FEED THE FUTURE TAJIKISTAN HEALTH AND NUTRITION ACTIVITY

FEED THE FUTURE

TAJIKISTAN HEALTH AND NUTRITION

ACTIVITY

Annual Progress Report October 2016 to September 2017

Cooperative Agreement #: AID-176-LA-15-00001 October 31, 2017

Annual Progress Report: October 1, 2016 – September 30, 2017 2

TABLE OF CONTENTS Acronyms and Abbreviations ................................................................................................. 3 Activity Implementation Summary ........................................................................................ 6 Progress Toward Targets .................................................. Ошибка! Закладка не определена. Progress Toward Activity Results ........................................................................................... 8 IR 1: IMPROVED QUALITY OF HEALTH CARE SERVICES FOR MNCH .......................................... 9 Outcome 1.1: Improved quality of health care services being provided in the FTF ZOI ............ 9 Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to

improved quality ......................................................................................................... 15 Outcome 1.3: Stronger facility and provider networks ......................................................... 17 IR 2: INCREASED ACCESS TO A DIVERSE SET OF NUTRIENT-RICH FOODS ................................ 20 Outcome 2.1: Diversified food consumption during the growing season and beyond .............. 9 Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to

value chains supported through FTF activities ............................................................. 23 IR 3: INCREASED PRACTICE OF HEALTHY BEHAVIORS AROUND MNCH .................................. 26 Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women,

and children under two ............................................................................................... 26 Outcome 3.2: Improved sanitation and hygiene-related behaviors ....................................... 29 Outcome 3.3: Increased use of health services for MNCH, including nutrition, sanitation, and

hygiene ....................................................................................................................... 31 IR 4: INSTITUTIONALIZE EVIDENCE-BASED MNCH SERVICES .................................................. 36 MONITORING, EVALUATION, AND KNOWLEDGE MANAGEMENT.......................................... 41 Budget Vs. Expenditure Analysis .......................................................................................... 44 SUB-GRANTS ....................................................................................................................... 44 CHALLENGES ENCOUNTERED AND ACTIONS TO OVERCOME ................................................. 45 Management and Staffing ................................................................................................... 47 PARTNERS ........................................................................................................................... 47 Annex 1: Activities planned vs. actual for the year ............................................................... 53 Annex 2: Equipment list provided in Year Two ..................................................................... 63 Annex 3: Scorecards of healthcare facilities ......................................................................... 63 Annex 4: Hospital level structure ......................................................................................... 63 Annex 5: PHC level structure…………………………………………………………………………………………………63 Annex 6: Nutrition strategy for THNA……………………………………………………………………………………63 Annex 7: Success stories……………………………………………………………………………………………………….63 Annex 8: List of publications and IEC materials……………………………………………………………………..63 Annex 9: THNA organizational chart……………………………………………………………………………………..63

ACRONYMS AND ABBREVIATIONS ANC Antenatal Care BPS Birth Preparedness School BTN Beyond the Numbers CE Community Educator CHE Community Health Educator CHP Community Health Promoter CHW Community Health Worker CME Continuous Medical Education COP Chief of Party CPG Clinical Practice Guideline DHIS District Health Information System DHS Demographic and Health Survey DOH Department of Health EBF Exclusive Breastfeeding EG Economic Growth (indicator) EmONC Emergency Obstetric and Newborn Care EPC Effective Perinatal Care FINCA Foundation for International Community Assistance (a nonprofit microfinance organization) FTF Feed the Future GAIN Global Alliance for Improved Nutrition GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit (“German Society for

International Cooperation”) HR Human Resources HQ Headquarters ICATT IMCI Computerized Adaptation and Training Tool IEC Information, Education, and Communication IFA Iron/Folic Acid IGA Income-Generating Activity IMCI Integrated Management of Childhood Illness IR Intermediate Result JICA Japanese International Cooperation Agency KfW Kreditanstalt für Wiederaufbau (“Credit Facility for Redevelopment”) KMC Kangaroo Mother Care M&E Monitoring and Evaluation MM Mentoring and Monitoring MNCH Maternal, Newborn, and Child Health MOHSPP Ministry of Health and Social Protection of the Population NGO Nongovernmental Organization Oblzdrav Provincial Health Department of the Government of Tajikistan PHC Primary Healthcare Center QI Quality Improvement


RHFA Rapid Health Facility Assessment RHS Recurring Household Survey SBCC Social and Behavior Change Communication SRIOG Science and Research Institute on Obstetrics and Gynecology SS Supportive Supervision STTA Short-Term Technical Assistance SUN Scaling Up Nutrition TAWA Tajikistan Agriculture and Water Activity THNA Tajikistan Health and Nutrition Activity TOT Training of Trainers TWG Technical Working Group UNDP United Nations Development Programme UNFPA United Nations Fund for Population Activities UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VDC Village Development Committee WASH Water and Sanitation Hygiene WEEP Women’s Entrepreneurship for Empowerment Project WHO World Health Organization ZOI Zone of Influence


Award Summary Activity Name Feed the Future Tajikistan Health and Nutrition Activity

Start Date and End Date September 29, 2016 through September 28, 2020

Prime Implementing Partner IntraHealth International, Inc.

Agreement Number AID-176-LA-15-00001

Sub-Awardees Mercy Corps and Abt Associates

Counterpart Organization Ministry of Health and Social Protection of the Population of Tajikistan

Geographic Coverage 12 districts in Khatlon Province, the Feed the Future Zone of Influence

The Feed the Future (FTF) Tajikistan Health and Nutrition Activity (THNA) is led by IntraHealth International. With its partners, Abt Associates and Mercy Corps, IntraHealth is working with the Ministry of Health and Social Protection of the Population (MOHSPP) to improve the health and nutrition of women and children living in Khatlon Province. The Activity seeks to improve the integration of maternal, newborn, and child health care at the family, community, clinical, and national levels, with an emphasis on nutrition, sanitation, and hygiene. The Activity promotes the use of evidence-based and ministry-approved clinical guidelines and practices; promotes healthy behaviors and practices; strengthens links among health facilities, communities, and other FTF initiatives; incorporates gender-equitable and culturally sensitive approaches; and leverages stakeholder partners. THNA’s official names:

English Feed the Future Tajikistan Health and Nutrition Activity Tajik Лоиҳа оид ба саломатӣ ва ғизо дар доираи ташаббуси

“Озуқаворӣ ба хотири оянда Russian Проект по здоровью и питанию в рамках инициативы «Продовольствие во

имя будущего Map of the FTF Zone of Influence in Tajikistan

Intervention Districts (new names as of 2016) 1. Yovon 2. Jomi 3. Khuroson 4. Vakhsh 5. Bokhtar 6. Sarband 7. Balkhi 8. Jaikhun 9. Dusti 10. Qabodiyon 11. Shaartus 12. Nosiri Khisrav


