USAID Nurture Semi-Annual Report, Year 4: FY2019: October 1, 2018 to March 31, 2019

Photo credit: Phongsamay Soukpaseuth

Cooperative Agreement Number: No. AID-486-A-16-00001 USAID/RDMA, Attn: Kongchay Vongsaiya, AOR Submitted by Delailah Borja, Chief of Party, USAID Nurture, May 8, 2019 Revised July 12, 2019 [email protected]

CONTENTS

Contents ...... 2 List of Tables ...... 3 List of Figures...... 3 Acronym List ...... 4 USAID Nurture Summary ...... 7 In the first half of Year (YR) 4, USAID Nurture achieved the following milestones:...... 8 Targets Reached Across Intermediate Results ...... 10 Program Implementation Progress ...... 14 New and Existing Sub-Award and Contract Status ...... 17 Major Impacts and Accomplishments by Intermediate Result ...... 17 Intermediate Result 1: Improved IYCF and WASH Behaviors in Household with Pregnant Women and Children under Two ...... 17 Intermediate Result 2: Improved Use of Quality Nutrition and Nutrition-Sensitive WASH Services/Facilities ...... 24 Health Service Delivery ...... 27 Cross-cutting Approach: Improved Enabling Environment for Multi Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities ..... 28 Deviations from Expectations for Performance Indicators ...... 29 Integration of Crosscutting Issues and USAID Forward Priorities ...... 30 Environmental Compliance ...... 31 Science, Technology, and Innovation ...... 32 Stakeholders Participation and Involvement ...... 32 Cost Sharing ...... 33 Planned Tasks/Interventions for the Next Reporting Period ...... 33 Appendix 1: Remaining Scale up of iNuW Districts ...... 36 Appendix 2: Number of People Trained During the Reporting Period of October 1, 2018 – March 31, 2019...... 38 Appendix 3: The USAID Nurture Key Demographic Data In Its Target Areas ...... 41 Appendix 4: Poster of “iNuW – Community Work ...... 42 Appendix 5: Cover Page of CF Guide ...... 43 Appendix 6: CF Coaching Guide ...... 45 Appendix 7: Summary of Toilet Prices ...... 47 Appendix 8: Pictures of Implementation in the Community ...... 48 Appendix 9: Success Story #1: Influence of a Sales Agent ...... 52 Appendix 10: Success Story #2: Enabling a Community Facilitator ...... 53

LIST OF TABLES

Table 1. Number of Children Under Five (0-59 months) Reached by USG-Supported Nutrition Programs, Disaggregated by Sex (Indicator Sub-IR2.1.3, HL.9-1) ...... 10 Table 2. Number of Children Under Two (0-23 Months) Reached with Community-Level Nutrition Intervention through USG-Supported Programs, Disaggregated by Sex (Indicator Sub-IR2.1.3, HL.9-2) ...... 11 Table 3. Number of Pregnant Women Reached with Nutrition Interventions through USG Supported Programs, Disaggregated by Age (Indicator Sub-IR2.1.4, HL.9-3) ...... 12 Table 4. Number of People Gaining Access to a Basic Sanitation Facility as a Result of USG- Assistance, Disaggregated by Sex (Indicator Sub-IR2.2.2, HL.8.2-2) ...... 12 Table 5. Number of Individuals Receiving Nutrition-Related Professional Training through USG-Supported Programs, Disaggregated by Sex (Indicator CCA-Output 2, HL.9-4) ...... 13 Table 6. Custom Indicator: Number of Mother/Caregivers of Children 0-23 Months Who Received Other Direct Maternal Infant and Young Child Nutrition Counseling through USG- Supported Programs, Disaggregated by Sex ...... 13 Table 7. Custom Indicator: Percentage of Household Visits Conducted by Community Facilitators Attended by Both Men and Women (Indicator IR1-Output 1) ...... 14 Table 8. iNuW Toolkit Key Features ...... 18 Table 9. Key Features of CF Home Visit and Coaching Guides ...... 19 Table 10. Rollout Training of iNuW ...... 20 Table 11. Number of Private Vendors Engaged in WASH Marketing ...... 25 Table 12. 1000 Days Nutrition Counseling Course Schedule ...... 27 Table 13. Q1 and Q2 FY 2019 Health Care Provider Capacity Building ...... 27 Table 14. Q1 and Q2 FY 2019 District Nutrition Multi-Sectoral Committee Meetings ...... 29 Table 15. Key non-GoL Stakeholders ...... 32 Table 16. Key GoL Stakeholders ...... 32

LIST OF FIGURES

Figure 1. Finalized iNuW Process ...... 23

ACRONYM LIST

ANC Antenatal Care AR Annual Report ARMI Association for Rural Mobilization and Improvement AW Abundant Water Organization A&T Alive & Thrive BFHI Baby Friendly Hospital Initiative BMS Breastmilk Substitute CF Community Facilitator CIEH Center for Information and Health CLA Collaborating, Learning, and Adapting CLTS Community Led Total Sanitation COP Chief of Party CSA Civil Society Alliance CSO Civil Society Organization DAFO District Agriculture and Forestry Office DDD Digital Data Divide DESB District Education and Sports Bureau DHC Department of Health Care DHO District Health Office DHIS2 District Health Information System 2 DHHP Department of Hygiene and Health Promotion DHR Department of Healthcare and Rehabilitation DNC District Nutrition Committee DP Development Partner DPO District Project Officer DQA Data Quality Assessment EENC Early Essential Newborn Care EPA Eicosapentaenoic Acid EPI Expanded Program on Immunization EU European Union FDD Food and Drug Department FY Fiscal Year GL Guideline GLEE Global Learning and Exchange GoL Government of Lao PDR

IFA Iron and Folic Acid IR Intermediate Result HCP Health Care Provider HH Household HPA Health Poverty Action INGO Non-Governmental Organization iNuW Integrated Nutrition and WASH IR Intermediate Result IYCF Infant and Young Child Feeding KHM Khammouane Province LAK Lao Kip LANI Lao American Nutrition Institute Lao PDR Lao People’s Democratic Republic LMIC Low and Middle Income Country LOA Life of Activity MCH Maternal and Child Health MCHC Maternal and Child Health Center MIYCN Maternal Infant and Young Child Nutrition MEL Monitoring, Evaluation and Learning M&E Monitoring and Evaluation MOH Ministry of Health MOU Memorandum of Understanding MSN Multi-sectoral Nutrition Strategy NIoPH National Institute of Public Health NMV Nutrition Model Village NNC National Nutrition Center Nam Saat National Center for Environmental Health and Water Supply NNS National Nutrition Strategy NPA Non-Profit Agency NPAN National Plan of Action for Nutrition ODF Open Defecation Free PADTEC Participatory Development Training Centre PDQ Partner Defined Quality PDR Lao People’s Democratic Republic PHD Provincial Health Department PNC Provincial Nutrition Committee

RDA Rural Development Agency RDMA Regional Development Mission for Asia RMNCH Reproductive, Maternal, Newborn and Child Health SAR Semi Annual Report SBCC Social Behavior Change Communications S1/FY19 Semester One of Fiscal Year 2019 SC Save the Children SCALING Sustainable Change Achieved Through Linking Improved Nutrition and Governance SCI Save the Children International SCUS Save the Children United States SDA Small Doable Actions SHS Senior Health Specialist SO Strategic Objective SUN Scaling Up Nutrition SVK Savannakhet Province TOT Training of Trainers UHS University of Health Sciences UNFPA United Nations Population Fund UNICEF United Nation’s Children Fund USAID United States Agency for International Development USG United States Government VIC Village iNuW Committee WASH Water, Sanitation and Hygiene WHO World Health Organization YDQ Youth Defined Quality

USAID NURTURE SUMMARY

Lao People’s Democratic Republic (PDR) experiences some of the highest rates of child and maternal mortality and malnutrition in Southeast Asia. Lao children remain some of Asia’s most undernourished, with national average prevalence of stunting at 33.0%, underweight at 21.1%, and wasting at 9.0% (Lao Social Indicator Survey, 2017). In response, the United States Agency for International Development’s Nurture Activity (USAID Nurture), led by Save the Children (SC) and implemented in partnership with the Government of Lao PDR (GoL) aims to contribute to a reduction in young child stunting in two target provinces of Laos by improving: 1) infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices; 2) the use of quality nutrition and WASH services/facilities; and 3) creating an enabling environment for improved nutrition.

USAID Nurture applies an Integrated Nutrition and WASH (iNuW) community mobilization approach to support behavior change at the household and community level. It also improves nutrition and health services by linking women and children to facilities and improving health worker capacity to provide services and promote optimal nutrition and WASH behaviors. USAID Nurture also leverages private sector relationships to facilitate supplies of products that support uptake of targeted WASH practices.

Through its integrated delivery model, USAID Nurture supports capacity development of the GoL as it clarifies roles and responsibilities across national, provincial and district levels to help ensure consistency and ownership of these efforts to implement National Nutrition Strategy (NNS) to 2025, the NPAN 2016-2020, and the National Social and Behavior Change Communication (SBCC) Plan. SC implements USAID Nurture across six districts in the central region of Lao People’s Democratic Republic (Lao PDR) — Xonnaboury, Atsaphangtong and Phine in Savannakhet Province and Mahaxay, Saybouathong and Ngommalath in Khammouane Province.

USAID Nurture’s extension through September 2021 builds on the collaboration and interest of the GoL to improve nutrition and WASH practices and services in a way that builds on existing systems for better sustainability. The extension also provides an opportunity for USAID Nurture to continue its engagement at the community level to increase household and community adoption of practices and products for improved nutrition and WASH outcomes, strengthening links to health services, while also expanding its work to improve consumption of diverse diets, and providing an added focus on adolescent nutrition.

During this reporting period, USAID Nurture recruited additional District Project Officers (DPOs) for Savannakhet and Khammouane. A team of WASH Marketing – one Manager based in Savannakhet, and two Officers based in Savannakhet and Khammouane respectively – were recruited between October and November 2018 after the previous WASH Manager left in August 2018. The new USAID Nurture Chief of Party joined on 19 January 2019. All new staff underwent orientation on their roles and responsibilities and received training to gain knowledge and understanding about USAID Nurture.

Under IR1, during the reporting period the iNuW component completed 5 of the planned 8 visits in the target villages, though it experienced slight delays until the beginning of Q2 to train new DPOs and new sales agents in six districts. From the end of Q2 USAID Nurture started to observe increased sales activities and purchase of WASH products.

Under IR2, USAID Nurture trained District Health Office (DHO) staff to conduct iNuW village visits and facilitation of iNuW committee members and Community Facilitators (CFs) during implementation in all USAID Nurture villages. Twelve more private vendors were recruited to provide supplies to target villages. The team also completed Module 3 on Complementary Feeding of the Maternal and Child Health (MCH) Nutrition Counseling Training Course for the remaining provincial and district teams.

USAID Nurture supported the multi-sectoral coordination of District Nutrition Committees (DNCs). During the period, DNC meetings were held from October- November 2018 and March 2019. Attendees reviewed current progress against national priorities and planned local implementation of GoL’s nutrition convergence model: Model Nutrition Villages. Results from the USAID Nurture key demographic data in target areas are available in Appendix 3.

IN THE FIRST HALF OF YEAR (YR) 4, USAID NURTURE ACHIEVED THE FOLLOWING MILESTONES:

Project Management  Completed and received approval for Y4 Workplan on December 21, 2018.  Completed and received approval for FY2018 Annual Report on March 4, 2019.  Currently recruiting one DPO to replace the one who resigned in Phine District in Savannakhet. The total number of DPOs in USAID Nurture is 23.  Recruited District Facilitators for both Savannakhet and Khammouane to support the Provincial Coordinator to conduct District Nutrition Committee meetings and to provide procurement and general support to field Senior Admin & Finance Officer.  Recruited a driver for Khammouane Office to replace the previous driver who left in July 2018. A team of WASH Marketing (1 Manager based in Savannakhet) and 2 Officers (based in Savannakhet and Khammouane, respectively) were recruited between October and November 2018 after the previous WASH Manager left in August 2018.  Onboarded permanent Chief of Party (COP) for USAID Nurture in January 2019.  Developed the annual Communication Plan for 2019.  Developed and received approval of an action plan to improve findings/recommendations from USAID Data Quality Assessment (DQA) conducted in November 2018.  Conducted annual meeting on February 7, 2019 with participants from the central, provincial and district level government, as well as USAID Nurture key staff from Vientiane, Savannakhet and Khammouane.

