improved coordination. THNA continued actively participating in national-level dialogue through the DCC and provided input into discussions on the most challenging issues raised at the MOHSPP level. 4.3.4, 4.3.5. Support a regional-level advisory and multisectoral coordination committee and facilitate meetings that the DOH convenes. Support TWG on health and nutrition. In Y3, THNA initiated the first two meetings of the TWG on health and nutrition at the regional level. More than 30 members of the TWG participated in the meeting representing WFP, UNICEF, GIZ, the Swiss Agency for Development and Cooperation, JICA, Aga Khan Health Services, Save the Children, the International Organization for Migration, and the HLSC. All partners presented their projects, briefly informed each other of new activities planned for the year, and coordinated joint actions and assessments/research. As the next step, the DOH took the lead and ownership of the TWG. 4.3.6, 4.3.11, 4.3.12. Support national-level quarterly advisory MNCH meetings at the MOHSPP as needed. Participate in the TWG on elaborating a new strategic plan on MNCH. Regularly present data to the DOH and MOHSPP. At the national level, the MOHSPP has not requested THNA to support the MNCH advisory group. THNA, however, has always participated in meetings organized by the MOHSPP on MNCH. THNA activities are included in the MOHSPP strategic plan on maternal, women, newborn, children, and adolescent care. THNA regularly presents data from the MNCH hospital database to the MOHSPP and DOH and discusses successes and challenges. THNA supported the MOHSPP and DOH in developing their plans to address the challenges. As part of the approved joint plan and coordinated cost-sharing with other donors, in Y3, THNA supported several TWGs: On the national standards in neonatal practice, including Kangaroo Mother Care guidelines: In Q4, the standards were submitted for approval, and THNA will support their implementation in Y4; On the comprehensive training package on nutrition: In Q4, the package including information on nutrition for pregnant and lactating women, child nutrition, growth monitoring, malnutrition, and counseling was piloted at the TOT of 16 regional PHC-level trainers supported by THNA (see Activity 3.3.9). Following the TOT, the comprehensive training package was submitted to the MOHSPP for approval; On the clinical standard in postpartum care: In Y3, with support from THNA and other donors, the clinical standard was revised and submitted to the MOHSPP for approval and further implementation; On the pre- and in-service medical training curricula on nutrition: THNA supported the MOHSPP’s Department of Medical Education in including the revised or newly developed standards (e.g., IMAM, nutrition in pregnancy, IYCF, and GMP) into the medical training curricula at medical universities, colleges, and the Institute of Postgraduate Medical Education. 4.3.7. Support community planning with a few VDCs via grants to local nongovernmental organizations for capacity-building and planning to identify priority community sanitation needs and support their solutions In Y3, THNA technical staff provided training on proposal development and fundraising for 33 VDC members from six districts (Levakand, Kushoniyon, Balkhi, Jomi, Dusti, and Khuroson). As a result,
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THNA received ten proposals on WASH from the most active committees to improve hygiene and sanitation in their villages. After reviewing and considering the proposals, five were selected for support (see Activity 3.2.1).
4.3.8-4.3.10, 4.3.13, 4.3.14. Conduct the national-level and regional-level nutrition forum. Contribute to joint efforts on implementation of a human resources database in Tajikistan. Revisit the m-health approach. ‘Lobby’ the MOHSPP for improved maintenance of equipment.
THNA did not implement these activities for the following reasons: National- and regional-level nutrition forum: These activities initiated by UNICEF in previous years did not receive support from the MOHSPP this year. Instead, THNA implemented its own successful nutrition competition at the regional level (see Activity 1.3.2); Implementation of a human resources database in Tajikistan did not receive much traction from national authorities. Instead, THNA started adapting its own online database, iHRIS, which is expected to be operational in Q1 of Y4; M-health approach: This activity had been delayed until the CHP/CE model is fully established and functioning. In the future, if any elements of the m-health approach can benefit CHPs or community members, THNA will implement them. ‘Lobby’ the MOHSPP for improved support for the maintenance of equipment: Instead of this ‘lobbying’ activity, THNA supplied 12 target CDHs with equipment as in-kind sub-grants.
