Preparing the Second Community-Based Early Childhood Development Project

Technical Assistance Consultant’s Report

Project Number: 37430 June 2008

Kyrgyz Republic: Preparing the Second Community- Based Early Childhood Development Project (Financed by the Japan Special Fund)

Prepared by EPOS Health Consultants GmbH Germany

For Office of the President, Kyrgyz Republic

This consultant’s report does not necessarily reflect the views of ADB or the Government concerned, and ADB and the Government cannot be held liable for its contents. (For project preparatory technical assistance: All the views expressed herein may not be incorporated into the proposed project’s design. KYRGYZ REPUBLIC

Office of the President

ASIAN DEVELOPMENT BANK

PREPARING THE SECOND COMMUNITY-BASED EARLY CHILDHOOD DEVELOPMNET PROJECT TA: 4797-KGZ

REPORT OF THE BASELINE AND NEEDS ASSESSMENT May 2007

EPOS Hindenburgring 18 Telefon: +49-(0)6172-930-370/373 Health Consultants GmbH D-61348 Bad Homburg Fax: +49-(0)6172-930-372 E-Mail: [email protected] Deutschland Homepage: http://www.epos.de

TABLE OF CONTENTS

1. Introduction ...... 4 2. Objectives and Tasks of the Needs Assessment Survey: ...... 4 3. Methodology of the Survey ...... 4 3.1 Target Group and Sampling ...... 5 3.2 Pilot Survey ...... 6 3.3 Implementation of the Survey in Raions ...... 6 4. Results ...... 7 4.1 Information on Parents and Socio-Economical Situation of the Families ...... 7 4.2 Iodine Salt Consumption and Anemia Problems...... 8 4.3 Access to Medical Facilities and Drugs ...... 9 4.4 Kindergartens ...... 10 4.5 Nutrition ...... 11 4.6 Children’s Development...... 12 4.7 Community Potential...... 14 4.8 Information about Children from Birth to 8 Years of Age...... 15 5. Conclusions ...... 18

Annex 1. Sampling Annex 2. Questionnaire in Russian, Kyrgyz, and Uzbek Annex 3. Instructions for conducting the survy Annex 4. Survey data in tables in figures

2 List of Abbreviations

AO Aiyl Okmotu ECD Early Childhood Development FAP Feldsher Accoucher (midwife) Post FGP Family Group Practice IDD Iodine Deficiency Disorders IDA Iron Deficiency Anemia KR Kyrgyz Republic NGO Non-Government Organization PPTA Project Preparatory Technical Assistance ToR Terms of Reference

3 ANNEX 1

Questionnaire Needs Assessment Questionnaire Pilot interview Needs Assessment Questionnaire

Questionnaire #______Name of an interviewer ______Date ______Name of respondent ______Time from ___ until______Name of supervisor ______Name of controller______

Rayon Notes of controller:

Aiyl okmotu

Village

Address

Telephone

Introduction Hello, my name is: ______Thank you very much for your time and cooperation. In our survey we are interviewing mothers of children under 8 years old. We select households randomly. The information received during our interview together with other interviews made in three oblasts will help us to understand the needs of small children in these oblasts. We hope that this information will help to our government in its work aimed for better development, improvement of health, nutrition, care and education of children under 8 years old. The questionnaire will take 35-40 minutes to complete. Your names and addresses will not be revealed to anyone.

Filter questions

1. Do you have children under 8? [ ] 1. Yes [ ] 2. No b finish interview

2. I need to talk to mother of these children. Is she at home? [ ] 1. Yes [ ] 2. No b finish interview

3. Do you agree to answer my questions? (This question should be addressed to the mother of child/children) [ ] 1. Yes [ ] 2. No b finish interview

24.01.2007 1 Needs Assessment Questionnaire Pilot interview

Information on parents/guardians of children under 8 in a family 1 Does a father of your children under 8 live together with you and your children? [ ] 1. Yes [ ] 2. No [ ] 3. Other ______2_3 Employment 2_1 Age 2_2 Education 2_4 Ethnicity status [ ] 1.Primary 2 [ ] 1. 18-23 [ ] 2.Secondary [ ] 1. Housewife / [ ] 1. Kyrgyz [ ] 2. 24-30 [ ] 3.Professional unemployed [ ] 2. Uzbek [ ] 3. 31-35 education [ ] 3. Russian [ ] 4. 36-40 [ ] 4.Incomplete higher [ ] 2. Farmer / [ ] 4. Tajik [ ] 5. 41-45 education agricultural [ ] 5. Kazakh [ ] 6. 46-50 [ ] 5.Higher education worker [ ] 6. Tatar [ ] 7. Older [ ] 6.No education [ ] 7. Other

Mother than 50 [ ] 3. Employed ______(Where?) ______

[ ] 4. Other ______

3_3 Employment 3_1 Age 3_2 Education 3_4 Ethnicity status [ ] 1. Primary [ ] 1. Unemployed 3 [ ] 1. 18-23 [ ] 2. Secondary [ ] 1. Kyrgyz [ ] 2. 24-30 [ ] 3. Professional [ ] 2. Farmer / [ ] 2. Uzbek [ ] 3. 31-35 education agricultural [ ] 3. Russian [ ] 4. 36-40 [ ] 4. Incomplete higher worker [ ] 4. Tajik [ ] 5. 41-45 education [ ] 5. Kazakh [ ] 6. 46-50 [ ] 5. Higher education [ ] 3. Employed [ ] 6. Tatar [ ] 7. Older [ ] 6. No education (Where?) [ ] 7. Other

Father than 50 ______

[ ] 4. Other ______

Questions on socio-economic situation of the family 4 Heating in the house Electrical 1 Gas 2 Wood Furnace 3 Other ______4

24.01.2007 2 Needs Assessment Questionnaire Pilot interview

5 Clean water used for drinking/cooking In the house 1 Outside the house 2 On the long distance (more than 1 km) 3 No access 4

6 Way of cooking food On electric stove 1 On gas stove 2 On wood furnace 3 Other ______4

7 Electricity: Do you have problems with electricity supply? Never 1 Seldom ( a couple of times a year) 2 Sometimes (monthly) 3 Frequently (weekly) 4 Very frequently (daily) 5

Iodised salt consumption

8 Did you ever hear of the importance of iodine for the health? [ ] 1. Yes [ ] 2. No [ ] 3. Don’t know 9 Do you think it is important to use iodized salt? [ ] 1. Very important [ ] 2. Rather important [ ] 3. Less important [ ] 4. Not important at all [ ] 5. Other______

10 Why do you think it is important to use iodized salt? (Mark off only one answer) (Interviewer: Don’t read listed answers) [ ] 1. Prevents from goitre [ ] 2. Prevents disorders in the development of foetus during pregnancy [ ] 3. Prevents from iodine deficiency disorders [ ] 4. Don’t know [ ] 5. Other ______

11 Is your salt is iodized? [ ] 1. Yes, salt is iodized [ ] 2. No, salt is not iodized [ ] 3. Don’t know

24.01.2007 3 Needs Assessment Questionnaire Pilot interview

12 May I look at salt you use for cooking? (Interviewer: Please, check if it is iodized salt) [ ] 1. Yes, salt is iodized [ ] 2. No, salt is not iodized [ ] 3. It is not clear [ ] 4. Other ______

Anemia

13 Were you ever diagnosed anaemic during pregnancy? [ ] 1. Yes [ ] 2. No b proceed to question 17 [ ] 3. Don’t know 14 If yes, were you prescribed iron tablets? [ ] 1. Yes [ ] 2. No [ ] 3. Don’t know [ ] 4. Other______

15 If prescribed iron tablets, about how many tablets did you take? [ ] 1. 0 - 30 [ ] 2. 31 – 60 [ ] 3. 60 – 90 [ ] 4. Don’t know [ ] 5. Other______

16 If you did not take the recommended number of tablets, why not? [ ] 1. Not enough money to buy

[ ] 2. Pharmacy or health facility too far [ ] 3. Side effects [ ] 4. Didn’t know how to take the tablets [ ] 1. Other ______

Access to medical facilities and drugs

The last time you had to seek treatment for your child(ren), where did you go? 17 [ ] 1. FAP [ ] 2. FGP [ ] 3. FMC [ ] 4. Rayon Hospital [ ] 5. Oblast Hospital [ ] 6. Local healer [ ] 7. Other______

24.01.2007 4 Needs Assessment Questionnaire Pilot interview

18 Did you have problems with access to medical help in 2006 when your children were sick or needed regular check? [ ] 1. Yes, I always had problems [ ] 2. Sometimes I experienced difficulties [ ] 3. I didn’t have any problems [ ] 4. No problems b proceed to question 20

19 Please, indicate if the following reasons were among difficulties you faced when you sought medical assistance?

Yes No

19_a No health facility in our village 1 2

19_b I don’t trust to our medical staff 1 2

19_c I had no money to pay for services 1 2

19_d Long distance was an obstacle 1 2

19_e Health facility was closed 1 2

19_f Other reason______1 2

Where did you get medicine last time when you needed it for you or your children? (not 20 being at hospital treatment) [ ] 1. Pharmacy point (Aptechnyi punkt) in our village [ ] 2. Pharmacy in rayon centre [ ] 3. FAP (medicine of humanitarian help) [ ] 4. FGP [ ] 5. FMC [ ] 6. Pharmacy in oblast centre [ ] 7. Friends, relatives, neighbors [ ] 8. Other ______

21 Did you have problems with getting medicine prescribed by a doctor for your children when they were sick last time? [ ] 1. Yes [ ] 2. No b proceed to question 23 [ ] 3. Don’t know [ ] 4. Other______

22 If yes, why? [ ] 1. Medicines were not available in nearest pharmacy [ ] 2. Did not have enough money to buy them [ ] 3. Our pharmacy was closed [ ] 4. We don’t have pharmacy in our village [ ] 5. Other______

24.01.2007 5 Needs Assessment Questionnaire Pilot interview

Kindergartens Do you think it is important for your children to attend kindergartens? 23 [ ] 1. Yes, very important [ ] 2. Partly important [ ] 3. It is not necessary b proceed to question 25 [ ] 4. Don’t know b proceed to question 25

If yes, please indicate for what reasons you would like your children to attend a 24 kindergarten? (Indicate only one answer)

[ ] 1. I am not at home, my child/children needs somebody to look after [ ] 2. My child can learn more in a kindergarten than at home [ ] 3. My child is together with other children in the kindergarten [ ] 4. There are trained specialists for educating my child/children [ ] 5. My child has special needs (if yes, please, ask what kind of special needs) [ ] 6. Don’t know [ ] 7. Other ______

Which type of kindergarten do you have in your village or AO? 25 [ ] 1. State [ ] 2. Community-based (organized by your local community’s initiative) [ ] 3. Private (belongs to a person) [ ] 4. Home-based (organized in a someone’s home in the village) [ ] 5. Don’t have any [ ] 6. Don’t know [ ] 7. Other ______

Nutrition

26 Please, indicate if your family eats the following food and how often Every day 1-2 times a week 1-2 times a month 3-4 times Never per year

26_a Meat 1 2 3 4 5

26_b Milk 1 2 3 4 5 products 26_c Vegetables 1 2 3 4 5 and fruit 26_d Eggs 1 2 3 4 5

27 Do you have the following in your household Yes No 27_a Cattle 1 2 27_b Milk cow 1 2 27_c Poultry 1 2 27_d Kitchen-garden 1 2

24.01.2007 6 Needs Assessment Questionnaire Pilot interview

Did you receive advice from your doctor/health care worker on your nutrition during 28 pregnancy?

[ ] 1. Yes [ ] 2. No b proceed to question 30 [ ] 3. Don’t remember [ ] 4. Other______

What were you advised by your doctor/health care worker about eating while you were 29 pregnant?

[ ] 1. Eat more food than usual [ ] 2. Eat the same amount as usual [ ] 3. Eat less than usual [ ] 4. Other ______

30 What was the actual situation with your nutrition during pregnancy?

[ ] 1. I ate more often than usual [ ] 2. As usual [ ] 3. Less than usual [ ] 4. Don’t remember [ ] 5. Other______

Did your diet during pregnancy include 31 Every day 1-2 times a week 1-2 times a month Never

31_a Meat 1 2 3 4 31_b Milk products 1 2 3 4 31_c Vegetables and fruit 1 2 3 4 31_d Eggs 1 2 3 4

Have you ever been instructed about children’s nutrition? 32 [ ] 1. Yes [ ] 2. No [ ] 3. Don’t know [ ] 4. Other______

Who gave you advice on children’s nutrition? 33 Yes No 33_1 Our family group doctor 1 2 33_2 Nurse 1 2 33_3 Doctor from FAP 1 2 33_4 Relatives/friends/neighbours 1 2 33_5 Other 1 2

24.01.2007 7 Needs Assessment Questionnaire Pilot interview

34 How often do you include the following food when feed your children under 8? Every day 1-2 times a week 1-2 times a month

34_a Meat, poultry, fish 1 2 3

34_b Diary products 1 2 3

34_c Vegetables and fruit 1 2 3

34_d Juice 1 2 3

34_e Egg 1 2 3

Children’s development Would you like to receive information on development and education of your children under 35 8? [ ] 1. Yes [ ] 2. No b proceed to question 37 [ ] 3. Don’t know

Please, indicate what information related to your child development would you like to learn? 36 Yes No 36_a How to bring up my child in a healthy way, that my child 1 2 stays healthy 36_b How to create a safe surrounding for my child to ensure 1 2 his/her security 36_c How I can understand my child and his/her needs 1 2

36_d How to teach good manners to my child to behave well 1 2 36_e How I can support my child attending a kindergarten 1 2 36_f How to prepare my child to enter school 1 2 36_g Children rights 1 2 36_h Other______1 2 37 Which way would you like to receive information on children’s development? Yes No 37_a Through books/brochures 1 2 37_b Through parent training 1 2 37_c Through TV programs 1 2 37_d Through radio programs 1 2

37_e Other______1 2

In your opinion, who should provide this kind of information to your family? (Choose one) 38 [ ] 1. FAPs’ staff [ ] 2. School teachers [ ] 3. AO staff [ ] 4. Social worker [ ] 5. Health worker [ ] 6. Other______

24.01.2007 8 Needs Assessment Questionnaire Pilot interview

39 When your children under 8 misbehave, how and how often do you punish them? Almost every time Sometimes Never 39_a Verbally (shouting) 1 2 3 39_b Physically (spanking) 1 2 3 39_c Not permit to do something 1 2 3 39_d Other 1 2 3

40 Are you or other persons responsible for caring of your children in your family involved in the following activities with your children? (check all that apply) Yes, we do it We do it We do it No, we every day several once a don’t do it times a week at all week 40_a Tell to the children fairytales 40_b Sing songs to the children 40_c Take the children outside 40_d Read books to the children 40_e Correct the child’s behaviour, when misbehaving 40_f Watch TV programs with the children 40_g Teach personal hygiene 40_h Do physical exercises 40_i Teach letters and numbers 40_j Other______

Community Capacity Have you ever heard something about programs/activities designed for families and children 41 and taking place in your Aiyl Okmotu? [ ] 1. Yes ---b which program/activity?______[ ] 2. No [ ] 3. Don’t know [ ] 4. Other______42 How would you assess your Aiyl Okmotu’s work aimed at improving the well-being of children in your village? [ ] 1. Very helpful [ ] 2. Helpful [ ] 3. Not so helpful [ ] 4. They do nothing [ ] 5. Don’t know [ ] 6. Other______

24.01.2007 9 Needs Assessment Questionnaire Pilot interview

43 Would you like to participate in programs or activities for parents if they will be offered for you? [ ] 1. Yes, with great interest [ ] 2. Probably yes [ ] 3. Probably no [ ] 4. Definitely no [ ] 5. Other______

Information on children under 8 in the family

44 How many children do you have under 8 years old? ______children

45 Do you have children under 8 with special needs or disabled? [ ] 1. Yes Please, specify______[ ] 2. No

In case there are more than one children under 8 select one child using a lottery method 46 Age of the child selected for the study: ______years If a child is a baby under 1 year old: ______months

47 Sex of the targeted child [ ] 1. Male [ ] 2. Female

24.01.2007 10 Needs Assessment Questionnaire Pilot interview

Age Specific Questions Please, take a list with questions corresponded to the age of a targeted child

0 – 12 Months Did you go for prenatal care during your pregnancy? 1 [ ] 1. Yes [ ] 2. No b proceed to question 4 [ ] 3. Other______

Were medical facilities available for you to have regular checking and medical assistance 2 during pregnancy? [ ] 1. Yes, I had no problems with medical observation during pregnancy [ ] 2. I had some problems with availability of medical facilities during pregnancy [ ] 3. I had serious problems with medical assistance during pregnancy [ ] 4. Other ______

Where did you go for regular checking and medical assistance during pregnancy? 3 [ ] 1. FAP [ ] 2. FGP [ ] 3. FMC [ ] 4. Other ______

4 Were you ever diagnosed with iodine deficiency during a pregnancy? [ ] 1. Yes [ ] 2. No b proceed to question 6 [ ] 3. Don’t know

5 If yes, what treatment did you receive? [ ] 1. Iodine capsules/tablets [ ] 2. Iodine injection [ ] 3. No treatment [ ] 4. Other ______

Where did you go for the delivery of your child?

[ ] 1. Maternity hospital 6 [ ] 2. FGP with beds ( ) [ ] 3. FAP with beds [ ] 4. Private clinics [ ] 5. At home [ ] 6. Other______

Was your baby registered and received birth certificate? 7 [ ] 1. Yes, I receive birth certificate after the baby was born b proceed to question 9 [ ] 2. Not yet, I am expecting receiving birth certificate soon [ ] 3. No, my baby doesn’t have certificate [ ] 4. Other ______

24.01.2007 11 Needs Assessment Questionnaire Pilot interview

If no, why your baby doesn’t have birth certificate? 8 [ ] 1. I don’t know where to register [ ] 2. I have a problem to get to the registrar office [ ] 3. I don’t have a passport [ ] 4. My marriage is not registered [ ] 5. I didn’t know about registration [ ] 6. I don’t have a passport [ ] 7. Other______

Did your baby receive all planned immunizations for his/her age? 9 [ ] 1. Yes, I go for every immunization when we are invited by our doctor [ ] 2. No, we missed some immunizations [ ] 3. I don’t know about immunization [ ] 4. Other ______

10 Has your child been breastfed? [ ] 1. Yes, regularly [ ] 2. I breast-ed my child before [ ] 3. No, I did not breastfeed at all

11 Who instructed you on how to breastfeed a child? [ ] 1. Medical worker [ ] 2. Mother/grandmother/female relative/friend [ ] 3. Don’t remember [ ] 4. Other ______

12 Do you use a feeding bottle as supplement for breastfeeding? [ ] 1. Yes [ ] 2. No [ ] 3. Other______

13 When did patronage nurse come to examine your child for the first time? [ ] 1. On the 3rd day [ ] 2. On the 10th day [ ] 3. On the 20th day [ ] 4. In one month [ ] 5. Later than one month [ ] 6. Other______

14 How often do you take your child to a doctor for regular checking? [ ] 1. Every month [ ] 2. Every 2 months [ ] 3. Every 3 months [ ] 4. Every 4 months [ ] 5. Only for immunization [ ] 6. When I am invited by a doctor [ ] 7. When child gets sick [ ] 8. Other______

24.01.2007 12 Needs Assessment Questionnaire Pilot interview

1 – 3 years Did your baby receive all planned immunizations for his/her age? 1 [ ] 1. Yes, I go for every immunization when we are invited by our doctor [ ] 2. No, we missed some immunizations [ ] 3. I don’t know about immunization [ ] 4. Other ______

2 Do you plan to enrol your child in the kindergarten before primary school? [ ] 1. Yesb proceed to question 4 [ ] 2. No [ ] 3. Don’t know

If no, why? 3 [ ] 1. There’s no kindergarten in our village [ ] 2. We have no money for it [ ] 3. Don’t think it is necessary [ ] 4. Other______4 Did your child have diarrhoea during last month? [ ] 1. Yes [ ] 2. No b Finish the interview [ ] 3. Don’t know b Finish the interview

5 If yes, what did your child receive for treatment? [ ] 1. Regidron (pack of powder to be mixed with water)? [ ] 2. Antibiotics [ ] 3. Don’t know [ ] 4. Other______

6 If you gave Regidron to child, where did you get it? [ ] 1. It was provided by FAP for free [ ] 2. I bought it in FAP [ ] 3. I bought it in pharmacy [ ] 4. I was given by friends/relatives/neighbour [ ] 5. Don’t know [ ] 6. Other______

24.01.2007 13 Needs Assessment Questionnaire Pilot interview

4 – 5 years

1 Does your child attend a kindergarten or any other pre-school program? [ ] 1. Yes [ ] 2. No b proceed to question 4 2 Which of the following types of kindergarten or pre-school your child attends? [ ] 1. State [ ] 2. Community-based [ ] 3. Private [ ] 4. Home-based [ ] 5. Don’t know [ ] 6. Other ______

3 Can you evaluate the kindergarten by following characteristics? Very good Optimal Poor Very poor 3_1 Quality of child care 4 3 2 1 3_2 Quality of teaching programs 4 3 2 1 3_3 Quality of nutrition 4 3 2 1 3_4 Presence of toys, books, 4 3 2 1

equipments 3_5 Quality of building and 4 3 2 1 facilities 3_6 Professionalism of teachers 4 3 2 1

4 If child does not attend kindergarten: Do you plan to enrol your child in the kindergarten before primary school? [ ] 1. Yes b proceed to question 6 [ ] 2. No [ ] 3. Don’t know

If no, why? 5 [ ] 1. There’s no kindergarten in our village [ ] 2. We have no money for it [ ] 3. Don’t think it is necessary [ ] 4. Other ______6 Did your child have diarrhoea during last month? [ ] 1. Yes [ ] 2. No b Finish the interview [ ] 3. Don’t know b Finish the interview

7 If yes, what did your child receive for treatment? [ ] 1. Regidron (pack of powder to be mixed with water)? [ ] 2. Antibiotics [ ] 3. Don’t know [ ] 4. Other______

24.01.2007 14 Needs Assessment Questionnaire Pilot interview

8 If you gave Regidron to child, where did you get it? [ ] 1. It was provided by FAP for free [ ] 2. I bought it in FAP [ ] 3. I bought it in pharmacy [ ] 4. I was given by friends/relatives/neighbour [ ] 5. Don’t know [ ] 6. Other______

6 – 7 years

1 Does your child attend kindergarten? [ ] 1. Yes [ ] 2. Attended before [ ] 3. No b proceed to question 4

2 Which of the following types of kindergarten does your child attend? [ ] 1. State [ ] 2. Community-based [ ] 3. Private [ ] 4. Home-based [ ] 5. Don’t know [ ] 6. Other______

3 Can you evaluate the kindergarten by following characteristics? Very good Optimal Poor Very poor 3_a Quality of child care 4 3 2 1 3_b Quality of teaching programs 4 3 2 1 3_c Quality of nutrition 4 3 2 1 3_d Presence of toys, books, 4 3 2 1

equipments 3_e Quality of building and 4 3 2 1 facilities 3_f Professionalism of teachers 4 3 2 1

4 What are you doing or have you done at home to prepare your child for school? (check all that apply) Yes No 4_1 We teach to speak correctly 1 2 4_2 We teach how to read, count, and draw 1 2 4_3 We talk about school 1 2 4_4 We teach how to be self-dependent 1 2 4_5 We do nothing 1 2 4_6 Other, please specify ______1 2

24.01.2007 15 Needs Assessment Questionnaire Pilot interview

5 Did your child have diarrhoea during last month? [ ] 1. Yes [ ] 2. No b Finish the interview [ ] 3. Don’t know b Finish the interview

6 If yes, what did your child receive for treatment? [ ] 1. Regidron (pack of powder to be mixed with water)? [ ] 2. Antibiotics [ ] 3. Don’t know [ ] 4. Other______

7 If you gave Regidron to child, where did you get it? [ ] 1. It was provided by FAP for free [ ] 2. I bought it in FAP [ ] 3. I bought it in pharmacy [ ] 4. I was given by friends/relatives/neighbour [ ] 5. Don’t know [ ] 6. Other______

24.01.2007 16 ANNEX 2

Household Survey Report CONTRACT 2007/01

NEEDS ASSESSMENT SURVEY

Final REPORT

January – March 2007

Prepared by expert group of CFG Company, Bishkek 1. INTRODUCTION

The PPTA Community Based Early Childhood Development Project aimed at improving health, nutrition, and psychosocial development of children from birth to 8 years of age, requested a needs assessment survey in 4 poor raions of Kyrgyz Republic republic. Among the tasks included in the ToR for the research company were preparing enough copies of the questionnaire, instructing the interviewers, conducting the field survey by interviewing mothers of early age children in their households, and preparing the report based on summarizing and analysis of the data.

2. OBJECTIVES AND TASKS OF THE NEEDS ASSESSMENT SURVEY

Objective: Administering the survey through interviewing mothers in households in 4 poor raions in Osh, Jalal-Abad and Batken oblasts with the aim to reveal the needs of children from birth to age 8 on strengthening their health, improving nutrition, and psychosocial development.

Tasks: Research: collection, systemization, summarizing of the information; Project-modeling: design of the questionnaire, examining of the documents; Conducting field research; Analysis of the results of the research and elaboration of the recommendations

3. METHODOLOGY OF THE SURVEY

The research consisted of two stages: pilot survey and interviewing the households; and summary and analysis. The questionnaire included seven blocks of questions: information on parents and children from birth to 8; questions on the socio-economical situation of a family; on iodine salt consumption and problems on anemia; on access to medical facilities and drugs; on kindergartens; nutrition; children’s development; and community potential.

During the research both qualitative and quantitative methods were used. The information received from the raions’ administrations and FGPs included the following: 1. Statistical information on the socio-economic situation of the population, ethnicity and quantitative composition of three target oblasts; 2. Statistical information from the FGPs; 3. Statistical information from oblast branches of the national Statistical Committee for 2001-2005

Qualitative research included: 1. Assessment of the socio-economic situation of the population in four target raions, information received from oblast/raion centers of FGPs; minimal basket of goods in Kyrgyz soms and food value; access to drinking water; 2. Pilot interviews were conducted in households with children under age 8 in Aravan raion in Osh oblast; 3. Discussions were conducted with representatives of AOs.

4 Quantitative research included: 1. Statistical data on the population in target raions; 2. Statistical data on the poverty level; 3. Statistical data on the ethnic composition in target raions.

3.1 Target Group and Sampling

The major target group included households where parents had at least one child under age 8.

In a given survey the sampling strategy followed the recommendations in the ToR in selecting the number of households according to the total numbers of households in each AO. In most of the AOs the number of households selected corresponded to the following scheme: Less than 500 – 5; 500 – 1,000 – 10; 1000 – 2000 – 20; More than 2,000 – 25. The total households interviewed were 1,155.

Conducting the needs assessment survey was divided into two phases. The first phase included conducting the sampling and interviews in the target raions in Osh, Batken, and Jalal-Abad oblasts. The goal of the second phase was determining the needs of the children from birth to 8 years of age.

The following tasks were fulfilled during the first phase:

Sampling of households in AOs in Suzak, Batken, Kadamjai, and Uzgen raions; Development of the pilot survey for testing of the questionnaire; Translation of the questionnaire; Preparation conducting the pilot survey; Revision and correction of the questionnaire after pilot survey; Development of the routes and route guides; Development of the schedule and program for the training, and preparing handouts; Establishment of contacts with AOs; Selection, training, and instructing the interviewers; Signing the contracts with interviewers, controllers, and drivers; Conducting the field survey; Entering of data in a computerized format with the codes of the responses and corresponding meanings.

The following tasks were fulfilled during second phase: Data processing, cleaning, and tabulation; Analysis of the data according to each sector; Development of the recommendations; Preparing of the final report; Translation of the final report into English

5 3.2 Pilot Survey

A pilot survey was conducted during the period 21-23 January in five villages in Nurabad and S.Yusupova AO. In total 14 interviews were conducted in the households with children under age 8. The tasks of the pilot survey were to test the questionnaire and make revisions and corrections by taking into account the results of the pilot interviews. As a result the questionnaire was revised and updated.

The questionnaire was translated into the Kyrgyz and Uzbek languages, the total number of copies in Kyrgyz, Uzbek, and Russian languages was 1,320. The routes and route schedules were developed, the program, schedule, and instructive materials for the training of interviewers were prepared.

Due to difficulties with communication with the AOs in three target oblasts, it was possible to only contact 60% of AOs and inform them about the survey; 40% of the AO heads were requested to provide information on number and addresses of households with early age children.

Time of the field works: from January 27th to February 6th.

3.3 Implementation of the Survey in Raions

The field works were conducted in Batken, Kadamjai, Uzgen, and Suzak raions

Batken raion, Batken oblast The raion consists of 10 AOs, the population is 93,792 people. On the 27th of January a work group of CFG Company arrived in Batken raion and rented an office. The next day they conducted training for interviewers. The contracts were signed with 12 interviewers. The sample size for the raion was 210 interviews. The supervisor for the raion, Murasheva Dilyara, distributed the work among interviewers according to the route schedules. Interviews were started in AOs Suubaty, Samarkandek and continued in Aksai and Karabak. Strarting from February 1 the controlling activities were implemented.

Kadamjai raion, Batken oblast The raion consists of 15 AOs, the population is 158,174. On the 29th of January training for interviewers was conducted, 14 interviewers were selected for work in the raion. Interviews were started in Pulgon village, AOs Khalmion and Kotormo. Works were continued in AOs Alga, Birlik, Markaz, Khaidarkan, Sovetski, Uch-Korgon and Kara-Dobo. On February 1 the survey was conducted in AOs Kyzyl-Jar, and Chaiuvai and on February 3 in AOs Orozbekova and Karajygach village. On the 3-4 of February controlling activities were started. Controller Ishembaeva T. went to AO Khaidarkan, Birlik, Alga, Khalmion, and Kyrgyzkyshtak.

Uzgen raion, Osh oblast The raion consists of 19 AOs, the population is 164,900. On 28-29 January the supervisor started preparation work: she met with officials from Kurshab AO, collected information on FAPs and FGPs, selected interviewers during training and signed contracts with 13 interviewers. Interviews were started in AO Kurshab and Kyzyl-Oktyabr, continued in AO Myrza-Ake, Don-Bulak, Karool, Tort-Kol, Jazy, Salamalik, Akjar, Jalpak-Tash, Ak-Jar, Jylaldy, and Bash-Dobo. Interviewers could not conduct interviews in AOs Kolduk,

6 Kara-Tash, Iyri-Suu, Changet, Zarger, Kyzyl-Too, and Altyn-Bulak due to the remoteness and inaccessibility by car in winter time.

Suzak raion, Jalal-Abad oblast The raion consists of 13 AOs, population is 203,081. On January 31st the training of interviewers was conducted by supervisor Abdykalykova A. 12 interviewers were trained. The interviews were conducted in AO Suzak, Tashbulak, and Kok- Art, continued in villages Yntymak, Ak-Yook, Kyzyl-Tuu, Vinsovhoz, Arkhangelsk, Joon- Kungoi, Jalgyz-Jangak, Donor, Komsomol, Min Orus, Dosh, Don-Kopuro, Bekabada, Yrys, Kyzayl-Senir, Munduz etc. On 2 February work was continued in villages Doskana, Kara-Mart, Oktyabrskoe, Jygach-Korgon, Kalmak-Kyrchyn, Orto Kanjyga, Chon Kanjyga, Jergetal, Communism, and other villages in all AOs of the raion. During 4-6 February the controlling work was conducted.

4. RESULTS

4.1 Information on Parents and Socio-Economical Situation of the Families

In this section information about parents of children under age 8 in a family and the socio- economical situation of the family is presented:

98.6% of children live in a full family; the age of mothers in most families (40.9%) was 24-30 years, at the same time the age of fathers was proportionally 24-40 years. Most of the parents had a secondary education (68.3% among mothers, 62.9% among fathers). The social status of mothers is 86.0% unemployed/housewives. Among fathers 67.2% are unemployed. Out of 13.1% of employed mothers 58.4% work in education, and 30.7% - in the sphere of medicine. Out of 29.3% of employed fathers 21.3% are involved in business, in the service sphere – 13.6%, state servants – 13.6%, have migrated to work in Russia – 13.6%, and 10.1% work in education. Ethnic composition of respondents selected for the interviews were as follow: Kyrgyz – 87.4%, Uzbek – 10.3%, Tajik – 1.5%, Russian – 0.3%, the same proportion as Turk, Kazakh, and Kurd ethnic groups. Factors that describe the economic situation in the families, in general 88.1% of families heat their houses by furnace. The water is located in the yard among 43.6%, 27% of families get water from a distance more than 1 km from home, and 26.4% don’t have access to drinking water. 53.4% of respondents experience problems with electricity supply sometimes (monthly), and 12.4% of surveyed families – weekly.

The following conclusions can be made on this section: Parents of children under age 8 are mostly people of a productive age – from 24 to 40 years old (about 80%); 65% of the respondents can be considered poor, since 67.2% of fathers and 86.6% of mothers in surveyed households are unemployed; 88.1% of households do not have electric or gas heating; There are serious problems in access to drinking water: remoteness from the house more then 1 km is among 27% of families, and 26.4% do not have access at all.

Recommendations: To increase and improve the professional and technical training of people in the oblast and raion centers, with the aim of reducing the level of unemployment; In the frame of the Programs “Clean water” and “Social initiative” NGOs and local communities should take more active initiatives in solving the problem of supplying people with drinking water. Though TV and radio programs regularly inform people about successful initiatives of local communities. State authorities should consider opportunities for creating work places for the unemployed; To use the potential of the civil sector and local communities in creating new work places; To consider the prospect of supplying electric and gas heating to houses.

4.2 Iodine Salt Consumption and Anemia Problems

The section of the survey on the consumption of iodine salt and problems with anemia, demonstrated following: 95.7% of respondents know about the importance of iodine for health; and using iodized salt was considered as “very important” among 71.4% and as “important” among 27.2% of respondents; 79% think that iodine prevents goiter and 8.2% that it prevents disorders of the fetus during pregnancy; During the interview salt used for cooking in households was checked for iodine content by examining the inscriptions on the bags of salt. 90.5% of salt were iodized, in 5.6% of cases it was difficult to identify, and in 3.9% cases salt was not iodized; 43.4% of women interviewed were diagnosed as anemic during pregnancy; In 81.4% of cases with anemia, the women were prescribed iron tablets, 42.7% took about 30 tablets, 20.9% took from 30 to 60 tablets and only 8.1% took from 60 to 90 tablets. 38.9% of the respondents who did not take the recommended amount of tablets indicated a shortage of money as one of the major reason (53.2%), fear of side effects (20.9%), lack of understanding (18.4%), and the remoteness of drug stores and medical facilities (7%)

The following conclusions can be made regarding to problems with IDD and IDA

Almost all respondents knew about the importance of iodine for health. Most of the respondents had heard about the prevention of goiter, but only a small proportion had heard that iodine prevents disorders of fetus; 4.3% of respondents did not know about the role of iodine for health, correspondingly in some households (3.9%) salt was not iodized; Almost half of women-respondents (43.3%) were diagnosed as anemic, most of them were prescribed iron tablets; Almost 39% of women who it was recommended should take iron tablets did not take the needed amount of tablets. Among the main reasons for not taking the needed amount of tablets recommended by a doctor were shortage of money and lack of understanding.

8 Recommendations: There is a neede to develop video and audio films stressing the importance of the role of iodine and iron for human organisms, especially for children. The aim is to further demonstrate this information on TV and by broadcasting it on the radio, as well as spreading other types of informational materials; Actively getting NGOs involved to work on the creation of complex informational materials on the importance of iodine and iron for the health of women and children; There is a need to conduct educational programs among the medical staff in medical facilities to raise the awareness on anemia; Consider the opportunity to open consultative points affiliated to FAPs, FMC, FGP to educate people on the importance of iodine and taking iron tablets for thier health.

4.3 Access to Medical Facilities and Drugs

In the section on the access to medical facilities, the survey demonstrated the following:

For the most available medical facility when they were seeking treatment for their sick children the last time, 43.4% respondents indicated FAPs and 32.4% - FGP; 7.9% of respondents took their sick children to a center of family medicine, 7.4% visited a raion hospital, and 4% an oblast hospital; In 2006 54.3% of respondents did not have problems with access to medical assistance when their children needed treatment or regular examination. At the same time 17.1% of respondents frequently had problems, and 16.9% indicated “sometimes”; Among difficulties, 60.9% indicated that they could not pay for medical services, 32.6% said that the long distance was a problem; 18.4% indicated their distrust toofdoctors, 17.2% said that the facility was closed, and 15.1% indicated an absence of medical facilities in their villages;

Regarding the access to drugs, responses were distributed as follows:

38.1% of respondents said that they got drugs in drug stores in their villages, 21.2% received drugs in FAPs from humanitarian aid, 18.3% in a raion pharmacy. 10.6% received medicines from the oblast hospital; 7.1% - in FGP; FMC – 3% 32.1% had problems obtaining medicines prescribed by a doctor for children. Among the problems 65.0% of respondents indicated shortages in money, 23.6% - absence of needed drugs in the nearest drug store, and absence of a drug store in a village was indicated by 10%.

The following conclusion was made on this section: The most available medical facilities for sick children were FAPs and FGPs because they were functional in almost all villages; 45.7% of respondents had problems with access to medical services; People experienced difficulties with access to medical services such as absence of money, long distances, low level of professionalism of medical specialists, inappropriate work of some medical facilities, and in some villages there was no medical facility; Out of 38.1% of respondents who experienced difficulties in getting drugs the biggest problem was absence of money for buying drugs

9 The absence of a medical facility in a village (15% responses) has a connection to inaccessibility of drugs (10%).

Recommendations: To consider opening medical facilities and drug stores in villages where it was indicated there were none; To strengthen control over quality of the drugs and drug distribution; From the state level, a flexible price policy regarding drugs for children should be established.

4.4 Kindergartens

In the section on kindergartens the following situation was revealed: For 82.8% of respondents, attendance at kindergartens was indicated as very important, out of that number 63.9% indicated that children can learn more there than at home; For another 15.9% there was no one to care for a child except his/her mother; 7.2% prefer professional specialists, 5.9% mentioned that their children are with other children in a kindergarten. 69.9% of respondents said that there are no kindergartens in their village or AO. Among known kindergartens most of them were state, with 1.1% - community based; the proportion of private or home-based kindergartens was very small (02% and 01% respectively).

The following conclusions were made regarding the situation with kindergartens:

Demands for kindergartens among parents is very high, most of the population value importance of kindergartens for the development of children; At the same time in most of the villages there are no kindergartens and parents who want their children to attend kindergartens face many obstacles and limitations.

Recommendations: In connection with implementation of the Law of KR “On finance and economical basis of local self-governing of KR” from September, 23rd, it is recommended to local authorities (AO) consider the chances of allocating funds from the local budget for opening kindergartens and preschools; To work with the active residents of the local communities to develop initiatives for opening community-based, private or home-based kindergartens; To develop instructive materials and programs for trainings on issues concerning the organization community-based, private, and home-based kindergartens.

10 4.5 Nutrition

In the section the following information was revealed: Only 15.9% of respondents said that they consume meat every day, 55.1% - 1-2 times a week, 24.8% - 1-2 times a month, 3.8% - 3-4 times a year. Regarding the consumption of milk products it can be noted that 36.7% of respondents consumed them 1-2 times a week; 31.5% - every day; 23.7% - 2-3 times a month; 3.4% - 3-4 times a year; The situation with consuming vegetables and fruits is slightly better, 41.7% of respondents said that they eat them every day, 36.9% - 1-2 times a week, 13.5% - 1-2 times a month; On the consumption of eggs the survey revealed that the majority of respondents eat eggs 1-2 times a week (37.7%), every day – 13.2%, 1-2 times a month – 34.1%; 3-4 times a year – 6.3%; The majority of respondents (63%) did not have cattle in their households, at the same time more than half had a cow (595%); Poultry was indicated in many households (61.3%); and the majority of respondents said that they have kitchen-gardens;

Nutrition during pregnancy Among women interviewed, 57.9% of mothers received consultations from doctors or health workers on nutrition, 40,5% did not; Among recommendations for 38% it was recommended to increase and enrich the diet; among the particular advice mentioned included more vitamins, milk products, eggs, meat, beef, and consuming less farinaceous food and sweets; In practice, 47.8% of mothers during pregnancy did not scientifically change their diet habits; 25.1% tried to eat more that usual; The diet during pregnancy included meat 1-2 times a week among 53.5%, 1-2 times a month among 24.5%; 17.5% did not consume meat every day; and 4% of respondents said that they did not eat meat at all; The majority of respondents (35.8%) consumed milk products 1-2 times a week; 28.1% - included milk products in their diet during pregnancy every day; 22.6% - 1-2 times a month; Vegetables and fruits were included in their daily diet during pregnancy among 55.9% of respondents; 1-2 times a week among 29.3%; 1-2 times a month – among 12.8%. Eggs were included in the daily food allowance among 11.6% of respondents; 1-2 times a week – 35.6%; 1-2 times a month – 29.9%; significant proportions of women did not include eggs in their diet during pregnancy (21.8%);

Consultations on children’s’ nutrition

About half of mothers interviewed received advice on children’s nutrition (4.,2%); most of the sources of advice came from health workers; family group doctors (29.4%); nurses (26.8%); FAP staff (23.3%); relatives/friends (32%); TV programs were mentioned among other sources of information on children’s nutrition (n=5);

11 The diet of children under age 8

Meat, poultry, and fish were included in the children’s diet in most cases 1-2 times a week (50.9%); 1-2 times a month – 30.6%; and daily – 11%. Diary products were included in 39% of cases 1-2 times a week; daily – in 36.1%; 1-2 times a month – 18.4%; Vegetables and fruits were included every day in children’s diets in 45.2%; 1-2 times a week – in 33.9%; 1-2 times a month – in 16.2%; 33.8% of mothers said that they included juices 1-2 times a month; 24.9% - 1-2 times a week, and daily – 15.9%; Eggs were included in 42.7% cases 1-2 times a week; in 30.4% of cases 1-2 times a month; daily – in 10.5% cases;

The following conclusions follow from the data:

The most frequent products in the daily and weekly food allowance are vegetables and fruits; Most of the population includes meat in their diet 1-2 times a week; and about quarter of the population – 1-2 times a month; milk products are included in the diet more frequently than meat; eggs are not in a daily ration in most of the families; a little better situation exists with consuming vegetables and fruits; Almost half of women (40.4%) were not instructed on their nutrition during pregnancy from health workers; During pregnancy about half of women did not change their usual ration on nutrition; their diet included more frequently vegetables and fruits; less frequently – meat and eggs; milk products also were not in daily diet the majority of women; About half of women were not advised concerning children’s nutrition; The composition of products included in the ration of children is almost the same as of the whole family in general; juices are rarely included in the diet of children

Recommendations

In national programs on supporting the nhealth of women and children, special attention should be paid to nutrition of pregnant women and early age children; Health workers from FAPs, FGPs, and FMCs should improve the educational and consultant work on the issues of children’s and pregnant women’s nutrition; To consider opportunities for the creation of special films on children’s nutrition and the nutrition of women during pregnancy, with further demonstrations on TV and on CDs and DVDs for distribution to the population. To work with local authorities and local communities on these issues.

