Quarterly Report October – December 2007: 1st Quarter FY08

This Project NOVA Quarterly Report describes the results of NOVA’s programmatic activities during the period of October 1 – December 31, 2007. Project NOVA is in full-scale implementation of all marz-level and national-level interventions in in accordance with its Statement of Work and FY08 workplan.

AREA 1: Improve RH/FP/MCH Performance of Select Networks

Tangible Result: Providers’ knowledge and skills improved

. In October Project NOVA conducted two newborn care training courses for 26 practicing obstetrician/gynecologists, neonatologists, pediatricians, anesthesiologists, nurses, and midwives as part of its Comprehensive Maternal and Child Health (MCH) training package. During a three-day Newborn Care and Resuscitation training course at Maternity, trainers used an interactive learning and teaching methodology allowing learners to actively participate in the presentations and discussions. The participants also practiced their newly-acquired clinical skills on anatomical mannequins. The two-day training on the management of newborn diseases was organized at the Institute for Perinatology, Obstetrics and Gynecology for practicing neonatologists from Project- supported health networks. During this training the participants visited the Newborn Intensive Care Department and familiarized themselves with the new equipment and techniques for the care of sick babies. Pre- and post-knowledge evaluation tests measured the effectiveness of these training events. On average, participants’ knowledge increased by 50% from 36.5% at baseline to 86.5% at the end of the training (See Attachment B for more details on NOVA’s training events during this quarter).

Training Courses Conducted by Project NOVA as part of Comprehensive MCH Training Package during October - December 2007 Training Course Network Number of Pre- Post- Knowledge participants test test Change Newborn Care Vedi 18 28% 78% 50% Management of Newborn Diseases All 8 45% 95% 50%

TOTAL 26 36.5% 86.5% 50%

. Training on newborn care completes the series of training interventions conducted by Project NOVA in its five selected health networks. As a result of the training activities, on average the providers’ knowledge increased by 38%: with the highest increases reported in the specific technical areas of infection prevention (45%) and newborn resuscitation and care (43%); and overall in Vedi (42%) and Talin (40%) (See table below).

Project NOVA Quarterly Report 1 of 17 October – December 2007 Overall Knowledge Increase Among Healthcare Workers Following Project NOVA Training Courses Disaggregated by Technical Areas and Health Networks Training Course Vedi Talin TOTAL

Newborn Care 50% 40% 37%  43%  47%  43% ANC/PPC 36%  42%  39%  32% 12%  32% Infant Care 33%  37% 32%, 33%  27%  21%  30% IP 46%,55%  24%, 54%  51%, 40% 47% 43%, 47% 45% EmOC 30% 40% 33% 30% 23%  31% OVERALL 42% 40% 38% 36% 32% 38%

. On October 2 Project staff launched its flagship Safe Motherhood Clinical Skills (SMCS) training courses for 102 community nurses from the five Project-supported health networks in the south (See table below). This self-paced performance-based training consists of eight modules carried out over the course of six to nine months. During this reporting quarter in preparation for the training events, Project NOVA revised and updated Modules 3, 6, 7 and Job Aids based on the state-of-the-art information in these technical areas. Module 7 revisions also incorporated a new section on gender issues and the role of the community nurse in addressing domestic violence and gender-related discrepancies in accessing health care in the community. Using updated versions of the modules, community nurses successfully completed Module 1-3 on the basics of nursing; infection prevention; and antenatal care (See Attachment B for details).

Health Post Community Nurses Enrolled into NOVA’s SMCS Training Network Marz Number of Coverage Nurses Talin 35 34 of 93 Health Posts in Aragatsotn; 37% coverage

Armavir Armavir 13 13 of 43Health Posts in Armavir; 30% coverage

Vedi Ararat 14 14 of 45 Health Posts in Ararat; 31% coverage

Vayk Vayots Dzor 15 15 of 37 Health Posts in Vayots Dzor; 41% coverage

Sisian 25 22 of 99 Health Posts in Syunik; 22% coverage

TOTAL 102 32% coverage

. In October Project NOVA conducted follow-up visits to 1) monitor key MCH practices introduced and/or enhanced during the Comprehensive MCH training courses and 2) speed up their integration into routine medical practice. Results of the follow-up visits revealed that although some technical areas still need improvement, overall newly-trained healthcare providers adhere to what they have learned with NOVA. All NOVA-supported facilities that deliver babies practice active management of the third stage of labor, but routine use of the partogram during labor continues to be a challenge due to the absence of a regulatory order from the Ministry of Health. In the area of newborn and infant care, healthcare providers typically use the newly learned approaches and principles, including the proper treatment of umbilicus, the initiation of breastfeeding within the first hour of birth, maintaining the newborn warm chain, offering breastfeeding counseling and information on infant and newborn health danger signs, and adhering to the principles of

Project NOVA Quarterly Report 2 of 17 October – December 2007 IMCI. However, most of the babies continued to be tightly swaddled. Project NOVA will continue its training follow-up visits to assist newly trained healthcare providers in the integration of acquired clinical knowledge and skills.