IR1: Improved IYCF and WASH Behaviors in Households with Pregnant Women and Children under Two  Completed training/refresher training for 408 VICs and 783 CFs (total 1,191 trainees) in all six districts by February 2019.  The iNuW component completed 5 of the planned 8 visits in the target villages, though some villages have completed as many as 7. The remaining visits will be conducted in Q3 and 4.  CFs delivered a total of 11,510 home visits to1,000 day households during this reporting period.  Collected extensive field-test and feedback from the implementers (DPOs and government partners) about the iNuW Toolkit in order to finalize. 8

 CF job aids and a CF home visit guide were produced for all CFs.  A CF coaching guide for the DPOs was finalized and ready for rollout.

IR2: Improved use of quality nutrition and nutrition-sensitive WASH services/facilities  Cooperation with Abundant Water Organization (AW) continues; interest and orders from the target communities for water filter gradually increased from 33 in FY 18 to 177. The AW also provided sales training to the USAID Nurture’s DPOs and PMs on January 9, 2019 and the training focused on the introduction of ceramic water filter, installation, maintenance and user support, costing, lessons learned from AW’s experience in other provinces, and communication channels.  Three existing private vendors (Khammoaune province: 1 in Mahaxay and 1 in Ngommalath district; Savannakhet province: 1 in Phine district) were visited to discuss their promotion plan in relation to USAID Nurture’s sales agents plan.  Between December 2018 and February 2019, 12 private vendors were recruited; with the 5 previously recruited, totaling 17 private sectors. New recruits included 7 in Khammouane (3 in Mahaxay, 3 in Ngommalath, and 1 in Saybuathong) and 5 in Savannakhet (1 in Atsaphangthong, 3 in Xonnaboury and 1 in Phine). The newly recruited private vendors actively took part in the sales agents training by introducing their business and cooperation approach and benefit-sharing.  WASH products totaling 328 units were sold to communities in six districts - 151 toilets (Savannakhet: 68 units, and Khammouane: 83 units), and 177 water filters (Savannakhet: 109 units, and Khammouane: 68 units).

Cross-cutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities  USAID Nurture supports district multi sectoral committees with practical logistics and financial support in order to help institutionalize this new platform for multi-sectoral nutrition governance. These committees are still developing a clear vision of their role in supporting local development; in this initial phase of meetings integrated nutrition related policies have been disseminated to enhance commitment amongst District leadership to improve nutrition. DNCs are still in the early stage of development, thus, concrete achievements are expected to materialize once DNC’s capacity is strengthened. In addition to direct practical support, USAID Nurture also works in partnership with the SUN CSA to provide indirect support sub-national committees to understand and address local nutrition priorities via increased coordination with local development partners.  In February 2019, SCI supported Scaling Up Nutrition Civil Society Alliance (SUN CSA) to organize the first training in Lao PDR for Civil Society Organizations (CSOs) on how to work with and support the efforts of Provincial Nutrition Committees (PNCs) and DNCs. The training is part of SUN CSA’s advocacy strategy that seeks to coordinate and strengthen sub-national multi-sectoral nutrition governance and resulted in the formation of a civil society nutrition advocacy working group. In March 2019, USAID Nurture cost share funds supported an advocacy working group member, Lao nonprofit association (NPA), Association for Rural Mobilization and Improvement (ARMI), to hold a joint meeting of the Savanakhet PNC and DPs involved in nutrition in Savanakhet province. USAID Nurture also participated in the event, which resulted in a better understanding of the cooperative approach to local nutrition governance for all participants. In Khammouane, SCI and Health

Poverty Action (HPA) are now beginning to discuss how to best support the various DNCs with similar objectives.  In early March 2019, USAID Nurture initiated discussions with district authorities including district vice governors and district health offices on water access issues and how these could be solved in villages that have water access limitation. As a result, each district reached out to both private sector and development partners active in the district to seek possible solutions. A discussion was also carried out with the Nam Saat Center for their advocacy and technical support on this issue at provincial and district levels.  Since early 2018, USAID Nurture, in cooperation with other development partners, (UNICEF, Plan International, SNV, World Vision, Rural Development Agency (RDA), World Bank) has been providing technical and/or financial support to National Center for Environmental Health and Water Supply (Nam Saat) in revising the national manual of Community-Led Total Sanitation (CLTS). The Nam Saat Director is currently reviewing the draft.  At USAID’s request, USAID Nurture provided logistical support in October 2018 to an assessment team focused on the development of a comprehensive health strategy for Laos, which also contributed to USAID Nurture’s objective of supporting the development of a comprehensive Maternal and Child Health strategy in Laos. The assessment helped position USAID to make more strategic investments in Laos from a comprehensive and holistic perspective. The USAID Nurture team and Acting COP supported the strategy team of about 28 people including development experts from USAID/Washington, USAID’s Regional Mission in Bangkok, the Laos Country Office, and Lao government officials to travel to 9 provinces throughout Laos including Savannakhet and Khammouane.  On 13 March 2019, USAID Nurture hosted the US Ambassador’s field visit to a USAID Nurture target village in Attsaphangthong District. The US Ambassador had a very lively and active interaction with children, villagers and the village committee members during the visit.

TARGETS REACHED ACROSS INTERMEDIATE RESULTS

Table 1. Number of Children Under Five (0-59 months) Reached by USG- Supported Nutrition Programs, Disaggregated by Sex (Indicator Sub-IR2.1.3, HL.9-1)

Percent of unique Number of unique Children under 5 beneficiaries beneficiaries reached reached LOA LOA Total Target FY19 Total Target FY18 SI/FY19 Total population FY17- Target Population FY17- FY21 FY21 Total 21,774 14,070 9,570 1,513 7,722 9,235 42% 66% - Male 10,869 7,035 4,785 795 3,778 4,573 42% 65% - Female 10,905 7,035 4,785 718 3,944 4,662 43% 66%

Note: Total population and Life Of Activity (LOA) targets for FY17-FY21 estimated from the household progress form.

 In FY18, the counting of CU5 beneficiaries was limited to the children aged 0-59 months old that belong to the 1,000 days households. In order to capture the CU5 children that do NOT belong to the 1,000 days household but received nutrition intervention through the participation of their parents/caregivers in the iNuW community events (as stated in the most recent revised MEL plan) the team introduced the counting of beneficiaries aged 24-59 months old during the organization of community events. This additional counting methodology explains the significant increase of CU5 beneficiaries from FY18 to Semester 1 of FY19 (S1/FY19).  Per the proposed revised MEL plan, the total reported is now all children under five in the community, resulting in an important increase in the total number of children reached under five years of age.

Table 2. Number of Children Under Two (0-23 Months) Reached with Community-Level Nutrition Intervention through USG-Supported Programs, Disaggregated by Sex (Indicator Sub-IR2.1.3, HL.9-2)

Percent of unique Number of unique Children under 2 beneficiaries beneficiaries reached reached LOA LOA Total Target FY19 Total Target FY18 SI/FY19 Total population FY17- Target Population FY17- FY21 FY21 Total 9,068 8,580 5,580 1,010 2,858 3,868 43% 45% - Male 4,577 4,290 2,790 535 1,395 1,930 42% 45% - Female 4,491 4,290 2,790 475 1,463 1,938 43% 45% Note: Total population and LOA targets for FY17-FY21 estimated from the household progress form.

The previously reported number reached (3,454) represented duplicated number of children under two. Duplicate counting was addressed after data being entered in the monitoring system (MS Access) and data cleaning in June 2019. Elimination of duplicate numbers was done through a query set up in the monitoring system in order to present the more relevant unique number to measure coverage of the beneficiaries.

There are a number of reasons for the striking results in reaching targeted children in the first half of FY19. Firstly, in the lead up to the conclusion of the first phase of USAID Nurture, teams accelerated implementation efforts, which considerably increased previous reach. There was a ten-fold increase in household visits in this period compared to FY18, for example. Secondly, this indicator was previously reported based on the number of children under five living in the 1000 days households only and has now been expanded to include children 24-59 months who’s parent or caregiver participate in Nurture activities.

Despite the fact that the above indicators were underachieved in FY17 and FY18, USAID Nurture still aims to reach the initial Life of Activity (LOA) target. The additional targets in the second phase of USAID Nurture have been adjusted to reflect the reality of the 0-23 months

and 24-59 months populations and the LOA target of these two indicators shows that USAID Nurture aims to reach majority of these children in the target villages.

Table 3. Number of Pregnant Women Reached with Nutrition Interventions through USG Supported Programs, Disaggregated by Age (Indicator Sub- IR2.1.4, HL.9-3)

Number of unique Percent of unique Pregnant women beneficiaries reached beneficiaries by USAID Nurture reached Total LOA LOA population Target Target Total Target over 5 FY18 S1/FY19 Total FY17- FY19 population FY17- years FY21 FY21 period Total 13,062 25,728 7,000 3,853 3,318 7,171 55% 28% < 19 years 1,959 3,859 1,050 578 498 1,076 55% 28% of age ≥ 19 years 11,103 21,869 5,950 3,275 2,820 6,095 55% 28% of age Note: Total population and LOA targets for FY17-FY21 estimated from the household progress form.

This indicator recognizes that USAID Nurture nutrition interventions to pregnant women are multi-fold, with community-wide activities, individual household visits, and also improved ANC care provided by healthcare workers. The results above show efforts are on track for FY19.

Table 4. Number of People Gaining Access to a Basic Sanitation Facility as a Result of USG-Assistance, Disaggregated by Sex (Indicator Sub-IR2.2.2, HL.8.2- 2)

People gaining Access to access to a basic Percent sanitation sanitation facility People People reached facility from USAID NOT without Nurture reache access People d by to LOA LOA without USAI sanitati Targ Targ Targ access D on et FY1 S1/FY Tot et et to Nurtu facility FY17 8 19 al FY17 FY19 sanitati re - - on FY21 FY21 facility 14,77 1,22 118,22 Total 119,444 3,391 76 1,148 1% 8% 7 4 0 Male 59,346 5,911 1,357 40 581 621 1% 11% 58,725

Femal 60,098 8,866 2,034 36 567 603 1% 7% 59,495 e Note: The number of people with and without access to a Basic Sanitation Facility is illustrated as before the start of the Activity.

As seen in Table 4 above, USAID Nurture experienced slow progress in the number of people with access to sanitation facility in the villages, which can be attributed to the insufficient reach of sales agents, remote and extremely difficult road conditions preventing the transportation of supplies, and limited water access. Village authorities showed little initiative and ownership in overseeing the mobilization of communities in relation to sanitation and hygiene. With USAID Nurture’s move to increase the number of sales agents across the six districts, the number of toilets is starting to increase in the target communities. Similarly, district authorities have also started to take initiative to influence village authorities to take action. Table 5. Number of Individuals Receiving Nutrition-Related Professional Training through USG-Supported Programs, Disaggregated by Sex (Indicator CCA-Output 2, HL.9-4)

Percent of Individuals Number of unique beneficiaries unique receiving training reached by USAID Nurture beneficiaries reached over Cumulative Cumulative Target Target FY17 FY18 SI/FY19 Total Target FY17- FY19 FY17-FY21 FY21 Total 2,352 264 198 1,015 923 2,136 91% Male 617 66 68 618 496 1,182 192% Female 1,735 198 130 397 427 954 55%

This indicator refers to training provided for Healthcare providers and Community Facilitators and, due to their enhanced involvement in supporting CF under the new training design, members of the VIC as well. Many more CFs were trained in the previous period than originally anticipated due to the revision of the CF training manual and skill building approach. USAID Nurture has 881 CFs and 906 VICs currently trained and operational. Additional CF training is not planned in the second half of FY19; with DPOs instead supporting CF capacity through monthly monitoring and coaching visits to them in the community so further increases are not expected. Table 6. Custom Indicator: Number of Mother/Caregivers of Children 0-23 Months Who Received Other Direct Maternal Infant and Young Child Nutrition Counseling through USG-Supported Programs, Disaggregated by Sex

Percent of unique Number of unique Mothers/Caregivers beneficiaries beneficiaries reached reached

LOA LOA Total Target Target Total Target FY18 S1/FY19 Total population FY17- FY19 population FY17- FY21 FY21 Total 24,435 12,174 2,700 1,799 7,916 9,715 40% 80% - Male 8,552 4,257 950 648 3,607 4,255 50% 100% - Female 15,883 7,917 1,750 1,151 4,300 5,451 34% 69% - Gender not 9 9 identified

The estimated total number of 1000 days households in all of the target villages is 8,145 of which USAID Nurture has reached 4,908 (60%). On average, the Activity has reached two caregivers per 1000 days households visited since the start of the counselling home visits. The significant increase of beneficiaries can be explained by the shifting definition of a caregiver that has been set for this semester report, based on the Lao context and culture (minimum age of the caregiver being reduced from 15 to 10 years old). As noted above, nine caregivers were not identified by gender during the data collection. This will be discussed with the respective CFs during coaching visits. Table 7. Custom Indicator: Percentage of Household Visits Conducted by Community Facilitators Attended by Both Men and Women (Indicator IR1- Output 1)

Household visits attended by both men Target and women LOA FY17- FY19 FY18 S1/FY19 FY21 Estima Estima ted perce ted perce number percent number percent numbe nt numbe nt r r Tot 32,743 67% 27,856 57% 1,921 52% 11,510 61% al

The Activity emphasized the importance of including both men and women before starting counselling sessions, as support from both parents is a preliminary step in triggering behavior change. As a result, the above table shows that home visits attended by women and men are increasing. Coaching with CFs will continue to stress the importance of male roles in 1000 Day Households, especially fathers.