4.6 Children’s Development

In this section, the survey demonstrated the following: Practically all respondents (90.1%) would like to receive information on the development and education of children under age 8; For 88.1% of respondents it was important to know how to bring up their children in a healthy way; 84.7% - how to create safe surroundings for their children; it was very important for parents to know how to teach good manners and behavior (85.8%); to

12 know how to understand the children and their needs (82.9%); most of the parents need information on children’s rights (86.1%); how to prepare entering school (83.3%); help in attending kindergarten (70.4%); The distribution of answers about possible ways of providing the needed information was as follows: through books/brochures – 77.6%; through parents’ training – 66.6%; through TV programs – 85.5%; radio programs – 48.4%. Other possible sources of information mentioned DVD, video (n=9); teachers (n=3); For the question of who should provide information on children’s development, most of the respondents indicated medical specialists including FAPs staff (69.3%); 11.1% of respondents think – educational specialists; For the questions regarding punishment measures, respondents gave the following answers: verbally punish 43.5% daily, and 49.6% - sometimes; physically – 67.9% did this sometimes; 2.6% - almost every time; 40,9% did not permit doing some activities; The distribution of answers related to ways of education for children were as follows in Table 1.

Table 1: Frequency of educational activities in a family (%)

Yes, we do it We do it We do it No, we every day several once a don’t do it times a week at all week Tell the children fairytales 14.8 33.3 24.8 24.5 Sing songs to the children 15.6 21.9 20.2 40.6 Take the children outside 1.9 5.6 43.3 45.7 Read books to the children 12.1 28.7 24.5 31.7 Correct the child’s behavior, 75.8 16.2 3.0 2.4 when misbehaving Watch TV programs with the 88.0 5.2 1.1 .3,4 children Teach personal hygiene 86.1 7.9 2.2 1.6 Do physical exercises 13.3 13.4 12.2 59.0 Teach letters and numbers 41.4 2.5 10.7 15.4

In the frame of this section the following conclusions can be made:

The demand fo educational information related to children under age 8 is very high; The most desired way of receiving the educational information is through TV programs, less through parents’ training; and radio programs; Based on the survey, health workers are the most appropriate people to be providers of such information; Verbal and physical methods of punishment children is widespread among parents; Among most common educational activities in families were watching TV programs with children;, teaching personal hygiene; correction of children’s misbehavior;

13 More than half of parents never do physical exercises; about half of parents do not take children outside for visiting public places; more than 40% never sing songs; and about quarter of parents never tell fairy tales to their children

Recommendations:

To develop educational and informational materials such as special TV programs, brochures, books, seminars for parents, and video films aimed at development and education of children under age 8; The development of programs and video films aimed at the prevention of violence in a family with further demonstration on TV, radio, DVD, as well as on posters; Practicing family therapy among parents in facilities such as FMC, FGP; Publications books designed for children with fairy tales, songs, etc. in the Kyrgyz language at reasonable prices.

4.7 Community Potential

In the frame of this section survey data revealed the following:

The majority of the respondents (82.6%) never heard about community programs/activities for the families and children taking place in AOs; 51.6% of respondents evaluate the work of AOs on ECD issues as very poor; 21,3% of respondents positively evaluated the work of AOs; 55.5% of parents demonstrated strong interest in participating in programs/activities organized by AO. Another 27.3% very likely would participate in such activities.

The following might be concluded: Most AOs do not initiate programs or activities directly aimed at improving the situation in families or children’s development; Most of the respondents negatively evaluated the work of their local authorities in their input into the well-being of early age children; The majority of mothers would support and take part in programs and activities for improving the well-being of their children and families initiated by AOs.

Recommendations Local authorities should strengthen their work on implementing community programs/activities designed for families and children; Actively use the potential of communities for supporting and further development of such programs and projects.

14 4.8 Information about Children from Birth to 8 Years of Age

Table 2: Number of children under age 8 in respondents’ families

Age of a child Proportion of families (%) From birth to 1 35.4 From 1 to 2 43.4 From 2 to 3 16.4 From 3 to 4 3.5 From 4 to 5 1 From 5 to 6 0.1 From 6 to 7 0.1

In 3.3% of families (n=25) surveyed there were children with special needs (disabled). Among them were children with cerebral paralysis (n=8); who are registered as disabled (n=4); Downs syndorm (n=3); speech problems (n=2); hearing problems (n=2), and others.

Table 3: Age of a child selected for the study

Age Proportion (%) From birth to 1 8.6 2 13.6 3 14.5 4 15.2 5 13.2 6 12.1 7 11.3

Sex of selected children: Male – 52.4% Female – 46.7%

Conclusions Most of the surveyed mothers had children from birth to 2 years old; The problem with children with special needs should be examined more carefully in a special survey for revealing their needs

Age group from birth to 12 months

65.4% of mothers received prenatal care during pregnancy; During pregnancy 26.1% of mothers met from minor to major problems with availability to medical facilities; 55.6% of mothers went to a FAP for regular checkups and medical assistance;

15 28.9% of mothers were diagnosed as having iodine deficiency during pregnancy; 66.7% of them received treatment by taking iodine capsules; 30.8% did not receive medical treatment; 93.9% of mothers gave birth in maternity houses, in other medical facilities – 3.8%, 3 respondents said that gave birth at home; 9.,9% of children born had birth certificates; another 53% were expecting to receive birth certificates; 97.7% of children received all planned immunization; 79.2% of mothers were advised on breastfeeding; 95.5% of mothers breastfed their children on regular basis; 79.2% of the advice given on breastfeeding was received from medical workers; 47% of mothers started to give supplemental food for their children; In 7% of cases, a patronage nurse had not come to the family; 76.5% of mothers take their children for regular checkups to a doctor every month;

Conclusions:

More than a quarter of respondents had problems with health during pregnancy; About one-third of the respondents had IDD; less of the half of them did not receive any treatment; Half of the mothers used a feeding bottle as supplemental food to breastfeeding; One-third of respondents indicated that the examination of newborns was not sufficient; 7% said that patronage nurse did not come.

Age group 1 -3 years old

98.1% of children received all planned immunization; 54.4% of parents said that they did not plan to enroll their children in a kindergarten; one of the main reasons for this was the absence of a kindergarten in their village (84.6%); For the last three months 86,8% of children did not have diarrhea. 12,4% of those who had diarrhea received Regidron in 56,8% of cases; 31,8% received antibiotics; 41,9% of those who gave to their children Regidron, received it from FAPs;

Conclusions: More than half of the parents did not enroll their children in kindergartens and preschool programs because they weren’t available, and lack of money; 12.4% of children had diarrhea; most of the children received Regidron; 42% of Regidron was received from FAPs on humanitarian basis.

Age group 4-5 years old

88.2% of children did not go to a kindergarten; in 83% of cases the main reason was the absence of a kindergarten in their village; Among those who attended kindergartens, (83,7% go to state kindergartens); (9,3%) to ; community-based.

Table 4: Evaluation of the kindergarten by criteria (%)

Very Good Poor Very good poor Quality of child care 2.6 7.7 66.7 23.1 Quality of teaching programs 2.6 20.5 61.5 15.4 Quality of nutrition 2.5 25.0 62.5 10.0 Presence of toys, books, 12.2 24.4 51.2 12.2 equipments Quality of building and facilities 10.0 27.5 475 15.0 Professionalism of teachers 2.4 7.3 68.3 22.0

6.5% of children in this age group had diarrhea during last three months; in 45% of cases children received Regidron, another 45% - antibiotics; 40% of those who gave Regidron to their children, received it in FAPs; another 40% bought it in a drug store.

Conclusions: Almost 90% of the children did not attend kindergartens and preschool programs; Most of the mothers gave a very low evaluation of existing kindergartens on all criteria; Half of the respondents did not plan to enroll their children in kindergartens because of their absence; During the last 3 month 6.5% of children had diarrhea; For treatment parents used either Regidron or antibiotics.

Age group 6-7 years old

88,5% of children never attended kindergartens; 86,4% of kindergartens were state; 13,6% - home-based.

Table 5: Evaluation of the kindergartens by parents according to following criteria (%)

Good Poor Very poor Quality of child care 25.0 65.0 10.0 Quality of teaching programs 20.0 70.0 10.0 Quality of nutrition 47.6 38.1 14.3 Presence of toys, books, equipments 38.9 44.4 16.7 Quality of building and facilities 27.8 55.6 167 Professionalism of teachers 22.2 55.6 22.2

17 Table 6: Types of educational activities that parents fulfill for preparing a child to school in a family

% of cases We teach to speak correctly 97.7 We teach how to read, count, and draw 94.4 We talk about school 92.5 We teach how to be self-dependent 94 We do nothing 16.9

93.5% of children did not have diarrhea during last three months; Among 6.1% of those who had diarrhea, received Regidron in 46.7%, antibiotics – in 40%. 44.4% of those who gave Regidron to a child received it in FAPs; 33.3% - bought in a drug store.

Conclusions: Most of the children of preschool age do not attend kindergartens or other preschool programs; Most of the kindergartens received very low grades; For preparing children to school 17% of parents did nothing; Almost 47% of children who had diarrhea during last three months received Regidron; in 44.4% of using Regidron parents received it in FAP for free; total number of children who had diarrhea during last three months were 6.1%.

5. CONCLUSIONS

The results of the survey conducted in the frames of the Community-Based Early Childhood Development demonstrated that the level of poverty in surveyed raions is quite high. This was concluded based on the following indicators: educational level; unemployment; nutrition; access to drinking water, IDD and IDA; accessibility to electric and gas supply; absence of or lack in medical facilities, drug stores, kindergartens and preschool programs; level of awareness of among local authorities and all population; and lack of family therapy.

The needs of children from birth to age 8 in families were ranked as follows (in descending order):

In access to kindergartens and preschool programs; In normal family microclimate; In balanced nutrition; In access to drinking water In access to medical facilities and drugs; In iodized salt; In educational and development programs.

Despite the difficulties of such as a tight schedule, lack of funds, remoteness of some villages included in the survey, the expert group of the CFG Company thinks that the goals and tasks of the survey were achieved.

18 Annex 1: Sampling

4 Target Raions

# Name of AO Population in Number of Sample size AO households in AO

Osh oblast Uzgen raion 1 Kyzyl-Oktyabr 12625 1803 20 2 Kolduk 4300 614 10 3 Kara-Tash 2246 395 5 4 Karool 12047 1941 20 5 Iyri-Suu 8308 1718 20 6 Changet 3250 567 10 7 Zarger 9608 1250 20 8 Jalpak-Tash 7145 1129 20 9 Jazy 12505 1612 20 10 Don-Bulak 10445 1729 20 11 Kyzyl-Too 7011 1120 20 12 Bash-Dobo 5370 990 10 13 Tort-Kol 10481 1810 20 14 Jylaldy 7424 1311 20 15 Ak-Jar 6530 1210 20 16 Kurshab 18703 2521 25 17 Myrza-Ake 16876 2152 25 18 Salam-Alik 6765 1112 20 19 Altyn-Bulak 3261 529 10 TOTAL in raion 335 Jalal-Abad oblast Suzak raion 1 Suzak 30907 5261 25 2 Kara-Daria 11749 2413 25 3 Barpy 19125 4037 25 4 Tash-Bulak 14435 2475 25 5 Yrys 25254 4189 25 6 Atabekov 22536 4409 25 7 Kyz-Kol 11774 2264 25 8 Kyzyl-Tuu 19977 4188 25 9 Bagysh 17483 3302 25 10 Lenin 7277 1457 20 11 Kurmanbek 9393 1934 20 12 Kok-Art 10299 1928 20

19 13 Kara-Alma 2872 601 10 TOTAL in raion 295 Batken oblast Batken raion 1 Batken 23692 5305 25 2 Dara 7803 1868 20 3 Karabak 13348 2898 25 4 Kara-Bulak 10295 2738 25 5 Suu-Bashy 4257 970 10 6 Kyshtut 7424 1803 20 7 Samarkandek 10084 2130 25 8 Tort-Gul 5268 1150 20 9 Ak-Tatyr 5750 1292 20 10 Ak-Sai 5871 1275 20 Kadamjai raion 1 Kadamjai 10194 2558 25 2 Orozbekova 14967 3102 25 3 Kotormo 8271 1943 20 4 Khaidarkan 10550 2552 25 5 Birlik 10571 1939 20 6 Akturpak 12235 2609 25 7 Kyrgyzkyshtak 6002 1140 20 8 Sovetskii 1085 269 5 9 Alga 7166 1619 20 10 Khalmion 16642 3210 25 11 Markaz 9848 2201 25 12 Kara-Dobo 10856 2475 25 13 Uch-Korgon 27705 5500 25 14 Maidan 10427 2321 25 15 Chauvai 1655 330 5 TOTAL in raion 525 TOTAL in three oblasts 1155

20 Annex 2: Questionnaire

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15 K , !? [ ] 1. 0 - 30 [ ] 2. 31 – 60 [ ] 3. 60 – 90 [ ] 4. S [ ] 5. J______

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J !

17 , , , ? [ ] 1. Z- (ZU) [ ] 2. I (I) [ ] 3. \ R (\R) [ ] 4. [ ] 5. T [ ] 6. R [ ] 7. J______

18 , , 2006 , ! ? [ ] 1. J, [ ] 2. N [ ] 3. [ ] 4. S, b 20

24 19 , , ? (T , !)

19_a 1 2

19_ 1 2

19_ S 1 2

19_ G - 1 2

19_ R 1 2

19_ J ______1 2

20 I ! ! !, ( ! )? [ ] 1. [ ] 2. [ ] 3. ZU ( ) [ ] 4. I [ ] 5. \R [ ] 6. [ ] 7. J, , [ ] 8. J ______

21 / , ! , ? [ ] 1. J [ ] 2. S b 23 [ ] 3. S [ ] 4. J ______

22 K , ? [ ] 1. [ ] 2. S [ ] 3. S [ ] 4. [ ] 5. J ______

23 W ! ? [ ] 1. J, [ ] 2. ] [ ] 3. S b 25 [ ] 4. S b 25

25 24 K , , ? , . (T )

[ ] 1. P- , [ ] 2. R , [ ] 3. R / [ ] 4. R [ ] 5. R (, ?)______[ ] 6. S / [ ] 7. J______25 P ! / T? [ ] 1. I ( ) [ ] 2. T ( ) [ ] 3. ] [ ] 4. J ( - ) [ ] 5. S [ ] 6. S [ ] 7. J ______

26 , , ! ! !:

P 1-2 1-2 3-4 S 26_a R 1 2 3 4 5 26_ R 1 2 3 4 5 26_ T 1 2 3 4 5 26_ 1 2 3 4 5

27 ! : J S 27_a (, , .) 1 2 27_ P 1 2 27_ J 1 2

27_ T 1 2

28 . ! ? [ ] 1. J [ ] 2. S b 30 [ ] 3. S [ ] 4. J______

26 29 P ! ! ? [ ] 1. U , [ ] 2. U [ ] 3. U , [ ] 4. J ______

30 P ! ? [ ] 1. [ ] 2. P [ ] 3. R, [ ] 4. S [ ] 5. J ______

31 ! : P 1-2 1-2 S 31_a R 1 2 3 4 31_ R 1 2 3 4

31_ T 1 2 3 4

31_ 1 2 3 4

32 / ? [ ] 1. J [ ] 2. S b 34 [ ] 3. S [ ] 4. J ______

33 P ? J S 33_1 S 1 2 33_2 R 1 2 33_3 ZU 1 2 33_4 // 1 2 33_5 J 1 2

34 P 8 !? P 1-2 1-2 S 34_a R, , 1 2 3 4 34_ R 1 2 3 4 34_ T 1 2 3 4 34_ 1 2 3 4 34_ 1 2 3 4

35 8 ?

[ ] 1. J [ ] 2. S b 37 [ ] 3. S 36 , !? (T ) J S 36_a P 1 2 36_ P 1 2 36_ P 1 2 36_ P 1 2 36_ P , 1 2 36_ P 1 2 36_ U 1 2 36_ J______1 2

37 ? (T ) J S 37_a 1 2 37_ 1 2 37_ 1 2 37_ 1 2 37_ J______1 2 38 , ! ? ( ) [ ] 1. ZU [ ] 2. ^ [ ] 3. T [ ] 4. [ ] 5. [ ] 6. J______

39 K ( 8 ) ! , ? N S 39_a ( ) 1 2 3 39_ Z ( ) 1 2 3 39_ S - 1 2 3 39_ J______1 2 3

28 40 - , , !, : ( , ) J, V ! 40_a 1 2 3 4 40_ U 1 2 3 4 40_ 1 2 3 4 40_ ] 1 2 3 4 40_ N 1 2 3 4 40_ 1 2 3 4 40_ Y 1 2 3 4 40_ J 1 2 3 4 40_ Y 1 2 3 4 40_ J______1 2 3 4

41 W /!! ! , ! T? [ ] 1. J b P /?______[ ] 2. S [ ] 3. S [ ] 4. J ______42 P T ? [ ] 1. T [ ] 2. [ ] 3. S [ ] 4. S !! [ ] 5. S [ ] 6. J ______43 [ - /, T? [ ] 1. J, [ ] 2. W [ ] 3. W [ ] 4. T [ ] 5. J ______

29 N! ! 8

44 W 8 ? ______

45 8 ! ? [ ] 1. J U ______[ ] 2. S

K 8 ,

46 : ______ K 1 : ______!

47 [ ] 1. R [ ] 2. L

, ,

0 – 12 !

1 T ! ? [ ] 1. J [ ] 2. S b 4 [ ] 3. J ______

2 G ! ! ! ? [ ] 1. J, [ ] 2. U , [ ] 3. G [ ] 4. J ______

3 ! !? [ ] 1. ZU [ ] 2. I [ ] 3. \R [ ] 4. J ______

4 W ! ? [ ] 1. J [ ] 2. S b U 6 [ ] 3. S 5 K , ! ? [ ] 1. O / [ ] 2. N 30 [ ] 3. S [ ] 4. J ______

I ? [ ] 1. 6 [ ] 2. I [ ] 3. ZU [ ] 4. ] [ ] 5. J [ ] 6. J______

7 N ? [ ] 1. J, , b 9 [ ] 2. S , [ ] 3. S, [ ] 4. J______

8 K , ? [ ] 1. [ ] 2. R [ ] 3. Y [ ] 4. [ ] 5. [ ] 6. J______

9 J ! ? [ ] 1. J, , [ ] 2. S, [ ] 3. [ ] 4. J ______

10 P ? [ ] 1. J, [ ] 2. P [ ] 3. S,

11 P , ? [ ] 1. R [ ] 2. R/, , [ ] 3. S [ ] 4. J ______

12 N , ? [ ] 1. J [ ] 2. S [ ] 3. J______

13 P ! ? [ ] 1. S 3- 31 [ ] 2. S 10- [ ] 3. S 20- [ ] 4. ] [ ] 5. U [ ] 6. J ______

14 P ? [ ] 1. P [ ] 2. P 2 [ ] 3. P 3 [ ] 4. P 4 [ ] 5. [ ] 6. P [ ] 7. P [ ] 8. J______

1 – 3

1 J! ! ? [ ] 1. J, , [ ] 2. S, [ ] 3. / [ ] 4. J ______

2 W ? [ ] 1. J b U 4 [ ] 2. S [ ] 3. S

3 K , ? [ ] 1. [ ] 2. S / [ ] 3. S , [ ] 4. J ______

4 G ! () !? [ ] 1. J [ ] 2. S b [ ] 3. S b 5 K , ! !? [ ] 1. «» ( ) [ ] 2. [ ] 3. S [ ] 4. J______6 K «V» , !? [ ] 1. () ZU [ ] 2. P ZU

32 [ ] 3. P [ ] 4. J // [ ] 5. S [ ] 6. J______

4 – 5

1 ? [ ] 1. J [ ] 2. S b 4 2 P ? [ ] 1. I ( ) [ ] 2. T ( ) [ ] 3. ] [ ] 4. S ( - ) [ ] 5. S [ ] 6. J______

3 !? T T U T 3_1 P 1 2 3 4

3_2 P 1 2 3 4 3_3 P 1 2 3 4 3_4 S , , 1 2 3 4

3_5 P 1 2 3 4 3_6 U 1 2 3 4 4 K : ? [ ] 1. J b 6 [ ] 2. S [ ] 3. S

5 K , ? [ ] 1. [ ] 2. S / [ ] 3. S , [ ] 4. J ______

6 G ! () !? [ ] 1. J [ ] 2. S b

33 [ ] 3. S b

7 K , ! !? [ ] 1. «» ( ) [ ] 2. [ ] 3. S [ ] 4. J______8 K «V» , !? [ ] 1. () ZU [ ] 2. P ZU [ ] 3. P [ ] 4. J // [ ] 5. S [ ] 6. J______

6 – 7

1 ? [ ] 1. J [ ] 2. [ [ ] 3. S b U 4

2 P / ? [ ] 1. I ( ) [ ] 2. T ( ) [ ] 3. ] [ ] 4. J ( - ) [ ] 5. S [ ] 6. J______

3 !? T T U T 3_1 P 1 2 3 4

3_2 P 1 2 3 4 3_3 P 1 2 3 4 3_4 S , , 1 2 3 4

3_5 P 1 2 3 4 3_6 U 1 2 3 4 4 ] ! ? ( , ) J S

34 4_2 R , , 1 2 4_3 R 1 2 4_4 R , 1 2 4_5 R 1 2 4_6 J. U, ______1 2 5 G ! () !? [ ] 1. J [ ] 2. S b [ ] 3. S b 6 K , ! !? [ ] 1. «» ( ) [ ] 2. [ ] 3. S [ ] 4. J______7 K «V» , !? [ ] 1. () ZU [ ] 2. P ZU [ ] 3. P [ ] 4. J // [ ] 5. S [ ] 6. J______

______ ______ ______V ______ ______ ______ ______P ______

P :

X , ______ . G """ 8 . " -"" " . G , 3 .. () " . G 8 -, , "" """ . 35-40 "" . -", .

"" 1. W 8 ? 3) T 4) L b

2. " . "? 1) T 2) L b

3. W " ? (G / ) 1) T 2) L b

36 ` -"" 8 - / ! ""

1 8 ? [ ] 1. T [ ] 2. L [ ] 3. G ______

2_4 2_1 L 2_2 G 2_3 W

2 [ ] 1. 18-21 [ ] 1. G [ ] 1. ` [ ] 1. P [ ] 2. 22-25 [ ] 2. T [ ] 2. Z [ ] 2. 8 [ ] 3. 26-29 [ ] 3. T [ ] 3.R. [ ] 3. T [ ] 4. 30-34 [ ] 4. L [ ] 4. L [ ] 4. [ ] 5. 35-39 [ ] 5. G [ ] 5. N [ ] 5. P [ ] 6. 40-44 [ ] 6. L [ ] 6. [ ] 7. 45-50 [ ] 7. U [ ] 7. [ ] 8. G_ [ ] 8. G ______- G______

3_4 3_1 L 3_2 G 3_3 W

3 [ ] 1. 18-21 [ ] 1. G [ ] 1. Z [ ] 1. P [ ] 2. 22-25 [ ] 2. T [ ] 2. R. [ ] 2. 8 [ ] 3. 26-29 [ ] 3. T [ ] 3. L [ ] 3. T [ ] 4. 30-34 [ ] 4. L [ ] 4. N [ ] 4. [ ] 5. 35-39 [ ] 5. G [ ] 5. [ ] 5. P [ ] 6. 40-44 / [ ] 6.

[ ] 7. 45-50 [ ] 7. G

[ ] 8. G ______[ ] 6. L [ ] 7. U [ ] 8. G ______

` -" - ""

4 ` " c 1 I 2 R/ 3 G ______4

5 W () ` 1 ` () 2

37 `" ( 1 . ) 3 P" / 4 6 X ! c 1 I 2 R 3 G ______4

7 c: W ? c 1 ] ( 1-2 ) 2 P ( ) 3 - ( ) 4 Y- ( ) 5

8 O - ? [ ] 1. T [ ] 2. L [ ] 3. G 9 O "" ? [ ] 1. 8" [ ] 2. [ ] 3. [ ] 4. [ ] 5. G ______

10 c ? (G ) (: ) [ ] 1. G [ ] 2. G "" "" [ ] 3. O( ) "" [ ] 4. G [ ] 5. G ______

11 ? [ ] 1. T, [ ] 2. L, [ ] 3. G 12 W "" ? (: 8 , , ) [ ] 1. T, [ ] 2. L,

38 [ ] 3. [ ] 4. G ______! ( )

13 G ! ( ) ? [ ] 1. T [ ] 2. L b 17- " [ ] 3. G 14 c , () ? [ ] 1. T [ ] 2. L [ ] 3. c [ ] 4. G ______

15 c , ? [ ] 1. 0 - 30 [ ] 2. 31 – 60 [ ] 3. 60 – 90 [ ] 4. c [ ] 5. G ______

16 c """ , ? [ ] 1. [ ] 2. J [ ] 3. P [ ] 4. [ ] 5. G ______ - /

17 G """"? [ ] 1. Z- (ZU) [ ] 2. `-" (I) [ ] 3. `-" (\R) [ ] 4. [ ] 5. T [ ] 6. L / [ ] 7. G ______

18 G " 2006- " " " "() ? [ ] 1. T, """ [ ] 2. P [ ] 3. S, """ [ ] 4. P"" b 20- "

39 19 W , "" , ""? TTG LTP

19_a G 1 2

19_ R 1 2

19_ R """ 1 2

""""

19_ 1 2

19_ R 1 2

19_ G ______1 2

20 W " ( )? [ ] 1. G [ ] 2. [ ] 3. ZU ( ) [ ] 4. I [ ] 5. \R [ ] 6. T [ ] 7. J, , [ ] 8. G ______

21 G , """ / " " " ? [ ] 1. T [ ] 2. L b 23- " [ ] 3. G [ ] 4. G ______

22 c " " " , ? [ ] 1. L [ ] 2. J [ ] 3. G [ ] 4. G [ ] 5. G ______

23 W ? [ ] 1. T, "" [ ] 2. - [ ] 3. b25- " [ ] 4. G b25- " 24 c , , ? P"", . 40

[ ] 1. R " -"" [ ] 2. R " , " " [ ] 3. R /" [ ] 4. R [ ] 5. R """ () ( , ) [ ] 6. G [ ] 7. G ______25 W / 8"" " ? [ ] 1. R [ ] 2. P ( ) [ ] 3. L, "" [ ] 4. `" ( -"" " ) [ ] 5. c [ ] 6. G [ ] 7. G ______X

26 W -" """ - " , """:

P" L 1-2 1-2 L c 3-4

26_a c 1 2 3 4 5 26_ 1 2 3 4 5 26_ L- 1 2 3 4 5 26_ L 1 2 3 4 5

27 W """ : T L 27_a R 1 2 27_ Y 1 2 27_ ` 1 2

27_ P 1 2

28 W " ? [ ] 1. T [ ] 2. L b 30- " [ ] 3. c [ ] 4. G ______

29 P ? [ ] 1. J " [ ] 2. J [ ] 3. J

41 [ ] 4. G ______

30 P ? [ ] 1. R " [ ] 2. P [ ] 3. P [ ] 4. c [ ] 5. G ______

31 P "" - ? P L 1-2 1-2 c 31_a c 1 2 3 4 31_ 1 2 3 4

31_ L- 1 2 3 4

31_ L 1 2 3 4

32 W - " ? [ ] 1. T [ ] 2. L b 34- " [ ] 3. G [ ] 4. G ______

33 W ? [ ] 1. G -" [ ] 2. R [ ] 3. ZU [ ] 4. // [ ] 5. G ______

34 W 8 "" - " ? P L 1-2 1-2

34_a c, , 1 2 3

34_ 1 2 3

34_ L- 1 2 3

34_ ^ 1 2 3

34_ L 1 2 3 G

35 W 8 "" ?

[ ] 1. T

42 [ ] 2. L b 37- " [ ] 3. G 36 W, """ " ? T L 36_a G ? 1 2 36_ G ? 1 2 36_ G "" 1 2 ? 36_ G - 1 2 ? 36_ G 1 2 ? 36_ G ? 1 2 36_ G 1 2

36_ G ______1 2 37 G "" " ?

T L 37_a P ( ) " 1 2 37_ - " 1 2 37_ " 1 2 37_ " 1 2 37_ G ______1 2 38 W , -"" ? (G ) [ ] 1. ZU [ ] 2. R [ ] 3. 8" [ ] 4. [ ] 5. [ ] 6. G ______

39 c (8 ) , "" ? P P c

39_a T () 1 2 3

39_ P ( ) 1 2 3

39_ G 1 2 3 39_ G ______1 2 3

40 W -""" "", ! , """" -, :( )

43 T, G L G

40_a G 40_ G 40_ G 40_ G 40_ G - 40_ G "" 40_ G "" 40_ J- "" 40_ "" 40_ G ______P /

41 W 8"" -"" " /! "" ? [ ] 1. T ------b P ?______[ ] 2. L [ ] 3. G [ ] 4. G ______42 8" - ? [ ] 1. [ ] 2. [ ] 3. [ ] 4. P "" [ ] 5. G [ ] 6. G ______43 " , 8""" "? [ ] 1. T, [ ] 2. , [ ] 3. , [ ] 4. L [ ] 1. G ______

` -"" 8 ""

44 W 8 ?

45 W 8 (""" ()) ? [ ] 1. T ______[ ] 2. L [ ] 3. c 8 , ! 46 X : ______ c 1 : ______

47 X [ ] 1. c [ ] 2. P X "" X """"

0 – 12

1 W "" ? [ ] 1. T [ ] 2. L b 4- " [ ] 3. G ______

2 P ? [ ] 1. T, """ [ ] 2. P""" , [ ] 3. P " """/ [ ] 4. G ______

3 G """ """"" ? [ ] 1. ZU [ ] 2. I [ ] 3. \R [ ] 4. G ______

4 P ( ) ? [ ] 1. T [ ] 2. L b 16- "

45 [ ] 3. G

5 c , ? [ ] 5. O / [ ] 6. O (/) [ ] 7. [ ] 8. G ______

P """? [ ] 1. "" " 6 [ ] 2. P I [ ] 3. P ZU [ ] 4. L [ ] 5. `" [ ] 6. G ______

7 W """ "" " ? [ ] 1. T, """" "" " b 9- " [ ] 2. , "" " [ ] 3. L, "" " [ ] 4. G ______

8 c , "" ? [ ] 1. P" [ ] 2. R " [ ] 3. R [ ] 4. R [ ] 5. P "" [ ] 6. G______

9 G """ ? [ ] 1. T, """ [ ] 2. L, """ [ ] 3. R """ "" [ ] 4. G ______

10 G ? [ ] 1. T [ ] 2. L

11 G ? [ ] 5. R [ ] 6. / [ ] 7. [ ] 8. L [ ] 9. G [ ] 10. G ______12 c " ? [ ] 1. T

46 [ ] 2. L [ ] 3. G ______13 W " ? [ ] 7. 3- [ ] 8. 10- [ ] 9. 20- [ ] 10. G [ ] 11. G [ ] 12. G ______14 W " - ? [ ] 1. [ ] 2. 2 [ ] 3. 3 [ ] 4. 4 [ ] 5. c""" [ ] 6. J " [ ] 7. G ______1 – 3

1 G """ ? [ ] 1. T, """ [ ] 2. L, """ [ ] 3. R """ "" [ ] 4. G ______

2 W ? [ ] 1. T [ ] 2. L [ ] 3. G

c , ? [ ] 1. G [ ] 2. P [ ] 3. G [ ] 4. G ______3 ! () ? [ ] 1. T [ ] 2. L [ ] 3. G 4 c ! , ? [ ] 1. «» ( ) [ ] 2. [ ] 3. G [ ] 4. G ______5 c «V» , ? [ ] 1. ZU () [ ] 2. ZU

47 [ ] 3. J [ ] 4. J// [ ] 5. G [ ] 6. G ______

4 – 5

1 W ? [ ] 1. T [ ] 2. L b 4- " 2 W ? [ ] 1. R [ ] 2. P ( ) [ ] 3. L, "" [ ] 4. `" ( -"" " ) [ ] 5. G [ ] 6. G ______

3 W "" ? c a S c 3_1 G 4 3 2 1

3_2 G 4 3 2 1 3_3 - 4 3 2 1

3_4 T , , 4 3 2 1 3_5 N 4 3 2 1 / 3_6 4 3 2 1 4 c : W " ? [ ] 1. T [ ] 2. L [ ] 3. G

c , ? [ ] 1. G [ ] 2. P [ ] 3. R "" [ ] 4. G ______5 ! ? [ ] 1. T [ ] 2. L

48 [ ] 3. G

6 c ? [ ] 1. «» ( ) [ ] 2. [ ] 3. G [ ] 4. G ______

7 c W «V» , ? [ ] 1. G () ZU [ ] 2. ZU [ ] 3. J [ ] 4. J// [ ] 5. G [ ] 1. G ______6 – 7

1 W ? [ ] 1. T [ ] 2. L b 4-

2 W ? [ ] 1. R [ ] 2. P ( ) [ ] 3. L, "" [ ] 4. `" ( -"" " ) [ ] 5. G [ ] 6. G ______

3 W "" ? c a S 8" 3_1 G 4 3 2 1 3_2 G " 4 3 2 1 3_3 - 4 3 2 1 3_4 T , , 4 3 2 1 3_5 N 4 3 2 1 / 3_6 4 3 2 1

4 W ! ? ( ) [ ] 1. """ "" [ ] 2. T, , " "" [ ] 3. R "" ""

49 [ ] 4. 8 "" [ ] 5. c [ ] 6. G. P"" ______5 ! ? [ ] 4. T [ ] 5. L [ ] 6. G 6 c , ? 4. «» ( ) 5. 6. G 7. G ______7 c «V» , ? [ ] 6. G () ZU [ ] 7. ZU [ ] 8. J [ ] 9. J// [ ] 10. G [ ] 11. G ______

______ ______ ______V ______ ______ ______ ______P ______

X , ______ , . G 8 . . G , 3 .. () . ^ 8 , . 35-40 . N .

3. W 8 ? 5) T ([ ) 6) O b

4. ! . ? 3) T ([ ) 4) O b

3. W ? (^ / ) 3) T ([ ) 4) O b

51 [ 8 -/ !

1 8 ! ! ? [ ] 1. T ([) [ ] 2. O [ ] 3. G ______

2_3 W 2_4 2_1 2_2 G

2 [ ] 1. 18-23 [ ] 1. [ ] 1. [ ] 1. P [ ] 2. 24-30 [ ] 2. T [ ] 2. Z [ ] 2. 8 [ ] 3. 26-29 [ ] 3. T [ ] 3.R. [ ] 3. T [ ] 4. 31-35 [ ] 4. O [ ] 4. P [ ] 4. [ ] 5. 36-40 [ ] 5. N [ ] 5. P [ ] 6. 41-45 [ ] 5. O [ ] 6. N [ ] 6. [ ] 7. 46-50 [ ] 6. G [ ] 7. G ______- [ ] 7. G__ [ ] 8. G______

3_4 3_1 L 3_2 G 3_3 W

3 [ ] 1. 18-21 [ ] 1. [ ] 1. Z [ ] 1. P [ ] 2. 22-25 [ ] 2. T [ ] 2. R. [ ] 2. 8 [ ] 3. 26-29 [ ] 3. T [ ] 3. P [ ] 3. T [ ] 4. 30-34 [ ] 4. O [ ] 4. N [ ] 4. [ ] 5. 35-39 [ ] 5. [ ] 5. P [ ] 6. 40-44 [ ] 5. O / [ ] 6.

[ ] 7. 45-50 [ ] 6. G [ ] 7. G [ ] 8. G [ ] 6. N ______[ ] 7. U [ ] 8. G ______

T -

4 c 1 I 2 R/ 3 G ______4

5 W () Y 1 Y () 2 Y ( 1 . ) 3 / 4

52 6 T ! c 1 I 2 R 3 T 4 G ______5 7 c: W ? [ 1 ] ( 1-2 ) 2 P ( ) 3 [ ( ) 4 [ ( ) 5

8 O ? [ ] 4. T ( ) [ ] 5. O [ ] 6. G 9 O ? [ ] 6. [ ] 7. [ ] 8. Y [ ] 9. [ ] 10. G ______

10 S ? (G .) (: ) [ ] 6. G [ ] 7. [ . [ ] 8. O( ) [ ] 9. G [ ] 10. G ______11 ? [ ] 4. T ([), [ ] 5. O, [ ] 6. G 12 W ? (: , , ) [ ] 5. T ([), [ ] 6. O, [ ] 7. [ ] 8. G ______

53 ! ( )

13 [ ! ( ) ? [ ] 4. T ([) [ ] 5. O b 17- [ ] 6. G 14 c [, () ? [ ] 5. T ([) [ ] 6. O ------17- [ ] 7. c [ ] 8. G ______

15 c , ? [ ] 6. 0 - 30 [ ] 7. 31 – 60 [ ] 8. 60 – 90 [ ] 9. c [ ] 10.G ______

16 c , ? [ ] 6. [ ] 7. J ; [ ] 8. P [ ] 9. [ ] 10. G ______

! - /

17 G ? [ ] 8. Z- (ZU) [ ] 9. [ (I) [ ] 10. [ (\R) [ ] 11. [ ] 12. T [ ] 13. L / [ ] 14. G ______

18 G ! 2006- ? [ ] 5. T ([), . [ ] 6. P . [ ] 7. T [ ] 8. U b 20-

19 W , ? [ OTP

19_a G 1 2

19_ R 1 2

19_ L 1 2

19_ R 1 2

19_ G ______1 2

20 W ! ( )? [ ] 9. G [ ] 10. [ ] 11. ZU ( ) [ ] 12. I [ ] 13. \R [ ] 14. T [ ] 15. J, , [ ] 16. G ______

21 G , / ? [ ] 5. T ([) [ ] 6. O b 23- [ ] 7. G [ ] 8. G ______

22 c , ? [ ] 6. O [ ] 7. J [ ] 8. G [ ] 9. G [ ] 10. G ______

23 W ? [ ] 5. T (), [ ] 6. P [ ] 7. b25- [ ] 8. G b25-

55 24 c , , ? G . ( ) [ ] 8. R - [ ] 9. R , [ ] 10. R / [ ] 11. R " [ ] 12. R () ( , ) [ ] 13. G [ ] 14. G ______25 W / T ? [ ] 8. R [ ] 9. L [ ] 10. O, , [ ] 11. Y ( - ) [ ] 12. [ [ ] 13. G [ ] 14. G ______T

26 W , :

P L 1-2 1-2 O 3- [ 4

26_a I 1 2 3 4 5 26_ 1 2 3 4 5 26_ - 1 2 3 4 5 26_ 1 2 3 4 5 ()

27 W ?: [ O 27_a R(, , …) 1 2 27_ Y () 1 2 27_ Y 1 2

27_ P (, , ) 1 2

28 W [ ! ? [ ] 5. T ([) [ ] 6. O b 30- [ ] 7. c [ ] 8. G ______

29 [ ? [ ] 5. [ ()

56 [ ] 6. [ [ ] 7. [ [ ] 8. G ______

30 [ ? [ ] 6. R [ ] 7. [ [ ] 8. [ [ ] 9. c [ ] 10. G ______

31 [ ? P L 1-2 1-2 [ 31_a I 1 2 3 4 31_ 1 2 3 4

31_ - 1 2 3 4

31_ 1 2 3 4

32 W ? [ ] 5. T ([) [ ] 6. O b 34- [ ] 7. G [ ] 8. G ______

33 W ? (P ) [ ] 6. G [ [ ] 7. R [ ] 8. ZU [ ] 9. P// [ ] 10. G ______

34 W 8 ? P L 1-2 1-2 34_a I, , 1 2 3 34_ 1 2 3 34_ - 1 2 3 34_ ^ 1 2 3 34_ 1 2 3 G ( )

57 35 W 8 ! ?

