Feed the Future Tajikistan Health and Nutrition Activity

FEED THE FUTURE TAJIKISTAN HEALTH AND NUTRITION ACTIVITY

Year 4 Annual Progress Report October 1, 2018–September 30, 2019

Submitted October 30, 2019 Revised November 15, 2019

TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS ...... 3 ACTIVITY IMPLEMENTATION SUMMARY...... 4 IR 1: IMPROVED QUALITY OF HEALTH CARE SERVICES FOR MNCH ...... 7 Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI ...... 7 Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality ...... 15 Outcome 1.3: Stronger facility and provider networks ...... 21 IR 2: INCREASED ACCESS TO A DIVERSE SET OF NUTRIENT-RICH FOODS ...... 26 Outcome 2.1: Diversified food consumption during the growing season and beyond ...... 26 Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities...... 31 IR3: INCREASED PRACTICE OF HEALTHY BEHAVIORS AROUND MNCH ...... 31 Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children six to 24 months of age ...... 31 Outcome 3.2: Improved sanitation and hygiene-related behaviors ...... 40 Outcome 3.3: Increased use of health care services for MNCH, including nutrition, sanitation, and hygiene ...... 44 Community Level ...... 44 Facility Level ...... 58 IR4: INSTITUTIONALIZED EVIDENCE-BASED MNCH SERVICES THROUGH NATIONAL-LEVEL POLICIES AND STANDARDS ...... 62 Outcome 4.1: Cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH ...... 62 Outcome 4.2: Evidence-based approaches for MNCH, including nutrition, sanitation, and hygiene, are sustainable ...... 63 MONITORING, EVALUATION, AND LEARNING ...... 66 GENDER ...... 73 STAFFING & MANAGEMENT ...... 74 BUDGET VS. EXPENDITURE ANALYSIS ...... 75 Sub-grants...... 75 COORDINATION WITH OTHER FTF PARTNERS ...... 78 COMMUNICATION AND KNOWLEDGE MANAGEMENT ...... 79 LIST OF ANNEXES ...... 84

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 2

ACRONYMS AND ABBREVIATIONS

ANC Antenatal Care KMC Kangaroo Mother Care CDH Central District Hospital IYCF Infant and Young Child CE Community Educator Feeding CHP Community Health Promoter MAM Moderate Acute CIP Centro Internacional de la Malnutrition Papa (“International Potato MDD Minimum Dietary Diversity Center”) MMF Minimum Meal Frequency CME Continuing Medical MNCH Maternal, Newborn, and Education Child Health DOE Department of Education MOHSPP Ministry of Health and Social DOH Department of Health Protection of the Population DQA Data Quality Assessment MUAC Mid-Upper Arm EG Economic Growth (USAID Circumference indicator) PHC Primary Healthcare Center EmONC Emergency Obstetric and QI Quality Improvement Newborn Care RHS Recurring Household Survey EPC Effective Perinatal Care SAM Severe Acute Malnutrition FTF Feed the Future TAWA Tajikistan Agriculture and GMP Growth Monitoring and Water Activity Promotion THNA Tajikistan Health and HCW Health Care Worker Nutrition Activity HL Health (USAID indicator) TOT Training of Trainers HLSC Healthy Lifestyle Center UNICEF United Nations Children’s ICATT IMCI Computerized Fund Adaptation and Training Tool USAID United States Agency for IEC Information, Education, and International Development Communication USG United States Government iHRIS Integrated Human Resource VDC Village Development Information System Committee IMAM Integrated Management of VIP Ventilated Improved Pit Acute Malnutrition WASH Water and Sanitation IMCI Integrated Management of Hygiene Childhood Illness WFP World Food Programme IR Intermediate Result ZOI Zone of Influence

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 3

ACTIVITY IMPLEMENTATION SUMMARY

IntraHealth International and its partner, Abt Associates, are pleased to submit to the Tajikistan Mission of the United States Agency for International Development (USAID) the Year Four (Y4, October 1, 2018–September 30, 2019) annual report for the Feed the Future (FTF) Tajikistan Health and Nutrition Activity (THNA). This report also serves as the Quarter Four (Q4, July–September 2019) of Y4 report. THNA is being implemented in partnership with the Ministry of Health and Social Protection of the Population (MOHSPP) of the Republic of Tajikistan. THNA’s goal is to improve the health status and nutrition of women and children who live in 12 southwestern districts of Khatlon Region, known as FTF’s zone of influence (ZOI). This progress report is consistent with the structure and content of THNA’s approved Y4 workplan.

As activity highlights for Y4, THNA: • Completed 52 out 61 program activities (85%) scheduled for Y4 (Annex 1); • Through the recurring household and agricultural practices surveys, demonstrated statistically significant improvements compared to baseline or control communities in the percentage of non-breastfed children 6-23 month old who receive a minimum acceptable diet; the percentage of children under five with diarrhea who receive more liquids and are breastfed more frequently; the percentage of women who made four or more antenatal care visits during the last pregnancy; the percentage of women who reported following proper water and sanitation hygiene practices; and the percentage of beneficiaries applying improved agricultural practices; • Improved the nutrition-related professional knowledge and skills of a total of 2,874 health care workers (HCWs) and 541 community volunteers (122% of the annual target); • Trained 1,016 HCWs on the management and prevention of anemia in women of reproductive age and children under five (280% of the annual target); • Reached 195,764 children under five with clinical and community-based nutrition interventions (140% of the annual target); • Helped identify 2,889 children under five with acute malnutrition, who were registered and received treatment at primary health care (PHC) level IMCI centers; • Reached over 99,514 pregnant women with clinical and community-based nutrition interventions (199% of the annual target); • Reached 720,583 individuals with food security programs (180% of the annual target); • Engaged 2,937 school students on the topics of life skills; food security; nutrition; agriculture; and water and sanitation hygiene (WASH) (179% of the annual target); • Conducted 7,239 cooking demonstrations (122% of the annual target) for 87,828 participants (73% of the annual target); • Established and facilitated peer support groups in 454 communities (91% of the annual target), reaching at least 4,995 community members (50% of the annual target);

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 4

• Exposed 7,365 community members (147% of the annual target) to social marketing messages on WASH and ventilated improved pit (VIP) latrines through 144 outreach events; • Identified and referred to PHCs 5,786 pregnant women for antenatal care (ANC), 1,044 children with signs of malnutrition, and 3,158 children with diarrhea through 303,993 household visits by community health promoters (CHPs) (97% of the annual target for visits); • Reached 4,617 community members with maternal, newborn, and child health (MNCH) messages (192% of the annual target) through 48 community health fairs. THNA also faced the following challenges. Under IR1: • Relatively low coverage of HCWs with continuing medical education (CME) on specific topics. For example, only 42% of PHC staff have been trained on the management and prevention of anemia, and 15% – on the IMCI Computerized Adaptation and Training Tool. THNA will continue supporting CME activities at nutrition resource centers to expand the coverage of HCWs; • Poor application of knowledge and skills on ANC, nutrition of pregnant women, infant and young child feeding (IYCF) and child growth monitoring and promotion (GMP) acquired by PHC providers through CME. THNA will continue supporting mentoring and monitoring and supportive supervision visits to PHC facilities to strengthen providers’ skills; • Low buy-in by health facilities into maintaining the MNCH database. In Y5, THNA will conduct a qualitative survey on the uptake of the MNCH database and will make recommendations based on the results; • Lack of progress on infection control and clinical safety at district-level PHC and reproductive health centers because of their poor water supply infrastructure. In Y5, with support from THNA, these facilities will complete their water supply improvement projects, and their infection control indicators are expected to improve; • Poor traceability (only 22%) of suspected child malnutrition cases identified by community volunteers because of lacking contact information. In Y5, THNA will work with volunteers on improving their case recording, reporting and tracking practices; • Barriers to treatment of malnutrition, such as transportation, laboratory, and hospitalization costs, which families cannot afford, as well as shortage of therapeutic food in some facilities. THNA advocates to the MOHSPP and regional Department of Health (DOH) for canceling all payments for treating children with malnutrition, and for effective distribution of therapeutic food between facilities. Under IR2: • A 10% attrition rate among community educators (CEs) over the year, which THNA managed by training 50 new CEs in addition to the 50 planned for Y4 (a total of 100 new CEs); • Barriers to implementing improved agricultural practices by households, including lack of irrigation in some geographic areas or high ground water levels in other areas compounded by climate change, lack of emergency extra funds in household budgets, high cost of poultry THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 5

vaccines sold in more doses than practical for individual households, or persistent use of large jars for canning. CEs will continue working with their community members through practical educational sessions on irrigation and drainage, winter food storage, cultural practices, household budgeting and family entrepreneurship, and poultry care to overcome these challenges • Completion of the two most closely allied with THNA FTF projects by the Tajikistan Agriculture and Water Activity (TAWA) and Centro Internacional de la Papa (CIP), in September 2019. By the time the new Sustainable Agriculture and Land Tenure (SALT) activity is awarded, THNA is also likely to be completed. Under IR3: • Lower than expected coverage of community members with cooking demonstrations and peer support groups (72% and 50% of the annual target, respectively). THNA was overly ambitious in setting the target of 20 participants per group: volunteers found it too challenging bringing together such large groups and keeping a high quality of discussion. The targets for next year will be more realistic; • Delays in construction of VIP latrines by community members at rural PHCs and six schools because THNA did not budget enough time for the environmental review required by USAID; because the communities lacked local resources for construction materials for above-the- ground parts of small latrines; and because THNA was not able to hire foremen and construction equipment under the terms of its cooperative agreement. To overcome these challenges, THNA provided local communities with construction materials for above-ground parts of VIP latrines, in addition to below-ground parts; and partners with WFP who funded the work of the foremen and rent of construction equipment. Construction of VIP latrines at rural PHCs and schools is expected to be completed in Q1 of Y5; • A 15% attrition rate among CHPs over the year, instead of 7.5% planned. To offset this attrition, THNA trained 301 new CHPs in Y4, instead of 200 planned; • Sub-optimal effectiveness of the referral system due to high service and reporting workload for CHPs, their dysfunctional relations with some HCWs, real or perceived costs of medical services for families, and family dynamics when pregnant women and mothers of children under five are not the ones making health-related decisions. THNA continues working with CHPs, HCWs and health authorities to maximize the effectiveness of patient referral from the community level. In future activities, the CHP catchment area should be smaller than the current 100 households; • Training and supportive supervision on integrated management of acute malnutrition (IMAM) in children, as well as a regional conference on the integrated management of childhood illnesses (IMCI) were postponed because of the delay in the revision of the guidelines on IMCI at the national level. THNA will implement these activities in Y5. Under IR4: • A delay in the revision and approval of the IMCI handbook and the ICATT/IMCI training package. This challenge is beyond THNA’s control, and THNA is expecting progress on the part of MOHSPP and WHO.

These and other achievements and challenges are described in detail below in this report.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 6

IR 1: IMPROVED QUALITY OF HEALTH CARE SERVICES FOR MNCH

Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI

In Y4, THNA implemented activities to improve the quality of health services in facilities of the 12 FTF districts, with the goal of achieving sustainability.

1.1.1. Provide a training of trainers (TOT) on Kangaroo Mother Care (KMC) for facilities from Cohorts I, II, and III

In Y4, THNA achieved 92% of its annual target by training 22 regional trainers (out of 24 planned) on national KMC guidelines. A shortage of HCWs in the FTF districts was the reason for not fully achieving the target. THNA had planned to train two neonatologists per district; however, only 20 are on staff, and of these, only 14 were available for the training. Photo 1. Implementation of KMC (photo credit: THNA) In Q2–Q4, following the TOT on KMC, 22 regional trainers cascaded 64 trainings to a total of 495 HCWs (79% of all hospital-level MNCH staff). In Q4, 11 trainers conducted 38 training sessions for 194 HCWs. In Q2–Q4, a total of 613 newborns under 2,000 g (3.3% of all newborns) were eligible for KMC (Figure 1). Of them, 215 newborns (35% of those eligible) received KMC (Photo 1). As demonstrated, the KMC rate is not very high, as it is not always indicated based on the condition of the newborn and mother (e.g., pregnancy complications, Caesarean section, sepsis, or artificial ventilation may make KMC inappropriate). Figure 1. Underweight newborns who received KMC in Y3 and Y4, %

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 7

In Q4, 94 underweight newborns received KMC out of 126 eligible (74%). This is a marked improvement compared to an average of 11% in Y3. As shown in Table 1, in all central district hospitals (CDHs) except those in Levakant and Nosiri Khusrav districts, neonatologists applied KMC to eligible newborns. The maternity departments in Levakant and Nosiri Khusrav CDHs do not accept premature deliveries before 34 weeks of gestation, and neither of them have a neonatologist on their staff.

Table 1. Total number of newborns eligible for KMC and who received KMC, by district, Y4

osiri Jomi Dusti Balkhi Jaikhun Kushoniyon Levakan Shahritus Qabodiyon N Khusrav Khuroson Yovon Vakhsh Total

Total number of newborns 2,487 1,519 2,077 1,200 1,121 886 2,015 2,162 366 1,258 3,190 1,826 20,107 1,500–1,999 g 43 27 45 37 21 1 26 42 0 35 59 16 352

1,000–1,499 g 25 35 25 28 12 0 13 26 0 21 56 20 261

Received KMC 25 27 36 17 13 0 9 18 0 20 37 13 215

Received KMC, 37% 44% 51% 26% 39% - 23% 26% - 36% 32% 36% 35% % of eligible

1.1.2. Train regional-level trainers and district-level PHC staff on anemia management and prevention in women of reproductive age and children under five In Y4, THNA achieved 105% of the annual target by training 21 district PHC trainers (20 trainers had been the target) on anemia management and prevention in women of reproductive age and children under five. THNA designed the training curriculum in partnership with the Republican Center of Family Medicine (Activity 4.1.3), and the MOHSPP approved it for implementation nationwide. The comprehensive training package is based on the World Health Organization’s guide entitled, “Iron Deficiency Anemia: Assessment, Prevention, and Control” and employs an interactive, participatory learning approach. As a result of the training, participant knowledge improved from 55% to 82% of correct responses on the pre- and post-training tests.

1.1.3. Train medical providers from rural PHC facilities on the management and prevention of anemia in women of reproductive age and children under five In Y4, THNA reached 280% of the annual target by training 1,016 HCWs on the management and prevention of anemia in women of reproductive age and children under five (390 HCWs was the target) by supporting 72 trainings provided by 21 district trainers trained under Activity 1.1.2. In Q4 alone, ten trainers from nine districts cascaded 25 training sessions to 156 HCWs. However, only 42% of all PHC staff have been trained on anemia management and prevention (Table 2).

In addition, during supportive supervision visits on ANC and IYCF (Activity 1.2.4), national trainers attended sessions on anemia in each resource center and provided feedback for improvement.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 8

Table 2. Training on the management and prevention of anemia, by district, Q4 and Y4

Jomi Dusti Balkhi Jaikhun Kushoniyon Levakan Shahritus Qabodiyon Khusrav Nosiri Khuroson Yovon Vakhsh Total

District PHC trainers 1 2 2 3 1 2 2 2 2 1 1 2 21

On-the-job trainings, Q4 - 4 3 - 3 2 4 - 3 3 1 2 25

On-the-job trainings, Y4 6 7 10 4 8 4 7 4 4 8 5 5 72

HCWs trained, Q4 - 16 24 - 17 16 16 - 9 15 26 17 156

HCWs trained, Y4 78 57 136 51 75 63 156 96 17 141 76 70 1,016

Total PHC HCWs 168 95 195 182 373 64 201 315 31 215 321 334 2,394

HCWs trained, % of total 46% 60% 70% 28% 20% 98% 78% 30% 55% 66% 24% 21% 42%

1.1.4. Create training packages and compile visual information materials for nutrition resource centers In Y4, THNA fully completed the establishment of 24 nutrition resource centers (out of 24 planned) and provided them with up-to-date training packages, visual materials, and an electronic library. In Y4, THNA designed simplified training and visual materials based on national guidelines and created an electronic library of all available MNCH guidelines, protocols, and standards, which were uploaded to the laptops provided to the nutrition resource centers. The nutrition resource centers will use these materials to sustain CME activities (Photo 2).

Photo 2. CME activities in Balkhi nutrition resource center (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 9

In Q1-Q4, THNA provided training materials on the following topics: • ANC; • Management of postpartum • Rohnamo (the handbook on MNCH); bleeding; • Danger signs during pregnancy; • Breastfeeding; • Nutrition during pregnancy and • IYCF; lactation; • Complementary feeding; • Gravidogram; • Growth monitoring of children; • Management of uncomplicated • Diarrhea management; delivery; • Hospital-based integrated • Premature delivery; management of childhood illness • KMC; (IMCI); • Abnormal labor activity; • Quality improvement (QI) committee • Emergency obstetric and newborn and QI indicators; care (EmONC) in hypertension • Infection prevention and clinical disorders; safety (MOHSPP’s Order 1119); • Resuscitation of newborns; • HIV/AIDS; • Hepatitis B and C.

THNA also printed and distributed some basic emergency protocols to CDHs and PHCs on the following topics: • Management of eclampsia; • Bishop score; • Management of bleeding; • Hemorrhagic shock; • Newborn resuscitation; • Management of obstructed labor; • Oxytocin administration; • Emergency care in hospital IMCI. • Blood loss measurement; These protocols are used as training materials, as well as visual aids in emergency situations.

1.1.5. Support local trainers in developing on-the-job training curricula and conducting trainings In Y4, THNA reached the target of having 24 training plans at the nutrition resource and training centers been developed and approved by facility managers. In Y4, THNA supported 2,037 CME sessions at both the hospital and PHC levels; 796 of them – in Q4. A total of 2,874 (95%) health providers received at least one training (90% being the annual target). To support the training process, in Q4, THNA provided training mannequins to 24 resource centers. At the hospital level, these included: an advanced simulator to assess fetal position, normal and breech deliveries, and intrauterine manipulation of the fetus; a newborn simulator for advanced life support training; and a baby care kit. At the PHC level, these included an abdominal palpation model and a baby care kit. The use of the mannequins will significantly strengthen practical skills of HCWs and the quality of services provided. Hospital-level training plans covered 19 topics, and PHC-level training plans covered 13 topics.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 10

In Y4, at the hospital level, nutrition resource centers provided 11,623 person-sessions1 through 1,223 CME sessions for 623 (100%) of hospital-based staff (Table 3 and Figure 2). In Q4, 623 hospital-level HCWs received 3,569 person-sessions through 448 CME sessions. Table 3. Number of CME person-sessions at 12 hospital-level nutrition resource centers, by district, Y4

Balkhi Jomi Dusti Jaikhun Kushoniyon Levakant Shahritus Qabodiyon Nosiri Khusrav Khuroson Yovon Vakhsh Total

Doctors 385 209 186 305 160 75 324 101 73 595 409 280 3,102

Midwives/ 991 409 314 626 861 345 1,175 352 189 675 2,010 574 8,521 nurses Total: 1,376 618 500 931 1,021 420 1,499 453 262 1,270 2,419 854 11,623

On average, each of the 623 hospital-level HCWs participated in an on-the-job training twice a month. Accordingly, each hospital-level staff person participated in at least one training on each of the 19 topics.

Figure 2. Number of CME training sessions at the hospital level, by topic, Y4

EmONC = emergency obstetric and newborn care; IMCI = integrated management of childhood illness; KMC = Kangaroo Mother Care; IYCF = infant and young child feeding; GMP = growth monitoring and promotion

The frequency of topics depended on several factors: recommendations from the mentoring and monitoring visits (e.g., infection control and effective perinatal care [EPC]), EPC scorecards, and QI indicators. Slow progress on QI indicators resulted in an increased number of trainings on a specific topic. Every month, the hospital-level resource centers covered 11 out of 19 topics, on average. In Y4, at the PHC level, nutrition resource centers provided 12,535 person-sessions through 814 CME sessions for 1,988 (83%) of PHC staff (Table 4 and Figure 3). Of these, 4,095 person-sessions were provided in Q4 through 348 CME sessions for 791 PHC staff.