ACTIVITY IMPLEMENTATION SUMMARY Following a slow start in Year One, the second year of the Activity saw a significant acceleration in both activities and progress. THNA’s key achievements during the reporting year include following:

• The Activity supported two national and provincial nutrition forums on the theme, “The First 1,000 days – the Foundation for National Development,” focused on a multisectoral approach to malnutrition that involves health, agriculture, food security and safety, education, economic development, water, and sanitation. Specifically, the program encouraged the enactment of a law on mandatory flour fortification, the enforcement of the Universal Salt Iodization Law, and the development of an innovative, multisectoral program focused on the first 1,000 days;

• A regional nutrition forum at the Khatlon Province-level gathered over 60 representatives from the 12 intervention districts in the zone of influence (ZOI) to discuss policies and initiatives on nutrition and its impact on health;

• In the health sector, the first national clinical practice guideline (CPG) for nutrition during pregnancy was approved by the MOHSPP, and 139 family doctors have been trained on it to date. An updated CPG on national obstetrics standards is pending MOHSPP approval. The other new standard on supportive supervision (SS) was also approved and implemented with close assistance from THNA. This SS guideline has been introduced in all ZOI facilities and has proved its uniqueness during the SS visits of Year Two;

• Monthly mentoring and monitoring (MM), as well as SS visits were conducted in all maternal wards of 12 district hospitals to track changes in the progress of infection control and other problematic areas. Progress has been reported in all wards, though significant challenges still remain, which will continue to be addressed during the future interventions;

• THNA entered seven more facilities from Cohort II and during the year was supporting all nine facilities in Cohort I and II;

• Seven maternal wards were supplied with essential medical equipment for introducing quality effective perinatal care (EPC) services to mothers and neonates;

• Quality continued to improve at nine district hospitals, with improvement increases ranging between 15% and 70% across 131 quality improvement (QI) indicators;

• A total of 300 full-time medical workers from maternal wards have been trained on QI and capacity-building to improve the quality of care and services provided to patients;

• Working with the MOHSPP and other development partners, THNA completed the revision of, obtained approval for, translated into Uzbek, and printed 60,000 copies of the booklet (rohnamo), “Instructions for Mothers’ and Children’s Lives” for distribution in the western areas of the ZOI;

• At the primary health care center (PHC) level, THNA promoted early and exclusive breastfeeding up to six months; appropriate complementary feeding education among health workers; vitamin A and zinc supplementation for children; iron, folic acid, and calcium supplementation for pregnant women; and increasing the variety and quantity of micronutrient-rich foods, using the same approach as that


which is implemented at the hospital level. As a result, 145 PHC providers from Cohort I and II were trained in nutrition, antenatal care (ANC) and nutrition counseling;

• In Year Two - 116,619 children up to 5 years of age and 34,563 pregnant women were reached by nutrition activities.

• THNA reached 87,006 households in the ZOI with trainings, home visits by community health educators (CHEs), and joint events with other FTF activities;

• THNA provided professional nutritional trainings to 2,339 people.

• A total of 250,169 people were trained on Food Security and Improved agricultural technologies in Year Two.

• 29,845 households were reached by CHEs on WASH (hygiene, sanitation and importance of VIP latrines) activities.

• During the reporting period, 12 market fairs to promote nutrient-rich food intake were conducted, in which over 3,550 people learned the benefits of improved nutrition, hygiene, and sanitation;

• A technical working group (TWG) on nutrition and health was established at the Oblast level and is fully functioning under leadership from the Department of Health (DOH);

• THNA is an active member of Scaling Up Nutrition (SUN) and participated in and supported all activities under this initiative;

• A new model of work with the community, involving the establishment of the community health promoter (CHP) network for enhancing community involvement on nutrition was developed, submitted, and approved by donors and IntraHealth headquarters (HQ) and will be implemented in Year Three activities;

• Education sessions on this new model were arranged for staff at the community level, and an international consultant was invited to support the smooth transition to and implementation of the CHP model in Year Three;

• In Year Two, THNA continued its collaboration with LDS Charities, UNICEF, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), the MOHSPP of Tajikistan, and the Health Department of Khatlon Province and supported emergency obstetric and newborn care (EmONC) training for 50 health workers from maternities in the ZOI;

• The Nutrition Behavior Survey, two rounds of the Recurring Household Survey (RHS), and the Economic Growth Indicator Survey were conducted throughout Year Two to collect critical data on anthropometric measures and nutrition issues, as well as to acquire values for the “application of improved technologies” indicator;

• Two short-term consultancies on digital health were carried out by IntraHealth in 2017, and Mercy Corps completed the mHealth Endline Survey Report in March 2017. The reports provided valuable data on the roles that information and communication technology will play in contributing to the work of THNA in Tajikistan.

• THNA awarded 13 in-kind sub-grants totaling $458,437 to district hospitals and clinics to improve the quality of health care provided to women and children;


• As of September 30, 2017, the Activity spent a total of $5,127,446, with $3,642,023 spent in Year Two or 99% of the approved Year Two budget.

Progress Toward Activity Results Based on the approved workplan for Year Two, THNA closely monitored all technical activities to ensure their implementation and completion by the end of the reporting year. THNA made a concerted effort to finalize the activities aimed at improving the nutritional status of women and children via strengthening health systems and services, increasing community awareness, instructing households on nutrition-related topics, and many other approaches, as described below. Full information on the implemented activities vs. those planned for Year Two is presented in Annex 1.

THNA conducts biannual surveys to identify differences in a range of outcomes related to nutrition and maternal, newborn, and child health (MNCH) indicators between households involved with FTF activities and the general population. The Recurring Household Survey (RHS) is intended to measure MNCH outcomes in FTF households to determine the impact of the FTF investment. None of the several large-scale household surveys isolate households affected by FTF activities. Essentially, the data collected by THNA will mirror selected topics of the Demographic and Health Survey (DHS), but to isolate the single variable of involvement with FTF interventions, the sample is FTF households only.

The second round of the RHS showed interesting results compared to the first round. Still showing high rate of stunting, the figure is significantly lower compared to the first round. Data showed that 17.2% of children were stunted versus 33.2% and 21.2% of non-FTF and FTF households, respectively, in the first round of the RHS. The 2012 DHS data showed that 26% of children under five were stunted. The latest round of the RHS indicated that 90% of women reported exclusively breastfeeding their children under six months of age, compared to the previous level of 34%. THNA hopes that data from the 2017 DHS will confirm this achieved progress.

