Photo credit: Vilaxay Intaxoun
USAID Nurture
Annual Report, Year 4: FY2019: October 1, 2018 to September 30, 2019
Cooperative Agreement Number: No. AID-486-A-16-00001 USAID/RDMA, Attn: Kongchay Vongsaiya, AOR Submitted October 31, 2019 by Delailah Borja, USAID Nurture Chief of Party Revised Submission December 13, 2019 [email protected]
Contents Contents ...... 2 Acronym List ...... 3 USAID Nurture Summary ...... 6 Results During The Reporting Period ...... 7 IR1: Improved IYCF and WASH Behaviors ...... 7 IR2: Improved use of quality nutrition and nutrition-sensitive WASH services/facilities...... 9 Cross-cutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities ...... 9 Major Impacts and Accomplishments by Intermediate Result ...... 10 IR1: Improved IYCF and WASH Behaviors ...... 10 IR 2: Improved Use of Quality Nutrition and Nutrition-Sensitive WASH Services/Facilities ...... 11 Crosscutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities ...... 20 New and Existing Sub-Award and Contract Status ...... 25 Challenges and Mitigation ...... 25 Environmental Compliance ...... 28 Science, Technology, and Innovation ...... 28 Stakeholders Participation and Involvement ...... 28 Sustainability, Local Solutions, and Partnerships ...... 30 Cost Sharing ...... 31 Planned Tasks/Interventions for the Next Reporting Period ...... 31 Appendix 1: List of Private Vendors ...... 34 Appendix 2: ODF Verification Tool ...... 35 Appendix 3: Cover Pages of Tools for Endorsement and Publication ...... 38 Appendix 4: Small Doable Actions (SDAs) ...... 40 Appendix 5: Pictures of USAID Nurture Activities ...... 41 Appendix 6: Completed iNuW Phasing Strategy (Village Visit Plan) ...... 42 Appendix 7: Sales Flipcharts (cover page) ...... 43 Appendix 8: Success Story about Change: Improving Newborn and Maternal Health and Nutrition in Laos ...... 44 Appendix 9: Success Story About Change: Lao Communities Make Progress Towards ODF Status 46 Appendix 10: Additional photos of breastfeeding, latrines, and hand washing ...... 48
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ACRONYM LIST A&T Alive & Thrive ANC Antenatal Care AW Abundant Water Organization BFHI Baby-friendly Hospital Initiative BMS Breastmilk Substitute CF Community Facilitator CCEH Center of Communication and Education for Health COP Chief of Party DFO District Facilitator Officer DHC Department of Health Care DHHP Department of Hygiene and Health Promotion DHO District Health Office 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 EPI Expanded Program on Immunization EU European Union FY Fiscal Year GoL Government of Lao PDR IFA Iron and Folic Acid INGO International Non-Governmental Organization iNuW Integrated Nutrition and WASH IR Intermediate Result IYCF Infant and Young Child Feeding Lao PDR Lao People’s Democratic Republic LOA Life of Activity M&E Monitoring and Evaluation
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MCH Maternal and Child Health MCHC Maternal and Child Health Center MEL Monitoring, Evaluation and Learning MIYCAN Maternal, Infant, Young Child and Adolescent Nutrition MIYCN Maternal, Infant and Young Child Nutrition MNV Model Nutrition Villages MoH Ministry of Health MoU Memorandum of Understanding Nam Saat National Center for Environmental Health and Water Supply NNC National Nutrition Center NNS National Nutrition Strategy NPAN National Plan of Action for Nutrition NSA Nutritional Sensitive Agriculture ODF Open Defecation Free PC Provincial Coordinator PNC Postnatal Care RDA Rural Development Agency RDMA Regional Development Mission for Asia RMNCH Reproductive, Maternal, Newborn and Child Health RMNCAH Reproductive, Maternal, Newborn, Child and Adoloscent Health SA Sales Agent SBCC Social and Behavior Change Communication SC Save the Children SCALING Sustainable Change Achieved Through Linking Improved Nutrition and Governance SCUS Save the Children, United States SDA Small Doable Action SI Social Impact SO Strategic Objective SUN Scaling Up Nutrition SUN CSA Scaling Up Nutrition Civil Society Alliance
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ToR Terms of Reference ToT Training of Trainers UNICEF United Nations Children’s Fund USAID United States Agency for International Development VIC Village iNuW Committee WASH Water, Sanitation and Hygiene WFP World Food Programme WHO World Health Organization
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USAID NURTURE SUMMARY
Lao People’s Democratic Republic (PDR) experience 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 the national average prevalence of stunting at 33 percent, underweight at 21 percent, and wasting at 9 percent. In response, the USAID Nurture Activity, led by Save the Children (SC) and implemented in partnership with the Government of Lao PDR (GoL) aims at contributing to a reduction in young child stunting in two target provinces.
USAID Nurture is being implemented across six districts of two provinces — Savannakhet and Khammouane — in the central region of Lao PDR. The approach focuses on: improving maternal, infant and young child and adolescent nutrition (MIYCAN) and water, sanitation and hygiene (WASH) behaviors in 1,000 Days Households (HHs) (with pregnant/lactating women and children under two); increasing access and use of quality nutrition, health services, and WASH facilities and products; and strengthening the enabling environment for improved nutrition and WASH through capacity building activities, multi-sectoral coordination and planning, particularly at provincial and district levels. This integrated delivery model supports the GoL in its implementation of the National Nutrition Strategy (NNS) to 2025, the National Plan of Action 2016-2020, and the National Social Behavior Change Communication (SBCC) Plan.
SC and the GoL’s close collaboration during the first four years of the USAID Nurture Activity facilitated scale up in hard-to-reach communities. USAID Nurture received an extension in July 2018 to continue through September 2021. Over the next two years, USAID Nurture will build 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. In Years 5 and 6, USAID Nurture has an opportunity to continue its engagement at the community level to improve household and community adoption of practices and products for improved nutrition and WASH outcomes, strengthen links to health services, expand work to improve consumption of diverse diets, and provide an added focus on adolescent nutrition. It also gives more time to further strengthen the capacity and ownership by government partners and communities.
In August 2019, USAID Nurture began discussions with the Ministry of Health (MoH) regarding the extension of the memorandum of understanding (MoU) for the project for the two-year cost extension. The process involves a government–led assessment of field implementation which will take place in early FY2020. This assessment is necessary to secure the approval of the MOU extension. USAID Nurture will involve the Regional Development Mission for Asia (RDMA) and USAID/Laos for guidance and support.
As of July 2019, the iNuW community mobilization component process composed of eight village visits, under Intermediate Result (IR) 1, was completed in all target 471 villages within the six districts. Additionally, Community Facilitators (CFs) continued to conduct 1,000 Days Household visits in their assigned villages. It is important to note that USAID Nurture witnessed the increase of sales activities and purchase of WASH products as a result of the increase of sales agents and the effectiveness of training.
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Under Intermediate Result (IR)2 (IR 2), USAID Nurture completed a rollout of the three-part “1,000 Days Nutrition Counseling Course”1 for health care providers in the two provinces and six districts as of February 2019. Health workers have started to use their learning in their day-to-day counselling in order to provide a lasting resource for future programs by MOH and other Development Partners’ (DPs) work. Significant effort was spent developing national job aids and standards that support and reflect the content of the 1,000 Days Nutrition Counseling Course.
Under the Crosscutting Approach, USAID Nurture has actively engaged with key government stakeholders during the annual meeting/steering committee meeting, provincial consultation meetings, site visits, provincial reflection meeting in Savannakhet with stakeholders from both provinces to present accomplishments and challenges in and solicit feedbacks and recommendations for planning and implementation. The government partners expressed their support and satisfaction on USAID Nurture. As part of a routine interaction with project staff, the team organized a meeting in January 2019 in Vientiane to prioritize activities for the remainder of the year.
RESULTS DURING THE REPORTING PERIOD
This section gives an overview of the key Year 4 activities across USAID Nurture intermediate result areas, cross-cutting approach, targets reached, and deliverables. IR1: Improved IYCF and WASH Behaviors
USAID Nurture made substantial progress under IR1. To date, USAID Nurture has completed the iNuW village visits - a key component of the USAID Nurture program in Phase 1 - in all 471 villages (Savannakhet: 202 villages and Khammouane: 269 villages). A total of 783 CFs were trained to conduct household visits in line with an iNuW phasing strategy. Additionally, 408 Village iNuW Committee (VICs) have been fully trained and/or received refresher training as of February 2019, and fully facilitated the nutrition and WASH interventions in their villages. CFs successfully delivered a total of 7,230 home visits to 1,000 Day Households during Year 4. To support the CFs in their delivery of home visits, USAID Nurture completed community activity materials, including the iNuW toolkit, and job aids for CFs and VICs. A CF coaching guide for the District Project Officers (DPOs) was also finalized and ready for rollout.