1 A “person-session” refers to a person participating in a training session, allowing for double counting. For example, if the same ten people participated in two trainings, there would be ten total people trained, but 20 person-sessions. THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 11

Table 4. Number of CME person-sessions at 12 PHC-level nutrition resource centers, by district, Y4

Jomi Dusti Balkhi Jaikhun Kushoniyon Levakant Shahritus Qabodiyon Nosiri Khusrav Khuroson Yovon Vakhsh Total

Doctors 309 35 76 69 85 22 407 100 315 130 78 31 1,657 Midwives/ 1,165 483 483 357 1,702 739 1,575 347 769 1,094 611 1,141 10,466 nurses Total: 1,474 518 971 426 1,787 761 1,982 447 1,084 1,224 689 1,172 12,535

Figure 3. Number of CME training sessions at the PHC level, by topic, Y4

EBF = Exclusive breastfeeding; ANC = antenatal care; WRA = women of reproductive age; CU5 = children under five; IYCF = infant and young child feeding; GMP = growth monitoring and promotion; IMCI = integrated management of childhood illness; ICATT = IMCI computerized adaptation and training tool

The frequency of training topics depended on the achievement of QI targets on ANC (Activity 1.3.2). Slow progress on QI indicators resulted in more training on a certain topic. PHC-level nutrition resource centers covered eight out of 13 topics, on average. None of the PHC- based resource centers covered all 13 topics. In Q4, national-level supervisors, as part of their visits (Activity 1.2.4), attended training sessions at PHC-level resource centers. The supervisors assessed the quality of training (Figure 4) based on the following criteria: • Resource center setup (cleanliness; availability of water; comfort; readiness to use a projector, computer, and printer); • Availability of visual materials provided by THNA; • Use of interactive training methods; • Trainers’ preparedness on the topic; • Participants’ engagement in the training process; • Feedback from participants.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 12

Figure 4. Average scores of training session quality at PHC-level resource centers, by district

Definition of scores: each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0 to 3: 0 = need for very substantial improvement; 1 = need for substantial improvement to reach standard level; 2 = need for some improvement to reach standard level; 3 = good or standard level.

1.1.6. Provide on-the-job trainings to midwives to enhance their capacity in MNCH and EmONC In Y4, THNA reached 206% of its annual target by providing on-the-job training on MNCH and EmONC through national-level trainers/supervisors for 248 midwives from the maternity departments of 12 CDHs and four numeric hospitals (120 midwives trained was the annual target). In Q4, 128 midwives received on-the-job training through 12 supportive supervision visits by national-level trainers/supervisors. The agenda for each on-the-job training included the supervisor participating in a training session provided by the local trainers, giving feedback to the trainers, and assessing the midwives’ knowledge and skills, as well as a simulated emergency and skills practice in the workplace. The results of the assessment demonstrate that midwives’ knowledge improved from 31% of correct responses at baseline in Q1 of Y3, to 88% in Q4 of Y4 (Figure 5). Figure 5. Midwives’ knowledge of EmONC, Q1 of Y3 and Q4 of Y4, % of correct responses

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 13

National trainer-midwives assessed the quality of the trainings based the same criteria listed under Activity 1.1.5 (Figure 6).

Figure 6. Quality scores of training sessions for midwives at hospital-level resource centers, by district

Photo 3. Midwife-mentor giving on-the-job training (photo credit: THNA) In Q2, district-level facilities selected ten local midwives as mentors to build the capacity of their colleagues (Photo 3). In Y4, these local midwife-mentors conducted 102 on-the-job trainings, engaging 107 midwives from numeric hospitals. Of these, 76 on-the-job trainings, which engaged 95 midwives, were delivered in Q4. Training covered all EPC topics, and trainees took a 31- question test on EPC (Figure 7).

Local trainers and mentors experienced some challenges in the training sessions, such as lacking answers to difficult questions and disputes with experienced midwives. In Y5, THNA will support a training on training methodology and interpersonal skills.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 14

Figure 7. Improvement of midwives’ knowledge on EPC, Q2 of Y3 and Q4 of Y4, by district

1.1.7. Provide mentoring and monitoring visits to health facilities to improve the quality of MNCH and to maintain the MNCH database

In Y4, THNA reached the goal of updating the facility-based MNCH database at 12 CDHs and making the MNCH database functional at 12 PHCs. In Y4, THNA provided 36 mentoring and monitoring visits to 12 CDHs and 12 district-level PHCs. Of these visits, 12 visits took place in Q4. THNA assisted QI committees in implementing their QI plans, collecting data, and analyzing the results from the MNCH database. During three meetings with the DOH (Activity 4.2.1), THNA presented MNCH data from 12 districts and advocated for better utilization of the MNCH database in decision-making. The fact that facility managers use the MNCH database to generate data for their quarterly and semiannual reports to the DOH is a significant THNA achievement. THNA still faces challenges in maintaining the MNCH database, such as: • Low motivation of HCWs to maintain the database and to enter and analyze the data; • High staff turnover; • The HCWs’ lack of understanding of the benefits of the MNCH database; • The lack of a nationwide database/application specifically for health data collection and reporting. To address these challenges, in Y5, THNA will support QI trainings and organize a roundtable with representatives of the 12 QI committees and the DOH to develop a sustainability plan for the MNCH database. In addition, THNA will implement a qualitative survey on the uptake of the MNCH database and will make recommendations based on the results.

Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality

1.2.1. Train local trainers at the hospital level on supportive supervision around EPC In Y4, THNA achieved 110% of the annual target by training 22 local hospital-level trainers on supportive supervision around EPC and EmONC (20 was the target). In Q2, THNA organized a two- THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 15

day training for 22 participants (20 obstetrician/gynecologists and two neonatologists) from the 12 FTF districts. These trainers now provide in-house supportive supervision and monitoring for hospital maternity department staff on EPC and EmONC. In Y4, these trainers also facilitated exchange visits between 12 facilities (Activity 1.2.2) to ensure that the providers are offering quality clinical services that reflect national clinical guidelines and standards. To date, over the lifetime of the project, THNA has trained 28 trainers/supervisors (the first six national-level trainers/supervisors were trained in Y2). Training local (rather than national-level) supervisors builds the sustainability of EPC practices at the regional and district level, so that EPC can be supported without the engagement of national-level experts. 1.2.2. Facilitate supportive supervision visits on EPC to Cohort I, II, and III facilities and numeric hospitals In Y4, THNA reached 100% of its annual target by facilitating 24 supportive supervision exchange visits by local district-level supervisors on EPC (24 visits being the annual target), which engaged 436 HCWs (allowing for double counting). In Q4, THNA facilitated 12 supportive supervision visits between CDHs of all 12 districts, engaging 172 HCWs from hospital maternity departments. In addition, in Q4, local supervisors provided 38 supportive supervision visits to numeric hospitals engaging 207 HCWs. The second supportive supervision visit was more difficult for us, as we had to implement recommendations and make improvements in our own department from the first visit. We also had to provide a supportive supervision visit to a neighboring facility, evaluate the changes they made and analyze their achievements and gaps. As a result, each team did their best to implement all recommendations and show improvements. Dr. Husnoro Boboeva, supervisor, maternity department of Shahritus CDH

In Q4, THNA conducted a roundtable to discuss the supportive supervision visit results, with each supervisor presenting scorecards on EPC. As a result of the roundtable discussion, each CDH maternity department created a QI action plan. Implementation of EPC in CDH maternity departments over the past three years has resulted in a 37% improvement in quality indicators, an average of 1.1 points gained toward the maximum of 3.0 (Figure 8). Dusti, Kushoniyon, Nosiri Khusrav, Balkhi, Yovon, and Vakhsh CDHs improved by more than 1.3 points, or 40%. Qabodiyon and Jaikhun CDHs demonstrated little improvement (an increase of just 0.6 of a point) due to the turnover of trained HCWs and poor infrastructure. For example, in Qabodiyon CDH, three chief doctors and four heads of maternity departments changed during the lifetime of the project. In Jaikhun CDH, there has been no running water since the start of the project, and the situation is expected to improve only next year.

In Q4, THNA presented the EPC scorecards from the 12 facilities, with significant improvements, to the DOH and MOHSPP via a nine-month report (Activity 4.2.3). To facilitate this activity, in Q2, THNA provided an autoclave as an in-kind sub-grant to improve infection control practices in the hospital maternity department of Shahritus CDH(Activity 7.12).

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 16

Figure 8. CDH scores on EPC scorecards, 2016–2019

Definition of scores: According to the World Health Organization’s EPC scorecard, each item is evaluated with information gathered by different sources to reach an overall score, ranging from 0 to 3: 0 = need for very substantial improvement (totally inadequate care and/or harmful practices, with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards); 2 = need for some improvement to reach standard care (suboptimal care but no significant hazards to health or of basic principles of quality care); 3 = good or standard care.

Photo 4. Newborns placed in an incubator as part of EPC (photo credit: THNA)

1.2.3. Train local trainers at the PHC level on supportive supervision around ANC and IYCF In Y4, THNA reached 100% of its annual target by training 24 PHC-level local providers on supportive supervision for PHCs. In Q2, THNA trained 20 providers though a two-day training on supportive supervision. Four doctors from Jomi, Kushoniyon, Nosiri Khusrav, and Yovon district PHCs

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 17

were trained in Q4 through on-the-job trainings, as they were not available for the training in Q2 due to competing responsibilities. As a result, participants’ knowledge improved from 42% to 90% of correct responses on pre- and post-training tests. This training and the supportive supervision activities that followed (Activity 1.2.4) emphasized counseling on the prevention and treatment of anemia, screening for preeclampsia during each ANC visit, and delivering key ANC and IYCF messages. In Y5, local trainers will continue providing supportive supervision to staff in their own facilities, as well as in partner facilities in the neighboring districts.

1.2.4. Facilitate supportive supervision visits around ANC and IYCF at the PHC level In Y4, THNA reached 100% of its annual target by facilitating 48 supportive supervision visits and follow-up meetings at district-level and rural PHCs (48 meetings being the annual target). In Q4, THNA facilitated 12 supportive supervision visits by national-level supervisors, which engaged 266 HCWs in 12 district PHCs. In addition, district-level supervisors trained under Activity 1.2.3 provided 12 supportive supervision visits, which engaged 53 HCWs in 42 rural PHCs. The main objective for national-level supervisor visits was to practice supportive supervision skills with district-level supervisors. These visits covered the basic principles of supportive supervision, conducting professional discussions of HCWs’ strengths and weaknesses, and providing feedback and motivating HCWs to improve the quality of their services. National- and district-level supervisors and PHC staff jointly reviewed 120 ANC charts and 120 pediatric charts of children under two. The chart review resulted in the following findings: • 70% of the charts included records on the height and weight of children and growth charts; • 60% of the charts included records on consultations and recommendations provided; • No children under 12 months of age were screened for anemia. District-level supervisors, in turn, provided supportive supervision visits to rural health centers. District supervisors also reviewed 120 ANC and 120 pediatric charts. The main success was that all women received the Rohnamo as part of their ANC visits, which was recorded in the charts. In Y4, THNA provided 40,000 copies of the Rohnamo to PHCs as an in-kind sub-grant to the DOH. The main challenge was the lack of records on nutrition counseling during pregnancy and on complementary feeding for children over six months of age. To address the findings of the ANC and pediatric chart reviews, the supervisors recommended training PHC staff on ANC, nutrition during pregnancy, and IYCF (Activity 1.1.5) via the nutrition resource centers. In Y4, the supervisors regularly presented the results of their supportive supervision visits at monthly medical staff meetings at the district level. Through these monthly medical staff meetings, in Y4, THNA reached approximately 2,100 HCWs staff from 483 rural and 12 district-level PHCs (87% of all PHC facilities in the THNA districts). In Q4, THNA reached 760 staff from 256 rural and 12 district-level PHCs. The monthly presentations resulted in the following recommendations for how to improve service delivery: • PHC staff should regularly review all pediatric charts for children under two, check GMP results, and assess the treatment of children with malnutrition; • PHC staff should regularly check ANC charts for appropriate ANC consultations and anemia management; THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 18

• QI committees should engage competent health specialists in attending supportive supervision meetings besides the trained supervisors; • QI committees should ensure that district-level doctors regularly visit rural PHCs. In Q3, to improve the quality of PHC services, THNA procured 270 instrument kits for family physicians and 800 kits for family nurses (an increase from 170 and 500 kits, respectively, based on THNA cost savings and the identified need). A delay on the part of the vendors has postponed delivery of these kits until Q1 of Y5.

1.2.5. Conduct supportive supervision visits on infection control at district-level PHCs In Y4, THNA achieved 100% of its annual target of providing 12 supportive supervision visits on infection control to district-level PHCs and CDHs. As a result, a total of 86 HCWs from 12 PHCs and 70 HCWs from 12 CDH maternity departments were engaged in supportive supervision on infection control. Supportive supervision visits covered two domains of clinical safety: (1) hospital auxiliary services (central sterilization rooms, laundry, etc.) and (2) patient care. The scores from the CDHs showed a significant improvement in the areas of infection control and clinical safety (Figure 9). Figure 9. Infection control and clinical safety at the hospital level, % of standards met

Since August 2017, CDHs in Yovon, Balkhi, Levakant, and Qabodiyon districts made significant progress in infection control, improving their indicators by approximately 20%. The average improvement across the 12 CDHs was 14%. In contrast, PHCs showed little or no improvement between June 2018 and May 2019 (Figures 10 and 11). The average improvement of clinical safety standards met at the PHC level was 1%. The main reason for this lack of improvement is the poor quality of the infrastructure, such as the lack of water supply and sewage systems, which requires capital investment. To alleviate some of these challenges, in Q3–Q4, THNA procured water tanks, pumps, and water towers for PHCs as a sub- grant to the DOH. The procurement was delayed because THNA did not budget the time necessary for the environmental review required by USAID. Delivery and installation of this water supply equipment is expected in Q1 of Y5.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 19

Figure 10. Infection control and clinical safety at reproductive health centers, % of standards met

Figure 11. Infection control and clinical safety at family medicine centers, % of standards met

1.2.6. Provide mentoring and monitoring visits on the use of EPC and IMCI equipment at the hospital level and oral rehydration rooms at the PHC level

In Y4, THNA reached 500% of its annual target by providing 60 mentoring and monitoring visits on the use of EPC, IMCI equipment, and oral rehydration rooms (12 visits was the annual target). Multiple questions from HCWs about maintaining and servicing the equipment was the reason for such a high number of mentoring and monitoring visits. THNA assessed the condition of the equipment and its proper use (Photo 5). Most equipment was found to be functional and operated properly. In Q4, three out of seven malfunctioning infant warming tables and two out of three malfunctioning autoclaves were repaired by the facilities themselves. The hospitals have ordered spare parts, and the remaining four infant warming tables and one autoclave should be repaired in Q1 of Y5.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 20

Photo 5. EPC equipment provided by THNA (photo credit: THNA) In Q4, THNA facilitated 12 supportive supervision visits by regional supervisors (Activity 3.3.13). During the visits, the supervisors visited ten oral rehydration rooms at the district level (of the total 36 equipped). All ten inspected rooms were functioning properly and had a sufficient supply of oral rehydration solution. In Q4, THNA requested a report on all of the inventory that was received by health facilities as part of in-kind sub-grants since the start of the project. In Y5, THNA will inspect the inventory and reconcile it with facility reports to document the status of all equipment provided through in-kind sub-grants over the project’s lifetime.

Outcome 1.3: Stronger facility and provider networks

1.3.1. Improve referral tools and develop forms to ensure the continuum of care for children with malnutrition and for pregnant women In Y4, THNA made significant progress toward the goal of establishing a continuum of care for children with malnutrition and for pregnant women. Throughout the year, THNA supported implementation of the referral and registration mechanisms among the community, rural, district and hospital levels of the 12 FTF districts. In addition, THNA supported two GMP campaigns to identify and refer children with malnutrition (Activity 3.3.14). In Y4, THNA established a continuum of services between the communities and health facilities to identify, refer, and treat children with malnutrition. When CHPs identify children under five with suspected malnutrition, they refer them to the local PHC. If mild malnutrition (<-1Z) is confirmed at the PHC level, the family receives counseling on nutrition and follow-up. If uncomplicated severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) is confirmed, treatment is prescribed at the PHC level. In cases of complications, such as anemia, the child is referred for hospital treatment. Upon discharge, PHC staff and CHPs follow up with the children at the household level. By the end of Y4, a total of 2,889 children under five with MAM (<-2Z) and SAM (<-3Z) were identified, registered, and received treatment at PHC-level IMCI centers, including 557 new cases identified in Q4 (Table 5). The largest numbers of children treated for SAM were in Shahritus, Balkhi, and Dusti districts, where therapeutic food is available at the PHC level, and in Kushoniyon district, where therapeutic food is available at the Bokhtar city PHC.

In Y4, CHPs identified and referred 1,044 children with suspected malnutrition, with 301 of them in Q4. Of children referred by CHPs, 160 (15%) were confirmed as malnourished and received treatment at the PHC or hospital level; 69 (7%) were not confirmed as malnourished; and 78% could not be tracked due to lack of contact information. In Y5, THNA will work with CHPs on improving their case recording, reporting and tracking practices. THNA advocated for every malnourished child and pregnant woman to receive appropriate health services free of charge (Activity 3.3.6).

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 21

Table 5. Cumulative number of children under five with malnutrition registered at IMCI centers at the end of September 2019, by district and severity of malnutrition FTF districts <-2Z <-3Z Total children with (MAM) (SAM) malnutrition

Jomi 82 8 90 Dusti 310 53 363 Balkhi 319 55 374 Jaikhun 121 32 153 Kushoniyon 60 47 107 Levakant 71 24 95 Shahritus 685 131 816 Qabodiyon 538 13 551 Nosiri Khusrav 18 7 25 Khuroson 77 28 105 Yovon 79 33 112 Vakhsh 79 19 98 Total: 2,439 450 2,889

During Y4, THNA identified significant gaps in the continuum of care for children with malnutrition. For example, only 22% of children with MAM and SAM received hospital-based treatment. The main barriers to treatment were transportation, laboratory, and hospitalization costs, which families cannot afford. In addition, there is a shortage of therapeutic food in some facilities. THNA presented these gaps at the quarterly coordination meetings with the DOH and the managers of CDHs and district PHCs supported by THNA (Activity 4.2.1), advocating for canceling all payments for treating children with malnutrition and for effectively distributing therapeutic food between facilities. To improve the continuum of care for pregnant women, in Y4, THNA distributed the Rohnamo and supported CME through nutrition resource centers for PHC staff (Activity 1.2.4). In addition, THNA supported CHPs, who identified and referred 5,786 pregnant women for ANC (Activity 3.3.4). Community health fairs also served the purpose of early identification and the referral of pregnant women for ANC (Activity 3.3.5). 1.3.2. Provide mentoring and monitoring visits to support QI committees at the hospital and PHC level In Y4, THNA achieved 117% of the annual target by providing 56 mentoring and monitoring visits (out of 48 planned for the year) to support QI committees at the hospital and PHC level. During these visits, THNA and QI committees addressed the following issues: • Availability of the required QI documentation in each facility; • Progress in implementing QI plans in 2019; • Internal quality monitoring, goal setting, and data analysis; • Gaps in collecting data and tracking indicators; • Need to expand QI activities to cover other departments beyond maternity and pediatrics. In Y4, with THNA’s support, CDH maternity departments and PHCs improved on all QI indicators (Figures 12 and 13). Between Y2 and Y4, improvements on some indicators reached 50%. THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 22

Figure 12. Average progress on EPC QI indicators in maternity departments at 12 CDHs, Y3–Y4, %

Figure 13. Average progress on ANC QI indicators at 12 PHCs, Y2-Y4%

1.3.3. Support and promote biweekly online conferences between supervisors/mentors and facilities

In Y4, THNA achieved 100% of its target by supporting 24 facilities with online mentoring support from tertiary-level facilities through 70 online conferences. In Q4, of 18 biweekly online conferences, 11 were at the hospital level and eight at the PHC level. In Y4, the main topic of support at the hospital level was implementation of KMC by neonatologists and updated clinical standards on the management of bleeding during delivery. At the PHC level, the main topic was the updated national clinical standard on ANC. Other topics of the biweekly conferences included: • Management of multiple complications in pregnancy (severe preeclampsia and bleeding, bleeding and renal failure, etc.); • Home-based KMC; • Treatment of newborns with intrauterine infections; • Referral of malnourished children.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 23

1.3.4. Organize exchange visits between facilities from Cohorts I, II, and III to share best MNCH practices including the “beyond the numbers” approach and IMCI In Y4, THNA reached 100% of its annual target by facilitating six exchange visits between facilities (out of six planned for the year): three exchange visits at the PHC level, engaging 61 HCWs, and three exchange visits at the hospital level, engaging 74 HCWs. In Q4, THNA supported two exchange visits between staff from CDH and PHC facilities. Exchange visits between facilities to share best MNCH practices is one of the activities of the QI Collaborative. During these visits, participants observe in practice the principles of QI, such as the use data to measure results and the team approach to decision-making and problem-solving. Despite similar working conditions, the same level of support from THNA, and almost the same challenges, the facilities are at different levels in implementing and improving the quality of MNCH care. Therefore, THNA supported exchange visits to those facilities that demonstrated the best QI results according to the QI scorecards (Activity 1.2.3): CDHs in Shahritus and Yovon districts, and PHCs in Dusti and Jomi districts. The exchange visits included a practical part, i.e., presentation of improved practices, and an analytical part on data collection and analysis. The agenda of these two exchange visits in Q4 included: • Comparing facility indicators for the nine months of 2019 with those of the same period in 2018; • Assessing the results of the in-house audit of critical cases in obstetric hemorrhage and severe preeclampsia; • Discussing trends in improving the quality of care: o An improvement in the quality of EmONC for women with bleeding and severe preeclampsia at five facilities; o A decrease in the frequency of Caesarean sections at three facilities; o An improvement in the resuscitation of newborns at two facilities; o An improvement in regular coverage with ANC and early registration of pregnant women. In Y5, THNA will prioritize the mentoring to those CDH maternity departments and PHCs that were not successful in achieving their QI goals.

