Improved Maternal and Child Health Through Connectivity (Financed by the Japan Fund for Poverty Reduction)

Home , Dushanbe, Rahimzoda, Rasht District, Roghun, Tavildara

Grant Assistance Report

Project Number: 46077 February 2013

Proposed Grant Assistance Republic of Tajikistan: Improved Maternal and Child Health through Connectivity (Financed by the Japan Fund for Poverty Reduction)

CURRENCY EQUIVALENTS (as of 25 January 2013)

Currency unit – somoni (TJS) TJS1.00 = $0.2099 $1.00 = TJS4.765

ABBREVIATIONS

ADB – Asian Development Bank ADF – Asian Development Fund CAREC – Central Asia Regional Economic Cooperation IEE – initial environmental examination IMCI – Integrated Management of Childhood Illnesses IMR – infant mortality rate JFPR – Japan Fund for Poverty Reduction JICA – Japan International Cooperation Agency MCH – maternal and child health MMR maternal mortality ratio MOH – Ministry of Health MOT – Ministry of Transport PIU – project implementation unit U5MR – under-five mortality rate VIMF – village infrastructure maintenance fund

NOTES

(i) The fiscal year (FY) of the Government of Tajikistan and its agencies ends on 31 December.

(ii) In this report, "$" refers to US dollars.

Vice-President X. Zhao, Operations 1 Director General K. Gerhaeusser, Central and West Asia Department (CWRD) Director C.C. Yu, Tajikistan Resident Mission, CWRD

Team leader F. Nuriddinov, Project Officer, CWRD Team members A. Chyngysheva, Portfolio Management Specialist, CWRD R. Idei, Transport Specialist, CWRD N. Kvanchiany, Associate Project Analyst, CWRD S. Roth, Senior Social Development Specialist (Social Protection), Regional and Sustainable Development Department Z. Wu, Transport Specialist, CWRD

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.

JAPAN FUND FOR POVERTY REDUCTION (JFPR) JFPR Grant Proposal I. Basic Data Name of Proposed Activity Improved Maternal and Child Health through Connectivity Country Republic of Tajikistan Grant Amount Requested $2,500,000 Project Duration 3 years Regional Grant {Yes / z No Grant Type z Project / { Capacity building II. Grant Development Objective(s) and Expected Key Performance Indicators Grant Development Objectives: The primary objective of the project is to improve maternal and child health results for isolated rural communities of five jamoats1 in Rasht district, one of the poorest regions of the country with the highest rate of food insecurity. Health services are poor and knowledge of health- promoting behavior is limited. The situation has worsened since March 2009 when the only bridge connecting the communities to the district center was destroyed by flooding. Residents now have to make a 17-kilometer detour to access the road to the district center. This has seriously constrained access to social services, especially health-care facilities, for communities lacking adequate local health services. The project outcome will be improved access of the marginalized rural poor in five jamoats in Rasht district to strengthened health services. The project will support (i) rehabilitation of the bridge and improvement of the rural road, which is linked to Central Asia Regional Economic Cooperation (CAREC) corridors 3 and 5; and (ii) increased use of effective health services and nutrition practices in communities. About 40,000 villagers will benefit from these interventions. Expected Key Performance Indicators: (i) The 66-meter bridge over the Sarbog river rehabilitated, and 18 km of the rural road linking Navobod, Obi Mehnat, Tagoba, Boki Rahimzoda, and Nusratullo Makhsum jamoats and Rasht district center improved (ii) 90% of health workers in health facilities of the target area updated on obstetric and infant care, and Integrated Management of Childhood Illnesses (IMCI) (iii) 20,000 people in the target area covered by the public information campaign to improve health behavior at the household level (iv) The rural hospital in Navobod equipped with a safe and operating ambulance; and 75% of emergencies reported in the rural health centers referred to the central hospital III. Grant Categories of Expenditure, Amounts, and Percentage of Expenditures Amount of Grant Percentage of Category Allocated in $ Expenditures 1. Civil Works 1,400,000 56.0 2. Equipment and Supplies 131,900 5.3 3. Training, Workshops, Seminars, and Public 76,700 3.1 Campaigns 4. Consulting Services 518,230 20.7 5. Grant Management 128,800 5.1 6. Contingencies 244,370 9.8 Total 2,500,000 100.0

1 Jamoat is Tajik for village cluster, the lowest administration division. 2

JAPAN FUND FOR POVERTY REDUCTION

JFPR Grant Proposal Background Information

A. Other Data Date of Submission of 11 October 2012 Application Project Officer Farrukh Nuriddinov, Project Officer Project Officer’s Tajikistan Resident Mission Division, E-mail, Phone Central and West Asia Department [email protected], +992 37 221 0558 Other Staff Who Will A. Chyngysheva, Portfolio Management Specialist, CWRD Need Access to Edit R. Idei, Transport Specialist, CWRD and/or Review the Report N. Kvanchiany, Associate Project Analyst, CWRD S. Roth, Senior Social Development Specialist (Social Protection), Regional and Sustainable Development Department Z. Wu, Transport Specialist, CWRD Sector Transport and ICT (primary) Health and social protection Subsector(s) Road transport (district and rural roads, road maintenance) Health systems (primary health care including village health care and first referral) Theme Social development Subtheme(s) Human development Targeting Classification Targeted interventions (TI–H) and MDGs TI (M4, M5) Name of Associated ADB Loan 2196-TAJ/Grant 0154-TAJ: Dushanbe–Kyrgyz Border Road Financed Operation(s) Rehabilitation Project (Phase 2) Loan 2359-TAJ/Grant 0085-TAJ: CAREC Regional Road Corridor Improvement Project Executing Agency Ministry of Transport through the Project Implementation Unit Contact: Mukhtor Negmatov, Executive Director, Project Implementation Unit Ayni 14, 73046 Dushanbe Tel: (992 37) 221 56 73 Fax: (992 37) 251 02 75 Email: [email protected] Grant Implementing Same as above Agency

B. Details of the Proposed Grant

1. Description of the Components, Monitorable Deliverables and/or Outcomes, and Implementation Timetable

Component A Component Name Improved and sustainable access for isolated communities through bridge and rural road rehabilitation Cost ($) $1,465,500 (excluding contingencies) Component Description The component will improve road access to Garm town, the Rasht

district center, for 58 rural communities of five jamoats affected by the flooding, and support establishment of a sustainable infrastructure maintenance mechanism.

Civil works. The project will (i) rehabilitate an existing 66-meter (m) bridge over the Sarbog river and (ii) improve an 18 km road from the bridge to the Rasht district center access road.

The bridge and road will link the communities to the main Dushanbe– Kyrgyz Republic border road currently being rehabilitated as part of CAREC corridors 3 and 5.2 This will enable the project to contribute to strengthening links with regional and local markets.

Community-based infrastructure maintenance mechanism. Community capacity will be developed to maintain infrastructure sustainably by replicating and reinforcing the decentralized operation and maintenance (O&M) scheme established under JFPR 9111-TAJ and JFPR 9078-TA.3 The project will build the capacity of key local stakeholders (local government, community-based organizations, and contractors) to carry out community-based maintenance work through participatory planning and mobilizing local resources.

The project will support in (i) forming road maintenance associations in the beneficiary jamoats; (ii) training the associations to build their technical and financial management skills so that properly kept; (iii) establishing village infrastructure maintenance funds (VIMFs) in all five jamoats to collect cash contributions from the community for O&M; 4 and (iv) providing essential road maintenance and safety equipment to the associations. This will ensure periodic maintenance is carried out after the defects liability period of civil works contracts for the bridge and road. Arrangements used for previous projects will be adopted to establish road maintenance associations. Community- based organizations should submit a clear statement of understanding and responsibilities to the Ministry of Transport

2 ADB. 2005. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Asian Development Fund Grant to the Republic of Tajikistan for the Dushanbe–Kyrgyz Border Road Rehabilitation Project (Phase 2). Manila; ADB. 2007. Report and Recommendation of the President to the Board of Directors: Proposed Loan, Asian Development Fund Grants, and Technical Assistance Grant to the Kyrgyz Republic and the Republic of Tajikistan for the CAREC Regional Road Corridor Improvement Project. Manila; ADB. 2009. Report and Recommendation of the President to the Board of Directors: Proposed Supplementary Asian Development Fund Grant to the Republic of Tajikistan for the Dushanbe–Kyrgyz Border Road Rehabilitation Project (Phase 2). Manila. 3 ADB. 2007. Proposed Grant Assistance to the Republic of Tajikistan for the Sustainable Access for Isolated Rural Communities Tajikistan (financed by the Japan Fund for Poverty Reduction). Manila; ADB. 2005. Proposed Grant Assistance to the Republic of Tajikistan for the Community-Based Rural Road Maintenance Project (financed by the Japan Fund for Poverty Reduction). Manila. 4 The results of previous projects proved that funds for VIMFs could easily be collected if the end users (villagers) are properly motivated to support development of their community. A lot of enthusiasm was observed among villagers for effective road maintenance. Two road maintenance associations were formed in Rasht district under JFPR 9111-TAJ for seasonal maintenance and other activities on the rural infrastructure required after project completion. The associations were trained to build up technical and financial management skills, and provided with essential road maintenance and safety tools. As of 2012, the local communities contributed about TJS16,000 ($3,300) to the VIMFs.

(MOT). A written agreement will be reached between the community organizations and local beneficiaries to ensure commitment to cash or in-kind contributions to the maintenance activities.

Following the positive experience under JFPR 9111-TAJ, the government through its local road maintenance units, will be actively involved in implementing the project by providing advisory, machinery, and staff support for routine maintenance. Monitorable (i) The 66 m bridge over the Sarbog river rehabilitated Deliverables/Outputs (ii) 18 km of rural road linking Navobod, Obi Mehnat, Tagoba, Boki Rahimzoda, and Nusratullo Makhsum jamoats and Rasht district center improved (iii) Decentralized community participatory O&M scheme adapted and implemented (iv) 100 representatives of local governments, small contractors, and rural communities trained on bridge and road O&M and operation of VIMFs (v) VIMFs established and operating in all five jamoats (vi) Essential safety and road maintenance tools procured and delivered to the road associations Implementation of Major Months 7–28: Rehabilitate the 66 m bridge Activities: Number of Months 7–28: Rehabilitate the 18 km of rural road from the bridge to months for grant activities the Rasht district center access road Months 16–20: Provide training on community-based infrastructure O&M Months 19–24: Establish VIMFs Months 24–28: Procure and deliver essential safety and road maintenance tools

Component B Component Name Improved and increased use of health services and nutrition practices in the targeted communities Cost ($) $471,750 (excluding contingencies) Component Description The following activities will be implemented in the five jamoats (Navobod, Obi Mehnat, Tagoba, Boki Rahimzoda, and Nusratullo Makhsum) of Rasht district that will benefit from the rehabilitated bridge and improved road connectivity.5

The activities will build on the methods and approaches developed by the ongoing Japan International Cooperation Agency (JICA) project for improving the capacity of health centers to deliver quality maternal and child health (MCH) services. The international experts working on the JICA project will assist in capacity building and other activities of the health component.