1.T ([) [ ] 4. O b 37- [ ] 5. G 36 W, ? ( ) [ O 36_a G ? 1 2 36_ G 1 2 ? 36_ G 1 2 ?

36_ G - 1 2 " ? 36_ G 1 2 ? 36_ G ? 1 2 36_ G 1 2 36_ G ______1 2 37 G ? ( )

[ O 37_a P ( ) 1 2 37_ T- 1 2 37_ 1 2 37_ 1 2 37_ G ______1 2 38 W , ? (G ) [ ] 7. ZU [ ] 8. R [ ] 9. [ [ ] 10. [ ] 11. [ ] 12. G ______

39 c (8 ) , ?

P P [

39_a T () 1 2 3

39_ P () 1 2 3

39_ G 1 2 3

58 39_ G ______1 2 3

40 W " , " , -, :( ) [, G L G 1. 2. 3. 4. 40_a G 1. 2. 3. 4. 40_ G 1. 2. 3. 4. 40_ G 1. 2. 3. 4. 40_ G 1. 2. 3. 4. 40_ G - 1. 2. 3. 4. 40_ G 1. 2. 3. 4. 40_ G 1. 2. 3. 4. 40_ P 1. 2. 3. 4. 40_ [ 1. 2. 3. 4. 40_ G ______1. 2. 3. 4.

L /

41 W [ ! /!! ? [ ] 5. T ([) ------b P ?______[ ] 6. O [ ] 7. G [ ] 8. G ______42 [ ? [ ] 7. T [ ] 8. [ ] 9.

59 [ ] 10. [ [ ] 11. G [ ] 12. G ______

43 , [ ? [ ] 5. T ([), [ ] 6. , [ [ ] 7. , [ ] 8. O [ ] 2. G ______

T 8

44 W 8 ?

45 W 8 ( " ()) ? [ ] 4. T ([) ______[ ] 5. O [ ] 6. G c 8 , ! 46 X : ______ c 1 : ______

47 X [ ] 3. c [ ] 4. P L () X

0 – 12

1 W ? [ ] 4. T ([) [ ] 5. O b 4- [ ] 6. G ______

2 [ ? [ ] 5. T ([), [ ] 6. U ,

60 [ ] 7. [ / [ ] 8. G ______

3 ^ ? [ ] 5. ZU [ ] 6. I [ ] 7. \R [ ] 8. G ______

4 [ ( ) ? [ ] 4. T ([) [ ] 5. O b 16- [ ] 6. G 5 c ? [ ] 9. O / [ ] 10. O (/) [ ] 11. [ ] 12. G ______

P ? [ ] 7. 6 [ ] 8. P I [ ] 9. P ZU [ ] 10. [ ] 11. Y [ ] 12. G ______

7 W ? [ ] 5. T ([), / 9- [ ] 6. [ , [ ] 7. O, [ ] 8. G ______

8 c , ? [ ] 7. P [ ] 8. R [ ] 9. R [ ] 10. R [ ] 11. P [ ] 12. G______

9 G ? [ ] 5. T ([), [ ] 6. O, [ ] 7. R

61 [ ] 8. G ______

10 G ? [ ] 3. T ([) [ ] 4. O

11 G ? [ ] 11. R [ ] 12. T/ [ ] 13. P [ ] 14. T [ ] 15. G [ ] 16. G ______12 c ? [ ] 4. T ([) [ ] 5. O [ ] 6. G ______13 W ? [ ] 13. 3- [ ] 14. 10- [ ] 15. 20- [ ] 16. G [ ] 17. G [ ] 18. G ______14 W - ? [ ] 8. [ [ ] 9. [ 2 [ ] 10. [ 3 [ ] 11. [ 4 [ ] 12. c [ ] 13. ^ [ ] 14. G ______1 – 3

1 G ? [ ] 5. T ([), [ ] 6. O, [ ] 7. R [ ] 8. G ______

2 W ? [ ] 4. T ([) [ ] 5. O [ ] 6. G

c , ? [ ] 5. G [ ] 6. P 62 [ ] 7. G [ ] 8. G ______3 ! () ? [ ] 4. T ([) [ ] 5. O [ ] 6. G 4 c ! , ? [ ] 5. «» ( ) [ ] 6. [ ] 7. G [ ] 8. G ______5 c «V» , ? [ ] 7. ZU () [ ] 8. ZU [ ] 9. J [ ] 10. J// [ ] 11. G [ ] 12. G ______

4 – 5

1 W " ? [ ] 3. T ([) [ ] 4. O b 4- 2 W " ? [ ] 7. R [ ] 8. L ( ) [ ] 9. O , [ ] 10. Y ( - ) [ ] 11. G [ ] 12. G ______

3 W ? T S T 3_1 G 4 3 2 1

3_2 G 4 3 2 1 3_3 T 4 3 2 1

3_4 T , , 4 3 2 1 3_5 L / 4 3 2 1 3_6 " 4 3 2 1

63 4 c : W !? [ ] 4. T ([) [ ] 5. O [ ] 6. G

c , ? [ ] 5. G [ ] 6. R [ ] 7. ^ [ ] 8. G ______5 ! ? [ ] 7. T ([) [ ] 8. O [ ] 9. G 6 c ? [ ] 5. «» ( ) [ ] 6. [ ] 7. G [ ] 8. G ______

7 c W «V» , ? [ ] 12. G () ZU [ ] 13. ZU [ ] 14. J [ ] 15. J// [ ] 16. G [ ] 2. G ______

6 – 7

1 W ? [ ] 3. T ([) [ ] 4. O b 4-

2 W ? [ ] 7. R [ ] 8. L (T ) [ ] 9. , [ ] 10. Y ( - ) [ ] 11. G [ ] 12. G ______

3 W ? T S T 3_1 G 4 3 2 1 3_2 G 4 3 2 1 3_3 T 4 3 2 1 3_4 T , , 4 3 2 1 3_5 L / 4 3 2 1 3_6 " 4 3 2 1

4 W ? ( ) [ ] 7. [ ] 8. T, , [ ] 9. R [ ] 10. T [ ] 11. [ [ ] 12. G. P ______5 ! ? [ ] 10. T ([) [ ] 11. O [ ] 12. G 6 c , ? 8. «» ( ) 9. 10. G 11. G ______7 c «V» , ?

65 [ ] 17. G () ZU [ ] 18. ZU [ ] 19. J [ ] 20. J// [ ] 21. G [ ] 22. G ______

66 Annex 3: Directive materials for the interviewers

Itinerary list

First, Middle, Last Name of Interviewer ______Interviewer’s Number______Name of settlement ______Oblast ______Rayon ______ ______

Indices of unattainability Asked Name of House Date of Needed Refused Can 3 Nobody Interrupted the street number visit person of not Sex Age at home interview is out Interview answer 1 2 3 4 5 6 7 8 9 10 11

Total indices of unattainability Number of house owners Nobody at home Refused to let in Needed person is out Can not answer Interrupted Interview

«_____» ______2007 Signature ______

67 ANNEX 3

Maternal and Child Health Focus Group Questionnaires Annex 3-Maternal and Child Health Questionnaires

Questionnaire for Mothers of Children < 1 year old February 2007

1. How old are you? 2. How old is your child? 3. Where did you deliver your child? 4. Why did you choose to deliver your child there? 5. How much weight did you gain in your pregnancy? 6. Did you eat about the same, more or less food during your pregnancy? 7. Did you have any complications during your pregnancy? If yes, what kind? 8. Did you go for postnatal checkups? If yes, where? 9. Did you take your child for a newborn checkup? 10. Are you breastfeeding now? 11. Are you giving water, formula, tea or food to the baby? 12. If yes, when did you start giving it? 13. (If over 6 months) What are you feeding your child now? How often? 14. Do you give tea to this child? If yes, how often? 15. Has this child been sick? 16. If yes, what did you do first? 17. To whom did you go for advice when the child was sick? 18. Was the child prescribed treatment? What kind? 19. Did you have any difficulty obtaining the treatment for the child? 20. How much weight did you gain during your pregnancy? 21. What did your child weigh when he/she was born? 22. Were you told you were anemic? 23. If yes, did you take iron tablets? If no, why not? 24. How many days did you and your baby stay in the maternity house after your child was born? Why? Annex 3-Maternal and Child Health Questionnaires

Questionnaire for Pregnant Women February 2007

1. How old are you? 2. How many children do you have? 3. How many months pregnant are you now? 4. How many prenatal visits have you had? Who did them? Where? 5. What kinds of examinations have you had? B/P? Weight? Sonogram? Blood test? Urine test?

6. Where do you plan to deliver your child? Why? 7. Have you been told that you are anemic? 8. If yes, are you taking iron tablets? 9. If you have complications during your pregnancy, what will you do? 10 Is it possible to obtain transportation if you have to go to the rayon hospital? The oblast hospital? ANNEX 4

ECE Focus Group Results Appendix 4-Focus Group Results and Discussion of Household Survey, Education AIYL OKMOTU

Focus group interview

Date: 9.2.2007 Participants: Heads of aiyl okmotu 7 men/1 women Age of participants: 20-50 years Amount of participants: 8 Submitted materials: No materials Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator

1. Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

I. Block: Experience of work

1. How long do you work as a head of aiyl okmotu?

2. What are urgent and important problems of families and small children in your villages? Necessity of kindergarten, no jobs

3. How do you cooperate with international organizations/project? ARIS, Actat (water running water), Mercicorp: furniture/nutrition, credit for poor families

II. Block: Status of existing kindergarten

1. How many children (0-7) are in your AO? 1 AO: 1200, existing building, existing school: 2 schedules. Rooms are available 2. AO: 2000, no buidling

2. Is there a kindergarten or other existing services for children? How many children are able to attend? Sovjet time yes, now no

3. What kind of problems do existing kindergartens have? (possible repariment) problems with financing, no possibility for salaries, transport + salary and nutrition: state; commual

4. What are the strenghts of existing kindergartens/ of future kindergartens? Difference in development of the children

5. Did you develop any community based project to support kindergartens? no Appendix 4-Focus Group Results and Discussion of Household Survey, Education III. Block: Inclusion

1. How are children from risk families covered by kindergarten? Children with social risks are not covered, responsibility on RAION level. In school: free text books. Problem of families with more children (can not pay: average: 6 children.

2. How many children with special needs live in your AO?: no information available

3. To which extent these children attend preschool establishments? Example of one mother who took 10 children with disability

IV. Block: Community based kindergartens

1. Do you have community based kindergarten? How many? No, only state kindergarten, 3% of children attend: 150 Som/month. Not all can pay Kindergarten only for rich people

2. How did you establish them? (irrelevant)

3. How do you finance them? (irrelevant)

4. Which kind of ressources did you need for it or would you need for it? (irrelevant)

5. What is the role of the parents in creating a community based kindergarten? Parents are ready to do something (examples of own initiatives)

6. What are parents able to contribute/What is AO able to contribute? Parents will contribute: bed. Important: examples, how to do it.

7. Which kind of structure/model does your AO need? a) full day b) half day c) at a certains person home d) during summer/winter e) should the service be mobile? f) Should it be a Mother school where mothers get “training”?

8. How do you see the position of AO in terms of LisencingAttenstation, selection of staff and quality control of a community based kindergarten? No information available

V. Block: Cooperation

1. Which help/cooperation do you need to establish/run a community based kindergarten - from the community - from social worker - CFC - resource kindergarten - raion educational department - oblast educational department

Community is ready, AO will support with building and communal costs There is poitilical will of the AO In kind contribution by parents Double budget: opportunities for AO? (too many problems): seen as formal possibility. Important for AO to decrease differences (poor/rich). AO has planning process Appendix 4-Focus Group Results and Discussion of Household Survey, Education

2. How should this support look like (in conrete way): activities, responsabilities, resources, training etc… 1) Building 2) Evaluate repairment (+ external support) 3) Furniture/Equipment 4) Availability of former teachers 5) Provision of Nutrition

3. What kind of program/document could help you, in planning your cooperating work? Information, how to do it, examples This is 1st time to talk about it Parents will not refuse initiatives

VI. Block: Improving Care and Education in the AO

1. By what means the situation of care and education for families in your AO could be improved? Kindergarten, vital necessity of kindergarten (development of the children)

2. Who (parents, Social workers, CFCs) need which information? Information how to start a kindergarten for the parents

3. How should this information been distributed? Somebody to come, to tell them

VII. V. Is there some important, which you want to tell us about child education and care

High expectations, tell us, how to start Telephone number of Oblast coordinator

VIII. VI. Do you have some questions towards us? Appendix 4-Focus Group Results and Discussion of Household Survey, Education

CFC EXPERIENCE

Focus group interview

Date: 7.2.2007 Participants: CFC of 1-st Project Age of participants: 20-50 years Amount of participants: 7 persons: 4 women, 3 men Submitted materials: Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator

1. Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

I. Block: Experience of work

1. As a CFC, for which activities were you responsible?

Development of children, parents training. 1st research (how many children), 2nd training

2. Which activities do you assess as successful (and how did you see the success)? Information about care, health nutrition, information about pregnancy. Change opinion of family, young parents don’t know how to care.

3. In which activities you were faced with problems? Where to make training, transport costs have to be covered privately

4. How do evaluate the training you participated? Everything was good, small groups, knowledge about children, 10 days

5. What are needs of families and small children in your villages? Need for a Kindergarten

I. Block: Organization of work as CFC (preparation/activity/cooperation))

1. What kind of tasks and activities should be changed according to your experience working with community and families within the 2nd ADB project? How to reach the village, transport on their own expenses (800 Soms salary)

2. What do CFCs need for their work? (Professional preparation? Equipment, educational materials/aids? Working contracts (as they finished)

3. How and regarding which contents CFC’s should be trained? Something new to change attitudes of parents Basic education of the CFCs: Technical expert (infrastructure); doctor, teacher, marketing expert, lawer, ingenieur, book keeper Appendix 4-Focus Group Results and Discussion of Household Survey, Education

4. How do you evaluate the material which you were working with? (Training book for parents, Material for VIF…) Books are good, they should be simple.

5. Where and how it would be most efficient to conduct training for parents (based on kindergarten, school, AO)? Important to do together, Most effective in FAP Or AO, together with social workers, in builings of FAPs

6. How do you see the role of CFC in community based kindergartens establishing/in cooperation with i. resource kindergarten ii. AO iii. Raion Educational Department iv. Oblast Educational Department?

Till now not much contact, question how to cooperate. Information by ressource Kindergarten how to organise and start kindergarten, as CFCs did not have adequate information how to establish a community based kindergarten

I. Block: Community mobilization

1. What does Community need to initiatives on Early childhood and Care? Support from the state is necessary

2. What CFC can do for community mobilization? Information about planing process. AO should organize this, they have the know how.

II. V. Is there some important, which you want to tell us about child education and care

It is not realistic, that all the costs are covered by community. Regarding Parent training: 20 groups were planned, 11 performed (9 groups not possible because of finished contract). Parents are interested, but disappointed, that there was no training.

2 Community based kindergarten are planned, now under repairment. Financial issues will be solved afterwards with AO. In 3-4 months the kindergartens will be opened

How long does it need, that Community starts with kindergarten: 2,5 years.

What is needed: village meetings

Concrete steps: v. find a building vi. study the priority needs of repairment vii. Decision of the AO to give building/land viii. Community contribution (20.000 Soms) in terms of natinal input ix. Important: Mobilisation of parents

III. VI. Do you have some questions towards us? Appendix 4-Focus Group Results and Discussion of Household Survey, Education

EDUCATIONAL DEPARTMENT

Focus group interview

Date: 8.2.2007 Participants: Inspector of Educational department Aravan Age of participants: 20-50 years Amount of participants: 1 persons (raion level), 2 persons Oblast Submitted materials: No materials Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator

Plan

1. Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

I. Block: Experience of work

1. How long do you work in department? 4 months

2. What are urgent and important problems of preschool education in your villages? No factory, agricultural society, field work. Level of live very low. Children are working after school on the market. Open issue, who takes care of them? Parents are busy with work.

3. Do you cooperate with international organizations/project? Some projects (Aga Khan)

I. Block: Status of existing kindergarten

1. How many children (0-7) are in your raion/oblast? 137.046

2. How many kindergartens do you have? How many children there? 4 kindergarten in Raion center, There could be observed some difficulties about statistics with municipality kindergarten (5 to 8)

3. What kinds of problems do exist regarding kindergartens? Urgent necessity of kindergarten and material problems

4. Did you help to develop any project to support kindergartens? Parents initiative, took old equipment. 1 or 2 rooms in school, equipment was here Appendix 4-Focus Group Results and Discussion of Household Survey, Education I. Block: Inclusion

1. Are children from risk family covered by kindergarten? Poor children in terms of kindergarten attendance are privileged

2. How many children with special needs are in your raion/oblast? No info available

3. To which extent they are attending preschool establishments? No info available

I. Block: Community based kindergartens

1. Do you have community based kindergarten? How many? Yes there are some, but it is general policy to promote kindergartens, to prepare for school (Oblast level). Any form can be promoted.

2. Do you help to finance them from state budget? Oblast educational department is not directly involved in financing 1)Community collects money 2) Looking for donors 3) Kindergarten can be supported by AO 4) Can be included in “state budget”

Number of kindergarten discussed: Osh: 21 (11 seasonal) Okat: 10 Aravan 10 (5 state, 5 municipal) Karakulja: 3: 2 state, 1 community

3. What kind of difficulties do you see in community based kindergarten organization? Financing: 1st project: Home based kindergarten: 1 teacher opened: a home based PEO and took children home: 3x/weed, 10 som/child, 20 children (=200 som).

4. What kind of resources could you provide from your position (community based kindergarten, preschool classes, school based group)? Training by the teacher qualification institute

5. What kind of resource is effective and optimal for your population and village (buildings etc.)? Issue of quality control has to be considered, they should work good

6. How do you assess the qualification of the preschool teachers? Teachers asks school to help, teachers should know about sanitary norms

7. How could be organized the training of the kindergarten teachers in future in an effective way? AO should pay per diem, Problem is transport Appendix 4-Focus Group Results and Discussion of Household Survey, Education

I. Block: Resource kindergarten work

1. How do you see the position of state kindergartens in terms of resource centers? In terms of the methodological cabinet Resource kindergarten should use the materials

2. What kind of criteria could be optimal for state kindergarten as resource centers? Methodological knowledge, the level must be high

3. What do they need and which kind of activities they should perform? Issue of transport

I. Block: Cooperation with raion and oblast educational departments

1. How your activity can help in preschool education promotion? Strategy support. Problem of different strategy between kindergarten and school. School expects preschool to prepare for school. Preschool defines itself in a different way (learning by playing)

II. Block: Bases for authorities

1. What kind of activities (meetings, seminar work) could help you in issues on ECD? To increase knowledge

2. What is your role (and others) in the monitoring process on preschool education development? Some parents do not believe in the effects of kindergarten, they are busy, financial problems. Learning through TV (only Kirgiz television),no books

3. How could you perform efficient quality control? This should be discussed with in the framework of the new standards

4. How should be organized the licensing system? i. permission from AO (Material, space, salary, financial issues) ii. permission from raion financial department

5. What kinds of support does community need Educational Department for kindergarten establishing? Difficult question Low salary for teacher, Community based kindergarten can work, if there is a law

III. Block: Role in community mobilization

1. How can you support community mobilization from your position? In terms of Strategically support

I. Block: Normative legal support

1. What kind of normative documents, programs, regulations could help in your work ? No information up till now Appendix 4-Focus Group Results and Discussion of Household Survey, Education II. Is there some important, which you want to tell us about child education and care

Parents need i. Building ii. Material for repair iii. The strategy must be, to have kindergarten under budget.

III. VI. Do you have some questions towards us?

INSTITUTE OF TEACHER QUALIFICATION

Focus group interview

Date: 5.2.2007 Participants: Main responsible person/director Age of participants: 50 years Amount of participants: 2 persons Submitted materials: No materials Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva

1. Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

I. Block: Experience of work

1. What is the role of the teacher training center regarding preschool education? Coordination of 3 oblasts, offering training courses (6 course: day courses, evening courses. Training of all preschool teachers + certificate. Long experience. Preschool faculty closed in Osh, only institution for training

2. Do you cooperate with international organizations/project? Aga Khan provided material, partly salary for courses paid (400 Som/day). Normally 10 Som/hour for external lecturers

3. Which kind of training are you offering for whom? 2 courses for 3 weeks 3 courses for 2 weeks for state kindergarten and private courses are free of charge for participants

4. How do you assess training needs of the professionals? Teachers provide a list of suggestions = basis for next courses Some teachers from AO come and ask for concrete training (problem of transport costs, partly living, Institute has some flats) Training needs based own initiative

5. How are you financed? Institute: state financed, problem of materials. Salary: 1.300 Soms Trainers: 10 som/hour (Aga Khan: 400/day) Appendix 4-Focus Group Results and Discussion of Household Survey, Education 6. Which kind of methodological/didactical approaches do you use? Training in terms of interactive approaches, exam + practice in kindergarten

7. Regarding qualification of preschool teachers, what is the biggest challenge in the training? Material basis, received material from Aga Khan, now material base is a problem

8. Government tries to improve the quality of training for preschool teachers. How can this be done? Through state programs. Mother School, Russian Programs

9. What is necessary to reach this goal? Very qualified trainers and material

10. How could be organized the training of the community based kindergarten teachers in future in an effective way? Teachers come here, problem of transport cost and per diem. There is a possible new strategy of the new director to create regional institutes

I. Block: Cooperation

1. How do you assess the cooperation with resource kindergartens? They see themselves as a resource centers, equipped by Aga Khan. Teachers can come and see/use the materials during training. Way of cooperation is open

2. How do you assess the cooperation with raion/oblast educational departments? Internal quality control within the Institute: exams. External by the educational department (child oriented, if child reaches the goals)

3. How do you see your cooperation with AO? Problem of co financing by parents: in OSH 300 Som/parents; villages: sometimes 5 Som. Problem of transport costs

4. How do you see your cooperation with Kyrgyz Academy? Trainers come once a year, give lectures, they should come more often

5. How do you see your cooperation with other donors (Aga Khan, Step by Step) Activities of Aga Khanare very much appreciated

I. Block: Role in community mobilization

1. How can you support community mobilization from your position? Promoting the idea and the importance of community based kindergarten

I. Block: Normative legal support

1. Which kind of normative documents, programs, regulations could help in your work? They have heart about new state standards, they are ready to implement, but up till now, need of information Appendix 4-Focus Group Results and Discussion of Household Survey, Education

I. Is there some important, which you want to tell us about child education and care Importance of training, ready to do something

II. VI. Do you have some questions towards us?

PARENTS Focus group interview

Date: Participants: Parents of preschool children 9 men/8 women, 3 professionals Age of participants: 20-50 years Amount of participants: 17 Submitted materials: Blocks Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator

Introduction: Tasks and reasons of meeting, what will happen with data. 1. Interview 2. Brief review of interview results 3. Farewell

Block: Child care and education

1. Who usually cares of your child? Mother

2. Where did you learn to care for your child? Grandmother

3. What does it mean “to care” for your child 6 children, caring “by the way”, caring= hygiene, wash the hands, to ask, poems, stories, Parents dream of good education Health professionals: To play, to Give attention

4. Do you need further information on care and development? In which way? Very important in terms of seminars, TV, TV not enough. Seminars

5. Who is performing which activity with your children? -> if activities of father are missing -> ask for father Mothers are doing and other siblings, Fathers: help to make housework, story telling

6. Are there episodes, when it is difficult to organise somebody to care for your child and your child stays alone and do you need a service for these times: Seen on the street!

Block: Developmental environment

1. What about toys at home? Which toys, books for children, things for painting? Some have toys, normally no books Older children care for the younger ones. Mother is busy. Difficult during season: older children to work on the Appendix 4-Focus Group Results and Discussion of Household Survey, Education field.

2. How do you teach your child hygiene (clean teeth, wash hands etc.)? Which of your children have own tooth brush? How to wash hands or face

3. What is important for your child to learn during these first years of live? Age: 0-1; 2-4 years, 5-6 years To prepare for school Comprehensive development education

4. If your child misbehaves, how do you react? Fathers: slight slapping “It is for the good” of the child

5. What does your child need to be happy? Comprehensive development (nurse), Education, Toys, equipment Books should be organised by AO, FAPs

Block: Relation to preschool education

1. Is it important for the child to attend kindergarten? Should be obligatory What to learn: preparation for school, letters, to count, hygiene, schedule of the day, social skills. Answers mostly given by professionals)

2. Do your children attend it? -> Where do you see the quality of the kindergarten? --- (no kindergarten closed 25 years ago

3. If not: Would you like your children to attend a kindergarten? yes

4. If yes: how it could be organised: a) full day (parents busy all the day) b) half day c) at a certain person home d) during summer/winter e) Should the service be mobile? f) Should it be a Mother school where mothers get “training”?

5. How do you see the payment? (How much/in which way could you contribute?) 1) to find building (there are empty buildings) 2) repair

Constraints: Impossible to pay 200 Som like in city Not more than 100 Som parents payment Better to give material (blankets, toys, matraces, everybody could give something) There are teachers, who have no work and could work as preschool teachers Appendix 4-Focus Group Results and Discussion of Household Survey, Education

IV. Community Mobilisation

1. How can you support the idea to create a kindergarten in your village?

Information about existing ideas Repair of Buildings, every parent will give something Support for repair

2. Which kind of support do you expect from AO? AO should be initiative (e.g. In terms of community mobilization)

Is there some important, which you want to tell us about child education and care

Importance of knowledge transfer (VIF), how to apply AO after the project can think, how it goes on AO could provide communal costs, nutrition Coverage of salaries is not possible; Salaries could be included in the plan of budget.

Do you have some questions towards us? When does 2nd ADB project start, who is responsible person? Appendix 4-Focus Group Results and Discussion of Household Survey, Education

PRESCHOOL TEACHERS

Focus group interview

Date: 5. + 7.2.2007 Participants: Head of a Kindergarten (children of parents with Tuberculosis), Head of community based kindergart Kulja Age of participants: 55 Amount of participants: 2 persons+ kindergarten teachers Submitted materials: Resource book for kindergarten teacher Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator of 1st project

1 Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

III. Block: Experience of work

1. How long do you work as a teacher? A: Very long, the only kindergarten for children of parents with tuberculosis. Children stay for 6 months, day and night. In soviet time it was closed, later opened. Salary from state, nutrition from Mercy Corp Now change of status, support through 1st project: COW, Piloting income generating

B: Kindergarten based on initiative of former kindergarten teacher

2. What is your education? Since 70ies working in the kindergarten, now director

3. What is your salary? Usually salary of kindergarten teacher: 1000,- Som (30 USD)

4. Which staff is working in the kindergarten? Nurse, Feldsher (3h/day)

I. Block: Conditions of existing kindergarten

1. How is the ratio staff/children, how big are the groups? 2 groups (younger: 20 children), older: 20 children. Wish to have a 3rd group

2. On which normative basis is the kindergarten working? NGO , but financing partly from state

3. What are necessary material conditions in the kindergarten (repair, heating, furniture etc)? 1st project: repair, Mercycorp: roof. Now necessary furniture. Appendix 4-Focus Group Results and Discussion of Household Survey, Education 4. Do you have enough educational materials, what is missing? No program, no material. Teacher produce material by themselves

5. Does nutrition in kindergarten meet the nutritional needs of the children? International aid (mercycorp). From state budget: 40 Som. Based on 1st project: income generating experimental model ( cow, goat) AO gives land

6. What is the payment for the child per month? no

7. Do you cooperate with health professionals to monitor health of the children? Feldsher: every day 3 hours, financed from state budget (vitamins, prophylaxis) Children leavers after 6 months go, open where they go.

I. Children coverage

1. Are children from risk family covered by kindergarten? Do they have privileges for payment? Some children without parents

2. How many children with special needs are in kindergarten? Some with physical problems

3. Since what age children attend your kindergarten? Early group + older group

I. Professional preparation

1. Which qualification courses did you have during the last three years? --- B: some information (TV available, music teacher available)

2. What kind of program do you use for education? State base program. No material

3. Do you know how to prepare teaching aids or toys for children? Yes

4. Do you have methodical literature, issued during last 5 years? ---

5. Are all necessary administrative documents available for you (health report, medical card of the children, TOR….)? Medical documents primarily No contacts with parents (as they are sick)

6. How do you define quality of your educational work in your kindergarten? Problem with tuberculosis Education Physical development Health and hygiene Appendix 4-Focus Group Results and Discussion of Household Survey, Education 7. In which subject do you need professional training, how it should be organised? Self production of training material Gymnastic exercises Language development Trainers should come from Arabaeva

I. Block: Resource kindergarten work

1. Which kind of help could provide a resource center for you? A: Unfortunately No contact B: some contacts

I. Block: Cooperation with raion and oblast educational departments

1. How raion and oblast educational departments cooperate with you? Raion budget (?)

I. Block: Work with parents

1 How do you cooperate with the parents? No because of disease

-How often do you meet with parents to talk and discuss some issues? -What do you discuss? - Do you tell them about aspects of children development? - How do parents help kindergarten? - Do they do material support? - Do you cooperate with them to solve some problems? - What kind of their support do you need? - What issues are important for parents (on which they should get consultations, training)?

II. Block: Cooperation with authorities

1. Does AO support you (financially etc.)? How did you organise the support? Providing building, land for cow, animals (from 1st project)

2. How is the kindergarten financed? Salary: state Communal (AO: land) Donations

3. Which kind of support does the kindergarten need from AO for establishing? Interagency cooperation

I. Block: Cooperation with international organizations

1. Did you try to get help from international organizations? Mercycorp 1st ADB project

2. What kind of help do you need? Material Appendix 4-Focus Group Results and Discussion of Household Survey, Education

II. Block: Role in community mobilization

3. How can you – as a kindergarten teacher - contribute to community mobilization? Find solution for consumables, material, heating

III. Block: Normative legal support

1. Which kind of normative documents, programs, regulations could help in your work? ---

I. V. Is there some important, which you want to tell us about child education and care

Books for the teachers Books for parents helped

II. VI. Do you have some questions towards us? Appendix 4-Focus Group Results and Discussion of Household Survey, Education

RESOURCE KINDERGARTEN WORK

Focus group interview

Date: second part of January, 2007 Participants: preschool teachers of a) resource kindergartens of the 1-st Project, b) state kindergartens in target raions of 2-d Project (without block 1.) Age of participants: 20-50 years Amount of participants: 7 persons (4 teachers, 1 director) Submitted materials: no materials Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator

1. Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

I. Block: Experience of a work

1. What does it mean from your point of view to be a resource kindergarten? TV, repair of building, selected within raion

2. Which kinds of activities are connected with the status as resource kindergarten? Should do training

3. What criteria for selection are existing (to become a resource kindergarten)? Kindergarten was famous in Soviet time, chosen from 3 without competition, good methodogical center, all teachers’ high education.

I. Block: Organization of resource kindergarten work with community based kindergarten

1. What kind of tasks and activities should be implemented by resource kindergartens supporting community based kindergarten? CB teacher will come

2. Which kind of support do community based kindergarten from your point of view? Community based kindergarten = important, help to organize community based

3. How often this support activity should be planed? First: 1 week, then once a month

4. Which kind of resources do resource kindergartens need for this task? Need methodological material, literature. TV just standing, no tapes

5. How many resscource kindergartens are needed? (e.g. in a raion?) 1 Appendix 4-Focus Group Results and Discussion of Household Survey, Education

6. What is the benefit, to be a resource kindergarten? Parents trust more, 150 children

7. What are the “costs/disadvantages to be a resource kindergarten? --

8. Training of kindergarten teachers of the community based kindergartens was 1 task of the resource kindergarten: there were major problems regarding knowledge transfer to community based kindergartens: why? How to produce materials, teacher should come 1 week, then every month (costs of transport is open issue: no public transport, need to take a taxi)

9. How to solve these problems in future? They can come, it is just problem of transport

10. How do you see teachers training organization and system of training work? Qualification center in OSH

I. Block: Organization of resource kindergarten work with families

1. How can resource kindergarten support families in the community/villages? e.g. by means of Mother school, resource kindergarten organises half day for 2-3 months for 15 children

I. Block: Cooperation with raion and oblast educational departments

1. What kind of support and activity raion and oblast educational departments do for you? Quality monitoring, information Indicators of quality: Health, Nutrition, Education

2. What kind of their help is necessary? For teachers training, work with family? In work with AO?

I. Block: Cooperation with local authorities

1. How do you cooperate with local authorities? Importance of AO, financing from state department

2. What kind of support from them do you need to work as a resource kindergarten? Material

I. Block: Cooperation with social workers/CFC

1. Are you familiar with the work of CFCs (under 1st ADB CBEDCP?) Yes, they were present, Resource kindergarten gave information, how to organize and start a kindergarten.

2. Which kind of support do you expect from them? Cooperation in the village

II. Block: Role in community mobilization

1. What can resource kindergarten do for community mobilization? Training Appendix 4-Focus Group Results and Discussion of Household Survey, Education

2. How should resource kindergarten cooperate for this work with educational departments, AO, social workers, international organization etc.? Important is, that all work together

I. Block: Normative legal support

1. What kind of normative documents, programs, regulations could help in your work as resource kindergarten? They have medical card Parents contribution: 120 Som Average income: 1000 Som

I. Is there some important, which you want to tell us about child education and care Mercicorp (nutrition: monitoring was here), repair, electricity (unfortunately transformator does not work. ADB: Television (necessity of methodological videos, one produced by themselves)

Voluntary fond of the teachers for further qualification (10 Som/month)

II. VI. Do you have some questions towards us? Appendix 4-Focus Group Results and Discussion of Household Survey, Education

SOCIAL WORKERS

Focus group interview

Date: 6.2.2007 Participants: Social workers in target raions Age of participants: 20-50 years Amount of participants: 4 persons Submitted materials: Experts: Dr. M. Pretis, Dr. L.Gagarina, Dr.E.Omuralieva Assistance: oblast coordinator

1. Introduction: Tasks and reasons of meeting. 2. Interview 3. Brief review of interview results 4. Farewell

III. Block: Experience of work

1. How long are you working as a social worker? 5-6 years

2. With how many families are you working approximately? 240 families/social worker

3. What kind of activities do you implement with family and children of early age? Social passport, monitoring of conditions of life Families with high risks: provision of financial support land (50% rent, credit)

4. What kind of professional preparation do you have? What subject did you have on ECD? no specific education: 1 cultural manager, 2 book keeper , 1 other

5. What kind of problems do you have in your present work? Distance, far villages, low salary (800 Som)

6. What are urgent and important problems of families and small children in your villages? Alcoholism, many children, small donations, no certificate of birth, birth at home, problems with documents (e.g. pension…)

I. Block: Community based kindergartens

1. Which needs regarding community based kindergartens do you observe in your AO? Families which are not working might not be interested, cannot pay

2. Which models of services (home based, mobile, community based) are necessary from your point of view? Full day Appendix 4-Focus Group Results and Discussion of Household Survey, Education 3. How these services should be organised?

4. How do you see the situation of socially disadvantaged families (e.g. regarding kindergarten attendence, payment of kindergarten fees..) See above

5. Community based kindergartens, how they should be financed?

State budget, AO, parents, support for very poor parents

II. Block: Capacity building

1. Which needs regarding knowledge on Early Childhood Childhood do you observe in families? Families have many children (up to 6), social workers see difference between now and soviet time. 6 of 10 parents could pay. Kindergarten could be example for mothers.

2. How could these needs be covered? Active mothers, former teachers

3. What can you contribute from your function as social worker? Information Education Consultation

Till now: no perspective, therefore no activities (helpless parents)

4. What do you need to be better able to support parents regarding their children’s needs? Perspective, budget

III. Cooperation with CFCs

1. Do you know about activities of CFCs in your AO? No relevant as raion not covered by 1st project

2. How do you see the cooperation between social work and CFCs? No relevant as raion not covered by 1st project

3. From your point of view, how can the work of CFCs in future be more efficient? No relevant as raion not covered by 1st project

4. What do they need (e.g. training, monitoring, higher mobility, material) No relevant as raion not covered by 1st project

5. How do you see role of CFC in community based kindergartens establishing? No relevant as raion not covered by 1st project

I. Block: Cooperation with resource kindergarten in work with families

1. In which kind of tasks and activities do you cooperate with resource kindergarten? No relevant as raion not covered by 1st project, no resource kindergarten Appendix 4-Focus Group Results and Discussion of Household Survey, Education I. Block: Cooperation with raion and oblast educational departments

2. How do you assess your cooperation with raion and oblast educational departments? They could show examples of kindergartens

I. Block: Cooperation with local authorities

1. What kind of support from AO do you need to work as a social worker?

2. What kind of support or structure does the community need from AO to establish kindergarten? Exemples, information, perspective

I. Block: Role in community mobilization

1. How can you support community mobilisation? Preparation for school

I. Block: Normative legal support

2. What kind of normative documents, programs, regulations could help in your work as CFC? No information available

II. Is there some important, which you want to tell us about child education and care

III. VI. Do you have some questions towards us? Appendix 4-Focus Group Results and Discussion of Household Survey, Education Preliminary analysis of the household survey (based on raw data and tables) regarding education and care show:

Among the 1,155 households involved in the survey, 1155 children were selected within the study: 130 children (age under 1 year), 422 age 1-3 years, 328 children age 4-5, 270 children age 6-7, 4 children over 7 years. The total number of children under age 8 in the households were 2211.

Of the selected children 52.8% were boys and 47% were girls. 3.3% (37) of the children showed special needs: mainly cerebral palsy (32%), leg-problems (12%). For 2 children speech problems were reported, 2 children suffered hearing problems.

86.4% of the interviewed women are unemployed, 68.3% of the fathers

Information on Education and Care

89.9% of the interviewed parents would like to receive information on development and education for their child under 8.

In specific,1017 wanted information about how to bring up the child in a healthy way, that the child stays healthy. 977 want to learn how to create a safe surrounding for the child to ensure his/her security. 957 want to learn how they can understand their child and his/her needs. 991 want to learn how to teach good manners to your child to behave well.

813 want to learn how they can support the child attending a kindergarten, 962 how to prepare your child to enter school, 994 about children rights.

84.6% Would like to receive information regarding development of your child through books or brochures. Almost three quarters of the parents would like to receive information through parent training, 92.8% through TV programs.

Only half of the parents (53.1) prefer radio programs in order to be informed. For 9 parents also other media (DVD and video) could be used.

Especially professionals from the health sector (FAPs' staff in 39.9% of the answers and Health workers 35.5%) could provide this information.

Activities with the children

The most frequent activities that parents shared with their children (at least once a month) are were watching TV (88.%), teaching hygiene (86.5%), correcting misbehaviour (76.4%), telling fairy tales (75.3%), reading books (68%), singing songs (59%), teaching letters and numbers (53.9%) and taking children outside (park, playground etc.) to perform some specific child related activities (53.9).

“Teaching” activities of the parents with their (preschool) children age 6-7

Almost all of those parents (97.7%) having children age 6-7 report that they teach their children to speak correctly. Again 94.4% teach how to read, count or draw. 246 parents out of 266 (92.5%) talk about the school with their child age 6-7. 94% (249) teach their child to be self- dependent. Only 39 parents (16.9%) say, that they do nothing with their child.

Punishment

94.4% of the parents (1076) report that they punish their child at least sometimes verbally. Only 52 parents never punish their child, when misbehaving. Appendix 4-Focus Group Results and Discussion of Household Survey, Education More than 7 out of 10 parents punish their child at least sometimes physically. More than half of the parents (53.5%) do not permit their child to do something, when misbehaving.

Importance of kindergarten

82.9% (n=1155) assess the attendance of a kindergarten as important. For employed mothers the importance of enroling a child in a kindergarten program is slighty higher than for unemployed mothers (in terms of working primarily in the household) Appendix 4-Focus Group Results and Discussion of Household Survey, Education Most (69.9%) said that a kindergarten is important because the child can learn more than at home. 15.9% of the parents assess a kinderarten important, because the children need somebody to look after them. 7.2% highlight the trained specialists in the facilities, 5.8% the importance of peer interaction. Only 6.4% point out, that a kindergarten is not important. Unemployed mothers rate the neccessity of a kindergarten slightly lower than employed mothers.

Existence of a kindergarten

278 parents (24.1%) report that there is a state kindergarten in the village or AO. 1.1% that there is community based kindergarten. For 7 of 10 parents there is no kindergarten in the village or AO.

Attendance of kindergartens

At the current moment within the 4 target raions 50 children out of 599 (age 3-7) attended a kindergarten (8.34%). Including 20 children, who at the moment of the survey did not attend a kindergarten, but were enroled before in a program, the attendence rate (age group 3-7years) increases up to 11.68%.

In terms of available sociodemographic data (including all preschool children age 0-7, see facility data) the attendance rate within the 4 target raions is 6.1%.

Wish to enrol children in kindergartens (Age 1-3)

Among 410 children (age 1-3) only 39.8% of the parents plan to enrol their children in kindergarten. However, more than the half of parents (54.4%) of this age group do not plan to enroll their children in kindergarten. Among these 223 parents not planning to send their children to kindergarten, the large majority (83.5%) indicated that there was no facility available.