Tangible Result: Training capacity strengthened

. Project NOVA continues the implementation and monitoring of the pre-service nursing and midwifery training pilot initiative at the Medical College. While Gyumri Medical College faculty members implement the pilot using newly-developed training curriculum, syllabus and methodology, Project NOVA conducts routine monitoring visits to the college. NOVA monitors to what extent the faculty members adhere to the content of the syllabus; what problems/discrepancies have been observed related to the course syllabus; to what extent does the faculty adhere to the timing, class agenda and session objectives; and do they use audiovisual materials, mannequins and interactive techniques. Monitoring visits revealed that overall faculty members adhere to the content and syllabus and routinely use audiovisual material and interactive training methodology. However training rooms themselves are small and inconvenient for classroom training. While the faculty is making strides to improve the quality of teaching, much work remains to be done to achieve the desired level. One of the main challenges to quality pre- service teaching is the discordance between the number of students and available resources and conditions (number of trainers, rooms for clinical practice in hospitals etc.) which go beyond NOVA’s scope of work under this initiative due to limited financial and human resources.

Tangible Result: Healthcare facilities equipped and renovated

. The renovations in Talin Medical Center Children’s Polyclinic and Sisian Medical Center Maternity Ward were successfully completed in November 2007. The official opening ceremony took place in Sisian on December 13 and in Talin on December 20. Coupled with better trained healthcare workers and available basic equipment, supplies and furniture provided by NOVA, renovated healthcare facilities will significantly improve overall quality of MCH services offered to the rural population. These improvements will increase utilization of services, including immunization of children under five, antenatal care and postpartum care.

Medical Centers Renovated by Project NOVA (updated) HEALTHCARE FACILITY (MARZ) RENOVATION BUDGET TOTAL (AMD) NOVA Other Talin Medical Center Children’s Polyclinic (Aragatsotn Marz) 10 034 127 64% 34% Sisian Medical Center Maternity Ward (Syunik Marz) 5 265 680 100% 0%

AREA 2: Strengthen Management and Supervision

Tangible Result: Quality assurance system at Hospitals introduced

. Project NOVA conducted three Marz Advisory Board meetings: in Sisian on December 13, in Artashat on December 11, and in Armavir on December 26. Meeting attendees included Project NOVA staff, health department authorities, and representatives from respective clinical training sites and local NGOs. Participants discussed the issues

Project NOVA Quarterly Report 3 of 17 October – December 2007 pertaining to the implementation pace of Project NOVA clinical training events; outcomes of Quality Assurance Team activities, including the results of self-assessments; dissemination and presentation of NOVA’s health education materials in rural communities and the clinical setting; and the current and future status of the Community Partnership for Health (CPH).

. The Project continues the implementation of its Quality Assurance (QA) activities. As part of this initiative, QA team members at two sites completed their third self-assessment which demonstrated small but tangible achievements across all dimensions (See table below). All sites established and use suggestion boxes for patients’ feedback; team members received and use infection prevention protocols; and sites have assigned rooms for the School of Motherhood and posted signboards with healthcare facilities working hours. All QA teams are working to solve the remaining problems identified in their action plans.

Scoring of Project NOVA Quality Assurance Self-Assessment Exercises DIMENSIONS Armavir MC Vedi Maternity Vayk MC Sisian MC Talin MC of Quality Self-assessment Self-assessment Self-assessment Self-assessment Self-assessment I II III I II III I II III I II III I II III Access 90 77 83 96 85 TBD 67 77 77 67 80 83 75 93 TBD

Responsiveness 69 58 78 80.5 83 TBD 72 83 89 69 72 72 86 94 TBD

Environment 68 76 76 74 74 TBD 84 92 TBD 84 84 84 76 87 TBD

Management 78 87 93 93 97 TBD 100 100 TBD 86 87 87 96 97 TBD

Technical 93 93 95 86 96 96 82 82 95 96 96 98 89 91 96 Competence

Total Score 83% 83% 88% 84% 91% TBD 80% 91% TBD 85% 88% 89% 85% 93% TBD

. In December 2005 the MOH released the Order on Antenatal and Postnatal Care Standard Services that mandated establishment of a School of Motherhood (SoM) and stipulated national regulations regarding the organization and provision of antenatal and postnatal services. Among other things it provided guidance for conducting the SoM. The SoM serves as an educational platform crucial for a positive pregnancy outcome and effective newborn and infant care practices. According to the MOH Order the SoM provides psychosocial support, physical and psychological preparedness for childbirth, information on the delivery process and its stages, and information related to a healthy lifestyle during pregnancy and the postpartum period. These themes are split up into five classes offered by practicing obstetrician-gynecologists on a regular basis. Pregnant women must attend all five classes starting with their first antenatal care visit to the Women Consultation Centers. Through attendance at the classes, pregnant women acquire practical knowledge and skills on such topics as woman’s lifestyle, tips on overcoming delivery-related fears, and exclusive breastfeeding (including correct position of the breast, breast care, etc). Fathers are highly encouraged to participate as well in order to gain an overall idea of pregnancy and delivery-related issues and to learn how to support their wives during the pregnancy, delivery, and postpartum periods. In spite of the MOH plans to institutionalize the SoM across Armenia, visits to the regions reveal that they barely function outside of

Project NOVA Quarterly Report 4 of 17 October – December 2007 the capital city. A number of different factors contribute to the slow start and implementation of this national initiative, including: - poor sanitary and physical conditions, as well as an overall unwelcome environment at healthcare facilities; - insufficient quantity or lack of health educational materials for pregnant women at the regional level; - lack of guidance, monitoring and supervision from the proper healthcare authorities, including a detailed outline of information for pregnant women at the regional healthcare facilities; - lack of motivation of healthcare providers to conduct SoM; - overall low public awareness on the existence and importance of SoM; - unclear national compensation requirements and mechanism for SoM; and - the national trainers and local healthcare providers’ passive attitude towards the national implementation of the SoM.