The RHS figures for anthropometric indicators showed inconsistent results. The percentages for wasting and underweight are much higher in the second round, while stunting is significantly lower. This difference can be explained due to seasonality: the first round was conducted in an abundant food season, while the second round was conducted at the beginning of a growing season, after a long, cold winter and a relatively cool spring. With regard to minimum acceptable diet, there was also a significant improvement in the second round; the program activity over several years should show improvements, so better numbers are to be expected in a sample high in FTF participants. Going forward, the goals of the RHS are to further increase confidence in these findings and to quantify the impact of interventions by conducting several more rounds of the survey. Table 1 presents the findings from the first two rounds of the RHS and the difference between the two rounds.


Table 1: Recurring Household Survey Results Indicator October 2016 May 2017 Percentage Change Wasting 7% 14.8% +7.8% Underweight 11.7% 13.6% +1.9% Stunting 21.2% 17.2% -4% Exclusive breastfeeding 92% 90% -2% Complementary breastfeeding 68% 80% +12% Minimum acceptable diet 12.6% 28.1% +15.5% Soap present at washing place 48.3% 75% +26.7% Storing food for winter 72% 95.8% +23.8% Receiving antenatal care (ANC) counseling messages 88% 92.5% +4.5% ANC visits (at least four) 52.6% 81.7% +29.1%

IR 1: IMPROVED QUALITY OF HEALTH CARE SERVICES FOR MNCH

During Year Two, THNA continued implementation of activities to improve the quality of health services for mothers and children in the FTF ZOI’s 12 districts. Progress has been achieved at each level as a result of a joint, multisided, comprehensive approach involving capacity-building, mentoring, supervision, grants, and equipment support. THNA has the major elements and approaches needed to reduce malnutrition in the ZOI by working to address the two major determinants of malnutrition―inadequate food intake and illness/disease. IR 1 of the Activity works to improve the quality of health care and to manage illness. At hospitals, improving the quality of essential health care is emphasized (e.g., ANC, emergency obstetric and newborn care [EmONC], and integrated management of childhood illness [IMCI]), along with promoting key nutrition interventions (e.g., vitamin A, zinc, oral rehydration solution for diarrhea, and optimal infant and young child feeding practices).

According the USAID’s Multi-Sectoral Nutrition Strategy 2014-2025, pregnancy and infancy are critically important periods of development for a child. Mothers and babies need to have good health services and nutrition to lay the foundation for the child’s future. High-impact health and nutrition interventions are essential for preventing maternal and child deaths. Integrating nutrition-specific interventions into maternal and child health activities is a priority for THNA. Qualitative health care and optimal maternal and child nutrition in the first 1,000 days—between conception and a child’s second birthday—ensures healthy mothers and newborns, good growth, and the future development of infants and children.

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

Hospital-level activities

In Year Two, following a WHO training course on EPC for midwives, doctors, and nurses from pilot maternal wards, the Activity continued to work on improving the quality of care provided to mothers and children at the hospital level. With this aim, the Quality Improvement and Clinical Safety Committees were created in collaboration with the DOH and local hospital administrations. To increase awareness of QI principles, two trainings were conducted for the 20 participants from Cohort I facilities in the Jomi and Dusti Districts. After the trainings, participants became aware of QI principles, the use of QI in health care, and patient-focused


approaches, among other concepts. Due to these trainings, facilities will now be able to measure the progress of QI interventions, as well as to design a list of internal indicators. The facility-based QI teams meet regularly to review data, identify areas in need of improvement, and implement and monitor improvement efforts. For these activities, the teams use QI approaches and tools such as the Plan-Do-Study-Act cycle, assessments, audits of critical cases and feedback, benchmarking, and best practices research. The following duties and responsibilities were assigned to the Quality Improvement and Clinical Safety Committees:

• Develop a QI plan for facilities; • Develop indicators and organize internal monitoring; • Establish an in-facility system for on-the-job training as part of continuous medical education (CME); • Lead accountability for removing barriers, assigning resources, and ensuring implementation of and

compliance with the approved recommendations that result from monitoring; • Review the findings from the analyses of adverse outcomes and design plans to avoid reoccurrence; • Provide support and coordinate activities to resolve clinical or service issues identified by the

monitors/supervisors; • Approve procedures related to quality, safety, and performance improvement initiatives; • Monitor competence patterns and trends to identify and respond to facility staff learning needs; • Review analysis of data related to quality and patient safety and recommend and monitor actions; • Monitor the progress of the Be Safe program and offer enhancements needed to further lead the

transformation effort; • Oversee, evaluate, and revise the Quality Improvement and Patient Safety Plan; • Recognize and celebrate successful performance improvement efforts and staff actions impacting

patient safety; • Provide quarterly data updates to the facility manager on the performance of selected indicators and

the overall QI plan.

Traditionally, Tajikistan has used an authoritarian inspection or control approach for supervision. This approach is based on the belief that health workers are unmotivated and need strong outside control to perform correctly. However, it has been shown that a supportive approach, where supervisors and health workers work together to solve problems and improve performance, improves health care delivery. To implement an effective, supportive supervisory system as a quality improvement tool, THNA has supported the design of the national guideline on supportive supervision (SS). THNA supported a technical working group (TWG) to design the national guideline, and trainings were conducted for national-level health workers supervising FTF ZOI facilities. In later stages, the guideline was adapted for supervisors who work in hospital and PHC facilities.

The National Guideline on Supervision describes: • Setting up a system for SS; • Planning visits for regular SS; • Conducting a supervisory visit; • Follow-up activities after visits.


According to the developed clinical practice guideline (CPG) on supervision, the Activity has supported the setting up an SS system between the National Tertiary Institute (the Science and Research Institute on Obstetrics and Gynecology [SRIOGP]) and facilities in the FTF ZOI through training of trainers (TOT) on SS. Thirty national-level specialists on effective perinatal care (EPC) and antenatal care (ANC) passed the SS training. Trained supervisors conducted a number of SS visits during this reporting year. Supervisors and QI facility teams worked closely to fill identified gaps and to improve the quality of care.

In addition to SS, the Activity supported mentoring and monitoring (MM) visits to the pilot maternal wards throughout the reporting year. The purpose of clinical MM was to ensure compliance with nationally approved standards, protocols, and regulations. To ensure objective assessment during visits, the experts used a monitoring tool approved by the Ministry of Health and Social Protection of the Population (MOHSPP). Monitoring data showed that maternal wards achieved results in the introduction of EPC, ANC, and the integrated management of childhood illness (IMCI) at the hospital and PHC levels. Significant results were achieved especially in the improvement of neonatal care, the appropriate and rational usage of antibiotics, nutrition and breastfeeding counseling, and the early registration of pregnant women. Relevant progress in infection control has been also observed during monitoring visits. Hospital administrators supported maternal ward staff in implementing the infection control principles. During MM visits, tests were conducted to assess the level of knowledge of health professionals, and simulations were conducted to determine the level of preparedness of medical facilities in providing emergency care. Test results showed that the medical staff is aware of standards and what is needed to introduce those standards; however, they do not transfer their theoretical knowledge into practice, therefore additional efforts are needed to change attitudes for practical implementation (Figure 1).

