USAID Nurture Photo Credit: Jittinee Khienvichit, USAID Annual Report, Year 2: FY2017: October 1, 2016 to September 30, 2017

Cooperative Agreement Number: No. AID-486-A-16-00001 USAID/RDMA, Attn: Robin Martz, AOR Submitted by Kamden Hoffmann, Chief of Party, USAID Nurture [email protected]

Contents

Acronym List ...... iv Project Summary ...... 1 Results ...... 2 New and Existing Sub-Award Status ...... 6 Major Impacts and Accomplishments by Intermediate Result ...... 8 Intermediate Result 1: Improved IYCF and WASH Behaviors ...... 8 Intermediate Result 2: Improved use of quality nutrition and nutrition-sensitive WASH Services/Facilities ...... 11 Community Service Delivery ...... 11 WASH Product Delivery...... 11 Health Service Delivery ...... 13 Intermediate Result 3: Improved Enabling Environment ...... 15 Implementation Challenges and Mitigation ...... 16 Deviations from Expectations for Performance Indicators...... 17 Integration of Crosscutting Issues and USAID Forward Priorities ...... 18 Environmental Compliance ...... 18 Science, Technology, and Innovation ...... 18 Planned Tasks/Interventions for the Next Reporting Period ...... 19 ANNEXES ...... 20 Appendix1: iNuW Toolkit: Community Section Outline ...... 21 Appendix 2: USAID Nurture Q&A for DFOs ...... 24 Appendix 3: Cover Pages of Tools Being Developed ...... 27 Appendix4: Phasing Strategy for Scaling up of iNuW Districts ...... 28 Appendix 5: WASH Marketing Roadmap ...... 29 Appendix 6: Selected Creative Concept – Image 1 (updated version) ...... 30 Appendix 7: Updated Behavioral Objectives for USAID Nurture ...... 31 Appendix 8: Success Story: Health Facility ...... 33 Appendix 9: Success Story: Community ...... 34

Figures

Figure 1. Child-centered WASH-Nutrition Integration Visual……………………………………………………………..9

Figure 2. iNuW Community Process…………………………………………………………………………………………………10

Figure 3. iNuW Capacity Building…………………………………………………………………………………………………....11

Figure 4. National Counseling Competencies…….…………………………………………………………………………….14

Figure 5. USAID Nurture Nutrition Coordination Plan Support…………………………………………………………15

Figure 6. Adolescent Sensitive Approaches in Nutrition Counseling…………………………………………………18 Tables

Table 1. Number of individuals receiving nutrition-related professional training……………………………….3 Table 2. Number of people trainined during the reporting period ...... 4 Table 3. Gender Analysis Perceptions and Practices…………………………………………………………………………..8

Table 4. iNuW CF Formation…………………………………………………………………………………………………………….11

Table 5. 4S Model…………………………………………………………………………………………………………………………….13

Table 6. Yr2 Health Care Provider Capacity Building…………………………………………………………………………14

iii

Acronym List

A&T Alive & Thrive BFHI Baby Friendly Hospital Initiative BMS Breastmilk Substitute COP Chief of Party CLTS Community Led Total Sanitation CF Community Facilitator DHC Department of Health Care DFO District Facilitator Officer DHO District Health Office DHIS2 District Health Information System 2 DHHP Department of Hygiene and Health Promotion DNC District Nutrition Committee DP Development Partner EENC Early Essential Newborn Care EU European Union GLEE Global Learning and Exchange GoL Government of Lao PDR IYCF Infant and Young Child Feeding INGO Non-Governmental Organization Lao PDR Lao People’s Democratic Republic MCHC Maternal and Child Health Center MIYCN Maternal Infant and Young Child Nutrition M&E Monitoring and Evaluation MOH Ministry of Health MOU Memorandum of Understanding MSN Multi-sectoral Nutrition Strategy NNC National Nutrition Center Nam Saat National Center for Water Supply and Environmental Health, the Ministry of Health NNS National Nutrition Strategy NPA Non-Profit Agency

NPAN National Plan of Action for Nutrition ODF Open Defecation Free PADTEC Participatory Development Training Centre PNC Provincial Nutrition Committee RDA Rural Development Agency RDMA Regional Development Mission for Asia RMNCH Reproductive, Maternal, Newborn and Child Health SBCC Social Behavior Change Communications SC Save the Children SCI Save the Children International SCUS Save the Children, United States SUN Scaling Up Nutrition TOT Training of Trainers UNFPA United Nations Population Fund USAID United States Agency for International Development VIC Village iNuW Committee WASH Water, Sanitation and Hygiene

Project Summary Laos experiences some of the highest rates of child and maternal mortality and malnutrition in Southeast Asia. Lao children remain some of Asia’s most undernourished, with national average rates of stunting at 35.6%, underweight at 25.5%, and wasting at 9.6%.1 In response, the U.S. Agency for International Development’s “Nurture” (USAID Nurture) aims to contribute to a reduction in young child stunting in targeted areas of Laos by improving: 1) infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices; 2) the use of quality nutrition and WASH services/facilities; and 3) the enabling environment for improved nutrition.

The project focus is on improving maternal and adolescent nutrition and IYCF and WASH practices targeting 1,000 Days households (households with pregnant women and mothers with children up to two years of age). USAID Nurture utilizes interpersonal communication, household-level support, and peer groups and links women and children with health services being improved by the project. USAID Nurture integrates nutrition and WASH through a community mobilization approach that incorporates a modified version of community-led total sanitation (CLTS). Communities are mobilized to assess and analyze their nutrition and WASH environment. This process spurs action to address nutrition-related issues resulting from poor IYCF practices and inadequate water, sanitation and hygiene, including environmental enteropathy, diarrhea and other conditions that limit nutrient absorption, a major driver of stunting. USAID Nurture leverages private sector relationships to facilitate supplies of products that support uptake of targeted WASH practices.

Through its integrated delivery model, USAID Nurture supports the Laos government as it clarifies roles and responsibilities across national, provincial and district levels to help ensure consistency and ownership of these efforts in support of the National Plan of Action for Nutrition.

USAID Nurture is implemented in six districts in Khammouane and Savannakhet provinces by Save the Children (SC) in collaboration with the Rural Development Agency (RDA). This partnership leverages both SC’s leadership in the implementation of large-scale integrated nutrition programs, and the RDA’s expertise in CLTS and community mobilization and facilitation. The project strengthens existing relationships with the Government of Lao PDR (GoL) to help ensure scale up in hard-to-reach communities.

12015 Lao Child Anthropometry Assessment Survey (LCAAS).

Results In Year (YR) 2, USAID Nurture achieved the following milestones:

Project Management  Signed the USAID Nurture Memorandum of Understanding (MOU) between the Ministry of Health (MoH) and Save the Children (SC).  Held the Project Kick-off Meeting and produced the YR1 (2017) USAID Nurture work plan with national, provincial and district government counterparts.  SC hired a new COP, Dr. Kamden Hoffmann, who started on August 23.  SC hired Mr. Outhikone (Kone) Souphomein as a Marketing Manager who started on July 3.

IR1: Improved IYCF and WASH Behaviors  Dr. Niramonh Rasprasith conducted the formative research and gender analysis study, which entailed focus group discussions, in-depth-interviews and observations, and presented findings at the USAID Nurture SBCC workshop.  USAID Nurture conducted an SBCC Workshop, to build SBCC capacity and to design the project’s SBCC plan. The GoL and development partners have since agreed to use USAID Nurture’s SBCC plan as the foundation of the National SBCC Plan.  USAID Nurture produced the community mobilization component of the Integrated Nutrition and WASH (“iNuW”) Community Toolkit consisting of nine Village Visits and drafts of the Household Visit and Peer Support Group components.  Village Visits 1 and 2 were pilot tested in Thakek district of Khammouane province. For Phase I, Visits 1, 2 and 3 were delivered in 20 villages (10 in Mahaxay and10 in Phine); and Visits 1 and 2were delivered in 10 villages of Xonnabouly.  Village Visit roll out continues in 50 additional villages in Phine, Mahaxay and Xonnabouly.

IR2: Improved use of quality nutrition and nutrition-sensitive WASH services/facilities  Contractor Geosys designed, implemented, and analyzed the results of the WASH market and value chain assessment. The report, including a literature review, mapping of available products and local entrepreneurs and sources of financing, was finalized in Q3.  In Q4, USAID Nurture began to build the marketing capacity of private sector vendors and link them to project villages for the sale of WASH products.  USAID Nurture developed orientation and training packages for Village iNuW Committees (VICs) and Community Facilitators (CFs).  In Q4, USAID Nurture provided Training of Trainers (TOT) in Savannakhet province for government district partners and District Facilitator Officers (DFOs). There were 27 participants from Mahaxay district (Khammouane province), and Phine and Xonnabouly districts (Savannakhet province).  Contractor Soap4Life trained 13 individuals to make and sell soap. Participants were from the Thakek pilot site and included RDA staff to build their capacity to conduct soap demonstrations in the communities.  In January-February USAID Nurture implemented a participatory nutrition services assessment at national, provincial, district and health center levels. The report was finalized in May, see final report entitled “Nutrition Services and Management Capacity Assessment Report: Phase I”.  Based on the findings of the nutrition services assessment, USAID Nurture designed a three-part health care provider and management staff training on nutrition counseling in collaboration with the Center for Information and Education for Health (CIEH) within the MoH in Q2.  Twelve provincial trainers for the new Nutrition Counseling curriculum were officially assigned in March.

 The first TOT in maternal nutrition counseling was conducted in April. Rollout to health center staff of Phine and Mahaxay districts immediately followed in Q3. Maternal nutrition training occurred in Xonnabouly in August.  The TOT for infant nutrition was conducted in Q3 and health center level training followed in both Phase 1 districts in July.

IR3: Improved Enabling Environment  To support nutrition governance and multi-sectoral coordination, USAID Nurture collaborated with UNICEF to roll-out multi-sectoral nutrition committees at provincial (UNICEF-led) and district (USAID Nurture-led) levels in Khammouane and Savannakhet. USAID Nurture reviewed internationally and locally used governance tools, helped prepare the agenda, and participated in the orientation meeting held 5-7 June. During this meeting, USAID Nurture agreed to support coordination and capacity building activities for the GoL (see Figure 5 on Page 15 for additional details).  Conducted quarterly review and work planning meetings with the GoL in Q3 and Q4.