Capacity of health centers to deliver quality maternal and child health and nutrition services. The project aims to work with health clinics in communities, which are the long-term health care providers, and enable health care professionals to respond to community health

5 The total population of all five targeted jamoats is 40,000, of which 13,000 completely depend on the bridge.

needs. Greater efforts will be made to identify and address MCH and nutrition needs. Specifically, the project will supplement information materials developed in reproductive and MCH programs by providing training and additional materials. If needed, it will provide basic clinical equipment to health-care staff, renovate health facilities, and implement the standard operating procedures and protocols for a variety of health problems that affect women and children. The activities will support patient referral to secondary and tertiary medical services to ensure comprehensive care during the construction of the new bridge.6 The renovations could also improve the quality of latrines and water-based sanitation in the health facilities. Training will be conducted for health workers, including midwives and doctors, on the hygiene and hand-washing. The Rasht district authority is committed to providing regular budgetary and staff resources for the maintenance of health facilities and equipment upon project closure.

Health workers will be provided with relevant educational materials developed earlier with the support of the United States Agency for International Development, United Nations Children’s Fund, World Health Organization, JICA, and United Nations Population Fund; and new materials to be developed with project support as needed. They will be trained to counsel 8,500 women and their families on behaviors that can improve family health and the infant mortality rate (IMR), under-five mortality rate (U5MR), and maternal mortality ratio (MMR).

Behavior change among individuals and communities to achieve better health outcomes. Health behaviors at the household level must be improved. Many traditional health treatments have little scientific merit and may even be contraindicated (e.g., urine therapy). The Soviet focus on curative care left communities with little knowledge about actions within their means to prevent and control malnutrition and illness.

The project will develop and implement behavior change communication activities to improve health through sustained behavior change of 20,000 project participants. It will assess current practices, beliefs, and perceptions to identify realistic options for changing practices within the current economic and food context. The project will rely on a variety of training and awareness-raising channels, including community-based education, counseling, schools, parent–teacher associations, local organizations (i.e., farmer associations, village infrastructure maintenance associations), and mass communication (i.e., local newspaper and radio), to cover the following topics:

6 Two types of health services are available in the project area (hospitals and primary health care). The rural hospital in Navobod provides services to the population of all five targeted jamoats. Under the primary health care service, 19 rural health centers and 41 health houses provide treatment on an outpatient basis. Each jamoat is served by at least one rural health center and several health houses. Health facilities are located 2–18 km from the rural hospital in Navobod.

(i) Appropriate breastfeeding and complementary feeding. The project will train health professionals who care for pregnant and lactating women by (i) introducing the locally adapted World Health Organization module on infant and young child feeding for complementary feeding; and (ii) promoting healthy and feasible practices to caretakers and other influential people (mothers-in-law, men, local health personnel, community health workers).

(ii) Positive feeding and child care practices. The project will engage caretakers and household decision makers to encourage continued breastfeeding of infants, increased fluid intake and continued child feeding during illness, and increased nutritional intake for children during recovery.

(iii) Improved hygiene. The project will promote improved hygiene behaviors, which provide the most immediate benefit to health. This will include proper hand washing with soap before preparing food or feeding a child and after defecation or cleaning a child. Information will include hygienic latrine upkeep to reduce the transmission of pathogens.

(iv) Adequate maternal nutrition. Pregnant women and mothers will be encouraged directly and through influential family members (e.g., the elderly and mothers-in-law) to eat more and varied foods.

(v) Dietary diversification. The project will encourage the consumption of a healthy diet rich in micronutrients, and emphasize the relationship between diet, health, and nutrition.

(vi) Prevention and care-seeking for diseases. As part of the IMCI approach, the project will supply parents with essential information about childhood diseases (pneumonia, severe diarrhea, asphyxiation, fever) and pregnancy-related diseases (hypertension, blood type incompatibility, anemia, and urinary tract infection), other infectious illnesses (malaria, tuberculosis, brucellosis), and the need for prompt attention. The messages will contain information about feasible actions that families can take to protect themselves from these illnesses.

A responsive emergency referral system. Many women in the project area give birth at home or at local health facilities that are not staffed or equipped to treat complications. If complications arise during pregnancy or delivery, their lives depend on access to a secondary or tertiary health facility in Rasht district. In addition, the road and the bridge alone will not secure timely transportation to health facilities since emergency transportation will also be needed. Thus, concomitant with the bridge rehabilitation, a referral and emergency transportation system needs to be established to ensure

that difficult cases are referred and transported to the district and tertiary hospitals on the other side of the river.

The project will procure and supply an ambulance to the rural hospital located in Navobod township nearby the road. The hospital provides services to all five targeted jamoats. One additional ambulance would be sufficient to support existing old vehicles located in two health facilities (i.e., Navobod and Shule), which cannot be used during the winter. The Navobod rural hospital has a gynecological department for 15 places with qualified and locally trained obstetrics and gynecology staff. When critical surgery is required, the patient will be referred to the Rasht district central hospital. Gasoline, driver, and other ambulance costs will be fully financed by the government as agreed upon during project appraisal. Monitorable (i) 90% of health workers in the health facilities of the target area Deliverables/Outputs updated on obstetric, infant care, and IMCI (ii) 20,000 of residents of the target area covered by the public information campaign to improve household health behavior (iii) Rural health centers in five jamoats provided with basic essential medical equipment (iv) Health facilities renovated (v) Rural hospital in Navobod equipped with a safe and operating ambulance (vi) 75% of emergencies reported in the rural health centers referred to the central hospital (vii) Improvements in participants’ knowledge demonstrated (viii) Information, education, and communication materials disseminated to members of the wider community Implementation of Major Months 4–6: Assess training needs of health workers Activities: Number of Months 7–16: Conduct training programs for health workers months for grant activities Months 6–12: Provide basic essential medical equipment to the health facilities Months 9–31: Undertake basic renovation of the selected health facilities Months 4–6: Assess current practices, beliefs, and perceptions among population Months 7–35: Implement behavior change communication activities Months 7–12: Purchase a new ambulance Months 13–36: Establish an effective referral system with responsive ambulance services

Component C Component Name Project management, monitoring, and evaluation Cost ($) $318,380 (excluding contingencies) Component Description This component will comprise (i) overall project coordination, supervision, management, and reporting; (ii) preparation of work plans, implementation guidelines, and procedures for grant financing; (iii) an independent social and poverty impact assessment;

(iv) annual independent external auditing; and (v) a final dissemination workshop.

Additional staff will be engaged for the existing Project Implementation Unit (PIU) to facilitate implementation. With the assistance of the local management consultant, the PIU will (i) undertake proper dissemination of information and reporting to key community stakeholders; (ii) recommend measures for project sustainability, and refine the existing institutional, financial, and participatory scheme; and (iii) ensure that transparency and accountability mechanisms are in place. Monitorable (i) Comprehensive project work plan, implementation schedule, and Deliverables/Outputs guidelines prepared and attached to the grant implementation memorandum (ii) Funds for each component utilized efficiently and transparently (iii) Effective construction supervision and fiduciary oversight in place (iv) Inception, quarterly and annual progress, and completion reports; semiannual environmental monitoring reports; financial reports; and poverty impact assessments prepared and submitted on time and of good quality (v) Final workshop carried out upon completion of the project (vi) Annual financial and project audits conducted by an independent auditor Implementation of Major Months 1–36: Project management (including staff recruitment Activities: Number of during the first four months), monitoring months for grant activities Months 4–6: Baseline survey Months 19–20: Midterm evaluation survey Months 32–33: Final evaluation survey Months 35: Final workshop Annually: Independent audit

2. Financing Plan for Proposed Grant to Be Supported by JFPR Funding Source Amount ($) JFPR 2,500,000 Government 386,000 (including in-kind contributions) Other sources (communities) 47,000 (in-kind contributions) Total 2,933,000

3. Background

1. The Government of Tajikistan identifies primary health care and MCH as top priorities in its comprehensive National Health Sector Strategy, 2010–2020. Poor child health outcomes in Tajikistan are caused by systemic health sector issues, including chronically limited financing and poor quality health services; poverty, particularly in rural areas; limited knowledge of health- promoting behavior; and poor access to clean water. Estimates for 2009 placed the infant mortality rate (IMR) at 52 per 1,000 live births and the under-five mortality rate (U5MR) at 61 per 1,000 live births compared to an IMR of 65 per 1,000 live births and an U5MR of 79 per 1,000 live births in 2005.7 Unsafe home deliveries are considered to be a major contributing factor to the high infant and maternal mortality rates.8

2. To achieve its Millennium Development Goal (MDG) of a two-third reduction in child mortality by 2015, Tajikistan’ needs to attain an IMR of 29.6 and an U5MR of 39.3 by 2015. One in three, or almost 300,000 children under 5 years are still stunted, a consequence of chronic nutritional deprivation that begins before birth if the mother is undernourished. Only 23% of children under 6 months are exclusively breastfed; more than half of the country’s children have low iodine levels and almost one-third have iron-deficiency anemia.9 The general population has insufficient access to health-related information and lacks awareness of the causes of ill health, particularly with regard to unhealthy diets contributing substantially to the burden of disease. Poor quality diet results from traditional preferences for fatty foods and animal products. 10 Behavioral change is needed to stop this vicious circle and contribute to the achievement of MDG 4 (reduce child mortality) and MDG 5 (improve maternal health) in the project area.

3. The project area (Rasht district) is one of the most traditional and conservative areas in Tajikistan. Women from the area are less likely than women from other regions to participate in community activities or seek health services.11 Both the IMR and U5MR are 10%–15% higher in Rasht district compared with other regions. The MMR was 59.8 in 2011 and has not improved for the last 10 years. The district is one of the poorest in the country and has the highest rate of food insecurity (11%–18% of the population is classified as extremely food insecure and 74% as moderately food insecure). A recent survey shows that 58% of respondents in Rasht district believe their quality of life has worsened over the last 2 years, while 72% report a decrease in their household income.12

4. The situation deteriorated when more than 13,000 residents of the most isolated rural communities in Rasht district were affected by the destruction of a bridge by floods in March 2009. The bridge played an essential role in connecting these communities with the Rasht district center. Since this incident, people in the communities have been forced to take a 17 km detour to access the road to the district center; this has seriously affected their access to social services. On 26 February 2010, the Government of Tajikistan requested Asian Development Bank (ADB) assistance for the rehabilitation of the 66 m bridge over the Sarbog river and improvement of an 18 km rural road from the bridge to Rasht district center. Although the bridge was temporarily repaired in 2010, any serious natural disaster can easily destroy it again and it is unsafe during the winter. In March 2010, ADB responded to the government’s request with

7 UNICEF. 2011. The State of the World’s Children 2011. Adolescence. An Age of Opportunity. New York. 8 WHO. 2010. Tajikistan: Health System Review. Dushanbe. 9 UNICEF. 2010. Micronutrient Status Survey in Tajikistan. Dushanbe. 10 WHO. 2010. Tajikistan: Health System Review. Dushanbe. 11 USAID. 2005. Development Assistance Program. Dushanbe. 12 Mercy Corps. 2010. Tajikistan Stability Enhancement Program: Baseline Survey. Tajikistan.