. All of the QA sites raised the issue of the absence of a functioning SoM. In response to this overarching problem, Project NOVA proposed strengthening regional MCH services through provision of the technical and financial support to the existing, but yet not fully functioning, SoM. In September 2007 Project NOVA established a Task Force composed of ob/gyns that will have the responsibility of implementing the activities of the SoM initiative. On November 27 – 28, 2007 at the request of Task Force members and in close collaboration with the MOH, Project NOVA conducted a SoM refresher course for ten practicing ob/gyns and midwives to cover content-related issues. In order to provide more guidance and supervision from the proper healthcare authorities, the Project involved the leading MOH RH specialist in charge of the national implementation of this initiative and an American nurse-midwife experienced in conducting birth preparedness classes in the U.S. Plans are underway to procure equipment and supplies needed for SoM for the five QA sites; increase public awareness regarding the existence and importance of SoM through organizing Happy Family children’s drawing contests at select public schools and attracting media attention to the opening of newly established SoM where award winning pictures will be used to decorate the walls of SoM in Vedi, Vayk, Sisian and Talin; and renovate premises at Vedi Maternity Women’s Consultation especially assigned for this purpose. Increased state compensation payment for MCH services under the terms of newly approved Basic Benefits Package for 2008, an improved physical environment, better prepared personnel, and more satisfied patients will serve as a motivational factor for healthcare workers to routinely offer SoM.

AREA 3: Improve RH/MCH Policy Formulation and Implementation

Tangible Result: RH/FP/MCH policies reviewed . Project NOVA contributed to the improvement of the national Child Birth Registration protocols in Armenia. Project staff worked closely with the Armenian Relief Union, who organized round table discussions on this issue. As a result, the Steering Committee worked through the Ministry of Justice to introduce an amendment to the RA Law on Taxes proposing to remove all fees associated with birth registration. At the same time, the Steering Committee asked the child protection units at the marz level to collect information on unregistered births and now they follow up with the registration of identified cases.

Project NOVA Quarterly Report 5 of 17 October – December 2007 . Project NOVA drafted an amendment to the Governmental Decree No. 1608 dated November 2, 2006 on the “Approval of the Order of Obtaining Permission and Advertisement Requirements for Drugs, Medical Equipment and Medication”. The proposed amendment would allow the advertisement of prescription medications in professional peer-reviewed scientific medical journals, a change needed to support existence of the newly established Journal of Obstetrics, Gynecology and Neonatology and other professional medical journals of this nature.

Tangible Result: Evidence-based RH/FP/MCH service delivery promoted . During the last year Project NOVA provided technical assistance to the Armenian Society of Obstetrician-Gynecologists and Neonatologists and the Institute of Perinatology, Obstetrics, and Gynecology in the establishment, development and production of the peer-reviewed Armenian Journal of Obstetrics, Gynecology, and Neonatology. The special inaugural issue (Vol. 1, No. 1-2) of this Journal was published (500 copies) and disseminated among Armenian healthcare providers in December 2007. The electronic version of the Journal is posted on the Project NOVA website (www.nova.am). The articles report on the achievements, clinical procedures, diagnostics and research findings related to the aforementioned fields; and cover four major thematic categories: 1) reproductive health, family planning and maternal & child health; 2) organization of healthcare services; 3) evidence-based medicine; and 4) chronics/historic overview. As this semiannual Journal also aims to promote the use of evidence-based medicine in routine clinical practice in the Republic of Armenia, its pages discuss the establishment of evidence-based medicine and provide detailed Systemic Reviews from the Cochrane Database.

. Project NOVA shared the following evidence-based materials in the monthly newsletters: updates on the need for the use of enemas in labor; effects of supportive care during labor; and optimal duration of exclusive breastfeeding. All evidence-based medicine updates along with relevant links are available on the Project NOVA website (www.nova.am) in both English and Armenian.

Tangible Result: Best practices and messages documented and disseminated . NOVA disseminated a new Success Story depicting achievements of the Dashtadem community in Aragatsotn marz where Project NOVA implemented the CPH initiative. As a result of this fruitful collaboration the village mayor and the Health Action Group (HAG) members renovated the community health post and acquired confidence in their skills.

. Project NOVA continues the distribution of monthly electronic newsletters to over 135 individuals from local and international organizations. The newsletters in both English and Armenian highlighted key project activities, including results of the follow-up visits to Kotayk and Gegharkunik marzes communities and expanding the use of GIS for health in Armenia. The newsletters also publicized the Inaugural issue of the peer-reviewed Armenian Journal of Obstetrics, Gynecology and Neonatology and the official opening of the newly renovated Pediatric Department of Talin Medical Center.