Targets reached across Intermediate Results During the reporting period, USAID Nurture met its target for trainings via twelve trainings and workshops. Table 1 provides details on the number of individuals receiving nutrition-related professional training through USG-supported programs, de-duplicated and disaggregated by sex. Table 2 provides the details regarding each of the twelve trainings and workshops, which includes the participants that attended more than one training or workshop (n=12)2.

Table 1: Number of individuals receiving nutrition-related professional training through USG-supported programs, disaggregated by sex FY2017: Oct 1, 2016 - August 31, 2017 Result Apr 1 - % Target Total Oct 1, 16 - August 31, achieved Mar 31, 17 17 Number of individuals receiving nutrition-related professional training through USG-supported program 141 57 141 198 140% By sex* Male 52 16 52 68 131% Female 89 41 89 130 146% By participant type Non-degree seeking trainees 141 57 141 198 140%

Degree seeking trainees N/A Indicator IR3-1, HL.9-4Indicator New degree seeking trainees N/A Continuing degree seeking trainees N/A

2 For all the training activities across different topics, names were recorded, entered into an electronic database, and assigned a unique identification code in order to keep track of unique individuals reached. For each training activity, the total number of people attending was tracked (see Table 2). This includes participants who attended more than one training or workshop. But to estimate the total number of individuals reached, the unique identification codes were used so that people who attended more than one training on the same topic were counted only once (see Table 1).

Period Name of events Date Trainees Female Male Oct 1, 16 - 1 Soap Training 05-09-Dec-2016 13 12 1 Mar 31, 17 2 SBCC workshop 20-24-March-2017 44 29 15 3 MCH Nutrition Counseling TOT 1 04-07-April-2017 15 10 5 4 MCH Nutrition Counseling Module I (Phine) 25-27-April-2017 25 21 4 5 MCH Nutrition Counseling Module I (MHX) 2-5-May-2017 23 19 4 6 MCH Nutrition Counseling Module I (Xonnabouly) 08-11-August-2017 26 24 2 Apr 1 - 7 MCH Nutrition Counseling TOT2 13-16-June-2017 11 8 3 September 8 MCH Nutrition Counseling Module II (Phine) 4-6-July-2017 25 22 3 30, 17 9 MCH Nutrition Counseling Module II (MHX) 17-19-July-2017 24 20 4 10 Healthy Growth Visit2 09-11-June-2017 37 25 12 11 Multi Scetoral Coordination Activity 1 09-11-July-2017 32 8 24 12 VIC & CF training 12-16-September-2017 27 14 13 Table 2: Number of People Trained during Reporting Period

Program Implementation Progress

Memorandum of Understanding: On 3 February 2017, the MOH, represented by Dr. Plath, the Director General of the Department of Health and Hygiene Promotion (DHHP), and SC, represented by Olivier Franchi, Country Director, signed the USAID Nurture Project Memorandum of Understanding (MOU). The United States Ambassador, Rena Bitter, spoke at the event held at the Settha Palace Hotel. Senior representatives of provincial health departments from Khammouane and Savannakhet, and representatives from other development partners, including UNICEF and the European Union (EU) participated.

Kick-off Meeting: After the signing of the MOU, Save the Children officially launched USAID Nurture during a kick-off meeting held 22-24 February 2017 in Vientiane. Senior representatives of provincial and district health departments, as well as central MOH staff from DHHP and its centers participated. The purpose of this meeting was to: 1) Orient participants to USAID Nurture and its linkages with national policies and strategies; 2) Clarify roles and responsibilities and reporting lines of all parties/levels and agree on reporting requirements and submission dates; 3) Orient GoL partners to SC and USAID requirements; and 4) Create a one-year (2017) USAID Nurture work plan, including village phasing strategy and selection criteria. The meeting also served to strengthen capacity of participants’ nutrition work planning and management skills. The one-year work plan, and the process to develop it, will subsequently be used as the basis of detailed quarterly planning and project progress review meetings to be held at district and provincial levels.

Procurement of Equipment and Supplies: SC received waivers from USAID to procure 14 motorbikes and 2 vehicles for use in the project locations. Procurement The process of securing all GoL approvals and clearances is complete and the vehicles have been transferred to the provinces.

Produced Project Products and Processes: To support implementation, USAID Nurture produced a number of project products and processes:

 iNuW Community Toolkit: The USAID Nurture team produced an initial draft of the community mobilization and triggering, featuring CLTS, component of the integrated USAID Nurture project activity toolkit. To allow for immediate implementation, this component of the toolkit draws on existing materials, such as the CLTS manual from the National Center for Water Supply and Environmental Health (Nam Saat), the Ministry of Health, which are already approved for use in Lao

PDR, with some adaptations, and improvements to create a more integrated nutrition-WASH approach, including mobilization processes.  Thakek Pilot Test: While awaiting the MOU approval and to reduce project delays, SC requested MOH approval to conduct preparatory activities, including the pilot testing of the community mobilization/triggering component of the USAID Nurture Toolkit in Thakek. Pilot tests for Village Visits 1 and 2 were carried out in Thakek, and Visit 1 delivered in all 20 Phase 1 villages (10 in Mahaxay and 10 in Phine) following an orientation session for GoL delivery agents. As part of the pilot test USAID Nurture trained four women from Thakek, six women from Sangthong district (VTE), and three RDA staff.

 Health Care Provider and Management Staff Capacity Building Assessment: In May, USAID Nurture completed the final report entitled “Nutrition Services and Management Capacity Assessment Report: Phase I”. The report describes nutrition services in term of supplies, services, supervision, and systems and emphasizes how the linkages between each have significant impact on capacity. The most crucial supply gaps found were zinc supplements, ANC ‘mother’s books and growth charts. There was no existing capacity in nutrition counseling services, nor in management of malnutrition and referrals, and most providers could not conduct growth assessment or charting correctly. Supervisory systems do not include nutrition services but antenatal care (ANC) is a universal priority and ANC can be co-opted as a nutrition counseling activity. Finally, the poor systemic support for nutrition was detailed in the responses of supervisors, lack of nutrition indicators and poor quality of exiting data in the District Health Information System 2 (DHIS2).

 WASH Marketing and WASH Product Delivery: Last year, SC worked with Soap4Life, a local social enterprise, to train select community facilitators to make and sell unscented soap products. This was to address a key barrier - consumers stated that they do not like to eat after using scented soaps. USAID Nurture ended the contract with Soap4Life based on contractual issues. April 6-7 2017, RDA conducted an informal assessment of the progress and perceptions among those trained in Thaket (n = 4). The assessment showed that the women most likely would not continue to make and sell soap after the pilot. No reasons were stated why; the assessment was very informal and did not probe for specific reasons. Save the Children’s newly recruited Marketing Manager is now developing a WASH Product Marketing Plan for all target products, including soap, given this shift away from Soap4Life.

In YR2, Geo-Sys produced a WASH Market Assessment Report outlining how best to introduce and/or scale up the supply of select WASH products and services (e.g. latrines, hand washing products, water filters, safe water storage containers, and material support for clean play spaces) in target villages to support households’ adoption of the project’s targeted WASH behaviors. Based on the assessment results, in the final quarter of FY 2017, USAID Nurture produced a Draft WASH Product Marketing Plan, which will be finalized in Q1 of FY 2018 in collaboration with the SBCC Task Force.

Based on this Plan, USAID Nurture will identify appropriate private vendors and engage them in order to build their capacity to market their products. Furthermore, we will build capacity among district partners to manage WASH products marketing to ensure quality of the products and fair price. Initially, USAID Nurture had planned to train Community Facilitators (CFs) – women from the target villages – to make and sell soap; however, with the termination of the Soap4Life contract, USAID Nurture has been exploring alternatives. One option is to centralize the production of soap to ensure its consistency and quality and to train CFs as sales agents for all WASH products promoted by the project. Commissions on sales would then serve as the financial incentive for serving as a CF.

Strengthened GoL Technical Capacity, Adherence to Global Standards USAID Nurture has been working closely with the GoL and other major partners, including the EU, World Bank, UNICEF, the World Food Program, and the Laos Scaling up Nutrition (SUN) Civil Society Network to: support development of a M&E plan for the National Nutrition Strategy; provide input into the national SBCC plan processes; engage GoL in regional and global learning; strengthen the code on the marketing of breastmilk substitutes (BMS); and to strengthen supportive supervision and breastfeeding support services.

 Code of Marketing of BMS: To gain momentum toward strengthening the code of marketing of breastmilk substitutes, the USAID Nurture COP presented Vietnam’s breastmilk substitute policy change experience on behalf of Alive & Thrive (A&T) on July 26th during a MOH organized meeting. The meeting topics included: 1) a discussion on how to improve BMS code legislation for breastfeeding promotion; 2) nutrition indicators to be included in the DHIS2; and, 3) discussion and planning for the nutrition SBCC Plan. USAID Nurture has been an active member of the informal Development Partners group that is developing a road map for upgrading the Laos marketing of breastmilk substitutes (BMS) agreement to better align it with the World Health Assembly Resolution 69.9. SC’s Health Specialist participated in the workshop to draft the new marketing regulation in August 2017.