10 the proposed project. However, due to concerns over the subsequent deterioration of security in the area, the Embassy of Japan in Tajikistan asked that the project be put on hold. Currently, the security situation has stabilized and the government has asked ADB to accelerate processing given the project’s strategic importance for development of the region. The Embassy of Japan supports moving forward with the project at this time.

5. ADB held several consultations with district authorities, communities, and women’s groups to identify primary and secondary stakeholders, their perceptions of current problems, and interest in the project. Inadequate access from the isolated jamoats to roads and to Rasht district center for more than 2 years has resulted in (i) a tenfold increase in transportation costs; (ii) economic isolation—products (including seeds, fuel, water) were not available at the market because of delays and increased transport costs, which also affected food and medical drug supply; and (iii) limited access to more comprehensive health-care services, causing an increase in child mortality and home deliveries.13 Women have experienced increased maternal morbidity and mortality since the bridge was destroyed, as their low family income does not allow them to pay for the increased transport costs to visit a health center in case of emergency or for prenatal care. Since the destruction of the bridge, one maternal death has been recorded. Local health facilities, particularly medical equipment, latrines, and sanitation, are also deteriorating.

6. Access to and use of quality health services is impaired by (i) lack of skilled staff;14 (ii) deteriorated facilities lacking utilities and adequate equipment and supply; and (iii) insufficient basic health care, health prevention services, and support for family health practice. The consultations with communities also confirmed a widespread low health-seeking behavior.

7. The project would support combined and interlinked health and transport interventions to improve the health of mothers and children. The bridge access and road improvement together with health interventions will have multiple synergetic social and economic effects: (i) improved transport services (e.g., availability, frequency, reliability, and costs); (ii) greater accessibility to health care resulting in improved health outcomes for women and children (due to an increased number of people seeking treatment for illness due to reduced travel times); (iii) better access to education opportunities; (iv) uninterrupted flow of agricultural goods and services (such as seed, fertilizer, and crops) across the river; and (v) growth in livestock raising through improved access to veterinary services and better access to market opportunities. The improved accessibility will increase economic opportunities of poor rural households, which in turn will contribute to increased income and, thus, improved health outcomes among women and children. The health information component of the project will increase demand for health services, and the project will support activities to match the demand by increasing the supply and quality of health services. The project will help ensure this supply by enhancing the mobility of health personnel and supplies by reestablishing the bridge and road connection and equipping the rural hospital in Navobod with a safe and operating ambulance.

8. The project was formulated in consultation with MOT, the Ministry of Health (MOH), local governments, rural communities, and development partners concerned, particularly the Embassy of Japan in Tajikistan and JICA, as well as people affected by the project. The project is categorized C for potential involuntary resettlement and indigenous peoples impacts since no land acquisition and impacts on indigenous peoples are foreseen. The due diligence confirms

13 According to women’s focus group discussions conducted by ADB staff in 2010 and 2012. 14 Not all the rural health centers in the project area have medical staff with university degrees; most are paramedical staff.

11 that the project does not pass through any environmentally sensitive areas and will not result in any significant negative environmental impacts, and therefore, the project is categorized B for the environment. MOT prepared an initial environmental examination (IEE) according to ADB’s Safeguard Policy Statement (2009) and national legislation and regulations. The IEE was disclosed on the ADB website on 24 September 2012. Project-affected people were duly consulted. The IEE includes an environmental management plan to minimize the project’s potential environmental impacts. MOT, assisted by an environmental expert, will be responsible for implementing the plan and submitting a semiannual monitoring report to ADB.

4. Innovation

9. The project is innovative. It will comprehensively contribute to improving people's livelihoods through strong attention and responsiveness to the health needs of the poorest while enhancing benefits that the CAREC road provides to residents of isolated areas. By combining effective and well-targeted interventions for sustainable road and health infrastructure improvement and creating relevant skills and knowledge, the project will ensure better access to quality health services and foster partnerships among local governments, community-based organizations, and health-care institutions in meeting the critical needs of women of reproductive age, mothers, and children.

10. The project will also pilot an innovative approach, which will help consolidate communities’ resources for addressing their needs, through the introduction of the village (road) maintenance fund for sustaining infrastructure improvement and local capacity created by the project. This approach can be adapted, integrated, or scaled up under other ongoing or upcoming interventions. The United Nations Development Programme, which has long-standing expertise in local governance and community mobilization, has established grassroots community-based organizations in most jamoats of Rasht valley.15 These organizations have contributed greatly to the empowerment of local communities, in particular women, and achieved significant results in social mobilization and community development. Given the level of local preparedness and absorptive capacity of the local communities supported by the United Nations Development Programme, potential for the project to be replicated in other communities of the district and region is good.

5. Sustainability

11. The project is designed to achieve sustainable and replicable improvements in the health care delivery system for mothers and children in Rasht district. The sustainability of the project will be safeguarded by the strengthened capacity of target groups. Local communities and trained health specialists will become the driving force for sustainability of project activities. By creating a critical mass of community understanding of health and nutrition issues, the project will help create a demand-driven and client-oriented environment for the local health- care system that would in turn facilitate sustainability of the project outcomes. The indicators set in the feasibility study will be used to measure project success, applicability, and sustainability. The government has confirmed its commitment to ensure use of the framework, material, and guidelines developed under the project for nationwide activities. Lessons from the activities and least-cost methods will be identified for information strategies and community participation in health.

15 The Rasht valley is a significant part of the region under direct republican jurisdiction and includes six districts (Jirgatol, Nurobod, Rasht, Roghun, Tavildara, and Tojikobod).

12. The availability of good access roads in the project area will result in more beneficial economic activities. In particular, agricultural production will expand considerably, leading to an increase in the net income of poor and vulnerable communities as a result of lower production costs and higher prices for agricultural products. The communities will expand the rural coverage of the community-based road maintenance mechanism developed under the JFPR 9078 and 9111 projects. The cash or in-kind contribution will be collected by a local community- based organization and be used solely for O&M. This will secure the minimum financial resources necessary for periodic maintenance. The project will reinforce the participatory community-based maintenance scheme to enhance accountability and strengthen the long-term sustainability of the project outcomes.

6. Participatory Approach

13. The project was designed in a participatory manner. It will be implemented with the participation of communities, jamoat leaders, district administrators, national government ministries, international and local nongovernment organizations, and international development partners working in the project area.

Primary Beneficiaries and Other Affected Other Key Stakeholders and Brief Groups and Relevant Description Description

About 40,000 villagers, particularly the Other key stakeholders and their benefits poorest women of reproductive age, mothers, include and children in five jamoats of Rasht district are expected to benefit from (i) community representatives, community organizations, and community health (i) greater access to basic services, workers; including health care leading to improved health outcomes; (ii) MOT, which will benefit from improved rural road maintenance planning and (ii) improved transport services (i.e., execution, and reduced road asset availability, frequency, reliability, and losses as a result of an established cost); effective local road maintenance mechanism; and (iii) smoother flow of agricultural goods and services across the river and along the (iii) local government, which will benefit road; and from improvements deriving from social and economic development due to (iv) better access to market opportunities improved road infrastructure and health services.

7. Coordination

14. The project is designed in consultation with relevant stakeholders and will complement a number of development projects in the area. The project design promotes consultation among all stakeholders, including MOT, MOH, the Ministry of Finance, local governments, the Embassy of Japan in Tajikistan, JICA, World Health Organization, United Nations Development Programme, United Nations Children’s Fund, World Bank, GIZ, and Global Funds. MOT will provide national coordination of the project and disseminate information on project activities to

13 all project stakeholders and partners through consultation workshops, seminars, and public awareness campaigns.

8. Visibility

15. Due to strong government ownership,16 the project is expected to attract wide public attention and be well covered by local mass media. The project team will ensure that the contribution of Japan in supporting the project is widely recognized. Japan's official development assistance logo and the JFPR logo will be used in publications, training programs, workshops, and any other materials produced under the project. All press releases issued by ADB and local news media for the JFPR project activities will acknowledge the financial contribution of the Government of Japan following the Guidance Note on Visibility of Japan. The Embassy of Japan will be invited to attend project events and ceremonies, including inauguration of the bridge and road opening, turnover of health facilities, and donation of an ambulance to the rural hospital. Behavior change communication activities among the population will promote the visibility and local awareness of the JFPR project. The project will collect videos, photos, and case studies before and during project implementation to show the impact of the project on the communities over time.

16. JICA and the Embassy of Japan have been consulted on the possible funding of the project and the project receives their strong support. The project was approved by the Government of Japan on 12 December 2012.

17. JICA is implementing a project for improving the maternal and child health care system in Khatlon region (southern Tajikistan). The project commenced in March 2012 and will end in March 2016. The project activity will be closely linked with the JICA project and will build on its methods and approach to improve the capacity of health centers to deliver quality MCH service. The international experts working on the JICA project will assist in capacity building and setting up the activity under the health component of the JFPR project.

18. ADB’s Tajikistan Resident Mission will be responsible for coordinating with JICA, the Embassy of Japan, and other international agencies for successful implementation of the project.

9. Detailed Cost Table

19. The total project cost is about $2.933 million equivalent. The government’s contribution to the project is estimated at $386,000 and the community contribution at $47,000. The central government will contribute $350,000 (25% of the total budget) for civil works and, through in- kind support, and cover the cost of office accommodation in Dushanbe ($36,000). The in-kind contribution of the local government will cover the cost of office accommodation at the project site and venue for trainings and seminars. The summary cost table and detailed cost estimates are in Appendix 2. The fund flow arrangement is in Appendix 3.

C. Links to ADB and Government Strategies and ADB-Financed Operations

1. Links to ADB and Government Strategies 20. The ADB country partnership strategy, 2010–2014 for Tajikistan emphasizes ADB’s continuing involvement in the transport sector through investments in domestic and regional

16 In 2009, Tajikistan's President Emomali Rahmon inaugurated the opening of a 30-ton bridge across Surkhob river built under JFPR 9111-TAJ.