. Project NOVA finalized the contents and produced 5,000 copies of a patient education family planning brochure “Do You Know Your Contraceptive Choice?” The Project started the dissemination of the brochure in healthcare facilities.

Project NOVA Quarterly Report 6 of 17 October – December 2007 . Project NOVA held health education brochure presentations in three rural communities – two in Armavir and one in Talin – for a total of 66 participants. The Project presented the following brochures: Antenatal Care and Healthy Pregnancy; 10 Things Women Need to Know after Having a Baby; The Future is in Your Hands; Do You Know Your Contraceptive Choices?; State Guaranteed Free Maternal and Child Healthcare Services and Social Protection of Pregnant Women.

. Project NOVA collaborated with national and local media representatives (Aragatsotn and Syunik media representatives) to depict major programmatic activities – Dashtadem and Katnaghbyur community health post opening in the Talin region, the Talin Medical Center Pediatric Department, the Sisian Medical Center Delivery Ward opening and Burns Supper donation. The official newspaper of the RA MOH, the Medical Bulletin, published an interview with the Project NOVA Chief of Party.

. During this reporting period, Project staff conducted two poster presentations at international conferences highlighting achievements, implementation strategies and lessons learned; - G. Panajyan, K. Baghdasarova “Perspectives of Strengthening Reproductive Cancer Prevention Skills by Family Physicians in Armenia” 15th European Annual Public Health (EUPHA) Conference; Helsinki, Finland, October 10 – 13, 2007. - T. Clary, H. Shahumayn “Capabilities of the Health Sector: The Experience of Project NOVA in Armenia” 135 American Public Health Association, Washington, DC, USA, November 3 - 7, 2007. . Project staff published the following five articles: - R. A. Abrahamyan, G.S. Avagyan, A. V. Kocharyan, G. V. Panajyan “Implementation of the National Program on Prevention, Early Detection and Treatment of Cervical Cancer in Armenia” Obstetrics, Gynecology, and Neonatology Scientific-Practical Journal; Vol. 1 No. 1-2; p. 8-9. - R. A. Abrahamyan, L. G. Khachatryan, L. A. Hovakimyan “Lipids Oxidation and the State of Antioxidant System during Pregnancy with Diabetes Mellitus” Obstetrics, Gynecology, and Neonatology Scientific-Practical Journal; Vol. 1 No. 1-2; p. 48-52. - G. G. Jerbashian “Evidence-based Medicine, Systematic Reviews and Cochrane Collaboration” Obstetrics, Gynecology, and Neonatology Scientific-Practical Journal; Vol. 1 No. 1-2; p. 52-54. - G. V. Panajyan, L. A. Hovakimyan, K. E. Adamyan “Micronutrient Supplementation During Pregnancy” Obstetrics, Gynecology, and Neonatology Scientific-Practical Journal; Vol. 1 No. 1-2; p. 65-66. - G. Jerbashian "Structural Weaknesses of Healthcare in Armenia" Caucasus & Central Asia Review Journal; Vol. 1 No. 6; p. 8-11.

Tangible result: Knowledge management capacity improved . Project NOVA conducted a series of interrelated events to further introduce Geographic Information System (GIS) in the health sphere in Armenia: - A three-day practical training on the introduction to GIS using ArcGIS Desktop was conducted for ten information technology specialists from the RA Ministry of Health, National Institute of Health, PHCR, World Bank Health Project Implementation Unit (WB HPIU), amongst others. Project NOVA staff carried out the training to educate

Project NOVA Quarterly Report 7 of 17 October – December 2007 local technicians in the use of GIS software and to develop a pool of local GIS specialists skilled in conducting health data entry and analysis.

- On December 5, 2007 a one-day workshop on the application of GIS in the health sphere was organized for the multidisciplinary group of national-level health officials, representatives from international organizations, and information technology specialists. A total of 23 participants from different national and international organizations had the opportunity to learn about worldwide GIS experience in the field of public health, reproductive health, Project NOVA’s GIS experience and the future of GIS. At the end of the workshop during small group discussions facilitated by NOVA staff, participants determined interesting GIS health tasks for Armenia such as identification of region-specific anemia rates, spread of periodic disease and botulism, correlation between environmental factors and infant mortality and morbidity, correlation between early births and/or miscarriages and proximity to the nuclear power station, etc. In addition, Project NOVA agreed to conduct periodic meetings on GIS health tasks in Armenia with officials and technicians working in different health organizations to promote enhancement of GIS application in health and collaboration in data sharing and analysis.

- On December 6 – 11, Project NOVA conducted an advanced GIS training for the previously identified eight information technology specialists from the Ministry of Health, National Institute of Health, WB HPIU, Save the Children, etc. to further improve their technical skills. NOVA provided the participants with a textbook, training materials and a trial version of ArcGIS software to be used within six months. At the end of the course trainees worked on one of the tasks defined by the workshop small groups. The participants designed maps of anemia cases and rates based on the data provided by World Vision Armenia. . Several software resources were studied and an appropriate one selected for development of the more user friendly NOVA-specific Intranet System.