PROGRAM IMPLEMENTATION PROGRESS

Communication Plan for Visibility and Advocacy Developed USAID Nurture developed a communication plan for FY 2019. The purpose of this communication plan is to:

1) Increase the visibility of USAID Nurture’s activities and accomplishments in Laos and globally through various social media, case studies, YouTube videos, etc.; 2) Garner support for collaboration and synergy among other development partners (DPs) and donors in Laos; 3) Develop user-friendly tools for increased engagement with GoL counterparts for data for decision making; 4) Encourage uptake of project counseling skills materials by GoL and DPs; and 5) Advocate for continued support for integrated programs such as USAID Nurture in Laos to contribute to improving the lives of families towards a healthier and productive future. USAID Nurture is in the process of recruiting a communication consultant (Q3) to ensure that all job aids and materials development are on track. All materials shared publicly will be cleared through USAID before publication.

Annual Meeting and Steering Committee As part of USAID Nurture’s MOU, the Activity held the fourth quarterly meeting as an annual meeting in Vientiane in Q2 of FY 2019 (February 7, 2019). The purpose of the meeting was to review results to date from last year, including technical and financial progress. Key staff from USAID Nurture, from Vientiane and the field and representatives of provincial and district government partners participated. There was a simulation of the iNuW Fair which is a part of the eight-village visit package. USAID Nurture team received positive feedback from the partners as well as shared issues e.g., lack of water in their communities.

Capacity Strengthened in M&E USAID Nurture retained the local monitoring and evaluation consultant to build the capacity of the Monitoring & Evaluation (M&E) team, assessed the capacity of the staff, prepared training materials and conducted training to all field teams in January 2019 on data flow process, proper use of forms and reiteration of the importance of monitoring, timely collection of data. The local consultant continued to support finalization of the Monitoring, Evaluation, and Learning (MEL) plan and the DQA action plan based on findings and recommendations from the most recent DQA activity.

Project Publications and Events To support implementation, USAID Nurture participated in several key forums and produced informative project materials.

National Nutrition Forum: USAID Nurture participated in the second Annual National Nutrition Forum attended by senior leadership from each province and key ministry. USAID Nurture’s activities were described in the presentations made by both Khammouane and Savannakhet provincial health departments and the USAID Nurture booth received many visits from attendees. The Senior Health Specialist (SHS) in her capacity as Chairperson of the Lao PDR SUN CSA management committee gave closing remarks on behalf of national and international civil society organizations calling for CSOs to prioritize support of the subnational multi-sectoral nutrition committees, as per USAID Nurture IR3. USAID Nurture developed a poster to provide an overview of USAID Nurture’s iNuW process at the community level in a simple infographic manner (Appendix 3 Poster of iNuW

Community Work). The poster was distributed in 471 villages and enabled communities to have a clearer understanding of USAID Nurture’s objectives and process, community visit process, and eight essential small doable actions.

GoL Technical Capacity Strengthened and Increased Adherence to Global Standards Code of Marketing of breastmilk substitute (BMS): Ministry of Health (MoH) continued development of the new BMS Code in Q1 and Q2. In December 2018, the task force met for the ostensible final review but it was determined that while consensus on content emerged, the draft was too poorly written for it to be submitted to the cabinet and so the Department of Health and Hygiene Promotion (DHHP) instructed technical staff to further revise. The improved draft was reviewed at an internal (GoL only) meeting on February 23, 2019. USAID Nurture and UNICEF have reiterated their willingness to support DHHP to finalize and endorse the new BMS code in 2019.

Breastfeeding Support Services: USAID Nurture and the Senior Health Specialist (SHS) (under cost share with Alive & Thrive) are working closely with the Early and Essential Newborn Care (EENC) Master Trainer team and the MoH Department of Health Care and Rehabilitation (DHR) to widen their scope to include breastfeeding services. Two central hospitals will be the first to implement draft national standards for breastfeeding services and through cost share and Phase 2 USAID Nurture funding, project districts and health centers will become the first local health facilities in the country to obtain this designation (per the 5 Goods and 1 Satisfaction national policy on hospital accreditation).

CODEX: In November 2018, the SHS travelled to Berlin Germany as a member of the Lao Government delegation to CODEX, the international body setting breastmilk substitute (BMS) composition and labeling rules. She was supported by Alive & Thrive cost share with USAID Nurture to attend at the request of MOH and while there supported the other two delegates of the NNC and FDD to speak on the floor in support of strong regulation. The SHS also facilitated Lao PDRs participation in a block of lower and middle income countries (LMICs) demanding stronger rules, including widening the scope of BMS products as those targeting any children under 36 months of age. These efforts are in line with GoL policy and priorities as per the NPAN to improve breastfeeding rates in support of improved child nutrition.

Well-Child Services: In Q1 and Q2 the SHS continued efforts to revise the MCH portable care record locally known as the ‘Pink Book’ with the MCHC task force. The draft is now complete and with the graphic designer for finalization. As a result of project efforts, the new Pink Book will introduce the first-ever Lao integrated well-child care schedule, specifying eight care contacts (nutrition, immunization, child development) for all Lao children over the first two years of life. Importantly, the Pink Book also has growth and nutrition charting areas for the first time. The chart provides clear guidance to HCP regarding expected tasks to be performed during a well-child visit and includes areas to chart nutrition counseling. Finally, the new Pink Book includes an integrated health education guide arranged by age for each of the care visits that consists of IYCF SDAs; the information pages function as a counseling job aid as well as information for parents. These innovations were adopted into the national guidance as a result of advocacy by the SHS based on the experiences of the USAID Nurture nutrition counseling program and demonstrate that components of the USAID Nurture model will be sustained after activity implementation.

Child Health Assessment: The MoH has now adopted the WHO-developed comprehensive Child Health Assessment tool after joint advocacy efforts by the SHS as well as WHO and UNICEF. This tool provided a participatory approach to reviewing health services for both well and ill children with heavy emphasis on routine nutrition care and data is primarily via exit interviews with caregivers, which is unique in the Lao context. The tool assesses crucial nutrition services the project has advocated for and provided training in, including breastfeeding counseling and support, feeding assessment and counseling, and growth monitoring and assessment and thus can replace the project’s nutrition services assessment. The tool was used in January-February in Khammouane and Savannakhet in one project district each and the project will provide support to PHD and DHO to conduct the assessment in all Nurture project districts in Q3. The data will be incorporated in the supervision support program planned in Phase 2. USAID Nurture will continue to advocate for this participatory and accountable approach to assessing service delivery and data-based service management by MOH and model data-driven management with DHOs throughout Phase 2.

NEW AND EXISTING SUB-AWARD AND CONTRACT STATUS

M&E Local Consultant Anolay Vongsouthi was re-contracted in FY 2019 to continue building the capacity of the USAID Nurture MEL team based on expressed needs, and supported finalization of the MEL Plan and preparation of the action plan from the most recent DQA findings and recommendations.

The Digital Divide Data (DDD) firm was hired to enter over 3000 data sheets collected from the field into a Microsoft Access program developed by the M&E Officer and consultant. The company was previously used to assist with the data entry load to prepare reports, to assess project deliverables to date, and inform USAID Nurture activities going forward.

The sub award with RDA ended in February 2018 and SC began the closeout process, including all documentation, reports, and reconciliation of financial records. While RDA’s role in USAID Nurture ended in February, SC completed final award close out procedures and records during this reporting period. As mentioned in the Annual Report, SC assumed full implementation of USAID Nurture and transferred all staff from RDA. While this was challenging, it went smoothly and staff are performing as required.

MAJOR IMPACTS AND ACCOMPLISHMENTS BY INTERMEDIATE RESULT

Intermediate Result 1: Improved IYCF and WASH Behaviors in Household with Pregnant Women and Children under Two

Community Led Total Sanitation (CLTS) Manual In cooperation with UNICEF, Plan International, World Vision, SNV, and World Bank, USAID Nurture has been supporting the revision of the national manual on CLTS of Nam Saat of the Ministry of Health. USAID Nurture through the Senior WASH Specialist, a member of the drafting technical working group, participated in a series of writing workshops. The manual will serve as a national guide for both government agencies and international organizations in implementing rural sanitation programs in Laos, focusing on sanitation behaviors, building community capacity and ownership, and ensuring sustainability. The revised version of CLTS, not only targets making Lao communities ODF certified, but

also total sanitation which covers latrine use, handwashing with soap, household drinking water, and clean home compound. The revised CLTS manual, in particular the ODF verification process and tools, will be adopted in the USAID Nurture iNuW toolkit so that it is in line with the national ODF criteria which are (1) toilet ownership (100%), (2) handwashing with soap (60%), (3) clean and safe drinking water (60%), and (4) clean home compound (60%).

National WASH Policy 2019 The Senior WASH Specialist was engaged in the WASH Development Partner Task Force led by UNICEF. Two meetings were held on February 11 and February 28, 2019 for development partners to provide an update about their WASH activities and to be introduced to the WASH policy for 2019. The key issues in the WASH policy includes strengthening national rural WASH programs, reducing rural-urban disparities regarding safe water access, strengthening and scaling up strategies in behavior change and marketing to eliminate open defecation in rural areas and improving access to basic sanitation level, addressing inequalities by prioritizing investments and service delivery to unserved poor and remote communities. At this stage, since the WASH DP Task Force is at its early stage of reactivation, draft TOR for the WASH DP Task Force was developed and discussed while DPs’ WASH related activities’ lessons and experiences were shared. Sub-groups will be set up in accordance to specific WASH specific issues. The focal point at this moment is UNICEF but the role will be rotated among DPs.

USAID Nurture iNuW Toolkit The USAID Nurture iNuW toolkit was revised based on review of field implementation and feedback from the field teams and government partners. The iNuW Toolkit will be finalized by the end of June 2019. See Table 8 below for a description of key features in the toolkit.