14 road links, and includes gender mainstreaming as a core crosscutting theme. The project will also support priorities of the National Development Strategy, 2006–2015 and the Tajikistan Living Standards Improvement Strategy, 2013–2015, which aim to broaden access to basic social services through developing the health-care system, education, water supply, and gender equality.17 The government signed the United Nations Millennium Declaration in 2000 and since then, has undertaken numerous initiatives to achieve the MDGs. The project will contribute to the achievement of MDG 4 (reduce child mortality) and MDG 5 (improve maternal health) in the project area.

Document Date of Last Document Objectives Number Discussion Country IN.327-11 April 2010 Support developing energy and transport partnership infrastructure and reforms strategy, 2010–2014 Crosscutting themes include regional cooperation, capacity building and governance, especially public financial management, procurement, and anticorruption activities, climate change and the environment, and gender mainstreaming

Country November Consistent with the country partnership operations 2012 strategy, 2010–2014. business plan, 2013– 2014

Tajikistan December Aims to broaden access to basic social living 2012 services through the development of the standards health-care system, education, science, water improvement supply, sanitation, housing, gender equality, strategy, and ecological stability 2013–2015 Focuses on energy security, transport infrastructure, agro-industry, logistics, and trade

Tajikistan’s March 2007 The third goal of the strategy focuses on national developing human potential aiming primarily at development increasing the scope and quality of social strategy, services for the poor and achieving the MDGs, 2006–2015 expanding public participation in the development process, and strengthening social partnerships

17 Government of Tajikistan. 2010. Poverty Reduction Strategy of the Republic of Tajikistan for 2010-2012. Dushanbe.

Document Date of Last Document Objectives Number Discussion National May 2010 Strengthen public governance in health; health improve quality, universality, and strategy of the nondiscriminatory access of health care; Republic of develop health sector resources and financing Tajikistan, 2010–2020

2. Link to Specific ADB-Financed Operation

21. The project builds on ADB’s road investments in Tajikistan that connect rural communities to main road arteries of CAREC corridors 3 and 5 rehabilitated under the ADB- funded Dushanbe–Kyrgyz Border Road Rehabilitation Project (Phase 2) and the CAREC Regional Road Corridor Improvement Project. By supporting the linkage to the improved transport corridors, the project would contribute to poverty reduction and socioeconomic development in the project areas as it will improve access of the rural population to livelihood opportunities and basic social services, reduce travel time, and make essential trips safer. By securing better access to health facilities, the restored road connection will particularly contribute to improved health outcomes for women and children.

Project Name Loan 2196-TAJ/Grant 0154 -TAJ: Dushanbe–Kyrgyz Border Road Rehabilitation Project (Phase 2)

Project Number 38236

Date of Board Approval 17 November 2005 (Loan 2196-TAJ[SF]) 24 July 2009 (Grant 0154-TAJ)

Loan Amount ($ million) 31.7 (ADF Loan) 20.0 (ADF Grant)

Project Name Loan 2359-TAJ/Grant 0085-TAJ: CAREC Regional Road Corridor Improvement Project

Project Number 39676

Date of Board Approval 24 October 2007

Loan Amount ($ million) 40.9 (ADF Loan) 12.5 (ADF Grant)

3. The Above-Mentioned Project’s Development Objective

22. ADB operations in the transport sector have targeted rehabilitation of a key regional transport corridor linking Tajikistan to the Kyrgyz Republic and onward to the People’s Republic of China. The corridor will provide the primary link between Dushanbe and the Rasht valley to the northeast in the Regions of Republican Subordination. Phase 1 of the Dushanbe–Kyrgyz

Border Road Rehabilitation Project was approved in November 2003 18 and phase 2 in November 2005. The CAREC Regional Road Corridor Improvement Project, approved in November 2007, completes the final section of the entire route, which is expected to increase the impact on economic cooperation and trade facilitation. The objective of the rehabilitation of the regional transport corridor is to (i) reduce poverty by decreasing the cost of transport and improving access to markets; and (ii) increase regional trade and cooperation by rehabilitating the road linking Dushanbe to Rasht Valley and on to the Kyrgyz Republic and the People’s Republic of China. ADB’s projects will (i) reduce transport costs on the Dushanbe–Kyrgyz border road; (ii) provide agricultural and industrial enterprises with all-weather access to markets within and outside the country; (iii) improve access for the poor rural population to markets, other economic activities, and social services by improving rural roads; and (iv) strengthen the government’s institutional capacity for efficiently managing the road network.

4. List the Main Components of the Associated ADB-Financed Operation No. Component Name Brief Description 1. Civil works Improvement of 236 km of the Dushanbe–Kyrgyz border road (mostly two-lane highway)

2. Consulting services Consulting services for construction supervision, monitoring, and evaluation, and the implementation of measures to improve road safety, auditing, and project management

3. Procurement Procurement of maintenance equipment for use for routine and periodic maintenance of the improved road sections

5. Rationale for Grant Funding Versus ADB Lending

23. In view of the debt sustainability issue, Tajikistan is currently eligible only to receive grants from the Asian Development Fund. The government has restricted its borrowing to a minimum and mainly for infrastructure and other sectors with higher economic returns. It is seeking grant financing for social sector projects. ADB operations in the transport sector focus mainly on rehabilitating key regional transport corridors, while the proposed JFPR grant will help the government support rural communities, particularly women in the poorest areas— representing the most vulnerable part of the society—to improve their health conditions through improved connectivity to regional corridors, particularly CAREC corridors 3 and 5.

D. Implementation of the Proposed Grant

Ministry of Transport, through the Project 1. Implementing Agency Implementation Unit

24. MOT will be the executing agency. The existing PIU, which has been implementing all ADB-funded road projects, will implement the project. It will be strengthened with additional staff

18 ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Technical Assistance Grant to the Republic of Tajikistan for the Dushanbe–Kyrgyz Border Road Rehabilitation Project (Phase 1). Manila (Loan 2062-TAJ).

17 to ensure proper coordination of the project interventions. The PIU will coordinate implementation of component B with MOH and JICA. All procurement under the project will be conducted in accordance with ADB’s Procurement Guidelines (2010, as amended from time to time). Individual consultants and the external auditor will be contracted in accordance with ADB’s Guidelines on the Use of Consultants (2010, as amended from time to time). Appendixes 4 and 6 provide details on the implementation arrangements and schedule.

2. Risks Affecting Grant Implementation

Type of Risk Brief Description Measure to Mitigate the Risk Limited sense of The Tajik population has a poor Effective information strategies responsibility sense of responsibility for personal will be elaborated to respond to among health. this risk. the population Inadequate Insufficient capacity for rural Capacity development of rural maintenance infrastructure maintenance and communities and local inadequate financial and government officials will ensure nonfinancial resources can result in minimum maintenance. a lack of periodic maintenance of bridges and rural roads. Risk of flooding The risk of flooding that could The detailed design for damage or destroy the bridge is rehabilitation of the bridge will relatively high in the project area. include measures to minimize the impact of flooding through repair or replacement of the railings, barriers, bridge decks, piers, and abutments.

3. Incremental ADB Costs

Component Incremental ADB Cost Amount requested $0 Justification Not applicable Type of work to be rendered by ADB Not applicable

4. Monitoring and Evaluation

Plan and Timetable for Key Performance Indicator Reporting Mechanism M&E Travel time to health-care (i) Baseline and end-line (i) Quarterly progress facilities reduced in the project survey reports produced reports by the PIU and area by 30% relative to 2012 by the PIU and consultants baseline data consultants (ii) Annual M&E report by (ii) Project progress reports the PIU and consultants produced by the PIU (iii) Semiannual field visit and consultants and site inspection by (iii) End of project ADB evaluation report by the

PIU The number of families (i) Baseline and end-line (i) Baseline and annual practicing IMCI in five targeted survey reports produced M&E report by the PIU jamoats increased by 30% by the PIU and and consultants relative to 2012 baseline data consultants (ii) Quarterly progress (ii) Local government reports by the PIU statistics (iii) Completion report

(iii) Project progress reports produced by the PIU and consultants (iv) End of project evaluation report by the PIU Percentage of births at health (i) Local government (i) Baseline and annual facilities increased from 45% in statistics M&E report by the PIU June 2012 to 70% by January (ii) Project progress reports and consultants 2015 in five targeted jamoats produced by the PIU (ii) Quarterly progress and consultants reports by the PIU (iii) End of project (iii) Completion report

evaluation report by the PIU Percentage of women of five (i) Local government (i) Baseline and annual targeted jamoats completing the statistics M&E report by the PIU required number of prenatal (ii) Project progress reports and consultants visits increased from 20% in produced by the PIU (ii) Quarterly progress June 2012 to 50% by January and consultants reports by the PIU 2016 (iii) End of project (iii) Completion report evaluation report by the PIU The number of women practicing (i) Local government (i) Baseline and annual exclusive breastfeeding for statistics M&E report by the PIU 6 months in five targeted (ii) Project progress reports and consultants jamoats increased from 45% in produced by the PIU (ii) Quarterly progress June 2012 to 60% by January and consultants reports by the PIU 2016 (iii) End of project (iii) Completion report evaluation report by the PIU

5. Estimated Disbursement Schedule

Fiscal Year (FY) Amount ($) FY2013 700,000 FY2014 1,200,000 FY2015 550,000 FY2016 50,000 Total Disbursements 2,500,000 ------

Appendixes

1. Design and Monitoring Framework 2. Summary and Detailed Cost Estimates 3. Fund Flow Arrangement 4. Implementation Arrangements 5. Procurement Plan 6. Implementation Schedule 7. Summary Poverty Reduction and Social Strategy

20 Appendix 1

DESIGN AND MONITORING FRAMEWORK

Data Sources and Design Performance Targets and Reporting Assumptions Summary Indicators with Baselinesa Mechanisms and Risks Impact Assumptions Improved child By June 2019, maternal mortality State government Continued and maternal rates decreased in the project statistics; statistics support by the health results in areas by 15% relative to 2011 data department of the government, five isolated Rasht district local authorities, jamoats in central hospital NGOs, and Rasht district communities By June 2019, child mortality rates End of project decreased in the project areas by evaluation report by Risks 10% relative to 2011 data the PIU Political instability and By June 2019, household income Millennium security situation increased in the project area by Development Goal 10% relative to 2012 baseline data indicator review and assessment

Outcome Assumptions Improved By January 2016, travel time to Baseline and end- Support from access of the health care facilities reduced in the line survey reports local authorities marginalized project area by 30% relative to produced by the and communities rural poor in five 2012 baseline data PIU and jamoats in consultants Adequate Rasht district to By January 2016, the number of financing strengthened families practicing IMCI in five Project progress available for health services. targeted jamoats increased by 30% reports produced maintenance of relative to 2012 baseline data by the PIU and road and bridge consultants Births at health facilities increased from 45% in June 2012 to 70% by End of project January 2016 in five targeted evaluation report by jamoats the PIU

Number of women of five targeted Local government jamoats completing the required statistics number of prenatal visits increased from 20% in June 2012 to 50% by January 2016