MONITORING AND EVALUATION
In Y3, THNA significantly restructured its monitoring, evaluation, and learning system to match the structure of the new CE/CHP model, as well as its field management through 12 district coordinators. THNA developed new data collection and reporting forms, as well as data entry and warehousing systems.
In November, THNA implemented the third round of the RHS, and in May–June, the fourth round was implemented. Also in June, THNA completed a qualitative internal mid-term review. The results of four rounds of the RHS, together with the results of the mid-term review, informed THNA’s annual work planning session in July–August, in addition to this annual progress report.
In Q3, THNA completed its recruitment and initial training of new volunteers. All volunteer data have been entered into THNA’s Microsoft Access database available in the Dushanbe and Bokhtar city offices. The database includes training data from previous activity periods, and data are updated on a regular basis. In Q4, THNA adapted its open source database, iHRIS, to the monitoring, evaluation, and learning needs of the project. In Y4, THNA will collect, store, and analyze data in iHRIS.
In Q4, THNA completed its annual Economic Growth Survey. Its results, available in Annex II, are used to assess progress toward some of the targets and are quoted in the text of this report.
THNA met or exceeded eight of its nine targets. The only exception is EG.3.2-1: Number of individuals who have received USG-supported short-term agricultural sector productivity or food security training, where the completion rate is 71.3%. The reasons for not meeting this target are: transitioning from CHEs who worked under Mercy Corps to CEs who work with the communities on agricultural topics; retraining former CHEs or recruiting new CEs; and establishing the data collection and reporting system
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with the new 500 CEs. These organizational efforts took almost two quarters, from October through February, and even though many CEs were working, some of the data were not reported. THNA encountered the same challenges with achieving the target for CHPs. However, because the CHPs’ reach was expanded from six to 12 districts, THNA was able to achieve the target.
Progress towards targets
Purpose / FY 18 achieved Indicator FY18 target FY18 achieved Output (%) HL.9-4: Number of individuals receiving Output nutrition-related professional training through 2,500 2,893 116% (IR 1, 2, & 3) USG-supported programs Output HL.9-1: Number of children under five reached 140,000 138,911 99.2% (IR 2 & 3) by USG-supported nutrition programs EG.3.2-17: Number of farmers and others who Output have applied improved technologies or 130,000 148,500 114% (IR 2) management practices with USG assistance EG.3.2-1: Number of individuals who have Output received USG-supported short-term 260,000 185,383 71.3% (IR 2) agricultural sector productivity or food security training EG.3-1: Number of households benefiting Output directly from USG assistance under Feed the 90,000 95,677 106% (IR 2 & 3) Future HL 9.3-1: Number of pregnant women reached Output with nutrition interventions through USG- 50,000 52,162 104.3% (IR 1, 2, & 3) supported programs HL.8.2-6: Percentage of households in target Outcome areas practicing correct use of recommended 94% 92% 98% (IR 3) household water treatment technologies Output HL.6.6-1: Number of cases of diarrhea treated 18,000 23,205 129% (IR 3) in USG-assisted programs HL. 6.2-1: Number of women giving birth who Output received uterotonics in the third stage of labor 30,000 39,387 131% (IR 1) through USG-supported programs
Communications and knowledge management
In Y3, THNA disseminated behavior change communication materials, as well as information about project activities, through a variety of means (Annex III): A THNA factsheet in three languages (Tajik, Russian, and English) was updated, printed, and distributed during public events (3,300 copies total). THNA produced a banner for the International Day of the Girl Child celebration on October 11. In October 2017, to support the Universal Salt Iodization Law, THNA produced a five-minute video, which was widely used during cooking demonstrations and CHP trainings. To promote complementary feeding for children aged six to 24 months, THNA produced nine short tutorial videos (five of which were produced in Q4). The videos demonstrate recipes for different complementary feeding dishes.