AREA 4: Increase Consumer Demand for High Quality RH/FP/MCH Services through Community Education and Mobilization, Renovation and Equipping of Facilities

Tangible result: Better informed and mobilized community in RH/FP/MCH . The Community Partnership for Health (CPH) initiative continues to function efficiently in 50 rural communities of Armavir, Talin, Vayk and Sisian health networks: - In November the renovation and/or furnishing of all 50 rural health posts was completed. Official (re)opening ceremonies with representatives from USAID, marzpetaran, MOH, supervisory healthcare facilities, and Project NOVA staff took place in November - December. - Depending on the size, financial situation and political will in each community, on average communities provided 35-70% in monetary and in-kind contributions for the successful implementation of programmatic activities. - Community-based libraries were established at each Health Post. - Community nurses have conducted health talks in all fifty communities. The five obligatory topics presented by the nurses are: pregnancy and postpartum period warning signs; healthy lifestyles during pregnancy; sick child care; infant feeding,

Project NOVA Quarterly Report 8 of 17 October – December 2007 including breastfeeding for the first six months; and family planning during postpartum and postabortion period. . In October 2007 Project NOVA conducted follow up visits to thirty rural communities of Kotayk and Gegharkunik marzes where the CPH initiative was completed in September 2006. The purpose of the follow-up visits was to assess the sustainability of the community-based project results and to recommend further actions to be taken. The major findings are as follows: - In the vast majority of rural communities, HAGs established by NOVA continue to function on their own. HAGs have been very active in select communities, and serve as a catalyst for change. Its members mobilize their community to identify and solve specific community-level problems, often going beyond its original scope of work which was only limited to health issues. - In cases of minor damages to the building where the Health Post is located (e.g. roof linkage, damaged wall plaster, etc.) the village mayors took responsibility for repairs. - Health Post furniture donated by Project NOVA was well maintained. - Health Posts were open and operational during assigned working hours. - Physicians from supervisory facilities continued visiting the communities on a regular basis. In many cases the supervisory healthcare facilities continued supplying essential medicine for the provision of primary healthcare services at Health Posts. - Community health libraries established by NOVA at Health Posts were well maintained. Community dwellers have been regularly using a variety of health education brochures and books in Armenian, and requested additional materials. - Following Project NOVA training in SMCS which included the module on working with community, Health Post Community nurses routinely organized health talks.

. A total of 29 follow-up Action Plans for the communities in Kotayk and Gegharkunik marzes were developed in support of RH/FP/MCH services. The general problems of the communities were almost the same and the plans concerning the solution of these problems were common: - Renovation of Health Posts’ water pipes; - Renovation of Health Posts’ roof damaged due to cold winter; - Acquisition of additional educational materials for the community library; - Acquisition of strips for glucometer; - Construction of Health Posts’ sewerage system; and - Gasification of Health Posts for heating during winter.

Tangible result: Local NGOs capacity strengthened

. Project NOVA has identified “Renaissance and Progress” to be the local partner non- government organization (NGO) to implement the activities associated with the CPH initiative in Ararat Marz. The “Renaissance and Progress” NGO will enter into an one- year subcontract with NOVA’s partner Save the Children to support community activities in Vedi health network in Ararat marz during Year Four of project implementation.

Tangible result: Health posts equipped and renovated

. In December 2007, NOVA completed the renovation of 44 Health Posts (see table below for more details) in Armavir, Talin, Sisian and Vayk networks.

Project NOVA Quarterly Report 9 of 17 October – December 2007 Health Posts Renovated by Project NOVA in October – November 2007 Renovation Budget Health Posts Renovated Network Population Total (AMD) NOVA Community MOH Haykavan Armavir 1550 644,600 70.3% 29.7% N/A Armavir 2463 923,350 54.9% 45.1% N/A Nor Kesarya Armavir 1770 804,600 71.6% 28.4% N/A Yeraskhahun Armavir 1728 2,743,550 44.0% 56.0 % N/A Armavir 1141 851,600 55.0% 45.0% N/A Araks Armavir 1690 934,350 53.1% 46.9% N/A Armavir 1725 1,153,800 47.4% 47.4% N/A Armavir 1060 473,900 78.9% 21.1% N/A Akunk Talin 835 1,676,200 30.5% 69.5% N/A Areg Talin 1007 1,163,900 44.4% 55.6% N/A Dashtadem Talin 716 2,162,850 24.0% 76.0% N/A Talin 804 1,838,100 27.4% 72.6% N/A Karmrashen Talin 650 2,584,300 19.4% 80.6% N/A Katnaghbyur Talin 1583 2,280,400 24.9% 45.9% 30.2% Nor Talin 612 1,847,300 27.7% 72.3% N/A Talin 614 916,350 46.2% 53.8% N/A Talin 550 1,626,200 30.4% 69.6% N/A Zarindja Talin 720 1,529,000 29.4% 70.6% N/A Agarak Talin 1140 10,591,670 10.0% 10.0% 80% Kakavadzor Talin 1200 941,950 47.6% 52.4% N/A Nerkin Sasunashen Talin 1110 745,350 52.5% 47.5% N/A Talin 347 760,700 58.3% 41.7% N/A Verin Sasunashen Talin 368 442,900 67.7% 32.3% N/A Talin 557 1,627,900 31.3% 68.7% N/A Sisian 346 633,000 68.2% 31.8% N/A Uits Sisian 404 475,300 62.9% 37.1% N/A Sisian 519 539,700 66.7% 33.3% N/A Sisian 450 583,950 65.0% 35.0% N/A Sisian 450 251,300 60.0% 40.0% N/A Sisian 540 640,350 66.2% 33.8% N/A Sisian 449 203,420 59.0% 41.0% N/A Sisian 380 1,032,550 70.7% 29.3% N/A Sisian 416 947,850 72.0% 28.0% N/A Sisian 529 1,178,590 66.5% 33.5% N/A Noravan Sisian 531 645,300 74.8% 25.2% N/A Vorotan Sisian 300 683,800 67.1% 32.9% N/A Arin Vayk 247 389,370 46.8% 53.2% N/A Vayk 420 406,650 51.9% 48.1% N/A Vayk 650 262,460 48.1% 51.9% N/A Vayk 1012 138,000 73.0% 27.0% N/A Vayk 817 1,390,090 31.0% 69.0% N/A Karmrashen Vayk 288 336,150 51.1% 48.9% N/A Saravan Vayk 280 577,920 62.1% 37.9% N/A Vayk 175 273,050 48.5% 51.5% N/A