1.3.5. Organize a district-level nutrition competition and exhibition among PHC facilities In Y4, THNA reached its target by supporting 12 district-level nutrition competitions and exhibitions entitled, “Healthy Nutrition for a Healthy Generation” among 12 PHC facilities. As a result, 60 participants from rural PHCs improved their knowledge and nutrition-related services. In addition to HCWs, competition participants included community members, such as young mothers and mothers-in-law (Photo 6).

Two teams of five participants competed in each district (24 teams in total). The program of each competition included a quiz for participants on healthy foods and a knowledge test on nutrition for pregnant women, women of reproductive age, and children under five. There were also presentations, poems, and songs about healthy and safe foods, breastfeeding, and complementary food for children. An additional quiz was offered to the audience on healthy nutrition.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 24

Photo 6. Nutrition competition (photo credit: THNA)

A total of 869 HCWs from district and rural PHCs, as well as over 1,000 community members attended district competition events and received essential nutrition information. THNA awarded prizes to all competing team members, such as branded aprons and bags, as well as special prizes to the winners, such as thermo pots and blenders. Based on the results of the district-level competitions, each district PHC formed a team to participate in the regional nutrition competition (Activity 1.3.6).

1.3.6. Organize a regional nutrition competition and exhibition among PHC facilities On August 9, THNA organized the Third Annual Regional Nutrition Competition entitled, “Healthy Nutrition for a Healthy Generation” in Bokhtar city (Photo 7). The goal of the competition was to increase the level of professional competence in PHC staff on nutrition. Almost 200 health professionals from PHCs, healthy lifestyle centers (HLSCs), the DOH, and the MOHSPP participated in the event and improved their knowledge of healthy nutrition (100 participants was the annual target). Photo 7. Participants at the regional-level nutrition competition in Bokhtar city (photo credit: THNA)

The competition was dedicated to the international Exclusive Breastfeeding Week (August 1–7), and 12 PHC teams competed by:

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 25

• Preparing and presenting a billboard about a specific local fruit or vegetable: its nutritional value, seasonality, possible recipes, etc.; • Developing and presenting a district action plan to increase the percentage of children under six months who are exclusively breastfed; • Taking a quiz on nutrition. The teams from Kushoniyon, Yovon and Jomi districts won the regional-level competition (Photo 8). THNA awarded the winning teams with special institutional prizes (refrigerators), while all participating teams received incentive prizes for their institutions (printers and air conditioners).

Over the four years of the project, we observed a trend towards improvement in the health services provided by health facilities in 12 pilot districts of Khatlon region. As part of the Feed the Future program, an integrated approach to medical services through collaboration of the local community with primary health care facilities was established. In addition, the clinical activities of the project focus on improving the knowledge of HCWs and the community on sanitation, hygiene, healthy nutrition in order to improve the health status of mothers, newborns and children. The main achievement of the project is training of trainers from among local health workers, which will ensure the sustainability of the project after its completion. Dr. Farida Khudoidodova, deputy director of the Republican Center of Family Medicine, interview with Asia Plus, a newspaper

Photo 8. The Yovon district team’s billboard at the regional-level nutrition competition in Bokhtar city (photo credit: THNA)

IR 2: INCREASED ACCESS TO A DIVERSE SET OF NUTRIENT-RICH FOODS

Outcome 2.1: Diversified food consumption during the growing season and beyond

2.1.1. Train 50 new community educators (CEs), to replace drop-outs, on four seasonal topics In Y4, THNA overachieved its annual goal by training and certifying 100 new CEs and providing refresher training to 40 active CEs (50 new CEs was the annual target). This overachievement is due to the 10% attrition rate among CEs in Y4, for which THNA did not plan. The trainings over three THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 26

quarters covered all four seasonal topics: (1) poultry and dairy production, (2) economic empowerment, (3) home garden management, and (4) postharvest methodologies. Knowledge of the training participants improved from 42–61% of correct responses on pre-training tests to 81– 86% of correct responses on the post-training tests (Table 6). At the end of Y4, THNA has 490 active CEs in 490 local communities. THNA is not planning to recruit new CEs in Y5. Instead, THNA will continue training the 50 CEs recruited in May 2019 on the three remaining topics they have not been trained on: poultry and dairy production, household budgeting and family entrepreneurship, and home garden management.

Table 6. Results of trainings for new CEs Month Training topics # of # of Pre-test Post-test new CEs active scores, % scores, % CEs Day 1: CE roles and responsibilities; Nov. 42% 81% 1 adult training methodologies 50 40 2018 Day 2: Poultry and dairy production 47% 83% Dec. Day 1: Household budgeting 52% 84% 2 50 40 2018 Day 2: Family entrepreneurship 61% 82% Jan. Day 1: Home garden management 3 50 40 56% 86% 2019 Day 2: Home garden management Day 1: Drying of fruits and May vegetables 4 2019 100 30 57% 84% Day 2: Canning of fruits and

vegetables; root cellar storage

2.1.2. Provide CE-led practical trainings for households on four seasonal topics In Y4, THNA achieved 97% of its annual target by reaching 233,274 individuals (out of 240,000 planned), with 366,207 person-sessions on seasonal agricultural topics. In Q4 alone, CEs reached 64,077 individuals with 91,744 person-sessions (an average of 186 individuals reached by each CE every month). In Y4, CEs from 499 THNA villages provided practical trainings to 104,057 households on the topics of poultry and dairy production (108,509 person-sessions), economic empowerment (household budgeting and entrepreneurship, 74,185 person-sessions), home garden management (84,085 person-sessions), winter food storage (56,355 person-sessions), and postharvest methodologies (43,073 person-sessions). CEs reached these households through individual home visits and by bringing several households together (Photo 9). Photo 9. CEs providing practical training and educational sessions for households (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 27

As a result of CE activities, in Y4, the coverage of community members with different agriculture and food security topics increased substantially compared to the baseline measured in Y2 (Figure 14). Figure 14. Respondents reporting participation in trainings on improved agricultural practices, 2017 vs. 2019, %

I have been storing various food items for winter season for many years. However, after participating in an educational session by our village volunteers, I learned about various new and safe ways of storage. Before, we used to prepare different types of preserves with eggplants, but now we understood that a single mistake can cause a disease. For me and my fellow villagers, drying eggplants for storage was a new method. During their sessions, the volunteers taught us several methods of drying, storing and cooking dry eggplants. Dry eggplants are an easy and safe food that can enrich our diet with vitamins and minerals during the winter season. We are very grateful to the project volunteers. Rano Karimova, beneficiary from Havaskor village, Qabodiyon district

Poultry is not new for me, but in recent years, death of my chickens has been upsetting me and it made me abandon raising poultry. However, by attending educational sessions by our village volunteer Mavjigul, I realized that I had gaps in some basic knowledge about poultry care. Particularly, I did not pay attention to their place of living, food and vaccination. Now, after my participation in the sessions, I began raising poultry again following all recommendations. I am happy that my family is constantly provided with nutritious products. Sharofat Eshmatova, beneficiary from Sadriddini Aini village, Qabodiyon district

2.1.3. Facilitate monthly peer learning sessions for CEs In Y4, THNA achieved 110% of its annual target by bringing together 593 CEs for 237 peer learning sessions (216 sessions had been planned) to share their experiences and improve their knowledge and skills (Photo 10). In Q4, THNA held 66 peer learning sessions for CEs. At their meetings, CEs shared their experiences through group work, presentations, role-plays, games, and other interactive exercises. Due to CEs’ achievements in their villages over the past year (Figure 15):

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 28

Figure 15. Respondents applying improved agricultural practices confirmed by enumerators, by type of technology, 2017 and 2019, %

• More households are selecting high-nutrient crops promoted by THNA and its partners, such as bok choy, beans, broccoli, Chinese cabbage, and cauliflower to diversify the diet of their families; • Some households are planting orange-fleshed sweet potatoes, a completely new crop they learned about through THNA: at least 100 households in Jomi, Shahritus, and Yovon districts successfully grew sweet potatoes not only to eat to improve their family’s nutrition but also to sell to increase their family’s income; • 46% of households are producing poultry based on THNA recommendations vs. 4% in 2017 (p<0.0001); • 42% of households vs. 0% in 2017 are following crop rotation principles to increase the quality and quantity of vegetables in their backyard gardens; using soil mulching techniques to preserve moisture in the dry summer season; and applying other cultural practices more frequently (p=0.0002); • 63% of households are making compost and using it to improve soil fertility vs. 32% in 2017 (p=0.0136); • 40% of households are adopting cheese-making and other dairy production techniques, vs. 27% in 2017; • 44% of households are implementing the methods of pest control vs. 3% in 2017 (p=0.0035) and 48% are implementing disease control methods vs. 4% in 2017 (p=0.0004) promoted by CEs; • 72% of households are using proper methods of canning, drying, and storing fruits and vegetables for winter consumption. The challenges discussed included: • Limited use of backyard gardens by households beyond the spring rainy season, as many areas have no irrigation;

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 29

• Widespread use of large, two- or three-liter jars for canning, despite the lack of refrigerators in many households, which poses the risk of infection; • Climate change affecting the quality and seasonal availability of many foods in target districts; • Managing household budgets to ensure there is extra money for emergencies; • Lack of poultry vaccination due to the high price of vaccines, which are usually sold in too many doses to be affordable or practical for households with a small number of chickens, as well as the lack of a veterinarian in most villages; • High levels of groundwater due to clogged drainage systems, which negatively affect crop yield. With THNA support, CEs will continue working with their community members through practical educational sessions on irrigation, winter food storage, cultural practices, household budgeting and family entrepreneurship, and poultry care to overcome these challenges. Photo 10. CEs at monthly peer learning sessions (photo credit: THNA)

At the peer learning sessions, THNA tested the CEs on topics relevant to their work to identify gaps in their knowledge. These gaps were then addressed through refresher trainings at the same meeting. The average percentage of correct responses on monthly tests in Y4 reached 83%. The tests helped identify and recognize 1,120 CEs (allowing for double-counting) with superior knowledge and practical achievements in their village, who were awarded small prizes as incentives. During the monthly meetings, THNA staff observed improved communication, presentation, and facilitation skills in CEs, as well as increased self-confidence. In Q3–Q4, THNA facilitated 20 CE cross-district exchange visits. Twelve winners of the district and regional CE competitions traveled to other districts to share their experiences and best practices at monthly peer learning sessions. The topics presented and discussed included: • Best facilitation practices; • Poultry management; • Drying of fruits and vegetables; • Household budgeting; • Canning and preservation; • Rational use of the home garden; • Growing seasonal crops; and • Using educational materials in sessions.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 30

Lola Sanginova, CE from the Boghparvar village, Bustonqala jamoat, Kushoniyon district was unable to participate in the volunteer competition, as she was undergoing surgery at that time. However, she is one of the most dedicated volunteers. As a result of her six-month efforts in the village, 30 households began composting, 15 households improved their chicken coops, and 50 families practiced improved methods of drying and canning fruits and vegetables. Encouraged by presentations of the winners of the CE competition from other districts, Lola expressed her desire to share her own achievements with volunteers in other districts. During two visits to the neighbouring districts, she conducted educational sessions on canning cauliflower and other fruits and vegetables.

Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities

2.2.1. Promote TAWA’s crops through THNA activities In Y4, THNA promoted TAWA and CIP crops through cooking demonstrations conducted by CHPs (Activity 3.1.7). THNA developed and tested six recipes using bok choy, sweet potatoes, and mung beans. In their communities, the volunteers shared the recipes with mothers-in-law, pregnant and breastfeeding women, and women with children under 24 months. The cooking demonstrations included such recipes as chickpea purée, homemade yogurt with fruits, and vegetable salad with bok choy and nuts. The volunteers also shared the recipes through their household visits (Activity 2.1.2). In addition, THNA promoted TAWA’s and CIP’s crops through school-based peer education activities (Activity 3.1.4). As both TAWA and CIP completed their activities in September 2019, THNA will not have closely allied FTF partners until the new Sustainable Agriculture and Land Tenure (SALT) activity is awarded.

IR3: INCREASED PRACTICE OF HEALTHY BEHAVIORS AROUND MNCH

Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children six to 24 months of age

3.1.1. Sign a new memorandum of understanding with the national Ministry of Education and Science or the regional Department of Education In Y4, THNA achieved the expected result of receiving government approval to expand its school- based activities from two schools, #16 in Jomi and #11 in Dusti districts, to an additional seven schools: #35 in Balkhi, #19 in Kushoniyon, #4 in Levakant, #9 in Qabodiyon, #7 in Jaikhun, #15 in Vakhsh, and #49 in Yovon districts. THNA and the Department of Education (DOE) chose these schools based on the following criteria: the availability of a school garden; the school having grades one through 11 (primary to high school); the availability of a canteen supported by the World Food Programme (WFP); and headmaster and teacher support for the initiative. The regional DOE provided THNA with a letter of support, allowing THNA to implement school-based activities under the auspices of the National Program on School Nutrition.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 31

3.1.2. Train Department of Education staff and teachers from the seven additional schools over a two-day training on THNA’s peer education curriculum In Y4, THNA overachieved its target by training and certifying 26 DOE staff and teachers (22 had been planned) on the extracurricular program for school peer educators on nutrition, WASH, gardening, and other life skills. The teachers included two from a boarding school. In Q1, THNA provided a two-day TOT for 24 participants: ten participants from the regional DOE and from seven district departments and 14 teachers (two from each of the seven new schools). The training curriculum covered the goals and objectives of the extracurricular school program, as well as specific topics on nutrition, WASH, life skills, and agriculture. As a result, the schools’ teachers organized a total of nine adolescent clubs, each consisting of 15 students from grades eight through ten. In addition, in Q2, THNA trained two teachers at the boarding school for orphans in Yovon (see Activity 3.1.3 below). I’ve been working as a schoolteacher for ten years. I love working with children. Over these ten years I use the same teaching approaches. THNA, however, changed my mindset when they trained me on the interactive learning methodology. I learned how to work with adult audience, how to use the peer-to-peer methodology, and how to use information materials more effectively. All these were new and interesting for me. My lessons became more interactive, the students actively participate and exchange their opinions, and enjoy learning with pleasure. The students and I grew very close to each other. I am now using the interactive learning methodology in my lessons in the regular school curriculum. Saodat Zardakova, teacher, school #49, Yovon district 3.1.3. Support teachers at nine schools on establishing and running peer education activities In Y4, THNA reached 179% of its annual target by engaging 2,937 school students in practical trainings on irrigation, crop rotation, fruit and vegetable storage, safe water, budgeting, nutrition, life skills, and WASH (Table 7). The annual target was a total of 1,635 students: 135 peer educators and 1,500 school students. Table 7. Number of school students engaged by peer educators in Y4 # District Jamoat Village School # Girls Boys Total 1 Balkhi Navobod Komsomol 35 55 58 113 2 Dusti G. Gulmurod Pasariq 11 89 109 198 3 Jaikhun Istiqlol Telman 7 168 172 340 4 Jomi Yakkatut Jovidon 16 135 115 250 5 Kushoniyon Bokhtariyon N. Qaraboev 19 182 187 369 6 Levakant Guliston Botrobod 4 271 276 547 7 Qabodiyon N. Niyozov Chorbog 9 198 203 401 8 Vakhsh Tojikiston Proletar 15 136 142 278 9 Yovon G. Yusupova Buston 2 49 186 170 356 10 Yovon Shah Karomatullo Boarding 31 54 85 Total: 1,451 1,486 2,937

In addition to the nine schools planned, at the request of the regional DOE and the director of the boarding school for orphans in Yovon district, THNA included this school in its peer education activities. Life skills, nutrition, and WASH are not topics in the regular school curriculum, but they can be especially beneficial for orphans and other disadvantaged children in their adult life. Introducing the THNA curriculum to the boarding school’s teachers will ensure that their future students will be exposed to these topics as well. The boarding school also has a garden where THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 32

students can practice their agricultural skills. In Q2, THNA conducted a two-day TOT for all 35 students in grades 8–11 and two teachers from the boarding school. THNA provided students and teachers with materials to run a peer education program at their school. During the school year, the teachers and peer educators engaged 50 other students in grades 5–7 in peer education activities on food security, nutrition, and health. To support the school-based activities (Photo 11), in Y4, THNA provided 20 teachers, including those from the boarding school, with stationery, training materials, and visual aids on irrigation, crop rotation, crop families, saving water, healthy foods, and the benefits of vitamin A. The teachers used these materials in the initial trainings of the peer educators. They trained 135 school students as mentors (peer educators) in nine schools, in addition to 35 mentors THNA trained at the boarding school for orphans in Yovon district. The trained teachers regularly monitored and supported students in their peer activities. During their sessions, peer educators used the active learning methodology. Each school dedicated a classroom for peer education activities, with information and visual materials provided by THNA and designed by the students themselves. To assist the teachers in effective implementation of the peer education curriculum, THNA provided 59 supportive supervision visits to schools. During the visits, THNA staff attended the sessions facilitated by the teachers and peer educators to observe, help, and provide recommendations. In Y4, THNA provided nine schools with an in-kind sub-grant of 15 types of agricultural tools. The students used them during practical sessions in their school gardens, where they practice their new agricultural skills by growing tomatoes, cucumbers, sweet potatoes, and other crops. Photo 11. School student activities (photo credit: THNA)

We, the students, usually think that only adults can teach us. We obey them, respect, behave and do not ask too many questions. Over the past six months, our peer Zokir Tursunzoda taught us several topics. He did it in a very interesting and memorable way. At Zokir’s lesson, we feel free to talk about anything on a given topic. I especially liked the topic of sanitation and hygiene. After his lesson, I made a washstand myself and installed it near the toilet in our house. Now my whole family wash their hands with soap after the toilet. Komron Saidov, 10th grade student, school #15, Vakhsh district

3.1.4. Collaborate with TAWA on promoting new crops at nine THNA schools In Y4, TAWA provided THNA with 4,500 tomato and 1,800 cucumber seedlings for nine target schools (500 tomato seedlings and 200 cucumber seedlings per school). Under the supervision of their teachers, the students practiced such agricultural skills as land preparation, planting, and

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 33

irrigation to grow these crops (Photo 12). As a result, the target schools harvested 2,650 kg of tomatoes and 1,850 kg of cucumbers, grown from the seedlings (Table 8). The schools provided this produce to their kitchens for elementary class lunches.