Table 8. iNuW Toolkit Key Features

Visit 1 – Sensitization . This is a workshop village leadership organized at the district level. . It is chaired by the district governor and lays the foundation for participants to recognize the current situation of nutrition and WASH and the significance of the problems. . This approach strengthens government support and creates collective action to the problems in a more formal way. Visit 2 – Triggering for . This visit facilitates communities in recognizing problems Healthy Growth related to nutrition and WASH and in planning to achieve community-wide target (ODF villages and communities that practice recommended SDAs) . The participating community members elect CFs and VICs themselves, along with detailed discussion with the new CFs/VICs about their role and USAID Nurture support. Women are promoted in the selection of CFs. Visit 3 – Nutrition and . This event allows participants to experience USAID WASH Fair Nurture’s project in a familiar and fun village “boun” atmosphere, designed to create a sense of community ownership around USAID Nurture goals and objectives; demonstrate key SDAs through participatory activities such as cooking competitions, quizzes, handwashing

demonstrations etc. at booths; and bring USAID Nurture to life in the village. Visit 4 – Progress . Health Center staff support CFs in conducting home visit Review and Support activities through demonstration, observation and coaching, VIC/CFs while DPOs work with VICs focusing on sanitation and updating the implementation status. Visit 5 – Progress . Health Center staff support CFs in conducting home visit Review and Support activities through demonstration, observation and coaching, VIC/CFs while DPOs work with VICs focusing on sanitation and updating the implementation status. Visit 6 – Community . Documentary day is a way of showing progress by filming Story nutrition and WASH focused discussions with community members. Footage in the village shows what has improved along with discussion of actions for improvements. Visit 7 – Progress . Health Center staff support CFs in conducting home visit Review and Support activities through demonstration, observation and coaching, VIC/CFs while DPOs work with VICs focusing on sanitation and updating the implementation status. Visit 8 – ODF . To verify open defecation status, including handwashing with Verification soap, household drinking water, and clean home compound. The verification team consists of provincial and district government partners and Health Center staff, representatives from district administration office, Nam Saat central and USAID Nurture staff. . Discussion of ODF celebration plan

CF Guide After its use starting from July 2018, the CF guide was revised based on feedback from DPOs, health center staff and CFs derived from field-testing in the two provinces. The CF guide was designed to be simple, quick and easy to follow and refer to when conducting a home visit activity, especially for low-literacy CFs (Appendix 4 Cover Page of the CF Guide).

CF Coaching Guide The CF Coaching Guide was developed as a tool for DPOs in providing technical support to CFs to identify areas of skill that need improvement, to plan with observed CFs on what and how to improve, and to follow up on after-action reports. During observations of each CF’s home-visit activity, the tool was used on a monthly visit to train CFs (Appendix 5 CF Coaching Guide).

Table 9. Key Features of CF Home Visit and Coaching Guides

CF Home visit Guide CF Coaching Guide for DPOs . An overview of 8 SDAs . The tool was not supposed to assess . 1,000-day graphic CF’s performance, rather the tool’s . A “Five-Fingers” graphic that shows purpose was for raising confidence and how to conduct home visits in five steps skills of CFs needed for delivering with clear explanation of each step and effective home visits guiding questions . A check list for DPOs to use in observing the CFs home visit steps

. An overview of the Home Visit Form, . Summary of what aspects are done well with clear explanation of each section in and what needs improvement, including the form how to improve and by when the follow-up will take place

Training of VICs and CFs During the reporting period, training events with revised content, particularly for CFs, were carried out through March 2019, including refresher training for previously trained CFs. The following table shows training events that took place in the districts.

Table 10. Rollout Training of iNuW

Total Start End No# of No# of No# Name of Event No # of date Date Females Males Trainees VIC Training-Phase 4 (04 villages 3/3) 1 _Mahaxay 05-Oct-18 05-Oct-18 8 0 8 VIC Training_Phase 5 (10 villages 1/2) 2 _Ngommalath 15-Oct-18 15-Oct-18 18 6 12 VIC Training_Phase 6 (10 villages 3 1/2)_Ngommalath 15-Oct-18 15-Oct-18 15 1 14 VIC Training_Phase 5 (10 villages 4 2/2)_Ngommalath 19-Oct-18 19-Oct-18 17 3 14 VIC Training_Phase 6 (10 villages 5 2/2)_Ngommalath 19-Oct-18 19-Oct-18 20 7 13 VIC Training_Phase 5 (10 villages 1/2 ) 17-Dec- 6 _Mahaxay 17-Dec-18 18 18 4 14 VIC Training_Phase 5 (10 villages 2/2 ) 21-Dec- 7 _Mahaxay 21-Dec-18 18 18 0 18 VIC Training_Phase 5 (10 villages 1/2) 8 _Saybouathong 18-Jan-19 18-Jan-19 17 0 17 VIC Training_Phase 5 (10 villages 2/2) 9 _Saybouathong 31-Jan-19 31-Jan-19 19 0 19 VIC Training_Phase 5+6 (10 villages 10 1/1) _Saybouathong 21-Feb-19 21-Feb-19 17 0 17 Total VIC Training 10 167 21 146

CF Training_Phase 4 (04 villages 3/3) 1 _Mahaxay 08-Oct-18 10-Oct-18 8 8 0 CF Training_Phase 5 (10 villages 1/2) 2 _Ngommalath 10-Oct-18 12-Oct-18 19 16 3 CF Training_Phase 6 (10 villages 3 1/2)_Ngommalath 10-Oct-18 12-Oct-18 20 20 0 CF Training_Phase 5 (10 villages 4 2/2)_Ngommalath 16-Oct-18 18-Oct-18 20 12 8 CF Training_Phase 6 (10 villages 2/2) 5 _Ngommalath 16-Oct-18 18-Oct-18 20 19 1 CF Re-Training_Phase 2 (10 villages 14-Nov- 6 1/2) _Ngommalath 12-Nov-18 18 20 7 13

CF Re-Training_Phase 2+3 (9 villages 14-Nov- 7 2/3 ) _Saybouathong 12-Nov-18 18 18 9 9 CF ReTraining_Phase 1 (10 villages 15-Nov- 8 1/1) _Mahaxay 13-Nov-18 18 20 17 3 CF Re-Training_Phase 3 (10 Villages 15-Nov- 9 1/2)_Ngommalath 13-Nov-18 18 17 5 12 CF Re-Training_Phase 2 (9 villages 17-Nov- 10 2/2) _Ngommalath 15-Nov-18 18 18 9 9 CF Re-Training_Phase 2+3 (9 villages 18-Nov- 11 1/3) _Saybouathong 16-Nov-18 18 18 10 8 CF Re-Training_Phase 3 (8 villages 2/2 21-Nov- 12 ) _Ngommalath 19-Nov-18 18 16 12 4 CF Re-Training_Phase 2+3 (8 villages 21-Nov- 13 3/3) _Saybouathong 19-Nov-18 18 16 7 9 CF Re-Training_Phase 2 (10 villages 23-Nov- 14 1/2) _Mahaxay 21-Nov-18 18 20 13 7 CF Re-Training_Phase 3 (13 villages 28-Nov- 15 1/2) _Mahaxay 26-Nov-18 18 26 19 7 CF Re-Training_Phase 2&3 (10 villages 13-Dec- 16 1/2 ) _Mahaxay 11-Dec-18 18 20 13 7 CF Training_Phase 5 (10 villages 1/2 ) 14-Dec- 17 _Mahaxay 12-Dec-18 18 20 20 0 CF Training_Phase 5 (10 villages 2/2 ) 20-Dec- 18 _Mahaxay 18-Dec-18 18 20 18 2 CF Re-Training_Phase 2&3 (10 villages 21-Dec- 19 2/2 ) _Mahaxay 19-Dec-18 18 19 18 1 CF Training_Phase 5 (10 villages 1/2) 20 _Saybouathong 15-Jan-19 17-Jan-19 16 16 0 CF Training Phase 5 (10 villages 2/2) 21 _Saybouathong 28-Jan-19 30-Jan-19 17 14 3 Total CF Training 21 388 282 106

Khammouane Total - 200 Villages 32 555 303 252

Total Start End No# of No# of No# Name of Event No# of Date Date Females Males Trainees VIC Training_Phase 5 (10 villages 1 2/2)_Attsaphangthong 09-Oct-18 09-Oct-18 20 2 18 VIC Training_Phase 3 (10 villages 1/2) 2 _Phine 09-Oct-18 09-Oct-18 18 0 18 VIC Training_Phase 4 (06 villages 1/2) 3 _Xonnaboury 12-Oct-18 12-Oct-18 12 0 12 VIC Training_Phase 3 (10 villages 2/2) 4 _Phine 15-Oct-18 15-Oct-18 15 2 13 VIC Traning_Phase 4 (10 Villages 5 1/1)_Attsaphangthong 16-Oct-18 16-Oct-18 19 2 17

VIC Training Phase 4 (14 villages 2/2) 6 _Xonnaboury 16-Oct-18 16-Oct-18 24 0 24 VIC Training_Phase 4 (9 villages 1/2 ) 26-Nov- 7 _Phine 26-Nov-18 18 18 0 18 VIC Training_Phase 5 (13 villages 1/1 ) 26-Nov- 8 _Xonnaboury 26-Nov-18 18 26 0 26 VIC Training_Phase 6 (9 villages 1/1 ) 11-Dec- 9 _Xonnaboury 11-Dec-18 18 17 0 17 VIC Training_Phase 5 (7 villages 1/2 ) 13-Dec- 10 _Phine 13-Dec-18 18 14 4 10 VIC Training_Phase 5 (10 villages 2/2 ) 17-Dec- 11 _Phine 17-Dec-18 18 20 0 20 VIC Training_Phase 6 (10 villages 1/1) 12 _Phine 14-Jan-19 14-Jan-19 19 0 19 VIC Training_Phase 4 (10 villages 2/2) 13 _Phine 15-Jan-19 15-Jan-19 19 1 18 Total VIC Training 13 241 11 230

CF Training_Phase 4 (06 villages 1/2) 1 _Xonnaboury 09-Oct-18 11-Oct-18 14 10 4 CF Training_Phase 5 (10 villages 2 2/2)_Attsaphangthong 10-Oct-18 12-Oct-18 20 9 11 CF Training_Phase 3 (10 villages 1/2) 3 _Phine 10-Oct-18 12-Oct-18 18 5 13 CF Training_Phase 3 (10 villages 2/2) 4 _Phine 16-Oct-18 18-Oct-18 19 2 17 CF Training_Phase 4 (10 villages 1/1) 5 _Attsaphangthong 17-Oct-18 19-Oct-18 20 19 1 CF Training_Phase 4 (14 villages 2/2) 6 _Xonnaboury 17-Oct-18 19-Oct-18 26 23 3 CF Re-Training_Phase 3 (10 village 14-Nov- 7 1/1) _Attsaphangthong 12-Nov-18 18 17 6 11 CF Re-Training_Phase 1 (10 villages 14-Nov- 8 1/1) _Phine 12-Nov-18 18 19 9 10 CF Re-Training_Phase 2 (10 village 14-Nov- 9 1/1) _Xonnaboury 12-Nov-18 18 18 15 3 CF Re-Training_Phase 3 (10 villages 22-Nov- 10 1/1) _Xonnaboury 20-Nov-18 18 22 15 7 CF Training_Phase 4 (9 villages 1/2 ) 29-Nov- 11 _Phine 27-Nov-18 18 18 11 7 CF Training_Phase 5 (12 villages 1/1) 29-Nov- 12 _Xonnaboury 27-Nov-18 18 24 23 1 CF Re-Training_Phase 2 (9 villages 2/2 13-Dec- 13 ) _Phine 11-Dec-18 18 18 5 13 CF Training_Phase 6 (9 villages 1/1 ) 14-Dec- 14 _Xonnaboury 12-Dec-18 18 20 18 2 CF Training_Phase 5 (7 villages 1/2 ) 16-Dec- 15 _Phine 14-Dec-18 18 19 15 4

CF Re-Training_Phase 2 (9 villages 1/2 17-Dec- 16 ) _Phine 15-Dec-18 18 18 7 11 CF Training_Phase 5 (10 villages 2/2 ) 20-Dec- 17 _Phine 18-Dec-18 18 20 20 0 CF Training_Phase 6 (10 villages 1/1) 18 _Phine 15-Jan-19 17-Jan-19 20 12 8 CF Training_Phase 4 (10 villages 2/2) 19 _Phine 16-Jan-19 18-Jan-19 20 5 15 CF Training_Phase 5+6 (10 villages 20 1/1) _Saybouathong 18-Feb-19 20-Feb-19 25 23 2 Total CF Training 20 395 252 143

Savannakhet Total - 195 Villages 35 636 263 373

Total Khammoune & 67 1191 566 625 Savannakhet - 395 Villages

Figure 1. Finalized iNuW Process

Open Defecation Free Discussion Between March 4 and 13, 2019, USAID Nurture together with central government partners (representatives from Department of Hygiene and Health Promotion, and Nam Saat) conducted field missions to discuss how to support communities to achieve ODF status within the timeframe with vice-district governors and district health offices in all six target districts. As a result, all the vice-district governors committed stronger support to USAID Nurture’s implementation process and closer supervision with village authorities. At the same time, consultation workshops with village authorities of the ODF focused villages in each district were organized and chaired by vice-district governors.