USAID Nurture developed two training videos (1) Introduction to Home Visit for CFs and (2) Introduction of CF’s Role. The second draft video has been completed and is being reviewed by the SCUS technical team. It is expected that by mid-November 2019, this video will be finalized and introduced to the field team (USAID Nurture and provincial/district government partners) so that they will be able to use them effectively with CFs on their coaching visits starting December 2019. To strengthen the understanding of concept and work related to WASH Marketing, USAID Nurture produced two videos to introduce WASH marketing Year 4. The first video will serve as a dissemination tool as well as advocacy
1 This training curriculum has been referred to as the “MCH Nutrition Counseling Training Course” and the “healthcare provider nutrition counseling training” in previous reports. However, the official name of the training as referenced in the National SBCC Strategy is “1,000 Days Nutrition Counseling Course” and all USAID Nurture reports going forward will use this official name.
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for marketing in the rural sanitation promotion work, while the second video will be used in refresher trainings for sales agents on sales activity steps.
ODF Training Prior to Open Defecation Free (ODF) verification, an ODF training was conducted in Savannakhet and Khammouane provinces in mid May 2019, by Nam Saat and USAID Nurture. The training covered ODF criteria and definitions, the verification process, use of forms, team roles and responsibilities, and how to conduct the ODF verification planning. Participants included representatives from provincial health departments, provincial Nam Saat, district health offices, health center staff, and USAID Nurture staff. As a result, the assigned teams acquired a good understanding of the verification process and criteria and were able to accurately assess the villages for ODF certification.
Table 1. ODF verification activity conducted in two batches Batch 1 Batch 1 Batch 2 # villages Passed New Re- Passed Total village verification Savannakhet Atsaphangthong 5 2 3 3 5 7 Khammouane Mahaxay 7 3 5 5 10 13 Ngommalath 5 5 - - - 5 Sayabouathong 3 1 0 2 2 3 Total 20 11 8 10 17 28
Out of 30 villages that were verified for ODF certification, 28 villages (11 in Svannakhet and 17 in Khammouane) met the ODF criteria (use/share toilets – 100 percent, clean compound – 60 percent handwashing station – 60 percent and safe drinking water- 60 percent). Only two villages were not able to meet the ODF criteria as they only got an overall rating of 93 percent due to (1) having high ground water tables, (2) lacked of labor (only elderly) to build their latrine in households, and (3) recent relocation.
USAID Nurture engaged in national advocacy to the Reproductive, Maternal, Newborn and Child Health (RMNCH) Secretariat, by providing technical advice to encourage the adoption of life stages or target group focuses approach to the essential Maternal and Child Health (MCH) service package. The life stages approach was encouraged to help MOH see the urgent priority for nutrition services for mothers and children, which were often overlooked. Additionally, it provides a model that advances quality, respectful care that is essential for behavior change approaches to improve nutrition outcomes. An integrated well child platform (discussed below) also prompted MOH to explicitly include adolescents in the strategic approach and key objectives. The draft mid-term review of the strategy (as of July 2019) calls for the sector to now officially be re-titled as RMNCAH, including adolescents with high visibility.
USAID Nurture developed and tested a new adolescent-specific small doable action (SDA). Based on the formative research findings, the new SDA urges adolescent girls to eat more during meals at home with her family and for those girls in school, to take a portion of family
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food with them to school each day. CFs will use the new adolescent SDA during their 1,000 Days Household visits and deliver the messages to adolescents and parents of adolescents.
As per the mid-term impact evaluation (by Social Impact - SI), the project observed an increase in learning both ANC practices – pregnancy registration and use of Health Center and breast feeding practices and an increase in children and families intake of nutritious foods.
In August 2019, USAID Nurture consulted with provincial agriculture offices about how the project could support their commitment to promoting Nutritional Sensitive Agriculture (NSA). The meetings were well received, however, it was found that in both provinces there is little planned or understood about NSA. This reflects a weakness in capacity and commitment for NSA nationwide. Both offices were unfamiliar with the nutrition SBCC strategy, including the agriculture-related components. While the NSA focal point in Khammouane had considerable interest to learn, she explained she had no tangible plans, budget or mandate. In Savanakhet, the responsibility for nutrition has been transferred repeatedly and thus the newest focal point could not give any clear needs as he is not yet familiar with the commitments of the National Plan of Action for Nutrition (NPAN) and SBCC. It would be helpful to provide briefings to both about SBCC approaches with the other members of the provincial multisectoral nutrition committees. In both provinces, NSA will remain a long-term goal rather than an action plan in 2020.
IR2: Improved use of quality nutrition and nutrition-sensitive WASH services/facilities
USAID Nurture made significant progress under IR2 related to the completion of quality materials for nutrition and nutrition sensitive WASH services/facilities. For example, the team contributed to the new national Maternal and Child Health handbook called Pink Book, which is a mother and child portable care record. Other important tools developed include a pregnancy wheel (gestational calculator), job aids, and a Nutrition Counseling Manual which the team is currently finalizing in the Lao language based on feedback from recent MOH and DP. Additionally, USAID Nurture supported the Department of Healthcare and Rehabilitation (DHR) to develop a national quality of care standard for clinical care programs, particularly for Newborn/Breastfeeding and Well Child Care.
Village Sales Agents (SAs) were trained on how to promote WASH products within their community as well as encourage WASH behavior change. They carried out planned events through sales activities (group and individual) with those who had no WASH products to focus on helping the community achieve ODF status. SI also documented an increased use of household water treatment technologies and the practice of hand washing and hygiene in the homes.
Cross-cutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities
USAID Nurture has made significant strides in achieving cross-cutting approaches around enabling a more integral environment in nutrition and WASH programming. The team has started to see an increased interest and enthusiasm from key stakeholders that was not
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present when the project began. The team has continued to support district multi-sectoral committees (DNC) by providing technical assistance in preparing agendas, facilitation, action planning, practical logistics and financial support to help institutionalize this new convergent platform for multi-sectoral nutrition governance. These committees are still developing a clear vision of their role in supporting local development. Therefore, in this initial phase of meetings, integrated nutrition related policies have been disseminated to enhance commitment amongst district leadership to improve nutrition implementation and interventions in their areas.
Communication Plan for Visibility and Advocacy Developed USAID Nurture developed a communication plan for Year 4. The purposes of this communication plan are 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 DPs and donors in Laos; 3) develop user-friendly tools for increased engagement with GoL counterparts on data for decision making; 4) encourage uptake of USAID Nurture’s counseling skill 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 developed several job aids and videos to use for further training and to promote USAID Nurture’s work with government and other DPs. Materials that were shared publicly were cleared through USAID before publication. Appendix 3 shows cover pages of tools that are being finalized for endorsement and publication.
Major Impacts and Accomplishments by Intermediate Result
IR1: Improved IYCF and WASH Behaviors
USAID Nurture Village Visits The completion of the iNUW village visits was a big achievement of USAID Nurture as it helped the community people recognize nutrition and WASH-related issues and identify ways to start addressing these issues in their village. Furthermore, they understood the importance of safe drinking water, stopping open defecation by having/using toilet, hand washing with soap and clean home compound. With the guidance and support of DPOs and district government partners, VICs facilitated, encouraged and maintained the momentum of the village people to collectively work together to achieve the target. They accomplished this by regularly discussing with the villagers the common issues at hand and inquiring how they can identify ways to deal with these issues, as well as how to support each other in the community.
Household Visits The CFs conducted 1,000 Days household visits to deliver messages and provide counseling to pregnant mothers, mothers of children under two years old, and other family members serving as caregivers such as grandmothers, fathers, older siblings, and other influential household members. They used the SDA messages to promote behavior change in their day- to-day practices. For example, CFs and field staff observed that mothers who received regular messages on the importance of early and exclusive breastfeeding are happy and proud that their babies do not usually get sick when they breastfeed them according to the SDA message. Some mothers compare their second baby who are breastfed and healthy to their first baby who did not get proper breastfeeding and were sickly (The team captured this in some of the
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success stories that USAID Nurture has featured). In addition, it was also observed that there has been an increase in the use of water treatment (water filters) among households who received messages and interventions from USAID Nurture. These observations were consistent with the mid-term impact evaluation findings.
Table 2. IR1: Improved IYCF and WASH behaviors in households with pregnant women and children under two
Year 4 LOA Cumulative Percent Indicator Code and Name Progress Target Reached against Target Against Target Target IR1-Output 1: Percentage of household visits conducted by 57% 68% - 67% 60% Community Facilitators attended by both men and women IR1-Output 2: USAID Nurture iNuW toolkit implemented in all 276 276 100% 471 100% villages
Both fathers and mothers are encouraged by the DPOs during their monitoring visits to participate during the 1,000 Days Household visits. The CFs constantly follow up and encourage fathers to join mothers during the home visits. This has increased their level of participation.