Another common reason why the child might not be enroled in kindergarten was because the family had no money (9.6%). Only 14 respondents (5.6%) think that it is not necessary.

Wish to enrol children in kindergartens and attendance rate (Age 4-5)

88.2% (291) of the children did not attend a kindergarten or any preschool program. Only 11.8% or 43 children of the 330 children age 4-5 were enroled in a service. Mostly they were in state kindergartens (83.7%), only 4 children were in a community based kindergarten, 1 child in a private and 1 in a home based form.

Respondents say, that the major reason (81.9%) for not enrolling the child in a kindergarten is that there is no kindergarten in the village. 9.7% report shortage of money and only 7.1% or 11 parents think that a kindergarten is not important for their child.

Attendance rate (Age 6-7)

88.5% (238) of the children did not attend a kindergarten or any preoschool program. Only 11.5% or 31 age 6-7 are recently or were enrolled in a service. Mostly they were in state kindergarten (86.4%), only 3 in a home based form. Appendix 4-Focus Group Results and Discussion of Household Survey, Education Assessment of the quality of the service

Age 4-5

Nearly ninty percent of 39 respondents with children in kindergarten or preschool programs said the quality of childcare is at least poor. Only 4 parents assess it as at least good.

Also regarding the teaching program parents report low satisfaction: 30 out of 39 assess the quality of teaching programs as at least poor, only one fifth of the parents finds the quality of provided nutrition as alt least good.

Assessed quality of toys, books, equipments is slightly better: “Only” 63.4% say, that the quality is at least poor. One third of the 39 repsondents assesses toys, books etc. as at least good.

The quality of the buildings is assessed as at least poor by 62.5% of the parents (39). Profesionalism of the staff also is rated at least poor by a large majority: by 90.3% of those parents with children age 4-5 attending a kindergarten.

Age 6-7

Seventy five percent of 20 respondents with children in kindergarten or preschool programs said the quality of childcare is at least poor. Only 5 parents assess it as good.

Also regarding the teaching program parents report low satisfaction: 16 out of 20 assess the quality of teaching programs at least poor, almost half of the parents finds the quality of provided nutrition as at least good.

Assessed quality of toys, books, equipments is slightly better: “Only” 61.1% say, that the quality is at least poor. One third of the 20 respondents assesses toys, books etc. as good.

The quality of the buildings is assessed as at least poor by 72.2% of the parents (20). Profesionalism of the staff also is rated at least poor by a large majority: by 90% of those parents with children age 6-7 attending a kindergarten.

Parent and Family Involvement in community mobilisation regarding Education and Care

8 of 10 respondents (954) reported that they never heard about programs/activities designed for families and children and taking place in your Aiyl Okmotu. 145 parents (12.6%) do not know, whether they heard or not. Only 53 parents (4.6%) were infomed about such activities. 3 parents were infomed about new year holiday, 2 about Tazalyk and about ulzk or ordo.

However, parents do not assess Aiyl Okmotu's work aimed at improving the well-being of children in the village very helpful: More than half of the parents (596 out of 1155) said, that “they do nothing”, for 100 parents (8.7%) AO is “not so helpful”.

For every fifth parent Aiyl Okmotu's work aimed at improving the well-being of children in the village at least helpful (21.4%). More than the half of the parents (55.8%) would be interested to participate in programs or activities for parents if they will be offered for you. More than one forth would probably participate (27.4%). ANNEX 5

Social Sector Questionnaire Annex 5, Social Sector Questionnaire

Questions for interviews with heads/officials of Raion Administrations

I. Introduction (background information, goals of the interview…)

II. Interviewing (7 thematically divided blocks of questions)

Block 1. General Information

1. Please, tell me how big is the group of poor and vulnerable population in your raion? 2. What are the main reasons (factors) for poverty in your raion? 3. What characteristics do you use to identify poor and socially vulnerable groups of population? 4. What are the main needs of poor households? 5. On your opinion, what are the possible ways to solve problems of poor households? 6. What is the ethnic composition of the population in your raion? 7. What is gender composition? 8. How big is the proportion of households with children of preschool age, headed by one breadwinner: single mother/single father?

Block 2. Children not attending preschool institutions

1. Do you have information about children not attending preschool institutions in your raion? 2. Can you name major reasons (factors) for not attending preschool institutions by children under age 8? On status of poverty On factor of ethnicity On status of household’s head On gender status On geographical location Other reasons - …?

Block 3. Children with special needs

1. Do you have information on children with special needs in your raion? What categories of such children do you have? (Disabled on vision, hearing, locomotor system, mental development delay, other - ?) Are they registered? Where? Do you have any activities on preparation such children for receiving an education? Is it possible to attend preschool institutions by such children?

Block 4. Inequality issues

1. Do you think the problems of social inequality are important among the population of your raion? Is the income gap big enough among population? Does factor of ethnicity impact on inequality? Is there inequality on geographical location among AOs? Annex 5, Social Sector Questionnaire 2. Does inequality among the population impact on chances of families in their access to ECD services, such as kindergarten, clubs, educational programs, medical services, adequate nutrition? How do the following factors contribute to their chances? Poverty - ? Ethnicity - ? Gender - ? Geographical location -? Status of the head of household - ? Other factors that impact on unequal access to ECD services.

Block 5. Awareness of population on ECD

1. How can you describe the level of awareness of population on ECD issues? 2. Awareness among poor and vulnerable households? 3. What are the main sources of information on ECD among population? 4. Do you think this information is accessible and full for parents of children under 8 and population in general? (Please, specify) 5. Do you think that pregnant women are sufficiently aware on adequate nutrition, issues on reproductive health, new-born babies’ and infants’ care?

Block 6. Paying capacity of the population

1. On your opinion, how much money do families with small children usually spend for their development and education? What are the opportunities/capabilities of poor families for their contribution in development of preschool age children? On your opinion, what is the demand for services on preschool development and education of children among poor families? Are they ready to pay for such services if there will be new opportunities and programs in their AOs?

Block 7. Possible ways and strategies of community’s participation

1. On your opinion, what are the ways for increasing awareness on ECD among poor households with children of early age? 2. What kind of projects might be initiated in your raion for improving services on ECD? 3. Are there active groups of local people in your raion that would support initiatives on improving situation with ECD? (Please, specify) 4. How it is possible to succeed and improve the situation on the following: On decreasing infant’s and children’s mortality - ? Improving nutrition of children and pregnant women - ? Physical and psycho-social development of children of early age - ? Preparedness of children for entering school - ?

III. Conclusion ANNEX 6

Results of the Baseline and Final Knowledge, Practice and Coverage Survey and Health Facility Assessment Results, Project Hope’s USAID Jalalabad Child Survival Project 2001 – 2006 Annex 6: Baseline and Final Knowledge, Practice and Coverage survey and Health Facility Assessment results, Project Hope’s USAID Jalalabad Child Survival Project, 2001-2006.

Base- Final Target Source Indicators line Survey 2003 2006 1 % delivery notes are made according to partograms; 0% 80% 50% HFA % of normal deliveries, and post delivery observation 2 are managed in accordance with adapted WHO’s 12% 84% 50% HFA protocols. % obs/gyns use adapted WHO’s protocols on management and treatment of pregnant women with 31 high risk (hestoza hypertension/pre-eclampsia, bleeding 27% n/a 55% HFA during pregnancy, delivery, after delivery and infections) % pregnant women are managed according to adapted 4 46% 79% 70% HFA WHO’s protocols % of health-providers consult women on danger signs 52 during pregnancy; delivery, post-partum, neonatal 10% 66.9% 60% KPC period, which require immediate medical care-seeking. % of women know about the danger signs during 6 pregnancy; delivery, post-partum, neonatal period, 31% 66.9% 70% KPC

Maternal and Newborn Care 30% which require to seek immediate medical assistance % of men know about the danger signs during 7 pregnancy; delivery, post-partum, neonatal period, 13% 36.8% 40% KPC which require to seek immediate medical assistance % of mothers know at least two Vit A containing 1 14% 57.8% 50% KPC products % of women taking Vit A supplementation (200, 000 2 0% 54.4% 80% KPC IU) immediately after birth % of children 6-71 months receiving two Vitamin A

Nutrition 15% 15% Nutrition 3 0% 75.5% 80% KPC

Maternal & Child Maternal & supplements per year 1 % of newborns breastfed within 30-60 minutes of birth 43% 84.1% 70% KPC % of infants breastfed exclusively for the first 6 months 2 13% 71.1% 50% KPC of life 10% % of persistent breastfeeding of children ages 9-23 3 61% 70.1% 90% KPC

Breastfeeding Breastfeeding months

1 The Project worked with MoH to revise national protocols to WHO standards. Protocols were not approved by MoH at the time of the survey; therefore data wasn't collected 2 Result of KPC survey of women of reproductive age’s knowledge on danger signs during perinatal and neonatal period. Base- Final Target Source Indicators line Survey 2003 2006 % of trained providers at polyclinics and FPG Centers 1 0% 71.4% 70% HFA will demonstrate adequate use of IMCI guidelines

% visiting nurses provide adequate consultation to 23 0% 86.1% 30% KPC mothers on danger signs in children under 5 years

% health-providers know at least 2 danger signs in sick 3 33% 100% 65% HFA children

IMCI % health-providers record the height growth of child and 4 0% 80.9% 50% HFA consult on physical development problems of children % of population at the household level informed about 5 47% 86.1% 80% KPC danger signs in children % of targeted population at the household level are 6 informed about the main principles of sick child care at 0% 84.8% 80% KPC home % children from 0 till 23 months sick with diarrhea 1 during the last two weeks are treated ORT or home 12% 90% 60% KPC available liquids % health-providers provide adequate consultations to 2 mothers on how to treat sick children under 5 according 0% 100% 50% HFA IMCI strategy

10% % mothers refer to health-facilities with children under 3 22% 57.5% 50% HFA 23 months sick with diarrhea % visiting nurse provide training for mothers on 44 management diarrhea cases at home, according IMCI 0% 69.1% 30% KPC

Control of DiarrhealDiseases strategy Increase 0% of mothers who seek medical care for child from 0 till 23 months with symptoms of ARI/pneumonia 1 35% 81.5% 70% KPC (strong cough and difficult breathing) for the last two weeks % mothers know 2 and more dangers of ARI/pneumonia 2 47% 86.1% 70% KPC in children under 5

10% % health-providers know 2 and more dangers of 3 33% 100% 65% HFA ARI/pneumonia in children under 5 % children from 0 till 23 months with signs of pneumonia received appropriate health facility-based 4 0% 75.6% 50% KPC treatment according IMCI strategy and mothers receive

Pneumonia Management Case adequate counseling on ARI/pneumonia

3 Result of survey of population knowledge on danger signs in children. 4 Results of mothers' knowledge of home-based care of child under 2 sick with diarrhea. Base- Final Target Source Indicators line Survey 2003 2006 % visiting nurses provide counseling on danger signs of 55 0% 86.1% 30% KPC pneumonia % population at the household level are informed about 6 0% 95% 80% KPC ARI/pneumonia % of mothers/caretakers who know at least 3 diseases 1 27% 71% 60% KPC that can be prevented by immunization % health-providers consult mothers with children from 0 2 25% 85.7% 50% HFA 5% till 23 months in immunization % visiting nurses consult targeted population in 36 0% 71% 30% KPC Immunization immunization % of adolescents can site two or more modern 1 23% 60.5% 60% KPC contraceptive methods % of adolescents know where to obtain modern 2 45% 74.5% 65% KPC contraceptive methods % of men who can site two or more modern 3 54% 84.2% 70% KPC contraceptive methods % of men and women who use modern contraceptive 4 47% 80.9% 65% KPC

Child Spacing 10% methods Source: Project Hope Jalalabad Child Survival Project Final Evaluation Report. 2006.

5 Results of mothers’ knowledge of dangers of ARI/pneumonia among children under 2 6 Results of mothers’ knowledge of immunization in children under 2 Needs Assessment Report - Second Community Based Early Childhood Development Project

TABLE OF CONTENTS

1 EXECUTIVE SUMMARY ...... 1 2 INTRODUCTION...... 3 3 METHODOLOGY...... 5 3.1 Objective, Scope and Coverage ...... 5 3.2 Instruments ...... 5 3.2.1 Household Survey ...... 5 3.2.2 Interviews, Discussions and Other Instruments ...... 8 4 BRIEF SUMMARY OF HOUSEHOLD SURVEY FINDINGS AND THE SITUATION OF THE RAIONS ...... 10 5 RESULTS AND CONCLUSIONS OF NEEDS ASSESSMENT...... 24 5.1 Maternal and Child Health...... 24 5.1.1 Maternal and Child Health Situation in Kyrgyzstan ...... 24 5.1.2 Needs as Perceived by the Beneficiaries...... 29 5.1.3 Access to Health Care...... 30 5.1.4 Quality of MCH Services ...... 34 5.1.5 Coordination within the Health System ...... 36 5.1.6 Health Workers’ Performance ...... 36 5.1.7 Pregnancy: Knowledge, Attitudes, Practices and Risk Factors...... 38 5.1.8 Child Caretakers Knowledge, Attitudes and Practices ...... 41 5.1.9 Major Conclusions and Recommendations...... 46 5.2 Mother and Child Nutrition ...... 48 5.2.1 General Nutritional Problems in the Country...... 48 5.2.2 Malnutrition and Chronic Energy Deficiency ...... 49 5.2.3 Micronutrient Deficiencies ...... 51 5.2.4 Breastfeeding and Complementary Feeding...... 56 5.2.5 Causes of Malnutrition and Micro-Nutrient Deficiencies...... 57 5.2.6 Major Conclusions and Recommendations...... 60 5.3 Early Child Care and Education (ECCE)...... 62 5.3.1 The Current ECCE Status ...... 62 5.3.2 Child Care Practices at Home and in the Community ...... 64 5.3.3 Access to ECCE services...... 67 5.3.4 Quality of the PEO Services...... 70 5.3.5 Constraints in PEO development ...... 71 5.3.6 Major Conclusions and Recommendations...... 73

ANNEX 1: Questionnaire ANNEX 2: Household Survey Report ANNEX 3: Maternal and Child Health Focus Group Questionnaires ANNEX 4: ECCE Focus Group Results ANNEX 5: Social Sector Questionnaire ANNEX 6: Results of the Baseline and Final Knowledge, Practice and Coverage Survey and Health Facility Assessment Results, Project Hope’s USAID Jalalabad Child Survival Project, 2001 – 2006

EPOS/IB/GOPA March 2007 I Needs Assessment Report - Second Community Based Early Childhood Development Project

TABLES:

Table 1: Selected raions and sample size for each raion ...... 7 Table 2: Schedule of training for interviewers ...... 8 Table 4: Numbers of households surveyed by AOs...... 10 Table 5: Presence of a father of children under 8 in a family...... 13 Table 6: The willingness of mothers to receive ECD information specified by topics ...... 21 Table 7: Ways of receiving the ECD information ...... 21 Table 8: Differences in classification of dead infants prior and after transition to WHO criteria ...... 26 Table 9: Neonatal Mortality by Weight (grams) in 4 Rayons in Osh Oblast. 2006 ...... 27 Table 10: Monitoring results of numeracy, literacy and life skills in 2001 and 2005 (UNICEF, 2006 page 74). . 62 Table 11: Average scores of test results by category of candidates...... 63 Table 12: Percentage of Attendance in PEO in Osh, Batken and Jalalabad Oblasts ...... 68

FIGURES:

Figure 1: Age of mothers and fathers surveyed ...... 13 Figure 2: Education of mothers and fathers ...... 14 Figure 3: Mothers’ and fathers’ employment status ...... 14 Figure 4: Mothers’ scope of activities...... 15 Figure 5: Fathers’ scope of activities...... 15 Figure 6: Ethnicity of parents surveyed...... 16 Figure 7: Clean/drinkable water in the household...... 17 Figure 8: Awareness of the population on the importance of iodine for health...... 17 Figure 9: Reasons for using iodized salt...... 18 Figure 10: Distribution of medical facilities to which respondents applied for assistance for their children...... 19 Figure 11: Nutrition of children under 8...... 20 Figure 12: Participation of mothers/parents in the activities on the education of children within a family ...... 22 Figure 16: Percentage of households that use solid fuels for cooking by region. Kyrgyz Republic, 2006...... 29 Figure 13: Percentage of children aged 0-59 months, examined at public health institutions with suspected pneumonia. Kyrgyz Republic, 2006...... 42 Figure 14: Percentage of children aged 0-59 months with suspected pneumonia, who received antibiotics treatment. Kyrgyz Republic, 2006...... 43 Figure 15: Percentage of mothers informed about two dangerous symptoms of pneumonia based on their education level. Kyrgyz Republic, 2006...... 43 Figure 18: Malnutrition among Under-Fives in Kyrgyz Republic according to UNICEF MICS 2006 ...... 49 Figure 19: Nutritional Situation of Under-Fives in Oblasts according to UNICEF MICS 2006 ...... 50 Figure 20: Prevalence IDD per 100.000 population ...... 52 Figure 21: Frequency distribution (%) of urinary iodine level in schoolchildren of Kyrgyzstan (2000-2001) ...... 52 Figure 22: Prevalence of ID per 100. 000 population ...... 54 Figure 23: Deficiency of vitamin A (in %) among Under-Fives in Karasuu raion, Osh oblast and Naryn raion, Naryn oblast ...... 55 Figure 24: Lifecycle: the causal links ...... 57 Figure 25: The “Window of Opportunity” for Improving Nutritions is very small pre-pregnancy until 18-24 months of age...... 58 Figure 17: Development of the Number of Preschools and Number of Children in the Kyrgyz Republic ...... 67

EPOS/IB/GOPA March 2007 II Needs Assessment Report - Second Community Based Early Childhood Development Project

ABBREVIATIONS

ADB Asian Development Bank ADRA Adventist Development and Relief Agency AO Aiyl Okmotu ARI Acute Respiratory Infections BCG Bacillus Calmette-Guerin (vaccine for tuberculosis) CBECDP Community Based Early Childhood Development Project CED Chronic Energy Deficiency CFC Child and Family Coordinator CFG Consulting Finance Group DHS Demographic and Health Survey EBF Exclusive Breast Feeding ECD Early Childhood Development ECCE Early Child Care and Education FAP Feldsher Accousher Point FGD Focus Group Discussions FGP Family Group Practice FMC Family Medicine Center FTI Fast Track Initiative GMP Growth Monitoring Promotion IDD Iodine Deficiency Disorders IDA Iron Deficiency Anemia IMCI Integrated Management of Childhood Illnesses JFPR Japan Fund for Poverty Reduction KAP Knowledge Attitude and Practices KPC Knowledge, Practice and Coverage survey LBW Low Birth Weight Rate MCH Maternal and Child Health MCN Maternal and Child Nutrition MDGs Millennium Development Goals MHIF Mandatory Health Insurance Fund MICS Multiple Indicator Cluster Survey MoE Ministry of Education MoH Ministry of Health NFNP National Food and Nutrition Policy NGO Non-Governmental Organization NPAN National Plan of Action for Nutrition ORS Oral Rehydration Salt PEO Preschool Educational Organizations PEPC Promoting Effective Perinatal Care PHC Primary Health Care PLA Participatory Learning for Action PMO Project Management Office PPTA Programme Preparatory Technical Assistance RMIC Republican Medical Information Centre SPSS Statistical Product and Service Solution TA Technical Assistance TACIS Technical Assistance for the Community of Independent States TH Territorial Hospital UNICEF United Nations Children’s Fund VAD Vitamin A Deficiency VIF Village Initiative Fund WHO World Health Organization WRA Women of Reproductive Age

EPOS/IB/GOPA March 2007 III Needs Assessment Report - Second Community Based Early Childhood Development Project

1 EXECUTIVE SUMMARY

1. Since March 20004, the First Community Based Early Childhood Development Project (CBECDP) is implemented in the Kyrgyz Republic with funding from the Asian Develop- ment Bank (ADB). An agreement to prepare a follow-on project, the Second CBECDP, has been reached between the Government of the Kyrgyz Republic and ADB in 2006. The first on-going CBECDP aims at contributing to the improvement of early childhood development (ECD) services in the Kyrgyz Republic covering (i) Child Health and Nutrition; (ii) Children’s Psychosocial Development through Early Childhood Care and Education; and (iii) Child Care at Home and in the Community through Capacity Building. The Second CBECDP will be built on and further develop the interventions carried out during the first phase.

2. In the framework of the Program Preparatory Technical Assistance for the Second CBECDP a needs assessment study was carried out by the team of national and international consultants. The results of this study are presented in this report. The objective of the needs assessment study was to identify the problems of young children, their families and the community with regard to Early Childhood Development (ECD), and the constraints that frontline workers, including health care workers, preschool teachers, and social workers, are facing in delivering ECD services.

3. The needs assessment study is based on an analysis of secondary data, a household survey, and systematic qualitative research to assess (a) the ECD status and problems related to ECD of the target populations in the selected raions; (b) child care practices at home and in the community; (c) access by children and families to ECD services, which include health care, preschool education programs, and social protection; and (d) constraints faced by the families and health care, preschool, and social workers. The needs assessment consists of sub-sector analyses in Maternal and Child Health (MCH), Maternal and Child Nutrition (MCN), as well as Early Child Care and Education (ECCE). Each sub- sector found areas that must be resolved if an effective ECD project is to be implemented in the Kyrgyz Republic.

4. In the MCH sector the following major needs were identified: mothers from rural areas encounter several obstacles to appropriate treatment. Barriers to healthy maternal outcomes are often categorized by the “4 delays”: Delays in recognizing danger signs of pregnancy, delays in taking action once the danger is recognized, delay in arriving at a facility with adequate maternity services, and delay in receiving appropriate services once at the health facility. Poor neonatal outcomes, in spite of skilled facility deliveries, point to significant deficits in the quality of medical care provided in the facility during and after the delivery. With the exception of remote rural areas, beneficiaries generally have a relatively high access to health services through the long established network of health facilities. However, the quality of these services suffer from outdates or unnecessary practices, high staff turn over, lack of appropriate laboratory support, and a lack of opportunities for health workers, particularly in Feldsher Accousher Points (FAPs), to upgrade their skills. Efforts to improve MCH services are hindered by unreliable data and limited capacity and empowerment to make decisions and act upon this data at the peripheral levels.

5. Beneficiaries in remote and poor areas have great difficulty in accessing essential drugs. Efforts are underway to reduce this problem through existing Ministry of Health (MoH) mechanisms and by establishing new local, private sector Non-Governmental Organiza- tions (NGO). However, the MoH and international partners must also more critically address the long term, national issue of supervising and monitoring the quality of the drugs and the pharmacies providing them.

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6. For MCN there needs to be a fresh look at the appropriateness of current nutrition-related programs, against the background of national as well as international policies and strategies. The MCN needs assessment examined ways to improve the health, nutrition and psychosocial development of children, from birth to 8 years of age – albeit in a holistic and multi-sectoral perspective. There is a great need for an assessment of the characteristics of the stunted child and its family, to arrive at appropriate interventions and behavioral change messages which are do-able, both from the providers’ and the clients’ perspectives. Iron deficiency anemia (IDA) is the most prevalent and severe nutritional problem in the country. It most likely affects the whole population and not only pregnant mothers, infants and preschool children.

7. In the ECCE sub-sector the primary needs identified are related to a lack of kindergartens in the villages. Although the parents were very interested in education for their children there was a shortage of financial resources to accomplish the needed establishment of the kindergartens. Some Aiyl Okmotus (AOs) are more innovative than others in finding ways to establish the programs for children. Often former kindergarten teachers from Soviet times are the catalysts behind innovation, but these former teachers will disappear within the years to come. There is a substantial need for the parents to enroll their children in kindergarten or preschool programs. Currently, this need cannot be satisfied, primarily due to a lack of preschool educational organizations (PEOs) in rural areas.

8. In addition, an analysis of poverty and capacity building found that poverty, especially in the remote rural areas, presents one of the largest challenges in both education and health in those areas. A lack of employment perspectives causes migration and disruption that could be avoided with adequate jobs in the rural areas. There is great potential for young women-mothers to be mobilized to provide innovative programs and in many AOs, this is already happening.

9. The problems identified in the needs assessment will be addressed in the Policy and Sec- tor Analysis which will lead to a strategy and the project design for the Second CBECDP. The Mid-Term Review Workshop following the Policy and Sector Analysis will serve as the forum for discussion of the key problems identified and the sector strategies developed with government and the major stakeholders. The findings of the needs assessment and the sector analysis as well as the outcomes of the mid-term review workshop will lead to the development of a final project design for the Second CBECDP.

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2 INTRODUCTION

10. Early Childhood Development (ECD) is focusing on the physical and psychosocial development of children during the first several years of life and comprises child health care, nutrition, preschool education and capacity building. There is growing evidence of the importance of ECD to human development, as children who are healthy, stimulated and well nurtured during their first years of life tend to do better in school and have a better chance to lead a healthy and independent life. With the collapse of the former Soviet Union ECD services in the Kyrgyz Republic were downscaled essentially and the ECD situation deteriorated largely as a consequence of the economic crisis and the declining social services. The first ADB financed CBECDP, which started in March 2004, therefore aims at arresting the deterioration in ECD and is contributing to the improvement of ECD services in the Kyrgyz Republic.

11. The first CBECDP covers the following aspects: (i) Child Health and Nutrition; (ii) Chil- dren’s Psychosocial Development through Early Childhood Care and Education; and (iii) Child Care at Home and in the Community through Capacity Building. Because the loan for the first CBECDP was small ($10.5 million equivalent), its community-focused activities covered only the 12 poorest raions, while it has also nation wide activities including vaccine support.

12. The Government of the Kyrgyz Republic requested TA from ADB to prepare the Second CBECDP. The TA is included in the Kyrgyz Republic’s country strategy and program up- date for 2006–2008, and was programmed for 2006. Fact-finding for the TA was carried out already in January–February 2006, and an understanding reached with the Govern- ment on the TA’s impact and outcome, scope, cost and financing, and implementation arrangements.

13. The impact of the TA will be to improve the health, nutrition, and psychosocial development of children up to 8 years of age. The outcome of the TA will be a project design that will achieve this impact and is compatible with ADB financing requirements. The TA out- puts are (i) a needs assessment of the targeted population, (ii) a policy and sector analysis and training, and (iii) a project designed for ADB financing. According to the Terms of Ref- erence (ToR) four key principles shall guide the TA, namely: (i) the targeting of the poor; (ii) participatory project development; (iii) an integrated life-style approach and (iv) sustainability.

14. The TA started in November 2006 with the Inception Phase, during which the Team Leader conducted first briefing meetings with major stakeholders. In December 2006, the Inception Phase was concluded with the Inception Workshop during which the outline of the TA was presented to and discussed with major stakeholders. Already existing thematic working groups on (i) MCH, (ii) MCN, and (iii) ECE were revitalized during this workshop through breakout working sessions in which major problems in the respective area were discussed with working group participants.

15. From December 2006 until February 2007 the needs assessment, including a household survey, analysis of secondary data, focus group discussions as well as key informant interviews, was carried out. The questionnaire for the survey was designed by the expert team, but the conduction of the survey was outsourced to a local research company, which was subcontracted for this purpose. The needs assessment covers major ECD areas, namely MCH, MCN, ECE and Capacity Building.

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16. The present report presents the findings of the needs assessment. Chapter 3 describes the methodology applied during the needs assessment. The results of the household survey are briefly summarized in chapter 4. Major findings and conclusions from the needs assessment related to MCH, MCN and ECE for the Second CBECDP are presented in chapter 5.

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3 METHODOLOGY

3.1 Objective, Scope and Coverage

17. The objective of the needs assessment is to identify the problems of young children, their families, and the community with regard to ECD, and the constraints that frontline workers, including health care workers, preschool teachers, and social workers are facing in delivering ECD services.

18. The needs assessment study is based on the analysis of secondary data, a household survey, and systematic qualitative research to assess (a) the ECD status and problems related to ECD of the target populations in the TA raions; (b) child care practices at home and in the community; (c) access by children and families to ECD services, which include health care, preschool education programs, and social protection; and (d) constraints faced by the families and health care, preschool, and social workers.

19. The needs assessment was carried out in the three oblasts of the Kyrgyz Republic, Bat- ken, Jalalabad, and Osh, and in 9 raions which have been initially selected as target raions for the community-based interventions of the Second CBECDP. The criteria for the selection of raions are (i) that raions have a poverty level above 50% in the Social Pass- port Data, (ii) that they were not included in the First CBECDP, and (iii) that no similar projects are currently implemented in the raions. According to the first two criteria, the following nine raions have been selected preliminarily: Batken Oblast: Kadamchai, Leilek, Bat- ken; Jalalabad: Bazaar-Korgan, Nooken, Aksy, Suzak; Osh: Aravan, Uzgen. A final selection of oblasts and raions to be covered in the framework of the Second CBECDP will be made once the collection of information on similar projects carried out in the raions has been finalized.

3.2 Instruments

20. For the needs assessment, a mix of quantitative methods (household survey), qualitative methods (focus groups and interviews with various experts and key personnel), and a review of secondary data were conducted. Each sector – MCH, ECCE and MCN – used the qualitative methods of focus groups and interviews somewhat differently and to varying degrees depending on the situation and location. There is a wealth of secondary data prepared by the Government of the Kyrgyz Republic, NGOs and various international organizations. This data was used to the extent possible and whenever suitable to avoid duplica- tion of previous efforts and to accomplish the maximum assessment within the time available.

3.2.1 Household Survey 21. The household survey was conducted in January and February 2007 by a Bishkek based social research firm, Consulting Finance Group (CFG), which was selected after reception and evaluation of the proposal of CFG and one other research company. CFG has existed since 2000 and has experience in social and political research, marketing, diagnostics of financial situation of companies, development of strategic and business plans, consulting on fundraising and investments, human resource management, and PR-consulting. The complete survey report is attached as Annex 2 to this report. The survey results were made available to the expert team for their needs assessment and the findings and results of the survey are reflected in this report.

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Questionnaire Design 22. The household survey questionnaire (Annex 1) was designed by the national and international health, nutrition, and education experts and PMO specialists. Information received during the inception workshop, where education and health professionals and managers from twelve pilot regions took part, also was taken into consideration during preparing the questionnaire.

23. Specialists of each sector prepared and suggested the scope of their questions for as- sessing needs related to their sectors (health, nutrition, preschool education and ECD). However it was impossible to include all suggested questions since the duration of one interview should not exceed 40-45 minutes. After intensive discussions with international and local specialists, PMO staff, ADB and EPOS, the questionnaire was finalized and approved in December 2006.

24. The questionnaire consisted of a total of 82 questions and was divided into several sub- sectors:

Information on parents/guardians of children (3); Questions on socio-economic situation of the family (4) Iodized salt consumption (5); Anemia (4); Access to medical facilities and drugs (6); Kindergartens (3); Nutrition (9); Children’s development (6); Community capacity (3); Information on children under 8 in the family and selected child (4) Age specific questions: - 0-12 months (14); - 1-3 years (6); - 4-5 years (8); - 6-7 years (7).

Sampling 25. It was decided to choose four raions from the nine target raions, two in Batken oblast, one in Osh oblast and one in Jalalabad oblast. In Batken oblast two raions out of three were selected, Batken and Kadamjai. Batken raion was selected as it is the poorest raion with a poverty level of 67.0%. Kadamjai (59.4%) and Lailak raions have almost the same poverty level. However Lailak’s location was not suitable for conducting the survey due to difficulties in reaching the raion. There are two (Uzbek and Tajik) border-control check points for those who go from Batken center to Lailak.

26. In Osh oblast out of two possible raions for the survey Uzgen raion was chosen due to the highest poverty level - 58.0%. In Aravan raion the poverty level is 51.5% and this raion is located very close to Osh city (20 km), which gives more opportunities for local population to access health and education services.

27. In Jalalabad oblast Suzak raion was chosen (poverty level 52,4%).This is the largest raion in the oblast with the highest density of population. The raion is multinational and a geographically mountainous region where people have specific needs compared to people living in villages located in the plain

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28. The survey was designed as structured interviews in randomly chosen households with at least one child under age 8. In the ToR for the research company it was recommended that the survey covers all 57 AO and the sample size in each AO should correspond to the size of the population according to recommended scheme:

In AO with less than 500 households – 5 interviews 500 – 1.000 households – 10 1.000 – 2.000 households – 20 More than 2.000 households – 25

Table 1: Selected raions and sample size for each raion Oblast Raion Nr. of households surveyed Batken Batken 210 Batken Kadamjai 315 Osh Uzgen 335 Jalalabad Suzak 295 Total 1155

29. The total sample size for the needs assessment survey was 1.155 households. The target group for the interviews included households with children under age 8. Interviews were conducted with mothers who have at least one child under age 8. Since the situation with primary schools is not among priority tasks of the ECD Project, it was recommended not to include in the survey children who had already started attending primary school.

Preparation Phase and Pilot Testing 30. During the preparation phase the questionnaire was translated into the Kyrgyz and Uzbek languages, 1.320 copies of the questionnaire were printed and the routes, program and handouts for the trainings were prepared. More than 60% of AOs were informed about the survey. Information on the families with early age children was requested from 40% of AOs.

31. With the aim of improving the questionnaire it was field tested by conducting pilot interviews. Pilot interviews were undertaken January 21-23 in Aravan raion in Osh oblast. In total 14 interviews were conducted in households in the villages of Pakhta, Nurabad, Kakir Piltan, Kairagach, Langar in Nurabad and S.Yusupova AOs. As a result of the pilot interviews the questionnaire was finalized by adjusting some aspects such as wording and adding additional options for the possible answers.

Training of the Interviewers 32. During training conducted in each selected raion interviewers were introduced to the project’s objectives and survey’s tasks. In total 60 interviewers were trained and instructed on how to select respondents, how to ask questions, to visually test salt, fill the questionnaire, etc. At the end of each training session the participants conducted several mock interviews which allowed them to understand the process of interviewing more accurately.

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Table 2: Schedule of training for interviewers Nr. of inter- Date Place viewers trained

January 28 Batken raion 12 In Batken oblast administration office block January 29 Kadamjai raion 14 In office of raion administration January 30 Uzgen raion 13 In Kurshab AO’s office January 31 Suzak raion 21 In Jalalabad State University’s research center

Control of the Survey Process 33. On February 1-4 the social scientist of the team visited all four raions to observe the survey process. In each raion temporary offices were rented where supervisors were collect- ing filled questionnaires and route lists; controllers were checking the questionnaires and controlling interviews in villages. Among difficulties were the remoteness of some villages and long distances between them. In general the respondents were open to answer the questions asked and demonstrated their hopes for improving the situation with ECD and receiving actual help.

3.2.2 Interviews, Discussions and Other Instruments 34. Qualitative data was collected through the use of focus groups and key informant interviews involving parents, medical workers, and educational personnel. In addition, Gov- ernment officials at the oblast, raion, and AO level were interviewed.

Maternal and Child Health 35. A series of key informant interviews and limited focus groups were held by both the international and national experts during field trips to the target raions. The results of these interviews are included in the narrative needs assessment and not listed separately. Infor- mation was triangulated with quantitative and qualitative findings from similar studies and programs recently implemented in the Republic. The qualitative interviews were important in supplementing the quantitative data from the household survey. The interviews were held with parents, health workers and other officials necessary to arrive at a determination of the needs in MCH for the 9 target raions.

36. There were four focus groups conducted, 2 focus groups of pregnant women and 2 groups of mothers of children under 2 years of age in Suzak Raion, Jalalabad Oblast. The questions for these focus groups are shown at Annex 3. The child health expert also conducted one focus group with health personnel at Jalalabad Oblast Hospital maternity house and conducted several interviews with maternity house and FAP personnel in Osh Oblast. Relevant findings from the MCN assessments that were conducted in Batken and Osh Oblasts, especially related to anemia, were integrated into the MCH findings.

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Early Child Care and Education 37. Focus groups and interviews were administered by semi-structured interview guidelines. Parents were asked about care and education, access to ECD services, community mobilization and information. Heads of AOs were primarily asked about the situation on preschool services, community mobilization, cooperation and financing. Preschool teachers and training institutions were asked about the current status on ECD and the situation regarding preschool services (including quality management). Administration was asked about community mobilization, implementation strategies and training needs. Activities were undertaken with the involvement of national and international specialists. Focus groups on ECCE were administered in the target oblast (Osh) in Kyrgyz, Russian and English.

38. The focus group interview for the parents was piloted and tested with a group of parents (n=12) in Bishkek on 4 February. Raions for focus groups were selected based on the poverty rate (Social Passport) and logistics (distance). Uzgen Raion had a poverty rate of 58%, while Aravan had a poverty rate of 51,5%. Annex 4 reflects the details of the focus groups for the education sector and discussion of survey data.

Table 3: Participants and location of ECCE focus groups Number of # Focus group Date Place participants

Deputy of Osh oblast administration, heads of 1 3 February 5 Osh city Uzgen, Karakulja raion administration Coordinator of the 1-st CBECDP, head of spe- 2 cific community based kindergarten (children of 2 February 5 Osh city parents with tuberculosis) Head preschool faculty of Institute of Teachers’ 3 Qualification, director of Institute of Teachers’ 2 February 5 Osh city Qualification Jylaldy (Uzgen raion), 4 Heads of aiyl okmotu 9 February 6 1 in Aravan 5 Social workers 4 February 6 Jylaldy (Uzgen raion) 6 Parents 17 February 6 Zarger (Uzgen raion) Head and preschool teachers of resource kin- 7 7 February 7 Kara-Kulja raion* dergarten of 1-st CBECDP* 8 Child and Family Coordinators (CFCs) 7 February 7 Kara-Kulja raion* Osh-Raion,Kara-Kulja Head and preschool teachers of Community 9 10 February 7 raion* based kindergarten Aravan Raion educational departments Aravan, Kara- 10 6 February 8 Osh city Kulja, and Osh oblast raion department * - to assess the needs of resource kindergarten, CFCs, community based kindergarten due to the fact that in the new target raions there are no resource kindergartens, that TA-team performed the focus group in the target raion of the 1st CBECDP.

Mother and Child Nutrition 39. Field visits were made to the three selected oblasts and to one raion and one FAP per oblast for key informant interviews, focus group discussions and when time permitted, house visits. The interviews and focus groups were conducted by both international and national experts.

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4 BRIEF SUMMARY OF HOUSEHOLD SURVEY FINDINGS AND THE SITUATION OF THE RAIONS

40. The survey was conducted in all AOs in Batken, and Suzak raions. One AO in Kadamjai and 7 AOs in Uzgen raions were skipped due to the difficulties in reaching them (most remote villages are located on a long distance between each other, or in mountainous places). However, the total number of interviews collected during the survey corresponded to the planned sample size.

41. The data received as a result of interviews in households were entered and analyzed in Statistical Product and Service Solution (SPSS). This report is mostly descriptive and includes frequencies of received responses, cross tables, diagrams, and comparisons.

Table 4: Numbers of households surveyed by AOs Number of Number of house- Oblasts Raions Aiyl Okmotus households holds surveyed Batken Batken Batken city 5305 25 Dara 1868 20 Karabak 2898 25 Kara Bulak 2738 25 Suu Bashy 970 9 Kyshtut 1803 21 Samarkandek 2130 26 Tort Gul 1150 20 Ak Tatyr 1292 19 Ak Sai 1275 20 Total 210 Kadamjai Kadamjai city 2558 11 Orozbekova 3102 39 Kotormo 1943 20 Khaidarkan 2552 25 Birlik 1939 20 Kyrgyz Kyshtak 1140 24 Sovetskii 269 10 Alga 1619 25 Khalmion 3210 25 Markaz 2201 26 Kara-Dobo 2475 32 Uch-Korgon 5500 27 Maidan 2321 26 Chauvai 330 5 Total 315 Osh Uzgen Kyzyl Oktyabr 1803 32 Karool 1941 31 Jalpak-Tash 1129 20 Jazy 1612 21 Don-Bulak 1729 24 Bash-Dobo 990 30 Tort-Kol 1810 20 Jylaldy 1311 25

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Number of Number of house- Oblasts Raions Aiyl Okmotus households holds surveyed Ak-Jar 1210 17 Kurshab 2521 55 Myrza Ake 2152 35 Salam-Alik 1112 25 Total 335 Jalalabad Suzak Suzak 5261 25 Kara Daria 2413 25 Barpy 4037 25 Tash Bulak 2475 25 Yrys 4189 25 Atabekov 4409 25 Kyz Kol 2264 25 Kyzyl Tuu 4188 25 Bagysh 3302 25 Lenin 1457 20 Kurmanbek 1934 20 Kok-Art 1928 20 Kara-Alma 601 10 Total 295 TOTAL 1155

42. All four raions (Batken, Uzgen, Kadamjai, Suzak), selected for the 2007 CBECDP needs assessment survey had a poverty level above 50%. The majority of poor people of Kyr- gyzstan live in rural areas. The selected raions can be characterized as rural, since there are no cities with a developed infrastructure. Uzgen city, the administrative center of Uzgen raion, was not included into the survey. Another city, Batken that was included in the survey, was a village and raion center until 2000 when it received the status of city and administrative center for the newly formed oblast. The social and engineering infrastructure, however, is very old, this includes sanitation, transmission facilities, telecommunica- tions, pavements, etc. There is no economic development in the city, nor any industries or services. The situation is characterized by a high level of unemployment and labor migration, especially among young people and the male population.