Number of women practicing exclusive breastfeeding for 6 months in five targeted jamoats increased from 45% in June 2012 to 60% by January 2016

Appendix 1 21

Data Sources and Design Performance Targets and Reporting Assumptions Summary Indicators with Baselinesa Mechanisms and Risks Outputs Assumptions 1. 58 By June 2015, 66-meter bridge Project progress Support from communities over the Sarbog river rehabilitated reports produced local authorities in Rasht by the PIU and and communities valley have By June 2015, 18 km of rural road consultants improved from the bridge to the Rasht district access to center access road improved End of project transport and evaluation report by social facilities Five rural communities provided the PIU with basic knowledge, skills, and equipment for conducting day-to- day infrastructure maintenance and minor repair works by June 2015

2. Targeted By June 2014, 90% of health Project progress communities workers in the health facilities of reports produced effectively use the target area updated on IMCI by the PIU and health consultants services and By June 2014, 90% of health nutrition workers provided with training on End of project practices obstetric and infant care evaluation report by the PIU By June 2015, 20,000 residents of the target area covered by the public information campaign to improve household health behavior

By March 2014, rural health centers in five jamoats provided with basic essential medical equipment

By February 2014, rural hospital in Navobod equipped with a safe and operating ambulance, and 75% of emergencies reported in the rural health centers referred to a central hospital

3. Effective Quarterly and annual reports on Project progress project project implementation as well as reports produced management, semiannual environmental by the PIU and monitoring monitoring reports, acceptable to consultants and ADB, prepared and submitted evaluation of within 45 days after the end of each End of project results related fiscal year evaluation report by the PIU

22 Appendix 1

Data Sources and Design Performance Targets and Reporting Assumptions Summary Indicators with Baselinesa Mechanisms and Risks The government’s grant completion report, acceptable to ADB, received Annual audit within three (3) months of physical reports completion of the project

Acceptable audited annual financial statements for the project (audit report and management letter) received by ADB no later than six (6) months after the end of each related fiscal year

Activities with Milestones Inputs 1.1 Improvement of 18 km of rural road from the bridge (Navobod town) to JFPR grant: the Rasht district center $2,500,000 1.1.1 Civil works contract awarded by August 2013 1.1.2 Civil works completed by June 2015 Government: 1.2 Rehabilitation of bridge over Sarbog river $386,000 1.2.1 Civil works contract awarded by August 2013 1.2.2 Civil works completed by June 2015 Communities: 1.3 Fostering community-based maintenance practices $47,000 1.3.1 Representatives of local governments, small contractors, and rural communities trained on bridge and road maintenance by October 2014 1.3.2 Establishment of VIMFs by February 2015 1.3.3 Essential safety and road maintenance tools procured and delivered to road associations by June 2015 2.1 Improve capacity of health centers to deliver quality MCH and nutrition services 2.1.1 Assessment of the training needs of health workers, conducted by August 2013 2.1.2 Training programs for health workers on obstetric and infant care and IMCI designed and delivered (design by December 2013, delivery by June 2014) 2.1.3 Basic essential medical equipment provided to the health medical facilities (study by October 2013, delivery by March 2014) 2.1.4 Basic renovation provided to the health facilities (needs assessment by January 2014, delivery by September 2015) 2.2 Facilitate behavior change among individuals and communities for better health outcomes 2.2.1 Assessment of current practices, beliefs, and perceptions for awareness-raising activities, conducted by September 2013 2.2.2 Behavior change communication activities developed and implemented (design by December 2013, delivery by January 2016)

Appendix 1 23

Activities with Milestones Inputs 2.3 Establish a responsive emergency referral system and transportation 2.3.1 Purchase of new ambulance by February 2014 2.3.2 Effective referral system with responsive ambulance service functioning by March 2014 3.1 Effective monitoring and evaluation of results 3.1.1 Baseline data on a set of quantitative and qualitative indicators collected and analyzed by August 2013 3.1.2 Midterm evaluation survey conducted by September 2014 3.1.3 An independent audit timely conducted (annually) 3.1.4 Final evaluation survey conducted by December 2015 3.1.5 Project completion report submitted by February 2016 IMCI = integrated management of childhood illnesses, JFPR = Japan Fund for Poverty Reduction, NGO = nongovernment organization, PIU = project implementation unit, VIMF = village infrastructure maintenance fund. a The “baseline data” and “target” for birth attendance, IMCI practicing, UMR, breastfeeding, visits to the health facilities, in the project area to be firmed up during Inception Mission. Source: Asian Development Bank.

SUMMARY AND DETAILED COST ESTIMATES 24 Appendix 2 Table A2.1: Summary Cost Estimate ($)

Component A. Improved and Grant Components sustainable access for Component B. Component C. isolated communities Improved and increased Project management,

Inputs / Expenditure through bridge and rural use of health services monitoring, and Total Category road rehabilitation and nutrition practices evaluation ($) Percent 1. Civil works (road and bridge rehabilitation, 1,350,000 50,000 0 1,400,000 56.0 as well as renovation of health facilities) 2. Equipment and supplies (safety tools, equipment and protective clothing; new 10,000 120,000 1,900 131,900 5.3 ambulance and essential medical equipment, PIU office equipment) 3. Training, workshops, seminars, and public campaigns (food for participants, IEC, training 5,500 71,200 0 76,700 3.1 materials, and other related costs) 4. Consulting services (detailed design, technical advisor, health, M&E, environmental and training experts and other technical 100,000 230,550 187,680 518,230 20.7 specialists, including related costs such as travel, accommodation and per diem; external auditors, etc.) 5. Grant management (management of the specific components and of the PIU, including 0 0 128,800 128,800 5.1 wages for project staff, travel costs and per diem, O&M, and recurrent costs, etc.) 6. Contingencies (0-10% of total estimated grant fund). Use of contingencies requires 244,370 9.8 prior approval from ADB. Subtotal JFPR Grant Financed 1,465,500 471,750 318,380 2,500,000 100.0 Government contribution (part of civil works, 350,000 0 36,000 386,000 provision of project office in MOT) Community's contribution (provision of project office at project site; accommodation and/or 1,000 10,000 36,000 47,000 venue for the trainings) Total Estimated Costs 1,816,500 481,750 390,380 2,933,000 ADB = Asian Development Bank, IEC = information, education, and communication, JFPR = Japan Fund for Poverty Reduction, M&E = monitoring and evaluation, MOT = Ministry of Transport, O&M = operation and maintenance, PIU = project implementation unit. Source: Asian Development Bank.

25 Appendix 2

1,000 1,000 nities (in-kind) (in-kind) Commu- Other Donors ment ment Govern

rement rement Method Method of procu- JFPR Amount

unit Total Total unit Subtotal 1,816,500 1,465,500 350,000 0 1,000 Subtotal 481,750 471,750 0 0 0 10,000 Cost per

Costs Contributions

3 500 3 1,500 1,500 8 1,200 8 9,600 9,600 1,7008 13,600 13,600 2,000 4 8,000 8,000 10 100 1,000 10 300 3,000 3,000 10 300 3,000 3,000 units Quantity Quantity

10,000 10,000 10,000

km 18 72,222 1,300,000 1,032,353 267,647 per per per per per per Unit meter meter 66 6,061 400,000 317,647 82,353 of IEC copies 100 10 1,000 1,000 workshop workshop workshop workshop workshop TableA2.2: Detailed Cost Estimate ($) es’ contribution)es’

a clothing clothing over Sarbog river river Sarbog over center district Rasht the with communities (communiti trainings workshop, two per sub-district) two workshop, sustainability sustainability manual (venue to be provided by local local by provided to be (venue government) (four workshops X 15-20 participants X 3 X(four workshops X 15-20 participants times) 2 X days X 2 times) days X 7 participants participants) 15-20 Supplies and Services Rendered Services andSupplies 1.3.1 and protective equipment tools, Safety 1.1.1 bridge 66-meter existing Rehabilitation an of 1.1.2 58 connecting road km of 18 Improvement 1.2.4 the venue for and/or Accommodation 1.4.1 Design Detailed LS 100,000 100,000 1.2.1 Orientation workshop (40-50participants per 1.2.2 materials workshop IEC and kind per 1.2.3 maintenance of the rural road Replication 2.1.1 2.1.1 care infant and obstetric on Training 2.1.2 workshops X 15-20 IMCI (four on Training 2.1.3 X each days 5 workshops (four training ToT 1.3 Equipment supplies and

works foraccess and Component Improved sustainable A. communitiesisolated andbridge through road rural rehabilitation 1.1 Civil 1.4 Consulting service service 1.4 Consulting 1.2 Trainingworkshops and for infrastructure 2.1 workshops, and seminars Training, Component B. Improved and increased use of health and use Component Improved increased B. services and nutrition practices

Costs Contributions 26 JFPR Appendix 2 Method Commu- Quantity Cost per of procu- Govern Other nities Supplies and Services Rendered Unit units unit Total Amount rement ment Donors (in-kind) 2.1.4 Behavior change campaign (IEC materials, 30,000 30,000 public and media events) 2.1.5 Training materials (development and 10,000 10,000

printing) 2.1.6 Accommodation and/or venue for the per 20 500 10,000 10,000 trainings (communities’ contribution) workshop 2.2 Health facilities infrastructure 2.2.1 Basic essential medical equipment, furniture, number 60,000 60,000 and tools 2.2.2 Basic renovation to the health facilities number 50,000 50,000 2.2.3 Purchase of the new ambulance number 1 60,000 60,000 60,000 2.3 Consulting service (international) 2.3.1 Remuneration (Technical advisor) Months 3 25,000 75,000 75,000 2.3.2 Per-diem Months 3 6,000 18,000 18,000 2.3.3 International air travel numbers 3 8,000 24,000 24,000 2.3.4 Misc. travel expenses trips 3 250 750 750 2.3.5 Communications (phone, internet, and months 3 200 600 600 courier) 2.3.6 Translator (incl. per diem in the field) months 3 1,000 3,000 3,000 2.4 Consulting service (national) 2.4.1 Remuneration (health coordinator) months 36 2,400 86,400 86,400 2.4.2 Per diem days' 180 50 9,000 9,000 2.4.3 Communications months 36 50 1,800 1,800 2.4.4 Trainers for provision of trainings to health person- 120 100 12,000 12,000 workers days Component C. Project management, monitoring and Subtotal 390,380 318,380 0 36,000 0 36,000 evaluation 3.1 Equipment and supplies (PIU) 3.1.1 Telephone, telefax machine number 1 200 200 200 3.1.2 Computer, printer, UPS number 1 1,200 1,200 1,200 3.1.3 Scanner and/or copying machine number 1 500 500 500 3.1.4 Office running costs (such as paper, toner, months 36 200 7,200 7,200 small equipment, computer service, cleaning services) 3.1.5 Communication costs (including telephone months 36 200 7,200 7,200 internet)