Monthly Meeting with District Government Partners Starting from August 2018, all six district teams have had monthly meetings with their government partners, respectively. Meetings focused more on the technical side of implementation, results of planned activities, and planning for the upcoming month. Monthly reports were submitted to DHOs.

Challenges and Mitigation

Initial training and roll out of the coaching guide has progressed slowly due to the lack of experience with coaching approaches in the Lao context. USAID Nurture will adjust DPO supervision accordingly to ensure high quality implementation. Additionally, incentives for VIC and CFs – VICs and CFs have raised the issue of insufficient incentives. District authorities asked if other types of incentives could also be given. One feasible incentive after initial consultation with district partners and village authorities, is to develop a certificate of appreciation with the person’s photo and signature from their district. The certifications will be handed over to all VIC and CFs.

Other challenges include:  Relocation of CFs: Young CFs tend to move out of their villages for various reasons such as marriage or employment in town, which means they stop volunteer work in their own villages. While it is beyond our control to prevent them from relocating, in order to lessen the impact, USAID Nurture will request Village Committees to help identify potential CFs in advance based on the USAID Nurture criteria for a timely replacement.  Availability of VICs and CFs: During harvest season between December and February, VICs and CFs are hard to reach during the daytime, especially in Atsaphangthong and Xonnabouly districts where everyone works in sugarcane fields, the main agricultural activity. Recognizing that fewer activities will occur during this period, USAID Nurture will prioritize crucial activities to be done and/or to work out with CFs and VICs alternative times to reach them.  Modeling toilet usage: VICs and CFs are seen as models in the community; however, many VICs and CFs do not have their own toilets at their homes. USAID Nurture is exploring with the private vendors to offer some promotions that may benefit the CFs and VICs, e.g. for every 10 toilets ordered one extra toilet will be given to CF or VIC whichever is the case in a particular village.

Intermediate Result 2: Improved Use of Quality Nutrition and Nutrition-Sensitive WASH Services/Facilities

WASH Product Delivery

Sales Agent Training In order to effectively and successfully carry out the new approach, DPOs were mobilized and trained by the WASH Specialist and WASH Marketing Manager to conduct training of sales agents in their respective villages. Nam Saat partners (both provincial and district levels) actively took part in the process – starting from the selection process of potential sales agents at the village level to becoming trainers for the sales agent training. The training was carried out concurrently across the six districts between January and February 2019.

WASH Private Vendors In cooperation with the district Nam Saat Unit, USAID Nurture identified and consulted select private vendors to motivate them to support improvements in household WASH access. Discussions focused on the benefits for businesses - potential profits, types of WASH products to be promoted and delivered, basic knowledge and skills on marketing or promotion channels, and investment calculation (investment capital, pricing, and basic business plans). To ensure the

regular delivery of toilets and water filters according to the orders received on a monthly basis, USAID Nurture, alongside district Nam Saat, supervised private vendors on a monthly basis on their production and delivery plan. With this regular supervision, better product delivery was observed; however, toilet delivery was behind schedule for some vendors in Gnommalath district, Khammouane province due to their infrequent lack of labor. The delivery of water filters for most vendors was on track because water filters does not need to be manufactured compared to that of toilets.

WASH Product Promotion Central to the promotion of WASH products at the community level are the sales agents. Regular support and supervision of sales agents is crucial to ensure that the monthly promotion plan activity is carried out according to plan and to encourage the sales agents to conduct the promotion activity. Supervision included review of results of the previous month’s planned activities, collect orders and update implementation status, discussion of technical and non- technical challenges, and facilitate making a monthly plan. Upon completing their training, the new WASH sales agents began selling their products in Feb 2019. The increase in the number of sales agents has started improving sales numbers.

Partnership USAID Nurture’s partnership with Abundant Water (AW) is adding value to the implementation of WASH activities. AW produces and supplies quality and reasonably priced WASH products and USAID Nurture uses their marketing materials (water filters). AW also built capacity of private vendors, and conducted field supervision themselves. Likewise, AW staff followed up with private vendors in Savannakhet and Khammouane to ensure technical knowledge of the products and skills needed to install the products. They also emphasized user support and planned refresher trainings for staff.

Table 11. Number of Private Vendors Engaged in WASH Marketing

FY19 Indicator Oct 1, Overall % Indicator Target 18- ID Total Total Achieved Mar 31, 19 Number of private sector Indicator outlets providing WASH 12 10 10 10 83 IR2-2 products Number of WASH Indicator products sold by sales 200 328 328 328 164 IR2.2-3 agents Number of sales agents trained on how to motivate 315 401 401 401 127 Indicator households and sell WASH IR2-3 products - Male 283 375 375 375 133 - Female 32 26 26 26 81

Under table 11, data shows that USAID Nurture surpassed its target on WASH products sold by sales agents. During the reporting period, majority of the sales are water filters (177) while the number of toilets sold was 151.

Challenges and Mitigation Limited water access – water access is a major issue that influences household willingness to construct, purchase products, and use a toilet facility. Since USAID Nurture was not designed to increase water access, USAID Nurture is reaching out to other development partners investing in water system construction/rehabilitation to improve the layering of activities in USAID Nurture villages. USAID Nurture is advocating for household water connections wherever feasible. Concurrently, USAID Nurture has advocated intensely with Central Nam Saat, along with provincial and district Nam Saat partners to engage in steering water construction organizations to our most water stressed communities. USAID Nurture is also assessing the feasibility of re-vitalizing Water-Sanitation Committees to collect water user fees and manage water point maintenance in communities that are most water- stressed.

Sales agents -- The key challenges identified regarding sales agents included the following: (1) Some trained sales agents do not conduct sales activity in villages outside their home village as initially planned. (2) As reported, villagers do not trust sales agents who are not from their own villages. (3) Village authorities are not consistently providing necessary facilitation for the sales agent who travel between villages. (4) Ethnicity strongly comes into play evidenced by sales agents of a different ethnic group not well received by the community.

In order to address these issues, USAID Nurture adjusted the sales agents approach over the past quarter. The approach was changed from having clustered sales agents (4-5 sales agents) covering 10 villages to creating village sales agents who are responsible for conducting sales only within their own village (usually VIC or CF). With the new approach, the number of sales agents reached 442 by the end of February 2019 compared to the planned 127 sales agents. After making this strategic adjustment, USAID Nurture began to see increases in toilet and water filter sales. While hiring additional sales agents was needed to meet WASH sales targets, the current WASH staff of three people cannot effectively mentor and supervise all 442 sales agents. Therefore, DPOs who work closely with VICs and CFs on a monthly basis will help follow up with sales agents in coordination with WASH marketing officers. See table below.

Location – large portions of the target communities are very remote, and far from private vendors and markets where basic materials are available. This affects product prices and transportation costs. Other challenges identified include capital investment on basic materials and equipment for toilet production, sufficient labor, and a business mindset. Communities that need to cross over rivers make a private vendor’s accessibility more difficult. In some cases, private vendors just drop the products by the river, and communities who ordered them have to transport the products by themselves. USAID Nurture will focus on promoting a simple and easy business – sale of water filters – since this business does not require a large amount of investment but rather needs some level of technical skills.

All current private vendors who agreed to engage in WASH marketing with USAID Nurture are located in town which are quite far from a large number of target villages. USAID Nurture will widen coverage of private vendors to offer more product accessibility to target villagers by increasing convenience and proximity of vendors. (See Appendix 6 Summary of Toilet Prices).

Transportation – as per previous experience, transportation of products, including installation, was difficult especially during the rainy season. As this is unavoidable, marketing activities intensify during the dry season although some marketing promotion events are still carried out in the rainy season.

Poverty – even though the issue of extreme poor families has been discussed with district authorities, possible solutions have not been identified. USAID Nurture plans to negotiate with private vendors to agree on a scheme to offer one free product for every 20 orders.

HEALTH SERVICE DELIVERY

Health Care Provider and Management Staff Capacity Building Program In the first two quarters of FY 2019, USAID Nurture and provincial training teams completed the rollout of the three-part health care provider nutrition counseling training as planned. See below table. Table 12. 1000 Days Nutrition Counseling Course Schedule

District 1000 Days Nutrition Counselling Course Mahaxay Full Training Course Completed December 2017 Phine Full Training Course Completed December 2017 Xonnaboury Full Training Course Completed September 2018 Ngommalath Full Training Course Completed November 2018 Saybouathong Full Training Course Completed November 2018 Atsaphangthong Full Training Course Completed February 2019

Since nutrition counseling skills have been provided to all health centers in USAID Nurture target areas, the next challenge is two-fold: to develop strong supervision and support by managers for the service to be implemented with quality, and to help DHOs transition to the well-child approach with every contact visit including nutrition counseling. The goal is for HCs to become capable of making appropriate referrals. See table below for total numbers trained during the reporting period.

Table 13. Q1 and Q2 FY 2019 Health Care Provider Capacity Building

Total Start End Femal Mal No. Name of Event Traine Date Date e e es 1000 Days Nutrition Counselling Module 1 30-Oct-18 1-Nov-18 20 18 2 III__Ngommalath 1000 Days Nutrition Counselling Module 2 31-Oct-18 2-Nov-18 26 24 2 II_Attsaphangthong

1000 Days Nutrition Counselling Module 3 6-Nov-18 8-Nov-18 11 7 4 III__Saybouathong 1000 Days Nutrition Counselling Module 21-Feb- 4 19-Feb-19 26 23 3 III__Attsaphangthong 19 Total 83 72 11

Scaling USAID Nurture Innovation In October 2018, the SHS was requested to provide training of Module 1 of the USAID Nurture 1000 Days Nutrition Counseling Course for the national antenatal care (ANC) trainer team and the leadership of Mother and Child Health Center (MCHC) and University of Health Sciences (UHS) that are responsible for the new national ANC guideline and training. This was an advocacy success resulting from the efforts throughout FY2018 to share the USAID Nurture method and approach. Dr Khanthong Siharath, Chair of the ANC taskforce, enthusiastically embraced the new approach and focus and as a result, the national ANC CME in-service course has been revised to last for three days. Day 2 is devoted to counseling using counseling techniques from USAID Nurture, including the six key competencies and the use of simulation and debrief in addition to inclusion of the SDA approach for ANC counseling on maternal nutrition.

The second achievement of national uptake of USAID Nurture innovations was through the revision of the national MCH handbook, also known as the ‘Pink Book’, which is the portable care record for pregnancy through age five and contains key health education information. The SHS has been deeply involved in the revision of this national resource since efforts began in March 2018 as noted in the previous semi-annual report (SAR) and annual report (AR). In the first two quarters of FY2019, the SHS successfully advocated for the development and inclusion of a national well-child care schedule in the ‘Pink Book’ that expands from the previous national vaccination schedule to specify that eight integrated care contacts from birth to age two are standard, including growth monitoring and nutrition counseling for infants and young children. Also, the child health education pages in the handbook have been completely re-written to be an age/stage based resource comprised of Small Doable Action style messages on breastfeeding, nutrition, hygiene and child development with methods taught in the 1000 Days Nutrition Counseling Course.

Challenges and Mitigation The most pressing priority now is to follow up on the success of the training rollout with solid investments in supportive supervision to ensure continued implementation of the new approaches to nutrition counseling.

Cross-cutting Approach: Improved Enabling Environment for Multi Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities

Nutrition Governance and Multi-Sectoral Coordination USAID Nurture supports the following coordination and capacity building activities at the subnational level: 1) quarterly meetings; 2) attending the Quarterly Provincial Nutrition Secretariat Meeting; 3) technical and coordination capacity building; 4) support for monitoring and supervision of activities in districts and villages; and 5) support for study visit/exchanges.

USAID Nurture is continuing to cooperate with the UNICEF provincial coordinator of KHM and SVK to support subnational coordination, in particular to support numerous DNC quarterly meetings in the first half of this year. All districts met twice over the last two quarters except Xonnaboury and Phinh, which both held second meetings in the first week of April 2019.