 Breastfeeding Support Services: GoL has now adopted breastfeeding as a crucial component of nutrition policy, but mechanisms for advocacy and practical support remain disjointed. USAID Nurture has actively engaged in advocacy opportunities across MOH departments. USAID Nurture participates in the Early and Essential Newborn (EENC) Secretariat’s quarterly meetings. The EENC secretariat in Lao encompasses Baby Friendly Hospital Initiative (BFHI)-related efforts and improved newborn care, and is the central mechanism driving efforts to make health facilities breastfeeding friendly. In September, WHO requested that the SC Health Specialist provide early input on the new ANC and PNC guidelines. As a result, the draft guidelines are now structured in a client-centered format and the counseling competencies and behavior change messages developed by the project are integrated into the draft document. These close linkages continue to ensure that the updated national service package and new guidelines reflect USAID Nurture pioneered approaches to nutrition-specific and nutrition-sensitive care, including the promotion of breastfeeding and appropriate complementary feeding in routine contact points. These efforts are directly tied to USAID Nurture’s health care provider and management staff capacity building program referenced above. New and Existing Sub-Award Status

Signed Subawards and Contracts, Initiated Activities SC signed agreements and contracts and/or modified existing contracts with the following organizations/firms in FY 2017:

Rural Development Agency (RDA): To deliver the WASH objectives for USAID Nurture, SC received USAID approval for a sub-award with the Rural Development Agency (RDA), a Lao social enterprise with expertise in WASH, and nationally recognized as a leading implementer of CLTS. RDA, having grown out of the Participatory Development Training Centre (PADTEC), is the country’s local implementer of CLTS, supporting its implementation in partnership with a number of INGOs, such as SNV, Plan international and CARE, and multi-laterals, such as UNICEF, and the World Bank. Staff have close and effective relationships with Nam Saat at each level of government and have delivered CLTS in Bokeo, Champasack, Huaphan, Saravan, Savannakhet, and Sekong provinces. Additionally, RDA is an innovator in community-centered development in Laos and is able to provide significant expertise in locally-

appropriate mobilization techniques and effective volunteer selection, training, and supervision. RDA is carrying out activity implementation in the phased villages according to the iNuW toolkit under the supervision of the USAID Nurture WASH Specialist. While the phasing plan is rolling out, there have been challenges in implementation. The District Facilitating Officers (DFOs) face challenges in reaching some villages due to the terrain, and it is very difficult to stay on schedule during the rainy season. In addition, RDA is experiencing high staff turnover, whether due to lack of capacity and being terminated, or leaving to go to another organization that provides better salaries. USAID Nurture is currently working with RDA to address these challenges and has been providing ongoing capacity building for the technical, operational, financial, and managerial capacity at all levels.

Geo-Sys: SC contracted Geo-Sys, a local firm to conduct a WASH marketing assessment and to develop a WASH marketing Plan for the project. The assessment examined how best to introduce and/or scale up the supply of select WASH products and services (e.g. latrines, hand washing products, water filters, safe water storage containers, and clean play mats to make clean play spaces for children) in target villages to support households’ adoption of the project’s targeted WASH behaviors. Geo-Sys initiated this scope of work in YR1, and completed it in Q1 of FY 2017.

Soap4Life: SC contracted Soap4Life, a local social enterprise, to train select community facilitators to produce and sell unscented soap products in the target villages (in addition to their responsibilities as SBCC agents). According to Soap4Life, unscented soap addresses an identified barrier to handwashing— villagers eat with their hands and do not like to eat after using scented soaps that may interfere with the taste of the food. Due to a variety of factors, the contract was ended with Soap4Life.

Futureview Consultants: Following the removal of the M&E Specialist key personnel position, USAID Nurture contracted Futureview Consultants to develop the project’s M&E system and database. This system allows the tracking of process and output indicators for all activities and process evaluations. It facilitates analysis and presentation of data for ease of use with project staff and partners, including GoL. USAID Nurture’s M&E Officer trained the DFOs on how to use the iPad. Final licenses and materials are being procured and USAID Nurture expects to test and launch the system in Q1 of FY 2018.

Niramonh Chanlivong: SC contracted a local consultant and her team to design and conduct a formative research/gender analysis study that informed USAID Nurture’s social and behavior change (SBCC)Plan.

Lisa Sherburne: SBCC consultant from the Manoff Group (former Nutrition SBCC Advisor from Save the Children United States (SCUS), is continuing to support the WASH Specialists in the finalization of the draft iNuW Toolkit. The toolkit will be revised based on an adaptive management approach, wherein all processes will be documented, and expects to be finalized in Q2 of FY 2018.

BlueGlass: In Q3, when USAID Nurture developed its SBCC Plan, the team recruited Blueglass to develop a creative concept for the iNuW Community Approach. They prepared four concepts using the Creative Concept Brief from USAID Nurture. Field testing took place in Q4 of FY 2017 to select the preferred concept; the revised concept and final report were shared with USAID Nurture and USAID in Q4 of FY 2017. Appendix 6 provides the concept USAID Nurture will use for products approved by USAID.

Major Impacts and Accomplishments by Intermediate Result

Intermediate Result 1: Improved IYCF and WASH Behaviors

Formative Research and Gender Analysis study: To inform the SBCC Plan, USAID Nurture conducted two studies. The first was a WASH value chain assessment (described further in IR2). The second, a formative research and gender analysis, was led by Dr. Niramonh Rasprasith with technical direction from Lisa Sherburne. The purpose of the formative research and gender analysis study Table 3: Gender Analysis Perceptions and Practices was to learn with communities, Access to • Health services: parents and husbands families and women about the resources are the gatekeepers, deciding when barriers and facilitators to optimal women may attend. adolescent and maternal nutrition, • Access to food is limited by food IYCF, WASH, and health care taboos/restrictions. seeking/use behaviors as well as the Knowledge, • Generally comparable knowledge about feasibility of improving nutrition- beliefs and nutrition and child care, but nearly all enhancing behaviors. The study also perceptions things related to home, food and explored gender norms and raising children is the woman’s role expectations and how these influence (not seen as hard work or even work). women and children’s nutrition, identifying perceptions and practices Practices and • Women rarely (if ever) participate in participation village meetings. related to being a good wife, mother, husband, and father. For instance, a Time and • No time for herself. “We women, we good wife and mother should stay space rest at night.” home to care for her home and children, while a good husband and Power & • When living with parents, “big father” father should go out and work to decision and “big mother” make the decisions. provide food. It also highlighted the making • When living as a couple, husband is heavy work burden women face and decision-maker. the critical need to engage husbands/fathers in food gathering, household care and cooking, and child care and feeding. These findings are being used to inform activities and communication to affect social norms as well as influence behavior change. During the reporting period, the research team conducted the field work, and analyzed and presented the data at the SBCC workshop. The study report was finalized in Q3.

SBCC Plan: Lisa Sherburne, on behalf of USAID Nurture, facilitated the 2-part SBCC workshop held 20- 24 March. The purpose of Part 1 (2 days) was to validate USAID Nurture’s formative research and gender analysis findings with key stakeholders, garner inputs to USAID Nurture’s SBCC Plan, and to contribute to the National SBCC Plan. Participants in Part 1 of the workshop included national, provincial and district GoL staff linked to USAID Nurture, and development partners, including USAID, World Bank, EU, UNICEF, CARE, and SNV. To enhance synergy with the national processes, the project invited UNICEF to present a national literature review conducted to inform the SBCC Plan.

The purpose of Part 2 (3 days), in which only USAID Nurture and GoL counterparts participated, was to 1) develop a common understanding of terms and concepts related to SBCC and steps to prepare an SBCC Plan among USAID Nurture Project partners; 2) reflect on the research findings and stakeholder workshop inputs in an SBCC framework including key behaviors, participant group profiles, a behavioral analysis and activities; and 3) prepare an SBCC Plan including key concepts and activities.

The second SBCC workshop was co-chaired by DHHP’s Center for Information and Education for Health (CIEH), one of the USAID Nurture focal point centers. Mr. VisithKhamlusa, the Deputy Director and some of his team fully participated in the workshop, reflecting that it was one of the best workshops he had attended, and more clearly articulated the SBCC process than any other. Mr. Visith is so pleased with USAID Nurture’s SBCC efforts that he proposed to DHHP and the World Bank, EU, and UNICEF—the primary development partners involved in and funding the developing the national SBCC Plan—that the USAID Nurture SBCC Plan be used as the platform for the national plan.

Ian Moise, WASH Technical Figure 1: Child-centred WASH-Nutrition Integration Visual Advisor from SCUS also participated in the SBCC workshop to provide technical support to USAID Nurture in development of its WASH marketing program. He shared the growing global recognition of the critical importance of putting the child in the center of WASH and nutrition programming decisions.

The national SBCC task force developed a revised version of the SBCC Plan, removing the formative research and putting in more information related to theory and communication channels. This draft zero was circulated to Development Partners and the GoL in Q4 of 2017 for comments. While comments are being collected on the zero draft from development partners (DPs), USAID Nurture has been working closely with UNICEF since the Nutrition Symposium and Forum, where the SBCC Plan was soft launched, (October 31 – November 1) to plan targeted capacity building for DPs and government regarding the SBCC process. USAID Nurture and UNICEF met in Q1 of FY 2018 to discuss a viable capacity building strategy. It was agreed that a select number of “Champions” among the DPs would start meeting monthly as a technical working group starting in January 2018 to discuss how to: 1) gather all qualitative and quantitative research completed in early 2018 to enhance the current SBCC plan; 2) work with DPs to produce appropriate communication materials to show the GoL that DPs are doing SBCC related activities while waiting for the SBCC Plan to be implemented; 3) plan two sub-national workshops based on the Whole System in the Room approach described in USAID Nurture’s Y3 Work Plan (where SC is taking the lead - one in Luang Prabang, through the Primary Health Care Project through and one in Savannakhet through USAID Nurture) in Q2/3 of FY 2018. Appropriate stakeholders will be invited at all levels to begin to build evidence regarding how to adapt the National SBCC Plan to a sub-national action plan, based on the specific regional evidence; and 4) after discussions with UNICEF, it was proposed to have a National workshop following activity #3 to share the evidence and results of the sub-national workshop to validate the approach at a national level; this is pending outcomes of the sub-national action plans and next steps as a result.

USAID Nurture iNuW Toolkit: In FY 2017, USAID Nurture started drafting the iNuW Community Toolkit. Figure 2 outlines the iNuW community process, Appendix 1 contains the iNuW community section outline, and Appendix 3 contains images of some of the tools being developed. USAID Nurture produced the guideline based on global evidence and national guidelines for the Village

Visits, which are the entry point for the project into target villages. A series of nine Village Visits will be delivered to each village. In Visit 1, the project secures permission from village leadership to implement USAID Nurture. In Visit 2, the village develops an action plan, which is to be completed by the end of the village visit cycle. In Visit 3, the village selects the VIC and the CF. Following this visit, USAID Nurture trains the VICs and CFs to support implementation of the Community Action Plan and deliver Peer Support Groups and Household Visits and the marketing component also begins (see IR2). Visits 4 to 8 comprise fostering family support and reviewing and documenting progress. Visit 9 is to verify Open Defecation Free (ODF) status and prepare for a celebration of achievement, including an ODF declaration.