Adolescents In Quarter 3 of FY 2019, USAID Nurture developed and tested a new adolescent-specific SDA. The new SDA urges adolescent girls to eat more during meals at home with their family and for those girls in school, to take a portion of family food with them to school each day. The SDA was developed based on the formative research findings that most adolescent girls do not eat sufficiently. This is in part because they are shy and do not take much of the usually limited supply of family food for themselves and instead prioritize others in the household to eat more food. Adolescent girls reported that parental encouragement would be the biggest motivator for them to improve their eating behaviors. However, most caregivers did not know adolescents have increased nutritional requirements. Therefore, the SDA was developed to be delivered to parents of adolescents, rather than the adolescents themselves, at the community level. IR 2: Improved Use of Quality Nutrition and Nutrition-Sensitive WASH Services/Facilities
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. USAID Nurture uses local technology to produce the powder by drying small fish, insects and frogs and turning it
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into a powder by 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 were discussed at the district and provincial level to determine other nutrition sensitive agriculture activities that may be supported/reinforced in the future. USAID Nurture will provide technical support to develop messages or approaches based on existing government or USAID Nurture materials and an SDA on diet diversity for children under two years old.
INuW Community Toolkit The USAID Nurture iNuW Toolkit was revised based on a review of field implementation and feedback from the field teams and government partners (see Table 2). Though the rest of the visits had previously been tested and finalized, Visit 8 – Progress Assessment and ODF Verification was only tested in April and finalized at the end of June 2019. Key features of the finalized toolkit are summarized below:
Visit 1 – Sensitization: A workshop for village leaders held at the district level and chaired by the district governor will have objective to lay the foundation for participants to recognize the current situation of nutrition and WASH and the significance of the problem. In addition, it strengthens government support and brings a collective action to the recognized problem in a more formal way.
Visit 2 – Triggering for Healthy Growth: This is carried out through visits to the community, facilitation to recognize problems related to nutrition and WASH and create plans to achieve community-wide target such as ODF villages, and recommended SDAs introduced by USAID Nurture. The other part of the visit is to support the community in electing CFs and VICs, while familiarizing the participants with the role of CFs and VICs.
Visit 3 – Nutrition and WASH Fair: An event that allows participants to experience USAID Nurture’s project in a familiar and fun village “boun” atmosphere. It is designed to create a sense of community ownership around USAID Nurture goals and objectives. It demonstrates key SDAs through participatory activities like cooking competitions, quizzes, and handwashing demonstrations at booths. This brings USAID Nurture to life in the village.
Visit 4, 5, and7– Progress Review and Support VIC/CFs: Health Center staff support CFs in conducting home visit activities through demonstration, observation and coaching, while DPOs work with VICs to focus on sanitation and updating the implementation status.
Visit 6 – Community Story: A documentary day that strives to show progress by filming nutrition and WASH focused discussions with community members. Footage in the village shows what has improved as well as discussion of actions for improvements.
Visit 8 – ODF Verification: This visit is divided into two sub-visits:
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Visit 8.1 ODF Verification: Occurs when the communities are ready for the verification process which includes a visit from the verification team which includes provincial and district government partners, Health Center staff, representatives from the district administration office, Nam Saat Central and USAID Nurture staff. The verification follows the revised ODF criteria: ODF 100 percent, handwashing with soap 60 percent, household drinking water 60 percent, and clean home compound 60 percent.
Visit 8.2 Participatory Assessment of Progress/Results: Is carried out in communities that have not reached ODF status. The focus is to assess current progress/results, to facilitate discussion challenges/difficulties communities have faced, and to help communities identify corrective actions in order to reach their own targets (achievement of ODF status and of having families practicing SDAs – who are supposed to serve as models).
In Year 4, all six district teams continued to conduct 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 District Health Offices (DHOs). The meeting was regularly organized on the 22nd of each month. After the meeting, monthly reports on USAID Nurture implementation was then submitted to the district government coordinator and deputy head of district health offices.
Table 3. Sub-IR2.1: Improved availability and quality of nutrition services
Year 4 LOA Cumulative Indicator Code Percent Population Progress and Name Target Reached against Target against Target Target Sub-IR2.1.2: Number of children under five (0-59 months) reached by USG-supported nutrition programs (F-indicator, Nutrition: HL.9-1) [1] Total 21,774 2,250 11,362 505% 14,070 92% Male 10,869 1,125 5,637 501% 7,035 91% Female 10,905 1,125 5,725 509% 7,035 92% Sub-IR2.1.3: Number of children under two (0-23 months) reached with community-level nutrition interventions through USG-supported programs (F-indicator, Nutrition: HL.9-2) Total 9,068 1,500 4,979 332% 8,580 70% Male 4,577 750 2,487 332% 4,290 70% Female 4,491 750 2,492 332% 4,290 69% Sub-IR2.1.4: Number of pregnant women reached with nutrition interventions through USG- supported programs (F-indicator, Nutrition: HL.9-3) Total 31,609 7,000 6,453 92% 25,728 40% < 19 years of age 4,741 1,050 968 92% 3,859 40% ≥ 19 years of age 26,868 5,950 5,485 92% 21,869 40% [1]: Total population and Life Of Activity (LOA) targets for FY17-FY21 estimated from the household progress form. As demonstrated in the tables above, significant progress was observed in Year 4; for sub- IR2.1. After the CF training on the revised home visit tool and iNuW tool kit, there was a marked increase in the number of 1,000 Days Households visited and increased participation
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during the iNuW community event. In Sub-IR2.1.3, there was an increased number of mothers/caregivers who participated in the households visits and iNuW community village visits events. Overall, most of the VICs and CFs are now better organized in identifying new 1,000 Days Households in the village and counselling is provided more rapidly at the early pregnancy stage. Furthermore, the increased inclusion of health center staff in USAID Nurture has improved the dissemination of mother health care messages at the village through their outreach programme.
Table 4. Sub-IR2.2: Improved availability and quality of nutrition-sensitive WASH services/ facilities
Year 4 LOA Cumulative Indicator Code Percent Population Progress and Name Target Reached against Target against Target Target Sub-IR2.2.1: Number of communities certified as open defecation free (ODF) as a result of USG assistance (F-indicator, WASH: HL.8.2-1) Total - 45 28 62% 164 17% Sub-IR2.2.2: Number of people gaining access to a basic sanitation facility as a result of USG assistance (F-indicator, WASH: HL.8.2-2) [2] Total 119,444 3,821 8,596 225% 16,650 52% Male 59,346 1,528 4,232 277% 6,660 64% Female 60,098 2,293 4,364 190% 9,990 44% Sub-IR2.2.3: Number of WASH products sold monthly by sales agents Total - 1,324 1,059 80% 5,830 20% Toilets - 455 761 167% 1,982 41% Water filters - 869 298 34% 3,848 9% [2]: The number of people with and without access to a Basic Sanitation Facility is illustrated as before the start of USAID Nurture. In Sub-IR2.2.1, of the 45 villages targeted to be certified as ODF, the USAID Nurture teams verified 30 villages but only 28 villages were certified as ODF which is equivalent to 62% reached based on Year 4 target. As mentioned in the Semi-Annual Report, the marketing activity could not be fully implemented until March 2019 when an additional 370 village sales agents were recruited and began their assigned work. In addition, the initial activity for village verification commenced in late Quarter 2 of FY2019 due to heavy rains, which partially affected the project. Additionally, some villages that were verified did not pass the ODF certification criteria. Under Sub-IR2.2.2, the increase of sales agents and their new acquired skills in promoting improved toilet construction with the communities helped to motivate people to purchase WASH products. Furthermore, the increase in WASH products sold by sales agents is mainly due to a wider reach of villages (one sales agent/one village) and better promotion of toilet and water filters in community events.
In Year 4 under Sub-IR2.2.3, there was a significant increase in the WASH product sales from businesses supported by USAID Nurture. This was due to increased USAID Nurture WASH staff at the provincial level; changes in sales agent recruitment strategies from cluster sales agents to one per village; increased support and mentorship from the DPOs; higher project
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and government focus; and stronger relationships with private sector partners. In addition, coordination at the provincial/district Nam Saat had improved.
Table 5. Output Indicator – IR2 and Crosscutting Approach
Year 4 LOA Cumulative Indicator Code Percent Population Progress and Name Target Reached against Target against Target Target IR2-Output 1: Number of mothers/caregivers of children 0-23 months who received direct maternal infant and young child nutrition counseling through USG-supported programs Total 24,435 2,700 13,841 513% 12,174 128% Male 8,552 950 6,380 672% 4,257 165% Female 15,883 1,750 7,461 426% 7,917 109% IR2-Output 2: Number of sales agents trained on how to motivate households and sell WASH products Total - 315 370 117% 508 89% Male - 284 346 122% 457 93% Female - 32 24 75% 51 59% IR2-Output 3: Number of private sector outlets providing WASH products
Total - 12 14 117% 23 91% CCA-Output 1: Percentage of districts with multi-sectoral plans for nutrition services developed as a result of USG assistance Total - 17% 0% - 100% 50% CCA-Output 2: Number of individuals receiving nutrition-related professional training through USG-supported program (F-indicator, Nutrition: HL.9-4) Total - 264 916 350% 2,352 91% Male - 66 492 752% 617 192% Female - 130 424 328% 1,735 55%
In SUB-IR2-Output1, the cumulative FY 2017-FY 2021 target was previously met due to the increased participation of caregivers in the CF home visits and iNuW community village visit events. This demonstrates that taking care of and providing healthy pathway to children under two is not only the role of the parents but also other people living in the household. It is important to note that in Quarter 3 and 4 of FY 2019 under CCA-Output 2, USAID Nurture did not conduct any nutrition-related professional training because all training planned in the Year 4 workplan had been completed. However, three districts - Mahaxay, Phine and Atsaphangthong - established their own district plans to set up two model nutrition villages on their own. Unfortunately, due to the DNCs’ limited understanding of their roles, technical capacity and lack of funding, they have not yet been able to select their respective model village nutrition villages.