Table 8. Tomato and cucumber harvests, by school, Y4 # District Jamoat Village School # Tomatoes Cucumbers (kg) (kg) 1 Balkhi Navobod Comsomol 35 250 150 2 Dusti G. Gulmurod Pasariq 11 400 250 3 Jaikhun Istiqlol Telman 7 400 350 4 Jomi Yakkatut Jovid 16 250 150 5 Kushoniyon Bohtariyon N. Karaboev 19 350 200 6 Levakant Guliston Botrobod 4 250 100 7 Qabodiyon N. Niyozov Chorbog 9 200 250 8 Vakhsh Tojikobod Proletar 15 400 300 9 Yovon G. Usupova Buston 2 49 150 100 Total: 2,650 1,850

Photo 12. Schoolchildren working in their school garden (photo credit: THNA)

Collaborate with CIP on promoting sweet potatoes In Q1 of Y4, THNA saw the results of collaborating with CIP in Y3: the students harvested 750 kg of sweet potatoes from their plots at school #11 in Dusti district and school #16 in Jomi district. Elementary school students received sweet potatoes as a supplement to their school lunches. Table 9. Sweet potato cuttings provided by CIP, by school # District Jamoat Village School # # of sweet potato cuttings 1 Balkhi Navobod Comsomol 35 1,000 2 Dusti G. Gulmurod Pasariq 11 576 3 Jaikhun Istiqlol Telman 7 1,000 4 Jomi Yakkatut Jovid 16 500 5 Kushoniyon Bohtariyon N. Karaboev 19 1,000 6 Levakant Guliston Botrobod 4 500 7 Qabodiyon N. Niyozov Chorbog 9 500 Total: 5,076

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 34

In Y4, THNA continued its collaboration with CIP. In Q3, CIP provided seven THNA schools with 5,076 sweet potato cuttings (Table 9). Under the supervision of trained teachers, the older students prepared the land and planted the cuttings. A CIP agronomist conducted supportive supervision visits to the seven schools growing orange-fleshed sweet potatoes. Students will harvest the sweet potatoes in Q1 of Y5. We had a good harvest of tomatoes and cucumbers this year, and we provided it to the school kitchen. It helped diversify the menu for children in grades 1–4. Since the harvest was good, we took care of its proper storage and preserved tomatoes as tomato paste. Now the school kitchen has natural tomato paste to use in wintertime. Sabohat Nazrimahmadova, teacher, school #7, Jaikhun district

3.1.5. Publish a collection of recipes for pregnant women, lactating women, and children aged six to 24 months In Y4, THNA reached 290% of its target by publishing 5,800 copies of its recipe book (the target was 2,000 copies) and distributing them to community volunteers and PHC providers. In Q1–Q2, THNA finalized a collection of recipes for women of reproductive age and children aged six to 24 months. THNA tested the recipe book in the field to assess the volunteers’ perception and understanding of the text and pictograms. The book includes recipes for dishes featuring nutritious crops, such as broccoli, bok choy, and orange-fleshed sweet potato, which were promoted by THNA’s partners (TAWA and CIP). The book also addresses the seasonality of different foods. There are 27 recipes in the book: 14 for children aged six to 24 months and 13 for pregnant and lactating women. The MOHSPP and Research Institute on Nutrition reviewed and approved the recipe book. Photo 13. Volunteers using the recipe book and other materials (photo credit: THNA)

In Q2–Q3, during the monthly peer learning sessions for community volunteers, THNA presented the recipe book and facilitated group work on its use during volunteer activities. The CHPs and CEs found the book extremely useful for their cooking demonstration sessions and cheese-making demonstrations, as well as for household use in the communities. In Q4, the volunteers continued using the THNA recipe book during cooking demonstrations, home visits, support group meetings, and cheese-making demonstrations (Photo 13).

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 35

3.1.6. Train 200 new CHPs, to replace drop-outs, on cooking demonstrations In Y4, THNA overachieved its target by training and certifying 301 newly recruited CHPs (a total of 200 was planned) on the cooking demonstration methodology. THNA emphasized promoting the recipes for pregnant and lactating women and children six to 24 months of age from the THNA recipe book. THNA recruited more CHPs than planned due to higher-than-expected volunteer attrition (Activity 3.3.2). THNA incorporated a practical training on conducting cooking demonstrations into the basic five-day training curriculum for CHPs. The newly trained CHPs received recipe books and aprons to conduct cooking demonstrations in their communities.

3.1.7. Conduct monthly cooking demonstrations for community members, led by CHPs In Y4, THNA achieved 72% of its annual target by bringing together 86,828 participants (of the annual target of 120,000) for 7,239 cooking demonstrations (122% of the annual target of 6,000) (Table 10). Table 10. Cooking demonstrations by district, Y4 District # of THNA villages # of cooking # of participants demonstrations Balkhi 60 67 1,195 Dusti 29 28 379 Jaikhun 42 40 700 Jomi 51 49 951 Khuroson 49 38 403 Kushoniyon 80 98 1,163 Levakant 11 3 44 Nosiri Khusrav 10 11 172 Qabodiyon 30 25 395 Shahritus 21 24 333 Vakhsh 60 55 787 Yovon 56 46 715 Total: 499 485 7,239

In Q4 alone, THNA volunteers conducted 1,823 cooking demonstrations for 17,416 participants (allowing for double counting). The average number of participants attending a cooking demonstration was 15, which is fewer than the 20 participants planned. In some communities, cooking demonstrations were part of peer support group meetings (Activity 3.1.8). Most of the ingredients for the cooking demonstrations were available in households; however, it was difficult for volunteers to access protein-rich ingredients free of charge. To promote recipes rich in protein, in Q3, THNA supported volunteers with a one-time allowance to purchase poultry, meat, or eggs. Using these products, CHPs demonstrated how to make complementary food for children over nine months and meals for pregnant and lactating women (Photo 14).

I participated in a cooking demonstration session conducted by our volunteer and enjoyed it very much. I learned about the benefits of using corn in salads and other meals. I learned that corn is a source of vitamin A, and vitamin A is necessary for growth and eyesight of our children. I have also learned about how to make popcorn for our children instead of unhealthy foods. I had never used corn in my meals before; I used it only to feed my chickens. Mohsharif Negmatova, Dusti 1 village, Vakhsh district

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 36

Photo 14. Children tasting dishes prepared at cooking demonstrations (photo credit: THNA)

As a result of the cooking demonstrations, the percentage of non-breastfed children six to 23 months of age receiving a minimum acceptable diet improved from 10% in 2016 to 53% in 2019 (p<0.05) and is significantly better in 2019 than 3% in control communities (p<0.04) (Figure 16). The percentage of women achieving minimum dietary diversity also improved, but this improvement was not statistically significant (Figure 17).

Figure 16. Non-breastfed children six to 23 months of age who achieved minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD), Recurring Household Survey (RHS) rounds 1–5 and control communities in 2019, %

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 37

Figure 17. Percentage of women achieving minimum dietary diversity (MDD) and average number of food groups consumed by women, RHS rounds 2–5 and control communities in 2019

3.1.8. Facilitate peer support group meetings for community members, led by CHPs In Y4, THNA achieved 91% of its annual target by establishing and facilitating at least one peer support group in 454 villages (500 was the annual target) for mothers-in-law, women of reproductive age, and men (Photos 15 and 16). As a result, THNA engaged an estimated 4,995 community members in peer support groups (50% of the annual target of 10,000 individuals, Table 11). Table 11. Peer support groups by district, Y4 District Total # of THNA villages # of support groups Estimated # of participants Balkhi 60 72 791 Dusti 29 24 261 Jaikhun 42 45 495 Jomi 51 49 537 Khuroson 49 47 522 Kushoniyon 80 60 655 Levakant 11 4 40 Nosiri Khusrav 10 9 99 Qabodiyon 30 27 294 Shahritus 21 22 245 Vakhsh 60 50 549 Yovon 56 46 507 Total: 499 454 4,995 In Q4 alone, THNA volunteers facilitated a total of 1,874 peer support group meetings for an estimated 17,416 participants (allowing for double counting). The average number of participants per group was nine. The most likely reason for not meeting the target of 20 participants per group is that THNA overestimated the ability of community volunteers to bring together this many participants and ensure the quality of discussion.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 38

THNA did not achieve its aim of establishing at least one peer support group in each village for each of the different target populations: mothers-in-law, women of reproductive age, and men. In Q4, there were no peer support group meetings in 38 out of 499 THNA communities, mainly due to CHP attrition. However, in many villages, there is more than one group meeting every month: in some large villages, CHPs facilitate more than one support group for the same target population. These peer support groups cover the topics of food diversity for women and children, exclusive breastfeeding for children under six months of age, and continuing breastfeeding until 24 months. Each group meets at least once a month to discuss a nutrition-related topic proposed by its participants or by CHPs. At first, I was reluctant to join the support group, but after becoming a member I have learned a lot about various health topics. Particularly, the information on exclusive breastfeeding was new for me. Although I have breastfed all my children, I had little information about its benefits for children. Now I know that exclusive breastfeeding is very crucial for healthy growth of a child. There were some young mothers in our neighborhood who gave their babies formula. I shared the information I learned about the benefits of breastfeeding with these young mothers and encouraged them to breastfeed their babies. I am happy that I could convince these mothers to breastfeed and could contribute to the healthy growth of their babies. Karomat Raupova, member of support group, SMP-540 village, Bustonqala jamoat, Levakant district

Photos 15 and 16. Support groups for women of reproductive age (top) and men (bottom) (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 39

Outcome 3.2: Improved sanitation and hygiene-related behaviors

3.2.1. Conduct 100 WASH fairs in 12 districts In Y4, THNA reached 147% of its annual target by exposing 7,365 community members (5,000 planned) to social behavior change messages on WASH and social marketing messages on VIP latrines through 144 outreach events (annual target of 100, Table 12). In Q4 alone, THNA reached 2,158 community members through 43 WASH events in 12 districts (Photo 17). WASH events served as a platform to deliver WASH-related messages, such as those about safe drinking water, environmental hygiene, and VIP latrines. CHPs, CEs, members of village development committees (VDCs) and HLSC representatives jointly organized these WASH events. Participants included women of reproductive age, in-laws, schoolchildren, husbands, and local PHC staff. By engaging children, who performed dramatic sketches and dances, recited poems, and participated in quizzes for small prizes (hand soap), THNA encouraged communities to adopt healthy WASH practices. At WASH events, THNA disseminated information, education, and communication (IEC) materials to community members on safe water storage and the ways that infections are spread (the “5 Fs”: feces, fluids, flies, fingers, and food).

Before, we already had a WASH event in our village, but it was kind of theoretical. Recently, a WASH event was organized by our neighbors, Shahlo Kholmatova and Latofat Atoeva. They are volunteers of the Health and Nutrition Project. Together with the medical staff of our village PHC, they organized the event on the PHC premises. They invited a local mason for a practical demonstration on building a VIP latrine at home. Before, no one thought much about latrines. Now, we understand the importance and benefits of safe toilets. After the WASH event, thanks to our volunteers, the people, whether it's in the mosques or on the streets, discuss the event and the benefits of VIP latrines. Qurbongul Mahramova, head of Shuro village, Dusti district

Table 12. WASH events by district, Y4

# District # of events # of households # of participants # of females # of males 1 Balkhi 22 849 1,108 972 136 2 Dusti 12 495 650 525 125 3 Jomi 11 420 550 522 28 4 Jaikhun 11 443 550 481 69 5 Kushoniyon 20 760 984 851 133 6 Khuroson 11 426 581 545 36 7 Levakant 7 273 383 293 90 8 Nosiri Khusrav 5 206 255 241 14 9 Qabodiyon 11 435 557 556 1 10 Shahritus 11 444 550 527 23 11 Vakhsh 11 436 572 558 14 12 Yovon 12 499 625 494 131 Total: 144 5,686 7,365 6,565 800

As a result of THNA’s WASH activities, between 2016 and 2019, the percentage of women who reported washing hands with soap after defecation increased from 24% to 88% (p<0.01), after cleaning the child – from 19% to 80% (p<0.01), before feeding the child – from 22% to 69% (p<0.04), before preparing food – from 21% to 82% (p<0.03), and before eating – from 24% to 78% (Figure

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 40

18). Compared to the control communities, women in THNA target communities reported washing hands with soap more frequently, but the only significant difference was in using soap before eating (78% vs. 8%, p<0.008).

Figure 18. Use of soap, RHS rounds 1–5 and control communities in 2019, %

Photo 17. WASH events in target villages (photo credit: THNA)

3.2.2. Support peer exchange visits between 16 community masons THNA almost met its target by having 15 community masons share their experiences of producing and marketing VIP latrines (16 was the target). In Q1, THNA organized a one-day peer exchange visit to one of the most successful community masons in Jomi district (Photo 18). Masons shared their experiences in the production and marketing of VIP latrines. As a result, 15 new masons received practical tips from their already successful peer on how to run or improve their own businesses. This exchange visit focused on the differences between various latrine types, their functionality, their advantages and disadvantages, factors in selecting a latrine type, and construction methods. The experienced master also introduced the tools used in construction. The peer exchange visit included both theoretical and practical parts, and by the end of the visit, the masons had produced a reinforced ring and slab. As a result, 15 new community masons will apply their new knowledge and skills in their everyday work in their communities. In Y4, the number of rings and slabs produced by community masons increased. In Y4, the masons produced 2,895 rings and 947 slabs, compared to 2,093 rings and 681 slabs in Y3. These numbers do not include the construction elements ordered by THNA for VIP latrines in health facilities (Activity 3.2.3). THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 41

Photo 18. Peer exchange visit by community masons to Jomi district (photo credit: THNA)

3.2.3. Install VIP latrines in 100 selected rural medical centers, with costs shared by local communities In Y4, THNA reached 60% of its annual target by supporting the completion of 60 VIP latrines at rural PHC facilities (100 latrines were planned) (Photos 19 and 20). THNA completed environmental review checklists and received USAID’s environmental clearance to construct VIP latrines at 113 sites (13 more than the annual target), including at the Shahritus CDH. THNA-trained masons delivered underground construction components for VIP latrines to a total of 75 sites. However, THNA has faced low completion rates for the VIP latrines’ construction by local communities due to their lack of material for the aboveground part of the latrine. To overcome this challenge, in Q4, THNA provided 58 sites with all construction elements, including cement blocks, doors, metal sheets for roofs, etc. Photos 19 and 20. Latrines at rural PHC facilities before (left) and after (right) THNA-supported construction projects (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 42

In Q1 of Y5, THNA will provide all necessary construction materials for constructing one-person VIP latrines at the remaining 37 sites. In addition, THNA will support the construction of an eight-person VIP latrine at the Shahritus CDH. As a medical worker, I didn't think of the importance of latrine at our facility until, together with THNA, we organized a health fair in our village. Many patients came from the surrounding villages, mostly pregnant women, women of reproductive age, and teenage girls who needed urine tests. Unfortunately, we didn’t have a latrine to serve them. We sent them to the neighboring houses to collect urine. After this event, I realized the importance of a toilet at PHC. I turned to the project with a request to build a latrine at our medical facility. Fortunately, the project granted my request and we should have a latrine built very soon. Ruzigul Mamatkulova, nurse from Muminobod village, Nosiri Khusrav district

3.2.4. Install VIP latrines and water reservoirs in nine schools In Y4, THNA made substantial progress toward the goal of improving WASH conditions for over 3,000 school students and faculty by supporting construction of eight-person VIP latrines at six schools and water storage facilities at one school (Photo 21). In Q3, THNA secured support from WFP for school latrine construction activities that are not permitted under the THNA cooperative agreement. These activities include construction oversight by certified foremen and the rental of construction equipment. THNA and WFP successfully reached an agreement for THNA to provide construction materials and for WFP to support the construction work. In Q4, THNA provided construction material to six schools. By the end of Q4, all underground works were completed at all six school sites. At three sites, the aboveground construction has been completed, and the communities are finishing the work. At three other sites, the aboveground construction is still in progress. THNA expects all six school latrines to be completed by community workers in Q1 of Y5.

Photo 21. School latrine construction site, school #15, Vakhsh district (photo credit: THNA)

3.2.5. Facilitate a roundtable among community masons and other stakeholders In Y4, THNA achieved its target of bringing up to 30 stakeholders to discuss WASH best practices, challenges, and solutions. In Q2, THNA organized a roundtable on WASH that brought 25 key stakeholders from the FTF districts to Bokhtar city. The objectives of the roundtable were to identify common goals around sanitation issues, promote VIP latrines in health facilities, support local masons in officially registering their businesses, and discuss common challenges and solutions. Participants included representatives of the Khatlon regional government agencies: Tojik Standart; the Tax Committee; the DOH; the HLSC, the regional and ten district sanitation and epidemiological services; and the State Unitary Enterprise of the Design, Production, Architecture and Planning under the Government of Khatlon Region, as well as the microloan agency

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 43

Mehnatobod, and five of the most active community masons. As a result of this roundtable, community masons received information on: • Tax optimization for their businesses, from the Tax Committee; • The sanitary and epidemiological requirements for latrines in health facilities and schools, from the sanitation and epidemiological services; • Cost-efficient ways of standardizing production, from Tojik Standart; • Accessing concessional loans at a low 3% interest rate, from the Mehnatobod microloan agency.

Outcome 3.3: Increased use of health care services for MNCH, including nutrition, sanitation, and hygiene

Community Level

3.3.1. Select and train 18 new district trainers over a five-day training to support CHP activities In Y4, THNA reached its target of training and certifying 18 additional government health providers as district trainers to support CHP activities. To replace drop-outs among district trainers, in Q1, THNA conducted a five-day TOT on the CHP model for 18 staff from PHCs and HLSCs from 11 districts. The DOH has assigned these staff as district trainers. Participants’ knowledge improved from an average of 36% of correct responses on the pre-training test to 95% on the post-training test. The training agenda included: • Adult learning concepts (communication, counseling, and interpersonal skills); • Healthy nutrition for mothers; • Danger signs in pregnancy; • Exclusive and continuing breastfeeding; • Complementary feeding for children six to 23 months of age; • Child development and GMP; • Hygiene and sanitation; • Anemia; • Goiter. Photo 22. District trainers’ engagement in THNA activities (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 44

As a result, a total of 36 district trainers (three per district) have been actively supporting and mentoring CHPs throughout the year. District trainers assist in selecting and training new CHPs (Activity 3.3.2), participate in monthly volunteer peer learning sessions (Activity 3.3.7), help facilitate volunteer competitions (Activity 3.3.8), contribute to monitoring the implementation of the joint action plan for CHPs, PHCs, and VDCs (Activity 3.3.6), and conduct supportive supervision visits to target communities (Photo 22). As a result, district trainers—who are in fact government employees of HLSCs and PHCs—represented THNA at monthly district medical councils.