. In October the Project completed the distribution of equipment and supplies to rural community nurses placed at Health Posts in four southern health networks. As a result, 85

Project NOVA Quarterly Report 10 of 17 October – December 2007 rural Health Posts in Talin, Sisian, Armavir and Vayk regions received basic equipment and supplies in the total amount of AMD 19,882,567.36 (estimated USD 65,188.74) (See table below). The remaining Health Posts in the Vedi health network will receive equipment and supplies upon completion of the renovation works in their sites scheduled for the end of this fiscal year.

Distribution of Equipment and Supplies to Health Posts Supported by Project NOVA PERIOD No of Health Posts Health Network, Marz TOTAL (AMD)

30 Talin, Aragatsotn Marz 6,820,849.46 July - Sept 2007 1 Armavir, Armavir Marz 259,552.43

4 Talin, Aragatsotn Marz 1,108,559.94

12 Armavir, Armavir Marz 3,246,910.07 Oct - Dec 2007 22 Sisian, Syunik Marz 5,376,790.05

16 Vayk, Vayotz Dzor Marz 3,069,905.41

Total 85 19,882,567.36

Research, Monitoring and Evaluation

. This reporting period Project NOVA worked to compare the results of the baseline and follow-up assessments of programmatic activities in Shirak, Tavush, Gegharkunik and Kotayk marzes that took place during project Years 1 and 2. The report will be finalized and translated into Armenian next quarter.

. As part of routine training follow-up and monitoring of programmatic activities in five health networks, Project NOVA assessed fulfillment of Project-supported facilities with USAID Family Planning Compliance rules and regulations. Four healthcare facilities from Armavir, Talin, Vayk, and Sisian networks were visited for family planning compliance monitoring using previously developed Family Planning Compliance Monitoring Tool. No violations of the USAID Family Planning Compliance requirements have been recorded or reported (See Attachment C for summary information).

. The Project made significant progress on the PMP by contributing to the following indicators (See Attachments A and B for a complete table of updated progress indicators and project NOVA conducted trainings): ~ Number of healthcare providers trained in RH/FP/MCH and other project-supported areas disaggregated by sex; ~ Number of facilities to which basic equipment and supplies were distributed; ~ Number of Health Posts and higher level facilities rehabilitated; ~ Number of follow-up Action Plans developed; ~ Number of professional publications, presentations and posters at international, national and regional conferences; ~ Number of health talks conducted by Health Post Nurses; ~ Number of women giving births who received Active Management of the Third Stage of Labor (AMTSL) through Project NOVA support.

Project NOVA Quarterly Report 11 of 17 October – December 2007 Management, Collaboration, and Coordination

. Progress on Annual Workplan: Project NOVA successfully accomplished almost all activities planned for the 1st Quarter in the Annual Workplan. In some instances activities were initiated and completed ahead of schedule. See the updated Annual Workplan report (Attachment C) for the status of each activity.

. Collaboration and coordination with MOH: Informal and formal meetings with MOH representatives took place during this reporting period to enhance collaboration and coordination of Project NOVA activities.

. Corporate visits and program support: Dr. Tim A. Clary traveled to , Armenia on November 12 – 21 to provide programmatic, managerial, and technical assistance to Project NOVA. Dr. Clary worked with the Project NOVA team to finalize arrangements on pending personnel issues, to review the overall status of the project, and to assist with the preparation of budget and programmatic scenarios. Zev Ross travelled to Yerevan, Armenia on December 1-12 to prepare and conduct GIS Training: Part II for administrators and decision makers and GIS Training: Part III for the newly-trained GIS technicians in the development of GIS data, layers, maps, etc. Zev Ross also worked with Project NOVA staff to review existing GIS and tabular data and discuss a general set of recommendations for the development of GIS maps and spatial database for health information in Armenia.