27 Appendix 2

nities (in-kind) (in-kind) Commu- Other Donors ment ment Govern sses, JFPR Fund = Japan sses,

rement rement Method Method of procu- JFPR Amount 244,370 244,370 0 0

Integrated Management of Childhood Illne of Childhood Management Integrated unit Total Total unit Cost per Costs Contributions

3 4,000 12,000 12,000 4,0003 12,000 12,000 1 6,000 6,000 6,000 6,000 1 6,000 6,000 units Quantity Quantity

Unit month month month month months 36 1,000 36,000 1,000 months 36 36,000 1,000 months 36 36,000 36,000 36,000 months 36 2,900 104,400 104,400 104,400 2,900 104,400 months 36 person- person- o-rate basis (ADB - 79.41% and the Government - 20.59%). Government - 20.59%). the and 79.41% (ADB - basis o-rate project implementation unit, ToT = training of ToT trainers unit,project implementation training = n, education, and communication,and IMCIn, education, = T Dushanbe (government ect site (communities’ ect site (communities’ environmental and ex-post and environmental in-kind contribution)in-kind contribution) contribution) under both components) both under environmental aspectsincluding JFPR contribution) TOTAL grantcosts TOTAL Total 2,933,000 2,500,000 0 386,000 0 47,000 Supplies and Services Rendered Services andSupplies 3.2.6 Final workshop 3.2.7 consultants Per diem for local days 270 day 50 1 13,500 3,000 13,500 3,000 3,000 3.2.8 consultants local for Communications months 39 20 780 780 3.2.5 and including evaluation Monitoring 3.3.7 - MO Office rent 3.3.1 Engineer 3.3.1 Engineer 3.3.2 and translator Secretary 3.3.3 Accountant 3.3.4 vehicle hire / or and transport Land 3.3.5 Per diem for PIU staff 3.3.6 - proj Office rent months months 36 1,300 36 months months days 28 46,800 400 36 240 700 46,800 600 14,400 19,600 21,600 50 14,400 19,600 21,600 12,000 12,000 3.2.1 3.2.1 (project supervision manager project Local expert 3.2.2 Environmental 3.2.3 audit (3 years) External 3.2.4 andsurvey Baseline impact assessment months 3 number 1,000 3 3,000 15,000 3,000 45,000 45,000 The disbursement for the Civil work category will be pr TheCivilon will be disbursement category for the work 3.3 Project Management 3.3 Project tosubtotal C = A Components of total (maximum 10% Contingency Subtotal 2,688,630 2,255,630 0 386,000 0 47,000

for Poverty Reduction, MOT = Ministry of Transport, PIU = of Transport, Ministry Reduction,for Poverty = MOT 3.2 Consulting service service 3.2 Consulting ADB = Asian Development Bank, IEC = informatio Bank. Development Source: Asian a

28 Appendix 3

FUND FLOW ARRANGEMENTS FOR THE JAPAN FUND FOR POVERTY REDUCTION GRANT

1. The Asian Development Bank (ADB) will channel the Japan Fund for Poverty Reduction (JFPR) grant directly to a JFPR imprest account, which will be established, managed, replenished, and liquidated by the project implementation unit (PIU) in accordance with ADB’s Loan Disbursement Handbook (2012, as amended from time to time) and detailed arrangements agreed upon between the Government of Tajikistan and ADB. The PIU will inform the Ministry of Transport, the executing agency, and the Ministry of Finance of all transactions, and provide them with copies of all financial statements and audit reports.

2. The PIU will adopt an imprest fund procedure, wherein ADB makes an advance disbursement from the grant account for deposit to an imprest account at a commercial bank acceptable to ADB, to be used exclusively for ADB’s share of eligible expenditures. The maximum ceiling of the imprest accounts will be set at 10% of the JFPR grant amount. The imprest account will be US dollar. The government may request that initial and additional advances to the imprest account be based on 6-months estimated expenditures be financed through the imprest account. The statement of expenditures (SOE) procedure may be used for reimbursement of eligible expenditures and to liquidate advances provided into the imprest account, provided that each individual payment does not exceed the equivalent of $5,000. The payments in excess of the SOE ceiling will be replenished based on full supporting documentation.

3. Detailed implementation arrangements, such as the flow, replenishment, and administrative procedures, will be specified in the grant administration memorandum and established through the JFPR letter of agreement. Furthermore, the PIU will (i) maintain separate accounts and records for the project financed by the JFPR grant; (ii) prepare annual financial statements for the project financed by the JFPR grant in accordance with accounting principles acceptable to ADB; (iii) have such financial statements audited annually by independent auditors whose qualifications, experience, and terms of reference are acceptable to ADB, in accordance with international standards for auditing or the national equivalent acceptable to ADB; (iv) as part of each such audit, have the auditors prepare a report (which includes the auditors’ opinion on the use of the JFPR grant proceeds and compliance with financial covenants (if any) as well as on the use of the procedures for the imprest account and statement of expenditures) and a management letter (which sets out the deficiencies in the internal control of the project identified in the course of the audit, if any); and (v) provide to ADB, no later than 6 months after the end of each related fiscal year, copies of such audited financial statements, audit report, and management letter, all in the English language, and such other information concerning these documents and the audit thereof as ADB shall from time-to-time reasonably request. The direct payment procedure will be used for payment to the civil work contractor(s) and international technical advisor.

4. The schematic funds flow arrangements are shown in Figure A3.

Appendix 3 29

Figure A3. Fund flow arrangements for JFPR funds

Asian Development

Bank

Civil work contracts for $1,350,000 $121,350 Consulting services road and bridge (international, technical rehabilitation $1,028,650 advisor)

Grant imprest account held at Project Implementation Unit (PIU)

Component A: Improved Component C: and sustainable access $115,500 $318,380 Project management,

for isolated communities monitoring and through bridge and rural evaluation road rehabilitation

Component B: Improved and increased use of $350,400 $244,370

health services and Contingencies nutrition practices in the targeted communities

Source: Asian Development Bank.

30 Appendix 4

IMPLEMENTATION ARRANGEMENTS

1. Executing agency. The Ministry of Transport (MOT), the executing agency for the project, will work closely with the Ministry of Health (MOH), local government, and the Japan International Cooperation Agency (JICA). MOT will assume responsibility for overall project management and oversight. The existing project implementation unit (PIU), established under previous and implementing ongoing transport projects, will be responsible for implementation of component A. The PIU will also coordinate with MOH and JICA in implementing component B. The Maternal and Child Health Department of MOH will be responsible for providing technical support and advice on the health component.

2. The project will finance additional staff and equipment to supplement existing PIU resources for implementing the project. The additional staffing will consist of a project engineer, an accountant, and a secretary and translator.

3. A local project manager will be engaged to (i) supervise project implementation, (ii) assess social and poverty impacts, and (iii) administer the project, including reporting to ADB and the government. The project manager, who will report to the PIU’s executive director, will be supported by a short-term local expert(s) for a baseline survey, environmental impact, and monitoring and evaluation activities. The PIU will recruit a local health coordinator to support implementation of the health component. In addition, an international health advisor for improving the maternal and child health care system will support implementation of health- related outputs of the project.

4. Implementation schedule. The project will be implemented over 3 years, tentatively from March 2013 to March 2016. It will include end-line surveys to evaluate the project outputs and outcome. The project preparation activities will be completed by the end of April 2013. These will include preparing the grant implementation memorandum, appointing and mobilizing the JFPR project manager and support staff, and engaging consultants for the health component and monitoring and evaluation activities, including baseline survey and impact evaluation, and implementation of the initial environmental examination plan. The detailed implementation schedule is in Appendix 6.

5. Procurement. Procurement under the project will be conducted in accordance with the Asian Development Bank (ADB) Procurement Guidelines (2010, as amended from time to time). Procurement of civil works will follow (i) international competitive bidding (ICB) procedure for bridge rehabilitation and/or road improvement contract that exceeds ICB threshold indicated in the procurement plan, and (ii) national competitive bidding (NCB) procedure for renovation of health facilities contract, a value of which meets the NCB threshold in the procurement plan (Appendix 5). The shopping method will be used for procuring contracts less than the threshold indicated in the procurement plan for basic essential medical equipment, furniture, tools, new ambulance, and small-valued items, including office furniture; while the direct purchase method will be used for procuring contracts below $10,000 for safety tools, equipment, and protective clothing. Local consulting firms will be engaged for printing information, education, and communication materials using a national short-listing given the small contracts estimated at $10,000–$20,000.1

1 If foreign firms express interest, they shall be also considered. A selection by national short-listing follows the same procedures as required under ordinary international short-listing except country balance and geographic spread.

Appendix 4 31

6. MOT will recruit all consultants under the project in consultation with ADB according to ADB’s Guidelines on the Use of Consultants (2010, as amended from time to time). Individual international and national experts are expected to be hired for the positions of project manager (national, 36 person-months), technical advisor (international, 3 person-months), health coordinator (national, 36 person-months), environmental expert (national, 3 person-months), baseline survey and impact assessment, and monitoring and evaluation (4 person-months). MOT will recruit the independent external auditor using the consultants’ qualifications selection (CQS) procedure subject to the contract value which is within $200,000.

7. The JFPR project activities will build on methods and approaches developed by the ongoing Japan International Cooperation Agency (JICA) project for improving the capacity of health centers to deliver quality maternal and child health services. The international experts working on the JICA project will assist in capacity building and carrying out the activities of the health component of the JFPR project. In particular, the team leader of the JICA project will be engaged under the JFPR project as a health technical advisor using the single-source selection method.2

8. Flow of funds. Flow of funds arrangements are summarized in Appendix 3. To facilitate disbursements, the PIU will establish an imprest account in a commercial bank acceptable to ADB. The PIU will manage the account and be authorized to sign withdrawal applications. The imprest account will be established, managed, replenished, and liquidated according to ADB’s Loan Disbursement Handbook (2012, as amended from time to time). The maximum ceiling of the imprest accounts will be set at 10% of the JFPR grant amount. The currency of the imprest account will be US dollars. The government may request that initial and additional advances to the imprest account based on 6-months estimated expenditures be financed through the imprest account. Interest earned on the imprest account can be used for the project, subject to ADB approval, within the approved total amount of the grant. Upon project completion and before the imprest account is closed, any unused interest should be returned to the JFPR fund account maintained at ADB if the remittance fee and other bank charges do not exceed the interest earned. The statement-of-expenditures procedure may be used for the reimbursement of eligible expenditures and the liquidation of advances made to the imprest account for individual payment transactions not exceeding the equivalent of $5,000. Payments in excess of this ceiling will be replenished on the basis of full supporting documentation. The direct payment procedure will be used for payment to the civil works contractor(s) and international technical advisor. The existing PIU is experienced in implementing externally aided projects and has sufficient financial management capacity to establish adequate accounting procedures and controls to efficiently administer the grant.