Health Service Delivery Counseling Book and Job Aids for Health Care Providers In Year 4, the first Lao language behavior change counseling skills manual for health staff was completed, in a joint effort with CCEH, to provide a lasting resource for future programs (by MOH and other DPs). A gestational calculator (also known as a pregnancy wheel) was
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developed per the request from the national ANC taskforce. The wheel formatted strategically to read easily. This wheel serves as a handy reminder of key nutrition SDAs for pregnant women as well as tips to provide counseling correctly. While the revised Pink Book is designed to function as the first line job aid for the counseling manual, there is significant interest in a standalone nutrition counseling job aid as well. In Year 5, USAID Nurture and National Nutrition Center (NNC) will produce a revised version of the 2015 Nutrition Counseling ‘Quick Guide’ to complement the manual’s content in a easy-to-use format.
Between March 4 and 13, 2019, USAID Nurture and central government partners (representatives from Department of Hygiene and Health Promotion, and Nam Saat) jointly 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 to stronger support to USAID Nurture’s implementation process and closer supervision of village authorities. The vice- district governors chaired the consultation workshops with village authorities of ODF focused villages to identify challenges and plan together to achieve the ODF target.
Pink Book The new national MCH handbook, a mother child portable care record (commonly termed the Pink Book), was finalized in Year 4 with significant inputs from USAID Nurture. Most of the services detailed and charted in the book are nutrition specific and/or sensitive, therefore, it is crucial for job aid and reference for integrated nutrition service delivery across the 1,000 Days Households. The book now provides charts for ANC and Well Child Care that follow the care and documentation standards taught in USAID Nurture districts as part of the 1,000 Days Nutrition Counseling Course and importantly establishes the first well-child care schedule. The previous vaccination schedule is expanded to specify eight standard integrated care contacts from birth to age two. Additionally, the child health education pages in the handbook have been completely re-written to be an age/stage based resource comprised of SDA style messages on breastfeeding, nutrition, hygiene and child development per the USAID Nurture approach.
USAID Nurture also provided technical input into the Pink Book User Guide and complementary Training of Trainers (TOT) curricula to ensure that ANC, birth, and Well Child services are delivered and charted correctly at health centers nationwide. The Pink Book will act as a guide for local health care supervisors as they coach health center staff in coming activity years. Matching funds from Alive & Thrive (A&T) were used to contribute to the costs to train a central Pink Book Master Trainer team. The TOT covers behavior counseling (per USAID Nurture model), breastfeeding support skills, and nutrition assessment and counseling for ANC and Well Child services.
Management Staff Capacity Building Program In Year 4, USAID Nurture and provincial training teams completed the rollout of the three- part health care provider nutrition counseling training as planned. After the training, health staff demonstrates improved capacity. The highest increases were after the first training with smaller increases after Module 2 and 3, likely because their pre-test scores were much higher after the repeat training. Through the three module training the average increase was 8% percent, the post-test was increased from 82 percent to 90 percent compared with the pre- test. Overall, staff showed very good improvement over the course of the trainings and
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demonstrated the ability to apply the six key counseling competencies and the SDA approach on completing the full series. See table below for total numbers trained during the reporting period.
Table 6. FY 2019 Health Care Provider Capacity Building
Total No. Name of Event Start Date End Date Female Male Trainees
1,000 Days Nutrition Counselling Module III 1 30-Oct-18 1-Nov-18 20 18 2 Ngommalath 1,000 Days Nutrition Counselling Module II 2 31-Oct-18 2-Nov-18 26 24 2 Attsaphangthong 1,000 Days Nutrition Counselling Module III 3 6-Nov-18 8-Nov-18 11 7 4 Saybouathong 1,000 Days Nutrition Counselling Module III 4 19-Feb-19 21-Feb-19 26 23 3 Attsaphangthong Total 83 72 11
Coaching and Supervision Capacity
Management and Supervision for Quality Service Delivery With the completion of the initial three rounds of counseling training to health centers and district outpatient MCH rooms in the USAID Nurture target areas, the next challenge is two- fold: to ensure strong supervision and support by district managers for health centers to provide nutrition-related ANC and Well Child care with quality, and to help DHOs transition to the Well Child approach so that every health care contact includes nutrition screening and counseling. The goal is to increase capacity and competency of health HC staff to be able to make appropriate referrals as well as providing first line counseling and support to caregivers. In the second half of Year 4, the SHS worked with the Maternal and Child Health Center (MCHC) and NNC to develop a Well Child services scorecard that includes counseling and serve a practical and national official resource for supportive supervision of nutrition services. At the end of Year 4, USAID Nurture formed a partnership with World Vision and WHO to pilot the Pink Book-based supervision of Well Child services in Savanakhet in conjunction with the Integrated Services assessment (implementation will begin in late 2019).
National RMNCH Strategy In Year 4, USAID Nurture led the effort to refocus the National RMNCH Strategy to be based on the needs of each key RMNCH life stage or target group. The success of that approach then enabled the creation of an integrated Well Child Health Services platform as well as explicitly inclusion of adolescents in the strategic approach and key objectives. The Secretariat has now renamed it as the RMNCAH strategy which adolescents are included in the Five-Year Action Plan.
WASH Product Delivery A streamlined approach between community mobilization through the iNuW process (demand creation side) and WASH marketing approach (supply side) is important in order to effectively and successfully carry out the USAID Nurture approach. All DPOs were oriented
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on how to support sales agents in their respective villages. Furthermore, the WASH team increased from two to three people to ensure more frequent and effective oversight of the marketing work at community with the village sales agents and at district level with private vendors.
Training of Nam Saat Officials In Quarter 4 of FY 2019, in order to strengthen understanding of sanitation marketing and government support, USAID Nurture conducted an orientation workshop on WASH Marketing for provincial and district government partners (Nam Saat) from Savannakhet and Khammouane provinces. As a result, all participants are now more familiar with marketing concepts in general, how the marketing approach and the engagement of the private sector contributed to the work on rural sanitation promotion, and how sanitation marketing strategies were deployed in the USAID Nurture sites. Furthermore, the group discussed and agreed to the WASH marketing activity plan for FY 2020-2021.
USAID Nurture plans to revisit relationships with other vendors by showing them the increased sales results over the past year, and introduce the other sales promotion options to all vendors in early November 2019. USAID Nurture recruited two additional vendors in Xonnabouly district, Savannakhet province, who involved in the WASH marketing activity. To ensure regular delivery of toilets and water filters according to the orders received on a monthly basis, alongside Nam Saat, supervised private vendors on a monthly basis on their production and delivery plan. Please refer to Appendix 1 for a list of current private vendors.
Sales Agents Support 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.
Sales Promotions In order to accelerate sales of WASH products, especially during the harvest period, USAID Nurture conducted one sales promotion option which entailed a no-down payment and interest-free installment for up to three months with 21 private vendors in six districts. Only three vendors agreed to try out the proposed option due to lack of rolling funds. Moreover, USAID Nurture collaborated with provincial and district partners to identify seven more sales promotion strategies. The seven sales promotion ideas are summarized in Table 7 and will be narrowed down to 1-2 strategies after completing discussions with vendors and other stakeholders:
Table 7. Potential Sales Promotion Strategies under Consideration
Sales Promotion Possible Risks Mitigation Approach Options Option 1 Lower profit margin . Ensure vendors understand Buy 20 toilets, 1 free that promotion is needed to toilet maintain regular sales in both low and high seasons, and ensure monthly sales so that
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business is more sustainable and expandable. . One of the successful business operations is to keep products sold on a regular basis so that cash flow is possible. . In the beginning of the business operations, the focus will be on quantity of sales. Option 2 . Collection of payment could . A formal certification letter 2 month down be overdue or difficult. will be issued from the village payment upon . If payment is to be collected head to vendors. installation by the village head, the . Payment collection will be on expected challenge is that a set schedule. However, the village head would be prior communication between occupied by a number of his vendors and village authorities tasks and/or be absent when will be done well in advance. payment needs to be collected. Option 3 . Collection of payment could . A formal certification letter 2 payment instalments be overdue or difficult. will be issued from the village – 50% of order and . Vendors will have double head to vendors. 50% upon delivery costs – collecting payment . Village head or VIC needs to twice in one location. manage payments to follow . If payment is to be collected the schedule. by the village head, the . Payment collection shall be on expected challenge is that a set schedule. However, the village head would be prior communication between occupied by a number of his vendors and village authorities tasks and/or be absent when will be done well in advance. payment needs to be collected.