Several of the Village Visits are designed for the team (including local Government) to support the VIC in the implementation of the Community Action Plans that communities have committed to. In addition, on a quarterly basis, the team will provide continued support to the VICs to support and maintain community-wide ODF as well as supportive supervision from DFOs/district partners to CFs on Peer Support Groups and Home Visits. Once Village Visits, Peer Support Group sessions and Home Visits are complete, an event will be held to recognize the iNuW team – VICs and CFs – together with the community to celebrate the achievement of ODF and “Model Healthy Family” status.

In the first phase, Visits 1-3 were delivered in 10 villages in Mahaxay and 10 in Phine, and Visits 1 and 2 were delivered in 10 villages of Xonnabouly. In September, USAID Nurture continued to roll-out Village Visits in these villages starting with Visit 3, including TOT (district partners, DFOs, USAID Nurture staff), and initiated Village Visits in 50 additional villages in Phine, Mahaxay and Xonnabouly. Appendix4 provides the current phasing strategy.

Figure 2. iNuW Community Process Engage private sector WASH product marketing

Visit 3: Select Visit 1: Obtain Visit 2: Develop Village iNuW Visit 9: permission to Community Committee and Visits 4, 5, 6, 7, 8, Celebration and work in Village Action Plan Community ODF Facilitators

Peer support groups

Train VIC and CF to deliver Household visits

Intermediate Result 2: Improved use of quality nutrition and nutrition-sensitive WASH Services/Facilities

Community Service Delivery Figure 3. iNuW Capacity Building iNuW Training: Regarding rollout of the VIC Committee Orientation Sessions iNuW toolkit, once VICs and CFs are 1. Integrated Nutrition and WASH (technical selected during Village Visit 3, USAID background on nutrition and WASH) Nurture, with GoL, conducts a 1-day 2. iNuW Committee Roles and Responsibilities orientation for the VIC members, and a 3- (including leadership principles) day training for CFs to support the iNuW 3. Overview of iNuW Community Visits, Peer Community Approach. In FY 2017, the Support Groups, Home Visits orientation and training packages were developed. The 1-day orientation for the 4. Management Skills (planning, mobilization, VIC entails six sessions, while the training coaching) for CFs is three days (15 sessions in total). 5. Monitoring form practice Through these events, the VIC members 6. Review of Village Action Plans and and CFs learn the nutrition and WASH Commitments content, acquire effective communication, CF Training Topics negotiation and problem-solving skills to 1. Integrated Nutrition and WASH (INuW) support households to overcome barriers 2. Village Action Plans to behavioral adoption, learn how to 3. Peer Support Groups – formation, support implementation of the community content/tools, session preparation, practice action plan, and use the activity 4. Facilitation skills monitoring tools. In addition, CFs learn 5. Home visits – tools, practice, reflection how to facilitate the Peer Support Groups and conduct Household Visits (Figure 3). In September, 6. Monitoring trainings began to roll out starting in 20 villages (10 in Phine and 10 in Mahaxay) with VICs being 7. Village delivery planning formed and CFs being selected (Table 4). In FY 2018, USAID Nurture will continue to implement the iNuW Community Toolkit, adding districts and villages according to the phasing strategy. The toolkit will be revised based on adaptive management, wherein all processes will be documented, and expects to be finalized in Q2 of FY 2018 through the participatory process with field staff and government partners. USAID Nurture is currently working on a plan to strengthen the ongoing sustainability of the intervention, and is consulting with field staff through the adaptive management process to have this plan ready in Q1 of FY 2018.

Table 4. iNuW CF Formation

Districts CFs selected Phine (10 villages) 20 CFs Mahaxay (10 villages) 20 CFs Total 40 CFs ( 18 female)

WASH Product Delivery Soap Maker Training: From 5-9 December2016, Soap4Life conducted the first soap making training. RDA staff participated in the training to ensure their ability to conduct soap making demonstrations during village visits. Since the training, some of the Thakek participants have continued to make soap, but have found it difficult to sell the product. Some villagers prefer scented soap, some do not like the product because it does not foam/bubble, and shops refused to carry the soap because it is

“unfamiliar.” This experience matches some of the GeoSys marketing assessment findings, and point to the importance of giving women strong marketing skills and marketing materials, focusing on the purpose of the soap – handwashing at key points to support children’s nutrition, and adjusting the product both to meet consumers’ preferences and to capture emotional triggers including their values of responding to children’s wishes.

WASH Market and Value Chain Assessment: Ian Moise, Senior WASH Advisor from SCUS, helped to orient the newly hired USAID Nurture WASH Advisor (Bounthavong Sourisak), and met with marketing research firm (GeoSys) representatives, and relevant government actors who will play a role in the WASH marketing program; they identified steps for developing and implementing the project’s WASH marketing plan and program. GeoSys conducted a WASH Market and Value Chain Assessment to determine how best to introduce and/or scale up the supply of select WASH products and services (e.g. latrines, hand washing products, water filters, safe water storage containers, and material support for clean play spaces) in target villages to support households’ adoption of the project’s targeted WASH behaviors. The team conducted the field work, which entailed multiple visits to test potential products, such as water filters and handwashing stations, analyzed the data, and presented the findings at the SBCC workshop. The study report was finalized and submitted to USAID in Q3.

In the final quarter of FY 2017, USAID Nurture produced a Draft WASH Product Marketing Plan, which will be finalized in Q1 of FY 2018. Based on this Plan, USAID Nurture will identify appropriate private vendors and engage them in order to build their capacity to market their products. Furthermore, the project will build capacity among district partners to manage WASH products marketing to ensure quality of the products and fair price. Initially, USAID Nurture had planned to train CFs – women from the target villages – to make and sell soap. However, with the termination of the Soap4Life contract, USAID Nurture will focus more on social and behavior change around using soap. USAID Nurture will explore options including identifying other viable soap making organizations in Vientiane.

WASH Activities: Based on the WASH Market and Value Chain Assessment, the following activities were taken in FY 2017 after the USAID Nurture Marketing Specialist was brought on board in July 2017. The overall marketing roadmap and some essential tools were developed and field-tested in Mahaxay, Phine, and Xonnabouly districts – focusing on three main elements of the marketing – (1) WASH products; (2) Capacity building for the private sector; and (3) Tool development. See Appendix 5 for the WASH marketing Roadmap. WASH products selected include pour-flushed toilets (the average selling prices range from 500,000 LAK to 750,000 LAK (approximately $60-$90 USD) excluding shelter, which is cheaper than building your own latrine), water filters, soap, water containers for children, and mats/brooms. Through surveys conducted among 18 private enterprises in six districts of Savannakhet and Khammouane, one of these 18 private enterprises were recruited for capacity building activities (one in each district). Three enterprises in Phine, Xonnabouly and Mahaxay districts have been trained on latrine production and provided with sales promotion tools. Importantly, government partners have been fully involved in these activities, for example, in interviewing enterprises, participating in trainings, seeking sales agents in communities, and facilitating the process. Tools developed included business skills training modules, sales tools, sales agent training modules, and selection criteria for enterprise and sales agents.

Currently, there are 16 sales agents recruited from VICs, CFs and other interested villagers and trained (10 sale agents in Xonnabouly and six in Phine). Regarding the work on drinking water treatment, based on the WASH Market Assessment Report we initiated discussion with Abundant Water (an INGO) on possibility of promoting one of the water treatment options to the rural poor communities by starting with setting up the link between Abundant Water Organization and local enterprises in Phine district.

Environmental compliance: To mitigate the potential risks of training women to make soap using soda/lye, Soap4Life trained women to use safety measures during the soap making process. Rather than a pre-/post-test, trainees were observed during the workshop to ensure they applied required safety measures. Soap4Life also provided all 13 trainees safety equipment. In observing this initial training, USAID Nurture identified a few areas for improvement, such as the safe storage of the lye, and appropriate safety eyewear. During trainings of enterprises, USAID Nurture will ensure latrine marketers have installation standards that ensure runoff water is managed, such as by digging soak away pits, and that latrines are constructed at least 30 meters from a drinking water source. Health Service Delivery Table 5. 4S Model Health Care Provider and Category Select assessment topics Management Staff Capacity  Pink mothers’ books, Job aides Building Program: To inform USAID  IFA tablets, Zinc, ORS Nurture’s health care provider and Supplies management capacity building strategy  Scales, Measuring tape, Length boards and the content of the training  Nutrition counseling for pregnant women workshops, the team designed and  Nutrition counseling for caregivers of conducted an assessment for the young children national, provincial and Phase 1 district  Growth measurement skills Skills levels. Drawing from Potter and  Growth charting skills Brough,3 USAID Nurture developed the “4S” model of health care capacity,  Community communication comprising supplies, skills, supervision and systems (Table 5). Using this model  Coach HCs in nutrition counseling as the guiding framework, USAID  Monitor staffing, supplies and recognize success Nurture then adapted the Global USAID Supervision Strengthening Partnerships, Results, and  Nutrition sensitive checklists Innovations in Nutrition Globally (SPRING) Project Nutrition Workforce  Track improved nutrition services & outcomes Assessment data collection tool.  Include needed staff and supplies in plans

 Include nutrition actions in basic service Systems Using discussions, interviews, package observations, and spot checks, the assessment guided health managers and  Regular meetings to track planning, budgeting, results and solve problems staff to reflect on the mandate, capacity, and status of 45 nutrition-specific and nutrition-sensitive services provided by the health center, equipment and stock out issues, as well as the status of supervision, data, and management systems. USAID Nurture added an observation and spot check component to triangulate findings.