9. Reporting. The project manager will prepare inception report, quarterly and annual reports on project implementation, as well as semiannual environmental monitoring reports, the form and content of which will be agreed with ADB. MOT, through the PIU, will officially endorse these reports to ADB with its comments. To facilitate project evaluation, the government agreed to provide a grant completion report, prepared with the support of the project manager, to ADB within 3 months of physical completion of the project. All reports will comprise an assessment of the project’s social and poverty impact and outputs, benefit monitoring, and recommendations for improving implementation.

2 The consultant proposed for single-source selection was selected by JICA on a competitive basis, and the price has been competitively established. The proposed expert was cleared for performance evaluation/sanction and eligibility.

32 Appendix 4

10. Monitoring and evaluation. A preliminary set of indicators for monitoring and evaluating project performance was agreed with MOT and MOH during project preparation. The grant implementation manual will include details of these indicators. At the beginning of project implementation, the project manager with the help of baseline survey and impact assessment expert will collect and confirm baseline indicators for social and poverty reduction impacts. The project manager will be responsible for monitoring project indicators during project implementation. MOT and the PIU will incorporate the suggestions and recommendations on project indicators and update in quarterly reports to ADB. The indicators for project evaluation will be measured at project completion. Gender-disaggregated data will be collected in the project area. MOT will also be engaged in monitoring and evaluation as it has accumulated sufficient experience in project monitoring through various ADB projects.

Appendix 5 33

PROCUREMENT PLAN

Basic Data

Project Name: Improved Maternal and Child Health through Connectivity Country: Tajikistan Executing Agency: Ministry of Transport Grant Amount: $2,500,000 Grant Number: ______Date of First Procurement Plan: This is Date of this Procurement Plan: 4 October the first procurement plan 2012

A. Process Thresholds, Review, and 18-Month Procurement Plan

1. Project Procurement Thresholds

1. Except as the Asian Development Bank (ADB) may otherwise agree, the following process thresholds shall apply to procurement of goods and works.

Procurement of Goods and Works Method Threshold

International Competitive Bidding (ICB) for Works $1,000,000 and above National Competitive Bidding (NCB) for Works Beneath that stated for ICB, Works

Shopping for Goods Below $100,000

2. ADB Prior or Post Review

2. Except as ADB may otherwise agree, the following prior or post review requirements apply to the various procurement and consultant recruitment methods used for the project.

Procurement Method Prior or Post Comments Procurement of Goods and Works ICB Works Prior NCB Works Prior

Shopping for Goods Prior Recruitment of Consulting Firms Consultants Qualification Selection (CQS) Prior

Recruitment of Individual Consultants Individual Consultants Prior

Note: A local consulting firm for printing of information, education, and communication materials will be engaged using a national short-listing given the small contracts estimated at $10,000–$20,000. However, if foreign firms express interest they will also be considered.

34 Appendix 5

3. Goods and Works Contracts Estimated to Cost More Than $1 Million

3. The following table lists goods and works contracts for which procurement activity is either ongoing or expected to commence within the next 18 months.

Advertisement General Contract Procurement Prequalification Date Description Value Method of Bidders (y/n) (quarter/year) Comments

Civil works $1.7 ICB No Q1 2013 Prior review for million1 rehabilitatio n of 66- meter bridge and improvemen t of 18 km road

1 Including $0.35 million government counterpart financing.

4. Consulting Services Contracts Estimated to Cost More Than $100,000

4. The following table lists consulting services contracts for which procurement activity is either ongoing or expected to commence within the next 18 months.

Advertisement International General Contract Recruitment Date or National Description Value Method (quarter/year) Assignment Comments

Health $0.12 SSS International The expert will technical million provide 3 advisor person-months input over 3 years

Local project $0.12 Individual Q1 2013 National Prior review manager million

National $0.11 Individual Q1 2013 National Prior review health million coordinator

Appendix 5 35

5. Goods and Works Contracts Estimated to Cost Less than $1 Million and Consulting Services Contracts Less than $100,000

5. The following table groups smaller-value goods, works and consulting services contracts for which procurement activity is either ongoing or expected to commence within the next 18 months.

Value of Procurement / General Contract Number of Recruitment Description (cumulative) Contracts Method1 Comments

Basic renovation to $50,000 1–5 NCB Prior review the health facilities

Procurement of basic $60,000 1 Shopping Prior review essential medical equipment, furniture, tools

Purchase of new $60,000 1 Shopping Prior review ambulance

Auditing services $15,000 1 CQS BTP

BTP = biodata technical proposal, CQS = consultants’ qualifications selection, NCB = national competitive bidding. Note: National consulting companies and individuals may be engaged in accordance with ADB guidelines to provide short-term specialist consulting support to the project implementation unit.

B. Indicative List of Packages Required Under the Project

6. The following table provides an indicative list of all procurement (goods, works, and consulting services) over the life of the project. Contracts financed by the government and others should also be indicated, with an appropriate notation in the comments section.

Estimated Estimated Domestic General Value Number of Procurement Preference Description (cumulative) Contracts Method Applicable Comments

Goods Procurement of $60,000 1 Shopping Prior basic essential review medical equipment, furniture, tools

Purchase of new $60,000 1 Shopping Prior ambulance review

Safety tools, $10,000 1 Direct Post equipment, and purchase 1 review protective clothing

36 Appendix 5

Works Civil works for $1,700,000 2 1 ICB Prior rehabilitation of 66- review meter bridge and improvement of 18 km road

Basic renovation to $50,000 1–5 NCB Prior the health facilities review

Estimated Estimated General Value Number of Recruitment Type of Description (cumulative) Contracts Method Proposal Comments

Consulting Services

International health $121,350 1 Individual Prior technical advisor (SSS) review

The expert will provide 3 person- months input over 3 years

National local project $120,000 1 Individual Prior manager review

National health $109,200 1 Individual Prior coordinator review

Environmental $3,000 1 Individual Prior expert review

Baseline survey and $6,000 1 Individual Prior impact assessment review expert

Monitoring and $12,000 1 Individual Prior evaluation expert review

Auditing services $45,000 3 CQS Biodata Annual technical service proposal

1 A contract value for safety tools, equipment and protective clothing or for any other procurement for direct purchase shall be below $10,000. 2 Including $350,000 government counterpart financing.

Appendix 5 37

C. National Competitive Bidding

1. General

7. The procedures to be followed for national competitive bidding shall be those set forth in Law of the Republic of Tajikistan on Public Procurement of Goods, Works and Services effective on 3 March 2006 with the clarifications and modifications described in the following paragraphs required for compliance with the provisions of ADB’s Procurement Guidelines (2010, as amended from time to time). 2. Eligibility

8. The eligibility of bidders shall be as defined under section I of ADB's Procurement Guidelines (2010, as amended from time to time); accordingly, no bidder or potential bidder should be declared ineligible to ADB-financed contracts for other reasons than the ones provided by section I of ADB’s guidelines. Bidders must be nationals of member countries of ADB, and offered goods, works, and services must be produced in and supplied from member countries of ADB.

3. Prequalification

9. Normally, postqualification shall be used unless explicitly provided for in the loan agreement and/or procurement plan. Irrespective of whether postqualification or prequalification is used, eligible bidders (both national and international) shall be allowed to participate.

4. Bidding Period

10. The minimum bidding period is 28 days prior to the deadline for the submission of bids.

5. Bidding Document

11. Procuring entities should use standard bidding documents for the procurement of goods, works, and services acceptable to ADB.

6. Preferences

12. No domestic preference shall be given for domestic bidders and for domestically manufactured goods.

7. Advertising

13. Invitations to bid shall be advertised in at least one widely circulated national daily newspaper or freely accessible, nationally known website allowing a minimum of 28 days for the preparation and submission of bids. Bidding of NCB contracts estimated at $500,000 equivalent or more for goods and related services, or $1,000,000 equivalent or more for civil works shall be advertised on ADB’s website via the posting of the procurement plan.

8. Bid Security

14. Where required, bid security shall be in the form of a bank guarantee from a reputable bank.

38 Appendix 5

9. Bid Opening and Bid Evaluation

(i) Bids shall be opened in public. (ii) Evaluation of bids shall be made in strict adherence to the criteria declared in the bidding documents, and contracts shall be awarded to the lowest evaluated bidder. (iii) Bidders shall not be eliminated from detailed evaluation on the basis of minor, deviations. (iv) No bidder shall be rejected on the basis of a comparison with the employer's estimate and budget ceiling without ADB’s prior concurrence. (v) A contract shall be awarded to the technically responsive bidder that offers the lowest evaluated price and meets the qualifying requirements set out in the bidding documents. (vi) No negotiations shall be permitted.

10. Rejection of All Bids and Rebidding

15. Bids shall not be rejected and new bids solicited without ADB’s prior concurrence.

11. Participation by Government-Owned Enterprises

16. Government-owned enterprises in Tajikistan shall be eligible to participate as bidders only if they can establish that they are legally and financially autonomous, operate under commercial law, and are not a dependent agency of the contracting authority. Furthermore, they will be subject to the same bid and performance security requirements as other bidders.

12. Right to Inspect and/or Audit

17. A provision shall be included in all NCB works and goods contracts financed by ADB requiring suppliers and contractors to permit ADB to inspect their accounts and records and other documents relating to the bid submission and the performance of the contract, and to have them audited by auditors appointed by ADB.

13. Fraud and Corruption

(i) The government shall reject a proposal for award if it determines that the bidder recommended for award has, directly or through an agent, engaged in corrupt, fraudulent, collusive, or coercive practices in competing for the contract in question. (ii) ADB will declare a firm or individual ineligible, either indefinitely or for a stated period, to be awarded a contract financed by ADB, if it at any time determines that the firm or individual has, directly or through an agent, engaged in corrupt, fraudulent, collusive, coercive, or obstructive practices in competing for, or in executing, an ADB-financed contract.