. Staff development: Project NOVA Administration and Finance Unit personnel attended a staff development workshop on Armenian accounting standards, practical application of chart of accounts, Armenian tax legislation in practice, and business etiquette training.

. Coordination with other international projects in Armenia: Project NOVA continues to collaborate with other international projects and organizations in Armenia to capitalize on their technical expertise, maximize the use of human and financial resources and avoid duplication of efforts:

- In October 2007 Project NOVA provided financial support in the amount of $20,000 to the implementation of the National Rubella and Measles Immunization campaign.

- Project staff participated in the number of events organized by international and national agencies and organizations working in Armenia: - Peace Corps Development Fair; - Local Government Project Part 3 Donors and Implementers Coordination Meeting on Decentralization; - Mobilizing Action Against Corruption (MAAC) workshop on USAID/Armenia’s Support of the Development of New National Anticorruption Strategy; - RA National Assembly Permanent Commission on Social, Health and Natural Protection presentation and discussion on the issues of healthcare and legislative regulations for adolescents and youth; - Mission East Healthy Start Project presentation and discussions regarding the situation with disabled children in Armavir Marz; - Partnership for Open Society presentation and discussions of situation with domestic violence and abuse of women in Armenia; and the

Project NOVA Quarterly Report 12 of 17 October – December 2007 - USAID Competitive Armenian Private Sector presentation and discussions on the proposed work activities for Armenian Pharmaceutical Industries cluster

- A total of $10,950 was secured from the British Embassy Burns Supper Fund to provide neonatal resuscitation equipment to Talin Medical Center. The newborn life- saving equipment was delivered to Talin Medical Center and staff were trained in the use of equipment by technical and medical personnel. Project NOVA organized a ribbon cutting ceremony on December 20 at Talin Medical Center. Mr. Robert Frazier, Acting Deputy Chief of Mission of the U.S. Embassy in Armenia, and Mr. Gideon Dewhirst, Deputy Head of Mission at the British Embassy in Armenia, joined Project NOVA and Talin Medical Center staff to celebrate the opening of the newly renovated pediatric department and the presentation of neonatal care equipment from funds raised through the British Embassy’s annual Burns Supper.

Upcoming Major Activities

. Continuation of SMCS training for Health Post community nurses . Annual meeting with key MCH national experts and trainers . Initiation of CPH activities in Vedi Region . Production and dissemination of select WHO Making Pregnancy Safer Posters . Development of health talks aid flipchart for Community Nurses . Implementation and monitoring of Gyumri pre-service training curriculum pilot initiative . Signing a sub-contract with “Renaissance and Progress” local NGO for implementation of project activities in 10 communities of Ararat marz Vedi network. Performing an orientation and in-job training of NGO’s staff, involved in project activities. . Continuation of CPH activities in Armavir, Talin, Sisian and Vayk networks.

Project NOVA Quarterly Report 13 of 17 October – December 2007 Attachment A. Progress on Project NOVA Indicators for Q1 FY08

Project- FY05 FY06 FY07 FY08 ACTUAL (D) today FY08 Project NOVA Progress Indicators ACTUAL ACTUAL ACTUAL TOTAL TARGET (A) (B) (C) Q1 Q2 Q3 Q4 (A+B+C+D) Number of people trained in MCH 229 259 430 36 954 170 Women N/A1 N/A 402 35 N/A N/A Men N/A N/A 28 1 N/A N/A Number of people trained in RH/FP 46 50 26 0 122 145 Women 37 41 24 0 102 N/A Men 9 9 2 0 20 N/A Number of providers completed Mana- 45 38 83 gement/Supportive Supervision training Number of people trained in other areas 1232 1533 202 414 519 26 (e.g. QI, IP, gender, GIS, etc.) Women 115 143 194 21 473 N/A Men 8 10 8 20 46 N/A Number of facilities (health posts) to which basic equipment and supplies 105 73 31 54 263 69 were distributed Number of new RH/FP/MCH training curricula/packages developed and 1 2 4 0 7 1 introduced Number of policy documents review- 2 2 3 0 7 1 ed/prepared Number of professional publications, 8 4 11 7 30 4 presentations and posters conferences Number of client and provider materials 55 0 5 4 developed, produced and disseminated Number of new approaches 0 1 1 0 2 16 successfully introduced Number of Health Posts rehabilitated 29 35 9 44 117 53 Number of higher level facilities N/A N/A 1 2 3 7 rehabilitated Number of Health Action Groups 30 367 56 0 122 10 established Number of follow-up Action Plans 0 298 29 40 developed Number of clinical training sites 6 6 6 18 established Number of health talks conducted by 600 423 9 227 2,347 TBD Health Post Nurses 1,097 Number of women giving births who received AMTSL through Project NOVA 458 731 1189 TBD support*