43. Each AO comprises 3-4 villages. Geographically many AOs in the selected raions are situated in mountainous regions with isolated communities and problems of accessibility. The population of these raions is mostly rural. It is difficult to distinguish the urbanized (more developed) population from the poor population in the selected AOs. The general rule is that villages located in lower places are in a better economic situation since they have better lands suitable for growing crops. In higher places, irrigation systems are missing. There are places where the ground contains so much salt that nothing can be cultivated there. However, villages in some AOs can be described as more developed as they are closer to the raion center (e.g. Pulgon village in Kadamjai AO), show some industrial activity (Ka- damjai factory), have big markets where people can sell their agricultural products (e.g. apricots, nuts) and earn money. The major source of income comes from agricultural activities.

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44. In most of the selected raions economic activities mostly include agriculture and small sized commerce. Most of the places are located far from economically developed and in- dustrialized centers. The only industrial enterprise – Kadamjai factory – today does less work as it used to during Soviet time. However, there is some progress in developing small enterprises, mostly due to the support of international projects. In Suzak raion, 16 small projects included the building of 5 brick-yards which were initiated with the support of a Swiss project. Sewing and crafts workshops opened by the raion administration and local communities as well as the ARIS project can also serve as positive examples of strengthening job creating capacities, mainly for women. According to the interview 820 households improved their situation. By the end of 2006 Suzak raion decreased the level of poverty from 52% to 49%.

45. The work of different projects of international organizations in Batken raion during the last year (24 projects, HOPE, UNICEF, etc) contributed to some growth in development of the service sphere among local people. Currently 10 donor organizations work here. Among them ARIS, UNICEF, United Nations Development Fund for Women (UNIFEM), United Nations Development Program (UNDP), US Agency for International Development (USAID), HOPE (Healthy Family Program), Technical Assistance for the Community of In- dependent States (TACIS), Organization for Security and Cooperation in Europe (OSCE).

46. At the same time poverty continues to be a major problem among the population. The difference in development between the upper and lower zones in Suzak raion is reflected by less development of the upper (mountains) zones compared to lower zones. Land in the upper zones is limited. People are mainly involved in cattle-breeding, have limited opportunities for commerce activities due to bad roads, especially in the winter time. Access to kindergartens and schools is difficult in some of these mountainous areas. Therefore, the geographical location is one of the important factors contributing to poverty and unequal life chances among the population.

47. Among the major problems of poor people is unemployment, absence of working enterprises, housing problems, limited plots of land for generating income from growing apricots, nuts, etc. The fertility rate is high. Families with many children are more likely to be among the poor category. Limited income in poor families is not enough to satisfy even the basic needs, such as sanitation, housing conditions, adequate food, clothes for children, and other basic everyday needs.

48. The problem with the shortage of clean/drinking water is very serious. In some villages (in Batken, Kadamjai), people have to buy water in the winter time (10 soms for a container; daily consumption by a family requires an average of four containers), and in the spring time they start to use water from irrigation canals. This results in sharp increase in enteric infections among the population. 26,4% of respondents of the survey indicated that they have no access to clean water, another 27% mentioned problems of the long distance for obtaining clean water. No clean water and appropriate sanitation at all or limited access to it is part of the symptoms which characterize extreme poverty.

49. The ethnic composition of the population is represented by mainly Kyrgyz and Uzbek (in many raions the proportion of Uzbeks is 30%). As far as access to ECD services is concerned, this finding was not indicated as significant. The problem might relate to some limits in educating children in the Uzbek language, since most school (and pre-school) programs are in Kyrgyz. More important are the status of poverty, geographical location, large number of small children in a family and the employment status of the head of a family. In addition to high poverty levels, it should be noted that many people are still expecting support from the state officials to solve their financial problems; generally, such people do not strive for improving their own situation.

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Information about Parents of Children under 8 Years of Age 50. Interviews were conducted with the mothers of children under 8 years of age. They were also asked about the fathers of the children and their presence in the family. This information might be useful for a comparative analysis of families with single mothers and both parents.

Table 5: Presence of a father of children under 8 in a family

Frequency Percent

Valid Yes 1139 98.6 No 12 1.0 Not applicable 3 0.3 Total 1154 99.9 Missing 1 0.1 Total 1155 100,0

51. The survey showed that most of the fathers stay together with their families (98,6%) despite the fact that the proportion of men from these raions working in Russia is quite significant. Given the traditional gender roles of both mothers and fathers, the survey did not include questions on the care-taking role of fathers since this function is mostly attributed to the mothers.

Figure 1: Age of mothers and fathers surveyed

25 Mother Father 20

0 18-23 24-30 31-35 36-40 41-45 46-50 Older than 50

52. As it can be seen from the data, the average age of mothers is 24-30 and of fathers 31-35.

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Figure 2: Education of mothers and fathers

80 70 60 50 mother 40 30 father 20 10 0

tion gher a ssional hi higher primery e uc ofe et ed secondary pl pr no

incom

53. As can be seen from the figure above, the majority of parents have secondary education.

Figure 3: Mothers’ and fathers’ employment status

100

60 Mother 50 Father 40

0 Unemployed Farmer, agricultural worker Employed

54. As can be seen from the figure above, an extremely high number of mothers and fathers are unemployed, i.e. 86% of mothers and 67,2% of fathers are unemployed.

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Figure 4: Mothers’ scope of activities

worker, local 0,73% production

medical 30,66% service/hospital

Service sphere2,19%

Commerce/ 5,84% business Mother's scope of activity Mother's Teacher/education 58,39%

State servant2,19%

020406080 Count

55. Employed women work mainly in educational and medical spheres.

Figure 5: Fathers’ scope of activities

Not applicable 1,94%

Service sphere 16,28%

Local 7,36% manufacturing firm

working in Russia 13,57%

Medical 3,49% service/hospital

Professional 1,94%

worker 10,47% Father's scope of activity scope Father's State servant 13,57%

commerce/ 21,32% business

teacher/education 10,08%

0102030405060 Count

EPOS/IB/GOPA March 2007 15 Needs Assessment Report - Second Community Based Early Childhood Development Project

56. Most employed fathers are working in the commercial and service fields (traders, drivers, etc.), left for work to Russia or work in state services, although it is hard to say on what positions. These data do not show the income of the families with working parents. How- ever, the big proportion of families with both parents unemployed demonstrated the presence of deep poverty in surveyed households.

Figure 6: Ethnicity of parents surveyed

100 90 80 70 60 Mother 50 Father 40 30 20 10 0 Kyrgyz Uzbek Tajik Russian Kurd Turk

57. This table shows that the majority of families were Kyrgyz, although the proportion of Uzbek population in these raions is very significant compared to other regions of the Re- public. It was noticed that most of the Kyrgyz population in surveyed raions speak Uzbek and the Uzbek population can understand Kyrgyz. The ethnic background of the parents surveyed did not seem to have a serious impact on the distribution of ECD services among the populations although a special survey on this issue could provide a more accu- rate picture.

Socio-Economical Situation in Families 58. The data on socio-economic indicators such as heating in the house, clean/drinking water, way of cooking food, and electricity in the house demonstrated a situation where most of the houses have furnace heating (88%), use wood furnace (inside/outside the house) for cooking food (86,9%) and have problems with supply of electricity.

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Figure 7: Clean/drinkable water in the household

in the house outside the house

2,95% on the long distance (more than 1 26,43% km) no access

43,59%

27,04%

59. The most serious factor that has an impact on the social situation of the population is related to shortages of clean/drinking water supply. In interviews with medical workers in FAPs, they were describing the situation in some villages where people have to buy drinking water during winter time and in spring time they start using water from irrigation systems. This results in high level of enteric infections.

Iodized Salt Consumption

Figure 8: Awareness of the population on the importance of iodine for health

Did you ever hear of the importance of iodine for the health?

Yes No 2,68% Don't know

95,67%

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60. As it can be seen, the awareness among the population concerning the importance of iodine for health is very high (95,67%). The majority of the population thinks that it is important to use iodized salt.

Figure 9: Reasons for using iodized salt

don't know3,78%

prevents from iodine 9,04% deficiency disorders

prevents disorders of 8,17% foetus

prevents from goitre 79,02%

020406080 Percent

61. Among the reasons for using iodized salt 79% of people mentioned prevention from goiter. 93% of the respondents believed that their salt was iodized. The salt check confirmed that 90,2% of the salt was iodized. Salt check was done by observing the packing (bag) of the salt that was used in the surveyed household for cooking. The inscriptions on the bag usually include the information on iodizing. If the salt shown to an interviewer was without the packing bag in the questionnaire if was indicated as “It is not clear”.

62. However, the iodized salt might be distinguished by the quality of iodizing depending on the producer. Some information received from the interviews with raion officials indicated that the process of iodizing salt is not of good quality in the region. Among the salt available on the markets, only few sorts can be characterized as properly iodized, most of them are produced in cottage industry without modern equipments.

Anemia 63. Out of the total of women interviewed, 36% of them diagnosed as anemic were prescribed iron tablets, however, the vast majority of them did not follow the prescriptions and took very few of the tablets needed to be effective. One of the main reasons for this was lack of money to buy needed quantity of tablets (84%). But others reasons given were fear of side effects and lack of understanding the importance of taking them. In his interview the director of Family Medicine Center in Suzak raion Mamatjan Miyanov said that 60 to 70% of pregnant women in the raion are diagnosed as anemic. Estimates in Osh and Batken estimate up to 80% of women are anemic.

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Access to Medical Facilities and Drugs

Figure 10: Distribution of medical facilities to which respondents applied for assistance for their children

30 Percent 43,79% 20

32,69%

7,95% 7,52% 4,02% 2,53% 1,49% 0 FAP FGP FMC Raion Oblast Local Other hospital hospital healer The last time you had to seek treatment for your child(ren), where did you go?

64. Based on the received information, among most available for people medical facilities are FAPs located in villages. 43,4% of respondents in need of medical assistance went to FAPs. The number of FAPs as medical facility of primary assistance is increasing in places following the National Program Manas Taalimi. At the same time most of them are not adequately equipped and heated. The medical staff of FAPs does not include a doctor although in villages with high density of population the presence of a doctor in a FAP would save people’s time and money needed to be diagnosed and receive prescriptions in hospitals (e.g. to a FAP in Tort-Gul AO in Batken raion 1.700 people are assigned and only one midwife and one nurse are working there; in Dara AO over 3.000 population and over 1.000 children are assigned to one FAP).

65. 34% of the respondents indicated that they met problems in the last year when they sought medical assistance for their children. 25,9% of problems were related to scantiness of money needed for medical service, 13,6% indicated difficulties related to transportation.

66. 36,6% of respondents indicated that for getting needed medicines for them and their children they turned to a pharmacy in their village. 31,9% indicated that they had difficulties with getting prescribed medicines. 20,8% of difficulties were connected to material hard- ships they faced.

Kindergartens 67. The majority of the respondents (82,8%) think that it is very important for children to attend kindergartens, and 9,4% think that it is partly important. Among the main reasons for attending the kindergartens, 63,9% indicated that in kindergartens children can learn more than at their homes and 14,5% said that they need somebody to look after their children.

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68. Among kindergartens they know about, 24% were state kindergartens. Only few people heard something about community-based or private kindergartens in their places. It is obvious that in all raions the gap between demand and supply of kindergarten services is critical. For instance, in Kadamjai raion for 13.730 children of preschool age, only 4 kindergartens were available and 620 children attended them (this information was received from local officials). In Batken raion with a total population of more than 93.000 people there are only 3 kindergartens in AOs and 2 in Batken city, 1 private kindergarten is located in Aksai village and is open only in summer time (information obtained from local officials).

69. From the received data it can be seen that out of employed (n=137) mothers 90,5% think that attendance to kindergarten is very important for their children, whereas among unemployed/housewives (n=991) this figure is slightly smaller (81,6%). 7% of housewives and 4% of working mothers think that it is not necessary for children to attend kindergartens. This comes mostly from the opportunities to take care of their children at home and poor conditions in kindergartens.

Nutrition 70. Questions on the situation related to nutrition in the families, during pregnancy and nurtur- ing children under 8, aimed at revealing the actual quality of nutrition needed for healthy growth of a child. The received data demonstrate that most of the families do not include meat, milk products, and eggs in their daily diet. The situation is slightly better with consumption of vegetables and fruits. The population in the southern region of the Republic is mostly agricultural, that is why the proportion of households that have cattle is not big (36, 8%), 59,3% of surveyed households have a cow, and 61,3% have poultry. Most of the households (88,2%) have kitchen-gardens.

71. Of all women interviewed 57,9% were consulted on their diet during pregnancy by health workers. The questions asked during the survey do not reveal the actual advice received from medical workers. Most of the women responded that their diet did not differ from their usual situation with nutrition (47,8%). In most cases, women’s’ diet included meat, diary products, and eggs 1-2 times a week and 55,9% of women ate vegetables and fruits every day. Almost half of the women (49,2%) were instructed about their children’s nutrition. However, as it is seen from the figure below the diet of children does not differ from the diet of their mothers during pregnancy.

Figure 11: Nutrition of children under 8

60 50 Daily 40 1-2 times a week 30 1-2 times a month 20 Never 10 Not applicable 0

h s s s e e fis gg , ruit uic E y f J r d oult an p s , e t Diary products abl Mea et g e V

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Child Development 72. Out of all mothers 90,3% would like to receive information on ECD. As it can be seen from the table below, all listed topics are very interesting for mothers to obtain information about.

Table 6: The willingness of mothers to receive ECD information specified by topics Yes No (%) (%) How to bring up my child in a healthy way, that my child stays 88, 1 1, 8 healthy How to create a safe surrounding for my child to ensure his/her se- 84, 7 5, 8 curity How I can understand my child and his/her needs 82, 9 7, 2 How to teach good manners to my child to behave well 85, 8 4, 4 How I can support my child attending a kindergarten 70, 4 19, 3 How to prepare my child to enter school 83, 3 6, 2 Children rights 86, 1 3, 5

73. Among desired ways of receiving the ECD information, TV programs were mentioned most frequently. The role of television is increasing in villages. Watching TV programs is one of the main entertainments in families, especially for women spending most of their time inside home. It is interesting that using DVD and video is becoming more widespread. Even using dish aerial is getting more popular. That is why among other forms of distribution information on ECD, many of the respondents (9 out of 18) mentioned DVD and video.

Table 7: Ways of receiving the ECD information Yes (%) No (%)

Through books/brochures 77, 6 14, 1 Through parent training 66, 6 25, 2 Through TV programs 85, 5 6, 7 Through radio programs 48, 4 42, 7

74. 69,3% of respondents indicated FAP’s staff and medical workers as main providers of information related to children’s development. This practice is inherited from Soviet time when a child from birth until school age was under intensive control of a pediatrician and a nurse who provided not only health care but instructed a mother about nutrition and development of a child. However, to continue using medical specialists as only providers of information on ECD will lead to overcharging medical staff of FAPs that usually have an enormous amount of work in the districts affiliated to it.

75. Questions designed for revealing daily practices in education of early age children within a family demonstrated the following picture. For correcting children for their misbehavior, respondents indicated that “sometimes” they use verbal punishment (scolding) as in 49,6% and physical punishment in 67,9%. Although this does not tell what in particular parents understand under verbal and physical punishment (spanking), it is quiet clear, that parents use systematically scolding and spanking when correcting the misbehavior of their children. An attempt to reveal other practices in education in a family lead to the results reflected in the following diagram.

EPOS/IB/GOPA March 2007 21 Needs Assessment Report - Second Community Based Early Childhood Development Project

Figure 12: Participation of mothers/parents in the activities on the education of children within a family

Teaching letters and numbers

Doing phisical exercises

Teaching personal hygiene

Watching TV programs together Don't do at all Once a month Correcting child's misbehavior Every week Every day Reading the books

Taking children outside

Singing songs

Telling fairytales

020406080100

76. As it might be seen from the figure above, education of children within a family mostly includes watching TV programs, correcting misbehavior of children, and teaching personal hygiene. Although it is difficult to reveal what types of activities are related to teaching hygiene as well as what particular TV programs parents watch together with children. Doing physical exercises and taking children outside (for entertainment) were indicated as most uncommon.

Community Potential 77. The majority of respondents (82,6%) indicated that they haven’t heard about any programs or activities designed for children in their AO. This indicates that problems of children and their mothers are not among priority issues for AOs to spend their efforts and resources in. Children of preschool age are counted as part of general family situation when for example a family has many small children and for this reason can be considered as needed or poor. These factors are subjects for providing material support from the side of AO.

78. The assessment of efforts of the AO’s aiming at improving the well-being of children shows that these are very low. 51,8% of respondents said that their AO “does nothing”. At the same time the demand of mothers for programs or activities that might have a positive impact on the well-being of their children is very high. 55,5% of interviewed mothers would agree “with great interest” and another 27,3% said that they most likely would agree to participate in such programs if they will be provided for them.

79. This demonstrates the high potential of young women-mothers who are eager to be trained or mobilized for community work. In the situation when most of the people still strongly rely on state officials as main source of support and solving their problems, more people begin to understand that they can do important things on their own initiatives. The information on positive experience of local projects might have followers in these regions.

80. Of all interviewed mothers, 43,4% had two children under 8 years of age; 16,4% had 3 children under 8 years of age. 37 children were indicated as disabled or having special needs, among needs were mentioned infantile cerebral paralysis (8), 2nd group of disability (4), legs problems (3), Down syndrome (3), speech and hearing problems.

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Age Specific Questions 81. 73,9% of mothers of children between birth and 12 months did not have problems with medical assistance during their pregnancy. Most of them went for regular check-ups to FAPs (55,6%) and Family Group Practices (FGPs) (37,8%). 93,9% of deliveries were done in medical facilities (maternity houses – 93,9%). 90,9% of children received birth certificates, 5,3% were expecting them and 3,8% didn’t have birth certificates. The main reason for not having a birth certificate is unregistered marriage.

82. Children in age group 4 – 5 demonstrated 3,4% of attendance to kindergarten, of the group of children between 6 -7 years of age, 4,1% were enrolled in kindergartens. Most mentioned kindergartens were state kindergartens (83 - 86%), some of them were indicated as community or home-based. However, the respondents some times were not clear about the difference between state or community kindergartens. Because of parents’ payments for caring for their children in such facilities, some kindergartens could be counted as community-based.

83. Most of the facilities were evaluated as having poor quality regarding the teaching programs, professionalism of teachers, nutrition, equipments, and buildings. Some of the kindergartens work only in summer because of heating problems. Despite these facts, more than half of mothers would like their children to be enrolled in kindergartens before they enter the primary school.

Conclusions 84. Poverty remains a major problem that hinders the ability to implement and to sustain needed programs in ECD in the rural areas. New and innovative ways need to be developed to help to alleviate poverty in those areas. The revitalization of industry in the rural areas is badly needed if poverty is to be reduced.

85. The AOs must become more involved if the needed activities are to be developed in the AOs and villages. The capacity of the AOs should be a priority in seeking methods to implement programs in the various underserved rural areas, whether it be health or education. The AOs are in an excellent position to identify and mobilize local assets in the most effective manner. The feeling by many that the AOs are not actively involved needs to be reversed.

86. The number and location of children with special needs should be identified and steps taken to make sure that these children are included in ECD programs and activities. The current system is not adequate to ensure that the apparent large number of children with special needs are adequately cared for or provided the same type programs as other children.

87. There is a high potential of young women-mothers who are eager to be trained or mobilized for community work. Many women in villages have already demonstrated their abilities to initiate activities aimed at improving their living. In the situation when most of the people still strongly rely on state officials as the main source of support and solving their problems, more people start to understand that they can do important things by their own initiative.

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5 RESULTS AND CONCLUSIONS OF NEEDS ASSESSMENT

5.1 Maternal and Child Health

88. Recent quantitative MCH studies in Kyrgyzstan provide information that can be helpful in understanding opportunities to reduce mortality and improve birth outcomes in the Second CBECDP. These studies are (i) a study on Medical and Social Factors of Infant Mortality written in the framework of the ADB and MoH Japan Fund for Poverty Reduction (JFPR) 9056 for Reducing Neonatal Mortality Project, (ii) the 2006 United Nations Children’s Fund (UNICEF) Multiple Indicator Cluster Survey (MICS), and (iii) several studies prepared in the framework of Project Hope’s Child Survival Project in Aksy and Bazarkorgon Rayons, including the 2002-2006 Baseline and Final Knowledge, Practice and Coverage (KPC) Survey Reports, the 2003 Detailed Implementation Plan and the 2006 Final Evaluation KPC and qualitative evaluation findings. These studies have been analyzed and used, in addition to the 2007 Second CBECDP Household Survey findings, for preparing this needs assessment of the MCH component given in this report. In addition, 2 focus groups of pregnant women and 2 groups of mothers of children under 2 years of age were conducted in Suzak Raion, Jalalabad Oblast in February 2007.

5.1.1 Maternal and Child Health Situation in Kyrgyzstan

Maternal Mortality 89. Despite a decrease in the Kyrgyz Republic from 61.0 in 2005 to 52.0 per 100 thousand live births in 2006, maternal mortality still remains high. Maternal mortality is very high in Jala- labad (78,3). In Osh oblast it is 49,9 per 100 thousand live births and in Batken 40,2. The raions with the highest maternal mortality rate are Aksy (133,5), Suzak (96,0), Batken (60,9), Kadamjai (55,3), and Uzgen (50,0) (Republican Medical Information Centre, RMIC). According to the UNICEF MICS 2006, the maternal mortality rate in Kyrgyzstan is much higher with 106 per 100 thousand live births, which corresponds to the international organizations estimates for the last 10-15 years. This is almost double the official MoH reports. Compared to maternal mortality rates in e.g. Uzbekistan (24 per 100 thousand live births in 2000) and Russia (65 per 100 thousand live births in 2000) this ratio is still very high, although it is much lower than the maternal mortality rate in Kazakhstan which was 210 per 100 thousand live births in the year 2000.1

90. Main reasons for maternal mortality in the Kyrgyz Republic are complications of severe hypertension in pregnancy, usually categorized as pre-eclampsia, and other indirect reasons, such as narcotic complications. Wide spread pregnancy malfunction is caused by lack of timely antenatal care and mismanagement during and after delivery. Although pregnant women are seen for antenatal care by health staff, almost twice as often as the international standards require, the quality and appropriateness of what is done during these interactions is poor. The lack of good quality perinatal care and lack of timely care- seeking for danger signs of pregnancy complications determines the severity and the outcomes. A mother and/or her newborn can receive up to 20 non-evidenced based drugs which are, at best unnecessary and expensive, and at worst extremely dangerous and detrimental to the outcomes. These factors are aggravated by a weak system of obstetric emergency care and a weak referral system.2,3

1 WHO Statistics: http://www.who.int/whosis/database/core/core_select.cfm. 2 Schutt, 2003. 3 Situational research of education and health care in the Kyrgyz Republic, 2005.

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91. Among mothers in Osh with infants who had died, a high rate of pre-eclampsia/eclampsia (15,9%) was detected. The global average rate is from 5 to 7%. This may be explained by a late diagnosis of hypertensive malfunction during pregnancy due to a lack of or late antenatal care in half of pregnancy cases. This high rate of pre-eclampsia is also related to very late health care seeking behavior for danger signs of pre-eclampsia and hypertension (swelling, headache, etc.). Some international perinatal experts say that the high rates of pre-eclampsia are due to the fact that many women are diagnosed with pre- eclampsia/eclampsia, although actually they do have a heart failure because of severe anemia. Hence they are mismanaged, contributing to the high maternal and newborn mortality rates.4 However, the frequency of premature delivery in Kyrgyzstan (5,6%) does not exceed the global rate.

92. Poor hygiene and quality of care during delivery contributes to the high amount of complications related to infection (sepsis). In spite of widespread knowledge that the first line in infection-prevention is hand washing, the team observed that in one rayon hospital, maternity patients and staff were using the same leaking toilet with no hand washing facilities nearby. These factors are aggravated by the poor skills of health staff in providing emergency obstetric first aid and the lack of such important basic medical products, as clo- nidine or oxitocine (T. Schutt, 2003). The weak referral system and lack of availability of more sophisticated care at referral hospitals make accessing appropriate Emergency Ob- stetric Care often impossible.5

93. Anemia is a concern for maternal and child health as well as a nutrition (see chapter 6). The prevalence of anemia among the majority of pregnant women and a large percentage of children raises the risk for the maternal and infant mortality considerably. Even though it is difficult to determine the exact levels of anemia at national level in the Kyrgyz Republic, all national and international MCH and MCN experts agree that anemia is probably the most significant population based threat to maternal and child mortality and to child’s mental and physical development in the country. Some experts believe that the severity of the problem and impact on maternal and neonatal outcomes is probably under-estimated.6

Infant and Child Mortality 94. There are several factors which affect the reliability of reported child mortality statistics. For one, not all children may be registered at birth, and therefore they either may not seek health care or may be missed by the health care system. There are a variety of reasons for not registering a birth: cost and distance for registering at the local administration office, unwillingness to admit having multiple wives, and migration. In addition mortality rates could be concealed by medical workers in order to avoid punishment for unsatisfactory health facility performance. There is also little quality control over data collection. Audits of maternal mortality are not anonymous and confidential. Some Medical experts involved in perinatal care even say that many recommendations as to pregnancy development are prescribed not for women’s benefit, but from fear that they will be punished in case of an unfavorable outcome”7. If health workers are not encouraged to report accurately, the quality of data will continue to be compromised. Measuring improvements and making program adjustments overtime will continue to be extremely problematic. Identification of the infant/child mortality level in the Kyrgyz Republic is further complicated by the fact that until 2004, the government continued to use live/stillbirth criteria established during the Soviet era. This led to the minimization of real infant/child mortality rates. From 2004, the Kyrgyz Republic began to employ live/stillbirth criteria recommended by the World Health Organization (WHO).

4 El Mohandes, A. and Smith, B. personal communications, February 2007. 5 Lyubchis, B and Gintautas, V. “Realization of Perinatal Services in the Kyrgyz Republic”, presentation at national Neonatal Mortal ity conference, Bishkek, Feb. 2007. 6 Phone interview with Dr. Aymun El-Mohandes, Feb. 2007 7 Evaluation of perinatal care in the Kyrgyz Republic, August 28 – September 9 2000

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95. According to MoH statistics the infant mortality rate has increased slightly over the last two years, from 35.2 per 1000 live births in 2005 to 36.0 in 2006. The infant mortality rate reported in the UNICEF MICS 2006 was 59.1, with 69.1 in rural areas with a slightly higher mortality rate for males than for females. The UNICEF MICS 2006 reported infant mortality as 49.8 nationally, and 57.0 for rural areas. According to WHO the infant mortality rate in Kyrgyzstan was 58 per 1000 live births in 2004. Compared to Russia and e.g. Ukraine, which had an infant mortality rate of 13 and 14 per thousand live births in 2004, this rate is still very high. Compared to other countries in the region (Kazakhstan - 63, Tajikistan - 91 and Uzbekistan - 57 per thousand live births) the infant mortality rate in Kyrgyzstan is below the regional average (WHO statistics).

96. The difference between the infant mortality rate as given by MoH and UNICEF/WHO may be attributed to a lack of knowledge among medical workers about the definitions for live and still births, or perhaps also from the concealment of the mortality rate for fear of punishment if mortality rates increase. The differences between these rates may also be due to the change in criteria for infant mortality after adopting the WHO definition. According to the Soviet methods, infants born without breathing were qualified as “stillbirths.” Infants born before 28 weeks of intra-uterine gestation with a weight of less than 1,000g and a height less than 35 cm, who died within the first seven days, were qualified as “miscar- riages.” Differences in classification of dead infants are summarized in the chart below published in the UNICEF MICS 2006.

Table 8: Differences in classification of dead infants prior and after transition to WHO criteria

Infant, born before 28th week of pregnancy Infant, born after the 28th week of pregnancy

with body weight <1000 g and height <35 cm with body weight >1000 g and height >35 cm No breathing, No breathing, Died but there are Survived but there are Died Survived within No other signs of within other signs of within within the No signs signs of life (palpita- the first 7 life (palpitation, first 7 first 7 first 7 of life life tion, traction, days of traction, pulsa- days of days of days pulsation of life tion of umbilical life life of life umbilical cord) cord) Prior transition Miscarriage Live birth Intra-uterine death Live birth to WHO criteria After Intra- Intra- transition uterine Live birth uterine Live birth to WHO death death criteria

97. According to the DHS (Demographic Health Survey) in 1996, the infant mortality rate in the poorest quintile group was 83 cases per 1000 live births, compared to 46 in the richest quintile. This represents the ratio of poor to rich of 1.81. The ratio between poor and rich related to Under-Five Child Mortality equals to 1.958. Major causes of infant and child mortality in Kyrgyzstan are conditions occurring in the perinatal period (62,7%), respiratory illnesses (16,7%), and congenital abnormalities (11,0%). In the countryside, where the standards of living are lower, the mortality rate of children is 1.6-1.7 times higher than in urban areas. It is necessary to note, that the 1-4 year old child mortality rate (when children begin to walk) is 2.3 times higher in villages than in cities.

8 Gvotkin D.: Social-economical indicators of health, nutrition and population in the Kyrgyz Republic, World Bank, Washington, Columbia DC., 2000.

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98. Mortality in the perinatal period is largely due to undiagnosed problems during pregnancy and bad quality of deliveries and neonatal care in health facilities. Recent research in Osh supported by ADB reported that 50,6% of the mismanagement of women in labor could be attributed to lack of qualifications of the doctors. In the case of mismanagement of neonatal cases, 38% were due to underestimation of the grave state of the newborn and 35% due to irrational tactics of nursing. Sixty-nine per cent of the infant mortality rate occurred during the neonatal period and 87% of this neonatal mortality occurred in the earliest neonatal period, from birth to 6 days in obstetrical institutions (Republic Information Centre, 2006.). These relationships were also confirmed in the Osh study which found that 62% of neonatal mortality was in the early neonatal period, and that early neonatal mortality represented 33% of all infant mortality in the 4 rayons studied. Since mothers and babies remain in the health facility between 2 to 5 days after the birth, most of this neonatal mortality is related to interventions that are done while the mother and child are under direct care of the health system.

99. Surprisingly, the Osh Neonatal Mortality Study found, that the majority of low birth weight newborns who died were reported being in the 2000-2500 gm weight range, the most sur- vivable weight. This indicates either poor recording and reporting practices or poor patient management, primarily by the doctor, at the maternity centre. For children who were already discharged from the maternity centre, this represents how babies in the early neonatal period “fall through the cracks” in the system. In the Osh neonatal study, evidence of asphyxia at birth was observed in 40,0% of newborns; 32,0% of them had severe asphyxia. Babies who survive similar conditions are likely to be adversely affected both mentally and physically. This has serious implications if these children enter the education system later in life.

Table 9: Neonatal Mortality by Weight (grams) in 4 Rayons in Osh Oblast. 2006 Up to 500- 1000- 1500- 2000- Rayon 500 900 1499 1999 2499 Alay (abs) 0 4 16 5 34 % 0,0 6,3 25,0 7,8 53,1 Karakuldzha 1 14 5 3 33 % 1,7 23,3 8,3 5,0 55,0 Nookat (abs) 0 16 21 20 128 % 0,0 8,2 10,8 10,3 65,6 Chonalay (abs) 1 3 2 2 11 % 5,3 15,8 10,5 10,5 57,9 TOTAL (abs) 2 37 44 30 206 % 0,6 10,9 13,0 8,9 60,9 Source: ADB JFPR Neonatal Mortality Study, 2006.

100. In 17,8% of newborns who died in the Osh study, there was no increase in body weight after discharge from the maternity home. Among the women surveyed, weight gain of 5 to 9 kg or more was found in 71,8% of pregnant women in Alay rayon, 58,8% of pregnant women in Chonalay, 44,3% of pregnant women in Nookat, and 43,6% of pregnant women in Karakuldzha raion. An increase in body weight of less than 5 kg was found in 35,9% of women in Karakuldzha rayon. A higher index of increased body weight (10 to 14 kg) was found in a greater number of women in Chonalay (41,2%), than in the other raions. Inade- quate weight gain can predispose to having a low birth weight infant and therefore place the baby at higher risk of death or disability.

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101. Although efforts are underway to improve obstetrical care in the Kyrgyz Republic, coverage with the neonatal integrated package has been limited. There are various problems connected with the training of personnel and the availability of medical equipment for conducting emergency perinatal treatment.

102. Major causes of morbidity in children after the neonatal period include: respiratory illnesses (44,5%), infectious and parasitic diseases (11,7%), digestive system illnesses, and endocrinal system illnesses (7%). In Batken oblast, respiratory illnesses are 24%; endocri- nology system illnesses 21%, 77% of which is goiter; and infectious or parasitic and blood diseases 9% each. Among blood diseases, 96% are Iron Deficiency Anemia, signifying that the oblasts in the south are endemic for iodine and iron deficiency.

103. There is still a high rate of child mortality in the first year of life in the home. In 2006, according to the official RMIC, 28,8% of deceased children died at home, out of these 18,4% were under 1 year of age. The highest percentage of children who died at home under 1 year were registered in Batken (21,3 %) and Lyaylyak (20,2 %) raions. The share of 2 year old children who died in the home has increased to 57,8%. The share of 2 years old children who have died at home is 75% in Lyaylyak and Aravan raions, 61,1% in Batken, 52,6% in Uzgen and 37,5% in Nooken raions. This indicates poor recognition of danger signs and also poor care health seeking by family members for infants and young children; and consequently the need for increasing awareness and changing health care seeking practices in the communities.

104. The most important cause for infant and Under-5 mortality is Acute Respiratory Infection (ARI). Mortality from ARI is a key indicator of public health services as mortality rates from ARI can be lowered by immunization, early recognition and health care seeking behavior for the ARI dangers signs. Reduced ARI mortality is also a good indicator for access to quality health services with well trained service providers and essential antibiotics are also important factors. However, ARI is not a major factor for morbidity among newborns until they leave the health facility.

105. Differences for ARI incidence between oblasts are great. In 2003 the incidence of ARI in Batken oblast was approximately 4 times higher than in Bishkek. Children diagnosed with ARI in the three southern areas (Batken, Osh and Jalalabad) are more likely to die from ARI than children living in the northern oblasts, Bishkek, Chui and Issyk-Kul oblasts, which have the lowest level of infant mortality rate from ARI.

106. ARI risk is related to general living conditions of children, such as children’s nutrition, their being in the cold, and also air pollution inside the homes9. In the Kyrgyz Republic, rural houses are warmed in the winter with a stove, thus poor circulation leads to smoky conditions in the houses. Indoor air pollution is a well-known contributor to child respiratory illnesses. According to the UNICEF MICS 2006, cooking with solid fuels (biomass and coal) leads to high levels of indoor pollution and is a major cause of health problems in the form of acute respiratory illnesses, particularly among children under five years of age. Accord- ing to the survey data, more than a third (37,3%) of all households in the Kyrgyz Republic use solid fuels for cooking. Large regional differences in solid fuel use exist, as well as differences between urban and rural areas. The highest consumption is recorded in the southern regions of the country: from 64,1% in the Jalalabad region, to 67.1% in the Osh region, up to 78,3% in Batken region (See Figure 16).

9 McCracken, J. and K. Smith, ‘Annotated Bibliography: ARI and Indoor Air Pollution, Environmental Health Project, Arlington VA, 1997.

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Figure 16: Percentage of households that use solid fuels for cooking by region. Kyrgyz Republic, 2006.

Bishkek 1,0 Chui 13,8 Talas 10,5 Osh 67,1 Naryn 35,9 Issyk kul 21,3 Jalalabad 64,1 Batken 78,3

0,0 20,0 40,0 60,0 80,0 100,0

107. Integrated Management of Childhood Illnesses (IMCI) services have been implemented by the First CBECDP (12 raions), UNICEF (5 raions) and Project Hope (2 raions). However, there have been significant financial barriers and obstacles to scaling up IMCI services to the entire country. In addition, IMCI protocols in Kyrgyzstan begin at 7 days of age; consequently the IMCI initiative does not address problems in the early neonatal period, from birth to 6 days.

108. The rate of disabled children under 14 years (those diagnosed as disabled for the first time) is 15.3 per 10 thousand children under age 14 years. Major causes of disability are diseases of the nervous system, 30.0 per 10 thousand children), congenital anomalies (15,4 per 10 thousand), and mental disturbances (14,9 per 10 thousand). The rate of primary disability of children in Suzak raion reportedly has grown significantly from 9.6 in 2005 and to 29,1 in 2006. According to the MoH, reliable data on disabilities and their related causes are not available for the entire country. However, preventable causes of child disabilities, such as neural tube defects resulting from folic acid deficiency, iodine deficiency, and cerebral palsy are acknowledged to be wide-spread throughout the country. Also screening for Phenylketonuria (PKU) was discontinued in 2003 due to lack of resources. When identified at birth, the diet of children with PKU can be controlled and mental retardation prevented. Disabled children may be hidden by their families. In addition health and rehabilitation services, such as physical and speech therapy, are generally not available in rural areas.

5.1.2 Needs as Perceived by the Beneficiaries 109. AOs interviewed mentioned: “lack of clean water, unemployment, and land distribution” as major problems for their communities. While existing Village Health Committees were not reviewed by this team, one of the team members has prior experience with established village health committees in Kyrgyzstan. The health problems most frequently mentioned by established village health committees through participatory problem identification sessions tend to include a wide range of both chronic conditions such as high blood pressure, certain infectious diseases such as brucellosis, and life style problems such as alcoholism. In initial discussions, maternal and child health problems do not emerge in priority discussions with village health committees. After communities have been “sensitized” they ac- knowledge that health of mothers and infants are both significant health problems at the local level. The more frequently mentioned MCH and nutrition related concerns include anemia and iodine deficiency. However, responses by the community members may be influenced by unintentional bias generated by selective donor initiatives, which have focused on iodized salt campaigns and anemia for example.

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110. Determining how the beneficiaries perceive their health needs requires additional qualitative and quantitative research. Some methods have been piloted by a few NGOs in a few rural regions of the country.10 Health officials in the oblasts, as well as NGOs working in rural regions, confirm that at the household level, the mother-in-law of the mother wields tremendous influence on both the preventive and treatment actions taken, or not taken for the child. In the more religious areas, such as Jalalabad, Muslim leaders (Imams) have influence, especially on men’s behaviors in health care seeking.11

5.1.3 Access to Health Care

Beneficiaries Perception of Access to MCH Services 111. According to the household survey conducted in January 2007 half of those surveyed (55%) stated that they did not have any problems finding medical help when their child was sick or needed a regular check up. However, of the 1/3 (34%, 393/1148) who reported either “always” or “sometimes” having problems accessing services, the most frequent complaint mentioned was “lack of money to pay for services” (61%, 299/491); followed by “long distance” to a facility (33%, 157/482). Seventeen per cent (82/478) reported that the health facility had been closed.

112. According to the survey 44% of those surveyed stated that they went to a FAP the last time that their child had an illness which required medical attention. An additional 33% stated that they went to an FGP. Thus 77% of those surveyed sought the nearest available health facility for their medical needs. Only 8% reported going to a Family Medicine Center (FMC).

Access to FAPs, FGPs and FMCs 113. According to the Manas Taalimi 2006-2010 project document “health care services provided by FAP staff are the most available type of before-doctor medical assistance.” Ma- nas Taalimi 2006-2010 therefore places particular emphasis on improving primary health care at the FAP level. However, while the FAP usually provides the first point of access to the health care system, many FAPs are still not properly equipped or staffed with adequately trained staff. In fact, many FAPs do not even have heat during the winter.

114. Until now the greatest support from health reform and donors has been concentrated on restructuring and training at the FGP, FMC and secondary levels of Primary Health Care (PHC), except CBECDP which has rehabilitated and equipped FAPs and trained feldshers in the 12 raions. This may lead to beneficiaries bypassing their local FAP and seeking care at a more distant FGP or FMC. Although the amount of time that doctors are able to spend with patients was not formally reviewed, FMC and FGP staff consistently mentioned that they are overworked due to high patient loads and lack of staff which might be due to the patients bypassing the FAP and going directly to the FMC or FGP.

Geographical Access 115. The geographical access to PHC facilities in the Kyrgyz Republic is relatively good with the exception of remote villages and mountainous raions, where access may be quite problematic. On average, primary health care facilities are situated about 1-3 kilometers distance from the houses of people in the catchments area of this facility. For most of the survey respondents (73%) the time spent reaching the closest health facility is less than half an hour. The majority of patients visit health facilities on foot and only one out of three (43% in the Batken oblast) reaches them by other means of transport.

10 As of 2006, Project HOPE in Aksy and Bazarkorgon; Aga Kahn in Alay and Chonalay; and Swiss Red Cross in Jumgal (and

starting in other rayons.

11 Project HOPE DIP ,p. 25.

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116. However, an analysis of people seeking medical care conducted by the Center of Human Potential Development (2002) has revealed that the choice of a doctor or health facility mainly depends on where the patient lives. In the great majority of cases, patients seek the health facilities closest to their houses mainly a FAP. Obtaining higher level medical care and making tests, necessitates going to other populated settlements that have FGP. Highly specialized services may require the family to travel to Bishkek, 700 km or more away.