Option 4 . Sales agents would be . In case of sales missing the Sales target setting for working under pressure. target in the third month, sales agents -- for . Sales agents might be sales figures could be rounded example if sales of 5 disappointed; for example, in up to 15 units and the sales units of the first two months sales agent would receive the products/month for 3 hit the target but miss the agreed commissions. months, a sales agent target in the third month. . Delivery logbook will be will receive an . Sales figures between the developed and counter-signed increased commission vendor and sales agent may each time by sales agent and from 40,000 LAK to be different, resulting in a vendor. 45,000 LAK or 50,000 conflict. LAK per unit. Option 5 . Some buyers may . Clear communication on the misunderstand that the price sales must be done in advance
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On sales day – if order when he/she buys is and on a regular basis to on the day or within 3 different (higher) after the prevent any misunderstanding to 5 days, e.g. lower sale. of the product prices. from 250,000 LAK to . Vendor has lower profit . Vendor will be convinced with 230,000 LAK (water margin. information that easily shows filter) the benefit of this approach.
Option 6 . Vendor would still be . Help the vendor understand 50-100% free transport reluctant to try this, and calculate possible profits, cost or installation especially for those that are e.g. # of villages, # of potential cost if the order is up far and remote. buyers vs. quantity to be sold. to 10 units within 3-5 days; or if a set of orders is up to 5 units of products within 3-5 days. Option 7 . Vendor would still be . Help the vendor understand Use of village fund if reluctant to try this, and calculate possible profits, available especially for those that are e.g. # of villages, # of potential far and remote. buyers vs. quantity to be sold.
Partnership Abundant Water Organization (AW), USAID Nurture’s key partner, conducted an orientation workshop for USAID Nurture staff on water filters and how to support sales agents conducting sales activities in early 2019, and also from time to time conducting field visits to Savannakhet and Khammouane provinces. Their technical knowledge and product manufacturing adds value to the implementation of WASH activities by ensuring technical knowledge of the products and skills needed to install and maintain the products.
Crosscutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH Programs among Government Officials, Service Providers, and Communities
Scaling USAID Nurture Innovation in Counseling While the 1,000 Days Nutrition Counselling Manual publication developed by USAID Nurture was only completed towards the end of Year 4, the 1,000 Days Counselling approaches have already been adopted and implemented by other MOH programs across Laos. In October 2018, the SHS provided training on Module 1 of the course for the national antenatal care (ANC) trainer team, which included the Mother and Child Health Center (MCHC) and University of Health Sciences (UHS). This was an advocacy success resulting from the efforts throughout Year 3 to share the USAID Nurture method and approach. Dr. Khanthong Siharath, Chair of the ANC taskforce, then revised the national ANC continuing professional development in-service course to add a day devoted to counseling skills practice 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.
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Well Child and Newborn Standards This year USAID Nurture was a key partner, along with WHO, in supporting the Department of Healthcare and Rehabilitation (DHR) to develop two national clinical standards for hospital accreditation per the 5 Goods, 1 Satisfaction Policy. USAID Nurture worked closely with WHO to successfully develop a comprehensive Newborn Care standard that prioritizes increased early initiation of breastfeeding. For Well Child services, USAID Nurture partnered with UNICEF to mandate nutrition screening and counseling (specifically breastfeeding and complementary feeding) as part of an integrated platform for child health. These standards are the indicators for hospital accreditation2 making them the highest level national platform for quality improvement. It is expected these updates will be launched in the RMNCAH mid- term review in late 2019.
From this breakthrough, CCEH has continued to develop counseling throughout the MOH. A number of different MOH stakeholders have asked them to provide training, including MCHC and Central Hospitals, and a range of development partners including LANI, WHO, UNFPA, and JICA. This is due to USAID Nurture’s efforts in developing training content, mentoring master trainers, and advocating to DPs and MOH partners. In July 2019, an agreement was made with UNFPA to work together with MOH (in particular CCEH) to develop an adolescent counseling skills training manual to complement the Adolescent Youth Friendly Services Guideline (which provides the technical standards for adolescent care). DHR gave a green light to the effort and UNFPA will launch a co-writing workshop in late 2019.
Multi-sectoral Committees USAID Nurture supports district multi-sectoral nutrition committees (DNC) with technical assistance, practical logistics and financial support to help institutionalize this new platform for multi-sectoral nutrition governance. In Year 4, USAID Nurture supported DNCs to hold regular quarterly meetings to implement the National Nutrition Strategy. These committees remain largely an information-sharing platform, as they are new structures within local governance systems. The meetings 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. In most cases, DNC members generally feel their mandate is to develop Model Nutrition Villages (MNV) (a GoL initiative to apply the convergence approach to the community level) in order to meet national nutrition targets. Table 8 describes the district nutrition multi-sectoral committee meetings from 2019.
2 In Savannakhet they will also likely be used to assess DH and HC service delivery by WB to verify quality of care for budget disbursements.
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Table 8. FY 2019 District Nutrition Multi-Sectoral Committee Meetings No# of No# of No# of District Event Date Participants Females Males Khammouane Mahaxay 29-Nov-18 38 18 20 27-Mar-19 41 19 22 Ngommalath 11-Oct-18 20 7 13 26-Mar-19 38 16 22 Saybouathong 26-Nov-18 25 10 15 28-Mar-19 39 14 25 Savanakhet Attsaphanthong 25-Oct-18 32 23 9 21-Mar-19 22 0 22 Xonnaboury 9-Oct-18 41 18 23 1-April-19 33 15 18 Phine 4-Oct-18 31 18 13 2-April-19 42 27 15
In August 2019, USAID Nurture consulted with provincial agriculture offices about how the project could support their commitment to promoting NSA. The meetings were well received but the team discovered there are few planned activities related to NSA and little understanding of NSA in both provinces. This reflects a weakness in capacity and a lack of commitment to NSA nationwide. Both offices were unfamiliar with the nutrition SBCC strategy, including the agriculture-related components. While the NSA focal point in Khammouane had considerable interest to learn, she explained that she had no tangible plans, budget or mandate. In Savanakhet, the responsibility for nutrition has been transferred repeatedly and thus the newest focal point could not give any clear feedback. It would likely be helpful to provide briefings to both about SBCC approaches, possibly together with the other members of the provincial multi-sectoral nutrition committees. In both provinces, NSA will remain a long-term goal more than an action plan in 2020.
GoL Technical Capacity Strengthened and Increased Adherence to Global Standards BMS Code While previously delayed due to weak political commitment, the new Prime Minister’s decree around the control of marketing of breastmilk substitutes shows important advances in Year 4. Additionally, there is strong indication it will be signed in 2019. USAID Nurture provided technical support in collaboration with UNICEF and A&T, including draft revisions, suggested texts, and regional examples and experiences throughout the past year. USAID Nurture led a DP taskforce to support the strategy in conjunction with UNICEF and SUN CSA in August 2019. USAID Nurture and UNICEF have reiterated their willingness to support DHHP to develop a monitoring and enforcement system in anticipation of the Breastmilk Substitute (BMS) code.
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National Nutrition Forum USAID Nurture participated in the second Annual National Nutrition Forum and organized a booth where participants could learn about the project’s activities. Both Khammouane and Savannakhet provincial health departments gave presentations describing USAID Nurture interventions. The SHS, in her capacity as chairperson of the Laos PDR SUN CSA management committee, gave closing remarks on behalf of the national and international civil society organizations. She called for CSOs to prioritize support of the subnational multi-sectoral nutrition committees, as per the USAID Nurture Cross-cutting Approach. USAID Nurture developed a poster to provide an overview of the iNuW process at the community level in a simple infographic manner (Appendix 3 Poster of iNuW Community Work). Following the Forum, 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.
Breastfeeding Support Services USAID Nurture, with cost share from Alive & Thrive, is working closely with the Early and Essential Newborn Care (EENC) Master Trainer team and the MoH DHR to widen their scope to include breastfeeding services. Two central hospitals will be the first to implement draft national standards for breastfeeding services. In addition, through cost share and Years 5-6 USAID Nurture funding, project districts and health centers will become the first local health facilities in the country to obtain this designation.
CODEX In November 2018, the SHS travelled to Berlin Germany as a member of the Lao Government delegation to CODEX, the international body setting BMS composition and labeling rules. She was supported by Alive & Thrive cost share with USAID Nurture to attend at the request of the MOH. While there, the SHS supported the two delegates of the NNC and Food and Drug Department (FDD) to speak on the floor in support of stronger regulations. 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 to those targeting any children younger than 36 months. These efforts are in line with GoL policies and priorities as per the National Plan Action for Nutrition (NPAN) to improve breastfeeding rates for improved child nutrition.
National WASH Policy 2019 The Senior WASH Specialist was engaged in the WASH Development Partner Task Force led by UNICEF. Two meetings were held in February, 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 include strengthening national rural WASH programs; reducing rural-urban disparities regarding safe water access; strengthening and scaling up strategies in behavior change; marketing to eliminate open defecation in rural areas; improving access to basic sanitation level; and addressing inequalities by prioritizing investments and service delivery to unserved poor and remote communities. Since the WASH DP Task Force is at its early stage of reactivation, a draft TOR 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.