1 Information on sex of participants of the clinical training sites’ trainings is not available 2 IP training 3 IP and gender sensitization training courses 4 GIS training (part I, II and III) 5 (1) The Future is in Your Hands; (2) Ten Things you Need to Know after Having a Baby; (3) 2007 BBP Poster; (4) 2007 BBP booklet; (5) Do you Know your Contracep ive Options 6 School of Motherhood 7 Includes 30 HAGs in Gegharkunik and Kotayk and 6 HAGs established in Lory under seed grants component 8 Follow-up HAGs in Gegharkunik and Kotayk 9 This number was adjusted in Q1 of FY 08 based on follow-up visits conducted in Gegharkunik and Kotayk marzes. 107 health talks were conducted in six communities with “Seed Grants” project component and 990 health talks were conducted in all other communities in Gegharkunik and Kotayk marzes. Data on 990 health talks were collected during the follow-up monitoring visits conducted in Q1 of FY 2007/2008

Project NOVA Quarterly Report 14 of 17 October – December 2007 Attachment B. Project NOVA Training Events during October – December 2007

Training Course Health Number of # of # of Participants Training Dates Pre- Post- Network participants Males Females test test COMPLETED Ob/gyns, nurses, midwives, Newborn Care and Resuscitation Vedi 18 1 17 October 2-4, 2007 28% 78% neonatologists, anesthesiologists Newborn Diseases Management All 8 0 8 Neonatologists October 10-11, 2007 45% 95% Introduction to GIS Using ArcGIS N/A 10 5 5 IT specialists October 22-26, 2007 Desktop (GIS Training: Part I) Refresher Training for the Schools of All 10 0 10 Ob/Gyns and Midwives November 27-28, 2007 Motherhood Application of GIS in the Health Sphere N/A 23 13 21 Public Health and IT specialists December 5, 2007 Workshop (GIS Training: Part II) Application of ArcGIS in Public Health N/A 8 3 5 IT specialists December 6-11, 2007 (GIS Training: Part III) ON-GOING Save Motherhood Clinical Skills November 13, 2007 -  Module 1 completed Vedi 14 0 14 HP Community Nurses 96%  Module 2 completed ongoing 77% 94%  Module 3 on-going 55% TBD Save Motherhood Clinical Skills October 16, 2007 -  Module 1 completed Armavir 13 0 13 HP Community Nurses 95.4%  Module 2 completed ongoing 65.1% 91.7%  Module 3 on-going 57.7% TBD Save Motherhood Clinical Skills November 6, 2007 -  Module 1 completed Talin 35 1 34 HP Community Nurses 97.6%  Module 2 completed ongoing 65.1% 89.6%  Module 3 on-going 57.4% TBD

Project NOVA Quarterly Report 15 of 17 October – December 2007 Training Course Health Number of # of # of Participants Training Dates Pre- Post- Network participants Males Females test test Save Motherhood Clinical Skills  Module 1 completed 98.4%  Module 2 completed Sisian 25 0 25 HP Community Nurses October 2, 2007 - ongoing 63.2% 94.0%  Module 3 completed 62.0% 93.4%  Module 7 – on-going 49.8% TBD Save Motherhood Clinical Skills October 23, 2007 -  Module 1 completed Vayk 15 0 15 HP Community Nurses 97.3%  Module 2 completed ongoing 76.8% 94.7%  Module 3 on-going 62.8% TBD

Project NOVA Quarterly Report 16 of 17 October – December 2007 Attachment C. Summary of Findings from Family Planning Compliance Monitoring Visits

During October – December 2007, the following four health care facilities have been visited by Project NOVA staff to assess family planning compliance: Vayk Medical Union, Sisian Medical Union, Talin Women Consultation Center, and Armavir Women Consultation Center. Below please find the summary of findings from our visits.

1. Do you currently provide any family planning All 4 facilities currently provide FP services. services? 2. What type of family planning services does 4 facilities provide IUD insertion/removal your facility provide? (check all that applies) 4 facilities prescribe pills 3 facilities administer Depo-Provera 4 facilities dispense condoms and/or spermicides 4 facilities provide FP counseling 1 facility provide FP referral 2 facilities provide emergency contraception services 2 facilities providing FP client routine check up 3. What family planning methods do you 1 facility have birth control pills currently have available at your facility? 3 facilities have condoms 2 facilities have IUDs 1 facility have spermicides 0 facilities have emergency contraception pills 1 facility have Depo-Provera 4. Do your providers use any financial or in-kind All 4 facilities DO NOT use any incentives to increase the number incentives to increase the number of family of FP users. planning users? 5. How are healthcare providers at your facility At all 4 facilities, there is no additional compensation for FP compensated for the provision of family services; everything is embedded in staff’s monthly salaries. planning services? 6. Is there a particular number of family 3 facilities do not have any targets for family planning clients planning clients you must reach? 1 facility information is missing 7. What are the consequences of not meeting N/A. See Q/A 6. the quota?

8. Are family planning IEC materials visibly All 4 facilities have family planning IEC materials visibly displayed displayed and/or available to clients at your and/or available to clients. facility? 9. What IEC contraceptive materials are 4 facilities have “10 things women need to know after having a available? baby” (postpartum brochure, Project NOVA) 4 facilities have “The future is in your hands” (postabortion care, Project NOVA) 2 facilities have the following other FP brochures: ~ Healthy Pregnancy (antenatal care, Project NOVA) ~ Two FP brochures from MSF

Project NOVA Quarterly Report 17 of 17 October – December 2007