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To support the integration of nutrition messages into agriculture-focused programs, in Q3, THNA produced and distributed 4,000 DVDs to CHPs and CEs. The volunteers have been using these DVDs during trainings, household meetings, and community events. The DVDs include 15 videos and one mp3 audio file on the following topics: o Iodized salt promotion (a THNA-produced informational video) o Complementary feeding (four THNA-produced tutorial videos) o Nutrition for pregnant women and adolescent girls (four THNA-produced tutorial videos) o The value of breastmilk (an audio jingle/song) o Safe toilets and drinking water (THNA-produced animated videos) o Cattle hygiene, farming, and breastfeeding (animated videos from partner organizations). An informational banner was developed and used at educational sessions on WASH in celebration of World Toilet Day. It was used in all WASH events during the year. A story on improving sanitation and hygiene, which was published on August 29, 2017 on the IntraHealth website, was subsequently published in FTF’s quarterly newsletter as “Taking Care of Business in Tajikistan” in December 2017. The link of the story was widely shared via social media. https://www.feedthefuture.gov/article/taking-care-of-business-in-tajikistan/. An animated video entitled “Using Boiled Water,” produced in three languages in Y2, was broadcast on First National TV Channel “Televizioni 1-umi Tojikiston” (Shabakai Avval) in primetime before the evening news, from November 7 to 22, 2017. An article on one of THNA’s mothers’ rooms was published on August 25, 2017 in USAID’s monthly newsletter. It was subsequently posted on IntraHealth’s “Picture It” blog on November 13, 2017 and widely shared via social media. http://intrahealth.tumblr.com/post/167450533578/a-new-mothers-room-in-tajikistan- women. A success story entitled, “Now, Safer Deliveries for Women in Tajikistan” about Bokhtar Maternity Hospital was prepared and submitted to USAID in December 2017 and was published on the IntraHealth website in January 2018. News of THNA’s maternal care successes were also published on USAID’s website in English and Russian, and the link was disseminated via social media. Later, this story was published on IntraHealth’s Vital blog and the Kaiser Daily Global Health Policy Report. https://www.intrahealth.org/vital/now-safer-deliveries-women-tajikistan https://www.usaid.gov/results-data/success-stories/safer-deliveries-women-0 https://www.kff.org/news-summary/intrahealth-blog-post-highlights-activities-to-improve- maternal-care-in-tajikistan/. A banner entitled, “Healthy Nutrition Map” was developed and produced for the farmers’ market and fair in Sokhtmon village, Tojikobod jamoat, Vakhsh district. Later, this banner was widely used in all 12 farmers’ markets and fairs held in the ZOI during the entire year. Another banner entitled, “Vitamin A” was also developed, designed, and produced for the farmers’ market and fair. This banner was also widely used in all districts in the ZOI during different events. A post about the first THNA farmers’ market and fair in Y3 was published on IntraHealth’s “Picture It” blog on December 21, 2017 and was shared via social media.