The assessment was conducted over two weeks in Q2 (Savannakhet: 30 January to 3 February 2017; Khammouane: 6 to 10 February 2017). It began with consultations with Savannakhet and Khammouane provincial health leaders and Phine and Mahaxay district health managers. Following these meetings, USAID Nurture staff visited 2 health centers in each Phase 1 district. The team interviewed staff on site, checked records, equipment, and observed patient care. The assessment identified the strengths and challenges of the Lao primary health care service, including nutrition

3Potter, Christopher, and Richard Brough. "Systemic capacity building: a hierarchy of needs." Health policy and planning 19.5 (2004): 336-345.

workforce size, composition, qualification, availability, gaps, and training status within the health center and integrated outreach service delivery levels. The assessment was conducted in Xonnabouly in July prior to launching the counseling training. The remaining three districts will undergo assessment early in FY 2018 and an update report will be released.

Maternal and Child Health (MCH) Nutrition Counseling Training Program: Based on the national consultative Figure 4: National Counseling meeting to establish national counseling competencies in Compentencies December 2016, USAID Nurture employed the agreed upon 1. Be respectful competencies, and the findings of the assessment, to 2. Listen actively develop the project’s nutrition counseling training program 3. Communicate clearly (Figure 4). In FY 2017, USAID Nurture and CIEH developed a 4. Build confidence 3-part health care provider training that uses a lifecycle 5. Empathize approach, focusing on the first 1,000 days: maternal 6. Help plan nutrition, nutrition for infants 0-6 months (breastfeeding), and nutrition for children 6-23 months (breastfeeding plus complementary feeding). The simulation- based course relies on trainers—all government officials from the project provinces—to model core counseling competencies while they guide learners in a debriefing process for each practice care encounter. The course format emphasizes that counseling skills should be applied across all care encounters and the course materials are modular to allow the training system to remain the same, while messages and behaviors can be updated and customized to local needs over time (and in keeping with national strategies, the Formative Research/Gender Analysis results, and new research). The course assumes all learners can improve their counselling skills through practice, regardless if they are beginners or already familiar with counseling. Lectures are not used, but crucial messages are reinforced through brief plenary discussions, debriefing, and reference handouts. Each session of the course concludes with local health leadership watching a demonstration of the skills and publically supporting their local health center staff to develop improved service standards and a supportive supervision plan. Training implementation follows the phasing strategy, reaching all health centers within a district for each training. Progress in FY 2017 is outlined in Table 6. Module 3 TOT curriculum was completed in September but the training was delayed until the first week of FY 2018 due to GoL availability issues.

Table 6. FY 2017 Health Care Provider Capacity Building

Event Participants No. Location Date Module 1 ToT Master Trainers 19 Vientiane April 4-7 Module 1 Training Health Center Providers & Supervisors 25 Phine April 25-27 25 Mahaxay May 3-5

26 Xonnabouly August 9-11

Module 2 ToT Master Trainers 15 Vientiane June 13-16 (3 new) Module 2 Training Health Center Providers & Supervisors 25 Phine July 4-6 (4 new) 25 Mahaxay July 18-20 (5 new)

Supervisory level: Recognizing that training requires supervision for lasting impact, USAID Nurture invites 1-2 members of the District Health Office (DHO) clinical supervision team to every training to

ensure they also understand and support the nutrition counseling behavior change approach. A post-training meeting is held to review the existing supervision system and ask the DHO members to describe how they will incorporate nutrition counseling into upcoming supervision visits to health centers. USAID Nurture offers practical advice, demonstrates job aids, and suggests techniques while emphasizing that supervision is a routine GoL work task and not a project activity. Managers are asked to comment at the conclusion of the workshop and provide feedback and encouragement to their cadre of health care workers.

Intermediate Result 3: Improved Enabling Environment

Nutrition Governance and Multi-Sectoral Coordination: To support the GoL to roll-out its mandate that each level (provincial and district) establish a multi-sectoral nutrition committee, USAID Nurture collaborated with UNICEF to launch this effort in Khammouane and Savannakhet.

National level: To support nutrition governance, multi-sectoral coordination, and capacity building, the USAID Nurture team participates in various existing national and sub-national platforms, including the National SBCC Task Force, the National Marketing of Breastmilk Substitute Code Task Force, the Development Partners Nutrition Working Group, and the Reproductive, Maternal, Newborn and Child Health(RMNCH) informal working group. In FY 2018, the team will continue to engage in the development of national policy frameworks, including the SBCC Plan, and code Figure 5. USAID Nurture Nutrition Coordination Support regulation. A portion of this effort is covered by matching funds provided by Alive and Thrive Provincial Nutrition Committee (PNC): (A&T). Support for monitoring and supervision of activities in project districts and villages. Sub-national level: A key role of the USAID Support for study visit/exchanges. Nurture Provincial Coordinator is to advocate for making nutrition a priority in provincial and District Nutrition Committee (DNC) of USAID Nurture districts: district-level work planning, and to build the  Quarterly meetings capacity of the GoL to do so. The Provincial Coordinators help facilitate the uptake of  Bi-annual meeting at provincial level components of the National Nutrition Strategy to  Technical and coordination capacity building 2025 and the National Plan of Action 2016-2020  Support for monitoring and supervision of activities in districts and villages and seek to build upon existing line ministry  Support for study visit/exchanges. management structures and forums to promote a vision of USAID Nurture actions as part of government service delivery.

To strengthen multi-sectoral nutrition coordination, the EU (via UNICEF) is supporting the GoL to organize functioning multi-sectoral nutrition committees at provincial levels. To launch this effort in Savannakhet and Khammouane provinces, UNICEF organized an orientation for GoL officials from July 5-7. To support this event, USAID Nurture reviewed internationally and locally used governance tools and helped prepare the agenda. To build management capacity, USAID Nurture agreed to support coordination and capacity building actions at provincial and district levels, which is included in Objective 1 on MOU (see Figure 5). This support supplements UNICEF’s efforts at provincial level, while USAID Nurture will support all aspects of district level coordination for the remainder of the project.

Implementation Challenges and Mitigation Staffing: As mentioned previously, the human resource pool and competition for the limited number of qualified staff remains a major challenge in the Lao context. The M&E Specialist recruited for the project was found to be under-qualified, so SC developed and implemented a replacement plan, which entailed contracting a firm to develop the system. Further, SC experienced turnover on the operations team as originally recruited staff resigned to assume roles in other organizations that provide higher remuneration.

In FY 2017, USAID Nurture was able to recruit and fill all vacant positions. The COP is identifying areas for capacity building, and plans to develop a contract for an M&E specialist based in Thailand in Q1 of FY 2018to support M&E systems and processes under the project, including a capacity assessment of all USAID Nurture staff to tailor support. In addition, USAID Nurture is working closely with the support services team at Save the Children International(SCI) in finance, awards management, and compliance. The team also receives support from SCUS Headquarters. Roles and responsibilities have been clearly laid out among the staff. Upon arrival, the COP met collectively and individually with Vientiane based staff members to review progress, and understand successes and challenges both professionally and personally. Ongoing weekly meetings have been set up with key staff members who need additional technical guidance. Bi-monthly staff meetings are now more efficient, focusing on the “hot items” each staff member is dealing with, and what needs to be done to assist or support each staff member. The COP also has requested staff members to meet more regularly where integration naturally occurs, for example, nutrition and WASH. This has allowed for standardization of messaging and approaches among activities and within toolkits and training materials produced by the project. See Appendix 7.

Partnership management: SC has still found challenges with RDA still being able to fully utilize their internal control and management systems; RDA has hired an international consultant fluent in Lao to assist the RDA finance and administrative management team in developing user friendly systems and writing policies that will assist RDA moving forward which expect to be rolled out by the end of 2017. In the meantime, SCI has developed payment checklists for different types of expenses such as staff advances, procurement, salary and general administrative expenses to ensure that RDA meets minimum requirements and internal controls. SCI has supported RDA to develop Human Resources (HR) Standards of Operation, which describe processes in detail with document requirements from the recruitment process until end of employment contract to ensure that RDA meets USAID requirements. SCI assisted in the development and implementation of a procurement policy, however, RDA still faces challenges in applying the policy. To minimize risk, SCI is organizing a framework agreement for main goods and service such as vehicle rental and training material (stationery), then RDA will use the same framework agreement as USAID Nurture.

Delays in implementation: USAID Nurture team experienced delays in implementing the iNuW toolkit for a number of reasons. First, the MOU took approximately one year to finalize preventing USAID Nurture from commencing community activities. Second, piloting and making subsequent changes to the iNuW Toolkit consumed a considerable length of time. The draft went through a number of revisions based on the formative research findings and consolidation of SBCC messages. Third, delays were in part due tothe prolonged rainy season, which prevented visitation in certain villages and meant villagers were busy with their planting work in the field. Fourth, it required more time to orient GoL partners and DFOs on the toolkit than expected, including additional explanation of the project goal and processes and time to become familiar with the steps and tools to be able to effectively carry out iNuW activities. The Lao translation of the English toolkit was also not always clear in the context and required additional explanation.

The USAID Nurture team is back on track with the phasing plan, starting implementation in 50 villages by the end of Q4 of FY 2017. USAID Nurture is discussing ways to ensure there are enough vehicles, staff, and other necessary materials in place throughout rollout to ensure scale up in Q1 of FY 2018. USAID Nurture will focus on: improving the facilitation skills of the field team coupled with some additional technical training on nutrition and WASH and its links to nutrition; increased attention to seasonal constraints when scheduling community work; conducting periodic training and supervision on data collection and data quality; and holding monthly team meetings at the district level with greater involvement of district partners. USAID Nurture will also hold learning and exchange events so that lessons learned can be shared among actors and with GoL partners and fed into the improvement of the toolkit and project process and approach.

GoL restrictions: In recent years, GoL has restricted space for civil society engagement. A potential new decree inhibiting INGOs from providing funds to non-profit agencies (NPAs) in Lao PDR may affect USAID Nurture’s ability to work with and build the capacity of local organizations to deliver integrated nutrition services. This potential decree does not have an immediate effect on the project, because RDA is a social enterprise and not an NPA.