Figure 1: Dynamic of EPC Implementation in Maternal Wards

Definition of scores: According to the WHO EPC scorecard, each item is evaluated based on information gathered by different sources to reach an overall score, ranging from 0 to 3:

0 = need for very substantial improvement (totally inadequate care and/or harmful practices, with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards); 2 = need for some improvement to reach standard care (suboptimal care, but no significant hazard to health or to basic principles of quality care); 3 = good or standard care.


Despite the fact that the MOHSPP has updated a national standard on management of hypertensive condition during pregnancy and the postpartum period, monitoring results have shown that one cause of complications was the lack of management of severe preeclampsia and eclampsia. Therefore, to update the skills and knowledge of health workers, THNA provided training for 20 health workers (gynecologists and anesthesiologists) during Year Two. To increase the effectiveness of EPC implementation and based on recommendations from the Rapid Health Facility Assessment (RHFA) of May 2016, the Activity, under its grant component, supplied Cohort II facilities with essential equipment. The choice of equipment was based on an evaluation of needs and agreed upon with each facility and the DOH in advance. Several meetings with donors (the Japanese International Cooperation Agency [JICA], Kreditanstalt für Wiederaufbau [KfW], and others) also helped to rationalize equipment support. It was agreed that JICA would provide support for future infection control equipment (such as facility-based laundry services) and that for KfW-supported facilities; THNA would take a case-by-case approach. In accordance with the above-mentioned essential equipment list, facilities received other medical equipment (See Annex 2, List of equipment provided). During Year Two, a total of seven facilities (maternal wards) were supplied with essential medical equipment for quality EPC services to mothers and neonates. THNA also supplied autoclaves and dry-heat sterilizers to tackle the problem of infection identified during RHFA and MM visits. The grants significantly improved conditions in maternities, which in turn led to a decrease in nosocomial infections, as shown in the scorecards from maternities (see Annex 3).

During Year Two, the facility approach used by THNA was positively evaluated by an external specialist with experience in MNCH care, Judith Moore, who identified several shortages in the current implementation and made recommendations for future implementation. During an open discussion with recently discharged women, there were reported cases of hospitals discharging women with prescriptions for formula, indicating that counseling on exclusive breastfeeding (EBF) at antenatal and postnatal stages needed to be emphasized. As the Activity, will be continuously working on quality of care and the promotion of EBF, the International Code on the Marketing of Breast Milk Substitutes has been discussed with the MOHSPP. Furthermore, education has been provided during ANC trainings about the harm that formula feeding in normal situations can create and the professional’s role with regard to breastfeeding promotion and formula usage. The facility directors and managers were also engaged in the DOH-level discussions to prevent the promotion of formula and to hold staff accountable for actions that breach guidelines. In support of this intervention, THNA agreed with facilities to establish nutrition corners in maternity departments of health facilities and to make information and communication materials and reminders available and visible in the form of posters, counseling materials, etc.

Another approach started by THNA in Year Two was Kangaroo Mother Care (KMC), or skin-to-skin contact (beyond the initial skin-to-skin contact at birth, this is a proven intervention to nurse low birthweight babies over a period of weeks/months). MM visits showed that this method is probably not utilized fully, and the potential exists to improve care through introduction of the KMC method (WHO, Method for care of


underweight newborns) in THNA pilots. During Year Two, an EPC training program was updated with emphasis on KMC, and national experts decided to scale up its implementation to cover the FTF ZOI, with THNA support. It appeared that while there was acknowledgment of the need for this approach and enthusiasm to introduce it, there was not great understanding of how to create a supportive environment and to select which babies could benefit from being cared for this way, or how to practically set up the unit.

During Year Two, the SRIOGP widely implemented KMC for babies at their tertiary level, as they are the one referral center for all premature deliveries and low birthweight babies. Introducing KMC at the tertiary level assisted mentors and supervisors to practice it, and there is a plan to introduce the system to FTF maternity units during MM and SS visits. It has been mentioned in supervisors’ reports that introduction of KMC will assist health care staff from district maternities to cope with lower severity low birthweight and premature babies. Consequently, costs for care and referrals to tertiary-level hospitals would decrease, thus saving time and money. In addition, mothers would be better prepared and more confident in handling and caring for their infants at home.

Several steps were taken by THNA staff to move this plan forward: • Facilities at maternal wards were provided with the latest guidelines, protocols, and training materials;

• Some modest equipment needs were included in the grant’s support program and were delivered to Cohort II maternities;

• SRIOGP staff were encouraged to establish a well-functioning KMC center in their facility to be a national center for KMC, and to scale up to FTF ZOI facilities in Year Three;

• Discussions were started on including KMC in medical, nursing, and midwifery curricula.

Primary health care activities

During Year Two, at the PHC level, THNA promoted early and exclusive breastfeeding up to six months; appropriate complementary feeding education for health workers; vitamin A and zinc supplementation for children; iron, folic acid, and calcium supplementation for pregnant mothers; and increased variety and quantity of micronutrient-rich foods.

Access to quality health care services is important for promoting and maintaining mother and child health; preventing and managing disease; reducing stunting, malnutrition, and premature delivery; and achieving health equity. The QI and nutrition interventions were conducted through formal and on-job trainings, monitoring, SS, and on-the-job training.

The Supportive Supervision tool, which is used at the hospital level, has now been introduced at the PHC level. Based on MM visits, PHC facilities in each district from Cohort I and II have developed one-year action plans that were approved by the Central Rayon Hospital director; these plans will be reviewed annually and changed according to progress outlined during MM visits. All facility action plans include activities for improving the quality of services in problem areas, such as: (a) regular internal monitoring; (b) continuous training and checking trainees’ knowledge and skills; (c) strengthening capacity and improving the


performance of PHC staff; and (d) solving technical issues related to infrastructure and equipment, including the supply of water and stable electricity. To strengthen the implementation during the reporting period, the Activity technical staff conducted meetings with the health administration personnel of the pilots, as well as with facilities’ QI teams, to follow up on the recommendations of the national mentoring teams and to facilitate continuous improvement. The jointly designed action plans were based on recommendations of the mentoring teams, as well as on THNA recommendations. These action plans contain the list of internal indicators that are collected and followed by the QI team itself and link to the internal monitoring system. Also, these plans (schedule of trainings, list of topics, and logistics) have been linked to the PHC staff capacity-building plan as part of CME. Later during the year, the Activity supported implementation of these training activities by providing handouts, training materials, and stationery.