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http://intrahealth.tumblr.com/post/168797869393/farmers-markets-and-fairs-the-feed-the- future/ An article entitled, “Feed the Future Encourages Healthy Eating in Tajikistan” about educational sessions on healthy food choices, food preservation and storage, family budget planning for meals, WASH, and gardening at schools was written and published on the front page of USAID’s Central Asia monthly newsletter. An article entitled, “Healthy food in healthy garden” on life skills activities implemented by THNA at schools was published in the local newspaper AGROINFORM.TJ in the Tajik language, as well as on its website. http://new.agroinform.tj/tj/2018/02/08/gizoi-solim-dar-bogi-solim/. After the media training in partnership with Internews, from May to September 2018, the following articles were published: o “1,000 days of the beginning of life” by Tavarali Sohibnazarov and Amonjon Mukhodinov o “Life and death of the mother” by Jumagul Mirzoeva, Ahliddin Muborov, and Islom Teshaev o “Anemia and its treatment and prevention” by Sairahmon Nazriev o “Okra and its benefits” by Akbar Muhamedov for Agroinform.TJ o “How to reduce diabetes” by Sulaimon Sultonov and Mashrabali Alovuddinov http://tavarali.blogspot.nl/2018/04/1000.html https://amoninfo.blogspot.nl/2018/04/blog-post_27.html https://khutalon.blogspot.nl/2018/04/blog-post_27.html https://nizomiddin-9393.blogspot.nl/2018/04/2015.html https://khutalon.blogspot.com/2018/07/blog-post_8.html http://new.agroinform.tj/tj/2018/07/04/javob-ba-savoli-honanda/ http://khatlon-ruznoma.tj/2497-zamin-am-nom-mediadu-am-non.html http://new.agroinform.tj/tj/2018/07/04/javob-ba-savoli-honanda/. THNA contributed to a master’s thesis entitled, “Behavior Change Communication to Improve Nutrition in Rural Tajikistan” by Shanna Ridenour, communications specialist for USAID Central Asia. Two 2 x 3 m informational banners were developed, designed, and printed: one was submitted to School #11 in Dusti district and the other to School #16 in Jomi district. The banners featured information on healthy food choices, food preservation and storage, family budget planning for meals, WASH, and school gardening. Furthermore, five A4 and A3 size photos were submitted to School #11. Six 1 x 1.2 m informational banners on crop rotation, irrigation, and crop families were developed, designed, and printed. They were provided to the two schools in Dusti and Jomi districts for use in their peer-to-peer clubs. A total of 2,450 new branded bags and 2,100 aprons were developed, produced, and distributed to CHPs and CEs to use during their work in communities. Promotional IEC materials were also developed, printed, and distributed to them for use during activities. A special folder and notepads were developed, designed, and printed (2,000 of each) in Q3, and they were distributed to CHPs and CEs at THNA trainings in Q4.
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The UNICEF flip-book and brochure on IYCF were re-designed according to THNA and FTF brand and marketing requirements; 2,500 copies of each were printed. These materials were distributed to THNA CHPs and CEs through the end of Y3. Cards on dietary diversity for women and children were developed, designed, and printed (1,800 sets of A5-sized cards) in Q3. Each set comprises 66 cards with necessary nutrient information. These cards were distributed to THNA CHPs and CEs through the end of Y3. A guide for CHPs on use of the MUAC tape was developed and printed (2,250 copies). In Q4, the guides were distributed to CHPs and CEs to use during their work in communities. Four THNA success story booklets in English were developed, designed, and printed (50 copies each). The topics of the booklets were: new medical equipment for Jomi district; safer deliveries in Kushoniyon district; safe toilets; and “Zumrad’s lifesaver.” The booklets were distributed among partners in Dushanbe and Bokhtar city. A success story entitled, “A Small Grant Solves A Big Water Problem” on providing drinking water to the village of Sanoat in Balkhi district was prepared and submitted to USAID after approval by IntraHealth International’s head office. A post on the donation of agricultural tools to high schools was published on USAID’s official Central Asia social media page. https://www.facebook.com/USAIDCentralAsia/posts/1818261611567587. Later in Q4, a success story entitled, “From the Ground Up” on school gardens and peer educators improving nutrition in rural Tajikistan was prepared and submitted to USAID. It was published on USAID’s Exposure page in English and Russian and was shared via social media. https://usaidcentralasia.exposure.co/from-the-ground-up https://usaidcentralasia.exposure.co/post-306973. At the beginning of Q4, THNA’s communication specialist participated in a USAID-organized one- day photography training to improve photography skills. A total of 30,000 copies of UNICEF IEC materials on the nutrition of pregnant women, exclusive breastfeeding, and complementary feeding (10,000 each) were reprinted. These publications were disseminated to all 12 districts of the ZOI as part of World Breastfeeding Week celebrations. Also, 6,000 of the copies were given to the DOH of Khatlon Region for distribution among PHC and hospital facilities. A banner/billboard for World Breastfeeding Week was developed and designed. A total of 29 copies of different sizes were printed after approval by the MOHSPP and USAID. They were intended for presentation along the central street in Bokhtar City, in maternity departments of CDHs, and for mothers’ rooms during World Breastfeeding Week celebrations. A success story entitled, “Better for the Baby, Better for the Family” on successful breastfeeding in the rural village of Navkoram, Yovon district was prepared, and after approval by IntraHealth International’s head office, was submitted to USAID. It was published on USAID’s Instagram page in English. https://www.instagram.com/p/BmBRmyNHyeD/?hl=en&taken-by=usaid. A story entitled, “Happy World Breastfeeding Week” was published on IntraHealth International’s website and disseminated via social media. http://intrahealth.tumblr.com/post/176498404608/happy-world-breastfeeding-week-in- october-2017.