The capacity and focus of each DNC varies quite widely. Some DNCs are still just developing an awareness of their mandate while others have begun to review detailed local issues. The key concern of a majority of committees is the “nutrition model villages” (NMV) program, a GoL initiative. Participant numbers for committee meetings are in the table below. The committees will require close support and coaching as they develop into their role as coordination bodies for nutrition. The meeting held thus far have helped to increase awareness of their role, disseminate national policy, and serve as a platform for multi-sectoral discussion on local nutrition priorities.

Table 14. Q1 and Q2 FY 2019 District Nutrition Multi-Sectoral Committee Meetings No# of No# of No# of District Event Date Participants Females Males Khammouane Mahaxay 29-Nov-19 38 18 20 27-Mar-19 41 19 22 Ngommalath 11-Oct-18 20 7 13 26-Mar-19 38 16 22 Saybouathong 28-Mar-19 39 14 25 26-Nov-18 25 10 15 Savanakhet Attsaphanthong 25-Oct-18 32 23 9 21-Mar-19 22 0 22 Xonnaboury 9-Oct-18 41 18 23 Phinh 4-Oct-19 31 18 13

DEVIATIONS FROM EXPECTATIONS FOR PERFORMANCE INDICATORS

MEL Plan The Results Framework was finalized in Q1 of FY2018. The Performance Indicator Reference Sheets were further reviewed and will be finalized together with the MEL Plan in July 2019.

MEL The MEL team is using Microsoft Access to record community level data that was set up by the MEL consultant. In January 2019, MEL team (MEL Officer and consultant) provided training to the iNuW Program Managers, newly hired DPOs and Data Entry Officers on how to use the form and understand the data flow process, indicators, and targets in order to improve their understanding of MEL. Prior to training, the MEL team conducted a capacity assessment of Data Entry Officers using a set of questionnaires, and trained them according to their capacity needs.

In November 2018, USAID conducted a Data Quality Assessment (DQA) at the Vientiane USAID Nurture office. One of the findings portrayed that while the MEL staff has a fairly good knowledge of data management and analysis, there is still a need to strengthen understanding of operational definition and disaggregation requirements of certain custom indicators. USAID Nurture plans to conduct training to re-orient relevant MEL and program staff to ensure a clear understanding of definitions for all indicators and conduct a second capacity-building workshop with the field team on data collection, routine monitoring, indicators, data flow, reporting, and quality control. Once the MEL plan is approved, USAID Nurture will develop a Lao language MEL guideline on reporting requirements. This document will direct new staff in how to utilize the tools and follow data collection procedures appropriately.

Challenges and Mitigation

A major challenge within the USAID Nurture’s MEL unit is the lack of strong capacity to manage and deliver quality data and analysis in order to help with quality implementation of activities. In order to mitigate this, USAID Nurture is recruiting a MEL Manager to lead the MEL work, supervise the MEL staff and to facilitate strengthening the capacity of MEL. In addition, through the Country Office Staff Development initiatives, the MEL staff are receiving training opportunities in monitoring, evaluation, accountability and learning. Furthermore, the MEL staff are getting continuous on-the-job training by working side by side with a national consultant who is currently supporting the MEL team.

INTEGRATION OF CROSSCUTTING ISSUES AND USAID FORWARD PRIORITIES

Gender Sensitive Considerations and Male/Female Involvement The redesign of the CF program including improved selection criteria and the new participatory and skills-based training have identified and supported a much higher number of female CFs compared to the initial CF activity rollout. Currently 68% (674) of active CFs are female. Low literacy and confidence of CFs remain a crucial challenge to project effectiveness thus USAID Nurture has invested in further training for DPOs and development of supportive coaching approaches for CFs.

Nutrition Sensitive Agriculture Interventions Since its inception, USAID Nurture has promoted dried fish/insect/frog powder as an acceptable, affordable and highly nutritious addition to young children and mothers’ diets. Livestock and fish production (including eggs and milk) have the advantage of providing food year-round while providing women and children with more varied diets. Animal-source foods are a great source of many important nutrients (e.g. protein and iron). They also contain nutrients that are more easily absorbed by the body than plant-based foods[1]. Fish are rich in vitamin B12, calcium, iron, zinc, fatty acids and animal protein, and some small fish are especially rich in vitamin A. When consumed as part of a meal, fish can increase the absorption of iron and zinc from other foods. Essential fatty acids, including DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid), which are only found in fish, are

[1] USAID Policy Brief www.usaid.gov/what-we-do/global-health/nutrition/nutrition-sensitive-agriculture-nutrient-rich- value-chains 30

critical for pregnant and lactating women as well as young children, as they are vital for cognitive development in the first 1000 days.

Consuming small‐sized fish species whole could contribute significantly to reducing the level of micronutrient and protein malnutrition. Fish products are more affordable and could therefore meet the needs of poor, vulnerable groups, particularly in rural and urban areas where limited economic resources prevent dietary diversity [2].

USAID Nurture uses local technology to produce the powder, by drying small fish, insects and frogs and turning it into a powder, using simple processing methods (mortar, pestle and sieve) to fortify local recipes. Uptake of the powder has been high, and it promises to be a key component in improving and diversifying diets of adolescent, children, and mothers.

Further possibilities and innovations are being discussed at the district and provincial level to determine other nutrition sensitive agriculture activities that may be supported/reinforced further on.

Raising the Role of Nam Saat for the Support of Private Sector Involvement In order to get Nam Saat (provincial and district) ready to take up rural sanitation promotion role in sanitation marketing, USAID Nurture has given attention to close participation of the Nam Saat in field work – identification, recruitment and training of private vendors and sales agents at village level. Participation in fieldwork helped the Nam Saat clearly understand the marketing process, its importance in promotion of rural sanitation access while building a sound foundation for their role relating to promotion and management of sanitation marketing work.

Trainers for iNuW Since its inception, USAID Nurture has focused in building capacity of both provincial and district government partners in the implementation of and leadership of the iNuW Visit process. The capacity building focuses on two aspects of (1) for provincial and district staff - planning and implementing activities with detailed steps for both community and household visits, and (2) for health center staff - coaching and mentoring community facilitators on home visit activity. Importantly, government partners have and will continue to be trained as trainers on the iNuW process to ensure that understanding and capacity remains at these levels. These efforts will serve as a strong foundation for future replication to other areas in the provinces

ENVIRONMENTAL COMPLIANCE

During trainings of WASH enterprises, USAID Nurture continues to ensure that latrine marketers and water filter have installation standards that ensure runoff water is managed, such as by digging soak away pits, and that latrines are constructed at least 15 meters from a drinking water source. The national latrine manual follows WHO/UNICEF guidance on water, sanitation and hygiene for reference. Examples of mitigation measures include latrine options, latrine installation guide, and sales agent flipcharts for education during sale events.

[2] Food Sci Nutrv.5(3); 2017 MayPMC5448337 31

On February 26, 2019, two staff (Senior WASH Specialist and Senior Operations Manager) from USAID Nurture participated in the USAID’s Environmental Compliance Regulations and Procedures Training organized at the American Center in Vientiane. The training introduced a systematic identification of types of environmental risks (different sectors) and background of regulations and procedures.

SCIENCE, TECHNOLOGY, AND INNOVATION

Nothing to report for this reporting period.

STAKEHOLDERS PARTICIPATION AND INVOLVEMENT

USAID Nurture continued to work closely with GoL officials at national and provincial levels and with other development partners to provide technical support to the GoL. Project staff are members of key working groups, including the Development Partners Nutrition Group, and the RMNCH Working Group, which provide USAID Nurture the opportunity to contribute to national dialogue, priority setting, and evidence-based policymaking and programmatic responses.

The following tables are lists of USAID Nurture’s stakeholders:

Table 15. Key non-GoL Stakeholders UNICEF/Nutrition IYCF guidelines and skill training RMNCH secretariat support, especially SO7 Well-Child Platform UNICEF/Health CF Training Manual cited as example for national VHV training revision WHO Key partner for RMNCH Mid Term Review, Child Health Assessment tool launch, ‘Pink Book’ revision HI Integration of Child Development screening and counseling into Well-Child platform and in the new ‘Pink Book’ SUN CSA NPAs and other leading INGO such as PLAN and WV collaborate on a unified CSO strategy for enhanced coordination at district and provincial level and support to multi-sectoral committees

Table 16. Key GoL Stakeholders

CIEH Develop rollout and publish 1000 Days Nutrition Counseling Course; support SBCC strategy development NNC Support the RMNCH sub-committee on nutrition (SO7), support delegation to CODEX and writing of the Lao BMS Code, Develop Well-Child care schedule, Launch Child Health Assessment tool MCHC Training on counseling for ANC central facilitators, support new national ANC guideline, support revision of the ‘Pink Book’, re- writing health education materials, support RMNCH secretariat conduct annual implementation review and mid-term review meeting

DHHP Support development of Lao BMS Code, midterm review of RMNCH strategy DHR Support EENC Committee/SO4 to broaden focus to breastfeeding services in facilities, develop national breastfeeding services program NIN Guest lecture on nutrition counselling techniques for first National Diabetes Conference.

COST SHARING

Alive & Thrive in Lao PDR is dedicated to developing breastfeeding friendly health systems, which fully aligns with the goals of USAID Nurture. The USAID Nurture SHS (via cost share with Alive & Thrive) is working closely with the Early Essential Newborn (EENC) Master Trainer team and the MoH Department of Health Care and Rehabilitation widen its scope to include breastfeeding services. Alive & Thrive also contributed to SUN CSA activities for subnational nutrition coordination between civil society and GoL, which is fully in line with USAID Nurture’s IR3.

USAID Nurture continues to coordinate with the grant Save the Children received from the EU for an integrated nutrition and WASH project in four Northern provinces, which began in late 2017. This project, SCALING, was designed to build on and use USAID Nurture tools and approaches. USAID Nurture staff provided technical assistance through the Senior Health Specialist, Senior WASH Specialist, and WASH Marketing Officer to ensure lessons learned are transferred and co-learning exists.

During the reporting period, SC used its own funds to pay a contract with CIEH to develop the rollout plan and publish the 1000 Days Nutrition Counseling Course.

PLANNED TASKS/INTERVENTIONS FOR THE NEXT REPORTING PERIOD

The following activities are anticipated to be implemented during the second half of FY 2019.

Program Management  Conduct quarterly review meeting  Hold a Phase 1 implementation review meeting  Facilitate MOU extension process  Develop Y5 & Y6 work plans  Start phase 2 implementation  Semi-Annual report approval  Submit FY19 annual report  Finalize MEL Plan  Support a USAID-funded midline evaluation in Q3  Execution of communication Plan  Initiate process evaluation activity

Intermediate Result 1: Improved IYCF and WASH Behaviors in Household with Pregnant Women and Children under Two

● Finalize coaching guide and continue support strengthening of DPOs skills to monitor and support home visiting. ● Design guide to new SDA for CFs to use in working with and giving messages to adolescent girls to eat more nutritious food not only in the home but also in school. ● Recruitment for one DPO to replace the one who resigned in Phine District in Savannakhet. ● Recruitment of a Provincial Coordinator (PC) to replace the current PC who is leaving at the end of April, 2019. ● Train DPOs and CFs on the new SDA specific to adolescents in the 1,000 days HH. ● Continue to roll-out visits (both community visits and supporting VICs and CFs), as per the phasing plan. ● Conduct Visit #8 “ODF Verification” in villages that are ready, eg. 100% toilet coverage or 100% toilet use. In villages that have less than 100% toilet coverage, the team will assess results, identify challenges, and make a plan. ● Conduct training on Visit #8 “ODF Verification” for Savannakhet and Khammouane provinces. ● Continue supporting CFs on the home visit activity, including increased promotion of dried powder as an important component of a diverse diet for SDAs 1, 7 and the new adolescent SDA. ● Produce two sets of videos – (1) CF orientation video on essential knowledge and the role of CFs, and (2) CF training video about how to conduct a home visit activity. ● Approval, printing and sharing to development partners and government partners of the final iNuW toolkit and CF job aids (CF Home Visit Guide & SDAs card). ● Conduct training of trainers on the iNuW process for provincial and district partners.