Appendix 6 39

40 Appendix 7 SUMMARY POVERTY REDUCTION AND SOCIAL STRATEGY

Country: Tajikistan Project Improved Maternal and Child Health Title: through Connectivity

Lending/Financi Japan Fund for Poverty Departme Tajikistan Resident Mission, ng Modality: Reduction grant nt/ Central and West Asia Department Division:

I. POVERTY AND SOCIAL ANALYSIS AND STRATEGY Targeting classification: Targeted interventions—household and MDGs M4, M5. A. Links to the National Poverty Reduction and Inclusive Growth Strategy and Country Partnership Strategy The Poverty Assessment Report 2009 indicates that 75.7% of all poor (and 70.9% of the extreme poor) live in rural Tajikistan, reflecting the demographics (73.7% of the overall population lives in rural areas) and higher poverty incidence in rural areas. The project will support priorities of the National Development Strategy, 2006–2015 and the Poverty Reduction Strategy, 2010–2012, which aim to broaden access to basic social services through development of the health care system, education, water supply, and gender equality. The National Population Health Strategy, 2010–2020, built on the National Development Strategy and the National Poverty Reduction Strategy, identifies primary health care and maternal and child health as top priorities. The Asian Development Bank (ADB) country partnership strategy, 2010–2014 for Tajikistan emphasizes ADB’s continuing involvement in the transport sector through investments in domestic and regional road links, and includes gender mainstreaming as a core cross-cutting theme. The project will contribute to achieving Millennium Development Goal (MDG) 4 (reduce child mortality) and MDG 5 (improve maternal health) in the project area. B. Results from the Poverty and Social Analysis during PPTA or Due Diligence 1. Key poverty and social issues. Tajikistan is a small landlocked country with a population of 7.6 million. Its mountainous terrain, poor transport infrastructure, and general remoteness are natural barriers to investment and external trade. The country is 3,000 kilometers from the nearest deep seaport. Tajikistan’s human development index value for 2011 is 0.607—in the medium human development category—positioning the country at 127 of 187 countries and territories.a In Tajikistan, poverty and social exclusion are quantitatively and qualitatively extensive, as well as socially ingrained in the country. Poverty is highest in rural areas, where subsistence economies prevail, as well as among households headed by women and households with children. Geographically, areas with the highest incidence of poverty include Rasht valley and other isolated and non-cotton-growing areas. The World Food Programme estimates that in 2010, about 10% of the rural population was chronically food insecure and another 17% very vulnerable to food insecurity.b The economic situation of the health care sector remains in a depressed state, with chronic underfinancing. In 2009, total health spending was 1.9% of the gross domestic product, significantly less than in 1991 (4.5%). This does not allow problems that have accumulated over the last two decades to be addressed. Furthermore, the expenditure structure of the health sector is far from optimal, as more than 70% of the country’s total health spending comes from patients’ out-of-pocket payments, with only some 16% from public spending and approximately 14% from donors. Health-care workers lack material and professional incentives to perform their duties in a qualitative way in the interests of the patients. Infant mortality rates are among the highest in the World Health Organization’s European Region and malnutrition is a major public concern.c Current estimates place the infant mortality rate (IMR) at 52.0 per 1,000 live births and the under-5 mortality rate (U5MR) at 61.0

Appendix 7 41 per 1,000 live births, compared with an IMR of 65.0 and an U5MR of 79.0 in 2005.d To achieve its MDG of a two-third reduction in child mortality by 2015, Tajikistan needs to attain an IMR of 29.6 and an U5MR of 39.3 by 2015. Rasht district is one of the poorest regions of the country and has the highest rate of food insecurity; 11%–18% of the population is classified as extremely food insecure, and 74% as moderately food insecure. Also, women from Rasht district, which is one of the most traditional and conservative in Tajikistan, are less likely than women from other regions to participate in community activities or seek health services. Both the IMR and U5MR are 10%–15% higher in Rasht compared with other regions, while the maternal mortality ratio (MMR) at 59.8 in 2011 has not improved since 2001. 2. Beneficiaries. The primary project beneficiaries are people living in Navobod, Obi Mehnat, Tagoba, Boki Rahimzoda, and Nusratullo Maksum subdistricts, which will directly benefit from bridge and road improvement. People from these communities have been forced to travel an additional 18 km to reach the district center due to the destruction of a bridge caused by the flood in March 2009. Focus group discussions with women in villages along and near the road revealed lack of direct access to the district center for more than a year resulted in (i) a 10 times increase in transportation costs; (ii) economic isolation—products (including seeds, fuel, water) were not available at the market because of delays and transport costs; and (iii) limited access to more comprehensive health-care services, resulting in increased child mortality and home deliveries. Consultation with the community and stakeholders has showed that in addition to difficulties accessing comprehensive health care at Rasht district center, the communities show low health-seeking behavior and expressed the need for more training on health issues. 3. Impact channels. The project is targeted at a particularly vulnerable population and will have positive impacts on health and health-seeking behaviors. About 40,000 villages will benefit from the project interventions. 4. Other social and poverty issues. The issue of deficiency of drugs, micronutrients, and vaccines in the project area is being addressed under national health programs and by United Nations Population Fund, United Nations Children’s Fund, World Health Organization and Global Fund. 5. Design features. The project activities represent a combination of health and transport interventions to improve the health of mothers and children. The health component will increase demand for health services, which will be matched by an increase in the supply of health services, while the bridge will help ensure this supply by enhancing the mobility of health personnel and supplies. II. PARTICIPATION AND EMPOWERING THE POOR 1. Summarize the participatory approaches and the proposed project activities that strengthen inclusiveness and empowerment of the poor and vulnerable in project implementation. The project was designed in a participatory manner and will be implemented with the participation of communities, jamoat leaders, district administrators, national government ministries, international and local nongovernment organizations, and international development partners working in the project area. 2. If civil society has a specific role in the project, summarize the actions taken to ensure their participation. The project will build the capacity of key local stakeholders (local government, community-based organizations, and contractors) to carry out community-based maintenance work through participatory planning and mobilizing local resources. The project will rely on a variety of training and awareness-raising channels, including community-based education, counseling, schools, parent–teacher associations, local organizations (i.e., farmer associations, village infrastructure maintenance associations) in developing and implementing behavior change communication activities. 3. Explain how the project ensures adequate participation of civil society organizations in project

42 Appendix 7 implementation. The project will be implemented in close consultation and collaboration with local governments with active participation of community and other stakeholders. 4. What forms of civil society organization participation is envisaged during project implementation? Information gathering and sharing Consultation Collaboration Partnership 5. Will a project level participation plan be prepared to strengthen participation of civil society as interest holders for affected persons particularly the poor and vulnerable? Yes. No. The project will support forming road maintenance associations in the beneficiary jamoats by (i) providing training, (ii) establishing village infrastructure maintenance funds to collect cash contributions from the community for operation and maintenance, and (iii) providing essential road maintenance and safety equipment to the associations. III. GENDER AND DEVELOPMENT Gender mainstreaming category: some gender elements A. Key Issues. The gender equity index value for 2009 is 52—positioning the country at 118 of 157 countries. This indicates that women have much fewer opportunities than man. A gender analysis identified gender gaps. Women have unequal access to and control over resources (i.e., property, land), as well as to basic social benefits, including education and health care. In 2006, only 39% of girls attending secondary schools graduated from grade 11, leaving those with inadequate education with low paid jobs in the informal sector. Women are not aware of their civil rights and many have no legal marriage certificates, which limits their property rights and access to funds. High birth rates in the project area cause women to focus on household activities and, accordingly, reduce their economic activity. B. Key Actions Gender action plan Other actions or measures No action or measure The project will address gender considerations within its activities by increasing men’s participation in family health and reproductive matters and understanding of health issues. IV. ADDRESSING SOCIAL SAFEGUARD ISSUES A. Involuntary Resettlement Safeguard Category: A B C FI 1. Key impacts. The project activity will not cause any land acquisition and resettlement or involuntary resettlement impacts. 2. Strategy to address the impacts. All activities will be conducted in the existing right-of-way and other available land with no involuntary resettlement impacts. A due diligence mission to the project site was fielded and a report was prepared. 3. Plan or other Actions. Resettlement plan Combined resettlement and indigenous peoples plan Resettlement framework Combined resettlement framework and indigenous Environmental and social peoples planning framework management system arrangement Social impact matrix No action

B. Indigenous Peoples Safeguard Category: A B C FI

Appendix 7 43

1. Key impacts. No ethnic minorities as defined in ADB’s Safeguard Policy Statement (2009) are identified in the project site to trigger the policy application. Is broad community support triggered? Yes No 2. Strategy to address the impacts. Not applicable, since no indigenous people are affected by the project. 3. Plan or other actions. Indigenous peoples plan Combined resettlement plan and Indigenous peoples planning framework indigenous peoples plan Environmental and social management Combined resettlement framework and system arrangement indigenous peoples planning framework Social impact matrix Indigenous peoples plan elements No action integrated in project with a summary

V. ADDRESSING OTHER SOCIAL RISKS A. Risks in the Labor Market 1. Relevance of the project for the country’s or region’s or sector’s labor market. The project includes assurances and covenants to promote core labor standards and hire workers from the project location. Unemployment Underemployment Retrenchment Core labor standards 2. Labor market impact. The bidding documents will ensure that the standards are respected throughout project implementation. Job opportunities will be open for skilled and unskilled labor during construction; workers from local communities will be prioritized if they meet the skill requirements. B. Affordability The project will reduce transport costs, contributing to affordable passenger services for the local population. C. Communicable Diseases and Other Social Risks 1. Indicate the respective risks, if any, and rate the impact as high (H), medium (M), low (L), or not applicable (NA): Communicable diseases Human trafficking Others (please specify) ___ HIV/AIDS (M)____ 2. Describe the related risks of the project for people in the project area. Some risks are related to HIV/AIDS and other sexually transmitted infections from the increased mobility of people, increased number of drivers, and influx of labor during construction. The health component will involve increasing community awareness of disease by providing training and developing Information, education, and communication materials. VI. MONITORING AND EVALUATION 1. Targets and indicators. By January 2016 (i) travel time to health-care facilities reduced by 30%, (ii) 30% more families practicing integrated management of childhood illnesses, (iii) 70% of births occur at health facilities, (iv) 50% of women complete the required number of prenatal visits, and (v) 60% of women practice exclusive breastfeeding for 6 months in all five targeted jamoats. The data will be obtained from baseline and end-line surveys, project progress reports, and local government statistics. 2. Required human resources. The project manager will implement monitoring of the poverty and social impacts supported by short-term national experts for a baseline survey and impact assessments, and monitoring and evaluation activities. The Ministry of Transport (MOT) will be engaged in monitoring and evaluation as it has accumulated sufficient experience in project

44 Appendix 7 monitoring through various ADB projects. 3. Information in PAM. A preliminary set of indicators for monitoring and evaluating project performance was agreed with MOT and the Ministry of Health during project preparation. At the beginning of project implementation, the project manager will collect and confirm baseline indicators for social and poverty reduction impacts. The Grant Implementation Manual will include details of these indicators. 4. Monitoring tools. The project manager will prepare quarterly, semiannual, and annual reports on project implementation; all reports will comprise an assessment of the project’s social and poverty impact and outputs, benefit monitoring, and recommendations for improving implementation. The indicators for project evaluation will be measured at project completion. Gender-disaggregated data will be collected in the project area. a UNDP. 2011. Human Development Report 2011. New York. b BTI. 2012. Tajikistan Country Report. Gütersloh: Bertelsmann Stiftung. c GIZ. 2011. Project Summary: Support to the Healthcare Systems Development in Tajikistan. Dushanbe. d UNICEF. 2011. The State of the World’s Children 2011. Adolescence. An Age of Opportunity. New York. Source: Asian Development Bank.