Early coverage of pregnant women remained a problem in FTF districts. Data from maternal departments showed that registration of women for delivery without previous ANC remains an issue. THNA continued to build PHC workers’ capacity by training 60 providers from Cohort I and II facilities to improve the quality of antenatal services, including nutrition counseling, for women at the PHC level. Trained family doctors and family nurses improved their skills in managing physiological pregnancy, preparing families for baby delivery, and counseling pregnant women and their families on issues related to mother and infant health.

Nutrition during pregnancy, breastfeeding, as well as in the prenatal period requires a particularly responsible approach from both health professionals and the family. Evaluation of existing national nutrition guidelines showed that no generalized, comprehensive, approved national guideline related to nutrition in pregnancy existed. In the previous ANC protocols and guidelines, nutrition was not widely covered or reflected. With the support of THNA, a group of experts from the MOHSPP, the Nutrition Research Institute, and Tajik State Medical University developed comprehensive guidelines for nutrition in pregnancy for PHC workers. Based on that document, the Activity supported the development of a training module for PHC staff on nutrition issues during pregnancy and for children under two to improve HWs’ knowledge and counseling skills regarding nutrition issues. As a result, using the developed guidelines, 80 PHC providers from Cohort I were trained on nutrition issues during the 1,000-day period.

MM and SS visits for ANC noted improvement of the internal indicators developed by the Quality Improvement and Clinical Safety Committees (Table 2). MM and SS visits were designed and conducted with emphases on nutrition counseling for pregnant women, intake of folic acid in the first trimester of pregnancy, improving detection and management of anemia during pregnancy, and improving the quality of prenatal counseling (including coverage of danger signs, physiological changes, postpartum contraception, breastfeeding, and decreasing the use of non-evidenced-based drugs).

Table 2: PHC Quality Improvement and Clinical Safety Internal Indicators % of pregnant

women registered early

% of pregnant women screened for eclampsia

% of pregnant women received nutrition counseling

% of pregnant women received folic acid during the first trimester

% of pregnant women received appropriate anemia therapy

District Q2 Q4 Q2 Q4 Q2 Q4 Q2 Q4 Q2 Q4

Jomi 67% 72% 10% 18% 30% 63% 27% 57% 17% 25%

Jaikhun 58% 58% 15% 25% 28% 54% 28% 30% 13% 18%


Dusti 58% 58% 10% 16% 60% 68% 20% 30% 21% 25%

Bokhtar 78% 80% 34% 44% 53% 58% 60% 60% 25% 30%

Balkhi 63% 69% 28% 33% 25% 36% 30% 30% 27% 25%

Sarband 54% 63% 26% 32% 30% 57% 30% 55% 21% 34%

Shaartus 65% 65% 15% 24% 30% 30% 30% 30% 18% 21%

Qabodiyon 58% 50% 19% 29% 28% 55% 30% 50% 18% 25%

As shown in the table, only two cases (5%) out of the 40 collected indicators showed a decrease. The majority improved significantly and some (8%) doubled.

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


During monitoring visits, gaps in infection control and clinical safety at the hospital level were found due to problems with implementing the National Prikaz for the Prevention Infection and Clinical safety in Healthcare. To improve infection control in the pilot facilities, the Activity supported infection control training courses for hospital- and PHC-level medical workers. Leading experts on clinical safety conducted several trainings for 93 participants from facilities of Cohort I, II and III. At the beginning of the training, the trainees’ knowledge was assessed; the average level of knowledge was 58%. The theoretical part of the training was accompanied by hands-on, practical skills-based training involving the health workers’ participation and subsequent discussion of the actions. The practical part, where the participants could see how infection control systems should be implemented and operated in practice, was based on recommendations from the SRIOGP. The main areas for improving infection control at facilities are the laundry, the kitchen, the recycling of waste through autoclaving, and pits for biological waste. Trainees learned best practices for separating personnel/patient flow and the zone of activity (including dirty, clean and sterile zones, transitional, semi-restricted, and restricted zones). Special attention was paid to practical work and standards of infection prevention in medical facilities, including rules for handwashing, the use of antiseptics for hands, and handwashing before surgical intervention/manipulations. Although post-tests showed an increase in knowledge up to 74%, this is still lower than the standard (80-85%). This lower percentage indicates the average low capacity of health workers and lack of CME. To achieve sustainable improvements in infection control practices, THNA supported MM visits. During these visits, national experts assessed the level of implementation of infection control national standards. The main problems faced were: (a) limited access to running water; (b) the poor condition of the infrastructure; and (c) the low capacity of health workers. The monitoring team worked closely with the facilities’ QI teams and provided recommendations to improve infection control and clinical safety.


The lack of an approved list of performance indicators and data collection systems remains one of the main identified problems in the medical facilities. On a quarterly basis, medical workers manually fill out DOH reporting forms, and for some measurement areas, there were no forms. Therefore, it was impossible to analyze maternal wards’ performance, to identify their weaknesses and strengths, or to track the implementation of EPC and other national standards. To implement a qualitative data collection system, to improve reporting, and to conduct clinical analyses of the intervention, the Activity developed a database that allows data collection from facilities on a quarterly basis. The Activity provided computers with the database preinstalled and Internet access to 12 pilot maternity hospitals. Given the low computer literacy of health workers, prior to distribution of the computers, an introductory training was conducted, in which representatives from all maternity departments (14 specialists) participated. During training, participants learned how to operate the computer, how to use the database, and how to enter data. The head of the maternity department of the Bokhtar Central District Hospital noted: “Finally, there will be a proper system with reports in our department. Now we can show our achievements and shortcomings in the work using real data. I will ask my children to teach me how to work on the computer.”

Optimal maternal nutrition is important for the survival of both mother and child, and it promotes women’s overall health. There are two critical conditions for which women’s nutrition affects survival outcomes: anemia and calcium deficiency. Anemia is a condition where a person’s blood has too few red blood cells or hemoglobin to transport oxygen to cells in the body. Maternal anemia is estimated to contribute to 20% of maternal deaths (Report of National committee of Confidential audit of maternal death 2014). It is also a significant cause of death for women of reproductive age even if they are not pregnant. Anemia in non-pregnancy increases the risk of severe maternal anemia during pregnancy, as there is an increase in iron requirements to support both maternal and fetal needs. Historically, women in Tajikistan have more than four children, and the interval between pregnancies is very rarely more than one to two years. These factors result in a significant number of pregnant women at constant risk of anemia. There is growing evidence that anemia is linked to increased blood loss during delivery and puts women at greater risk of postpartum hemorrhage. Postpartum hemorrhage is the leading cause of maternal deaths in the country (35%) (Med Stat 2016).