Deviations from Expectations for Performance Indicators

As per the requirements of the award, during the reporting period, SC developed and submitted the USAID Nurture MEL Plan within 90 days of award. Following receipt of comments from USAID, the plan was revised and approved. USAID decided to move the step-wedge evaluation study out of the USAID Nurture work plan to allow for an independent evaluation of the project and to direct USAID Nurture’s attention to implementation. SC re-focused the project’s evaluation on implementation research and studies. During the transition from the previous COP to the new COP, there were delays in revisions to the preliminary approved MEL plan. Once the new COP was onboard, the MEL plan, including the Results Framework and Performance Indicator Reference Sheets, were reviewed in Q4 of FY 2017. The USAID Nurture Results Framework has been approved by USAID and the MEL plan will be updated and re-submitted to USAID for review and approval. USAID Nurture is working closely with USAID to finalize these components, and ensure that Social Impact, the organization that will be carrying out the impact evaluation, has the necessary indicators and definitions. Due to these delays, USAID Nurture’s targets for the project are being revisited based on the reality and contextual situation.

USAID Nurture contracted a firm, Futureview, to develop the project’s M&E system in FY 2016 and the system will be up and running in Q1 of FY 2018. As mentioned earlier, this entailed designing the system, including developing the input tools, reporting and analysis tools, and reporting templates and dashboards, as well as training the USAID Nurture team to use the system and providing related manuals, such as the manual of operations and the training guide. Monitoring and evaluation by RDA has not yet commenced as this will take place after iNuW visit five. However, RDA has assisted Futureview with background information and provided comments on the data system being developed.

In Q4 of FY 2017, USAID conducted a Data Quality Assessment (DQA) in Vientiane and Savannakhet Provinces. USAID will finalize the report from the findings, and USAID Nurture will take action on the report recommendations starting in Q1 of FY 2018.

Integration of Crosscutting Issues and USAID Forward Priorities

Gender Equality and Female Empowerment: During the reporting period, the team designed and carried out formative research and gender analysis. In FY 2017, USAID Nurture ensured that through both the health care worker trainings and iNuW rollout adolescent health was addressed. An example of this is displayed in Figure 6.

Figure 6. Adolescent Sensitive Approaches in Nutrition Counseling

Adolescent-Sensitive Approaches in Nutrition Counseling The original 1,000 Days Nutrition Counseling curriculum developed by USAID Nurture was designed based on a respectful care and client-centered models. As a result, the design explicitly tried to identify how to improve the quality of services provided to vulnerable groups which in this context are namely adolescent mothers, ethnic minority mothers, very poor mothers, and the intersections of these groups. The barriers to services for these groups are manifold but USAID Nurture is ideally suited to address one prevailing barrier: quality of care.

In this context, quality of care approaches to in nutrition services include: 1. Culturally competent care. Research shows rude treatment and discrimination reduce health seeking behavior by adolescents. The first of the six counseling competencies taught is “be respectful” followed by instructions to empathize, communicate clearly, listen actively, and build confidence. All of these are critical for adolescents to feel well cared for and to actually receive quality care. 2. Appropriate messages. One size fits all approaches to health education that offer idealized and impractical advice mean adolescents realize little benefit from attending services. The formative research identified that adolescent mothers are culturally-unable to rest or eat additional meals so behavior changes messages were changed to provide suggestions adolescents could adopt (additional bites, sitting after eating, etc.). 3. Skilled providers. The curriculum was designed based on the knowledge that most health center staff are themselves young and have little experience with respectful care practices. The training is built on a simulation and debrief model where trainers model the six competencies in how they teach and then use critical questions for group discussion to help trainees examine how they work. They are asked to note what barriers young mother experience, examine if their advice will be feasible for young mothers, asked to practice ways to speak more clearly. The training has communication drills to ensure everyone leaves with the skills to communicate in ways that promote confidence and ability to change amongst even the most marginalized mothers.

Sustainability Mechanisms (including local solutions and partnerships): USAID Nurture has worked in close collaboration with GoL at all levels to identify project geographies to ensure locations meet GoL needs and are desired by government counterparts, which fosters their willingness to engage and local activities and feel ownership. We continue to do so as we develop the project technical content and delivery approaches and as we implement activities. USAID Nurture also significantly contributes to national-level systems strengthening and capacity building efforts across policy, clinical practice, and communications. Environmental Compliance N/A for this reporting period.

Science, Technology, and Innovation N/A for this reporting period.

STAKEHOLDERS PARTICIPATION AND INVOLVEMENT

As noted above, USAID Nurture worked closely with GoL officials at national and provincial levels as well as with other development partners to determine project locations, and to provide technical support to the GoL. Project staff are members of key working groups, including the Development Partners Nutrition Group, and the RMNCH Working Group, which provide USAID Nurture the opportunity to contribute to national dialogue, priority setting, and evidence-based policy making and programmatic responses.

Planned Tasks/Interventions for the Next Reporting Period The following activities are anticipated to be implemented during the first half of FY 2018:

 USAID Nurture will assist in the design and implementation of the sub-national workshop planned in Luang Prabang, document, and learn lessons for the second sub-national workshop in Savannakhet.  Additional materials and tools related to iNuW toolkit, such as, job aids (home visit, peer support group [matching game]), and Activity Guide for CF and VIC, will be further developed.  USAID Nurture will continue to roll-out Village Visits in current phase 1 and phase 2 (Phine and Mahaxay: 50 villages) and in current 20 phase 2 villages of Xonnabouly. Starting from early Nov 2017, the community visits will start in Gnommalath (20 villages, phase 1) and Saybouathong (10 villages, phase 1).  As USAID Nurture is adding adolescent girls as a target audience we will explore opportunities with United Nations Population Fund (UNFPA)and discuss the feasibility of testing Noi, as a tool for communication.  USAID Nurture will provide TOT on “Training Delivery to VIC and CFs at community level” in Savannakhet province for government provincial-district partners and DFOs. There will be 27 participants in total from Mahaxay district (Khammouane province), Phine and Xonnabouly districts (Savannakhet province).  Continue implementation of iNuW Visits four through nine for phases 1 and 2 in Mahaxay, Phine, and Xonnabouly districts.  Commence iNuW phases 2 and 3 in Yommalath and Xaybouathong, and phase 2 in Atsaphangthong district.  Orientation of Visit 4 (Communication Collective Action) will be conducted in Savannakhet and Khammouane provinces for government provincial-district partners and DFOs.  Orientation and training will be provided to VICs and CFs in 30 villages (10 in Mahaxay, 10 in Phine, and 10 in Xonnabouly).  Advertise for remaining DFO positions in the districts of Phine, Atsaphangthong, Ngommalath, Attsaphanthong, and Saybouathong.  Set up offices in Yommalath, Saybouanthong and Atsaphangthong in Q1 of FY 2018.  The Marketing Specialist will finalize the Draft Marketing Plan to be shared for comment.  Supportive supervision will roll out for the health workers trained in nutrition counseling.  USAID Nurture will build the marketing capacity of private sector vendors and link them to project villages for the sale of WASH products.  Organize 2nd and 3rd TOT training for USAID Nurture team and GoL partners on community facilitation skills.  USAID Nurture will work with the UNICEF provincial coordinator to prepare for one training/orientation for the District Nutrition Committee (DNC) secretariat in mid-November2017.  SCI’s Award team to support and monitor RDA.

ANNEXES

Appendix1: iNuW Toolkit: Community Section Outline

Time Facilitators Participants 2 hours USAID Nurture Staff (1) Village Authorities and District Government Staff (3) Objectives and Activities Meet with village leadership (members of the village committee) to: . Introduce the USAID Nurture activity, its goal, intermediate results, and modes of implementation . Recognize the importance of addressing WASH and nutrition to achieve 1 improvements in children’s growth and development Preparation . Appreciate that you will be visiting their village to learn with them about their nutrition, sanitation and hygiene situation . Understand the USAID Nurture mobilization and triggering purpose and process, and the number of Village Visits to be conducted . Plan for Visit 2, including the venue, day, time, and facilitator roles and responsibilities . Help USAID Nurture to know more about their community and how visits should be conducted (e.g., divide ethnic groups because of language)

Time Facilitators Participants 4 hours USAID Nurture Staff and Whole community District Government (6 people) Objectives and Activities 2 Create demand and spark action among all community members, including first 1,000 Triggering for days and adolescent households, to recognize their nutrition and WASH needs through a Healthy series of interactive activities: Growth . Understand the consequences and costs of poor child and adolescent girl growth . Become aware of the environmental risks to healthy growth . Believe that our community can help all children and adolescent girls grow healthy at key times through (easy and fun) nutrition and WASH actions . As a community, commit to take action to improve child and adolescent girl growth

Time Facilitators Participants 2 hours USAID Nurture Staff and Individuals who committed in Visit 2, District Government (2-3 Village Authorities, Village Committee & people) interested community members Objectives and Activities Increase community ownership and sustainability by: . Confirming iNuW Committee members identified in Visit 2 and their roles and responsibilities . Identifying Community Facilitators through a participatory process 3 . Finalizing the Community Action Plan to realize commitments in nutrition and WASH Community (timeline, responsibilities) Leadership . Creating a project name/identity for the village . Enhancing their understanding of USAID Nurture and the integrated nutrition and WASH approach . Developing a community capacity building plan to support committee to implement action plan

*Community facilitators are trained following this visit and initiate household visits, peer support groups

Time Facilitators Participants 4 hours iNuW Committee Whole community USAID Nurture Staff and District Government (6 people)

Objectives and Activities Harness traditions of collective support into nutrition and WASH actions and address the underlying gender norms that contribute to malnutrition and encourage father 4 involvement: Collective . Calculate the cost of different toilet owning options and together construct one Action household’s toilet to understand the toilet options and price and provide hands-on practice in toilet construction . Produce a detailed toilet purchasing plan for suppliers . Collectively as a community prepare insects by roasting and pounding into a dried powder for pregnant women and children 6-24 months to eat. Eat together, and generate commitment to support all families . Generate commitment to collectively support all households to construct their toilets and prepare food for young children

Time Facilitators Participants 2 hours USAID Nurture Staff and District iNuW Committee and CFs Government (4 people)

Objectives and Activities 5 Build family support to encourage family-wide action to support nutrition improvements: Family . Understand that nutrition and WASH is family business: it is about providing for the Support family and caring for the family. Everyone has an important role! . Introduce a simple, homemade handwashing station. This will demonstrate and provide hands-on practice in making one as a family business . Review progress to date in the Community Action Plan