Intermediate Result 2: Improved Use of Quality Nutrition and Nutrition-Sensitive WASH Services/Facilities ● The 1000 Days Nutrition Counseling Course will be edited, designed and published. ● Job aids to support the training package will be developed including counseling guides and a pregnancy dating wheel. o Publish a pregnancy wheel (gestational age calendar) as a job aid for ANC nutrition counseling in conjunction with national launch of new ‘Pink Book’. ● Both the counseling course and job aids will include promotion of dried powder as an important component of a diverse diet for SDAs 1, 7 and the new adolescent SDA. ● Launch nutrition services supervision program in project districts in conjunction with Child Health Assessment tool roll out and release of the new ‘Pink Book’. ● Design job aid on adolescent nutrition counseling by health care staff. ● CF work/provide nutrition-adolescent specific messages during HH visits. ● Begin support to project district hospitals and health centers to become first subnational facilities deemed ‘Centers of Breastfeeding Excellence’. (cost share - A&T) ● Conduct provincial workshop to present and discuss public-private partnership in two provinces. ● Training provincial and district Nam Saat in the management of WASH marketing and in the quality assurance of products and services delivered by private vendors. ● Continue providing support to all sales agents and private vendors on a monthly basis. ● Apply various channels of sales promotion to communities during the rainy season. ● Produce two sets of WASH marketing videos: (1) WASH marketing -- this one describes how marketing works and contributes to rural sanitation promotion, and (2) Sales Agent training – this video serves as training job-aid for sales agents training. ● Continue partnership with Abundant Water Organization in terms of supply, tracking, quality assurance and user support. 34

● Increase coverage of private vendors for the communities situated far away from town centers.

Cross-cutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities ● Work with the SUN CSA Advocacy Working group and the SUN CSA advocacy focal point for SVK, continue to provide technical support multi-sectoral coordination activities in coalition (A&T). ● Provide logistical and financial support for district multi-sectoral committees in six project districts quarterly. ● Continue providing support to National Center for Environmental Health and Water Supply (Nam Saat) to revise the national CLTS Manual. Further support will include the development of the National CLTS’ Trainer Guide. ● With support of the National Nam Saat Center, USAID Nurture will reach out to partners who are active/potentially active in Khammouane and Savannakhet provinces regarding construction/rehabilitation work of community water systems. ● USAID Nurture will engage Nam Saat at local levels (provincial and district) to work with existing village committees (WatSan Committees) to strengthen their role and capacity in improving water supply system/facility especially in the USAID Nurture’s most water stressed communities. ● Under the leadership of district government partner through DNC, discuss appropriate engagement with DAFO for the work on NSA.

Monitoring and Evaluation  Conduct data quality audits for private vendors.  Upon approval of the MEL plan, USAID Nurture will develop a Lao language MEL guideline on reporting requirements, which include, but are not limited to the list of indicators with clear operational indicator definitions, role and responsibilities at each level and clear data flow from community to central level. This document will also facilitate the newcomers to utilize the tools and follow data collection procedures appropriately.  USAID Nurture will conduct a second capacity-building workshop with field team staff on data collection, routine monitoring indicators and data flow, reporting and quality control.  USAID Nurture will conduct a process evaluation/monitoring in Q4 to assess the reliability of program implementation.

APPENDIX 1: REMAINING SCALE UP OF INUW DISTRICTS

2019 District Phase # of Villages April May June Description Visit Visit Visit Phine 1 10 V9-o - 100 2 20 v9-o - 5 staff 3 20 v7 V8 - 4 20 V6 V7 V8 5 20 V6 V7 V8 6 10 V8 - - 70 90 40 Xonnabouly 1 0 - - - 2 10 - v9-o - 62 3 10 - v9-o - 3 staff 4 20 v7 V8 - 5 12 v7 V8 - 6 10 V7 V8 62 42 62 1 0 - - 2 0 - - Atsaphangthong 3 10 - v9-o 40 4 10 - - - 4 10 V8 - - 2 staff 5 20 V7 V8 5 20 - - 70 30 30 Ngommalath 1 0 - - - 2 20 - v9-o - 111 3 10 V7 V8 v9-o 3 10 V7 V8 v9-o 4 staff 4 15 V5 V6 - 4 15 - V7 V8 5 21 V6 V7 V8 6 20 V6 V7 V8 111 76 111 76 Mahaxay 1 10 - v9-o - 93 2 20 - v9-o - 5 staff 3 24 V7 V8 v9-o 4 20 V7 V8 5 19 V6 V7 V8 93 63 93 43 Saybouathong 1 0 - - 2 10 - v9-o 65 3 15 - v9-o 3 staff 4 10 - V7 V8 5 20 V4 V5 V7 5 20 V6 6 10 V4 V5 V7 36

6 10 V6 30 95 40

APPENDIX 2: NUMBER OF PEOPLE TRAINED DURING THE REPORTING PERIOD OF OCTOBER 1, 2018 – MARCH 31, 2019

Total Even Start End Femal Mal No# Name of Event Traine t ID Date Date e e es NE08 VIC Training-Phase 4 (04 villages 5-Oct- 8 1 2 3/3) _Mahaxay 18 5-Oct-18 8 0 NE08 CF Training_Phase 4 (04 villages 8-Oct- 10-Oct- 2 3 3/3) _Mahaxay 18 18 8 8 0 NE08 CF Training_Phase 4 (06 villages 9-Oct- 11-Oct- 3 4 1/2) _Xonnaboury 18 18 14 10 4 NE08 VIC Training_Phase 5 (10 villages 9-Oct- 4 5 2/2)_Attsaphangthong 18 9-Oct-18 20 2 18 NE08 VIC Training_Phase 3 (10 villages 9-Oct- 5 6 1/2) _Phine 18 9-Oct-18 18 0 18 NE08 CF Training_Phase 5 (10 villages 10- 12-Oct- 6 7 2/2)_Attsaphangthong Oct-18 18 20 9 11 NE08 CF Training_Phase 5 (10 villages 10- 12-Oct- 7 8 1/2) _Ngommalath Oct-18 18 19 16 3 NE08 CF Training_Phase 6 (10 villages 10- 12-Oct- 8 9 1/2)_Ngommalath Oct-18 18 20 20 0 NE09 CF Training_Phase 3 (10 villages 10- 12-Oct- 9 0 1/2) _Phine Oct-18 18 18 5 13 NE09 VIC Training_Phase 4 (06 villages 12- 12-Oct- 10 1 1/2) _Xonnaboury Oct-18 18 12 0 12 NE09 VIC Training_Phase 5 (10 villages 15- 15-Oct- 11 2 1/2) _Ngommalath Oct-18 18 18 6 12 NE09 VIC Training_Phase 6 (10 villages 15- 15-Oct- 12 3 1/2)_Ngommalath Oct-18 18 15 1 14 NE09 VIC Training_Phase 3 (10 villages 15- 15-Oct- 13 4 2/2) _Phine Oct-18 18 15 2 13 NE09 VIC Traning_Phase 4 (10 Villages 16- 16-Oct- 14 5 1/1)_Attsaphangthong Oct-18 18 19 2 17 NE09 CF Training_Phase 5 (10 villages 16- 18-Oct- 15 6 2/2)_Ngommalath Oct-18 18 20 12 8 NE09 CF Training_Phase 6 (10 villages 16- 18-Oct- 16 7 2/2) _Ngommalath Oct-18 18 20 19 1 NE09 CF Training_Phase 3 (10 villages 16- 18-Oct- 17 8 2/2) _Phine Oct-18 18 19 2 17 NE09 VIC Training Phase 4 (14 villages 16- 16-Oct- 18 9 2/2) _Xonnaboury Oct-18 18 24 0 24 NE10 CF Training_Phase 4 (10 villages 17- 19-Oct- 19 0 1/1) _Attsaphangthong Oct-18 18 20 19 1 NE10 CF Training_Phase 4 (14 villages 17- 19-Oct- 20 1 2/2) _Xonnaboury Oct-18 18 26 23 3 NE10 VIC Training_Phase 5 (10 villages 19- 19-Oct- 21 2 2/2)_Ngommalath Oct-18 18 17 3 14

NE10 VIC Training_Phase 6 (10 villages 19- 19-Oct- 22 3 2/2)_Ngommalath Oct-18 18 20 7 13 NE10 MCH Nutrition Counselling 30- 23 4 Module III__Ngommalath Oct-18 1-Nov-18 20 18 2 NE10 MCH Nutrition Counselling 31- 24 5 Module II_Attsaphangthong Oct-18 2-Nov-18 26 24 2 NE10 MCH Nutrition Counselling 6-Nov- 25 6 Module III__Saybouathong 18 8-Nov-18 11 7 4 NE10 CF Re-Training_Phase 2 (10 12- 14-Nov- 26 7 villages 1/2) _Ngommalath Nov-18 18 20 7 13 NE10 CF Re-Training_Phase 3 (10 12- 14-Nov- 27 8 village 1/1) _Attsaphangthong Nov-18 18 17 6 11 NE10 CF Re-Training_Phase 1 (10 12- 14-Nov- 28 9 villages 1/1) _Phine Nov-18 18 19 9 10 NE11 CF Re-Training_Phase 2+3 (9 12- 14-Nov- 29 0 villages 2/3 ) _Saybouathong Nov-18 18 18 9 9 NE11 CF Re-Training_Phase 2 (10 12- 14-Nov- 30 1 village 1/1) _Xonnaboury Nov-18 18 18 15 3 NE11 CF ReTraining_Phase 1 (10 13- 15-Nov- 31 2 villages 1/1) _Mahaxay Nov-18 18 20 17 3 NE11 CF Re-Training_Phase 3 (10 13- 15-Nov- 32 3 Villages 1/2)_Ngommalath Nov-18 18 17 5 12 NE11 CF Re-Training_Phase 2 (9 15- 17-Nov- 33 4 villages 2/2) _Ngommalath Nov-18 18 18 9 9 NE11 CF Re-Training_Phase 2+3 (9 16- 18-Nov- 34 5 villages 1/3) _Saybouathong Nov-18 18 18 10 8 NE11 CF Re-Training_Phase 3 (8 19- 21-Nov- 35 6 villages 2/2 ) _Ngommalath Nov-18 18 16 12 4 NE11 CF Re-Training_Phase 2+3 (8 19- 21-Nov- 36 7 villages 3/3) _Saybouathong Nov-18 18 16 7 9 NE11 CF Re-Training_Phase 3 (10 20- 22-Nov- 37 8 villages 1/1) _Xonnaboury Nov-18 18 22 15 7 NE11 CF Re-Training_Phase 2 (10 21- 23-Nov- 38 9 villages 1/2) _Mahaxay Nov-18 18 20 13 7 NE12 CF Re-Training_Phase 3 (13 26- 28-Nov- 39 0 villages 1/2) _Mahaxay Nov-18 18 26 19 7 NE12 VIC Training_Phase 4 (9 villages 26- 26-Nov- 40 1 1/2 ) _Phine Nov-18 18 18 0 18 NE12 VIC Training_Phase 5 (13 villages 26- 26-Nov- 41 2 1/1 ) _Xonnaboury Nov-18 18 26 0 26 NE12 CF Training_Phase 4 (9 villages 27- 29-Nov- 42 3 1/2 ) _Phine Nov-18 18 18 11 7 NE12 CF Training_Phase 5 (12 villages 27- 29-Nov- 43 4 1/1) _Xonnaboury Nov-18 18 24 23 1 NE12 CF Re-Training_Phase 2&3 (10 11- 13-Dec- 44 5 villages 1/2 ) _Mahaxay Dec-18 18 20 13 7 NE12 CF Re-Training_Phase 2 (9 11- 13-Dec- 45 6 villages 2/2 ) _Phine Dec-18 18 18 5 13