117. According to a research made by the Association of Family Group Practice (2005) the distance of the FAP from FGP is between 1,5 to 70 kilometers, from the FMC to territorial hospitals12 (TH) between 2 to 98 kilometers, from FAP to TH between 1 to 160 kilometers. These distances to higher levels of health facilities are quite considerable and do present financial restrictions to access to poor families. Government emergency transportation systems have broken down since the breakup of the Soviet Union and there are no vehi- cles equipped for women who have significant complications nor do they have transport- able incubators for premature or low birth weight infants. Therefore many newborns die during transport by family members.13

Financial Restrictions 118. Although the accessibility of public health services has improved slightly due to the introduction of the Public Guarantee Program in 2001, which provides all types of medical and sanitary assistance free of charge to poor individuals, geographical distances to health facilities still present considerable barriers to access in terms of finances. During interviews with Jalalabad respondents, it was found that many people do not seek medical care because of travel expenses. For example, going from the village to a medical facility at the distance of about 12 kilometers would require spending at least 30 or 50 soms, a sum that is problematic for most village people.

119. The Government’s introduction of a cost-recovery system has been met with great reluc- tance on the part of the population, as they not only need to deal with new fees for different types of services and drugs, but also with the removal of Government subsidies in every other aspect of their lives as well. Health workers report that they are facing a population that does not always seek services because of these new costs. When they do see patients who are sick and need care, the patients usually cannot afford to buy the medicines prescribed. Thus, the health provider is often frustrated as they are unable to help his/her patients.

120. Wages of public employees (including health care staff) are often below the poverty line. This causes low morale of medical workers and is conducive to demanding informal additional payments from patients. This situation has become a widespread practice in the system of public health services and makes the financial burden of families with a low income even heavier.

Birth Registration 121. The UNICEF MICS 2006 revealed that 6% of children under five years of age had not been registered at the civilian registry office. The most frequent reasons for not being registered found by the UNICEF MICS 2006 included: unregistered marriages (34%), high cost of registration (4%), and the registration office was too far (8%). According to the needs assessment survey conducted during this assignment, 9% (12/132) of the mothers surveyed with children born during the previous 12 months had not been registered.

12 The financial arrangements under the single payer system required a new organization of health care facilities, and in 2002 rayon hospitals began to be transformed into “territorial hospitals” or affiliates of territorial hospitals (including territorial city hospitals). 13 Interviews with Osh Perinatal Center, Osh Oblast Maternity Hospital, Susak Territorial Hospital, Dec 2006 and Jan 2007. ADB JFPR Osh neonatal mortality report, 2006.

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122. In addition to survey data, FMC doctors in Uzgen and Karakul raions in Osh Oblast stated that they considered unregistered children as a major problem. FMC staff also mentioned that unregistered children are usually not registered at an FGP or in the Mandatory Health Insurance Fund (MHIF). In one FAP visited, a review of the out patient register revealed 18 unregistered newborns for the year 2006. Five of these eighteen newborns were recorded as being born at home.

123. Children who are not registered most likely come from poorer and less educated families. In addition to the unregistered beneficiaries, there is migration within the country for economic and sometimes family birthing practices. There is also cross border migration from Tajikistan and Uzbekistan. Both unregistered and migrant children are most likely at the highest risk for poor health, disease, and for missing opportunities for education. These children are probably missed and not tracked by the health care system. Consequently, unregistered and migrant children are not likely to appear in reported morbidity and mortality statistics, either in the MHIF or MoH Health Information Systems.

Access to Essential Drugs 124. The most frequent source for beneficiaries obtaining drugs in the raions surveyed during this needs assessment was “a pharmacy in the village” (38%, 423/1126). The next most frequently reported source mentioned was a “FAP” (21%, 235/1126), and then a “pharmacy in the raion center” (18%, 203/1126). Among those reporting difficulty obtaining medicine for the last illness, the most frequent reason mentioned was “lack of money” 63% (241/380).

125. Even when beneficiaries may have access to drugs, they are either not completely aware of the required treatment, or else cannot or do not complete the recommended course for treatment. For example, nearly one half (43%) of women surveyed reported that they were diagnosed as anemic during pregnancy. Eighty one per cent of those diagnosed as anemic reported that they were prescribed iron tablets. However, only 8% reported completing or nearly completing full course treatment for anemia by taking between 61 to 90 tablets. When asked why they did not complete the required course of iron tablets, 52% (84/163) reported that they lacked the money; 20% dropped out because of side effects, and 18% said that they did not know that they need to continue taking the tablets throughout their pregnancy.

126. A co-payment system for purchasing drugs has been introduced through the Mandatory Health Insurance Fund. This mechanism primarily involves the private sector and those who are enrolled in the Mandatory Medical Insurance Fund. However, the Mandatory Health Insurance Fund medicine co-payment plan alone, does not yet completely solve the problem of the lack of access to the appropriate and quality drugs in the poorer and less accessible raions, where there is less likely to be an approved pharmacy.

127. CitiHope and the Adventist Development and Relief Agency (ADRA) distribute drugs to selected FAPs in certain raions. CitiHope provides drugs in Osh, Jalalabad and Batken oblasts, however this assistance is a time limited supply of surplus drugs only. In addition to the issue of supply, the quality and the appropriateness of the medicines received by the beneficiaries remains unanswered without an effective and routine quality control monitoring system in place. While the Government can certify pharmacies for participating in the Mandatory Health Insurance Fund (MHIF) drug co-payment scheme, the MoH does not have the resources for monitoring pharmacies once approved.

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128. The analysis of the medicine resource information shows, that there is no well-developed mechanism of an incentives based distribution of medicines to children under 5 years old. In some raions medicines are given by the medical worker (Jety-Oguz - 64,7 %), in some cases more often parents buy medicines on their own (Nookat - 91,4 %, Naryn - 81,8 %), and in some raions people almost equally buy and receive medicines from a medical worker (Aravan - 71,4 %). Only 16,1 % of mothers said that they did receive medicines in the system of Mandatory Health Insurance. While a significant proportion of the population (44%) first seeks health care at a FAP, there is no routine system at any level in place for maintaining drug supplies or quality control over drugs at the FAP level. Consequently a significant amount of antibiotics are obtained without prescription. This contributes to un- justified usage of antibiotics.

Access to Immunization Services 129. According to MoH immunization statistics and the UNICEF MICS 2006, 90% or more of children in the country receive Bacillus Calmette-Guerin (BCG) vaccine (vaccine for tuberculosis) before their first birthday. This high immunization coverage for BCG reveals a high level of access to health services for children in the Kyrgyz Republic. Also, the low incidence of the childhood vaccine preventable diseases shows that nearly all beneficiaries have access to and seek immunization services. For example, measles cases in Kyr- gyzstan have remained below one case per 100,000 since the year 2000 (source: RCI SES). While other indicators of child health remain below acceptable standards, the MoH immunization service shows that an infrastructure exists for reaching nearly the entire population with effective health services.

Access to Laboratory Services 130. Beneficiaries who are using health services may not be correctly diagnosed, or receiving the appropriate medications due to inadequate laboratory support. The MoH recognizes the weaknesses in diagnostic capacity owing to under funded and outdated laboratories. Considerable effort has been initiated to improve the quality of the laboratory network at both primary and secondary levels and in both the curative, and the preventive and sanitary hygiene systems. While there are 442 clinical diagnostic laboratories throughout the country, a recent assessment of laboratory services in Kyrgyzstan conducted by the Citi- Hope project in May 2006 reported that laboratory services “are not sufficiently effective” (draft assessment report, 15.05.06). Some of the reasons cited in the report include: high turn over of staff, lack of training for staff, lack of equipment and reagents, and the absence of effective quality control.

Access to Emergency Medical Care 131. Data from qualitative research point out that emergency obstetrics is a serious problem in the rural raions. The quality of the “Safe Motherhood” program differs especially in the rural areas. According to the needs assessment of emergency obstetrical care made by the Ministry of Health in 2005, emergency obstetrical care services are available in each raion of the republic, city and oblast centers. However they are unavailable for some women from distant areas.

132. There is a lack of qualification in providing emergency care. The poor quality of medical services at hospitals, inadequate and late care (for bleeding), underestimation of pregnant woman’s condition seriousness, inadequate therapy of pre-eclampsia, poor quality of anesthetic care for pregnant and recently delivered women lead to maternal mortality. A high rate of anemia is also an important factor in lethal bleeding increase.

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133. In the obstetrical departments there are no special beds for intensive therapy for newborns, not enough neonatology specialists, or anesthetic and intensive care specialists. Al- though there is good equipment provided by international donors, primary intensive care is a big problem due to insufficient technical skills and expertise.

5.1.4 Quality of MCH Services

Quality of Primary Health Care Facilities 134. PHC for the population is carried out by FGPs under which FAPs operate with medical workers at the rural community level. PHC personnel provides out-patient care to the population, including children, perinatal care for pregnant women, assistance with home deliveries as needed, after-birth care, as well as consultations on healthy life style and disease prevention. Feldshers are the main providers of medical services for 25% of the Kyrgyz Republic population. This population lives mainly in remote rural areas cut off from qualified medical care in winter.

135. Monitoring of 10 FAPs in Osh oblast (Aravan and Alay raions) conducted by the Associa- tion of FGP (2005) showed that FAPs provide insufficient quality medical services. None of the FAPs had proper equipment available, furniture and linen supplies did not comply with requirements, and none of them had functioning systems of water supply, sewage and heating.

136. FAPs have no telephone communications in case of emergencies. Feldshers have no opportunity to consult with the FMC or the TH. Transporting women in childbirth is usually left to pregnant women’s relatives or FAP staff. Local AO are formally obliged to provide inhabitants with motor transport to assist in transporting pregnant women. However, AO lack funding and there is no control mechanism to ensure that transport is actually provided. FAPs have the opportunity to keep pregnant women and carry out “easy” deliveries, but most FAPs lack heating, sometimes electricity, and basic laboratory equipment, greatly re- stricting delivery services.

137. Working conditions of FAP staff are very bad and do not contribute to the job satisfaction of this staff. Medical workers of FAPs work three-quarters or full-time without any extra benefits. The reception of patients is often conducted in only one oven-heated room or at the FAP workers’ or the patients’ houses due to the lack of centralized heating. The working day is not limited and night work is not paid. The number of population served is 2-5 times more than the original standard of serving a population between 500 and 200014. There are no means of transportation which complicates medical services provided. A basic part of the FAP worker’s salary is spent on getting to the FGP or FMC a minimum of 5- 6 times per month by taxi as other types of transport is not available. In almost all FAPs there are no clinical protocols available.

138. Due to the lack of funds for transport in FMCs, specialists cannot make outreach visits to FAPs. Even family doctors assigned to FAPs do not regularly visit FAPs. Therefore medical services provided by FAPs are mostly without supervision. In addition, some of the health staff working in FAPs are not adequately qualified. Evidence for the low quality of services provided in some of the FAPs are the maternal mortality cases at hospitals in Ka- damjay raion, and the reported cases of maternal mortality after deliveries conducted by FAPs in Jalalabad and Osh oblasts (information centre, 2006).

14 According to the document "Health Systems in Transition, Kyrgyzstan" by the European Observatory published in 2005, the FAPs " were established in the Soviet period to serve small villages and remote locations with populations between 500 and 2000."

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139. In the framework of integrating public health services with primary health care, the role and the responsibility of FAP personnel for preventive activities and health promotion is increasing along with their interaction with the population, local communities and NGOs. There is a need to improve feldshers’ skills, provide professional support and improve their proficiency through strengthening of relations with family doctors and provision of sanitary transportation.

Quality of Facility Deliveries 140. Contrary to the situations found in most developing countries, where home deliveries are the norm, the vast majority of women in the Kyrgyz Republic deliver in health facilities. Al- though some women may prefer to give birth at home, particularly in rural areas where there are difficulties with transport and the overall costs related to hospitalization may become expensive. The UNICEF MICS 2006, which interviewed 1,197 women aged 15-49, found that nationally 97.7% of deliveries were conducted in health facilities. In Batken and Jalalabad oblasts the hospital delivery rate was 88.5% and 92.5% respectively. One hun- dred per cent of deliveries in Bishkek, Chui and Issyk-Kul oblasts reportedly took place in hospitals. According to the 2007 CBECDP needs assessment survey, 97,7% of deliveries occurred in hospitals in Batken, Osh and Jalalabad oblasts. In most cases deliveries were attended by doctors (76%) and assistant medical personnel (21.2%). There was reportedly no medical care in only 2.8% of the deliveries.

141. However, the wealth index of a household also has an impact on the type of medical assistance at delivery. The UNICEF MICS 2006 reported that 63.3% of the poorest households had their deliveries assisted by doctors, while 32.5% of the poorest households received assistance from a nurse or midwife. For the richest quintile group these indicators measured 92.2% and 6.6%, respectively. Assistance at delivery also varies by ethnicity. The UNICEF MICS 2006 results by ethnic groups showed that the percentage of deliveries assisted by doctors is a little higher for Russian respondents (86.4%) compared to other groups, and they have 100% of their deliveries in medical institutions. The percentage of deliveries assisted by doctors for Kyrgyz women reached 74.2%, while just 22.5% of births were assisted by nurse or midwife. For Uzbek women the percentages were 72.5% and 23.7%, respectively.

142. The poor neonatal outcomes, in spite of skilled facility deliveries, point to deficits in the quality of care provided in the facility during the delivery. In over 50% of the mortality cases in the JFPR 9056 for Reducing Neonatal Mortality in Osh study, the cause was determined to be the result of poor medical management by the doctor. The process of labor is inadequately monitored and fetal distress too infrequently addressed in time to prevent significant oxygen deprivation to the fetus. Conditions of the fetus during labor and of the newborn immediately after birth are inadequately measured and acted upon.

143. The study demonstrated that babies are not consistently evaluated using Apgar scores at 1 minute and 5 minutes after birth, even when the initial Apgar assessment showed the neonate to be in serious condition. Babies who have low Apgar scores at birth are frequently not vigorously resuscitated. Implementation of the Live Birth Definition, introduced in 2003 has identified many babies who should be resuscitated who would have been allowed to die in the past. But the new recognition of viable infants has been slow to be accepted in rural hospitals.

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144. Lithuanian perinatal consultants recently contracted by the MoH to advice on perinatal services in the Kyrgyz Republic found that many hospitals lacked adequate diagnostic equipment. In addition they found a lack of evidenced-based medicine, lack of observation of basic hygiene, especially hand washing, and basically no difference between the quality of services in Territorial and Oblast Hospitals. Quality at City and Oblast Hospitals is often worse than in Territorial Hospitals (TH).

145. According to a perinatal care assessment made by WHO G. Siupsinkas 2002 in obstetrical institutions of the republic, excessive use of medicine during deliveries, including inappropriate use of antibiotics occurs widely, was noted as a major problem. This finding empha- sizes the necessity to design a system of regionalized care based on consistent standards for each level and based on international standards.

5.1.5 Coordination within the Health System 146. There is no referral system in the Kyrgyz Republic for patients at risk for perinatal mortality. In FAPs and rural THs only physiological deliveries may take place. TH and Oblast Hospitals are performing similar functions as FAPs, although they are supposed to be able to manage more complicated pregnancy cases and provide perinatal and neonatal assistance at a higher level. However, the fact that FAPs cannot provide proper referrals to higher levels of care, results in neonatal and maternal mortality.

147. There is no government transportation provided for pregnant women and newborns from the FAPs to the higher levels of health care services. Pregnant women often seek higher levels of care independently. This situation may be explained by financial and transportation problems, as well as by a lack of recognition of pregnancy risk signs at the earlier stages. Without referral of high risk pregnancies to a higher level of health services, the risk for pregnancy complications, disabilities, and even death are greatly increased.

148. A public health service system in Kyrgyzstan is being developed and therefore cannot yet ensure quality care. Because of the lack of well defined and coordinated services, many clients, especially women and children, must go to various facilities and levels in seeking medical care for their illness or health problem. There is insufficient coordination and integration of MCH programs, such as breast feeding and antenatal care. This uncoordinated and vertical approach to primary health care, leads to decreased effectiveness. It should be emphasized that the vertical approach to MCH and PHC is also attributable to the selective and intervention specific nature in which donors, international organizations, and NGOs provide their assistance and implement their projects. Because of this lack of coordination among PHC programs, as well as the staff shortages at all levels, medical staff must assume multiple roles in multiple programs; and therefore do not have adequate time to effectively perform their duties for all of the health programs.

5.1.6 Health Workers’ Performance 149. While 44% of the population apparently goes to a FAP for medical care, interviews at national, raion and FAP levels indicate that FAP staff have few opportunities for training. Training on IMCI for example has concentrated on doctors in the FGPs and FMCs except in the 12 raions which were supported by CBECDP, and other few raions supported by other donor projects. Even among those who have been “trained” in IMCI, most attended only one workshop several years ago. One raion IMCI coordinator interviewed stated that her IMCI training was over two years ago. Thus the quality of care which the beneficiaries are receiving at the FAP level especially remains a serious question.

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150. Today 18 clinical protocols (standards) for obstetric care have been prepared and adapted (for 3 levels of medical care), but only 4 neonatal protocols have been produced, with only 2 approved. However, the major problem is to put these protocols into practice, and to monitor their implementation by medical workers. Besides the insufficient number of clinical protocols for neonatology, but also for the mid-level (e.g. nurses etc) health staff, existing clinical protocols (standards) need to be revised and distributed to all specialists. The most urgent challenge today is to ensure country-wide dissemination and implementation of these protocols as well as the introduction of monitoring mechanisms.

151. The 2006 ADB Osh Neonatal mortality reduction study found that in 85% of cases where the newborn had died, antenatal care was inadequate. Problems included late registration of woman by a doctor (10.1%), irregular “dynamic supervision of the pregnant woman” (67.8%), poor-quality, irregular antenatal home nursing (71%), absence of specialists examination (29.6%), “absence of sanitation of chronic infection centers” (19.6%), no treatment of infections (19.5%), absence of laboratory research” (11.2%).

152. Although most doctors in FGPs and FMCs have received training in IMCI, frequent changes of trained staff due to retirement, pregnancy and child care leave, etc. lead to a lack of trained staff. An assessment of health care providers at the PHC level demonstrated incomplete knowledge about warning signs during pregnancy, delivery and after delivery. The assessment also showed that frontline health workers also rarely demonstrate satisfactory knowledge and skills on the management of sick children. The assessment revealed that the majority of health care providers had not received any professional training in the last 5 years.

153. The needs assessment also found shortages of basic equipment and supplies important to implement the national IMCI strategy and that health care facilities were under-utilized by the population. (In 2006, the Ministry of Health undertook a national inventory of the conditions and equipment in the FAPs). The lack of adequate equipment also contributes to low staff morale. In the majority of health care facilities the health workers do not follow appropriate disinfecting and cleaning protocols and most of the health facilities in villages do not have adequate clean water supplies.

154. In 2006, WHO conducted an IMCI performance review of 121 trained medical workers working in 68 health facilities, 35 of which were maternity houses. Medical workers were observed treating children with high fever, coughing/difficult breathing/pneumonia (71%) or diarrhea (25%). Overall 2 or 3 times as many doctors as medical assistants or family nurses were evaluated. The report found several instances where IMCI protocols were followed but also found that several areas needed strengthening including:

Lack of nutrition counseling by health care workers Over or under classification of pneumonia Hospitalizing some children who did not need to be hospitalized; and not hospitalizing some children who needed to be hospitalized Lack of demonstration of how to properly give medicines to a child Few mothers observed giving the first dose of medicine to a child Lack of counseling on the dangers signs to look for in the child at home Not checking to see if mothers understood the instructions which they were given Only 39% of medical workers completed all required tests before hospitalizing children Need for doctor approval before hospitalizing sick children IMCI protocol taking an average of 18 minutes, while MoH protocols only allow 12 minutes.

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155. Overall the WHO assessment found that both health workers and care givers were happier with the quality of care given using IMCI protocols and that children are now brought to doctors earlier in illness when the symptoms are less severe and unnecessary drugs are given less often.

156. In some cases severe pneumonia may be underestimated and leads to insufficient treatment at out-patient level and late hospitalization. In addition over diagnosis of pneumonia leads to unreasonable prescription of antibiotics, or bacterial infection may be underestimated and antibiotics are not prescribed. Wrong classification of anemia is also widely noted, leading to not administering anti-anemic treatment.

157. One other survey showed that more often child nutrition problems are not detected. The most frequent problems of nutrition found were an insufficient amount of children’s nutrition (37,5 %), insufficient frequency of foods (36,2 %), food of liquid consistence (32,3 %), and giving a child tea (41,5 %). The least attention is paid by medical workers to the questions of child feeding frequency during illness, and accordingly during the mothers’ consultation.

158. Medical workers spend little time on and bring little attention to mothers on the correct usage of medicines. One of the reasons for late seeking of medical care is the ignorance of mothers and care takers of signs showing that it is necessary to return to a medical institution immediately. The analysis has shown that medical workers often fail to alert mothers in relation to “fast and complicated breathing”, “blood in stool” and when a child “drinks little” in spite of the fact that these are the very first signs of diarrhea or respiratory diseases in children under 5 years.

159. Overall the 2007 CBECDP needs assessment shows that it is necessary to improve medical workers’ practice in the following areas: systematic estimation of disease seriousness rate, patient assessment, classification and recommendation for treatment for pneumonia and anemia cases under WHO guidelines, emphasize on infant feeding and care, providing emergency medical care to children before hospitalization, improving interpersonal dia- logue practice between medical worker and patients, and improving arrangements for provision of treatment facilities and sick children with necessary medicines.

5.1.7 Pregnancy: Knowledge, Attitudes, Practices and Risk Factors

Pregnant Women’s Knowledge of Danger Signs 160. Many complications during pregnancy, delivery and the perinatal period cannot be pre- dicted, but they may be avoided if a woman diagnoses alarming clinical signs early within this important period. Analysis of the maternal mortality rate conducted by the Ministry of Health shows that a certain share of maternal mortality could have been avoided if a woman had sought help when the first danger signs appeared. However a research study (“Safe motherhood” 2005) shows that only 30% of respondents know about hypertensive pregnancy dysfunction, 13% know about bleeding risk and 13.6% know nothing. Knowl- edge of women about problems during delivery is better (42,4%). 25% of women new of danger signs after birth, 22% of women knew nothing about them.

161. In two target raions in Bazarkorgon and Aksy in Jalalabad Oblast, the Project Hope’s baseline study found that knowledge of the danger signs of pregnancy was very low. Only 22% of mothers and 6% of men could cite at least two danger signs of labor and delivery; only 39% of mothers and 27% of men could cite at least 2 danger signs during the 7 days after delivery; and 51% of mothers and 14% of men could cite two danger signs of pregnancy.

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162. Globally, more than 40% of maternal deaths occur in the postpartum period (within 6 weeks of delivery), yet only 58% of mothers received a postpartum visit in these raions. Antenatal care attendance was 79%, yet only 57% of mothers received information on danger signs during these visits.

Health Seeking Behavior of Women 163. The level of the population’s trust in health workers is high. Of 1,339 respondents surveyed, 1,140 (85%) said that for reproductive health problems they would appeal for medical care at a health facility. 95 (7%) mentioned conducting self-treatment; 34 (2.5 %) appealed to sorcerers; and 65 (5 %) consulted with parents, friends, relatives.15

164. In the Kyrgyz Republic 73% of women register at primary health care facilities early in their pregnancy (under 12 weeks). In some areas the percentage is far higher: In Batken and Jalalabad oblasts the share is 75%, in Osh 83 %. At primary health facilities registration for pregnant women is provided free of charge. It includes an overall examination, general analysis of blood and urine, microscopy of vaginal smear, sugar contents in urine and blood. Also included are electrocardiogram and ultra-sound examination of small pelvic organs, provision of emergency care, medicinal administration as prescribed by clinical protocols.

165. However mothers from rural areas encounter several obstacles to appropriate treatment. Barriers to healthy maternal outcomes are often categorized by the “4 delays”: Delays in recognizing danger signs of pregnancy, delays in taking action once the danger is recognized, delay in arriving at a facility with appropriate maternity services, and delay in receiving services once at the health facility. The first two delays are largely under the control of the woman and her family, while the last two involve the health and transportation systems.

Pregnant Women’s Compliance with Recommended Therapies or Preventive Measures 166. Project Hope’s baseline focus group discussions in Aksy and Bazarkorgon Rayons found, that knowledge about the importance of care during pregnancy was fairly high. When asked what things are important to take into consideration, mothers replied that they should not work as hard, that carrying water and working in the fields was too much and they should get enough rest, while at the same time stay relatively active (the latter during pregnancy).

167. However, surviving on a subsistence agriculture-based economy, more and more women are forced to take on the responsibility of planting and harvesting on their small plots of land, which is labor intensive. In addition, they are also bringing in income by working in the ‘bazaar’ where they can sell their agricultural products and other things. During Soviet times, they would only work on collective farms and were able to earn an adequate salary. Now that those farms are closed and much of the population is left jobless, they have to try to sell their own agricultural products to replace the income.

168. Therefore, in many cases, although they know that they should reduce their workloads, in practice, women continue to work hard until close to the time of childbirth. They also continue to carry water from the river or other water sources, cook and take care of children and the household. Both women and men say that husbands are willing to help out with baby-sitting, but in reality, that help is often not available until late in pregnancy.

15 Formation of new approaches to population health care in the rural raions of the Kyrgyz Republic, Human Potential Development Centre, 2002.

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169. The Project Hope study found that in spite of the tendency to be passive, rather than pro- active, prenatal care attendance in Jalalabad is relatively good. On the other hand, the cost of visits, and sometimes the distance to the nearest health facility, contributes to mothers occasionally missing appointments. Surprisingly, almost 35% of respondents to the recent 2007 CBECDP needs assessment survey answered “no” when asked if they attended prenatal care during their last pregnancy, a figure significantly lower than the ex- pected antenatal coverage in the target population. Approximately 34% of women in the needs assessment survey waited to seek care until after the first trimester of pregnancy to go for the first visit.

170. According to the Project HOPE Jalalabad Child Survival Project baseline survey, 76% of women received prenatal care during the first trimester of pregnancy but only 58% of mothers received post-natal care home visits, something that requires further investigation.

Nutrition Related Health Problems of Mothers and Children - Iodine deficiency and Anemia 171. Iodine deficiency is both a nutritional problem and a preventable clinical medical condition that can lead to permanent mental and developmental problems in the child. In spite of intensive efforts at salt iodization, deficiency remains a significant threat to fetal development in pregnant women in the proposed project raions. Slightly less than 29% of mothers in the needs assessment survey had been diagnosed with iodine deficiency, of whom around 70% received iodine capsules or injections for treatment.

172. Mothers interviewed in the Jalalabad Maternity Houses who had not taken prescribed tablets, however, indicated that if they had known how important it was to take the iron tablets, they would have been able to find the money to buy them. This was confirmed in focus group discussions with women in Batken that revealed that they had been given prescriptions for iron tablets, but not counseled on how the iron tablets would help the mother and infant to be healthy or any impact that anemia may have on the growth or development of the infant. This demonstrates lack of counseling skills on the part of health personnel and should be further investigated.

173. Two international MCH specialists, Dr. Ayman El Mohandes and Dr. Barton Smith, independently confirmed that they observed women with severe anemia (Hgb< 6) in labor in Kyrgyz Maternity Houses. Their anemia in some cases was so severe that the women were also in heart failure. Doctors in the maternity centers did not to appear to appreciate the critical nature of their condition16. WHO standards recommend that women with hemo- globin levels that are this low should receive blood transfusions. Severe anemia cannot be treated with iron tablets and diet and is considered a pathologic medical condition requiring specialized treatment by trained medical personnel.

174. In the 2002 Jalalabad survey, both mothers and grandmothers mentioned anemia as a problem and most attributed this problem to poor diet. Some women think that it is also due to eating chalk, which is a common practice in certain areas. Others also correctly attributed the condition to when intervals between pregnancies are not long enough. In addition, black tea, an inhibitor for iron-absorption, is traditionally consumed with every single meal and exacerbates the situation. Poor families in winter often have nothing but bread and tea to eat, with meat once a week, or less.

175. Health facility providers report that there is no systematic distribution and consumption of iron folate, despite the MoH policy that supports this. The main barrier appears to be that women have to pay for the tablets and their importance to the health of the mother and the baby is not understood.

16 Personal communications, February 2007.

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5.1.8 Child Caretakers Knowledge, Attitudes and Practices

Parents Knowledge 176. Knowledge of MCH and other nutrition key preventive behaviors, such as the 16 key behaviors of Community IMCI, are known to be very low. For example, in 2002, Project HOPE’s Child Survival Project Baseline Knowledge, Practice, and Coverage study of mothers (and fathers) with children less than 2 years of age found that only 51% of mothers and 14% of fathers could name 2 danger signs of pregnancy, only 12% gave Oral Re- hydration Solution (ORS) for diarrhea, but 44% gave pills or syrup; and only 13% of mothers exclusively breastfed their child until 6 months of age. 39% took iron tablets during pregnancy, but only 2% of them took them for the recommended 90 days or more17.

177. Promotion of Healthy Life-Style was considered inadequate in 72% of cases in the Osh study. This was evidenced by women not knowing the basics of “a healthy way of life” (40,2%); family members not allowing the woman to rest (14,8 %) and adverse psycho- logical climate in family (6,2 %,). Evidence of poor household behaviors included poor hygiene and sanitation of the household (37,9%), poor hygienic behaviors by family members (36,7%), and unsanitary food 43,8%.

Parents Attitudes towards Health Facilities 178. Interestingly, when asked about “who should provide information concerning the development of your child,” 75% (800/1061) of those surveyed mentioned the “health worker.” Only 12% (128/1061) mentioned a school teacher, 7% (71/1061) an AO, and 6% (59/1061) a Social Worker. Apparently the beneficiaries highly value the health worker as a source of information about bringing up their children. However, health workers, especially at the frontline of health services, the FAP, receive little or no in-service training for updating their knowledge. Interviews by the team supported that staff in FAPs have never received training concerning communication skills for more effective interaction with beneficiaries.

Care-Seeking for Sick Newborns 179. Even though over 40% of families of dead newborns in the JFPR Osh neonatal survey identified the seriousness of the child’s illness within the first three days of the onset, in only 23,1% of cases did respondents seek help on the first day after the beginning of the disease, 20,2% within 2-3 days, 10,6% on days 4-5, 7,7% on days 6-7. Remarkably in 18,3% of cases, care was not sought until 10 and more days had passed. More often, it was the child’s father (19%) who decided to seek help, followed by the mother (15%), grandmother 11%, and family council 4%.

180. In most cases, the child was delivered to a medical station by transport, in 22,2% of those cases by a private car, and in 3,7% by ambulance. In 14,8% of cases, the child was delivered on foot. Lack of transportation is frequently cited as a reason for seeking care late and why timely referrals to higher level health facilities are not obtained. Those who most frequently examined a child were obstetricians (5,8%), then doctors (3,8%) and doctor’s assistant (3,8%), then doctors-surgeons and neonatologists (1,9%).

17 Project HOPE: Healthy Lifestyles for Women and Children, Jalalabat Oblast Kyrgyzstan 2002-2006, Detailed Implementation

Plan, 2003.

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181. Fifteen percent of patients were directed from the first health care establishment to a TH or oblast hospital. Transportation was rarely provided to these families. When answering the question: “Describe the condition of a child when it was brought to another establishment,” 13,8% of respondents remarked “extremely grave,” 11,1% stated “rather satisfactory condition". A small number of the respondents mentioned such symptoms as pallor or cyano- sis, “slackness,” capricious, and refusal to eat. Some of these terms are difficult to interpret. The majority of respondents in the Osh Neonatal Mortality Study (51,8%) expressed the opinion that there were no delays in treatment at any level of receiving medical aid, only 11,1% of respondents considered, that there was a delay in receiving of medical help. However, according to the respondents, only 12.5% of cases were treated by professional specialists.

182. When asked during Focus Group Discussions (FGDs) in Jalalabad what they considered as danger signs for a child, almost everyone, men and women alike, mentioned cough and fever. The normal treatment for a cough will be to rub alcohol or ointment on the chest to give it some warmth. The common practice for the treatment of fever is also to cover the child’s body with alcohol. In view of these current practices, prompt care-seeking is likely to be an issue – this was also noted in the autopsy reports in the Osh neonatal mortality study. In 2002 in Bazarkorgon, 8 child deaths were reported as being due to pneumonia. Of the 5 that were well documented, 2 appeared to have been late in care-seeking, and one was a misdiagnosis on the part of the Feldsher, who thought that the infant had a simple ARI. Pediatricians also mention that patients will come in after the infant/child has had a fever for a day or two, and the history reveals that the child has had a cough since many days before.

Treatment and Care Seeking for Infants and Children with Pneumonia

183. It is essential that a child should receive timely antibiotics when they have pneumonia. De- lays of even 24 hours can result in the death of an infant. The UNICEF MICS 2006 found that out of the 167 mothers who had children under five with suspected pneumonia within the past two weeks, 63% brought their children to relevant medical institutions. Mothers with higher education (76,3%) sought treatment for their children more often than mothers with only secondary education (59,5%).The largest proportion of children (80,5%) examined in medical institutions lived in the Osh region, while just 21,8% of these children came from the Batken oblast (see Figure 13).

Figure 13: Percentage of children aged 0-59 months, examined at public health institutions with suspected pneumonia. Kyrgyz Republic, 2006

Bishkek

Chui

Talas

Osh

Naryn

Issyk kul

Jalalabat

Batken

0 102030405060708090

Source: UNICEF MICS 2006

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184. The use of antibiotics for treatment of children under five years of age with suspected pneumonia differs by region. Just 13,1% of children from the Batken region with suspected pneumonia received antibiotics treatment, while 85,9% of children in the Talas region and 100% of the children of Naryn region received such treatment. The survey showed that the use of antibiotics increases as the child approaches age 23 months, and then decreases.

Figure 14: Percentage of children aged 0-59 months with suspected pneumonia, who received antibiotics treatment. Kyrgyz Republic, 2006

Bishkek city

Chui

Talas

Osh

Naryn

Issyk kul

Jalalabad

Batken

0 20406080100

Source: UNICEF MICS 2006

185. Neonates with pneumonia are at the highest risk of death from pneumonia and should be the age group with highest antibiotic use. Specifically, 45,6% of children received antibiotics during their first year of life. 55,7% received antibiotics during the second year of life, and about 40% over 2 years old received treatment. But only 41% of respondents knew at least two danger symptoms of pneumonia. The higher the level of education, the higher the level of their awareness, however. Mothers of children aged 0-59 months living in urban areas (50,2%) knew more about pneumonia than mothers living in rural areas (35,8%). The level of awareness about two dangerous pneumonia symptoms is also positively related to the household wealth index. Nearly 30% of mothers in the poorest household group knew about pneumonia symptoms, while in the middle group 39,3% of mothers and in the richest group, 55,2% of mothers were informed about it.

Figure 15: Percentage of mothers informed about two dangerous symptoms of pneumonia based on their education level. Kyrgyz Republic, 200618

0 primary secondary higher

Source: UNICEF MICS 2006

18 2006 UNICEF MICS.

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186. A sick newborn, especially one with pneumonia can die within hours of the onset of symptoms. Generally, care-seeking within 24 hours of the onset of fast or difficult breathing is the indicator for appropriate caretaker action. The 2006 JFPR Osh Neonatal Mortality Pro- ject Study found that late care seeking for a sick newborn contributed to their deaths. “Only 17,3% of questioned families decided to ask for medical help.” Reasons given were that even though the mother knew that there was a problem with the child “nobody from family members knew and defined a risk degree”.19

Control of Diarrhea 187. The needs assessment survey was done during the winter when diarrhea prevalence is normally low. The survey found that 6% of children had diarrhea in the month before the survey. Of these with diarrhea, 40% were treated with antibiotics. This finding is consistent with other recent national surveys that indicate children are unnecessarily receiving antibiotics for diarrhea. Treating diarrhea with antibiotics is a waste of precious family resources and can result in antibiotic resistance in the population. Over 46% of children also received ORS, the preferred treatment for uncomplicated diarrhea without dysentery.

188. Similar results were found in Project HOPE's 2002 survey where 17% of children had diarrhea in the two weeks preceding the survey. Of those children, 6% of mothers gave ORS and 6% gave home fluids. But 44% of mothers gave pills or syrup, consistent with overuse of antibiotics. This is in spite of the ORS often being free and given out at FAPs, and antibiotics requiring payment. This is further evidence that families will find resources to pay for medications, even if they falsely believe that those unnecessary medications are needed.

189. All participants in Project Hope’s 2002 FGDs in Aksy and Bazarkorgon complained about the lack of access to clean water or piped water in most communities. Water pipes and systems have deteriorated and repairs and replacements as a general rule, not been done. Many people in rural areas are forced to use river water as a drinking source and complain that they are getting this drinking water from the same place where others are washing clothes. Local water chlorination is not a common practice.

190. In many households, hygiene and sanitation conditions are deplorable. Many have ques- tionable latrine facilities. Hand-washing is reportedly done whenever a person comes in from outside, including the latrine. Mothers even mentioned that breasts should be cleaned before the baby suckles. Religion also dictates that hands are supposed to be washed before touching an infant. In practice, some of this may be more or less symbolic at times though; done with a few drops of water, rather than washed properly with soap.

Breastfeeding 191. In 2004 the National Council participants developed 16 key family practices of child care at the family and community levels which are now being implemented. On some of the practices there are sufficiently convincing results, in particular on breast feeding of children under 6 months. In the republic the practice of breast feeding is widely spread and well accepted by the population. According to State Medical Research Center 2005, 77% of children under 6 months were breast fed.

19 These explanations are difficult to interpret due to translation.

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192. Immediate breastfeeding and giving colostrum soon after childbirth is commonly practiced in Kyrgyzstan – (49% of mothers in the Jalalabad survey breastfed within the first 30 minutes, and 39% breastfed between 30 minutes and 8 hours). In hospitals where personnel have been trained in the MoH/WHO Making Pregnancy Safer program, mothers and babies “room-in” together rather than babies placed in a central nursery such as they were in Soviet times.

193. Exclusive breastfeeding until the baby is approximately 6 months of age, however is not the norm. Globally, exclusive breastfeeding has been proven to be the single most effective intervention to reduce infant deaths. According to the mothers in the focus groups conducted in February 2007, most of them have been told by the health provider that they should exclusively breastfeed their baby until the age of six months, but compliance with that recommendation is low. The UNICEF MICS 2006 found that less than 36% of infants 0-6 months are exclusively breastfeed. The 2007 CBECDP needs assessment survey alarmingly found that 47% of breastfeeding mothers were supplementing with a bottle. This practice is extremely dangerous in unsanitary households and can contribute to diarrhea, malnutrition and infant death. Only 9% of mothers in the 2002 Jalalabad survey with children <6 months exclusively breastfed, and this was confirmed in focus group discussions undertaken at the time. Mothers said that they usually add boiled water or tea to the baby’s diet in the first six months. Many will also give the baby bread, softened with water, porridge containing flour, oil and sometimes sugar, or cookies crumbled up in milk. Those who feel that they do not have enough breast milk, and those who can’t breastfeed at all, will give the infant cows milk as well20. A traditional custom, not practiced by all, is the use of a piece of fat, often kept inside a cloth, pinned to the child’s clothing or stuck into something so that the child cannot swallow it.

Appeal for Medical Care. 194. The needs assessment survey found that over 77 % of the parents of deceased children who died after 1 month of life, had appealed for help outside of home. Judging by the listed answers, it is possible to note, that the overwhelming number of the dead children received the aid from medical personnel at a FAP, FGP and hospital. In some cases parents appealed for help to traditional healers, relatives and others. In every fifth case parents sought assistance too late because of their low awareness of the disease.

195. A delay in seeking medical care for more than 3 days may be explained by insufficient knowledge of parents about symptoms of different illnesses and it lead to a lethal end. As a result in 3 cases children died on the way to hospital. In 5 cases children died at home and nobody could justify the parents’ fault for non-appeal for medical care. During a child’s illness more than one in five parents did not seek medical care in due time, that led to 32,5 % of children dying without adequate medical care, either at home or on the way to hospital.21

196. One of the reasons for delays in seeking medical care may be a low standard of population well-being. In the countryside the majority of families are unable to meet the minimal physiological needs of basic food stuff for their children. Many children start under eating from a very early age, which is a risk factor for children’s anemia development, malfunction of nutrition and infectious diseases.

20 Using a community-based approach, the Child Survival Project raised the EBF coverage to 50% by the end 0f 2006. 21 Use of Verbal Autopsy for Estimation of Reasons that Lead to Infantile Death 2001.

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197. The involvement of the population in health issues necessitates more attention to be paid to elderly women: grandmothers on paternal or maternal lines, and other skilled household women who are the key “persons” in the family, responsible for decision-making on different family health questions. Moreover an aggravating process is the migration of the able- bodied population, leaving children with their grandmothers makes the work with this category of population even more important.

198. Unfortunately, this potential for strengthening family and community health often remains unused. The state strategy and programs of public health services development are aimed at the nucleus of any family and assume that young mothers are able to make independent decisions concerning their own health and the health of their children. As a result, medical informative actions and literature originally were aimed at this very group. Al- though, as usual, young women have quite limited opportunities to take decisions or adopt new practice without help from their mothers and mothers-in-law.