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An informational article on the nutrition contest and exhibition among the ZOI’s PHCs in conjunction with World Breastfeeding Week was prepared and submitted to USAID, with ten photos for further dissemination. A total of 12 nameplates with district names were developed and disseminated to all participants for use during the nutrition contest and exhibition. To support the integration of nutrition messages into HLSC programs and to link to value chains supported through FTF and cooking demonstration activities, 12 USB drives were distributed to 12 PHCs who were given TVs from THNA in Q4 as a result of the competition. These USBs include 18 THNA-produced tutorial videos. A total of 265 information boards were developed, produced, and distributed to rural PHCs to inform the population about THNA’s cooperation with local branches of the DOH in rural Tajikistan. At the end of Y3, THNA developed, filmed, and edited two short video reports on THNA’s successes in its third year. https://www.dropbox.com/s/235fssbd4fe2nrp/Photoreport_Y3Activity.mp4?dl=0#. Lastly, THNA developed a communications manual that will be presented to all staff during the next annual review meeting at the beginning of Q1 of Y4.
BUDGET VS. EXPENDITURE ANALYSIS
The breakdown of expenditures against the current obligation is presented in Table 15 below. Table 15. Project-to-date obligation and burn rate Approved Actual Actual Spent to Cooperative Remaining Budget Category Year 3, September 30, Burn rate Agreement Budget Quarter 4 2018 Budget Personnel & Consultants $2 627 610$ 184 488 $1 523 811 $1 103 799 58% Fringe Benefits $986 498$ 52 571 $498 185 $488 313 51% Travel $500 989$ 30 378 $391 274 $109 715 78% Equipment $7 500$ - $8 265 -$765 110% Contractual $4 611 358$ 113 643 $3 254 801 $1 356 557 71% Other Direct Costs $2 349 738$ 223 879 $1 226 913 $1 122 825 52% Total Direct Cost $11 083 693 $604 959 $6 903 250 $4 180 443 62% Indirect Cost $2 075 139$ 111 559 $1 083 855 $991 284 52% Total $13 158 832 $716 518 $7 987 105 $5 171 727 61% The breakdown of expenditure by program element/funding source is presented in Table 16 below. Table 16. Quarterly expenditures by funding stream Year 3 Program element Quarter 4 4.5.2.8: Nutrition sensitive agriculture (ES-GFSI) $203 410 3.1.6 Maternal Child Health (GH-C) $350 235 3.1.9 Nutrition (GH-C-GFSI) $162 873 Total $716 518
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SUB-GRANTS
An in-kind sub-grant totaling $13,885 was awarded to VDCs to support WASH-related activities in Yakkatut village (Jomi district), Sanoat and Uzun villages (Balkhi district), Yangi Yul village (Kushoniyon district), and A. Murodov village (Shahritus district) in Q1. A small in-kind sub-grant totaling $1,389 was provided to School #11 in Dusti district and school #16 in Jomi district for agricultural tools in Q2. An in-kind sub-grant totaling $49,436 was provided for 12 nutrition resource centers at district- level PHCs in Q4. An in-kind sub-grant totaling $9,459 was provided to 16 community masons for metal molds to produce VIP latrines in Q4. In Q4, THNA completed solicitation procedures for future in-kind sub-grants for 11 nutrition resource centers at the CDH level; for 36 oral rehydration rooms; and for sub-grants to VDCs to supply safe water to four schools and one village. Procurement and delivery will be completed in Q1 of Y4.