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Community Led Total Sanitation (CLTS) Manual In cooperation with UNICEF, Plan International, World Vision, SNV, and the World Bank, USAID Nurture has been supporting the revision of the national manual on CLTS in Nam Saat of the Ministry of Health. USAID Nurture’s Senior WASH Specialist participated in a series of writing workshops as a member of the drafting technical working group. 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 including latrine use, handwashing with soap, household drinking water, and a clean home compound. The revised CLTS manual, particularly 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%).
The revision of the manual was completed in mid-September 2019 and dissemination workshop was prepared – workshop agenda, budgeting with financial support from different development partners, and official invitation letters to be issued from the MOH. The two day workshop is scheduled for December 2019.
Gender Sensitive Considerations and Male/Female Involvement As reported in the semi-annual report for Year 4, 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 self-confidence of CFs remain a crucial challenge to project effectiveness. Therefore USAID Nurture has invested in further training for DPOs and development of supportive coaching approaches for CFs.
Monitoring, Evaluation, and Learning (MEL) The Results Framework and Performance Indicator Reference Sheets were further reviewed and revised in Year 4. USAID Nurture submitted a final draft of the MEL Plan in Quarter 3 of Year 4 and received approval in early September 2019.
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. Prior to the training, the MEL team conducted a capacity assessment of the Data Entry Officers using a set of questionnaires, and trained them according to the capacity needs identified.
In November 2018, USAID conducted a Data Quality Assessment (DQA) at the Vientiane USAID Nurture office. One of the findings demonstrated that while the MEL staff has fairly good knowledge of data management and analysis, the teams needs to strengthen their understanding of operational definitions and disaggregation requirements of certain custom indicators. USAID Nurture used the findings and recommendations to develop 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
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control. Furthermore, with the approval of the MEL plan, USAID Nurture is in the process of developing 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.
New and Existing Sub-Award and Contract Status SC signed agreements, contracts and/or modified existing contracts with the following organizations and firms in Year 4:
M&E Consultant USAID Nurture retained the local monitoring and evaluation consultant to build the capacity of the M&E team, assess the capacity of the staff, prepare training materials and conduct training to all field teams in January 2019 on data flow process, proper use of forms and reiteration of the importance of monitoring, and timely collection of data. The local consultant will orient and hand over the MEL tasks to the new MEL Manager who will be on boarded in early December 2019.
The Digital Divide Data (DDD) This firm was hired in March 2019 to enter over 3,000 data sheets collected from the field into a Microsoft Access program developed by the M&E Officer and consultant for the semi- annual report. 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.
Souphavady Thonggouane, Video Development on Community Facilitators A Lao national consultant was hired in June 2019 to develop two videos featuring CFs. The two video scripts were reviewed by USAID and endorsed by the Center of Communication and Education for Health (CCEH). The footage was taken in early August 2019 in Atsapangthong district, Savannakhet province with participation of CCEH staff, including provincial health department and district health office.
Humanitarian Media and Video Development of WASH Marketing This media company was contracted in late July 2019 to produce two videos on WASH marketing. These videos will be used for training vendors and sales agents, raising awareness on the WASH marketing approach for advocacy to facilitate support from the government, and sharing information with other DPs. USAID and CCEH reviewed the scripts and the filming is expected to take place in late October 2019.
Graphic Design Support for CLTS Manual Graphic Designer, Mr. Olod Santhichack, was recruited in August 2019 to provide graphic design, page-layout and publication support to complete the Nam Saat Center’s National Community-Led Total Sanitation (CLTS) Manual.
Challenges and Mitigation Project Management During this reporting period, USAID Nurture experienced high staff turnover and so the project spent time recruiting for field replacement positions as well as a new Chief of Party and for new positions such as a WASH Marketing Officer, MEL Manager and Sr. Project Manager. All new staff underwent orientation of their roles and responsibilities and received
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training to gain knowledge and understanding about USAID Nurture. USAID Nurture also provided capacity building training to provincial, district and health center staff to prepare them to take over the responsibilities of mentoring, guiding and monitoring village activities.
Flood Prone Area About one fourth of USAID Nurture’s target villages flood annually; therefore, sales agents received technical advice related to the best locations for toilet installations and after-flooding cleaning and disinfection. Where the groundwater table is high, raised toilet foundations were also introduced. During May and June 2019, 92 target villages (33 villages in Savannakhet and 59 villages in Khammouane) were affected by flooding. This also meant no activities like coaching visits, 1,000 Days Household visits, or sales activities were conducted during the period. In order to make up lost time, USAID Nurture intensified the coaching visits to the VICs’ and CFs so that they would be able to conduct their role to the extent possible during the flood period with minimal coaching supervision from USAID Nurture teams.
Sales Promotion Options A number of vendors would like to try out the proposed options as shown in Table 7, in their respective villages, however, due to limited cash-flow capability and business mindset (lack of understanding of marketing elements - Product, Promotion, Place, and Price (4 P’s)) only a few vendors have agreed to give it a try. By introducing and convincing vendors to try out the proposed sales promotion options, the information will cover both possible risks and mitigations; and importantly, how certain profits would be derived from carrying out any of the options.
Sales Agents A number of trained sales agents have not carried out sales activities despite having monthly sales targets. One reason is that the planting season happened in June and August when most villagers were out in their rice fields, therefore limiting face-to-face support from the WASH marketing team. In response to the mentioned situations, USAID Nurture mobilized DPOs to spend more time on their coaching visits to CFs and VIC to support sales agents, especially focusing on discussing sales agents’ concerns, sales activity conduction skills, and raising technical knowledge in addition to introducing sales promotion ideas. Several other constraints were identified in communities such as villagers do not trust sales agents who are not from their own villages, village authorities are not consistently providing necessary facilitation for the sales agent who travels between villages, and 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, the team adjusted their approach in early 2019 to have village sales agents conduct sales only within their own villages.
Location of Target Communities A portion 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 continue to widen coverage of private
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vendors to offer more product accessibility to target villagers by increasing convenience and proximity of vendors, coupled with the introduction of sales promotion options.
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, it is reaching out to other development partners (World Vision, Health Poverty Action, LuxDev) 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.
Relocation of CFs In Year 4 alone, an estimated 50 CFs and 60 VICs migrated out of their villages which created a challenge in maintaining a volunteer workforce. These 110 volunteers did not continue their work either as CFs or VICs. Specifically, of the 450 CFs trained in FY 2019, about 11% CFs dropped out because they migrated to other places/villages. While it is beyond our control, USAID Nurture has been trying to mitigate the impact by coordinating and requesting Village Committees to help identify potential CFs in advance based on the USAID Nurture criteria to replace the migrated CF members. Equally important, in order to maintain the interest and motivation of these newly elected CFs and/or VICs, USAID Nurture continued to provide on-the-job training.
Gathering Communities for Activities During planting and harvesting seasons it was difficult to gather villagers for community visit activities in the morning as most participants were busy tending their fields. The field staff adjusted by conducting community visits in the early evening to allow more people to participate. Similarly, during the 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. Recognizing that fewer activities occur during this period, USAID Nurture prioritizes crucial activities to be completed and/or to work out with CFs and VICs alternative times to engage.
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 private vendors if it is possible to offer some promotional to motivate the CFs and VICs, e.g. for every 10 toilets ordered one extra toilet will be given to a CF or VIC depending on the circumstances in a particular village.
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Poor Families Based on the government’s Poor Family Criteria3 (2,635 families in total according to reports from the six district reports), account for 7% of the poor families (36,400) in USAID Nurture sites. These families have household incomes less than USD 20 (180,000 LAK) a month and are considered to have the least affordability for the uptake of WASH products in a short time. USAID Nurture will explore appropriate options in Quarter 1 of Year 5. A few of the options may include, providing financial support to the poor families through private vendors, negotiating with private vendors to roll out the seven sales promotions (or at least the poor families could obtain some free toilets from sales surplus), and cooperating with other development partners such as World Vision who have been implementing their activities in Phine and Xonnabouly districts with a few villages overlapping with USAID Nurture.
Environmental Compliance
On February 26, 2019, two staff (Senior WASH Specialist and Senior Operations Manager) from USAID Nurture participated in 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. As a result, the staff are now better able to guide and advice on (1) appropriate toilet installation location considering ground water level, proper installation distance from any water sources, (2) proper underground lining (proper sealing of tubes to ensure no leaks to underground water), and, (3) proper drainage out of toilets e.g. importance of having a soak pit. During the WASH enterprises training, USAID Nurture continues to ensure that latrine and water filter marketers have installation standards and that they are environmental compliant.
Science, Technology, and Innovation
N/A for this reporting period.
Stakeholders Participation and Involvement
As reported in the FY 2019 semi-annual report, 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.
3 Prime Minister’s Decree No. 201/GOL, dated 25 April 2012
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Table 9. 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 counselling into Well-Child platform and in the new ‘Pink Book’ SUN CSA NPAs and other leading INGOs such as PLAN and WV collaborate on a unified CSO strategy for enhanced coordination at district and provincial level and provide support to multi- sectoral committees
Table 10. Key GoL Stakeholders
CCEH Develop rollout and publish 1,000 Days Nutrition Counselling 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 counselling 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.