199. From the cultural traditional point of view, old people and rural state institutions are re- spected by the rural population. Rural people trust the older fellow-villagers and local institutions, thus this approach was used as the basis for establishment of Village Health Committees in Naryn oblast. Also the implementation of the “Health Community Activities” model in two pilot raions of Jalalabad oblast and 3 raions of Batken oblast should be noted

5.1.9 Major Conclusions and Recommendations 200. Overall, beneficiaries have a relatively high access to health services through the long established network of health facilities. However, the quality of these services suffer from high staff turn over, lack of appropriate laboratory support, and a lack of opportunities for health workers, particularly in FAPs, to upgrade their skills. Nevertheless, the beneficiaries apparently value the health workers as their primary source for information concerning the development of their children. Unregistered and migrant children could represent a significant high risk group of beneficiaries who are being missed by both the health care and the health information systems.

201. Even when services and drugs may be available, the 2007 CBECDP needs assessment and other available data consistently show that beneficiaries do not adequately follow prescribed treatments and also seek care for life-threatening situations too late. This results not only from a lack of knowledge among beneficiaries and inadequate counseling by health staff, but also from the prevailing medical concept among health workers that the beneficiary should only follow orders from medical authorities, and not participate in their own health care. This lack of participation by the beneficiary in their own health care is also evident from the lack of provision by the MoH to the beneficiary of a personal health record, such as a family record of immunizations or a growth chart for the child. It is also exacerbated by the collapse of the referral system. Attitude and behavior change among health workers, and a concise yet informative family record card are needed for improving both the quality of health services and compliance with prescribed treatment by beneficiaries.

202. Cost-effective models of addressing the household and community issues (Component 3 of IMCI) have been piloted in Kyrgyzstan, and elsewhere in Central Asia, but sufficient efforts to learn from and scale up these models have not yet been undertaken. Developing and sustaining a referral system will require providing transportation, along with a sustainable budget for recurring costs.

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203. Further reduction in morbidity and mortality can be achieved and patient loads can be reduced in FGP's, FMC's and hospitals, if the MoH and Manas Taalimi, and the donors and international organizations direct greater attention to prevention and a public health approach for primary health care, especially at the first and the most accessible entry point for health care for most beneficiaries, the FAP.

204. The First CBECDP, the Swiss Red Cross, Citihope and UNICEF have initiated pilot projects in selected raions, and the MoH has introduced a co-payment mechanism through the MHIF to improve the access to essential drugs by poor and remote populations. How- ever, the issues involved for establishing a nationwide drug distribution system, which includes financing, supervising and monitoring the quality of the drugs and the pharmacies providing them, have not yet been adequately addressed. Guaranteeing proper stock management and an uninterrupted supply of essential drugs in both government and private sector pharmacy systems must also be included in the development of any essential drug distribution system or scheme. Adequate coverage of specific pharmaceutical com- modities such as iron/folate tablets and low-cost antibiotics, along with counseling for their proper use of them is required for sufficient reduction of maternal, infant and child priority causes of morbidity and mortality to achieve the target MDGs in the Kyrgyz Republic.

205. To reduce neonatal and maternal mortality, the improved obstetrical and neonatal practices that have been achieved with implementing the Promoting Effective Perinatal Care (PEPC) Program should be extended to the entire population. IMCI, which has been ap- propriately adopted by Kyrgyzstan, needs to be extended through out the health care system. All primary health care providers, including feldshers and family nurses should be trained, equipped, and supervised. This will also require providing at least the key IMCI medications.

206. Demonstrating the impact of the above measures will require continued improvement in the health information system, along with improved protocols and monitoring, and an integrated approach by donors and the MoH. Monitoring and health information system improvements require better design and training to insure that the data collected are analyzed and used to make decisions at all levels: health facility, rayon, oblast, and republican.

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5.2 Mother and Child Nutrition

207. The needs assessment for MCN requires taking a fresh look at the appropriateness of current nutrition-related programs, against the background of national as well as international policies and strategies in order to contribute to the achievement of the MDGs22.

208. During the 2007 CBECDP needs assessment the following documents were reviewed:

Secondary data: research and surveys Secondary data from RMIC and from medical institutions Reports of the First CBECDP: Baseline Survey 2004, Mid-term Progress Report 2006 Needs assessment survey for Second CBECDP Data from Osh, Jalalabad and Batken oblast and selected rayons for the Second CBECDP Reports from UNICEF, ADB and other relevant donors and NGOs

209. Field visits were paid to the three selected oblasts and to one rayon and one FAP per oblast for key informant interviews, focus group discussions and when time permitted, house visits.

5.2.1 General Nutritional Problems in the Country 210. The dramatic changes that have occurred during the last decade have generated massive poverty. The burden of the economic and social transformation affects particularly the following categories: families with many children, single mothers, majority of rural population, internal migrants, persons with disabilities, young people excluded from the labor market. The strategies of the disadvantaged families and other social categories are precarious.

211. Most developing countries have a National Food and Nutrition Policy (NFNP) and a Na- tional Plan of Action for Nutrition (NPAN). Draft NFNP and NPAN for Kyrgyzstan are available but have not yet been endorsed by the Kyrgyz Government. Food and nutrition security are not mentioned in the Kyrgyz national development strategy, nor is nutrition one of the priority programs in Manas Taalimi. It is, therefore, not surprising that there is a lack of information of the nutritional status of representative samples of the population.

212. Some indicators of nutritional status of the general population are published by the RMIC and are based on information, collected in the health facilities. Information includes IDA, IDD, malnutrition, overweight, active rickets and its consequences, disaggregated by the following categories: (a) adult and teenage population; (b) children under 14 years of age and separately for Under-Fives (c) under one year and (b) 1-4 years of age. There was no time to assess the quality of the data. During field observations and key informant interviews it was noted that (a) an examination of pregnant mothers and children takes about 5-10 minutes; (b) weighing scales were not regularly checked and (c) pregnant mothers and children were measured (weight and length/height) with clothes on because it was very cold and examination rooms were not heated. Inconsistencies in statistics may thus be partly attributed to unreliable measurements or inappropriate clinical diagnosis (no quality assessment is done regularly).

22 MDG related to Infant Mortality Rate (especially peri-neonatal mortality), Maternal Mortality Rate, reduction of hunger – stunting – IDA and IDD.

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213. Other databases almost exclusively pertain to pregnant mothers and Under-Fives - the target groups in donor supported programs. Information was usually collected in the context of monitoring and evaluation of these programs, such as Breastfeeding Promotion and Baby Friendly Hospitals, IMCI, IDA and IDD. They are, therefore, not representative for the country as a whole – except the UNICEF MICS 2006.

5.2.2 Malnutrition and Chronic Energy Deficiency 214. Adults and children, visiting health facilities: According to RMIC 2005, the overall prevalence of underweight (chronic energy deficiency) was 83 per 100.000 among adults and adolescents, and about 4 times higher among children under 14 years (380 per 100.000). The prevalence among infants was about 7 times higher than in the 1-4 year age group, 2980 and 373 per 100.000 respectively. The picture in the oblasts selected for the Second CBECDP, compared to the national figures, is not consistent but in general appears to be worse (Annex 2).

215. Malnutrition among Under-Fives (based on surveys): According to the most recent coun- trywide survey (UNICEF MICS 2006)23, among the children aged 0-59 months in Kyr- gyzstan:

3.4 % are underweight 0.3 % are severely underweight 13.7 percent are stunted and 3.7 % severely stunted 3.5 % are wasted and 0.4% severely wasted 5.8% obesity Under-Five in Kyrgyz Republic were stunted and not wasted.

Figure 18: Malnutrition among Under-Fives in Kyrgyz Republic according to UNICEF MICS 2006

Stunted Wasted Underweight

10 Percent

0 <6 mos 6-11 mos 1yr-olds 2yr-olds 3yr-olds 4yr-olds Age

23 Monitoring the Situation of Children and Mothers. Findings from the Multiple Indicator Cluster Survey implemented in the Kyrgyz Republic. Preliminary Report July-August 2006/ National Statistics Committee & UNICEF

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216. The prevalence of stunting was higher than the national average when mothers only had secondary education (15%), compared to those who completed higher education (9.6%). Figure 18 shows that that the prevalence of stunting at age 0-6 months (5%) was already twice higher than the probability in a healthy population, suggesting a low length (and weight) at birth. Thereafter, an exponential increase in stunting was observed till 12-23- months/one year (25%) to remain at this level till 5 years of age. A very similar pattern as reported for other developing countries24, indicating a short window of opportunity to prevent growth faltering and pregnant mothers and children 0-24 months as the first target group for direct interventions.

217. Some indication that malnutrition also is an underlying factor for infant mortality in Kyr- gyzstan can be deduced from the study on risk factors for infant deaths, 2000-2005, conducted in four raions of Osh oblasts. The range in no weight increase after discharge was 19.0-36.8% while 21.5-36.8% lost weight between discharge and time of death.25

218. Overweight appears to be an emerging problem in Under-Fives (2x higher than the probability in a healthy population). Interestingly, obesity in children is most prevalent in Issyk- kul and Talas, two regions with also the highest stunting occurrence among Under-Fives (Figure 19). In agreement with observations in other countries a higher prevalence of overweight was recorded among children with higher educated mothers, e.g. 4.9% (secondary education) and 8.9% (higher education).

Figure 19: Nutritional Situation of Under-Fives in Oblasts according to UNICEF MICS 2006

Batken

Jalalabad

Issykkul

Naryn Stunted Osh Wasted Overweight Talas

Chui

Bishkek town

Kyrgyz Republic

0 5 10 15 20 25 30 Percent

219. The RMIC 2005 (health facility) data base contradicts the emergence of overweight, reporting a prevalence of less than 100 per 100.000 among adults, teenagers and age group < 14 years. If the inconsistency with UNICEF MICS 2006 data is real, one tentative conclusion is that Under-Fives coming to health facilities are more underweight (from the lower socio-economic stratum) than overweight.

24 Shrimpton R et al. The worldwide timing of growth faltering: Implications for nutritional interventions. Pediatrics 2001, 107:75 25 Reducing neonatal mortality– JFPR 9056: Medical and social factors of infantile mortality and its forecasting The final report, Bishkek 2006 – MoH Kyrgyz Republic & The National Center of pediatrics and Children's Surgery

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220. Three other studies/surveys reported on the nutritional status of young children. a) Underweight among children under three years in Karasuu region was about 7%26. b) 25% of children in the Kyrgyz Republic are characterized by moderate or severe stunting, 3% were severely underweight, and 11% moderately underweight27 . c) In Karasuu raion 30% of Under-Fives were underweight and stunted whereas the corresponding figure for Suzak raion was 28, 8%28.

221. Chronic Energy Deficiency among women of reproductive age: There is a paucity of information about the nutritional status of women of reproductive age (WRA) and specifically of pregnant and lactating mothers. A study on factors related to neonatal mortality reported weight gain in pregnancy of mothers, who lost a child within 12 months after birth. A mod- est weight gain (5-9 kg) was recorded in 71.8% of pregnant women in Alay rayon, at 58.8% of pregnant women in Chonalay, at 44.3% of pregnant women in Nookat and at 43.6% of pregnant women in Karakuldzha raion. Poor weight gain (less than < 5 kg) was found in 35.9% of women in Karakuldzha rayon. Adequate to large weight gain (10-14 kg.) was more in Chonalay (41.2%), than in other raions.

222. Qualitative data (dietary history) collected in the Second CBECDP needs assessment survey in three oblasts illustrate the poor quality of habitual diets of families. Nutritious foods were usually eaten only once or twice a week (meat 55%, milk products 37%; vegetables and fruit 37%) (compare Annex 2). Overall there was no difference in the food consumption pattern of the family and that of pregnant mothers and Under-Fives, indicating that intra-family distribution of available foods was equitable. One can thus assume that the inadequate quality of the home diet is primarily attributable to poverty – which shows the limitations of nutrition counseling without interventions to improve food security. Further- more, maternal nutrition during pregnancy is one of the major factors influencing fetal growth and low birth weight (LBW). As LBW rate is known to be a risk factor for peri- and neonatal death29, efforts to reduce early infant death need to include surveillance of maternal undernutrition at any level and appropriate interventions.

5.2.3 Micronutrient Deficiencies 223. Some micronutrient deficiencies, in particular IDA, IDD, vitamin A deficiency (VAD) and zinc deficiency, contribute to high infant and maternal morbidity and mortality rates, as well as retardation in physical and mental development of children30. Prevalence data exists only for the donor supported programs for IDD, IDA and VAD.

224. Prevalence of Iodine Deficiency Disorder: RMIC 2005 data illustrate the geographical differences in goiter prevalence due to geo-physical conditions. Information of the City De- partment of the Sanitary-Epidemiological Inspection of the Kyrgyz Ministry of Health shows a comparative decrease in IDD (Figure 20). The trend was explained by an improvement of knowledge of the population about the symptoms and ill consequences of IDD and a subsequent increase in the availability and use of iodised salt. However, of the 15% of WRA diagnosed with goiter only 58% used iodine pills. About 4% of Under-Fives had goiter. This low rate is most likely an underestimate due to inappropriate diagnosis. The same percentage (55 %) of children was reported to have been given iodine pills31.

26 Study of anemia among women of Kara-suu rayon (district), Osh oblast. Bishkek, 2003 27 Demografical Medical Survey of the Kyrgyz Repupblic, 1997. 28 Investigation of health, nutrition, education and life conditions of pregnant women and children in the age of 0 to 8 years old in Kara-suu and Suzak regions (Research Group of the Consulting company “Socium Consult”, 2003. 29 Kusin JA et al:. Maternal BMI: the functional significance during reproduction, in: EurJClinNutr, suppl 3: S56-67; Kramer MS & Victora CG:: Low birth weight and perinatal mortality. In:RD Semba&MW Bloem. Nutrition and Health in Developing Countries. Humana Press 2001:57-70 30 Child survival. Lancet, supplement 2003; Jackson AA, ed. Nutrition as a preventive strategy against adverse pregnancy out comes. J Nutr. 2003; 133 supplement; Child Development Series Lancet 2006, 2:Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. 31 Institutional Strengthening of community development of young children. Main report, Asian Development Bank

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Figure 20: Prevalence IDD per 100.000 population

4666,3 4247,9

3405,1 3316 2507,9 2828,3

1327,2

266,5

1998 1999 2000 2001 2002 2003 2004 2005

Source: City Department of the Sanitary-Epidemiological Inspection of the Kyrgyz Ministry of Health

225. A recent survey in 5 regions of Naryn oblast and in 3 regions of Jalalabad oblast diagnosed IDD of light degree as a result of insufficient iodine consumption. In 4 regions of Osh oblast the survey revealed improvement of the situation compared with the previous investigations: iodine index in all raions fit to the normal index32. In a doctorate study on IDD, urinary iodine levels were determined in 2.093 schoolchildren of 9-10 years. The me- dian value was 64 mcg/l, which corresponds to a mild degree of iodine deficiency. The distribution of the values is shown in Figure 21. Severe, moderate and mild degrees of iodine deficiency were diagnosed in 25%, 17% and 27% of the respondents respectively. Only 32% of school children had a normal iodine level.

Figure 21: Frequency distribution (%) of urinary iodine level in schoolchildren of Kyrgyzstan (2000-2001)

35 32

30 27 25 25

20 17 15

10 5

0 <20 mcg/l 20-49 mcg/l 50-99 mcg/l >100 mcg/l

32 Sultanalieva, R.B.: Iodine status in organisms of children (Jalalabad, Naryn and Osh oblasts of Kyrgyz Republic). Results of the biological monitoring, 2006.

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226. Consumption of iodized salt: According to UNICEF MICS 2006 three out of four households used adequately iodised salt (15+ per 1000 life births). The salt was more likely to be adequately iodised in urban areas (84.5%) than in rural areas (70%), as well as in richest households (84%) as compared to the remainder of the households (69%). Insufficient salt iodine levels (<15 per 1000 life births) were observed in 21% of households and in only 2.7% was the test result negative, thus confirming that virtually all the salt supplied in the Kyrgyz Republic is being iodised, although at a minimum level and barely according to the national standard. The First CBECDP Midterm Review also concluded that in their project raions the IDD component has been successfully implemented, but that continued efforts must be made to improve the quality of iodization. Similar conclusions were drawn in the final report of Sustainable Food Fortification.33 The 2007 CBECDP needs assessment survey reported appropriate knowledge about the importance of iodine for health (96%), and a 90% actual use of iodised salt by household in the selected raions for phase 2.

227. Iron Deficiency Anemia: Anemia is probably the most prevalent micronutrient deficiency related problem in the country, with major ill consequences for Infant Mortality Rate and Maternal Mortality Ratio. Nationwide information on anemia prevalence in the Kyrgyz Re- public was obtained through the 1997 DHS within the MEASURE DHS+ Project. About 65% of pregnant women were found to be anemic, namely 2% severe, 32% moderate, and 31% mild degrees respectively. The World Bank, USAID, and UNICEF consider a country with maternal anemia prevalence of equal to or greater than 40 percent to indicate a problem of severe public health importance34. However the Kyrgyz Ministry of Health considers anemia data to be unreliable due to deficiencies in the quality of laboratory analysis and reporting mechanisms35.

228. Based on the data of the National Centre for Pediatrics and Child Surgery in Kyrgyzstan anemia of various severity levels was identified in 27% among children 0-16 years old. The highest prevalence of anemia (42%) was recorded in Osh (southern) region. Preva- lence of anemia among children in the rural area is almost 2 times higher, than in urban areas (34,2% in villages and 19,7% in towns). The corresponding figures for breastfed infants was 63%, 1-3 years children 42%, preschool age children 26% and school age children 21%.

229. During 2001 - 2003, anemia in women of reproductive age was the lowest in Issyk-Kul oblast (26.2 percent in 2001 and 22.8 percent in 2003), followed by Chui oblast, about 49.5 percent to 40.2 percent respectively. Jalalabad oblast shows high and increasing anemia rates (about 61.8 percent in 2001 to 76.5 in 2003). Karakuja rayon in Osh Oblast reported 60% anemia in pregnant women and 30% in children (2007).36 According to the research by ADB within the JFPR 9056 for Reducing Neonatal Mortality (2005), 83.3 % of mothers were found to be anemic at different levels. The highest anemia rate was found in Kara-Kulji (95.7%) and Nookat (82.9%) raions. Anemia in these areas is endemic, and requires a major change of nutrition habits of the population, as well as routine prescription of medicines containing iron. Other potential contributors to anemia (e.g. intestinal parasites, malaria, genetic conditions, other micronutrient deficiencies) have not been systematically investigated. 37

33 JFPR 9052 Sustainable Food Fortification in Central Asia and Mongolia, Final Report, Bishkek 2006. 34 World Bank, USAID, UNICEF, et al,: Anemia Prevention and Control: What Works. Part I Program Guidance, 2003. 35 Interview with Ainura Ibrahimova, Deputy Minister of Health, Feb. 2007. 36 Field trip report 24 to 26 January 2007 Gulmira Najimidinova. 37 Interviews with Airnura Ibrahimova, Tobias Shute, Barton Smith, 2007.

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230. According to RMIC 2005 data the prevalence among adults and teenagers (2910 per 100.000) was lower than that in group < 14 years (3,375 per 100,000) and among Under- Fives the prevalence among children 1-4 years consistently exceeded that of infants. While IDA was very common during pregnancy and at delivery, the differences in prevalence on the two occasions were inconsistent and most likely due to the quality of Hb assessments. In an evaluation of the quality of IMCI, anemia of different degrees was detected in 41.3% of Under-Fives38.

231. Information of the City Department of the Sanitary-Epidemiological Inspection of the Kyr- gyz Ministry of Health shows that in the past 10 years there was no decrease in the prevalence of IDA in the population.

Figure 22: Prevalence of ID per 100. 000 population

1714 1538,8 1506 1505 1444,1 1319,3 1301,5 1268,2

1998 1999 2000 2001 2002 2003 2004 2005

232. In connection with an IDA prevention program in Karasuu rayon, Osh oblast and Naryn oblast39, baseline surveys were conducted, covering WRA and children under three. In Osh oblast 52% of WRA (15-49 years of age) were anemic, of which 4% severe. Among children under three about 4% had severe anemia, 27% moderate (acute in report) and 53% mild (moderate in report) degrees of anemia. Anemia prevalence was highest in the age group 25-29 years (19,6%), and lowest among 15-19 years old (8,7%). About 72.4% of all anemic women and 44% of the severe cases received an appropriate medical treatment. Anemia of different degrees was detected in 84% of children under three years.

233. In Naryn oblast overall prevalence among WRA was 32%. Differences between regions were observed in prevalence and severity of IDA, viz in Kara-suu region 57.2% (of which 63.3% mild degree), whereas in Suzak region it was 81.8% (of which 63.2% moderate and 4.8% heavy). Only 39% of the diagnosed cases received an appropriate medical treatment. Among children under three anemia was detected in 73% and about half received iron supplements (18% of age group 4-6 months).

38 Report «Quality evaluation of the Integrated Management of Childhood Illnesses (IMCI) implementation and outline of barriers for its sustainability on all levels of Primary Health Care», Bishkek 2006. 39 (a) MoH/Kyrgyz Republic – UNICEF: Study of anemia among women of Kara-Suu rayon (district),Osh oblast, 2003. (b) MoH/UNICEF Hb level research in women of reproductive age and children under three years of age in Naryn oblast, 2001.

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234. While poor dietary intake due to poverty significantly contributes to maternal mortality, a lack of knowledge and interpersonal communications skills on the part of health care staff results in the women not understanding the importance of treating their anemia for their own health, as well as the health of their babies40. The 2007 CBECDP needs assessment survey found that 81% of women were prescribed iron tablets. However, only 8% took 60- 90 tablets. Reasons given for not taking the pills were lack of money (53%), fear of side effects (21%), and lack of understanding (18%). Only 7% gave remoteness of the pharmacy as a reason41. A quick evaluation conducted in Chuy and Issyk Kul oblasts also revealed that 72% of 261 women surveyed had never taken iron supplements during pregnancy (T. Schutt, 2003). During an interview conducted in January 2007 in Batken oblast, local health authorities estimated that 80% of pregnant women are anemic, an interview with 6 mothers of children under 2 years old, revealed that during their pregnancies all of them were anemic. Among these 6 women, only 1 had received anti-anemia drugs during her pregnancy. Of those who did not receive these drugs (most likely iron tablets), 3 women answered that they did not know the importance of taking them, “because all women are anemic and anemia is not curable.” Another woman responded that “it’s harmful to receive any drugs of chemical origin.” Two other women responded that they did not have money to buy the drugs.42

235. Vitamin A Deficiency (VAD): RMIC does not report on VAD among children or pregnant women attending health facilities. During the National Conference “Improvement of Family and Community Practices on Child Health” in 2004 in Bishkek organized by UNICEF a background document was presented, which included one article on serum vitamin “A” among Under Fives.43 Serum levels of vitamin A were determined in a sample of 252 children in Kara-suu, Osh, in the south, and 252 children in Naryn raion, Naryn oblast, in the north at the Kazakh Academy of Nutrition. Normal serum level was found in 23%, border- line conditions in 44% and deficient level in 33% (Figure 23). Among those with deficient serum Vitamin A levels, 94% were categorised as moderate and 8% as severe.

236. The reported principal reasons for VAD among children were (a) lack of information for mothers; (b) low consumption of vitamin A rich foods; (c) the high rate of infectious diseases; (d) 84,6 % pregnant mothers did not use any vitamin preparation.

Figure 23: Deficiency of vitamin A (in %) among Under Fives in Karasuu raion, Osh oblast, and Naryn raion, Naryn oblast

47 47 50 44 43 40 41 39 40 35 28 30 18 20 10 0

6-12 13-24 25-36 37-48 49-60 month. month month month month

deficiency of vitA border-line condition

40 Najimidinova, Gulmira, Field trip report to Osh and Batken Oblasts, January 2007. 41 CFG Needs Assessment Survey Report, March 2007, p.7. 42 Najimidinova, Gulmira, Report on Field Trip to Osh and Batken Oblasts, January 2007. 43 Evaluation of the prevalence of Vitamin A deficiency in the Kyrgyz Republic. UNICEF 2002.

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237. MoH carries out a bi-annual mass distribution of high-dose vitamin A capsules for children aged 6-59 months. In addition, vitamin A supplements are supplied through the health system to mothers after giving birth. Data of UNICEF MICS 2006 on the status of vitamin A supplementation of 6-59 month-old children and post-partum mothers (within 8 weeks after delivery) is based on the recollection by mothers/caretakers of the six months period prior to the interview. About 47% of eligible children received a vitamin A supplement. The percentage was higher in urban areas (52% versus 44% in rural areas), in children whose mothers had higher education (58% compared to 43% with secondary education) and in females (49% versus 45% males).

238. For children aged 6-11 months at the time of the survey, nearly 40% of mothers reported that the infant had not received a supplement, but the responses for this age group are likely influenced by the timing of the last round of the national supplementation scheme. Only half of the women with a live birth during the 2 years prior to the survey confirmed that they received a vitamin A supplement within 8 weeks after giving birth. The differences between urban and rural areas and between the respondent’s educational levels are small.

239. Rachitis (rickets) diagnosed in health facilities is reported (RMIC) but no population-based statistics were identified. Nevertheless, RMIC data can be considered covering the age groups concerned because all infants and young children go to a health facility for vacci- nation and periodic exams. According to RMIC 2005 report the prevalence for the country as a whole was about 30 times higher among infants (4874 per 100.000) than among age group 1-4 years (177 per 100.000). In the three selected oblasts for the Second CBECDP the lowest prevalence was reported for Jalalabad (infants 925 and 1-4 years 50 per 100.000 respectively). Although there are no population-based statistics for rickets published by WHO or UNICEF and therefore international comparisons are not possible, the RMIC data on rickets in the Kyrgyz Republic is of importance in itself as it shows that:

(a) there is a rickets problem in KR; (b) there are regional differences and it should be clarified why; (d) there is no Order by MoH (and in Manas Taliimi) to deal with rickets.

5.2.4 Breastfeeding and Complementary Feeding 240. The Kyrgyz Republic has adopted the WHO/UNICEF Program on Protection, Encourage- ment and Support of Breast Feeding. The National Committee on Support and Encour- agement of breast feeding was created in 1996. Since 1999 the Initiative of Benevolent At- titude to Child Hospitals was introduced and scaled up in the country. UNICEF MICS 2003 reported an exclusive breastfeeding (EBF) rate from 0-6 month of 36%, continued breastfeeding rate of 28% and timely complementary feeding of 45%.

241. The UNICEF MICS 2006 gave the following results: (a) 65% of mothers started breastfeeding within one hour and 90% within one day after giving birth; (b) only one-third of children were exclusively breastfed up to 6 months (about 10% in urban areas and among infants of mothers with higher education); (c) more than two out of three are still breastfed by age 12-15 months, and 28% till the second birthday. Complementary foods were introduced in 50% after 6 months of age, 40% after 9 months at least three times daily. Appar- ently EBF in the first 6 months remains too rigid for changes. A critical review should be made of the current ways of promotion complemented by an assessment of enhancing and obstructing factors, using social science methodologies.

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5.2.5 Causes of Malnutrition and Micro-Nutrient Deficiencies 242. At the individual level theoretically there are two vicious circles leading to malnutrition (stunting) and micronutrient deficiencies. The first relates to the lifecycle: poor communities are confronted with the intergenerational cycle of undernourished mothers, who are more likely to give birth to low birth weight babies, who in turn become stunted children44 and small adults with impaired physical and mental development and higher risk of degen- erative diseases45. Stunted and undernourished women are prone to deliver low birth weight babies, who are physically and metabolically already negatively affected at birth (Figure 24). The consequences of LBW and the public health significance of LBW are borne out by its contribution to the global burden of disease46, e.g. its association with high peri- and neonatal mortality, poor postnatal growth, impaired immune function, poor cognitive development47.

Figure 24: Lifecycle: the causal links

Lifecycle: the causal links

Higher mortality Impaired rate mental Increased development risk of adult chronic disease Reduced capacity Baby to care for baby Low Birth Untimely / inadequate We ight weaning Frequent Elderly infections Malnourished Inadequate catch up Inadequate food, health & Inadequate growth care Inadequate foetal food, nutrition health & care Child Stunted Reduced Woman mental Pregnancy Malnourished capacity Low Weight Gain Adolescent Inadequate food, health & Stunted care Higher maternal mortality Inadequate food, health & Reduced care mental capacity

Source: Ending Malnutrition by 2020, draft report to ACC, SCN, March 1999

44 Grantham-McGregor SM (1998) Small for gestational age, term babies, in the first six years of life. Eur J Clin Nutr 1998; 52 (Suppl 1): S59-64.:S59-S64. Martorell R, Kettle Khan L, Schroeder DG (1994) Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nut 48:S45-S57 45 Barker DJP: Mothers, Babies and Health in Adult Life. Edinburg, Livingstone, 1998. 46 Murray CJL, Lopez AD (eds): The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990. Cambridge, MA. Harvard University Press. 1996. 47 Ending Malnutrition by 2020: Fd Nutr Bull. Supplement to 21 (3), September 2000, chapter 2.

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243. The second cycle is commonly known as the synergism between malnutrition and infection and the weanling dilemma. After 6 months of age breast milk is not sufficient anymore to cover the daily requirements in calories, protein and micronutrients. However, complementary foods are often contaminated, resulting in frequent diarrhea. Other infections like respiratory tract infections, parasites and worms add to the high morbidity load, as infectious diseases increase dietary requirements, and morbidity is a contributing factor or even the primary cause of growth faltering. If there is no catch-up growth after an illness, a down- ward spiral sets in – morbidity results in growth deficits and in turn malnourished children are more prone to infectious diseases48. It is, therefore, not surprising that the most critical period for young children is age 0-18 months49 (Figure 25). Hence, the window of opportunity to maintain an adequate nutritional status of Under-Fives, to prevent growth faltering or to ensure catch-up growth is small.

Figure 25: The “Window of Opportunity” for Improving Nutritions is very small pre-pregnancy until 18-24 months of age.

244. At the family level nutritional deficiencies exist due to (a) food insecurity (people cannot produce or buy enough foods to cover their daily needs); (b) interfamily distribution of foods (available foods are distributed equally to all family members, no priority is given to pregnant/lactating mothers and young children) and (c) Knowledge Attitude and Practices (KAP) (lack of knowledge about dietary requirements and nutrition-detrimental food habits). It is obvious that knowledge of the situation-specific causes is essential to have cost- effective interventions (appropriate for the identified causes) which are targeted to the most vulnerable.

245. The review of secondary data (surveys and research results) as well as the household surveys conducted for the on-going and the Second CBECDPs only identified information on breastfeeding practices and the type and timing of the introduction of complementary foods. The results were equivocal. Infants/preschool child feeding is characterized by: (a) short duration of exclusive breast feeding but continuation of breast feeding till about the end of the second year; (b) scheduled breast feeding instead of on-demand; (c) tea, water, other fluids are given even before 3 months of age; (d) about 30% use bottle feeding; (e) complementary foods are of low energy density (liquids, gruels) and poor quality (bread, seldom milk, meat, fish, eggs, beans, vegetables and fruit). No population-based data on child morbidity are available, nor on child feeding practices during illness.

48 Tomkins AM: Malnutrition and infection. Geneva, UN ACC-SCN Special Report Series, 1986; Pelletier DL : Malnutrition, morbidity and child mortality in developing countries. In . Too young to die: Genes or gender? New York (NY): Department of Economic and Social Affairs, Population Division, United Nations; 1998, pp. 109–32. 49 Shrimpton R et al: The worldwide timing of growth faltering: implications for nutrition interventions, 2001, in: Pediatrics 107 (5):e75

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246. One can conclude that there is a great lack of information, which can explain why pregnant mothers, infants and preschool children are anemic; a large percent of Under Fives is stunted; an appreciable percent of Under Fives have current or past rachitis (RMIC 2005), overweight may be an emerging problem and one can continue. The list is very likely lar- ger, as a situational analysis (nutrition survey) was never done. Basically, only the top of the iceberg is visible.

247. Similarly, no information is available on food and nutrition security at the household level. A concentration on nutrition promotion without taking into account what households (and mothers) can afford to do, will ultimately lead to disappointment – or even worse – indiffer- ence from the side of health staff and patients/clients. It overestimates what is realistic in the household situation.

248. The raions selected for the CBECDPs were among the poorest in the respective oblasts and that was obvious during the field visits and discussions with key informants and families/mothers. Food insecurity can be mainly attributed to poverty due to full or concealed unemployment. Many heads of households were daily laborers, never knowing whether there is work for the day.

249. Households having one or more members working in neighboring countries were visibly better off. They had well maintained houses; good clothes and mothers mentioned that the family could afford meat, eggs, milk, and vegetables every day. No distinction was made between gender and age groups in the intra-family distribution of foods. However, mothers do not prepare special complementary foods for their infants and toddlers. They get part of the family diet, and no food taboos were mentioned. The same applies to pregnant or lactating mothers.

250. Mothers from poor households reported illness (brucellosis and TB) of the father or themselves as another cause of their vulnerable situation. They have to buy the drugs but seldom manage to pay for a full treatment course. Those having a social network survive from donations in money or kind. Some were eligible for a subsidy of 100 som per person per month from Ministry of Labour and Social Protection. This amount is barely sufficient to cover their daily food needs. Consequently their daily diet usually consists of bread, po- tatoes, pasta, tomatoes and tea. Many mothers know that they are anaemic. They get a prescription but acknowledged that they don’t like the pills and preferred injections. One mother bought vitamin ampoules for 300 som! They knew that the poor quality of their diet was the culprit and resigned in their fate of poverty.

251. Even for households having land food production is hampered by lack of tools, seeds and fertilizers – but above all by the severe water problem. The latter also limits having home gardens. Pot culture – as done in urban agriculture in South East Asian countries – may be a solution.

252. In the face of this situation, it is not surprising that the Kyrgyz Republic still has significant malnutrition problems. However, the available information and the way data are presented do not provide a comprehensive picture of who in the population are affected (data almost exclusively pertain to Under-Fives), when malnutrition starts (data are presented in a too aggregate manner) and why (only presentation of percentages per indicator, no identification of related risk factors for a single indicator, such as stunting or IDA etc.). It is recommended that means be developed to collect population-based nutrition data on a regular basis to supplement project-related surveys periodically (every five years). Sentinel sites, possibly already available for other surveillance purposes, can be utilized to reduce costs.

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5.2.6 Major Conclusions and Recommendations 253. As far as Protein-Energy Malnutrition is concerned, Under-Fives tend to be stunted but not wasted. The well-analyzed UNICEF MICS 2006 data (the only one identified data base, covering a representative sample of the population) illustrates that stunting does exist at 6 months of age (5%), increases moderately in the second half year but exponentially increase between 12-24 months (15%), and remains at this level till age 4 years. This trend clearly indicates that children 6-24 months are the first (and probably the only) target group for direct health and nutrition interventions.

254. Theoretically inadequate food intake, in combination with a high morbidity load (including worms and parasites) – so-called synergism of malnutrition and infection – are the immediate causes of stunting at the individual (child) level. In a family context, food availability, allocation of foods to the child, composition and energy-density of complementary foods, and child care are the main underlying factors. There is a great need for an assessment of the characteristics of the stunted child and its family, to arrive at appropriate interventions and behavioral change messages which are do-able, both from the providers’ and the clients’ perspectives.

255. It is recommended that community-based activities be given a priority, including Growth Monitoring and Promotion (GMP). GMP provides an entry point for the behavior change interventions and the basis for such animating exercises as Participatory Learning for Action (PLA). Such efforts should be expanded throughout the country as resources permit and it should be seen as an integral part of the MoH program, not as a project that comes to an end as donor funding terminates.

256. The nutritional status of infants (0-12 months) cannot be separated from that of their mothers – in pregnancy and during lactation. Undernourished (chronically energy deficient = CED) pregnant women tend to be even more undernourished after delivery (known as maternal depletion as fat reserves were used to subsidize fetal growth). It is known that particularly the fat content of breast milk is lower in chronically energy deficient mothers. While breast feeding promotion must be vigorously pursued, if at all feasible weight and height of lactating mothers should be measured and appropriate actions should be taken for those with a BMI < 17 (moderate to severe CED).

257. No information of the nutritional status of women of reproductive age could be identified. As stated before adequate maternal nutrition during pregnancy indirectly but significantly contributes to the achievement of MDG goals for Infant Mortality Rate and Maternal Mor- tality Rate. Low birth weight predispose to peri- and neonatal mortality, and even post- neonatal mortality. CED and micronutrient deficiencies are associated with maternal mortality. Hence, at least weight and height (BMI) should be included in all health (and nutrition) surveys. Pending the availability of such information, weight and height already recorded during antenatal visits can be properly analyzed (if quality of measurements is ensured!) and obviously appropriate actions should be taken.

258. Anemia (IDA) is the most prevalent and severe nutritional problem in the country. It most likely affects the whole population and not only pregnant mothers, infants and preschool children. The remarks made for data analysis and presentation of Under-Fives nutritional status pertain to IDA as well. Unless data are presented, relevant for action, it is a waste of money to collect, analyze and report them.

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259. There are three strategies to address micronutrient deficiencies, in this case IDA, namely (iron) supplementation; food fortification and dietary approach. In view of the magnitude of the problem wheat fortification is the most appropriate and potentially the most cost- effective and sustainable approach. At present the many constraints (production, marketing, affordability, awareness, etc.) will limit its effect at the short term but given the need for wheat fortification as a line of prevention, all efforts must be directed to overcome these obstacles. Launch a vibrant and vigorous Campaign that will inform both the public and the policy-/decision-makers about the nature, extent, the (health, education, economic) consequences and costs of IDA in the Kyrgyz Republic. At the same time subsidize its use in well-targeted groups (geographical or socio-economic or biologically vulnerable) and selected institutions (kindergarten, preschool, etc.). With such an intervention one will hit at least three birds with one stone: (a) stimulate the producers (mill owners) as it will increase the market; (b) familiarize the families (mothers) with the taste, color, texture of the fortified wheat; (c) among regular users a potentially shift in degree of IDA from severe to moderate; moderate to mild and mild to normal.

260. Iron supplementation has been routinely implemented with the same protocol and the same approach, apparently without effect. Is that so or (a) are available Hb values not reliable?; (b) are we filling a leaking bucket (mal-absorption due to tea consumption, worms, parasites?; (c) are iron pills always available?; (d) is compliance the major constraint?) It should be noted that severe anemia (IDA) are cases that belong to the clinical maternal health component. Iron supplementation is used as a strategy for prevention and reduction of mild and moderate degrees of IDA. All efforts should be directed to an effective approach.

261. The dietary approach in IDA is unknown in the Kyrgyz Republic. Ultimately nutritional deficiencies should not be addresses as infectious diseases. Any community-based strategy for prevention of IDA should include efforts to improve the availability and affordability of nutritious foods. Nutrition is a cross-cutting issue and requires a multisectoral and holistic approach.

262. IDD: The political commitment, supported by the required legal endorsement for iodization of salt, the effective collaboration – coordination of the Government and donors in financial and technical terms, the focus one a clear strategy for production, marketing and promotion of iodized salt has resulted in a success story. Maintenance of the surveillance system as well as a continued promotion (using all entry point for adequate behavior and practice) are essential to prevent a fall-back. In addition, full support should be given to have a universal salt iodization according to the quality prescribed.

263. Vitamin A deficiency exist at the sub-clinical level. The current intervention of a bi-annual distribution of massive dose vitamin A capsules to Under-Fives and mothers in the postpartum period need to be continued until the population can afford to have preformed vitamin A rich foods.

264. Rickets (rachitis) systematically appears in RMIC statistics (health facility based). It is recommended to pay attention to the diagnosis and prevention of this deficiency at the FAP and community levels.

265. Most project-related surveys, such as Project Hope, CBECD1, report positive changes in mothers’ knowledge of and attitude to the recommendations for the duration of EBF and the timing of complementary foods. The usually do not report a change in practice. Also in the population-representative sample of UNICEF MICS 2003 and UNICEF MICS 2006 infant feeding practices did not significantly change. A critical review should be made f the current ways of breast feeding and child feeding promotion complemented by an assessment of enhancing and obstructing factors, using social science methodologies.

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5.3 Early Child Care and Education (ECCE)

5.3.1 The Current ECCE Status 266. The term Early Child Care and Education for children refers to activities with children under compulsory school age, regardless of setting, funding, opening hours or program content (OECD 2002)50.

267. Recent reports from UNESCO (2005)51 and OECD (2006)52 highlight that the fundamental grounds of children’s emotional, intellectual, physical and social development are laid in their early years. These fundamentals address the importance of the connecting links between health, nutrition and early access to education especially for children originating from weak social and/or migration backgrounds or suffering from a disability. The most effective early child development programs provide direct learning experiences to children and families, are targeted toward younger and disadvantaged children, are of longer duration, higher quality, higher intensity, and are integrated with family support, health, nutrition, or educational systems and services (CDS, 2007)53. Consequently, in the field of education and care, a lack of preschool education services can be seen as a high risk pro- voking multiple developmental delays, including poor achievement in school.

268. UNESCO (2006)54 describes that with the earlier extensive provision of preschool and early childhood education in kindergartens in the Kyrgyz Republic, the majority of the children joining the school system already knew how to read and write. However, after the decline of PEO system in the 1990ies most children now enter grade 1 unprepared either academically or socially.

269. Findings of a research conducted in the Kyrgyz Republic during the period 2001 to 2005 show an overall trend to deteriorating school achievements and declining standards in the quality of primary education in Kyrgyz Republic55. This trend was disclosed through the results of numeracy and literacy tests conducted in the framework of research studies. Re- sults in literacy and numeracy in primary school substantially decreased between 2001 and 2005. According to a UNESCO/UNICEF (2001/2006) 56 survey, about 40% of pupils of primary school failed the literacy and numeracy test and nearly 20% failed life skills57.