CHALLENGES ENCOUNTERED AND ACTIONS TO OVERCOME
Scaling up the recruitment, training, and support for CHPs in six additional districts to cover the entire FTF’s ZOI presented a challenge in Q3, which was quite successfully met by the THNA team. THNA staff mobilized all internal resources in March, April, and May to launch the CHP/CE model in all 12 districts in Y3. The attrition of community volunteers, both CEs and CHPs, presented a challenge throughout the year. Although THNA encouraged VDCs to select motivated individuals to fill these roles, the motivation of volunteers varied widely. While most were motivated by the need to improve the health and nutrition of women and young children in their communities, some were more interested in receiving material incentives from THNA. Also, some volunteers withdrew immediately after the initial training or soon thereafter due to what they perceived to be THNA’s high expectations of volunteers, bordering on what would be expected of paid staff. Volunteer expectations were addressed at the THNA work planning session and were revised to be more realistic in Y4. Engaging HLSC and PHC staff as district trainers for CHPs was designed to ensure linkage between volunteers and the government health sector and to provide future sustainability; however, this system has not been very effective. Health care staff see their need to support CHPs as an additional burden that is outside of their regular responsibilities, despite the existing order from the MOHSPP requiring HLSCs to coordinate community-based health activities. Staff turnover in HLSCs was also a significant challenge, as a number of district trainers prepared by THNA left the public health system. In Y4, THNA will continue its efforts engaging the public health sector in its community volunteer model by selecting and training additional district trainers. Ensuring a continuum of care for women and children among the community, PHC, and hospital levels has been a challenge. There are system gaps, such as the lack of an established referral system between CHPs and PHCs, and from the hospital level back to the communities. There are also financial barriers to health services. For example, sometimes people referred from the
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community or PHC level do not seek further services due to real or perceived high costs, including those related to transportation, laboratory services, and other examination services. THNA will continue to work on improving the continuum of care for women and children by implementing the joint action plan for CHPs, PHCs, and VDCs and the referral procedure as part of this plan. Also, community volunteers will continue working with households on family budgeting and savings for future expenses, including ANC and other health care services. Engaging younger women (daughters-in-law, kelins) with children directly in THNA activities faces traditional family barriers, as men and mothers-in-law are the decision-makers in Tajik households. They oftentimes do not allow CHPs to contact the kelins or to visit them at home, and they do not allow the kelins to participate in community outreach activities, such as cooking demonstrations or peer support groups. THNA is overcoming these traditional barriers by first engaging family decision-makers in THNA activities. Engaging men in THNA activities has been a separate challenge. THNA is encouraging men to participate by engaging VDC leaders, who are often also the religious leaders in their communities. Despite continuing medical education trainings, mentoring and monitoring visits, and supportive supervision visits, the capacity of HCWs at the PHC level remains low. This problem is exacerbated by the fact that PHC work is not prestigious and medical workers tend to migrate. HCWs need constant mentoring on QI plan development, implementation, and indicators. In Q3 and Q4, THNA worked with IntraHealth’s home office to streamline, standardize, and tighten local procurement procedures. A revised set of documents was developed, and local procurement procedures were updated. In addition, IntraHealth negotiated with USAID on an umbrella sub-grant to a single sub-recipient in Khatlon Region, the DOH. These factors led to a slowdown in procurement and in-kind sub-granting. THNA will catch up with local sub-granting in Y4. In Q3, both IntraHealth and Abt Associates offices in Tajikistan underwent two extensive, unscheduled audits by local authorities: one by the Chamber of Accounts and the other by the Tax Committee. Although no substantial observations emerged, these audits took substantial time and effort on the part of administrative and finance staff, as well as THNA leadership.
GENDER
Since January 2016, almost in parallel with the technical start of THNA activities, Tajikistan has been guided by the United Nations Development Program’s Sustainable Development Goals, the fifth of which is gender equality.