Time Facilitators Participants 2 hours USAID Nurture Staff and District iNuW Committee and CFs Government (2 people) 6 Review & Objectives and Activities Support Sustain community momentum through: Progress . Review progress of the Community Action Plan . Plan how to continue to make progress in the Community Action Plan . Conduct house-to-house visits to provide support to households, as needed

Time Facilitators Participants 4-5 hours iNuW Committee Whole community USAID Nurture Staff and District Government (4 people)

7 Objectives and Activities Village Share and discuss community-wide progress, and engage additional family and Documentary community support for continued action through visual evidence of needs Day . Document progress and challenges in achieving the Community Action Plan through video . Motivate families to fulfill their commitments and/or maintain their progress and new actions

Time Facilitators Participants 2 hours USAID Nurture Staff and District iNuW Committee and CFs Government (2 people) 8 Review & Objectives and Activities Support Sustain community momentum Progress . Review progress of the Community Action Plan . Plan how to continue to make progress in the Community Action Plan . Conduct house-to-house visits to provide support to households, as needed

Time Facilitators Participants 8 hours iNuW Committee Whole community Village Authorities District Government and USAID Nurture Staff (5-7; # 9 depends on size of village) Verification and

Certification for Objectives and Activities Celebration Recognize community achievements . Celebrate progress in the Community Action Plan . Recognize achievements by the VIC and CF, as well as model families . Motivate families to maintain their progress and new actions

Appendix 2: USAID Nurture Q&A for DFOs

USAID Nurture overview/Q&A

This document provides answers to common questions about the USAID Nurture project. Using this document helps to ensure that project staff, when speaking on behalf of the USAID Nurture project, do so accurately and consistently.

What is the purpose of USAID Nurture? USAID Nurture’s goal is to reduce stunting in targeted areas of Lao PDR. It will contribute to such a reduction by developing and testing an integrated nutrition and water, sanitation and hygiene (WASH) model that enhances the nutritional status of children in targeted districts and villages by: 1) Improving infant and young child feeding (IYCF) and water, sanitation and hygiene (WASH) behaviors in households with pregnant women and children under two years (1,000 Day Households) 2) Increasing access and use of quality of nutrition and WASH services/facilities/products 3) Strengthening the enabling environment, through capacity building and reinforcing multi-sectoral coordination, planning, and financial planning, particularly at provincial and district levels.

Project efforts are underpinned by gender, social and behavior change communications (SBCC), monitoring, learning and evaluation, and capacity building.

What does USAID Nurture aim to achieve? The primary impact USAID Nurture aims to achieve is a reduction in the prevalence of stunting in children <5 years in target areas. The project also seeks to achieve uptake of the following behaviors:

Areas Behaviors Infant and young child • Early initiation of BF feeding • Exclusive breastfeeding for 6 months • Continued breastfeeding until 24 months • From 6 months, age appropriate quantity of food, diversity of food with animal source food • Read child cues to actively track food; avoid processed foods / milks • Preserve animal source food and feed to child • Family support with time for breastfeeding, active feeding Maternal Nutrition • Pregnant women eat an extra meal with animal source protein each day • During pregnancy, family support to collect and allocate extra food to pregnant woman • During pregnancy, family support more rest for pregnant woman from the time the baby moves • Husbands take pregnant women for early ANC from (start in first 3 months of pregnancy) • Breastfeeding women eat extra food each day Adolescent nutrition • Eat 3 full meals each day, with diverse food including vegetables and animal source protein • Delay childbearing until 18 years or older • Seek health services with new husband Clean compounds and • All households clean animal feces off compound daily toilets • All households construct and use toilets (when in village) Baby WASH • For children under 2 years: handwashing with soap before feeding/ self-feeding • safe disposal of stool • clean play area • clean drinking water from 6 months • Family support for these practices

What are the main strategies and activities of the project? USAID Nurture aims to: 1. Strengthen the Government of Lao PDR’s capacity to implement the National Nutrition Strategy and National Plan of Action for Nutrition, to coordinate nutrition actions at provincial and district levels, and to plan and implement nutrition activities.

2. Improve IYCF and WASH behaviors by:  Conducting community mobilization and triggering sessions to enhance recognition of nutrition as a priority and to spur action  Conducting monthly household visits to 1,000 days households to provide social and behavior change communications and support  Facilitating peer support groups to foster collective learning, support, and action, such as exclusive breastfeeding among new moms 3. Improve the quality of nutrition services by building health care providers nutrition-related counseling skills. 4. Improve communities’ access to WASH products, such as latrines, soap, and safe water storage containers, that support the adoption of priority WASH behaviors. The project will train select village women to make and sell a natural soap product, and build the capacity of local entrepreneurs to create business plans and market their WASH products.

What are the 1,000 days and why are they important? The 1,000 days is the period from between a woman’s pregnancy and her child’s 2nd birthday. Poor nutrition among women and children during this time can cause both short and long-term consequences for a child. In the short-term, chronic malnutrition— known as stunting, which is when a child is short for his/her age—can lead to death or ill health. In the long-term, stunting causes irreversible damage to a child’s brain development and physical growth. This damage can lead to decreased intellectual ability and poorer school performance, reduced earning potential, shorter adult height, and increased illness, such as diabetes and certain forms of cancer. Stunting not only causes immediate and long-term harm to an individual, but it creates an economic burden for countries, by increasing avoidable health care costs, and increasing productivity losses.When nutrition is improved during these 1,000 days, much of these serious and irreversible harms can be avoided.

Why does the project also target adolescent girls? Targeting women and girls once they are pregnant is often too late to prevent poor outcomes, and to break the intergenerational cycle of malnutrition.In Lao PDR has one of the highest adolescent marriage and birth rates in the region. This is a problem because adolescent girls tend to deliver prematurely, particularly compared to adult women, and children born to girls under the age of 17 are significantly more likely to die in the first year of life. These children also have an increased risk of stunting, diarrhea and anemia. Adolescent girls stop growing during pregnancy, which increases their risk during delivery.

Why does the project have a WASH component? Poor sanitation, hygiene and consumption of unsafe water contribute to malnutrition. WASH is related to nutrition because poor WASH practices can lead to diarrheal infections, which hinder a child’s ability to absorb nutrients from his/her food. New research also shows that a child’s exposure to a fecal-contaminated environment (environmental enteropathy) is also linked to chronic malnutrition (stunting). Such exposure reduces the body’s use of essential nutrients.

Who funds the project? USAID Nurture is funded by the United States Agency for International Development (USAID). “USAID is the lead U.S. Government agency that works to end extreme global poverty and enable resilient, democratic societies to realize their potential” (https://www.usaid.gov/who-we-are).

Who implements the project? USAID Nurture is implemented by Save the Children (lead organization) in partnership with Rural Development Agency (RDA) and the Ministry of Health of the Government of Lao PDR. The project’s primary government partner is the National Nutrition Center housed within the Department of Health and Hygiene Promotion.

Save the Children began its operation in Lao PDR in 1987, and is the leading child rights organization in the country. The organization strives to ensure that children’s rights to education, health and nutrition, protection and participation are fulfilled at all times, including during disasters (https://www.savethechildren.net/).

RDA is a Lao social enterprise. Having grown out of PADTEC, a training institution, RDA is the country’s local implementer of community led total sanitation (CLTS) and has WASH expertise. RDA is also an innovator in community-centered development (http://rda.org.la/ .

What is the project duration? USAID Nurture is currently funded as a 3-year project, which officially started in January 2016 when USAID awarded the grant to Save the Children. Village-level activities will begin following the signing of the project’s MOU.

Where is USAID Nurture being implemented? USAID Nurture will be implemented in 6 districts (3 each) of 2 provinces: Savannakhet (Atsaphangthong, Phine, Xonnabouli)and Khammouane (Mahaxay, Saybouathong, Yoummalath). The project will apply a phased-implementation strategy over the project period. This means USAID Nurture will be implemented initially in select villages of 2 districts, and then expand approximately every 6 months until activities are implemented in all villages across the 6 districts. Pilot activities will also be conducted in 5 villages of Thakek of Khammouane province.

Savannakhet and Khammouane were selected as USAID Nurture locations because they have a stunting prevalence above 40% and combined account for approximately 20% of all stunted children in Laos. Further, key behaviors that help to prevent stunting, such

as exclusive breastfeeding and safe disposal of child feces, are practiced at a rate far lower than national averages. This means there is room for significant improvement. In addition, these provinces are not well covered by other nutrition development programs, giving USAID Nurture the space to implement.

Table 1. Data for Proposed Provinces Compared to National Data Data National Savannakhet Khammouane

Population size 6.77m 825,879 337,314 Stunting (%) 44.2 40.8 40 National prevalence of stunted children <5 (%) - 14 5 Exclusive breastfeeding rate 40.4 16.5 13.4 % HH using improved sanitation facilities 56.9 39 42 % of children whose last stools disposed of safely 18.6 9.8 3.7 Source: Lao PDR Social Indicator Survey (LSIS), 2012.