Clinical safety and infection prevention are bottlenecks not only in maternal wards but in all departments of district hospitals, including PHC-level facilities. These issues are mainly due to the absence of a general standard system of recycling, problems with the water drain and water supply, and problems of sterilization and heating. Within the limits of THNA, it is impossible to provide assistance to the whole of the district hospital, yet within the workplan, THNA invited a local infection specialist to carry out an assessment to support PHC facilities and develop a plan to improve clinical safety and infection prevention. After the situation analysis, a plan of action was elaborated, approved, and implemented by each facility in Cohort I and II.


To tackle gaps in infection control and clinical safety at the PHC level, PHC workers were included in trainings on the implementation of the National Prikaz1 for the Prevention Infection and Clinical safety in Healthcare. Practical work for trainees was also provided at the clinical facility, which was helpful for introducing and implementing infection control national standards at the facility level.

Other findings from monitoring visits revealed that facilities have misread and misinterpreted the meaning and reporting process from national protocols and algorithms, due to the different requirements from inspection entities (hadamot, SanEpidemStantsiya [Sanitary & Epidemiological Station – SES]). THNA, in conjunction with other donors, started assisting in resolving this situation by raising these issues at the national level and initiated a revision of protocols by the MOHSPP to optimize and simplify the approach. During this reporting year, the Activity provided technical assistance to the MOHSPP working group on the development of protocols and algorithms; all of these documents were discussed in depth and have been submitted to the MOHSPP for approval.

Outcome 1.3: Stronger facility and provider networks

During Year Two, the THNA technical team compiled comprehensive data on the structure of health care facilities at the hospital and primary care levels in all 12 FTF districts (Annex 4, 5). This process immediately revealed bottlenecks and shortages at the different health care levels.


The next step of QI activities was the implementation of a “Beyond the Numbers” (BTN) approach in Cohort I and II facilities; this is an audit methodology aimed at improving the quality of care in maternities through confidential, evidence-based, professional case reviews. Instead of the traditional approach of finding a person to blame for a bad outcome, BTN uses a QI approach to look at how current systems of care are failing to produce quality results, focusing on issues such as technical capacity; the existence of clear clinical protocols, tools and guidelines; as well as adequate supervision. To implement the WHO BTN approach, trainings were conducted for 40 medical workers from the eight maternity hospitals. Following trainings, trained teams provided analyses of two to three critical cases of severe preeclampsia and postpartum hemorrhage that occurred in their facilities. Analysis-based recommendations were presented and discussed with the staff during regular meetings and were implemented in practice. To improve the implementation of the BTN approach and refine the methodology, THNA supported cross-visits between pilot facilities. BTN had been implemented previously in some THNA maternal departments with assistance from other programs, so those facilities served as an example for others that had just started to introduce the BTN approach. Teams participated enthusiastically and demonstrated a good understanding of this approach. Cross-visits were facilitated by national coordinators of BTN, and short refresher trainings were also provided during these visits. As a result of the BTN implementation in FTF facilities, THNA organized a roundtable to discuss achievements and challenges initiated by district BTN teams, where each team presented improved statistics and practice changes attained due to implementation of the BTN approach. For example, in the Bokhtar maternal ward, the number of intrapartum fetal deaths decreased

1 In 2015, the MOHSPP issued the Prikaz for the Prevention Infection and Clinical safety in Healthcare to establish a nationally accepted approach to infection prevention and control. The guidelines provide an evidence base on which health workers and health care facilities can develop detailed protocols and processes for infection prevention and control that are appropriate for their specific situation.


from nine (2016) to five (2017); in the Qabodiyon maternal ward, the number of cases of postpartum hemorrhage decreased from 16 (2016) to nine (2017). The most important achievements attributed to the BTN intervention during Year Two were:

• Improved facility readiness for emergency obstetric care; • Increased interest of medical workers in participating in educational sessions; • Decreased blood loss; • Reduced number of organ removal surgeries (hysterectomies); • More active involvement of the administration in the process of improving quality of care; • Decreased intrapartum deaths of the fetus.

Such cross-visits became a platform for creation of the collaborative QI network between facilities in the FTF ZOI. Additionally, during the reporting period, and as part of effective EPC implementation, THNA in conjunction with the MOHSPP, the American Academy of Pediatricians, and Jhpiego, conducted a TOT and follow-up training on EmONC for participants from the 12 pilot maternal wards (a total of 50 participants). The main topics of the training provided by the American specialists were management of severe preeclampsia, eclampsia, bleedings (hemorrhage), and care for underweight newborns (including the KMC method). These trainings have been an ongoing joint activity since the start of THNA and are a continuation of the Quality Health Care Project. These trainings revealed a positive impact on practices at the facility level, as an interactive approach and practical skills were prioritized. During Year Two, EmONC trainings for mid-level health workers (nurses, midwives, and neonatal nurses) were conducted together with doctors from maternity departments (neonatologists and OB/GYNs); this combination of personnel in the training reinforced both the established facility-based multidisciplinary team and the importance of teamwork in the provision of emergency care for mothers and newborns. As a result of these trainings at the Oblast level, each facility received educational materials from the American college (i.e., dummies, delivery sets, and sets for newborn resuscitation). In Year Three, THNA is planning to use these materials to equip training rooms, to be established in the coming year, for daily clinical practice and on-the-job trainings for health personnel.

During SS and MM visits, it was reported that the role of midwives at the facility level has not been recognized appropriately. Due to low and inadequate doctors’ capacity, as well as shortages of doctors at the facility level, the midwife is a responsible and accountable professional who works in partnership with women to give necessary support, care, and advice during pregnancy, labor, and the postpartum period. In some rural maternal wards, there is no doctor, and it is the midwife’s responsibility to assist with delivery and to provide care for the newborn. This care includes instituting preventive measures, promoting normal birth, detecting complications in mother and newborn, assessing the need for medical care or other appropriate assistance, and carrying out emergency measures. The midwife also has an important responsibility in health counseling and education. Unfortunately, due to continuous disregard for the midwife’s role, the quality of existing medical education and the professional capacity of midwives continues to worsen. Monitoring visits showed that midwives from pilot facilities were not able to provide necessary routine and emergency care. In collaboration with the


National Midwifery Association, on-the-job trainings were conducted for 52 midwives from maternal wards in Dusti, Jomi, Balkhi, and Bokhtar Districts.

Figure 2: Results of Pre- and Post-Tests for Midwives

Post-training evaluations showed that the midwives had increased their theoretical knowledge and practical skills. However, there was also a significant discrepancy between the obtained theoretical knowledge and its implementation in practice (Figure 2).

As shown in Figure 2, even one on-the-job training for midwives showed significant results at the post-test (in Dusti, a fourfold increase in knowledge was obtained). THNA will continue to support the capacity of midwives, as they are the main workforce at the hospital and PHC levels, and will support the implementation of quality interventions at the district level. I addition, midwives are the most stable part of the health workforce, as they are unlikely to migrate to another region or overseas.