I have 30 years of experience as a midwife. I thought that I had enough experience working with the community, as I had always been among people. At the first day of training, I felt insecure and constrained. For five days, the trainers taught us to use interactive methods. The most memorable moment was when the participants showed role-plays. We carried out a lot of group work, practical sessions, prepared and delivered presentations. Thanks to this training, I improved my facilitation and presentation skills and began to communicate freely the key messages to the target group. I gained a lot of experience as a trainer. Now, conducting training and public speaking is a pleasure for me. Rakhimova Zebo, trainer from Vakhsh district

As a district coordinator of Yovon district I supervise the work of 120 CHPs. I have expertise in the field of education, and I am familiar with the topics on health and nutrition in children. I am actively participating in the trainings organized by THNA. But sometimes it’s hard for me to answer specific questions from volunteers on topics related to maternal and child health. When the program recruited local trainers, we selected Dr. Soibegim Rushtova. She answers to every volunteer’s questions, reinforces the topic with examples from her experience and explains the risks of malnutrition, underweight and anemia. Her explanations are well remembered by the volunteers. Dr. Rushdova regularly participate in monthly volunteer meetings, community events, and in the selection and training of new CHPs. Dr. Soibegim makes a significant contribution to the effective implementation of our project. I appreciate her input. Havasmo Rahmatulloeva, district coordinator, Yovon district

3.3.2. Select and train 200 new CHPs, to replace drop-outs, on the basic five-day curriculum In Y4, THNA achieved 155% of its annual target by selecting and training 309 new CHPs from all 12 districts to replace drop-outs (200 new CHPs was the original target). The reason for the overachievement is a higher-than-expected CHP attrition rate. The main reasons for attrition include migration, family issues, and unfounded volunteer expectations of THNA, such as expecting material incentives. THNA’s ambitious targets and reporting requirements also contributed to volunteer attrition. To ensure the proper selection of new volunteers, THNA facilitated over 160 meetings with candidates to describe and discuss the roles and responsibilities of volunteers. During the selection meetings, VDC representatives and community members recommended candidates for volunteers (Photo 23). In Y4, THNA staff together with district trainers conducted 15 five-day trainings for new CHPs. Pre- and post-training tests demonstrated an improvement in participant knowledge from an average of 36% to 83% of correct responses. In Y4, the attrition rate among CHPs was 11%. At the end of the year, 1,162 CHPs were providing services in their communities. In Q4, to replace drop-outs, THNA recruited 150 new CHPs. THNA will train these newly recruited CHPs in Q1 of Y5. I live in the village by the name 1st of May. We have a health facility in the village, where Dr. Azamat Ashurov has been working for the past two years. In November last year, the project trained him as THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 45

a trainer. In turn, he taught me as a volunteer for five days. Since the end of 2018, I have been working closely with him. He is a qualified doctor and I have only nine grades of school, but he explains everything clearly, so I understand. During all the events in my village, including cooking demonstrations and WASH events, Dr. Azamat is always with me. I also help Dr. Azamat in identifying pregnant women and sick children and refer to him. Sometimes I invite parents with children to him for immunization. Because of our close collaboration, people started equally respecting us. They call me doctor’s assistant. It is very flattering and pleasing to me. I'm very grateful to the project that gave me such an opportunity. Holova Guldasta, CHP, Jomi district

Photo 23. CHP selection and training (photo credit: THNA)

3.3.3. Select 12 assistant district coordinators In Y4, THNA achieved its annual target of selecting 12 assistant district coordinators. Assistant coordinators are active, experienced, and successful CHPs whom THNA hires to provide individual mentoring and supportive supervision to other CHPs around home visits, cooking demonstrations, and peer support groups. In Q1, district coordinators recommended candidates for interview and approval by THNA management. In Y4, assistant district coordinators visited 400 villages in FTF districts to provide mentoring support to volunteers (Photo 24). District coordinators and their assistants jointly selected the communities to visit based on volunteers’ reports. Both the most and least successful volunteers received visits from assistant district coordinators. Together with the CHPs, the assistants visited households and health facilities, attended support group meetings, and cofacilitated cooking demonstrations and WASH events. At their visits, the assistants learned about and verified the experiences of the most successful CHPs and provided support to those who were struggling. As a success story, Mohira Rosimurodova, an assistant district coordinator in Levakant and Kushoniyon districts, was selected for a district coordinator position that had become vacant. An active CHP, Robiya Nurova from Kushoniyon district, replaced her as the assistant. Assistant district coordinators helped in selecting new CHPs (Activity 3.3.2). As a result, the organization of community events and the quality of CHPs’ monthly reports improved. The percentage of incorrectly filled volunteer reports decreased from 38% in October 2018 to 8% in August 2019 (see Data Quality Assessment [DQA] results in the Monitoring, Evaluation, and Learning section of this report).

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 46

Photo 24. Assistant district coordinators during community visits (photo credit: THNA)

Even though the project taught me for five days about volunteer work, my own experience in my village was very limited. There were many questions that remained unanswered for me, and I struggled. Since Ranogul became assistant district coordinator, she visited my village several times. She supported me in my work. She was particularly helpful in helping with my practical sessions, such as support groups. Ranogul taught me how to explain topics to people in a simple way. Now I am one of the best volunteers. I participated in the volunteer competition, and I am very thankful to Ranogul. Muslima Kholiqiva, CHP, Kalinin village, Balkhi district

When I began my work as CHP, I did not know where to start. In a five-day training, we were taught a lot. Although I grew up in my own village, I was worried whether I could go to people's homes and educate them. I thank Robia, assistant district coordinator, who provided timely support and accompanied me during the first household visits. She introduced my tasks and the goal of the program to the community. I feel the support of Robia in writing monthly reports, organizing cooking demonstrations and meetings with VDCs and health workers. She encouraged me in these activities, and I am more confident now. In August, I visited other districts to share my experience during monthly peer learning meetings. I am grateful to Robia, for her support and supervision. Zulfia Sirojeva, CHP, Hayoti nav village, Kushoniyon district

3.3.4. Provide household visits by CHPs Photo 25. CHPs at household visits (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 47

In Y4, THNA reached 97% of its annual target by reaching 303,993 households through CHP home visits, educational sessions, and other activities (with 312,000 households being the annual target). As a result of their home visits (Photo 25), CHPs identified and referred 5,786 pregnant women, 1,044 children with signs of malnutrition, and 3,158 children with diarrhea to PHCs. Volunteers and district coordinators followed up with PHCs regarding each of these cases to confirm the accuracy of the numbers and to ensure that appropriate services were provided. In Q4 alone, CHPs reached 71,467 households and identified and referred to PHCs 1,233 pregnant women, 296 children with signs of malnutrition, and 1,150 children with diarrhea. One of the results is a significantly (p<0.02) higher percentage of women who reported giving a child with diarrhea more fluid: 80% in 2019 compared to 33% in 2016 (Figure 19). The percentage of women who reported giving the same or an increased amount of food to a child with diarrhea also increased, but the increase was not statistically significant. Figure 19. Children receiving more liquid and food during diarrhea, RHS rounds 1–5 and control communities in 2019, %

Between 2016 and 2019, there was a significant increase, from 44% to 93% (p<0.02), in the percentage of women who knew that a baby should receive more breast milk during diarrhea than usual. The proportion of women with this knowledge in control communities in 2019 was 28%, which is significantly lower (p<0.003) compared to THNA target communities (Figure 20). Figure 20. Respondents who know that a baby should receive more breast milk during diarrhea, RHS rounds 1–5 and control communities in 2019, %

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 48

In Y4, during their home visits, peer support groups, and cooking demonstrations, CHPs provided individual and small groups counseling sessions on exclusive breastfeeding (151,491 person- sessions), complementary feeding for children over six months (140,912 person-sessions), nutrition for pregnant women (108,834 person-sessions), WASH (144,765 person-sessions), diarrhea (69,261 person-sessions), danger signs in pregnancy (73,872 person-sessions), iodine and its deficit (76,844 person-sessions), anemia (63,704 person-sessions), and immunization (53,459 person-sessions). These activities reached 53,319 pregnant women and 178,518 children under five.

Mamlakat Saidrahmonova, a CHP from Jamiyat Dehqon village in Shahritus district, at a household visit, found a girl, Amina, who was very thin. Mamlakat measured Amina’s arm with a MUAC [mid- upper arm circumference] tape and found that she was malnourished. The girl’s mother said that the family had not sought medical advice because they did not think the child’s condition was serious. After the information received from Mamlakat, the family brought Amina to the nearest rural health center. Amina was examined by a health worker and diagnosed with moderate malnutrition. The responsible nurse provided Amina with therapeutic nutrition available in Shahritus district at the PHC level, which improved the girl’s condition. Mamlakat is proud that the child received all necessary medical care and now she is much healthier. In July, Mamlakat identified four malnourished children in her village and referred them all to the rural health center. (Photo 26)

Photo 26. A child with signs of malnutrition identified by a CHP in Yovon district in March (left) improving over six months (center and right) (photo credit: THNA)

I observed the Afghonovs family for the past six months, after I had identified their malnourished nine-month-old twins. The first time I measured them with the MUAC tape in March 2019 and referred them to the rural health facility. The doctor confirmed that the children were underweight. He advised the parents to take the children to the central district hospital. They were reluctant at first, but later I convinced them and accompanied the mother with children to Doctor Kamolov, who is responsible for underweight children at the central district hospital. Since then, together with the doctor and the parents, I am working on improving and diversifying the nutrition of these children. The recent measurement with MUAC shows green, which indicates that the children’s nutritional status has improved. I am glad that my efforts lead to good progress. Bibirokiya Hasanova, CHP, Boshkaynar village, Yovon district THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 49

3.3.5. Conduct 48 local health fairs in remote rural communities In Y4, THNA achieved 100% of its annual target by conducting 48 local health fairs in 48 remote communities of the 12 FTF districts. THNA achieved 192% of its target by reaching 4,617 community members with MNCH messages (2,400 community members being the annual target). THNA facilitated visits to remote villages by family practitioners, specialists (obstetrician/gynecologists, pediatricians, and ultrasound diagnosticians), and lab technicians (Photo 27). The CHPs and HLSC staff provided health and nutrition information to women waiting in line to see a physician. As a result, in Y4, THNA provided access to MNCH and other services for: • 2,511 women of reproductive age, 1,016 of whom were pregnant (146 newly identified and registered); • 1,391 children (631 boys and 760 girls); • 715 older women. Ten children identified as malnourished received consultation and referral. Urine protein (a preeclampsia condition) was found in 287 pregnant women, who received referrals for additional ANC. In Q4 alone, THNA organized nine local health fairs, reaching 759 patients in the most remote rural communities, including: • 310 women of reproductive age, 229 of whom were pregnant (18 newly identified and registered); • 349 children (68 boys and 241 girls); • 100 older women. Five children identified as malnourished and seven pregnant women with protein in urine received consultations and referrals.

Photo 27. Health fairs in remote rural communities (photo credit: THNA)

We were very pleased with a health fair held in our village. This was a great opportunity for our community located far from the center of the district, to receive qualified medical care. In addition, people received information messages on exclusive breastfeeding, complementary feeding for children, prevention of anemia and diarrhea, and nutrition for pregnant and lactating women. Khayriddin Khojaev, head of Domullo Azizov village, Kushoniyon district

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 50

Photo 28. Twins with signs of malnutrition identified during a health fair in Dusti district (photo credit: THNA) I have twins, Fotima and Hussein, born in December 2018. Due to financial difficulties, my husband migrated to Russia. Caring for five children, the twins and three older children, is very difficult. Even when the children are sick, I cannot get away to visit a doctor. That’s why I am very grateful to our volunteer, Tojinisso Zagmatova, to Dr. Hakimjon Berdiev, and to the organizers of the health fair who visited my home, examined the children and gave recommendations. Modarmo Khaidarova, mother of the twins, Shakhrinav village, Dusti district (Photo 28)

3.3.6. Update the joint action plan for CHPs, PHCs, and VDCs and facilitate regular meetings between them at the local, district, and regional levels In Q1, the DOH extended the timeframe for the joint action plan for CHPs, PHCs and VDCs through September 2020. By mutual agreement between the DOH and THNA, the plan did not require any updates; it just needed to be implemented. In Y4, as a result of implementing the joint action plan, CHPs identified and referred to PHCs 5,786 pregnant women, 1,044 children with signs of malnutrition, and 3,158 children with diarrhea. These figures constitute 38% of the annual target of 26,000 cases of all types (estimated 20 identifications/referrals per CHP). In Y4, THNA improved the referral tracking between CHPs and PHCs. The CHPs provide THNA with patient names and the reasons for referral. District coordinators reconcile this information at monthly district-level PHC medical council meetings, where they also discuss challenges in client referral and access to services with PHC managers and staff. In Q4 alone, CHPs identified and referred 1,233 women and 1,446 children (Activity 3.3.4). CHPs continued their close collaboration with rural PHCs in accordance with the joint action plan approved by the DOH. The volunteers continued submitting reporting forms with patient names and reasons for referral. In Y4, THNA continued inviting managers and staff of district-level PHCs and HLSCs to the volunteers’ monthly peer learning sessions (Activity 3.3.7). These meetings serve as a good platform for CHPs and HCWs to discuss their successes in joint activities, challenges, and solutions. CHPs raised several issues, including the fees for registering pregnant women for ANC, the fees for lab work, the low quality of services at rural facilities, and the long distances and costs associated with travel to district-level facilities. Based on the feedback from volunteers and HCWs, as well as from the monitoring visits to the target villages, cooperation between HCWs, volunteers, and VDCs strengthened considerably over the past year. CHPs face several challenges in identifying and referring cases to PHCs: • Clients referred by CHPs often do not even try to access medical services because of real or perceived costs; • Some HCWs do not recognize CHPs as a valuable resource for improving the health of their community: they do not engage with CHPs at the community level, nor do they respond to invitations to take part in the monthly volunteer peer learning sessions;

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 51

• The CHPs’ workload is very heavy, with home visits, cooking demonstrations, peer support groups, monthly meetings, and data reporting—the workload of 100 households per volunteer originally calculated by THNA is most likely too heavy. THNA continues working with CHPs, HCWs and health authorities to maximize the effectiveness of patient referral from the community level. After I had started working with the volunteers, my work became easier. Salomat Tadzhiboeva - our volunteer and my assistant, helps me with everything. Our village is large, and it was difficult for me to observe everyone on my own. It was particularly difficult to identify pregnant women, to register and to give advice at the same time. Some women didn’t disclose their pregnancy and we identified them at late stages. However, now, with the help of Salomat, most of our pregnant women are detected early, are under our observation, and undergo the necessary laboratory tests. Salomat is closer to women and they feel comfortable disclosing their pregnancy to her. When danger signs are detected, pregnant women are referred to us. Consequently, there are no births at home. The help of volunteers is timely and it’s valuable for us. Shukrona Islomi, PHC worker, Yakatut village, Jomi district

Photo 29. THNA volunteers and district coordinators meeting with PHC staff (photo credit: THNA)

3.3.7. Facilitate monthly peer learning sessions for CHPs In Y4, THNA achieved 156% of its annual target by facilitating 336 peer learning sessions (of the annual target of 216), with 1,582 CHPs (618 CHPs every month, on average), 270 VDC representatives, 914 PHC staff, and 138 HLSC representatives and active partners. The reason for overachieving the quarterly target was an increased number of meeting participants. THNA aims to engage 50% of all CHPs in monthly meetings to ensure their bimonthly participation. With the addition of PHC providers and VDC representatives, THNA had to increase the number of meetings to keep the group size manageable. Over the year, almost 380 rural PHC staff attended peer learning sessions. In Q4, THNA held 84 peer learning meetings for a total for 1,776 CHPs, allowing for double counting. At these meetings, CHPs shared their experiences through group work, presentations, role-plays, games, and other interactive exercises. THNA staff recognized an improvement in CHPs’ skills in facilitating, presenting, measuring with the mid-upper arm circumference (MUAC) tape, and identifying children with malnutrition. During peer learning meetings over the past year, CHPs shared their achievements. The most well- recognized achievements are as follows: • CHPs identify pregnant women early and refer them for ANC. CHPs also refer pregnant women with danger signs. Many CHPs accompany pregnant women to rural health facilities THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 52

and even to CDH maternity departments. As a result, more pregnant women are registered early for ANC and fewer births are occurring at home. This success is supported by a significant increase (p<0.01) in the percentage of women who made four or more ANC visits during their last pregnancy, from 56% in 2016 to 86% in 2019 (Figure 21). Figure 21. Women who had four or more ANC visits, RHS rounds 1-–5 and control communities in 2019, %

86%

69% 68% 60% 56% 48%

Oct'2016 May'2017 Nov'2017 Jun'2018 Jun'2019 Jun'2019 Control

Figure 22. Respondents who know that pregnant women should eat more than usual, RHS rounds 1–5 and control communities in 2019, %

Figure 23. Respondents who know that lactating women should eat more than usual, RHS rounds 1–5 and control communities in 2019, %

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 53

• CHPs identify and refer more children with malnutrition and diarrhea. This may have affected the hospitalization rates of children with malnutrition reported by HCWs. CHPs follow up with families with malnourished children until the children are fully recovered. • CHPs conduct more cooking demonstrations in their communities. In some villages, people asked for cooking demonstrations at their households. As a result, women are using the recipes promoted by volunteers for pregnant and breastfeeding women and children over six months of age. The knowledge of women about nutrition during pregnancy and lactation improved significantly compared both to 2016 and to control communities in 2019 (Figures 22 and 23). • CHPs are more successful in establishing and facilitating community peer support groups for mothers-in-law, women of reproductive age, and men. Volunteers recognize more support from mothers-in-law in referring their pregnant daughters-in-law for ANC. • CHPs themselves organized and conducted WASH events in their communities and contributed to the construction of VIP latrines in health facilities. A CHP from Balkhi district noted that as a result of her WASH event, 33 out of 55 households now have washstands. • CHPs are better accepted and appreciated by their communities. Volunteers note that community members have become more engaged in promoting and addressing the health needs in their communities. In two villages in Khuroson district, Navzamin and Pakhtaobod, the communities recognized the importance of health services and constructed rural PHC facilities with their own resources. • Volunteers feel that collaboration between CHPs, CEs, local HCWs, and VDCs has improved. At the peer learning meetings, CHPs discussed the following challenges, among others: • Gathering community members for events is challenging because they may be busy with house chores and field work. It was difficult for CHPs to gather the expected 20 people for cooking demonstrations and peer support group meetings. • Not all pregnant women referred by CHPs to health facilities actually access those health services because decisions in the household are made not by pregnant women, but by mothers-in-law or men (Figure 24). ANC is often deferred due to the real or perceived costs of lab tests, ultrasounds, and other services. Figure 24. Women making decisions regarding their own health care, RHS rounds 1–5 and control communities in 2019, %

• Despite the acceptance of CHPs by most community members, some households still do not accept CHPs or do not follow their recommendations on health and nutrition matters. For

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 54

instance, some men in Mehrgon village, Jomi district do not allow CHPs to conduct counseling and educational sessions in their households. • Despite CHPs’ efforts around exclusive breastfeeding, some women still feed their children under six months with formula and/or animal milk, either instead or in addition to breast milk. At the peer learning sessions, THNA tested CHPs on topics relevant to their work to identify gaps in their knowledge. These gaps were then addressed through refresher trainings at the same meeting. The average percentage of correct responses on monthly tests in Y4 reached 81%. The tests helped identify and recognize 1,544 CHPs (allowing for double counting) with exceptional knowledge and practical achievements in their villages, who were awarded small prizes as incentives. In Y4, THNA facilitated 38 CHP cross-district exchange visits, which were very popular among volunteers. A total of 23 winners of volunteer competitions traveled to other districts to share their experiences and best practices at monthly peer learning sessions. These highly successful volunteers discussed a variety of topics, including: • Who is a volunteer? What is volunteerism? Who can become a volunteer? • Successful volunteers as assistants to district coordinators; • Information materials that help volunteers conduct effective sessions; • What is effective group work? • What is important when organizing a cooking demonstration? • Results of close collaboration between CHPs and CEs; • Effective work with young mothers and mothers-in-law; • How to work in communities with Uzbek- and Tajik-speaking populations; • How to improve facilitation skills. In Y4, THNA identified additional health and nutrition information needed to be disseminated to the communities. In Y5, THNA together with HLSC staff will prepare information and key messages on (1) intestinal parasites and dehelminthation, and (2) care for children with diarrhea and the prevention of environmental enteropathy. In our village, we are three community health promoters. Every month, we talk about the importance of iodized salt in households. Once I visited a household where I found non-iodized salt, and I asked to show me the shop where the salt wat purchased. I thought to myself: It would be so much better to work with entrepreneurs and educate them on the benefits of iodized salt. Next day, I gathered businessmen and gave them a small session on why we need iodized salt, and why it is so important for our community. Without much difficulty, I persuaded them to bring only iodized salt to our village. Umeda Abdulloeva, CHP, Somoni village, Jaikhun district We had a monthly meeting, where Rajabgul Komilova was introduced to us as the best volunteer from Balkhi district. We all looked at her with interest when she started a conversation and told her story about how she organized a special place for cooking demonstration. In the village, there is a large garden where Komilova works, and in the garden, there is a small room that was abandoned. She and her family cleaned and renovated the room. She invited three other volunteers and they hung up all the informational materials, banners, and posters on the walls. Everyone brought dishes from their houses and thus a special place for cooking demonstration activity was made ready for all volunteers. This is very convenient not only for us, but also for the women. CHPs don’t need worry about a place for demonstrations and can invite participants easily. After I returned home from the meeting, I kept thinking about how I could also organize such a place and become the best volunteer. I discussed this idea with the health workers in my village. There is THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 55

one free room in the health facility and the director agreed to give this room for cooking demonstration. Now pregnant women and women with children under five years of age come to the health facility and here we organize cooking demonstrations. It’s convenient because health workers can easily participate. After the cooking demonstration, they can consult the women who need it. This shows teamwork and good collaboration between health workers, community and CHPs. Thanks for Rajabgul for a good idea. Latofat Orifjonova, CHP, Havaskor village, Qabodiyon district Through meetings and events, I realized that there is much information about healthy food, but little information about unhealthy foods among children. In my sessions, I decided to give more information about the negative effects of unhealthy foods on children's development. I gave examples and compared a healthy to an unhealthy diet. Instead of unhealthy foods like instant noodles, chips, artificial juice powder, sweet artificial yogurt and croutons, I recommended them to make homemade crackers, homemade yogurt with fresh fruits, and homemade juices that are good for children. Of course, the advantages of breastfeeding and timely complementary nutrition are necessary for the development of children, but after three to four years, the consumption of artificial nutrients also harms the health of children and affects proper development. Cross-visits gave me the opportunity to tell other volunteers in Jaikhun, Balkhi and Shahritus districts about this. During my talks, questions and answers, I saw the enormous support of our volunteers and reaffirmed for myself that I have indeed chosen the right path. Ahmadsho Huseinov, CHP, Miskinobod village, Vakhsh district I am a volunteer and am proud of my volunteer work. In our village, some pregnant women are not registered with doctors, and some families refuse vaccination. Once, I heard someone say that his grandchildren had fallen ill after vaccination. That is why he opposed vaccinating his grandchildren. He did not want to listen to my explanations and told me that I was not a doctor and did not know what immunization was. I showed him my volunteer's certificate and showed his family and him the informational materials about vaccination (in the Rohnamo) and the importance of immunization. I emphasized that after immunization, the child might have a fever for only one or two days, but the benefit will be the prevention of infectious diseases for the child for many years to come. After my explanation, they finally relented and took their children to the village medical facility for vaccination. In my daily work, there are many such cases, and I am glad that with my work I am helping to improve the health of the children in my village. Tamanno Toshmatova, CHP, Faroqat village, Qabodiyon district Photo 30. CHPs at monthly peer learning meetings (photo credit: THNA)

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 56

3.3.8. Competition for service excellence and other incentives for volunteers In Q1–Q2, THNA ran 11 district-level competitions for service excellence among community volunteers (Photo 31). The goal was to recognize the best volunteers and motivate others to excel in their community work. These events brought together a total of 376 volunteers (167 CHPs and 149 CEs) identified through their monthly service reports and knowledge tests at monthly learning sessions. THNA engaged the contestants in group and individual exercises, quizzes, and role-plays. As a result, 66 volunteers (six per district, three CHPs and three CEs) were recognized as the competition winners. They were awarded with diplomas and sets of saucepans of varying sizes for cooking demonstrations in their communities, as well as blankets. Other participants received symbolic gifts and letters of appreciation.