NE12 VIC Training_Phase 6 (9 villages 11- 11-Dec- 46 7 1/1 ) _Xonnaboury Dec-18 18 17 0 17 NE12 CF Training_Phase 5 (10 villages 12- 14-Dec- 47 8 1/2 ) _Mahaxay Dec-18 18 20 20 0 NE12 CF Training_Phase 6 (9 villages 12- 14-Dec- 48 9 1/1 ) _Xonnaboury Dec-18 18 20 18 2 NE13 VIC Training_Phase 5 (7 villages 13- 13-Dec- 49 0 1/2 ) _Phine Dec-18 18 14 4 10 NE13 CF Training_Phase 5 (7 villages 14- 16-Dec- 50 1 1/2 ) _Phine Dec-18 18 19 15 4 NE13 CF Re-Training_Phase 2 (9 15- 17-Dec- 51 2 villages 1/2 ) _Phine Dec-18 18 18 7 11 NE13 VIC Training_Phase 5 (10 villages 17- 17-Dec- 52 3 1/2 ) _Mahaxay Dec-18 18 18 4 14 NE13 VIC Training_Phase 5 (10 villages 17- 17-Dec- 53 4 2/2 ) _Phine Dec-18 18 20 0 20 NE13 CF Training_Phase 5 (10 villages 18- 20-Dec- 54 5 2/2 ) _Mahaxay Dec-18 18 20 18 2 NE13 CF Training_Phase 5 (10 villages 18- 20-Dec- 55 6 2/2 ) _Phine Dec-18 18 20 20 0 NE13 CF Re-Training_Phase 2&3 (10 19- 21-Dec- 56 7 villages 2/2 ) _Mahaxay Dec-18 18 19 18 1 NE13 VIC Training_Phase 5 (10 villages 21- 21-Dec- 57 8 2/2 ) _Mahaxay Dec-18 18 18 0 18 NE13 VIC Training_Phase 6 (10 villages 14-Jan- 58 9 1/1) _Phine 19 14-Jan-19 19 0 19 NE14 VIC Training_Phase 4 (10 villages 15-Jan- 59 0 2/2) _Phine 19 15-Jan-19 19 1 18 NE14 CF Training_Phase 6 (10 villages 15-Jan- 60 1 1/1) _Phine 19 17-Jan-19 20 12 8 NE14 CF Training_Phase 5 (10 villages 15-Jan- 61 2 1/2) _Saybouathong 19 17-Jan-19 16 16 0 NE14 CF Training_Phase 4 (10 villages 16-Jan- 62 3 2/2) _Phine 19 18-Jan-19 20 5 15 NE14 VIC Training_Phase 5 (10 villages 18-Jan- 63 4 1/2) _Saybouathong 19 18-Jan-19 17 0 17 NE14 CF Training_Phase 5 (10 villages 28-Jan- 64 5 2/2) _Saybouathong 19 30-Jan-19 17 14 3 NE14 VIC Training_Phase 5 (10 villages 31-Jan- 65 6 2/2) _Saybouathong 19 31-Jan-19 19 0 19 NE14 MCH Nutrition Counselling 19-Feb- 21-Feb- 66 7 Module III__Attsaphangthong 19 19 26 23 3 NE14 CF Training_Phase 5+6 (10 18-Feb- 20-Feb- 67 8 villages 1/1) _Saybouathong 19 19 25 23 2 NE14 VIC Training_Phase 5+6 (10 21-Feb- 21-Feb- 68 9 villages 1/1) _Saybouathong 19 19 17 0 17 Tot al 1274 638 636

APPENDIX 3: THE USAID NURTURE KEY DEMOGRAPHIC DATA IN ITS TARGET AREAS

Key Demographic Characteristics number percent Data source Total population 199,693 - Estimation based on - male 99,218 49.7% the household - female 100,475 50.3% progress form Total number of households 35,843 - Estimation based on the household - 1,000 days households 8,145 23% progress form Total number of pregnant women 13,062 Estimation based on - below 19 years old 1,959 15% the 2015 Population and Housing Census - aged 19 years old and above 11,103 85% & 2017 LSIS data Total number of caregivers 24,435 - Estimated three - male 8,552 35% caregivers per 1,000 - female 15,883 65% days household Total number of children under 5 21,774 - Estimation based on years old the household - male 10,869 49.9% progress form - female 10,905 50.1% Total number of children under 2 9,068 - Estimation based on years old the household - male 4,577 50.5% progress form - female 4,491 49.5%

APPENDIX 4: POSTER OF “INUW – COMMUNITY WORK

APPENDIX 5: COVER PAGE OF CF GUIDE

APPENDIX 6: CF COACHING GUIDE

Community Facilitator Support Visit

CF Name Date trained

DPO Name Date of last support visit

Date Number of HH Visits since last support visit Village

Performance Standard Verification Criteria Yes / No Comments 1. CF can confidently 1Early ANC explain the 8 SDAs [as soon as know, get IFA, Benefits: will explain how to have healthy pregnancy, listen to heartbeat, checks baby is growing well] 2 Eating more at each meal [Growing baby requires more food, eat all kinds of food you have, eat more bites, eat more frequently, set aside food as ‘snack’, try to sit a while after eating] 3 4 5 6 7 8

2. CF conducts HH 1. Introduction Visit effectively States objective of visit to HH on arrival and gets their consent Greets all HH members and records attendance correctly Maintains eye contact with HH members as much as possible Projects voice so that all HH members can hear 2. Assess Visually assesses HH status Asks open questions about HH behaviors Listens closely and summarizes what HH has told them Reviews SDA of last visit and verifies/assesses what changes have happened Gives at least 1 positive encouragement or praise Allows HH to ask questions and answers them as best able

3. Think Identifies 1-2 SDAs to share based on HH answers and status 4. Suggests Shows the SDA card (illustration?) Correctly explains the desired SDA to the HH Gives example of how others have implemented the selected SDA 5. Help Plan Asks individual members of HH to describe how they will implement the SDA Asks HH to explain what they have decided to do (in their own words) Seeks agreement to visit again (makes appointment) After: Notes chosen SDA with sticker Notes next visit appointment 6. CF is able to reflect CF able to identify correctly at least 2 things they do well on own progress as CF is able to identify 1-2 things they are not confident about mentor and yet demonstrates self- CF able to describe what they would like to improve as a awareness home visitor CF able to identify what further support/practice/information they need 7. CF committed to CF maintains forms for review by DPO their tasks CF implements planned visits as agreed TOTAL SCORE

Action Strongest skills today: Planning

Skill to improve:

Actions CF will take to improve:

Actions DPO will take to support CF:

APPENDIX 7: SUMMARY OF TOILET PRICES

3 concrete rings, concrete Savannakhet: 490,000- lid (round), toilet head 580,000 LAK Khammoune: 490,000- 510,000 LAK

3 concrete rings, concrete Savannakhet: 530,000- lid (square), toilet head 580,000 LAK Khammoune: 490,000- 560,000 LAK

3 concrete rings, tiled Savannakhet: 580,000- concrete lid (square), toilet 660,000 LAK head Khammoune: 580,000- 610,000 LAK

4 concrete rings, concrete Savannakhet: 590,000- lid (round), toilet head – 680,000 LAK offset Khammoune: 580,000- 690,000 LAK

3 concrete rings, concrete Savannakhet: 720,000- lid (square), toilet head – 835,000 LAK offset Khammoune: 670,000- 830,000 LAK

APPENDIX 8: PICTURES OF IMPLEMENTATION IN THE COMMUNITY

Home visits conducted by CFs to 1,000 day families

Sales agent conducting a group sales events in Phine A vendor delivering water filters to a village in district, Savannakhet province Phine district, Savannakhet province

A private vendor delivering latrines to village in Toilets being installed by a private vendor in Gnommlath district, Khammouane province Xonnabouly district, Savannakhet province

Supervising toilet installation in Attsaphangthong Toilet installation completed in district, Savannakhet province Gnommalath district, Khammouane province

Checking installation of a water filter in An offset toilet being installed in Attsaphangthong district, Savannakhet province Phine district, Savannakhet province

iNuW Visit #7 “Community Story” where villagers see their own progress and discuss Just completed toilet, Xonnabouly remaining tasks to reach targets – ODF village district, Savannakhet province and families practicing the recommended SDAs

A villager transporting concrete rings Villagers in Phine district digging a hole for their home for installing their toilet, toilet, Savannakhet province Xonnabouly district, Savannakhet province

APPENDIX 9: SUCCESS STORY #1: INFLUENCE OF A SALES AGENT

Mr. Kan Khamphoumy is 59 years old and lives with his wife and 7 children in Alang Village, located along the small Houykatong river, about 4km from the nearest health center in Xonboury district, Savannakhet province in southern Laos. Like their neighbors, he and his family are rice farmers who supplement their income with small livestock raising.

In early 2019, Mr. Kan applied to become a WASH product sales agent, supported by the USAID Nurture. He received training on the importance of home sanitation - how water filters and toilets help keep families healthy as well as information about costs, local vendors, and marketing techniques. Mr. Kan’s village is a ready market for these products thanks to the intensive community mobilization work done by the local health department and USAID Nurture. Families increasingly understand why building a toilet is a smart investment and Mr. Kan helps make the process of purchasing and transporting the materials plus construction as convenient and cost effective as possible. At 550,000 kip (about $65 USD) for a basic pour flush toilet, modern sanitation is a big investment for most families. Caption 1: Mr. Kan and his neighbors have already done the hot and dusty work of digging Despite all obstacles, in just two months, Mr. Kan sold pits for cement tanks for their new toilets. 19 water filters to his neighbors so they can avoid the hassle and time of collecting firewood and boiling water every day. Even more impressively, he has already convinced five families to make the investment to build their own toilet – they have already placed their orders and dug the pit for the waste tank. “I am inspired by the sincere interest of these families to improve their sanitation and I am confident that I will be able to sell more”, Mr Kan happily shared.

Previously, when families wanted to build a toilet, they had to travel to town and purchase materials piecemeal and organize shipping themselves. Prices were high and families lacked negotiating power. With the investments in WASH marketing by the USAID Nurture product, sales agents like Mr. Kan help make the process simple by having set price contracts that get the full set of materials delivered at pre-negotiated discount rates. Mr. Kan understands the significance of this investment and works with families to encourage them to plan and save. He is proud of his contribution to ensuring healthier families in his community and looks forward to the day his village is certified open Caption 2: Mr. Kan explains how a simple and affordable defecation free. water filter provides tasty and safe drinking water.

APPENDIX 10: SUCCESS STORY #2: ENABLING A COMMUNITY FACILITATOR

Ms. Phamy Malaythong, aged 20, sits in the shade of the Buddhist temple located in front of her house in Naphakeo village. Ms. Phamy is not yet married which is unusual at her age here in Mahaxay District, Khammoune Province in central Laos and her family is smaller than most - she lives with her parents and one younger sister. Like everyone in this village, they are rice farmers.

When USAID Nurture began community mobilization activities in Caption: Ms Phamy, 20, visits a new young mother in her Naphakeo, Ms. Phamy got involved. She village to encourage her to exclusively breastfeed her infant. wanted to support her community’s efforts to improve nutrition of young children for a better future, and ensure her community better cares for children and mothers. She decided to volunteer when she heard USAID Nurture was hiring Community Facilitators, a crucial volunteer role charged with making monthly visits to families with young children and infants. With support from her family, Ms. Phamy volunteered and to her delight, her neighbors chose her. After receiving training in Boualpha district, she returned home and started regular nutrition visiting. Farming life does not leave much free time for extra activities but her strong family support means she has been able to prioritize her work. “My family supports me. I know they are proud of me and that increases my motivation to keep trying to do my best. If they did not agree, I could not take so much time for my responsibilities.”

Ms. Phamy has found mornings are the best time to catch pregnant women and mothers of infants and young children at home. So far, families have welcomed her visiting. Though she still gets nervous sometimes, her first successes have improved her confidence. She recently visited a woman who was newly pregnant and explained why it is important to go to the local health center for antenatal care soon after becoming pregnant. In this area most women do not attend the recommended number of ANC appointments. This time however, things were different. “I explained how important ANC is and the next time I came to visit her she told me she did it!”

Of course, changing longstanding customs is not always easy. Some families still question how important exclusive breastfeeding is or why young children need to so frequently. In cases where families are hesitant, Ms. Phamy has found it important to work in a team with village leaders to support her suggestions and help get the support of everyone in the household—including the older generation. As more and more families understand Ms. Phamy’s role as a CF and hear her message that small changes can heave big impact on lifelong health, she expects to see more and more families adopting improved behaviors.