In collaboration with the MOHSPP and development partners, THNA participated in the adaption of the MNCH Handbook. During Year Two, THNA designed the implementation plan for the Handbook’s introduction at the PHC level and printed 60,000 copies in the Tajik and Uzbek languages. The MNCH Handbook was developed to improve the quality of service and counseling, as well as access to ANC and care for newborns and children under five. Building on the MNCH Handbook’s introduction to the health system, THNA supported a TOT for 36 PHC medical workers from pilot districts. Trained trainers in turn will provide cascade trainings for medical workers and community health workers (CHWs) on the utilization of the MNCH Handbook. Birth preparedness school (BPS) is one important intervention for improving the quality of ANC. The active utilization of the school helps health workers raise awareness about health and nutrition in pregnant women and their families, and as a result, improves the quality of antenatal and postnatal care and the decision-making process at the family and community level. The cooperation among the family doctor, the family, and the CHP through the BPS will increase the community’s attention to solving the problems of safe

14,20%

37,50% 33,70%

45,50%

62,50% 59%

63,00% 63%

43% 39% 39%

43%

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

70,00%

Dusti Jomi Balkhi Bokhtar

Theoretical pretest

Theoretical posttest

Practical skills


motherhood, that is, the community’s willingness to participate in the organization of emergency medical care for mothers and children and to promote nutrition for women and children. The project supported SS visits for BPSs in the pilot districts. However, the visits showed that the medical facility staff were not interested in the active work of BPSs due to the following problems:

• There is no responsible worker at the facility level to liaise with BPSs; • There are no guides or information materials for BPSs; • The community is not aware of the goals and objectives of BPSs.

The causes of stunting in children are influenced by the mother’s nutritional status before and during pregnancy, non-exclusive breastfeeding in the first six months of life (also a major cause of wasting), inadequate complementary feeding, and not continuing to breastfeed from six to 23 months. What mothers consume affects the vitamin and essential fatty acid content of their breast milk. Both acute and chronic infections, caused by poor water and sanitation practices and exposure to environmental pathogens, also are significant causes of stunting. Exposure to toxins such as aflatoxin has been implicated as a cause of stunting, while exposure to heavy metals (e.g., lead) increases the risk of iron deficiency. THNA is identifying women early in pregnancy and disseminating messages about optimal nutrition. THNA is continually increasing the capacity of health service providers to deliver information about essential nutrition actions, recommended by WHO, during ANC. During ANC, mothers receive advice about optimal diet during their pregnancy and during lactation, and about optimal breastfeeding practices in the first six months. Supplies of iron/folic acid (IFA) supplements are reportedly better than they were in 2012, when only 1% of mothers had taken 90+ IFA supplements during their last pregnancy (180 IFA supplements are the approximate recommended intake). Unfortunately, health workers do not always give women IFA supplements, and counseling about how and why to take IFA may not be provided to all women. Through trainings, mentoring, and supervision at the PHC level, THNA is raising awareness at health facilities (and in communities) about the importance of women taking IFA as early as possible in the pregnancy and the recommended dosage. Messages about why, how, and when to take IFA supplements and how to manage potential side effects can (and should) be introduced early. A job aid and counseling cards with the appropriate messages are under development, to be introduced in Year Three. In Year Three, the Activity plans to support the development of a manual “Nutrition in Pregnancy” for medical staff and also to increase the work with schools through QI committees and CHPs. IR 2: INCREASED ACCESS TO A DIVERSE SET OF NUTRIENT-RICH FOODS Under IR 2, THNA promotes dietary diversity and quality by increasing families’ access to nutritious foods. A major effort is underway to increase the availability of nutritious foods by assisting and supporting small-scale agricultural production, mainly through home gardening; sustaining the availability of safe, nutritious foods by supporting household-level food preservation and storage; and improving access of home-based producers to markets. In Year Two, an international consultant on nutrition, Rae Galloway, traveled to Tajikistan. Based on a desk review, field visits, and discussions with government staff, nutrition stakeholders, THNA staff, and community


members, a background report (situational analysis) on nutrition was written. This report includes information on how nutritional status is measured, the prevalence of malnutrition globally and in Tajikistan, the causes and consequences of malnutrition, coverage of optimal nutrition behaviors, and some of the programs to address malnutrition. A final section discusses important program approaches that make a difference in reducing stunting and malnutrition. Based on the situation analysis, a nutrition strategy for THNA was developed (Annex 6). The overall goal of the THNA Nutrition Strategy is to prioritize the reduction of stunting in its goals and program activities. Stunting is the most prevalent nutrition problem in Tajikistan (which has the highest rate of stunting of five Central Asian countries) and has long-term consequences for individuals; the performance of the health, education, and agriculture sectors; and national development. Advocacy about the problem may be required at all levels (but with a focus in the ZOI) to create a paradigm shift from a curative/treatment model of addressing malnutrition to a model focused on prevention in the window of the first 1,000 days―during pregnancy through two years of age. Outcome 2.1: Diversified food consumption during the growing season and beyond In Year Two of THNA, the multisectoral approach to addressing nutritional issues continued, as nutrition activities were integrated into other sectors, such as food security, agricultural, and WASH activities. Nutrition-specific activities will be detailed in this section. Several trainings were conducted at the health facility and community level, in addition to promoting the consumption of nutritious food at the household level. Trainings had a particular focus on pregnant and lactating women with children under two years of age in the 12 districts of the ZOI. In the year under review, community activities on nutrition-specific interventions were conducted, focusing on the first 1,000 days’ window. These interventions at various events promoted optimal infant and young child feeding practices and the consumption of diverse food from the ten and seven food groups for women and children, respectively. Trainings were conducted for community and program staff to ensure the topics could be subsequently taught to the primary and secondary target beneficiaries. In addition, trainings on IMCI were conducted for community volunteers.

Events focused on the reduction of stunting. During the events, THNA promoted: • Iron-rich food; • Vitamin A-rich food; • Different food groups for women and children; • Use of iodized salt; • Healthy cooking methods to reduce nutrient loss during food preparation and cooking; • Planting of various crops to promote accessibility of diverse nutrient-rich foods throughout the year; • Good practices for storing produce; • Handwashing, focusing on the four critical points (e.g., food safety, touching animals); • Infant/child care practices.