Participation in the competition gave me confidence in my volunteer activity. I met many volunteers from other villages. We exchanged contacts and agreed to communicate with each other to share experiences. We have a lot in common and we have many things to share. I have already planned exchange visits to neighboring villages. Shoira Sheralieva, CHP competition winner, Shahritus district

In Q2 of Y4, THNA held a regional competition among the winners of the district-level rounds for the Best Community Health Promoter and the Best Community Educator. A total of 63 volunteers from 12 districts (31 CHPs and 32 CEs) met in Bokhtar city. This was a rare opportunity for volunteers from different districts to meet each other and share their experiences. THNA engaged volunteers in a series of interactive exercises emphasizing teamwork, leadership abilities, and counseling and facilitation skills, rather than knowledge.

Photo 31. Volunteer competitions (photo credit: THNA)

As a result, six volunteers (three CHPs and three CEs) were selected as the winners. They received symbolic “Best THNA Volunteer” plaques and different cooking appliances or utensils, depending on their achievement during the competition: a small baking oven, a thermo pot or a saucepan. The other participants received gifts and certificates of participation. I was not expecting the volunteers to have such high-level skills. I was amazed at how they answered the questions, and their presentation skills and knowledge in both maternal and child health and agriculture were also commendable. Healthy lifestyle centers at the regional and district levels will in every way contribute to the further development of the volunteer movement in villages. Dr. Hakim Khudoiberdiev, regional HLSC director

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 57

In Q4 of Y4, THNA announced a new round of district-level competitions among community volunteers. In this competition, all volunteers were invited to present photos, videos, or essays about their own work and achievements. The goals of this round are to elicit visual and written materials from and about the work of community volunteers, to encourage volunteers to document and share their work through communication channels, to recognize the best communicators, and to publicize THNA’s community work to stakeholders at different levels. By the end of Q4, THNA received 115 essays, 95 photos, and 15 videos for the competition from community volunteers in all 12 districts. THNA will announce the competition results in Q1 of Y5, at the monthly volunteer peer learning meetings in October. In Y4, community volunteers also received the following incentives: • 1,229 large blankets, 57 of which were also given to the winners of volunteer competitions (in addition, 807 were distributed in Q4 of Y3); • 1,868 large saucepans, 129 of which THNA awarded at volunteer monthly meetings to the best local partners: rural health workers, HLSC staff, and the most supportive VDC members; • 1,651 steam pots, of which the remaining 129 will also be awarded in Q1 of Y5 to the winners of the volunteer competition and the best community partners. In Q4, 1,868 umbrellas procured in February 2019 were finally delivered. They will be distributed as incentives to volunteers in Q1 of Y5.

Facility Level

3.3.9. Train local trainers at the hospital and PHC levels on supportive supervision around IMCI/integrated management of acute malnutrition (IMAM) This activity has been postponed until Y5 and will be implemented through nutrition resource centers. In Y4, the MOHSPP, with donor support, initiated a revision of the IMCI handbook and reporting forms to include the referral of children with malnutrition. In Y5, THNA will support this revision (Activity 4.1.1) with subsequent trainings on supportive supervision around IMCI/IMAM. In Y4, THNA has implemented a referral tool for children with malnutrition in 12 FTF districts (Activity 1.3.1).

3.3.10. Facilitate supportive supervision visits to hospitals and PHCs on IMCI and IMAM This activity has been postponed until Y5, following Activity 3.3.9.

3.3.11. Conduct two-day trainings for health care staff from numeric hospitals on hospital IMCI/IMAM This activity has been modified due to the revision of the IMCI handbook and reporting forms initiated by the MOHSPP (Activity 4.1.1). Knowing that the revision may take a long time, THNA implemented this activity and trained HCWs on hospital IMCI though the hospital-level nutrition resource centers. As a result, in Y4, THNA reached 152% of its annual target by training 91 HCWs from numeric hospitals (46 doctors and 45 nurses/midwives from 12 districts, Table 13) through two-day trainings on hospital-level IMCI at nutrition resource centers. In Q4, 44 HCWs from numeric hospitals (28 doctors and 16 nurses/midwives from 11 districts) were trained. THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 58

Table 13. HCWs from numeric hospitals trained on IMAM and the preparation of therapeutic nutrition in Y4, by district

Jomi Total Dusti Nosiri Balkhi Yovon Vakhsh Vakhsh Jaikhun Khusrav Khusrav Levakant Shahritus Khuroson Khuroson Qabodiyon Kushoniyon

# of doctors 3 6 6 6 4 1 2 1 2 3 5 7 46

# of neonatal and 3 1 5 1 12 1 3 - 4 2 8 5 45 pediatric nurses

Total # of HCWs 6 7 11 7 16 2 5 1 6 3 13 12 91

In addition, in Y4, district trainers provided 635 CME person-sessions at hospital-based nutrition resource centers. In Q4 alone, hospital-level nutrition resource centers provided 258 person- sessions on hospital-based IMCI.

As a result of the trainings, more malnourished children were identified (Activity 3.3.14), and their hospitalization and treatment rates also increased (Figure 25). In Dusti, Balkhi, and Shahritus districts, therapeutic treatment is available at the PHC level, and children with a weight per height Z-score <-2Z, and sometimes <-3Z, receive outpatient treatment. Therefore, the average percentage of children with malnutrition hospitalized in these districts is only 11%, while in other districts the average is 27% (Table 14). In Qabodiyon district, most children with malnutrition receive treatment at Shahritus PHC facilities because of their proximity.

Figure 25. Number of children hospitalized with SAM, by district and quarter, Y4

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 59

Table 14. Percentage of children with malnutrition hospitalized, by district, Y4 District % of children with malnutrition hospitalized Dusti 18% Treatment available at the Balkhi 12% hospital and PHC level Shahritus 3% Average 11% Jaikhun 21% Jomi 64% Kushoniyon 20% Khuroson 20% Treatment available only at Levakant 13% the hospital level Nosiri Khusrav 32% Qabodiyon 7% Vakhsh 36% Yovon 34% Average 27%

3.3.12. Train medical providers from rural PHC facilities on nutrition topics In Q1, THNA trained 349 HCWs (of the annual target of 390) from 340 rural health centers through 19 two-day training sessions on mother and child nutrition. Of these training participants, only 116 (33%) were physicians, while the rest were midwives and family nurses. Pre- and post-training tests demonstrated an improvement in participants’ knowledge from an average of 62% to 89% of correct responses. Photo 32. Training at a nutrition resource center (photo credit: THNA) In Y4, THNA supported trainings for HCWs on nutrition- related topics through CME activities at 24 nutrition resource centers reported under Activity 1.1.5 (Photo 32). Through these CME activities, THNA reached 328% of its annual target by training a total of 1,279 HCWs at the PHC level (390 was the annual target). Overall, both at the PHC and hospital levels, THNA supported 9,559 person-sessions on nutrition-related topics at 24 nutrition resource centers: 1,612 person-sessions for doctors and 7,947 for nurses (Table 15). Of them, 241 HCWs were trained through 3,148 person-sessions in Q4: 530 for doctors and 2,618 for nurses.

To support this activity, in Q2, THNA provided furniture for 24 rural PHCs through an in-kind sub-grant to the DOH (Activities 7.2 and 7.4). In Q4, THNA provided 376 scales and 342 height meters for rural PHCs (Activity 7.4). Based on an updated needs assessment and available budget, THNA procured more scales and height meters than the 250 initially planned.

In Y5, THNA will continue supporting CME activities for PHC HCWs.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 60

Table 15. Number of person-sessions on nutrition at 24 nutrition resource centers, by level and topic Hospital level PHC level

and and

Total under five under IYCF IYCF pregnancy pregnancy

Nutrition Nutrition Rohnamo Rohnamo in i n Malnutrition

Breastfeeding Breastfeeding children Nutrition of women

Doctors 133 181 141 106 155 170 207 118 50 351 1,612 Nurses 452 567 278 215 1,225 1,588 931 937 495 1,259 7,947 Total: 585 748 419 321 1,380 1,758 1,138 1,055 545 1,610 9,559

3.3.13. Support district IMCI centers in regular IMCI computerized adaptation and training tool (ICATT)/IMCI trainings

In Y4, THNA achieved 150% of the annual target by training 361 HCWs on ICATT/IMCI (240 HCWs trained being the annual target). Of them, 79 HCWs were trained in Q4. In Y4, nutrition resource centers at the PHC level delivered 37 CME sessions on ICATT/IMCI, of which 12 were delivered in Q4 for 28 doctors and 51 nurses from PHCs. In Q4, 34 out of 79 participants achieved the required scores and received electronic ICATT/IMCI certificates. In Y4, THNA supported this activity at the PHC level by providing 12 laptops for 12 district IMCI centers. In Q4, THNA conducted a TOT on ICATT/IMCI for 13 directors of the regional and district IMCI centers. At the end of training, each participant created a schedule of ICATT/IMCI trainings at the district level. In Q4, THNA facilitated 12 supportive supervision visits by regional supervisors to district IMCI centers to ensure the quality of the ICATT/IMCI trainings. During the visits, the supervisors: • Checked adherence to the training schedule; • Verified the content of the training sessions; • Ensured the completeness of the course by staff and the awarding of certificates; • Discussed training needs with trainees and provided feedback. In Q4, the supervisors reported that IMCI centers had implemented the following recommendations from Q2: • Created lists of HCWs and training schedules on ICATT; • Reported on CME activities quarterly; • Organized obligatory computer skills trainings for HCWs. Other recommendations, such as bonuses and other types of motivation for HCWs to take ICATT/IMCI training, have not been implemented, which slows down uptake of the training. Considering that the total number of PHC staff in FTF districts is 2,394, their coverage with ICATT/IMCI training is still low (only 15.1%). In Y5, THNA will work on the sustainability and quality of ICATT/IMCI training through nutrition resource centers at the PHC level and under the supervision of QI committees.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 61

3.3.14. Organize semiannual GMP campaigns and referral of children under five with malnutrition by local PHC providers for treatment During Y4, THNA helped identify 1,296 children with MAM and SAM (weight to height <-2Z and <- 3Z, respectively) in the 12 FTF districts through two semiannual GMP campaigns. In Y4, THNA supported 288 person-sessions on GMP at PHCs and hospitals to refresh HCWs’ knowledge and skills in weight and height measurement and the use of the MUAC tape. Of these, 136 person-sessions were provided in Q4. As a result of the GMP campaigns in Y4, 1,296 children were newly diagnosed with MAM or SAM, and 376 with mild malnutrition (weight to height <-1Z) (Table 16).

Table 16. Number of children under five diagnosed with malnutrition, by district and Z-score Y4 Q1 (December 2018) Y4 Q3 (June 2019) Total # of children <-2Z <-3Z Total # of children <-2Z <-3Z with SAM or MAM with SAM or MAM Total: 418 364 54 878 671 207 % 87% 13% 76% 24%

No children with a score <-4Z have been identified in the past 18 months. This finding may be the result of THNA’s progress in the screening, referral, and follow-up of children with malnutrition at all stages of care and the effective promotion of proper nutrition for mothers and children. To support the GMP campaigns, in Q4, THNA provided rural PHC facilities with 376 scales and 342 height meters (Activities 3.3.14 and 7.4). 3.3.15. Conduct a regional-level conference on the progress of IMAM activities This activity has been postponed until Y5. Its timing will depend on the progress made under Activities 3.3.9, 3.3.10, and 4.1.1.

IR4: INSTITUTIONALIZED EVIDENCE-BASED MNCH SERVICES THROUGH NATIONAL-LEVEL POLICIES AND STANDARDS

Outcome 4.1: Cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH

4.1.1. Support the technical working group in updating the ICATT/IMCI training package In Y4, the MOHSPP postponed its approval of the updated ICATT/IMCI training package until the hospital-level IMCI pocketbook has been revised. The World Health Organization initiated the revision of the pocketbook to integrate ICATT/IMCI into one guideline for both levels of care. It is expected to be approved in Q1 of Y5. In Q4, THNA provided support and participated in the work of the technical working group on updating the IMCI handbook. THNA expects that the updated ICATT/IMCI training package will be approved and implemented in Y5.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 62

4.1.2. Develop a comprehensive training package for PHC workers on nutrition for mothers, newborns, and children under two In Y4, THNA fully completed the development of a comprehensive training package for PHC workers on nutrition for mothers, newborns, and children under two and had it approved by the MOHSPP by Order #873 on October 20, 2018. The training package is currently implemented nationwide and is included in the postgraduate training curricula for family doctors and family nurses at the Republican Center of Family Medicine, the Tajik Institute of Postgraduate Training of Medical Staff, Tajik State Medical University, and the Republican Medical College.

4.1.3. Develop a comprehensive training package for PHC workers on anemia management for adolescent girls, pregnant women, and women of reproductive age In Y4, THNA fully achieved the expected result by developing a comprehensive training package for PHC workers on anemia management and prevention in women of reproductive age and children under five. THNA designed the training curriculum in partnership with the Republican Center of Family Medicine, and the MOHSPP approved it for nationwide implementation by Order #107-001 on May 17, 2019. Currently, the training package is included in the curricula for family doctors at the Republican Center of Family Medicine, the Tajik Institute of Postgraduate Training of Medical Staff, and Tajik State Medical University.

4.1.4. Implement the guidelines on neonatal care, including KMC In Y4, THNA made significant progress toward implementing the guidelines on neonatal care, including KMC. THNA trained 22 district trainers on KMC who, in turn, have trained 495 HCWs. As a result, 41% of eligible newborns in THNA districts received KMC in Y4 (Activity 1.1.1).

4.1.5. Support local participation in national events on nutrition The Third National Nutrition Forum was postponed until Q1 of Y5. THNA will support this event by presenting the results of its four years of work, inviting district representatives, and inviting the winners of the regional nutrition competition to create an exhibit.

Outcome 4.2: Evidence-based approaches for MNCH, including nutrition, sanitation, and hygiene, are sustainable

4.2.1. Coordinate the implementation of the joint action plan among PHCs, CHPs, and VDCs through quarterly DOH-level meetings with PHC managers and other key stakeholders In Y4, THNA reached its annual target by organizing four quarterly coordination meetings with stakeholders in Bokhtar city. A total of 56 district health care managers and DOH and MOHSPP representatives took part in the meetings: 12 PHC managers, 12 heads of district hospitals, 12 directors of hospital IMCI departments, 12 heads of district HLSCs, the head and five representatives of the DOH, and two staff members from the national HLSC, including its deputy director. THNA staff included senior management, the clinical team, and district coordinators. THNA also invited representatives from UNICEF and WFP. As a result of these meetings, the stakeholders agreed on the following actions:

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 63

On the part of the DOH: • Provide a proposal to the MOHSPP to include MAM and SAM to the list of IMCI conditions excluded from fees for services under Decree No. 600 of the Government of the Republic of Tajikistan of December 2, 2008; • Collect and analyze data on the growth and development of children under five, including MAM and SAM indicators, for regular statistical reporting and monitoring; • Train staff on IMCI at each PHC; • Monitor the activities of the QI committees.

On the part of PHCs: • Actively engage in the selection and support of volunteers; • Improve the early detection and registration of pregnant women and children with malnutrition; • Exchange information and closely collaborate with volunteers on the referral of pregnant women, malnourished children, and children with diarrhea; • Improve the quality of home visiting services and outpatient treatment for children with malnutrition; • Train rural PHC staff on nutrition and counseling of pregnant women and children under five as part of CME at nutrition resource centers; • Strengthen the interaction between CHPs and HCWs in the implementation of the joint action plan; • Actively participate in THNA’s health fairs and nutrition competitions; • Participate in cooking demonstrations and support groups meetings; • Motivate volunteers by providing them with services free of charge.

On the part of HLSCs: • Actively engage in the selection and training of new volunteers; • Engage trained volunteers in community activities that promote healthy lifestyles; • Increase media awareness of healthy nutrition and healthy lifestyles, especially for children and mothers; • Strengthen the role of volunteers in identifying and referring pregnant women and children with malnutrition; • Organize seminars for the heads of VDCs and for active community members; • Strengthen work with family members (mothers-in-law and husbands) and religious leaders on healthy nutrition, sanitation, and hygiene; • Increase interaction between volunteers and medical staff on the implementation of the joint action plan; • Actively participate and support THNA’s health fairs and nutrition competitions; • Participate in volunteer monthly sessions, which are organized by THNA.

On the part of THNA: • Support activities to improve the nutrition of women and children under five within the workplan approved by the MOHSPP; • Provide information materials; • Provide monitoring results and recommendations to the DOH and PHCs;

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 64

• Transfer the organizational and management experience in supporting community volunteers to the HLSCs.

4.2.2. Support World Breastfeeding Week in collaboration with other partners In Y4, THNA achieved 215% of its annual target by reaching at least 4,300 community members with publicly disseminated exclusive breastfeeding messages during World Breastfeeding Week. During World Breastfeeding Week, CHPs conducted sessions on exclusive and continuing breastfeeding in target villages, reaching over 4,300 community members with key messages. For these events, THNA printed and distributed 1,500 Tajik-language brochures on exclusive and continuing breastfeeding entitled, “Breastfeeding is the basis of life.” In addition, THNA supported the DOH in implementing regional activities during International World Breastfeeding Week (occurring over ten days in Tajikistan, August 1–10), which would mirror those at the national level. THNA printed 13 banners and one billboard poster for the DOH, as well as 6,000 copies of the “Breastfeeding is the basis of life” brochures for the 12 target districts. In addition, during World Breastfeeding Week, THNA organized four health fairs (Activity 3.3.5).

4.2.3. Regularly present data from the MNCH database to the DOH and MOHSPP In Y4, THNA clinical staff regularly updated the MOHSPP and DOH of Khatlon Region on THNA’s progress and achievements through written reports and presentations at official meetings. In particular, THNA reported on infection control monitoring at the PHC and hospital levels, the results of the GMP campaign, capacity-building activities by nutrition resource centers, CME sessions at nutrition resource centers, and the nutrition competition among PHC facilities.