Other important stakeholders for the project include USAID and the Embassy; therefore, USAID Nurture hosted the US Ambassador’s field visit on March 2019 to a USAID Nurture target village in Attsaphangthong District. The US Ambassador had lively interactions with children, villagers, and the village committee members. The trip proved useful in conveying the important work that USAID Nurture is achieving in Laos and the positive impact experienced at the village level.
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. This 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
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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 nine provinces throughout Laos including Savannakhet and Khammouane.
SUN CSA 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 to coordinate and strengthen sub-national, multi-sectoral nutrition governance, which lead to the formation of a civil society nutrition advocacy working group. In March 2019, USAID Nurture cost share funds supported an advocacy working group member, the 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 August 2019, the advocacy working group met for the second time per its agreed semi-annual schedule. Each focal point provided a recap of their experience trying to establish a dialogue with their PNC and SUN CSA agreed to help document these experiences for dissemination at the National Nutrition Forum.
Sustainability, Local Solutions, and Partnerships
Related to engaging with USAID Nurtures various stakeholders, the project is committed to ensuring sustainable local solutions and partnerships, particularly in light of USAID’s emphasis placed on the Journey to Self-Reliance. In Year 4, USAID Nurture provided capacity-building support to the Provincial Health Department, District Health Staff, and Health Center staff to help them better handle the provision and management of health and nutrition counselling services. Support to improve local capacity includes leadership training, coaching, supervision and mentoring, planning, and strengthening of integrated nutrition services. In WASH, USAID Nurture provided capacity building training to Nam Saat staff and engaged in WASH field activities, including taking the lead on ODF verification and certification. All of these activities help strengthen the local capacity and contribute to Laos’ Journey to Self-Reliance, so that over time, the system is strong enough to maintain the needs of the community on its own.
In the spirit of strong collaboration and coordination, as part of USAID Nurture’s MOU, USAID Nurture held an annual meeting with the GoL in Vientiane in Quarter 2 of Year 4 (February 7, 2019). The purpose of the meeting was to review results to date from the previous year, including technical and financial progress. Key staff participated from USAID Nurture in Vientiane and representatives from provincial and district government partners. The team conducted a simulation of an iNuW Fair which demonstrated key SDAs through participatory activities like cooking competitions, quizzes, drinking water treatment and handwashing demonstrations. The meeting participants had the opportunity to experience each of the simulated activities. This led to their increased understanding of USAID Nurture’s iNuW village visit activities that usually take place in the villages. During the meeting, USAID
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Nurture team received positive feedback from the partners as well as shared issues e.g., lack of water in their communities.
Cost Sharing
SC, along with UNICEF, is a key partner on Alive & Thrive (A&T) South East Asian policy initiative. SC serves as A&T’s Laos country focal point, identifying and seizing on opportunities to strengthen the policy environment to promote, protect, and support breastfeeding. Although not community-based, these efforts directly support the achievement of USAID Nurture’s aim to improve breastfeeding practices, given that many women choose not to breastfeed when they are offered free formula milk at delivery, or stop when they must return to work. At the community-level, USAID Nurture supports women to overcome these barriers to optimal breastfeeding. At the national level, USAID Nurture continues to push for stronger legislation and supportive policy.
A&T support allowed USAID Nurture to provide technical support to BMS regulation writing task force to advance the strengthened regulation expected to be signed by the Prime Minister’s office in late 2019. A&T and USAID Nurture created a taskforce to provide technical support to the ministry as they develop violation monitoring tracking system and raise awareness about the policy within the private sector.
Planned Tasks/Interventions for the Next Reporting Period
The following activities are anticipated to be implemented during the first half of Year 5.
Intermediate Result 1: Improved IYCF and WASH Behaviors in Household with Pregnant Women and Children under Two CFs/VICs promote SDA with 1,000 Days Households Continue to conduct coaching visits to CFs and VICs and support community-wide activity to be carried out by VICs and CFs Implement recognition schemes for CFs and VICs DPOs coach health center staff and CFs on new adolescent SDA and CF rollout during 1,000 Days visit Develop adolescent nutrition counseling and health service module as per national adolescent and Youth Friendly Guideline Conduct training of trainers on adolescent module Roll out adolescent nutrition counseling and health service module as per national adolescent and Youth Friendly Guideline in six districts Support enhanced cooperation within agriculture and health on SBCC approach on nutrition sensitive behavior change in agriculture Develop Diet Diversity for under two years old children SDA (NSA) Train CFs and VICs on new NSA SDA and CF roll out during 1,000 Days home visit Support DNCs with messaging and behavior change to model nutrition village Conduct ODF verification and conduct recognition of star families
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Roll out videos on CFs for training/refresher training for existing and new ones; Develop and roll out plan for latrine discount to poor Households Work with WASH vendors to stimulate purchase of WASH products Endorsement and publication of materials and tools related to iNuW
Intermediate Result 2: Improved Use of Quality Nutrition and Nutrition-Sensitive WASH Services/Facilities Support roll out of MCH Pink Book charting and care standards Develop integrated nutrition service supervision and coaching plan with PHD and DHO Support PHD to provide support to DHO to conduct routine supervision and coaching of integrated nutrition service Support annual standard external assessments of the DHO and HCs integrated nutrition services Continue to conduct coaching visit to sales agents and private vendors Roll out WASH marketing videos for training/refresher training for sales agents and information sharing Conduct introduction of sales promotions options with private vendors Conduct customer satisfaction survey Organize community events to promote nutrition and WASH behavior throughout VIC and Village chiefs led quarterly village meeting Conduct WASH marketing training for districts and provincial government partners Continue recruitment and training of private WASH enterprises and sales agents Edit and publish the 1,000 Days Nutrition Counseling Training Manual in Lao and English Continue to work jointly with RMNCAH Strategic Objective 7 (Nutrition) Committee as well as UNICEF and WHO to pursue a coordinated national nutrition services program model that reflects USAID Nurture innovations and techniques
Cross-cutting Approach: Improved Enabling Environment for Multi-Sectoral Nutrition and WASH National Manual of Community-Led Total Sanitation (CLTS) Continue to support to improve the nutrition service and coordination at the national level Support the dissemination and workshop at national level on the national CLTS manual Support the development of CLTS Trainers’ Manual Continue to provide technical and/or financial support to multi-sectoral district committees and ongoing efforts to coordinate with Provincial level committees and related stakeholders including UNICEF
Monitoring & Evaluation Summarize MEL guideline in Lao language Develop and implement accountability tool for local community Routine coaching, supervision and monitoring of data collection and data entry by DPOs Conduct data quality audits for private vendors Conduct internal DQA in Quarter 1 of Year 5 Facilitate USAID DQA in Quarter 2 Year 5 Share Activity results to stakeholders during full project review
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Enhance monitoring of toilets that are newly constructed through WASH marketing monitoring system 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.
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Appendix 1: List of Private Vendors
Khammoaune Province (12 vendors) Mahaxay Gnommalath Saybouathong 1. Mr. Khong Thonglith 1. Ms. Sombounsap 1. Mr. To Sayaphet Phone: 030 9310 577 Phongsavath Phone: 030 5969888 Coverage: Thongkang village Phone: 020 9872 7272 Coverage: whole district Coverage: whole district, except mountainous area 2. Ms. Panta 2. Mr. Khonesavanh 2. Mr. Phouphet Keobolakoth Phone:030 9465 015 Phithatthep Phone: 020 9576 6199 Coverage: Phaiphavieng, Phone: 030 5575 5623 Coverage: whole district Nakhai Coverage: Phakhong (water filter) 3. Ms. Pok 3. Mr. Thongdam Phone: 020 5568 4355 Phone: 020 5643 94444 Coverage: Nadee, Coverage: Phaiphavieng Phonesaat 4. Mr. Khamsing 4. Ms. Maniphone Sayaphet Linsomphou Phone: 020 9140 0777 Phone: 020 22158 452 Coverage: Panam Coverage: town 5. Mr. Ounthsy Phomesay 5. Mr. Phommee Phone: 020 95510936 Phone: 030 5670094 Coverage: Nathone Savannakhet (9 vendors) Atsaphanthong Xonnabouly Phine 1. Ms. Jook & Mr. Yui 1. Mr. Vanvilay 1. Mr. Souvannaseng Phone: 020 5544 1108 Phone: 020 9977 0070 Phaisounlaphong Coverage: whole district Coverage: whole district & Phone: 020 9854 7755 Beungxag Coverage: town, mountainous area 2. Mr. Chanthanom 2. Mr. Kilo 2. Mr. Loima Sayachack Kuanmuangchanh Phone: 020 9898 6373 Phone: 020 9673 3330 Phone: 020 9888 1558 Coverage: Tangvai Coverage: town, except Coverage: whole district Lamthouay mountainous area 3. Mr. Inpan Phone: 020 5226 2518 Coverage: Nonghangmee 4. Mr. Vanvilay Phone: 020 9977 0070 Coverage: Nonghangmee 5. Ms. Manikhom Phone: 030 9841449 Coverage: Nongbualao, Napheng
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Appendix 2: ODF Verification Tool
SUMMARY OF ODF VERIFICATION RESULTS (FORM 2)
Integrated Nutrition and WASH
Savannakhet and Khammouane Provinces, Lao PDR
Village: ______District: ______Province: ______Verification Date: ______
Verification team Full name Role Organization Signature 1. 2. 3. 4. 5. 6. 7. 8.