Table 10: Monitoring results of numeracy, literacy and life skills in 2001 and 2005 (UNICEF, 2006 page 74). Life skills Literacy test Numeracy test

Passed Failed Passed Failed Passed Failed

2001 75 25 59.1 40.9 81.4 18.6

2005 77.9 22.1 44.2 55.8 58.8 41.2

50 OECD (2002), “Strengthening Early Childhood Programs: A Policy Framework”, in Education Policy Analysis, Paris 51 UNESCO (2005): EFA Global Monitoring Report. (Data available at: http://portal.unesco.org). 52 Stephen Machin (2006): Social Disadvantage and Education Experiences, in OECD Social, Employment and Migration Working Papers No. 32: DELSA/ELSA/WD/SEM(2006)1 53 Child Development Series (CDS) (2007). Child development in developing countries. Strategies to avoid the loss of development tal potential in more than 200 million children in the developing world. Vol 369 January 20, 2007, available: www.ich.ucl.ac.uk/website/ich/academicunits/cihd/NewsandEvents/Engle_paper.pdf 54 Unesco (2006): Country profile prepared for the Education for All. Global Monitoring Report 2007 55 MoE (2006): Comparative Results of Pupils’ Achievements in Numeracy, Literacy and Essential Skills in 2001 and 2005. Bishkek 56 UNESCO-UNICEF (2001). Monitoring of Learning Achievements (4th grade) 57 UNICEF (2006): Monitoring of Learning Achievements (4th grade). Bishkek, 2006

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270. The UNESCO supported “Monitoring Progress in Education (8th grade) International Re- search” 58 undertaken in 2002 – 2003 in the Kyrgyz Republic substantially evidences lower achievements in mathematics and sciences. The research findings indicate that progress in education is falling faster in rural than in urban schools. This conclusion is supported by data from the Ministry of Education, Science and Youth Policy (MOESYP) and the results of the General Republican Test for school leavers, which has been established in 2003 (Fast Track Initiative, p. 11). Average scores of tests decreased to a higher extent in rural areas than in urban areas:

Table 11: Average scores of test results by category of candidates 2003 2004 2005

Total in the Republic 114.2 122.4 112.7 Bishkek school leavers 136.4 144.3 137 Oblast centre school leavers 120.1 127.1 118.5 Rural school leavers 108 114.9 103.6

271. Interview data with Oblast Educational Department, too, indicate a substantial threat that school relevant developmental processes show a general deterioration in regions without institutionalized ECCE services.

272. Preschool teachers report a substantial lack of preparation for children not attending the kindergarten. Together with the empirical data collected within the scope of the above mentioned monitoring and testing instruments, the assessment of the stakeholders themselves demonstrates that the decline of the preschool services in post-Soviet times has had a negative impact on the general development potentials (in terms of future school achievement) of children in Kyrgyz Republic.

273. A lack of kindergarten facilities may also result in overcrowding the early grades of primary school, particularly in rural areas. Before independence, when kindergartens provided care for 1 to 6-year-olds, most children started grade 1 at 7 years of age. In 1991, 27,200 6- year-olds attended grade 1; in 1999, 40,000 6-year olds were attending grade 1, suggesting that families are using grade 1 as kindergartens. The result is added pressure on grade 1 teaching (UNESCO 2005).59

274. These negative impacts are also likely to show future major macroeconomic effects. Bartik (2005)60 points out, that states have begun to view educational investments as important economic development tools. From a national perspective, preschool education increases the present value of real earnings by almost $4, per $1 of preschool spending. A decline or even lack of preschool education therefore decreases future economic power (mainly in terms of human resources) of the Kyrgyz Republic.

58 UNESCO (2003). Monitoring Progress in Education (8th grade). Bishkek 59 UNESCO, (2005), EFA Global Monitoring Report. (Data available at: http://portal.UNESCO.org). 60 Bartik T.J. (2005): The Economic Development Benefits of Universal Preschool Education Compared to Traditional Economic Development Programs. W.E. Upjohn Institute for Employment Research, Michigan.

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275. In addition, a special emphasis should be put on the specific situation of children with disabilities since this group is at risk of being excluded from any kind of preschool education. The registration of children with special needs at an early age is no common practice. They are mainly registered in medical facilities. However, there are no special programs for supporting such children. They are considered as part of a family problem and parents of such children are entitled to apply for material support, generally granted only once, or ask for help in placing a child in a hospital or for paying the costs of medical treatment. In- tegrative education at schools and kindergartens in the Kyrgyz Republic began in 1997 in 10 kindergartens and 19 schools. (NAP 2001)61. The objectives of the Integrative Educa- tion project were early detection and integration of children with special needs into the comprehensive educational system and to provide dignified life and conditions for children to fulfill their potential. (ADB 2004)62. Taking into account possible risk groups showing a disability or a disadvantage with up to 7% of children per birth year (Soriano, 2005)63, it can be assumed that children with special needs are mostly excluded from preschool education in the Kyrgyz Republic.

276. Generally, one decade later, this situation shows some changes. In 2007, 20 special kindergartens could be identified, representing a 100% increase of facilities. However, the establishment of special facilities for children with special needs is only one aspect in integrative education. The major goal has to be the inclusion of children with special needs into mainstream kindergartens. Based on available data (Save the Children UK)64, only first steps towards full inclusion and participation of children in the Kyrgyz Republic can be observed. In Osh-City, for instance, 5 kindergartens offer integrative settings in mainstream PEOs for 14 children, in Naryn for 20 children.

5.3.2 Child Care Practices at Home and in the Community 277. ADB (2004)65 observed a general lack of official data on Education and Care indicators in general in Kyrgyz Republic. Available ADB data (2005)66 showed that families had some ideas about what were the physical capacities of their children; however they were not aware of cognitive and emotional abilities of children. Parents did not recognize the importance of engaging their children in activities and games that would stimulate their learning skills. These results show that better parenting programs should raise the parents’ awareness on both the needs and importance of child development activities in their early years of life.

278. UNICEF (2006)67 reports that in rural areas in the Kyrgyz Republic parents are paying insufficient attention to their own children. Their care is focused on physical needs with almost no attention to mental, cognitive and emotional development of the child. Major findings of the study are that (a) parents have difficulties in identifying the knowledge and skills which preschool age children should have with respect to their age and that (b) parents do not have adequate information on how to bring up children. As a matter of fact, information on nutrition, infant care, health and preschool preparation is lacking (UNICEF 2006, p. 9ff).

61 National Action Plan “Education for all”, 2001. 62 1st ADB CBECD Project’s Inception report, 2004. Bishkek 63 Soriano, V.: Early Childhood Intervention in Europe. Brussels: European Agency for the Development in Special Needs Education), 2005. 64 Data presented during expert interview by national advisor on inclusive education of Save the Children UK (2007). 65 1st ADB CBECD Project’s Inception report, 2004. 66 1st ADB CBECD Project’s Baseline report: Working paper, 2005. 67 UNICEF: Monitoring of Learning Achievements (4th grade). Bishkek, 2006.

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279. Relatives are likely to look after children when women are working (mostly by “controlling” the activities of the child), but most of the time children are left on their own.

280. Observations made by the national and international team while traveling through the villages showed that preschool children were seen in the streets left to themselves or being carried by siblings not older than 7 years. School age children, too, were observed transporting water from wells or central water pipes into their homes. Also due to the necessity to start to work in early years it can be assumed that preschool children left unattended or not given the care they need, will not develop the skills and abilities required by teaching institutions to sufficiently master their school career.

281. A significant numbers of children work on fields or farms owned by their families, starting at the age of 7 – 9 (61.2%). Most working children aged 9 and above have already been working for more than two years (Fast Track Initiative, 2006, p.15)68. ILO (2001)69 highlights that child labour e.g. in Bishkek even extends to children younger than 5 years of age (begging children on the streets). Some children drop out of school, as they have to work. According to ILO, statistics on the number of working children under the age of 15 in Kyrgyzstan are unavailable. However, 5,000 to 7,000 children were estimated to be living and working on the streets70.

282. Regarding care activities, mothers spend up to 1 hour per day sleeping or watching TV (UNESCO)71. Also ADB (2004)72 points out that family activities were mainly limited to watching TV and going out (of the house). Within the present household survey, too, the most frequent activity that parents shared with their children was watching TV (88%).

283. Within the focus group in Zarger, mothers reported to be the main persons responsible for the process of caring for the child. The knowledge and skills of how to “care” for a child mainly comes from the grandmothers (“babushkas”) or any other older women in the wider family context. Fathers are mainly busy with field work. Mothers-in-law also have an influence on how to take care of the newborns (UNESCO). Collected answers within the current focus groups are in contrast to 2005 ADB73 data, where families reported that fathers are much more involved in care and education activities. These contradictory findings can be partly explained by the assumption of highly socially desirable answers within surveys. For instance, it is highly socially desirable that fathers are involved in education and care, even though daily practice might be different. The PEAKS study74 (2006), too, showed that participation of fathers in early childhood education and care is insignificant regardless of the ethnic groups.

284. Some difficulties could be observed when parents were asked to describe their perception of how “to care for a child”. In this context, most of the responses came from professionals (former preschool teachers, medical staff). For parents to take care of their children means to teach their children “to wash their face and hands, to ask for something or to know poems and stories”. The most frequent activities that parents shared with their children were watching TV (88%), teaching hygiene (86.5%), correcting misbehavior (76.4%).

68 Education for All: Fast Track Initiative. Accelerating process towards quality universal primary eduation (World Bank, Unicef, MoE), Bishkek, 2006. 69 ILO: Child Labour in Kyrgyzstan. An Initial Study, 2001. 70 LABORSTA, ILO Bureau of Statistics:, [database online http://www.ilo.org/stat/], 2003 71 UNESCO (2006): Kyrgyzstan – Early Childhood Care and Education (ECCE) Programmes. Country profile prepared for the Education for All Global Monitoring Report 2007. 72 First ADB CBECD Project’s Inception report, Bishkek, 2004. 73 First ADB CBECD Project’s Baseline report, Working paper, Bishkek, 2005. 74 PEAKS: Parent and Community Involvement in education in pilot regions (monitoring and evaluation report), Bishkek, 2006.

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285. Caring occurs more incidentally since mothers are obliged to work 6-7 hours per day in the household. Older children keep younger children “busy”, parents report that it is important to them, that the toddlers are busy. Focus group data show that challenging behavior of the children could be corrected by “soft slapping” – depending on the age of the child. Mostly fathers express that this is for the “child’s good”. ADB report (2005) highlights the risks of extensive verbal punishment of the children.

286. What can be observed is a lack of “joint attention” of the parents in terms of doing something “meaningful” together with the child (e.g. performing family games, playing together etc). However, this aspect of “joint attention” is seen as a major stimulating factor regarding the development of the child (e.g. increasing attention and cognitive skills in young children.)

287. In addition, UNICEF states that “families do not practice joint activities with their children (except for work related activities)” and 3-5 years old children start to be involved in housework (UNICEF 2006, p. 10). Current household survey data describe that in families, usually having 5 to 6 children, older children take care of the younger ones. Both UNICEF and ADB data indicate that the first step to raise awareness regarding the needs of children is informing/teaching parents.

288. Parents report having only few toys at home. There are almost no books available for children. Fathers show little knowledge of how to produce toys for their children. They emphasize that they would need more information on child development and care, or by seminars or via TV. Also books for parents are regarded as useful. Organizing seminars or distribut- ing books could be organized through the AO, FAPs or schools. Seminars on education and care are assessed as being efficient if social workers and/or medical staff participate.

289. Findings of the 2005 ADB baseline study also show that relatively few families have sufficient learning materials available in the house, especially in Kyrgyz. The currently ADB, UNICEF and AGA Khan support TV program „Keremet-Koch“ should be highlighted in this context as a successful tool to raise awareness for parents and attract the attention of small children.

290. Focus group findings are in accordance with household data results pointing out the need of information for parents, lack of adequate stimulation material (e.g. books for children) , especially in Kyrgyz language, and needs of (skilled) persons to look after the child, as mostly older siblings take care of the younger ones. Caring processes are mainly connected with watching TV, hygiene, correcting behavior, and story telling.

291. The 2005 ADB baseline study, too, concludes that parents need to understand the importance of their children’s early years in life in which they gain most of the skills necessary to grow up healthy. Recent data reflect a similar picture: Both the secondary data analysis and qualitative research indicate that the knowledge of parents on the development, care and education of children within rural areas of the target raions is low in terms of develop- mentally adequate stimulation and care of the child. Television and seminars organized by specifically trained staff from the pedagogical or medical/social field are regarded as suitable ways to inform parents of child development.

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292. Regarding Community Initiatives on ECCE, the focus groups with the Heads of AO highlight the important role of AOs in the implementation of programs. However, data of the current household survey indicate that more than half of the parents do not think that at present AOs contribute much to the child’s wellbeing. Another 8.7% assesses AO as “not so helpful. 8 of 10 respondents reported that they never heard about programs/activities designed for families and children taking place in the AOs. Comparable data also could be found in the 2005 ADB baseline survey. Furthermore, focus group findings with parents - with the exception of the strong community orientation in Aravan (Mahalia) - indicate a lack of substantial community initiatives on education in the visited villages.

293. The Parents (focus group in Zarger), however, seem to be aware of this situation: “We are dreaming our children will have the opportunity to have an education”. On the other hand, in some raions of the target regions, parents also showed a certain degree of passivity: “Until now we did not think of kindergartens, as we thought that there is no possibility”.

5.3.3 Access to ECCE services 294. Since the Kyrgyz Republic gained its independence, the preschool education system has shrunk drastically due to the universal closure of state kindergartens owned by enterprises and collective and state farms, which were unprofitable or bankrupt. The number of preschool institutions declined due to the general socio-economic crisis in the country, and the majority of kindergarten buildings being sold off for private commercial use. (Fast Track Initiative, FTI, 2006 p. 7).

295. The number of preschool facilities has declined substantially since the independence of the Kyrgyz Republic (see figure 17): The number fell from 1.604 in 1990 to 448 in 2005.

Figure 17: Development of the Number of Preschools and Number of Children in the Kyrgyz Republic 75

units thousand people 1600 160,0 1400 140,0 1200 120,0 1000 100,0 800 80,0 600 60,0 400 40,0 200 20,0 0 0,0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Number of preschool institutions Number of children (thousands)

75 MoE, Education Development Strategy of the KYRGYZ REPUBLIC 2007-2010; Approved by the Ministry of Education on 19.10.06 (order # 658/1).

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296. According to data from the Statistics Committee and Ministry of Education (MoE) currently, about 9% of children between 4 and 7 years are covered by state kindergartens (National Statistics Committee, 2006)76. With the deterioration and the decline of state kindergartens during the post-Soviet period, the coverage of children by preschool education in remote regions sometimes dropped to 3%77.

297. UNESCO (2006)78 evaluates the overall percentage of children entering primary education in the Kyrgyz Republic with previous preschool experience 13.9% (regarding school year 2003/2004). In comparison, OECD (2002, p.14)79 points out, that most children living in the OECD countries will spend at least two years in early childhood education and care settings before beginning primary school.

298. State kindergartens are mainly located in oblast and/or raion centers. The above mentioned decline of kindergartens affected rural preschools to a higher degree. Despite the large number of rural inhabitants, only 27% of all children attending PEO in the country are of rural origin. Therefore equal access to PEOs especially in the peripheral rural areas of the raions is not assured at the moment. In 2003 ADB launched a project “the Community- Based Early Childhood Development Project (CBECDP)”. This project plans to cover over 20.000 preschoolers through creation of community-based kindergartens in extremely poor raions.

299. These extremely poor regions (as identified by the Social Passport Data) show an even more severe lack of PEOs (e.g. in the target raions of the 2nd ADB project the current attendence rate is 3.5%) ranging between 2.4 and 4.3% of all children (age 0-7). This is lower than the national average (approx. 9% according to MoE 2006) in the Kyrgyz Re- public.

Table 12: Percentage of Attendance in PEO in Osh, Batken and Jalalabad Oblasts Oblast + target Number of chil- Number of chil- Number of % of at- raions (2nd ADB dren in the tar- dren attending PEO tendence CBECDP) get raions* PEO

OSH (Aravan Uzgen, 127 643 2726 32 2.13 Karasui)

BATKEN (Batken raion, Kadamjai raion, Lialiakski 72 334 2662 26 3.68 raion)

JALALABAD (Alabukin- ski raion, Aksyi raion, 126 462 5892 78 4.66 Bazar-korgon, Nauken raion, Suzak raion) Source: MoE

76 National Statistics Committee of Kyrgyz Republic. Education and Science in Kyrgyz Republic. Statitistics collection. Bishkek, 2006. 77 Community Based ECD Project: Guidelines of Establishing Community-based Kindergartens, Bishkek, 2005. 78 Unesco (2006) Kyrgyzstan: Early Childhood Care and Education (ECCE) programmes. Country profile prepared for the Educa tion for All Global Monitoring Report 2007. 79 OECD: “Strengthening Early Childhood Programs: A Policy Framework”, in Education Policy Analysis, Paris, 2002.

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300. Results of the needs assessment survey as well as data of Development Strategy show that over two thirds of parents would like their children to attend pre-school organizations (Development Strategy of the Kyrgyz Republic 2007-2010, p.9)80. Secondary and sociodemographic data indicate high unmet needs of parents regarding the availability and attendance of kindergartens for their preschool children (e.g. comparable data available for European countries indicate up to 75% kindergarten attendance of preschool children).

301. Recent household survey data indicate that for 81.9% of the parents’ lack of sites can be seen as the biggest obstacle to enroll children in PEOs. With respect to ADB (2005) data, too, what parents mostly need is the establishment of preschools, indicating that there is a real demand and need from the local population for preschools.

302. ADB (2005a)81 shows that the main motivation of parents to enroll children in PEOs is the necessity of full day care and preparation for school. Similar reasons and needs were also found by UNICEF (2006): The main expectations of parents with respect to preschool attendance are that the child should be provided a full day care program if we take into consideration that full day kindergartens were the only available model to date. Other important expectations: the right routine for children, activities for child development and preparation for school.

303. Data about the assessment of alternative forms of kindergarten (e.g. half day care) have to take into account the work situation of parents. For urban areas, alternative forms of municipality based kindergartens were not accepted by the parents due to work related schedules (UNICEF 2006). However, within the first CBECDP, due to factors of practical implementation (premises, heating), a major part of established kindergarten followed also alternative models, and this even though – due to work schedule and transport – parents would have preferred full day models.

304. Expert interviews and a focus group with parents in Zarger, Osh Oblast, showed a high need for kindergartens. However it also showed that many parents do not have a clear picture about the spectrum of alternative and possible models for preschool education and how to implement them. This data corresponds to former research according to which the precondition of establishing community based kindergarten is community mobilization (ADB 2005a). The community assesses the needs by themselves (e.g. full kindergarten due to parents’ working hours and necessary resources (e.g. possibilities to organize heating in winter time) in order to organize their own PEO. Some staff resources (unemployed former preschool teachers) could be identified. Focus group data are congruent to UNI- CEF as generally human resources are available: The main problems are space (establishment and facilities) and financing.

305. Parents working during day time and preparing children for school were reported to be major reasons to enroll a child in a PEO. In Zarger no kindergarten was available for 1,800 households (about 1,700 children at preschool age). The last kindergarten was closed 25 years ago. Parents reported a lack of information about the possibility of establishing a PEO. They expressed the desire to be informed on how to proceed to open a community based kindergarten. The AO should play a key role within such a process.

80 MoE, Education Development Strategy of the KYRGYZ REPUBLIC 2007-2010; Approved by the Ministry of Education on 19.10.06 (order # 658/1) 81 First ADB CBECD Project’s : Baseline report, Working paper, Bishkek, 2005.

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306. However, focus groups with the social workers (Jilaldy) pointed out, that in remote villages unemployed mothers, especially from a socially disadvantaged background might show some hesitation to enroll their children in a kindergarten, as the mothers themselves are at home the whole day. Household findings were in accordance with this assessment of the social workers. Nevertheless, creating a community based kindergarten could have some functional model for this highly vulnerable target group. Social workers estimate, that 6 to 10% of the parents are able to contribute concrete payment for a kindergarten. From their point of view most of the parents need their children to be in full day kindergartens.

307. Heads of the AO within the focus group pointed out, that there is a lack of information on how to establish community based kindergartens even though they report good knowledge about other international programs (e.g. ARIS). They felt that parents need kindergartens, especially full day services. The AO could cover operating costs such as heating and electricity; whereas the issue of salaries is pending. Some heads of AOs pointed out, that the cash contribution of the community (e.g. with respect to repairs or basic equipment) due to the general economic situation of AOs should be reconsidered within the 2nd ADB project. However, “contributions in kind” of the community could be increased. Further- more, increased repair costs (material) should be taken into account when calculating future Village Initiative Fund grants. The time consuming application process within the VIF grants should also be reconsidered. Suggestions were made to implement VIF- assessment or steering commissions on oblast level to accelerate decision processes. The AO estimates that concrete payment from parents might range between 50 to 150 Som per month. Nutrition could partly be provided in kind. However, parents or initiative groups need concrete information on how to proceed (how to write a project, create a budget).

308. The situation in a village in Aravan raion was slightly different as the AO was faced by a strong community initiative (mainly by the parents and a former kindergarten teacher of a closed state kindergarten). Experience in a community based kindergarten in Kara-Kulja raion also showed that a major initiative to establish a kindergarten was coming from a former kindergarten teacher, and that subsequently the AO found ways to co-finance the PEO. In the focus groups, the AOs expressed that it might not be a problem to find suitable houses or premises, but there is a need to repair them. In this context the AOs were informed about possibilities of support from international donors (ADB, ARIS, Aga Khan, Mercy Corp).

5.3.4 Quality of the PEO Services 309. In addition to a quantitative decline in preschool programs, the quality of preschool programs also deteriorated. The existing 448 kindergartens currently employ 2,388 teachers, not all of whom have adequate professional training and opportunities improve their professionalism (FTI, p8.)

310. UNESCO (2006) assesses that only 45.5 of preschool teachers are trained: The state-run preschool services employ more than 3,693 preschool workers. 1,761 workers have a higher education, 1,147 workers have a special college degree, 453 workers have primary education and 332 workers have incomplete higher education.

311. Based to the high turnover of professionals in this sector, the analysis showed a lack of reliable data on the present educational status of the preschool teachers. However, the situation for community based kindergarten is almost more difficult. As monitoring and in- service training structures for community based kindergartens are not yet implemented, kindergartens in communities run the risk to have no trained staff at all. Financial constraints can be regarded as major obstacle to participate in existing qualification offers (e.g. by the Teacher Qualification Institute). Furthermore, due to a shortage of books and

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the inexistence of internet connections, a lack of methodical state-of-the-art information for the teachers can be observed.

312. To increase the quality of the services, a major focus has to be put on the issue of qualification, primarily on in-service training for the teachers, mainly using the structure of resource kindergarten and of teacher qualification institutions. Just now (spring 2007), a major training initiative within the 1st ADB project for community based kindergartens and resource kindergartens was launched.

313. Based on observations within the focus group meetings (see annex) the quality of the premises, sanitary facilities, furniture and equipment can be assessed as poor. These observations are congruent with the parents’ assessment of the quality within the current household survey. An extensive photo documentation has been made during the field visits of the TA team, indicating that the quality of the infrastructure decreases with the distance to raion centers (see annex). There is an urgent need to assess the basic require- ment of repairs. A major emphasis has to be put on sanitary issues (toilets) and the heating situation, as both aspects pose a major threat to health parameters of the young children.

5.3.5 Constraints in PEO development

Cost factor 314. A major constraint is the cost of establishing PEOs. Even though the AOs express their will to co-finance, e.g. communal costs, salaries of the staff remain an open issue. In villages (e.g. in Aravan) with a high community mobilization it was possible, however, following an initiative taken by a former state kindergarten teacher and the parents, that the staff salary was included in the state budget. This example was observed in other AOs, too.

315. AOs might have the know-how to initiate projects aiming at the development of PEOs, but report major concerns with respect to financing and therefore seem to remain in a “waiting” position. Parents express their need to establish a PEO, but lack the concrete know-how and remain mostly passive, if no key-person is available to give the impulse.

316. The two level budgets within the scope of ongoing decentralization processes are seen as a possible way out of this dilemma, even though final proceedings are still open. Payments from the parents are primarily based on the yearly budgets of the kindergartens, creating substantial differences between the PEOs in different regions.

Infrastructure and Equipment 317. As pointed out in the household survey and observed within the focus groups with educational departments, the teacher qualification institute, and resource kindergartens, the quality the equipment and the infrastructure is deteriorating. The establishments visited during the focus group meetings – with increasing distance from central urban structures – showed a continuous decrease in infrastructural quality (e.g. sanitary facilities, heating). Furthermore it could be observed, that community based kindergartens – compared with existing state kindergartens – suffer a substantial shortage of equipment. This deficiency is partly compensated by the kindergarten teachers’ initiatives to create their own methodological materials, assisted by the parents.

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Qualification of the Teachers 318. In addition to the fact that in some community based kindergartens the teachers may not have any specific training in the field of ECCE, the information transfer (e.g. from the Teacher Qualification Institute or from resource kindergartens to the community based kindergarten teachers) can be seen as a further major constraint.

319. Again the cost factor is crucial. Transport costs (connected with the decrease of public transport) and per diems seem to be major reasons to limit the necessary knowledge transfer. Secondary aspects (e.g. methodological guidelines for resource kindergarten on how to support community based kindergartens) might be solved easier once the questions of concrete knowledge transfer and transport are solved.

Monitoring 320. The recent change in the landscape of PEOs requires establishing more community based kindergartens. This will need clear regulations and monitoring tools for the local administrative bodies. Current standards are mainly guided by former Soviet models. The monitoring of community based kindergartens – also with respect to health and hygiene standards – is an open issue. This includes any kind of licensing or attestation, which – according to the focus groups – should be organized on the regional level.

Information on Care and Education 321. Information on care and education is currently provided to parents mainly by grandmothers or elderly persons in the family or via TV. These “babushkas” were socialized in former Soviet times within well established educational systems (kindergarten – schools etc.) and are an important source of knowledge in issues related to education.

322. Information on care and education within the current parent generation is transmitted from these grandmothers with limited external support – mostly given by health workers. It remains open to what extent modern theories of attachment, needs orientation, sensitivity, and self-efficacy are available. Therefore, during the next generation, existing “intuitive” knowledge on education and care may “fade out” without external professional input (e.g. through booklets on development and care, seminars or TV programs for the parents alone or together with the child).

323. This effect could also be witnessed within the focus groups of parents, as it seemed quite difficult for parents to define the adequate care and education for their children. To prevent this “washing out” of still existing knowledge, major efforts should be undertaken to sensi- tize parents regarding early child care and education by trained staff.

Community Mobilization 324. Stakeholders with sufficient motivation (e.g. former kindergarten teachers in the villages) can be found to mobilize parents, even though most of them are near retirement. Given their age, these “resources”, too, will slowly disappear. There is, however, a need to use these “resources” as promoters for community mobilization during the forthcoming years. They have the necessary knowledge and motivation to establish community based PEOs.

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5.3.6 Major Conclusions and Recommendations

Conclusions 325. There is a substantial need for the parents to enroll their children in kindergarten or preschool programs. Currently, this need cannot be satisfied, primarily due to a lack of PEOs, especially in rural areas. Parents primarily need full day services, even though there might not be enough information about alternative forms.

326. Financing these services (especially the salaries of the teachers) is a major inhibiting factor. Current financing systems (mainly the contributions of the parents and the salaries of the teachers) are quite heterogeneous. There is a need to find comparable ways of financing PEOs throughout the Kyrgyz Republic, especially with respect to the pending situation of “double level budgets”.

327. Strong community mobilization – mainly based on (one) stakeholder(s) – has the capacity to overcome this constraint – in close co-operation with the AO. The community will need concrete know-how from experienced experts in the field as to how start initiatives in the field of PEOs.

328. Existing services need to improve their quality (on the level of infrastructure, professionalism of the staff, and equipment). The quality of premises decreases the more they are located in rural areas. Community based kindergartens are affected to a higher extent by quality threats than urban (state) based kindergarten. Basic hygiene (toilets) and safety standards (unsecured sites) were not met in some kindergartens. Heating is a major concern in many community based kindergartens.

329. Methodological equipment is primarily based on creative strategies of the kindergarten teachers with the help of the parents. Especially the function of resource kindergartens will have to be clarified: The transfer of knowledge (in terms of a cascade model) has to be ensured, solving the problem of logistics (transport and accommodation costs for participating teachers) and of available state-of-the-art material or information. The transfer of knowledge top down has to be improved.

330. Monitoring structures need to address new alternative forms of community based kindergartens (including information of all relevant partners: educational departments, heads of kindergarten).

331. Existing information on care and education in the families tends to “fade out”. Parents, especially in rural areas, are mainly occupied with work and daily routines, caring processes focus on hygiene and on the question of how to keep the child busy. The lack of PEOs risks bringing about a situation where preschool children will experience a lack of age adequate stimulation. Therefore, both the knowledge and the skills of parents to care for their child should be increased, e.g. through seminars, brochures or TV programs. A special focus should be given to the situation of fathers.

332. Generally, the current ECD status in Kyrgyz Republic can be seen as highly connected to:

a clear lack of information and access to information of the for child parents with respect to both the education and care of preschool children; poor living conditions (mainly in rural areas of the target raions) increasing the risk, that due to work schedules small children are left alone or kept busy by older sib- blings without necessary age adequate attention a lack of preschool services decreasing the number of enrolled children

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threats regarding the quality of existing services, be it on the level of infrastructure (safety, hygiene, heating), be it on the level of furniture, equipment or necessary space for child centered activities. The danger, that developmental parameters of children especially with respect to academic skills in rural areas begin to decrease and that the main responsibility for socialization lies with the school system (at a moment where the child has already gone through major developmental processes).

Recommendations and Strategies 333. There is no doubt, that more children in the Kyrgyz Republic have to be enrolled in PEOs. As already pointed out, the decline of relevant life skills and of knowledge on education and care within the general population represent major threats for the future development of the Kyrgyz Society. However, recent data show a certain ambiguity regarding necessary structures to reach this goal:

334. Based on the data shown above (decline in school-relevant skills, low percentage of national enrolment in PEOs compared to other countries) there is an objective need to enrol a higher number of children in PEOs to respond to the current situation of children not being mature enough (both in cognitive, emotional and social respects) to cope with the challenges of the school system. Therefore, increasing the number of enrolled children can be considered as one of the major strategies to oppose poor academic output and drop-out tendencies. To reach this goal the number of enrolled children is the main indicator, regardless of the type and form of PEO. Alternative forms (e.g. half-day groups allowing for 2 distinct groups to be cared for, one after another.) might increase the number of enrolled children to a higher extent than full-day groups. Furthermore, the necessary equipment for half-day groups may be less cost intensive compared to a full-day service (e.g. the necessity of beds).

335. On the other hand, it can be supposed that the only increase of 100h for preparatory groups or mother schools before children enter school cannot be considered as efficient alternatives compared to e.g. half day groups. Preparatory groups and mother schools primarily focus on academic skills and do not provide for the necessary social and emotional and motor empowerment the children go through while in a half- or full-day PEO.

336. Therefore, the second objective need focuses on prolonging the period of enrolment. Chil- dren should be enrolled in PEOs, if possible, three years before school. In most developed countries, up to 90% of children (age group 1 year before entry in school) attend PEOs. One emphasis during this year prior to school is to teach children “how to learn”. Short preparatory courses – within this context – only teach pre-academic skills (literacy, numeracy), but not how to initiate processes of information management (e.g. in terms of self-guided learning processes, group learning processes etc.). Objectively, this necessary “preparatory year” is not related to a specific form of PEO (as e.g. European experiences show). For decades PEOs in Central Europe were primarily organised as half-day models; with more women wishing to be employed and thus compelled to use full day services, such PEOs have become more important during the last years.

337. As seen above, parents themselves report that they wish to enrol their children in full day services. This wish primarily stems from their experience made in Soviet times. Since parents (and also professionals) do not have sufficient information about alternative models, they express doubts about the concrete implementation of alternative forms:

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338. Their main arguments referred to the following:

Availability of healthy food in PEOs Logistic problems (transport of the children from home to PEOs) taking into account the parents’ work on the job or at home Issues of childcare (availability of an adult person while parents are working, despite a high rate of unemployment)

339. Increase the numbers of PEOs, especially in rural areas to facilitate age adequate social- emotional and cognitive learning processes for preschool children in the Kyrgyz Republic is thus of primary concern. The rate of attendance – compared to international numbers is far too low. Low enrollment rates are mainly due to a lack of services. Especially rural areas – after the collapse of the Soviet Union - were affected to a higher extent by the deterioration of the preschool system than urban areas. The difficult financial situation of the parents cannot be identified as the main obstacle to enroll children in PEOs. However, this aspect has to be taken into account when it comes to financing community based PEOs. At the moment, parents’ contributions differ significantly.

340. A special emphasis has to be put on the situation of disabled children. The majority of such children (if they are enrolled in PEOs) are attending special state kindergartens. At the moment most children with special needs are excluded from the PEO system. Main- stream inclusion of children with special needs just starts and needs substantial improvement, especially regarding the number of fully integrated children in mainstream PEOs.

341. Apply flexible realistic and needs oriented models of PEO establishment. Due to the necessity to find suitable premises, perform repairs, facilitate basic equipment and enable transport of the children to PEOs in remote areas, the models to be applied will have to be flexible: Even though parents know and appreciate “full day models”, including the possibility for the children to rest (beds) and providing nutrition (which in areas with the risk of malnutrition is important), the establishment of other alternative forms have to be considered. Due to financial restrictions or the unavailability of premises, it will not be possible to establish full day services in all AO or villages.

342. As the State Standard facilitated the necessary legal frame for alternative forms the following strategies have to be considered to reach the primary goal to increase the number of children in programs: i. To use empty school rooms e.g. in terms of half day models ii. To “split full day service” into 2 half day services to provide access e.g. for 2 groups (morning group/afternoon group), taking into account issues of transport of the children. iii. To create home based models (comparable to European models of “day mothers”, taking into account the necessity of an juridical body, quality control and payment for such services. Mainly in Europe these services are run by NGOs who ensure basic qualification of the “day mothers/teachers”, quality control, parent contribution and paying of salaries. Within community mobilization and participation processes it should be considered, that parents themselves create such bodies. iv. To use seasonal models e.g. for those parents who are going on “jailoo”. v. To integrate mobile services for extremely remote areas or children following “jailoo” vi. To strengthen – together with the school system – preparatory courses (100 hours) before entering 1st grade.

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343. Identify motivated and experienced stakeholders to mobilize the community. Comapred to the Health System (VHC, FAPs ect.), the (preschool) educational sector within the communities shows a lack of existing (community mobilizing) structures (e.g. in terms of a Vil- lage Education Committee). However, experience shows that communities can be mobilized to establish PEOs, if motivated and experienced stakeholders (mainly former preschool teachers from Soviet times) can be identified). These key persons in the educational field – more so than other respectful person in the village – are motivated, to mobilize the community. They have the necessary know how, both in terms of organizing a PEO and in terms of the developmental needs of the children. In close cooperation with AO and existing structures of community mobilization, these key persons should be identified and made responsible for the process of establishing PEOs.

344. Provide necessary information how to establish a PEO. Motivation of the communities to establish PEOs does not seem to be the main issue. Parents are motivated – even if they do not experience satisfactory support by the local authorities. Possible funds to repair premises or to obtain necessary basic equipment are another motivating factor. However, communities show a lack of concrete knowledge how to start and implement projects to establish a PEO. Furthermore – based on their own socialization within the Soviet Union - parents do not always have concrete ideas about possible “alternative” models of PEOs. Therefore easy and understandable information has to be provided for the communities and the key person, how to design a project, to open a community based PEO (a) how to mobilize the community, (b) how to find a building, (c) how to assess repairs needs and collect own contribution, (d) how to write a project proposal including sustainable budgets, (e) how to start and ensure basic quality criteria.

345. Closely co-operate with the community and the AO regarding PEOs. Above mentioned activities require close cooperation with local authorities, including Educational departments e.g. on raion and oblast level and information transfer from resource networks (e.g. resource kindergarten, teacher qualification institute)

346. Establish transparent and comparable systems of financing of PEOs (parent’s payment, AO, state). In addition to the operative activities of the Community, regulatory and normative systems of financing have to be worked out to ensure sustainability of established PEOs. This has to be performed on the government level (MoE), taking into account, that the current system creates a major inequality in terms of access to PEO systems: Urban families – with access to existing state kindergartens – obtain services (theoretically free of charge, with the exception of nutrition for which they pay). Rural families – with no access to State kindergartens have to find ways of financing without support of the state. Conse- quently, this means that parents in rural areas (if AOs do not cover the salaries of the teachers) have to contribute to a much higher extent to these costs than parents in urban areas, or have no access to PEOs.

347. This inequality leads to different salary systems in the field of preschool education (teachers in rural areas within community based PEOs obtain a substantially lower salary, partly in kind). Or community based PEOs have to rely on income generating activities. This inequality has most probably major impacts on the issue of basic staff education (qualified teachers will not be working in the villages), on staff retention or staff-turnover and consequently on the quality of the services. A Law on Education will have to solve these major inequalities, including normative cost models, also taking into account the situation of socially disadvantaged families and families with a disabled child. As the community based forms will not be able to generate substantially higher revenues, major changes within the state kindergarten systems have to be considered

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348. Increase the quality of services, of the professional training and of monitoring structures, in close co-operation with health services: The issue of quality is connected with

a. Aspects of the structure of PEOs (infrastructure, equipment, available toys, books, consumables) b. Aspects of teachers qualification and (pedagogical) program implementation c. Aspects of quality monitoring or control by local authorities, educational departments, parents and other relevant stakeholders

349. Infrastructure, equipment and material for the children (within the target raions of the 2nd ADB project) will most probably need external financial support in terms of e.g. VIFs. The AOs therefore claim that the available finances (1st ADB project USD 5000,-), contributions of the AOs (20% - 10% in cash and 10% in kind) should be reconsidered. The increase of costs regarding reconstruction and the general financial situation of AOs has been mentioned in this context.

350. However, lessons learnt from successful strategies show that the motivation and the skills of the parents, too, should be used to a higher extent for instance when it comes to creating specific tools. A major focus should therefore be given to parents training programs, particularly to the practical skills of fathers (e.g. creating toys for their children or for the PEO – based on the methodological support of the key person or future kindergarten teacher).

351. Teacher qualification within the field of community based PEOs is highly connected with information transfer (e.g. availability of information) and financial aspects (mainly transport costs). From the point of view of laws and regulations, clear definitions of teachers education requirements for the different forms of community based PEOs are pending.

352. On the other hand, the importance of a concrete basic training (e.g. for unqualified staff) and of further education (qualification) for preschool teachers has to be highlighted: Teacher qualifications’ institutions and resource kindergartens play a key role. Cascade models of training have to be implemented, e.g. by common seminars for all professionals (e.g. on oblast level) and e.g. follow up trainings in resource kindergartens for the community based teachers or even professionals without formal education who work in this field (e.g. regarding home based or mobile models). To make early childhood programs more efficient and comprehensive, teachers’ qualification should also include aspects of child health and nutrition. On the other hand efficient teacher qualification requires a consistent strategy of monitoring and state control. This aspect refers to

a) Attestation/accreditation processes when establishing a PEO b) Monitoring systems by the Educational Department (including possible incentives or consequences e.g. regarding the existing norms of the 3-years cycles of teacher qualification).

353. Empower parents regarding information on care and education and parenting skills in close co-operation with health services. Based on the financial situation of families and fading out of knowledge traditionally transferred by “babushkas” or other adult family members, information on care and education (for the early years of the child) should be increased. Consciously involving fathers into this process should be considered since fathers might have other skills and motivation than just “listen to seminar speakers”. Interna- tional experience shows, that fathers could be motivated if they can do things together with their children (e.g. creating toys together).

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354. A major focus should be put – not only on information – but also on raising the awareness of what children need to get stimuli from their environment (depending on the age of the child). Even though watching TV might be one of the main activities of parents together with their children, it also could be used to interact with the child and to create joint attention.(e.g. to talk together about the program).

355. Based on already created parents training programs within the 1st ADB project, future training (e.g. by means of seminars) should include aspects of awareness raising and concrete changes in daily practice.

356. It is important that professionals providing training for the parents should have a specific education in this field. In terms of efficiency it is not enough to provide a short term training within a couple of days. It is strongly recommended that professionals empowering parents have an in-depth professional education in this field (kindergarten teacher, medical staff) and that potential trainers can include initiators of community mobilization processes aiming at the establishment of PEOs.

357. Parents’ training programs furthermore should take into account the availability of parents (a whole day might be too much) and their participation in the evaluation process. The major goal should be to change education and care practice. Furthermore, parents should be provided with basic information on education and care which could be used in daily life to raise their awareness on ECCE processes (such as booklet in Kyrgyz, a daily “calendar” about facilitating child centered activities at home etc.). Based on lessons learnt, raising the awareness through mass media (TV program „Keremet-Koch“) should also be promoted, including booklets, comics etc. for the children themselves.

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