4.2.4. Support national-level quarterly advisory MNCH meetings at the MOHSPP as needed In Y4, THNA participated in most MNCH-related meetings and workshops at the national and regional levels. In Q4, THNA staff participated in 11 MNCH and nutrition-related meetings. The MOHSPP revived the MNCH Coordination Council for national and international partners. The MNCH Coordination Council will serve as an effective mechanism for strategizing goals, assessing possibilities, and offering input into the development of the National Health Strategy 2030. THNA will support a national workshop in preparation for the Third National Nutrition Forum in October 2019. 4.2.5. Host two Donors Coordinating Council meetings to discuss nutrition awareness activities THNA representatives regularly attended the Donors Coordinating Council meetings on health during Y4. No requests came from the European Commission to host Donors Coordinating Council meetings.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 65

MONITORING, EVALUATION, AND LEARNING

In Y4, THNA’s activities on monitoring, evaluation, and learning included the following: • Fully revising, redesigning, and simplifying the data collection forms for CHPs and CEs; • Reorganizing data management and targeting of expected results to the level of specific districts and individual community volunteers; • Shifting data entry and storage from Microsoft Excel to IntraHealth’s online integrated Human Resource Information System (iHRIS) database; • Running regular data quality assessments, which resulted in the improved accuracy of data reported by community volunteers; • Developing and implementing THNA’s annual learning plan around barriers to exclusive breastfeeding and the community-based referral system for children with malnutrition and pregnant women, based on USAID’s principles of collaborating, learning, and adapting; • Implementing the fifth round of the Recurring Household Survey (RHS) and the third round of the Recurring Agricultural Practices survey, to measure THNA’s outcome indicators; • Submitting THNA’s first peer-reviewed publication, which was selected for a poster presentation at the upcoming FTF 7th Annual Scientific Symposium on Agriculture entitled “Nutrition: Pathway to Resilience” in December 2019 in Nepal.

Data collection instruments

In Q1, THNA fully revised and redesigned the data collection forms for CHPs and CEs. To simplify data collection, several forms were merged into one. The new forms also allowed additional data to be collected. Piloting of the data collection forms showed that community volunteers favored the revised forms over the old ones. Instead of printing the forms for the full year, THNA provided them to volunteers on a monthly basis at the peer learning sessions, so they could be adjusted quickly if necessary.

Targeting expected results

THNA reorganized its data management so that community service data could be collected and tracked at the individual volunteer level. Previously, THNA tracked data at the village level, which did not allow the assessment of project-wide reporting rates or the recognition of achievements by individual volunteers. The new THNA data management approach allows service targets to be set for individual volunteers and, cumulatively, for all volunteers in a district. Then, it allows the reports and achievements of specific volunteers to be tracked, and the highest-achieving volunteers can be recognized at monthly peer learning sessions. THNA believes that this reorganization was one of the reasons why Y4 targets were significantly overachieved: it improved reporting rates and incentivized community volunteers to excel in their community work. iHRIS

In Y4, IntraHealth completed the adaptation of iHRIS so it could meet specific THNA needs. These included the collection, tracking and reporting of data on the level of individual volunteers; data disaggregation meeting USAID reporting requirements; and tracking activities specific to THNA, such as training and counseling topics, cooking demonstrations, peer support groups, etc.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 66

Subsequently, in Q4, THNA shifted the storage of data from Excel to iHRIS. In Y5, THNA will use only the iHRIS database for data storage and analysis.

Data Quality Assessment (DQA)

In Y4, THNA checked more than 500 data sources (community volunteer reports) for data accuracy. Between October 2018 and August 2019, data quality improved from 62% to 92% of correctly reported data (Figure 26).

Figure 26. DQA results, Y4

11% 8% 9% 10% 9% 8% 18% 20% 38% 33%

89% 92% 91% 90% 91% 92% 82% 80% 62% 67%

October November December January March April May June July August Q1 Q2 Q3 Q4

Reported correctly Reported incorrectly

Based on the DQA results, THNA adjusted its reported achievements in Y4: indicator EG.3.22 was underreported by 6% in Q1–Q3; indicator HL.9-33 was overreported by 10%; and indicator HL.9-24 was overreported by 18%. The annual report (the “Progress toward targets” table below) has been adjusted based on these DQA results.

Learning plan

In Q1 and Q2, THNA designed its annual learning plan, which incorporates USAID’s principles of collaborating, learning, and adapting project experience. In Y4, the learning plan focused on improving the community-based referral system and identifying barriers to exclusive breastfeeding.

In Q2, to improve the community-based referral system, THNA implemented a reporting form on which CHPs record the personal information of individuals referred to PHCs. THNA uses this information in meetings with health providers at the village, district, and regional level to reconcile the numbers recorded by CHPs with those provided by HCWs (Activities 3.3.6 and 4.2.1).

2 EG.3.2: Number of individuals participating in USG food security programs 3 HL.9-3: Number of pregnant women reached with nutrition-specific interventions through USG-supported programs 4 HL.9-2: Number of children under two (0-23 months) reached with community-level nutrition interventions through USG-supported programs

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 67

In Y4, CHPs identified and referred 2,579 children with diarrhea, 5,306 pregnant women, and 1,044 children with suspected signs of malnutrition. Since Q2, 84% of those identified with suspected signs of malnutrition had reached health facilities. Due to lack of resources, THNA was able to track only the identified and referred children with signs of malnutrition. Tracking identified and referred beneficiaries has been very challenging for THNA in previous years; however, with the learning plan, there is now a mechanism in place that further links CHPs with health facilities. In Y5, THNA will work with CHPs and health facilities to scale up the community- based referral system. In Q2, to increase prevalence of exclusive breastfeeding in the target communities, THNA conducted a series of focus group discussions and interviews to identify barriers to exclusive breastfeeding. The main factors preventing women from exclusive breastfeeding were found to be a lack of family support for breastfeeding women, the burden of household and field work, and some myths surrounding the practice. Based on these results, THNA designed key messages on exclusive breastfeeding for CHPs to promote through various interventions at the community level. The results of last RHS revealed that 72% of households in target communities do practice exclusive breastfeeding, which is 4% lower than in Y3. THNA believes that since the key messages on barriers to exclusive breastfeeding were introduced to CHPs only in Q2, and the RHS was conducted in Q3, it was too soon to measure the outcome of the CHPs’ sessions on barriers to exclusive breastfeeding.

Recurring Household Survey (RHS)

In Y4, THNA conducted the fifth round of the RHS. Eight teams of THNA district coordinators surveyed four target and two control communities. THNA selected the control communities from districts in Khatlon Region that are not in the FTF ZOI but have similar characteristics as those of the target districts. The field work took place from June 11 to 15, 2019. THNA staff interviewed a total of 364 respondents: 244 in the target and 120 in the control communities (100% response rate). See Annex 2 for the RHS report.

Recurring Agricultural Practices Survey

In Y4, THNA completed its third round of the Recurring Agricultural Practices Survey. Field work for the third round was conducted from September 18 to 24, 2019. Four teams of THNA district coordinators interviewed 404 respondents. See Annex 3 for the full report.

FTF’s 7th Annual Scientific Symposium in Nepal

Based on the results of five rounds of the RHS, THNA submitted an abstract that was selected for a poster presentation for the upcoming 7th Annual Scientific Symposium, in Nepal from December 10 to 12, 2019. See Annex 4 for the abstract.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 68

Progress toward targets

Progress Purpose FY19 Q-ly FY19 quarterly achievements toward Indicator / Output target target annual target Q1 Q2 Q3 Q4 HL.9-4: Number of individuals receiving Output nutrition-related 696 671 758 1,290 (IR 1, 2, 2,800 700 122% professional training (99%) (96%) (108%) (184%) & 3) through USG-supported programs HL.9-1: Number of children Output under five reached by 44,603 49,781 56,373 59,119 (IR 2 & 140,000 35,000 140% USG-supported nutrition (127%) (142%) (161%) (169%) 3) programs EG.3.2-24: Number of farmers and others who Output have applied improved 240,000 145,000 N/A N/A N/A N/A 165% (IR 2) technologies or (165%) management practices with USG assistance HL.9-3: Number of Output pregnant women reached (linked 21,137 23,553 33,614 26,542 with nutrition 50,000 12,500 199% to Result (169%) (188%) (269%) (212%) interventions through 1, 2, & 3) USG-supported programs HL.6.6-1: Number of cases Output 1,517 1,380 3,906 15,188 of diarrhea treated in USG- 20,000 5,000 110% (IR 3) (30%) (28%) (78%) (304) assisted programs HL. 6.2-1: Number of women giving birth who Output received uterotonics in the 17,088 7,459 11,220 13,069 35,000 8,750 140% (IR 1) third stage of labor (195%) (85%) (78%) (149%) through USG-supported programs EG.3.3-10: Percentage of female participants of USG New nutrition-sensitive 90% 90% 90% N/A N/A N/A 100% Indicator agriculture activities (100%) (100%) consuming a diet of minimum diversity EG 3.2: Number of

New individuals participating in 400,000 100,000 149,151 162,426 171,421 196,797 180% Indicator USG food security (149%) (162%) (171%) (197%) programs

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 69

Detailed analysis of selected indicators In Y4, THNA reached 195,764 children under five, of which 96,605 (49%) were boys and 99,159 (51%) were girls. THNA achieved 140% of the annual target in Y4. Through clinical activities, in Y4, THNA reached 31,358 children under five.

In Y4, THNA had initially reported reaching 178,518 of children under five through its community- based activities, but this number was adjusted based on the results of the DQA. The assessment revealed that THNA overreported data on children under five by 18% in Y4, therefore THNA adjusted the achievements by 18%.

Figures 27–29 show the community-based monthly achievements by district in Q4 on three FTF indicators. The monthly targets for each district were based on the expected number of beneficiaries to be reached by each volunteer per month and the number of volunteers in the district. With regard to indicator HL.9-1, in Q4, THNA reached 45,782 children under five, of which 20,025 (47%) were boys and 22,757 (53%) were girls (Figure 27). THNA achieved 122% of the quarterly target for Q4. Through its clinical activities, THNA reached 13,337 children under five. The reasons for overachieving the target include the following: (1) Underestimating volunteers’ potential when setting the target a year ago when the new CE/CHP model was in operation for just a few months; (2) Data collection and tracking on the level of individual volunteers introduced in Q1, as well as simplification of data collection forms, which significantly improved reporting rates; (3) Setting and monthly tracking of the targets on the level of specific districts and individual volunteers throughout the year. THNA has set a more realistic target for Y5 based on Y4 results.

Figure 27. HL.9-1: Number of children under five reached by USG-supported nutrition programs HL.9-1: Indicator’s Target Achievement, July–Sept. 2019 (%) 250%

200%

150%

100%

50%

Jul Aug Sep TARGET

In Q4, there was only one district, Levakant, that did not meet its quarterly targets. The main reason for the unmet targets remains underreporting and inaccuracy in the provided data, which has been confirmed by THNA DQAs.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 70

Figure 28. HL 9-3: Number of pregnant women reached with nutrition interventions through USG- supported programs HL.9-3: Indicator’s Target Achievement, July–Sept., 2019 (%) 300%

250%

200%

150%

100%

50%

Jul Aug Sep TARGET

In Y4, THNA reached 99,514 pregnant women, of whom 14,854 (15%) were under 19 years old and 84,660 (85%) were over 19 years old. Through clinical activities, in Y4, THNA reached 51,527 pregnant women. THNA achieved 199% of the annual target in Y4. The reasons for overachieving the target include the following: (1) Underestimating volunteers’ potential when setting the target a year ago when the new CE/CHP model was in operation for just a few months; (2) Data collection and tracking on the level of individual volunteers introduced in Q1, as well as simplification of data collection forms, which significantly improved reporting rates; (3) Setting and monthly tracking of the targets on the level of specific districts and individual volunteers throughout the year. THNA has set a more realistic target for Y5 based on Y4 results.

In Y4, THNA had initially reported reaching 53,319 pregnant women through its community-based activities, but this number has been adjusted to 47,987 based on the DQA results, which revealed that on average, THNA overreported data on pregnant women by 10% in Y4.

In Q4, THNA reached 26,454 pregnant women, of whom 5,295 (20%) were under 19 years old and 21,250 (80%) were over 19 years old. THNA achieved 212% of the quarterly target for Q4. Through its clinical activities, THNA reached 13,337 pregnant women.

In Q4, eight out of 12 target districts did not achieve their quarterly targets, which may be due to the fact that there are fewer pregnant women in these districts than in other districts or due to inaccuracies in the reported data. It is also possible that the volunteers in these districts did not target households with pregnant women.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 71

Figure 29. EG 3.2: Number of individuals participating in USG food security programs EG.3.2: Indicator’s Target Achievement, July–Sept., 2019 (%) 300%

250%

200%

150%

100%

50%

Jul Aug Sep TARGET

In Y4, THNA reached 720,583 individuals with food security programs, of whom 144,117 (20%) were male and 576,466 (80%) were female. THNA achieved 180% of the annual target in Y4. The reasons for overachieving the target include the following: (1) Underestimating volunteers’ potential when setting the target a year ago when the new CE/CHP model had been in operation for just a few months; (2) Data collection and tracking on the level of individual volunteers introduced in Q1, as well as simplification of data collection forms, which significantly improved reporting rates; (3) Setting and monthly tracking of the targets on the level of specific districts and individual volunteers throughout the year. THNA has set a more realistic target for Y5 based on Y4 results.

In Q4, THNA reached 196,797 individuals with food security programs, of whom 34,830 (18%) were male and 161,967 (82%) were female. THNA achieved 197% of the quarterly target for Q4, and all districts were successful in achieving or overachieving their targets.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 72

GENDER

THNA implements its nutrition strategy by targeting women of reproductive age who are at an increased risk of having micronutrient deficiencies and raising malnourished children. THNA focuses on individuals and families by supporting direct, targeted interventions, such as individual counseling and peer support groups, which facilitate transformative learning. THNA incorporates gender-sensitive approaches into its nutrition-specific interventions, in line with the nutrition strategy and in accordance with the results of the nutrition behavior study. This integration includes strengthening THNA’s targeted approach to women by encouraging opportunities for improving livelihoods and savings through the agricultural sector and by focusing on men as household providers and purchasers of nutrient-rich food. THNA implements its nutrition strategy by targeting women of reproductive age, with a focus on individuals, families, and peer support groups, to facilitate transformative learning. Support groups were organized for women of reproductive age, for mothers-in-law, and for men. Involving men and women in agricultural activities gives women equal access to resources. Through the provision of agricultural counseling and training sessions to households, THNA increased women’s knowledge in home garden management. THNA involves both men and women in practical household budgeting trainings, which highlighted the role that women can play in making decisions regarding daily household expenses. THNA continued other income-generating activities for women through poultry farming and food preservation. To achieve its objectives at the community level, THNA engaged 1,866 volunteers (499 CEs and 1,367 CHPs) from 499 villages. Of all volunteers, 1,711 (92%) are women. CEs promote agricultural and WASH practices, while CHPs focus on women’s and children’s health and nutrition. Both types of community volunteers attempt to engage both men and women. The volunteers’ goal is to ensure that the entire community is aware of the benefits of exclusive and continuing breastfeeding, and the nutritional needs of pregnant and lactating women, as well those of children under two. Of the total number of participants at THNA’s community-level events, an average of 80% are women. At the health system level, 284 (77%) of the 371 HCWs who received nutrition- related professional training from THNA were women. Another THNA activity related to gender is the construction of VIP latrines, accessible by males and females separately, six targeted schools. Furthermore, THNA trained 135 peer educators (86 of whom are girls, 64%) on issues related to their own health and hygiene. In Y4, THNA conducted 48 health fairs at the community level. The main reason for these events was to provide health services to women and children in the most remote communities. The total number of beneficiaries was 4,617, of whom 3,986 (86%) were women. In Y4, THNA strived to strengthen its work with men as family decision-makers through peer support groups. THNA volunteers initially focused on peer support groups for mothers-in-law, then for younger women with children; the focus is now on men. The survey on barriers to exclusive breastfeeding that THNA conducted in Q2 also highlighted the need for and importance of men’s support in this area. In Q3, THNA encouraged CHPs to promote exclusive breastfeeding concepts to male family members through different means, including peer support groups. By the end of Q3, at least 24 peer support groups for men were functioning in THNA communities.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 73

STAFFING & MANAGEMENT

THNA is led in country by IntraHealth International’s chief of party, Roman Yorick, and is supported by the deputy chief of party from Abt Associates, Gulnora Razykova. At the end of Y4, THNA is fully staffed with a total of 54 staff members, including 49 IntraHealth International and five Abt Associates staff. Of the staff members, 33 are located in the Bokhtar city regional office. In Y4, seven staff members resigned from their positions and were replaced with four staff members, who were either promoted within THNA or newly recruited. The responsibilities under three positions—nutrition coordinator, food security coordinator, and community coordinator—were divided among other THNA staff, and those positions have not been refilled. To strengthen its procurement and sub-granting activities, in Y4, THNA formed a procurement unit within the finance and administration department in Dushanbe. The unit is staffed by procurement officer Alisher Orzuev, who transitioned from the administration officer position at Abt Associates, and grant officer Suman Ansori, who transitioned from the position of IntraHealth’s finance officer. An updated THNA organizational chart is presented in Annex 5. In Q1, THNA conducted a survey on staff training needs. Based on the results, THNA conducted several in-house trainings on computer skills, procurement, agriculture, report writing, time management, and safety and security. In Y4, 12 IntraHealth International staff received sanatorium treatment certificates covered by the 2018–2019 social tax.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 74

BUDGET VS. EXPENDITURE ANALYSIS

The breakdown of expenditures against the current obligation is presented in Table 17. Table 17. Project-to-date obligation and burn rate Approved Actual Actual Spent to Cooperative Remaining Budget Category Year 4, September 30, Burn rate Agreement Budget Quarter 4 2019 Budget Personnel & Consultants $2 627 610 $ 156 973 $2 202 861 $424 749 84% Fringe Benefits $986 498 $ 55 447 $713 502 $272 996 72% Travel $500 989 $ 8 418 $434 321 $66 668 87% Equipment $7 500 $ - $8 265 -$765 110% Contractual $4 611 358 $ 106 538 $4 030 975 $580 383 87% Other Direct Costs $2 349 738 $ 267 385 $1 801 176 $548 562 77% Total Direct Cost $11 083 693 $594 760 $9 191 100 $1 892 593 83% Indirect Cost $2 075 138 $ 123 283 $1 525 348 $549 790 74% Total $13 158 832 $718 043 $10 716 448 $2 442 383 81% The breakdown of expenditures by program element/funding stream is presented in Table 18. Table 18. Quarterly expenditures by funding stream Year 4 Program element Quarter 4 4.5.2.8: Nutrition sensitive agriculture (ES-GFSI) $178 715 3.1.6 Maternal Child Health (GH-C) $396 228 3.1.9 Nutrition (GH-C-GFSI) $143 099 Total $718 043 Sub-grants

In Y4, THNA provided $279,214 worth of medical, training, and office equipment; furniture; construction materials; and printed information and communication materials in the form of sub- grants to the DOH and its facilities. This amount constitutes 28% of the total $1 million budgeted for sub-grants within THNA. By the end of Y4, THNA had disbursed a total of $844,895 (84.5%) worth of sub-grants. THNA will disburse the remaining $155,105 (15.5%) in Y5.

7.1. Sub-grant of agricultural tool sets for seven schools In Q1, THNA provided agricultural tools to seven secondary schools in Balkhi, Jaikhun, Kushoniyon, Levakant, Qabodiyon, Vakhsh, and Yovon districts. The total cost of this in-kind sub-grant to the DOH was $3,362.83. In Q4, THNA started the procurement of agricultural tools for three secondary schools in Khuroson, Shahritus, and Nosiri Khusrav districts. The delivery is expected in Q1 of Y5. The total cost of this in- kind sub-grant to the DOH is $1,329.88.