Inequitable gender roles with regard to maternal health and nutrition in the FTF ZOI are manifested mostly in household decision-making. In most of the households in the FTF ZOI, food distribution is inadequate and does not always consider the special nutritional needs of THNA’s targeted groups: adolescent girls, women of reproductive age, pregnant and lactating women, and children under five.
In Y3, THNA continued implementing its nutrition strategy by targeting women of reproductive age who were most at risk of micronutrient deficiencies and of having malnourished children. THNA utilized a family-focused approach and supported more direct interventions, such individual counseling and peer support groups, which facilitated transformative learning.
In agricultural educational activities, targeting women was a means of strengthening the link between gender and nutrition by establishing women’s substantial contributions in the areas of food collection,
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preservation, and preparation. These included poultry farming, home cheese-making, vegetable and fruit drying, and making home preserves. These activities resulted not only in providing nutrients and protein for the household but also in generating additional income. This extra income contributes to women, especially female-headed households, having access to more nutritious food, and their savings gave them the means to purchase non-food items that would otherwise not be available to them.
Typically, the purchase of food items is reserved for men in the household; however, some households are headed by women, particularly mothers-in-law. THNA seeks to reach these female-headed households with messages to purchase nutrient-rich food. These messages were promoted during outreach campaigns at farmers’ markets and fairs, open field days, cooking demonstrations, and peer support group discussions.
In Y3, THNA staff participated in two gender-focused events. In April, THNA senior management staff participated in the joint Partners’ Meeting on Sexual Misconduct. Information from the meeting was also provided to the THNA staff at the Dushanbe and Bokhtar city offices. In May, THNA staff participated in a gender-based violence training organized by the project Integrating Gender and Nutrition within Agricultural Extension Services.
MANAGEMENT AND STAFFING
THNA is led in country by IntraHealth’s chief of party, Roman Yorick, who joined the project in January. He is supported by the deputy chief of party from Abt Associates, Gulnora Razykova. In Y3, THNA optimized its management structure. After two Monitoring and Evaluation (M&E) managers left THNA in Q3 and Q4, the position of one M&E officer was eliminated. The M&E department is now headed by an M&E manager with an M&E officer in the Bokhtar city office directly reporting to him. In Q4, the operational manager position was eliminated and its functions were merged with those of the finance manager to create the new position of Finance and Administrative Manager. The chief and deputy chief of party work with a management team of five: Clinical Director Tahmina Jaborova; M&E Manager Faridun Khudonazarov; Financial and Administrative Manager Rahimjon Sharipov; Human Resources Manager Naim Yakubov; and Regional Manager in Bokhtar city Ato Tabarov. At the end of Y3, THNA is fully staffed, including 51 IntraHealth and six Abt Associates staff. At IntraHealth’s home office, THNA is supported by Program Manager Karen Doll and Program Officer Fikre Keith. IntraHealth’s business partners provide backstop for M&E, human resources, finance and contracts, grants, and procurement issues.
PARTNERS
THNA continues to be implemented through successful collaboration between IntraHealth International and Abt Associates. With its long history in the country, Abt Associates continues to bring its extensive connections and experience to THNA’s clinical and MNCH activities under IR 1, IR 3 (3.3), and IR 4. In Y3, modifications #4 and #5 to the sub-agreement between IntraHealth and Abt Associates were signed to bring it in line with the approved annual workplan and budget.