Brief demographic information Village team Population Full name Contact number Female VIC 1. Under 5 children 2. Households CFs 1. Families 2. 1,000 day families Sales Agent 1. Latrines
ODF verification results Topics # Percent Results Passed/Not HHs Passed 1. Toilets (owning and having) – 100% # Toilets verified # Pour-flushed type # Dry-pit latrine # Shared toilets
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2. Handwashing with soap – 60% # HHs have handwashing station in kitchen area # HHs have handwashing statition near toilets 3. Household safe drinking water – 60% # HHs treat their drinking water (disaffection, filtration) # HHs have clean drinking water containers, container have lids 4. Clean home compound – 60% # HHs have clean home compound, with on feces (human and animal feces, rubbish # HHs have drainage
Based on the verification, the village Passed Not Passed
Next steps 1. ______2. ______3. ______4. ______5. ______
Signature Signature Village Chief ODF Verification Representative
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Data Collection Form (FORM 1) (Household)
Village: ______District: ______Province: ______Verification Date: ______
HH Ord Nam Toilet (100%) Handwashi Safe Clean cod er e ng with drinking home e soap (60%) water compoun (60%) d (60%)
flushed type - pit latrine -
# Toilets verified# Pour # Dry# Shared# toilets % HHs# have handwashing HHs# have station in kitchen handwashing area % station near toilets HHs# treat their drinking water HHs# clean have (disaffection, drinking water filtration) % containers, container lids have HHs# clean have compound, home HHs# have with on feces drainage (human and animal % feces,rubbish
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Appendix 3: Cover Pages of Tools for Endorsement and Publication
Trainers’ Guide for Conducting CF Training (1) Introduction: CF role, essential knowledge for CFs, and how to train CFs, (2) Introduction of SDAs, (3) Steps for conducting a home visit, (4) role play (home visit), (5) home visit form, and (5) review and summary Guide for CF for Conducting Home Visit (1) Cover page (2) Reminder of key SDAS, dividing into 4 stages of early pregnancy, late pregnancy, children 0-5 months, and children 6-24 months
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Guide for CF for Conducting Home Visit (3) Shows five steps of home visit. (4) Provides brief description of how to fill in the home visit form and the overview of the Home Visit form.
Guide for VIC Updated sections: ▪ Roles and responsibilities ▪ Supervision and support to CFs ▪ Update of the status of the implementation
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Appendix 4: Small Doable Actions (SDAs)
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Appendix 5: Pictures of USAID Nurture Activities
Household Monitoring Visit by DHO and DPO in Phine District
Household Visit by CF in Xonnaboury District
Sale Agent Training in Attsaphanthong District
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Appendix 6: Completed iNuW Phasing Strategy (Village Visit Plan)
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Appendix 7: Sales Flipcharts (cover page)
Sales flipchart used by sales agents The tool consists of (1) discussions, (2) stories, (3) competing prioritization, and (4) toilet options.
Sales poster for water filter
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Appendix 8: Success Story about Change: Improving Newborn and Maternal Health and Nutrition in Laos
Community facilitators help raise awareness with local families
“The doctor took really good care of me. My second girl has never been sick.” May 2019 – The dense evergreen forests of Khammouane province are punctuated by outcroppings of limestone mountains providing a mysterious setting to everyday life in this remote, rural part of Laos. Mahaxay district is about 50 kilometers from the capital of Khammouane province, far away from the urban bustle of Thakhek.
It is in a quiet village we find Ms. Khone, a 29-year-old mother of two, working under her stilted house. Her youngest daughter, 5-month-old Yaya, is tied to her back while she sweeps along the dirt floor. Her husband, Mr. Ning, works as a laborer while she takes care of the household and the family.
“When I was pregnant with my first daughter, I had Ms. Khone and her young daughter in no idea what was happening to my baby in my belly the shade under their house on stilts. and I didn’t know who could give me any advice. I didn’t go to the health center for any checkups Photo by Ms. Phounxap Keopanya, USAID Nurture because I didn’t know I needed to,” she says shyly. “When my little girl was born, she had some small health issues. The doctor later told me that she might have been able to help me if I had gone to the health center while I was pregnant.”
Ms. Khone’s story is shared by many women and families in Khammouane province and in other remote parts of Laos. Although there may be health centers and services available, there are several barriers to accessing them. Health centers are often located in more urban areas, which means that women have to travel long distances, arrange their own transport and have someone accompany them. Additionally, women and families sometimes do not realize the importance of antenatal care and nutrition. This means health services are often underused.
Working closely with government partners, USAID Nurture encourages pregnant women to make regular visits to health centers early in their pregnancy so that health care professionals can provide support. The period before birth is a crucial time for families to learn more about how to have a healthy pregnancy and how to care for their child. Health centers can also provide information to parents on the risks and symptoms of pregnancy, labor and delivery, and encourage delivery with the help of a skilled health care provider. These visits also provide birthing space information, which can help to improve infant survival.
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USAID Nurture supports monthly household visits conducted by trained community facilitators. Working closely with USAID Nurture staff and government partners, these community facilitators promote a series of small doable actions for 1,000 days families. Among these are actions for improving nutrition and hygiene in the family, encouraging exclusive breastfeeding and seeking out antenatal care early in pregnancy.
When Ms. Khone got pregnant with her second child, she was visited by the village’s community facilitator. “The community facilitator made several visits and we talked about how to improve my health and my child’s health. I learned many things from her and now I practice keeping my home compound clean and boiling water for drinking. Now I also clearly understand why breastfeeding my child is so important. She also advised me to visit the doctor at the health center so that I could get regular checkups. The doctor took really good care of me. My second girl has never been sick.” She smiles at little Yaya who plays in her mother’s lap.
The first 1,000 days between pregnancy and age two is a critical period for ensuring that children develop healthily. USAID Nurture works with communities and government partners in 471 villages in Khammouane and Savannakhet provinces to promote the well- being of mothers and children.
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Appendix 9: Success Story About Change: Lao Communities Make Progress Towards ODF Status
Village Committees play key role to encourage improved practices
“We don’t have to run to the forest to go to the bathroom anymore!” September 2019 – “I feel very proud today,” Mr. Khamsee says with a smile. Mr. Khamsee is a village chief – a position that comes with certain responsibilities and duties. He is proud of his village as it is one of the first five villages to be awarded Open Defecation Free (ODF) status in his district. “When the project started, only a few houses had a working toilet. Now everyone has access to a latrine. We don’t have to run to the forest to go to the bathroom anymore!”
Phonelai village is located in Mahaxay district in Khammouane province – about 19 kilometers from the district capital of Mahaxay. 65 households live in this small hamlet in rural Laos and most villagers farm or raise animals for their livelihoods. Far from the modernity of the more developed, urban parts of Mr. Khamsee stands in the middle of his the country, Phonelai is a quiet, sleepy town and village progress takes time. Photo by Mr. Bounmy Sayalath, USAID Nurture
When USAID Nurture first began working in the village in August 2018, there were only three latrines in use. Most villagers agreed that all households should have a latrine, but without a clear plan, it seemed impossible. Mr. Khamsee was selected by the project staff to form a Village iNuW Committee (VIC) to support the implementation of the innovative Integrated Nutrition and WASH (iNuW) approach used by USAID Nurture. USAID and government staff began encouraging VICs and other community champions to lead and take ownership of the project initiatives to achieve their nutrition and WASH (water, sanitation and hygiene) goals.
Being awarded ODF certification by the government is no small achievement. In order to qualify, a village must meet the four national ODF standards, including 100% toilet use, 60% handwashing with soap, 60% treated drinking water and 60% clean home compounds. Mr. Khamsee was one of the first of nearly 1,000 VIC members selected by USAID Nurture and has been a champion for the iNuW model employed by the project. As Mr. Khamsee was an influential community leader who was willing and able to lead nutrition and WASH efforts in his village. He was best placed to support and encourage his village.
Mr. Khamsee explains, “We were successful in our village only because we had a real plan to build the latrines and meet the criteria for ODF certification. Our village had two trees that we had to cut down. We realized that we could use the money that we got from selling the two trees to build latrines. Now, 50 units out of the 65 in the village have their own latrines. The remainder are using a shared toilet. Another reason we were successful was because we
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all worked well together. It all began when we set the goals for the village early in the year together with all the villagers. Since then, the VIC, community facilitators, the village chiefs and the community members have all been supporting each other closely. This has finally enabled our village to be successful in becoming an ODF village.”
“USAID Nurture has really benefited my community and we will continue to follow the suggestions and recommendations of USAID Nurture. I hope the project and government staff continue to support our village so that our children can be healthy and have a bright future.”
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Appendix 10: Additional photos of breastfeeding, latrines, and hand washing
Photos by Mr. Bounmy Sayalath, USAID Nurture
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