Appendix 3: Cover Pages of Tools Being Developed

Appendix4: Phasing Strategy for Scaling up of iNuW Districts

2017 2018 2019 District Phase # villages Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Phin 1 10 v1 v2 v3 v4 v5 v5+v6 v7+v8 v9 100 2 20 v1 v2 v3 v4 v5 v6 v7 v8 v9 3 20 v1+2 v3+4 V5 V6 V7 V8 V9 4 20 v1+2 v3+4 V5 V6 V7 V8 V9 5 20 v1+2 v3+4 V5 V6 V7 V8 V9 6 10 v1+2 v3+4 V5 V6 V7 V8 V9 10 10 10 10 20 20 20 30 50 50 70 90 80 60 60 50 50 30 10 10 10 10 Mahaxay 1 10 v1 v2 v3 v4 v4 v5 v5+v6 v7+v8 v9 93 2 20 v1 v2 v3 v4 v5 V6 v7 v8 v9 3 20 v1+2 v3+4 V5 V6 v7 V8 V9 4 20 v1+2 v3+4 v5 V6 V7 V8 V9 5 23 v1+2 v3+4 V5 V6 V7 V8 V9 10 10 10 10 10 20 20 20 30 50 50 70 70 83 63 63 43 43 23 23 Xonnabouly 1 10 v1 v2 v3 v4 v5 v6 v7 v8 v9 62 2 10 v1 v2 v3 v4 v5 v6 v7 v8 v9 3 20 v1 v2 v3 v4 v5 v6 v7 v8 v9 4 12 v1 v2 v3 v4 v5 v6 v7 v8 v9 5 10 v1 v2 v3 v4 v5 v6 v7 v8 v9 10 10 10 10 20 20 40 40 52 62 52 52 52 32 32 22 22 10 Saybouathong 1 10 v1 v2 v3 v4 v5 v6 v7 v8 v9 65 2 15 v1+2 v3+4 V5 V6 V7 V8 V9 3 10 v1+2 v3+4 V5 V6 V7 V8 V9 4 20 v1+2 v3+4 V5 V6 V7 V8 V9 5 10 v1+2 v3+4 V5 V6 V7 V8 V9 10 10 25 35 35 55 55 65 65 40 30 30 10 10 Atsaphangthong 1 10 v1+2 v3+4 V5 V6 V7 V8 V9 40 2 10 v1+2 v3+4 V5 V6 V7 V8 V9 3 20 v1+2 v3+4 V5 V6 V7 V8 V9 10 10 20 20 40 40 40 30 30 20 20 Yoummalath 1 20 v1 v2 V6 V7 V8 V9 111 2 20 v1+2 v3+4 V5 V6 V7 V8 V9 3 30 v1 v2 v3 v4 v5 v6 v7 v8 v9 4 21 v1 v2 v3 v4 v5 v6 v7 v8 v9 5 20 v1 v2 v3 v4 v5 v6 v7 v8 v9 20 20 40 70 70 91 71 91 91 71 71 71 41 41 20 20

Appendix 5: WASH Marketing Roadmap

Appendix 6: Selected Creative Concept – Image 1 (updated version)

Appendix 7: Updated Behavioral Objectives for USAID Nurture

Behavioral Objectives Small, Doable Actions

Adolescent Girls

. Eat an appropriate quantity of food each day . In school girls take extra food for lunch . Eat a diverse diet, including animal source . Girls finish 3 meals worth of food each foods day . Delay marriage and childbearing until after 18 . Eat 1-2 eggs a day years . Discuss family planning options with a health worker before marriage Pregnant Women

. Eat an additional 400-500 kcal each day Families: . Eat a diverse diet, including animal source foods . Collect extra fish, frogs, eggs and . Take rest during the second and third vegetables each day trimesters . Help pregnant woman eat more, and . Seek early antenatal care many kinds of foods at meals . Share pregnant woman’s work once baby starts moving Pregnant Women:

. Set aside food during preparation to eat between meals . Preserve and store food to eat during pregnancy . Let food settle for some time after eating . Seek ANC as soon as pregnancy starts Breastfeeding and Infant and Young Child Feeding

Breastfeeding . Place newborn on breast at birth immediately . Initiate breastfeeding within 1 hour of birth . Keep baby as close to mom as possible, . Breastfeed exclusively with breastmilk, no continue to feed often other food or liquids (e.g. Cerealac/rice), for . Breastfeed often, especially when breasts 6 months feel full . Breastfeed for adequate duration (until child . Breastfeed until baby shows they are full is full) (e.g. hands relax, come off breast . Ensure baby receives initial colostrum from naturally, sleep) birth . Avoid water or rice until child is 6 months . Always breastfeed before leaving your baby because breastmilk is adequate food with others

Child Feeding . Breastfeed baby until 2 years of age . Feed child eggs if possible . Give the baby an age-appropriate quantity of . Put child’s food into separate bowl so food each day caregiver knows how much they eat . Provide a diverse, adequate diet, including . Provide animal foods for your baby animal-source foods (refer to UNICEF because they can help prevent “bland standards for adequacy) blood” . Promote feeding of iron-rich animal sources Additional messages for children 6-12 months: foods to prevent/reduce anemia . Avoid milks and processed (junk) foods . Preserve protein rich foods (cicada,

Behavioral Objectives Small, Doable Actions

. Practice active feeding grasshopper, cricket) . Continue to breastfeed until the child is 2 . Give extra bites of rice with protein years of age powder (fish, frog, pork, meat) . Help child finish all food (eat more) by talking, playing . Minimize sweets, biscuits Additional messages for children 13-24 months:

. Separate family food before adding spices Sick Child Feeding For child under 6 months:

All Children: . Give extra breastmilk during and at least one week after illness . Bring child to health center for wellness For child 6-24 months: checks and when ill . Provide appropriate care during illness, . Give extra breastmilk and other liquids including extra feeding, and one week after during and for at least one week after illness illness . Give extra food during and at least one week after illness WASH

. Construct a toilet All Households: . Use the toilet . Safely dispose of child stools in toilets . Buy a toilet . Use the toilet . Scoop children’s stool into a toilet

. Treat drinking water (boil, filter, other) First 1,000 Days Households: . Store treated drinking water safely . Boil or filter water for child 6 -24 months . Keep safe water in a clean, dedicated container for child

. Wash hands with soap at critical times First 1,000 Days Households: . Wash child’s hands with soap at critical times . Buy soap for handwashing . Set up handwashing station next to house . Wash hands with soap before feeding child . Wash child’s hands with soap before eating . Keep children’s areas clean First 1,000 Days Households:

. Sweep compound area where child walks or plays before child goes outside

Appendix 8: Success Story: Health Facility

Health Staff Help Families Make Big Changes Strengthening nutrition services at health facilities is improving nutritional behaviors.

“I’m not going to do hard work and I’m going to eat more!” Just 10 weeks after her first nutrition counseling training, Nurse Minda was already seeing the positive results of her new skills.

Health care workers in Laos, like Minda, have been emphasizing the importance of breastfeeding, diverse diets, rest and good hygiene for pregnant women for many years but poor nutrition-sensitive behaviors remain widespread. Despite a record of rapid economic growth in Laos, the country currently suffers some of the highest rates of child and maternal mortality and malnutrition in Southeast Asia. Malnutrition is the single Midwives and nurses role play counseling scenarios during largest underlying cause of child mortality in training to hone their skills. Laos, contributing to almost 60% of all child deaths. Undernourished children have an increased risk of mortality, more illness, delayed development and poorer school performance.

In 2017, USAID, the Government of Laos, and Save the Children, began working together to improve the quality of nutrition services provided at local health centers and hospitals in Khammouane and Savanakhet provinces through the USAID Nurture project. Initial research found that people were aware of good nutritional practices but felt unable to make changes. The research also uncovered that health care workers were frustrated by their inability to convince families to improve their behaviors.

USAID Nurture worked with the Lao Ministry of Health to develop a National Social and Behavior Change Communication plan that reflected the research findings tailored to the local communities. USAID Nurture partnered with the Ministry of Health’s Center for Information and Education for Health to develop a new in-service training program to enable staff to use the key elements in the plan that were related to the training program. The three-module skill building course enables health staff to provide practical, targeted counseling for the 1,000 days (from conception to age 2) window of opportunity for lasting nutrition. Health care workers learn key counseling competencies they can apply in all areas of their work and learn how to help clients choose effective but doable actions that have large payoffs.

“Before I would talk a long time,” said Minda, “But this time I used what I learned to find the most critical nutrition issue for the mom. We discussed it and made a plan together.” When women return for follow up visits, Minda sees them keeping to their plans and staying healthier throughout their pregnancies.

Appendix 9: Success Story: Community

Growing Together for a Brighter Future in Laos Strong collaboration between the United States Agency for International Development (USAID), the Government of Lao People’s Democratic Republic (Lao PDR) and Save the Children is improving maternal and child nutrition in Laos, one village at a time.

Ms. Hin Phommasanh lives in Donghongkham, a rural village in Laos PDR in an area with high malnutrition and where only one-third of households have toilets. With support from the USAID Nurture project, the community has committed to improving nutrition, sanitation and hygiene practices to give their children the right start in life. Despite a record of rapid economic growth in Lao PDR, the country suffers some of the highest rates of child and maternal mortality and malnutrition in Southeast Asia. Undernourished children have an increased risk of mortality and illness, delayed development and poorer school performance. The USAID Nurture project, led by Save the Children in collaboration with the Government of Lao PDR, is working to improve nutrition for women and children under two in 471 villages in six districts in Khammouane and Savannakhet provinces. In each village, the project undertakes a series of nine visits to trigger community awareness of poor nutrition and its links to sanitation and hygiene. These visits build village commitment to action for improved maternal, adolescent and child nutrition. The first visit provided an introduction of USAID Nurture to the village leaders. The second visit helped community members assess their own village situation and risks through different participatory activities, like storytelling, community mapping, and village walks. Despite the demands of planting season, families were eager to participate, and 40 villagers participated in the day’s activities. One of the participants was Ms. Hin, mother of seven children, ranging from 1 to 18 years old. She shared: “Our Village Chief told us these activities would benefit our children. I want to help our children and other children in the community.” A key activity was a village walk that allowed residents to visualize and understand sanitation and hygiene issues in their community and how they are associated with malnutrition. On the walk Ms. Hin noted the location of households with adolescents, pregnant women and young children, pointed out instances of areas where villagers openly defecate and noted unclean homes and children’s play areas.

Following the walk, Ms. Hin shared what she had seen and learned with the rest of the village. Participants agreed the community should plan to take action to improve children’s and adolescent’s healthy growth. The villagers nominated Ms. Hin to be part of the Village Committee to administer the action plan. She said “I am proud to help our village to improve nutrition for our children.”

When asked about the village visit, Ms. Hin shared that she had fun participating in the day’s activities and said:

“We learned how important good nutrition is to children’s growth, especially for children under two like my youngest daughter and for teenage girls. They need special attention with the right kinds of food each day. We also need to keep our village clean and free from animal feces that can make our children sick. I want to make sure all the children in our community grow up healthy and strong so they can get an education and a good job for a bright future.”

As of October 2017, almost 600 villagers from 60 USAID Nurture-supported villages have agreed to create community action plans to support children’s healthy growth.