7.2. Sub-grant of furniture for 24 new community PHCs In Q2, THNA provided furniture for 24 community PHCs in Khatlon Region. The total cost of this in- kind sub-grant to the DOH was $28,168.86.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 75

7.3. Sub-grant of furniture and equipment for oral rehydration rooms In Q1, THNA provided medical furniture and basic equipment for 36 oral rehydration rooms in the 12 FTF districts of Khatlon Region. The total cost of this in-kind sub-grant to the DOH was $50,021.00.

7.4. Sub-grant of 250 sets of scales and height meters for PHCs In Q3, THNA procured 376 scales and 342 height meters for rural PHCs. Based on an updated needs assessment and available budget, THNA procured a larger number of items than initially planned. Delivery and distribution of the items were completed in Q4. The total cost of this in-kind sub-grant to the DOH was $28,288.53.

7.5. Sub-grant of additional computers for nutrition resource centers/IMCI centers In Q3, THNA purchased computer equipment for nutrition resource centers/IMCI centers at PHCs in the 12 FTF districts. In Q4, THNA distributed the computers during a training on ICATT/IMCI at the end of August. The total cost of this in-kind sub-grant to the DOH was $6,409.61.

7.6. Sub-grant of 12 sets of training dummies for PHCs and CDHs In Q3, THNA procured four types of training dummies in the United States. Delivery and distribution of the items were completed in Q4. The total cost of this in-kind sub-grant to the DOH was $39,975.00.

7.7. Sub-grant of furniture and equipment for 11 nutrition resource centers at the hospital level In Q1, THNA provided furniture and office equipment for nutrition resource/training centers at CDHs in 11 FTF districts of Khatlon Region. The total cost of this in-kind sub-grant to the DOH was $47,085.00.

7.8. Sub-grant to provide water supply for the maternity and pediatric departments of Dusti CDH In Q1, THNA received environmental clearance from USAID for this in-kind sub-grant. THNA procured plumbing and construction materials for the water supply and sewage system at the pediatric and complicated pregnancy departments of the CDH in Dusti district. In Q3, THNA provided the CDH with additional construction materials to build two septic tanks. The total cost of the procured goods was $10,874.00.

7.9. Sub-grant of 170 kits for family doctors at district PHCs In Q3, based on cost savings and identified need, THNA procured 270 kits for family doctors. In Q4, the delivery process began, and distribution to beneficiaries is expected in Q1 of Y5. The current cost of this in-kind sub-grant to the DOH is $25,530.96.

7.10. Sub-grant of 500 kits for family nurses In Q3, based on cost savings and identified need, THNA procured 800 kits for family nurses. In Q4, the delivery process began, and distribution to beneficiaries is expected in Q1 of Y5. The current cost of this in-kind sub-grant to the DOH is $34,833.44.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 76

7.11. Sub-grant to install VIP latrines in 100 selected medical centers From Q1 to Q3, THNA provided concrete rings and slabs to construct the underground portion of VIP latrines at 75 rural PHCs and delivered construction materials for the aboveground portion at 58 PHCs of Khatlon Region (Activity 3.2.3). The cost of this in-kind sub-grant to the DOH is $35,481.63. In Q4, THNA completed the selection and environmental checklists for the construction of one- person VIP latrines in 37 PHCs, and an eight-person VIP latrine in Shahritus CDH, for a total of 113 latrines. The completion of this sub-grant is expected in Q1 of Y5. The current cost of this additional in-kind sub-grant to the DOH is $35,481.63.

7.12. Sub-grant to improve infection control in maternity departments (autoclaves) In Q2, THNA provided one autoclave to improve infection control in Shahritus CDH. This procurement was combined with Activity 7.14.

7.13. Sub-grant of water pumps and water tanks for 12 PHC facilities In Q4, THNA provided water pumps and tanks, as well as construction materials for building water towers in nine medical facilities of Khatlon Region. THNA will report on the completion of this sub- grant after the medical facilities have finished the construction work in Y5. The total cost of this in- kind sub-grant to the DOH was $48,035.00.

7.14. Sub-grant to provide awards for a scorecard-based competition among health facilities In Q1, THNA completed procurement procedures for two lung ventilators and two phototherapeutic lamps for newborns for CDHs in Dusti, Jomi, and Yovon districts. This procurement was combined with Activity 7.12, at a total cost of $13,739.00. The medical equipment was provided through an in-kind sub-grant to the DOH in Q2.

7.15. Sub-grant for awards for the nutrition competition among PHCs In Q4, THNA provided air conditioners, printers, and small household-type refrigerators for participants and winners of the nutrition competition among PHCs. The total cost of this in-kind sub-grant to the DOH was $6,341.60.

7.16. Sub-grant of MNCH handbooks (Rohnamo) for PHC facilities to support pregnant women and children under two In Q2, THNA provided 40,000 copies of the MNCH Handbooks (Rohnamo) as an in-kind sub-grant to the DOH. The total cost of this sub-grant was $8,553.00.

7.17. Sub-grant to install VIP latrines and water reservoirs in six schools in Khatlon Region In Q4, THNA provided construction materials for eight-person VIP latrines. THNA will report on the completion of this sub-grant after the local communities have finished the construction work. The total cost of this in-kind sub-grant to the DOH was $40,178.00. In addition to the sub-grants above, in Q1, THNA completed the following two in-kind sub-grants initiated in Y3.

Metal molds In Q1, THNA delivered metal molds to 16 community masons to produce concrete rings and slabs for constructing VIP latrines in target districts of Khatlon Region. The total cost of this in-kind sub- grant was $9,466.87. THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 77

Plumbing and construction materials for five VDCs In Q1, THNA provided plumbing and construction materials as an in-kind sub-grant to five VDCs in Dusti, Levakant, Kushoniyon, Jomi, and Balkhi districts to improve WASH conditions in four secondary schools and in one village. The total cost of materials under this in-kind sub-grant was $5,056.49. In Q4, THNA also started procurement for the following in-kind sub-grants to be disbursed in Y5.

Sub-grant for providing kitchen utensils in 12 schools in Khatlon Region In Q4, THNA started the procurement of kitchen utensils to support peer education activities and cooking demonstrations in 12 target schools. Delivery and distribution are expected in Y5. The estimated cost of this in-kind sub-grant to the DOH is $1,182.75.

Sub-grant for providing printing materials for HLSCs in Khatlon Region In Q4, THNA started the procurement of printed IEC materials to support the regional and 12 district HLSCs in Khatlon Region. Delivery and distribution of the materials are expected in Y5. The cost of this in-kind sub-grant to the DOH is $4,006.50. COORDINATION WITH OTHER FTF PARTNERS

In Y4, THNA closely collaborated with its FTF partners, including at least six agriculture- and nutrition-based USAID-funded activities: TAWA, Land Market Development Activity, CIP, UNICEF, the World Food Programme, and the Aga Khan Development Network. TAWA, CIP, and THNA staff regularly met to plan joint activities around school gardening, the promotion of new crops, and agricultural trainings. In Q1, effective collaboration with CIP resulted in harvesting 972 kg (~2,143 lbs.) of sweet potatoes from the demonstration plots of two farmers in Jaikhun district. An additional 750 kg (~1,653 lbs.) of sweet potatoes were harvested from two school plots in Dusti and Jomi districts. Through cooking demonstrations, counseling sessions, school activities, and agricultural trainings, THNA promoted the nutritional benefits of sweet potatoes to households with children. In Q1, during their peer learning sessions (Activity 2.1.3), CEs presented TAWA’s new crops in group discussions to promote planting them in home gardens. In Q1, THNA continued promoting TAWA’s crops through cooking demonstrations (Activity 3.1.7). Six new recipes for bok choy, sweet potato, and mung beans were developed, tested, and shared with the target groups: pregnant and lactating women and women with children aged six to 24 months. The cooking demonstrations also included the existing recipes for broccoli, a vegetable that TAWA also promotes. In Q1, joint activities with UNICEF, the World Bank, and the World Food Programme on the implementation of approved guidelines on IMAM resulted in a revised monitoring tool to evaluate IMAM implementation. THNA supported regular meetings with partners to coordinate joint activities. In Q1, THNA in collaboration with JICA supported a TOT on the revised and approved neonatal standards, which now include Kangaroo Mother Care. As a result of the cooperation, THNA and JICA started joint actions on the EPC implementation plan in Kushoniyon and Levakand districts. In Q2, effective collaboration with TAWA resulted in planting 4,500 tomato and 1,800 cucumber seedlings provided by TAWA at nine target schools (500 tomato seedlings and 200 cucumber seedlings per school). Under the supervision of their teachers, the students practiced such THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 78

agricultural skills as land preparation, planting, and irrigation to produce these crops (Activity 3.1.4). Together with TAWA, THNA volunteers promoted crops through recipes for women and children six to 24 months of age during household visits (Activity 2.1.2) and cooking demonstrations (Activity 3.1.7) in their communities. In January, THNA initiated a coordination meeting with FTF partners on the implementation of IMAM in the 12 FTF districts. As a result, in Q2, FTF partners coordinated all IMAM implementation activities to avoid duplication and gaps. As part of this coordination effort, THNA worked on improving community outreach and identifying and referring children with SAM. Coverage of children with SAM is low at both the inpatient and outpatient level in all 12 FTF districts. THNA collaborates with UNICEF on building the capacity of community health workers to perform outreach and refer children with SAM to health facilities. In Q2, THNA also participated in several workshops initiated by international partners around MNCH and nutrition. These included: • The Tajikistan 1,000 Golden Days Implementation Workshop, which provided an orientation on the revised social and behavior change strategy to reduce stunting; • An Optima Nutrition Study workshop in Tajikistan implemented by The World Bank; • A meeting on the strategy for preventing and controlling noncommunicable diseases in the Republic of Tajikistan for the period of 2013–2023. In Q3, THNA initiated a coordination meeting with WFP and UNICEF on implementation of IMAM in three FTF districts (Balkhi, Shahritus and Jomi) at PHC level. As a result, a referral system between PHCs and hospitals was strengthened. WFP shared with THNA information on children with SAM for improved outreach and referral. In Q3, seven THNA schools received 3,500 orange-fleshed sweet potato cuttings from CIP (Activity 3.1.4). In Q3-Q3, THNA coordinated with WFP responsibilities in supporting the construction of eight- person VIP latrines at six schools (Activity 3.2.4).

COMMUNICATION AND KNOWLEDGE MANAGEMENT

In Y4, THNA disseminated social behavior change IEC materials, as well as information about project activities, through a variety of means.

IEC materials for community volunteers

The following IEC materials were produced for community volunteers in Y4:

• The THNA communications manual developed in Q4 of Y3 was presented to all project staff; • 5,500 copies each of brochures in Tajik on household budgeting and crop rotation, as well as 5,600 copies of the poultry care guidebook were developed, printed, and presented to 500 CEs for further dissemination and use in educational sessions; • 75 banners on crop rotation, irrigation, and crop families (25 banners per topic) were provided to nine district schools for their peer education programs;

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 79

• 5,000 copies of posters on infection prevention (the “5 Fs”) and 5,110 copies of posters on safe drinking water in Tajik (A4 format) were distributed to community volunteers, as well as at 144 WASH fairs (Activity 3.2.1); • A banner (2 x 3 m) on safe drinking water was produced for 100 WASH fairs in the 12 districts. In addition, 35 smaller (1 x 1.2 m) banners on the storage, safety, and usage of drinking water were produced for district coordinators, their assistants, schools, and THNA WASH staff; • 3,340 copies of posters and brochures on handwashing, diarrhea, helminths, and anemia (600 copies each), danger signs for mothers and children (240 copies), sanitation and marketing (300 copies), as well as the World Health Organization’s “Five Keys to Safer Food Manual” (400 copies) were printed and presented to CHPs and CEs for further dissemination and use in educational sessions; • 300 copies each of UNICEF brochures on food for pregnant women, exclusive breastfeeding, and complementary feeding were produced for CHPs and CEs to use in educational sessions; • Banners (1 x 1.2 m) on the nutrition pyramid (80 copies), the healthy nutrition map (50 copies), and vitamin A (80 copies) were produced for nutrition resource centers, rural PHCs, THNA district coordinators, their assistants, and district schools; • 500 sets of food diversity cards (A5 format) on dietary diversity for women and children were printed in Q1. Each set comprises 66 cards with necessary nutrient information. These cards were presented to CHPs and CEs to use in educational sessions; • The recipe book in Tajik for women of reproductive age and children aged six to 24 months was developed, designed, and tested, then 5,800 copies were printed. They were disseminated to district coordinators, their assistants, and CHPs and CEs to use in cooking demonstration sessions, and to PHC providers to use in nutrition counseling sessions; • 40,000 copies of the Rohnamo (the MNCH handbook for pregnant women and mothers with children under two) were distributed to PHCs; • To support the Universal Salt Iodization Law, THNA developed a new poster on the benefits of iodized salt. After MOHSPP and USAID approval, 6,500 copies of the poster were printed for CHPs and CEs, and for the Agency of Standardization, Metrology, Certification and Trade Inspection under the Government of the Republic of Tajikistan; • 1,700 DVDs were distributed to CHPs and CEs to support the integration of nutrition messages into agriculture-focused programs. The DVDs include 15 videos and one mp3 audio file on the following topics:

o Iodized salt promotion (a THNA-produced informational video); o Complementary feeding (four THNA-produced tutorial videos); o Nutrition for pregnant women and adolescent girls (four THNA-produced tutorial videos); o The value of breast milk (an audio jingle/song); o Safe toilets and drinking water (THNA-produced animated videos). o Cattle hygiene, farming, and breastfeeding (animated videos from partner organizations). THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 80

IEC materials and clinical guidelines for HCWs The following IEC materials were produced for HCWs in Y4: • UNICEF’s IYCF flipbook (840 copies) and instruction brochure (720 copies); • 500 copies each of posters (A3 format) in Tajik on handwashing, blood loss management, medical waste management, and the Bishop score; • 180 copies each of posters (A2 format) in Tajik on eclampsia management for hospitals and PHCs, management of obstetric bleeding, management of preeclampsia, and nutrition for children aged seven to eight months and nine to 12 months; • 180 copies each of posters (A2 format) in Tajik and Russian on the newborn resuscitation procedure; • 25 copies each of posters (A3 format) in Tajik on hemorrhagic shock management and head insertion anomalies; • 180 copies each of posters (A3 format) in Tajik on gravidograms, chlorine preparation, medical waste management, rehydration solution, and oxytocin administration; • Three informational boards (1 x 1.5 m) on exclusive breastfeeding and nutrition for women of reproductive age and children aged six to 24 months for the MOHSPP’s national event.2,300 copies of the clinical guidebook “Healthy Child Care – 0 to 24 Months” designed by THNA and approved by the MOHSPP and USAID in Q2 were printed and submitted to the MOHSPP and district HCWs; • 600 copies each of the clinical guidebook “Kangaroo Mother Care” designed by THNA and approved by the MOHSPP and USAID in two languages (Tajik and Russian) were printed and submitted to the MOHSPP and district HCWs; • 1,070 copies each of the National Protocol on Nutrition in Pregnancy Guideline and IMCI Chart Booklet for pregnant women were printed in Tajik for the MOHSPP and HCWs; • 270 copies each of the IMAM Guideline and EDL-2018 Guidebook in Tajik for the MOHSPP and HCWs; • 60 copies of the “Guideline for Infection Control Supportive Supervision in Hospitals and PHCs”; • 3,300 copies of GMP monitoring forms for GMP campaigns in the 12 FTF districts; • 4,670 copies of a guide on the use of the MUAC tape in Tajik for HCWs, GMP campaigns, and CHPs and CEs; • A total of 12,000 copies of UNICEF IEC materials on nutrition for pregnant women, exclusive breastfeeding, and complementary feeding, as well as a Mercy Corps brochure on anemia (3,000 each) were provided to the MOHSPP for World Breastfeeding Week; • 6,000 copies of the “Breastfeeding is the basis of life” brochure were given to the DOH of Khatlon Region for distribution among PHC and hospital facilities; • 2,500 (A4 format) and 400 (A1 format) “Breastfeeding Benefits” posters were printed for nutrition resource centers, rural PHCs, THNA district coordinators and their assistants, and district schools, as well as for MOHSPP events;

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 81

• 500 posters on the Nutrition Map and Vitamin A, as well as 1,000 UNICEF posters on Iodine Salt were produced for the MOHSPP; • A billboard and banners for World Breastfeeding Week were developed and designed. A total of 14 copies of different sizes were produced after MOHSPP and USAID approval. They were intended for presentation along the central street in Bokhtar city and in maternity departments of CDHs during World Breastfeeding Week celebrations. Media publications

The following articles, success stories, and other media were published in Y4: • An article entitled, “Crisis situation in Tajikistan” on latrines in Khatlon Region’s rural schools was published via the media outlet www.ozodi.org. THNA contributed information about VIP latrines and project activities to solve sanitation issues. • A success story entitled, “Midwife Skills Save Lives in Tajikistan” on the midwife’s significant role in reducing maternal and newborn mortality in Tajikistan was submitted to USAID. Later, it was published on Abt Associates and USAID websites, and the link was disseminated via social media. • A success story entitled, “Better for the baby, better for the family” on successful breastfeeding and nutritional support of THNA in the rural villages, which was submitted to USAID in Y3, was posted on the USAID Exposure page in March 2019, under the title “Better Nutrition for Moms and Babies.” The story was also combined with an informational article on the nutrition contest and exhibition among PHCs that THNA held in conjunction with World Breastfeeding Week in August 2018. • A success story entitled, “The Right Training and Equipment Save Tajik Triplets’ Lives” on the life-saving antenatal and neonatal care given to a mother and her premature triplets was prepared and submitted to USAID. Later, it was published on USAID, IntraHealth International, and Abt Associates websites, and was picked up by the Global Health Hub. It was also posted on many social media pages. • A success story entitled, “Protecting Preemies” on helping premature babies thrive and providing KMC in rural Tajikistan was submitted to USAID. Later, it was posted on USAID’s exposure page. • A ten-minute documentary film about volunteer activities was scripted to promote volunteerism in Tajikistan. Based on USAID’s suggestions, the script will be divided into three short (i.e., two-minute) videos in Y5. • A success story entitled, “Improve Nutrition through Poultry Farming” on the CE trainings on poultry farming for rural THNA beneficiaries was submitted to USAID after IntraHealth International HQ’s approval; • An article entitled, “Tajikistan Health and Nutrition Activity” on project activities in Qabodiyon district was published in local district newspaper Takhti Qubod; • A post entitled, “World Breastfeeding Week in Tajikistan” was posted on USAID’s Central Asian Facebook page where the head of the MOHSPP talked about THNA’s support during the national event in Dushanbe.

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 82

• An article entitled, “Healthy Nutrition for Heathy Generation” on THNA celebrating World Breastfeeding Week, combined with information about the nutrition contest and exhibition among the PHCs held in conjunction with World Breastfeeding Week, was published on Asia Plus Media Holding’s website. The link was shared via social media. FTF- and USAID-branded and marked materials The following materials were produced and/or distributed in Y4: • A total of 130 branded bags and 150 aprons were produced and distributed to new CHPs and CEs to use during their work in communities; • Another 250 each of branded bags, aprons, and mugs were distributed at nutrition competitions among HCWs; • Three banners (2 x 3 m) and 80 pins were produced, and 40 different photos were printed for the best district and regional volunteer competitions in the 12 districts; • A THNA factsheet was updated based on the results of Y3 activities. After USAID approval, it was printed in two languages (Tajik and English) and distributed during public events (500 copies total). • 96 plaques (90 x 60 cm) and 25 plaques (size A5) with USAID branding for the nutrition resource centers, oral rehydration rooms, and pediatric departments that received in-kind grants from THNA. • Two THNA technical briefs summarizing the approaches and results of four years of work: “Community-based approaches to improve maternal and child health and nutrition in Tajikistan” (Annex 6) and “Collaborative quality improvement of maternal, newborn and child health services in Tajikistan” (Annex 7).

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 83

LIST OF ANNEXES

Annex 1. Program activities scheduled for Y4 Annex 2. Recurring Health Survey (RHS) report Annex 3. Third Recurring Agricultural Practices report Annex 4. FTF 7th Annual Scientific Symposium abstract Annex 5. THNA organizational chart Annex 6. Technical brief on THNA community-based approaches Annex 7. Technical brief on THNA collaborative QI approaches Annex 8. Environmental compliance report

THNA Year 4 Annual Progress Report: October 1, 2018–September 30, 2019 84