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Collaboration with FTF activities
THNA is committed to close cooperation with its FTF partners, including at least seven agriculture- and nutrition-based USAID-funded activities: TAWA; Land Market Development Activity; CIP; Women’s Entrepreneurship for Empowerment Project; UNICEF, WFP, and the Aga Khan Development Network. THNA cooperates with partners in promoting improved agricultural inputs, including seed and fertilizers; best practices; and joint demonstration plots for agriculture-related activities. In Q3, TAWA conducted two TOT sessions on cheese-making (semi-solid and solid cheese) and dairy production to THNA district coordinators (see Activity 2.2.1), and THNA conducted 12 farmers’ markets and fairs, inviting TAWA’s farmers to promote their new crops to THNA households (see Activity 2.2.2). During the THNA farmers’ markets and fairs, TAWA provided new crops, introduced them to the community, and provided information about innovative technologies in agriculture. In turn, THNA participated in TAWA’s open field days to demonstrate new recipes developed by THNA’s nutrition specialist using the new crops. In Q2, THNA provided one TOT on cooking demonstrations to TAWA staff. On Q2 and Q3, TAWA supported THNA’s school-based activities by evaluating the quality of the school’s land for gardening activities involving adolescents. As a result, schoolchildren planted 400 tomato and 400 sweet pepper seedlings provided by TAWA, and over 500 sweet potato cuttings provided by CIP for gardening activities with adolescents in school plots (see Activity 3.1.2). In Q2, TAWA provided practical sessions on fruit tree pruning at THNA’s supported schools. During Q2, in partnership with TAWA, THNA provided trainings for VDC members and organized a field trip to TAWA-supported greenhouses. To support THNA’s school-based activities, CIP conducted a training on planting OFSP. In Q1, THNA staff participated in the “Orange-Fleshed Sweet Potato Cooking Quality Test” in preparation for the launch of the new crop. CIP and THNA developed demonstration plots in school gardens, and crops are expected to be harvested in Q1 of Y4. TAWA, CIP, and THNA technical staff meet regularly to plan joint activities with regard to school gardening projects, farmers’ markets and fairs, and TAWA’s open field days. During Q4, THNA and other FTF program partners collaborated on joint targeted interventions to increase positive nutrition outcomes through multisectoral coordination and programming efforts. THNA actively participated in national-level activities organized by the Global Alliance for Improved Nutrition, which promotes wheat flour fortification and salt iodization. In Y3, THNA closely collaborated and coordinated with other FTF activities and international organizations to facilitate the smooth and timely implementation of initiatives on nutrition, with the goal of preventing stunting by addressing its proximal causes (see more below).
Collaboration with the international community
As a member of SUN in Tajikistan, THNA’s representative participated in meetings arranged by the MOHSPP (see Activity 4.1.8). In Y3, joint activities with UNICEF and WFP on IMAM resulted in the integration, revision, and approval of guidelines on IMAM. THNA supported regular meetings and designed mapping on IMAM implementation to coordinate joint activities (see Activity 3.3.9).
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To support THNA’s activity on screening for malnutrition and referral for treatment at the community and PHC levels, WFP provided 1,250 MUAC tapes to THNA (see Activity 3.3.9). In Y3, THNA in collaboration with UNICEF and WFP supported the MOHSPP TWG to develop a comprehensive nutrition package revise IYCF protocols for future trainings, with the goal of having 100% of PHC HCWs fully trained on these topics in all 12 FTF districts in Y4 (see Activities 3.3.9 and 4.3.6). As part of its collaboration with UNICEF, in Y3, THNA continued implementing the Instructions for the Lives of Mothers and Children (Rohnamo) in 12 districts at the hospital and PHC levels (see Activities 3.3 and 4.3.2). In Q2–Q4, THNA continued its close cooperation with JICA, WHO, and GIZ to support the MOHSPP TWG in developing neonatal standards and standards on managing bleeding during pregnancy, in labor, and after delivery (see Activities 1.1.1 and 4.3.12). In terms of clinical activities, THNA actively collaborates with donors (JICA, KfW, and GIZ) working in the same FTF districts to coordinate efforts on effective QI measures of MNCH services. As result of the cooperation, THNA and JICA agreed on a joint action plan on EPC implementation in Kushoniyon and Levakand districts in Y4. THNA technical staff will continue to provide mentoring and technical support, and JICA in turn agreed to support infection control implementation in CDHs by supporting laundries. THNA shared its experience and best practices on EPC implementation with the GIZ-funded program implemented by M4Health and agreed to support exchange visits by some CDHs from non-FTF districts visits.
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ANNEXES
Annex I. QI indicators on ANC
Annex II. Results of THNA’s economic growth survey, September 2018
Annex III. THNA IEC materials and media coverage in Y3
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