Dietary diversity is better for mothers and for older children (18-23 months). Consumption by young children, even those younger than six months, of foods of low nutritional quality (i.e., junk foods) is reportedly increasing, though the extent of the problem needs to be verified. For health workers to deliver information on dietary diversity to new communities, THNA crafted interventions that focus on how to prepare foods and feed children of this age. During Year Two, THNA continued to increase the capacity of community educators (CEs) to relay information on various topics related to the promotion of dietary diversity. The primary topics were related to canning and safe food storage. Through cascade trainings provided by field coordinators and THNA staff, communities were educated on safely preserving fruits and vegetables in glass jars for use in winter as a rational method for securing a varied diet throughout the year. Apples, pomegranates, lemons, onions, sweet peppers, potatoes, and carrots were some of the recognized and more familiar fruits and vegetables. Teaching food storage techniques and promoting product storage in the winter guarantees access to a year-round provision of different food products, and in particular, vegetables and fruits. During community sessions, THNA field coordinators and CEs emphasized, among other things, the importance of fruits and vegetables as part of a well-balanced diet. Eating a diet rich in fruits and vegetables can help lower the risk of many health conditions, including high blood pressure, heart disease, stroke, and certain kinds of cancers. However, if they are not handled properly, fruits and vegetables can also become a source of food-borne pathogens. For example, they can become contaminated with listeria, salmonella, or other bacteria. Their taste, texture, and appearance can also suffer if they are not stored properly. Thus, information about the proper cleaning and storage of fruits and vegetables is of paramount importance.

Year One saw the successful start of joint farmers’ markets and fairs with the Tajikistan Agriculture and Water Activity (TAWA); these were continued during Year Two to demonstrate the proper preservation and storage of food products at competitions and exhibitions. Events were carried out to promote local products and crops, as well as products promoted by TAWA, and information about their storage and preparation was disseminated to communities and farmers. Complementary food recipes were collected through competitions at such fairs supported by THNA and others by FTF partners. Recipe development and cooking demonstration sessions were used and were popular with mothers. To improve complementary feeding in children six to eight months in age, mothers and mothers-to-be participated in cooking demonstrations to learn how to prepare the recipes hygienically, what foods could be substituted if families did not have certain foods (e.g., substituting legumes for meat), and how to feed foods to children. One cooking demonstration showed how to prepare salads from beetroot leaves, from broccoli, and from cauliflower, as well and fruit/vegetable smoothies (e.g., from beetroot). Approximately ten different recipes were introduced, and preparation steps were demonstrated at the events. Prepared foods were also distributed to participants to promote dietary diversity within their families. The events were organized and conducted in close collaboration with TAWA home economists, regional and district health departments, as well as local hukumats.


Similarly, nutrition and WASH messages were reinforced to community members at these events through poetry reading, dance, role-playing, and fun quizzes. The THNA slogan “having a smart child who will do well in life” was included in every speech and performance during the events. All THNA partners and implementers, including Oblast and district government officials, health representatives, and community members, were involved in organizing and conducting these events at the community level. More than 1,000 information, education, and communication (IEC) materials were distributed during the events. To promote improved irrigation for household gardens, in Year Two, THNA in collaboration with the nongovernmental organization (NGO) Neksigol Mushovir conducted trainings at the community level in Shaartus, Jomi, Bokhtar, and Jaikhun Districts for residents of remote villages. The selected villages have all experienced challenges accessing drinking and irrigation water, and farmers rely on old, decaying systems to obtain water. Participants were provided with manuals and were trained on irrigation management, drip irrigation, rainwater irrigation, and general water management in relation to crop moisture requirements.

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

To promote the increased intake of animal protein, THNA began trainings in poultry management in Year Two. Joint trainings with TAWA were provided for THNA staff on the care and feeding of poultry via improved pens, feed, and vaccinations. Following this initial training, THNA staff conducted trainings for poultry producers in Sarband, Jomi, Yovon, Bokhtar, Balkhi, and Jaikhun Districts and covered topics on poultry breeds, purchasing birds, chicken coop design, chicken keeping rules, sanitation, feeding, egg production, and vaccinations. The purpose of the training was to help households manage poultry farming—the raising of birds domestically and commercially for the sale of meat and eggs. Trainings utilized interactive methods such as group work, individual work, group presentations, and discussions and covered recording expenses, economic efficiency, and evaluating the profitability of meat and egg production. Participants received a poultry management guide and DVD that THNA produced.

THNA also participated in all trainings organized by the International Potato Center on orange-fleshed sweet potato and potato production innovations (Phase II). THNA attended learning events facilitated by Prof. Zulfiya Davlyatutarova of the Institute of Botany, Plant Physiology and Genetics, addressing the process of adapting 15 varieties of orange-fleshed sweet potato micropropagated seedlings into in vitro seeding and growing the seedlings in the nursery. The varieties were presented to the farmers at one of the demonstration plots in Khatlon Province.


During Year Two, field coordinators extended their knowledge in the practice of drying fruits and vegetables. Households were then trained on fruit and vegetable drying techniques to increase the quality and quantity of their products and to extend the shelf-life of foods. The majority of households in the pilot areas are drying agricultural products for two purposes: for family consumption and for selling. The improved products allow households to have access to nutritious food for a longer amount of time and can increase the family’s income. The trainings covered which fruits and vegetables are suitable for drying, including pears, peaches, plums, apricots, carrots, celery, corn, green beans, potatoes, and tomatoes. The participants had a chance to share their experiences and learn about effective local technologies for drying fruits and vegetables.

The training on fruit and vegetable drying techniques included the following topics:

• Types of drying equipment; • Methods of drying food at home; • Optimal temperature for drying produce; • Optimal moisture levels for the different types of produce; • Methods of drying food at home (i.e., oven, sun, air, and microwave drying).

Fruit dying technology was introduced not only as a nutrition improvement measure, but as an income-generating activity (IGA). Direct trainings on fruit drying as an IGA were conducted with support from the Women’s Entrepreneurship for Empowerment Project (WEEP) and IMON International in communities within Shaartus, Jaikhun, Jomi, Bokhtar, Balkhi, and Vakhsh Districts. The majority of households who have the opportunity to earn income from their dried agricultural products experience problems related to business and marketing plans. Thus, to address these issues, the trainings instructed participants on how to start and manage a family or group business, as well as how to identify markets where dried fruits and vegetables are in high demand.

In Year Two, field coordinators also conducted direct trainings on small-scale dairy production, and primary milk processing and consumption to households in Khuroson, Bokhtar, Jomi, Jaikhun, and Balkhi Districts. Special attention was paid to the rules for using a separator for removing milk fat known as qaimoq. During educational sessions at the community level, guidelines for milking cows and methods for determining the quality of milk and its storage were explained. Milk processing to obtain cream, sour cream, cottage cheese, kefir, and cheese was also demonstrated. In rural areas, many families purchase and herd livestock to have access to dairy products. They prepare kefir, yogurt, and cottage cheese, mostly for family consumption or for selling locally. Yet much like the trainings on fruit drying, small-scale dairy production has also been introduced as a possible IGA. Trainings on transitioning family dairy production into an IGA were conducted in Khuroson, Jomi, and Bokhtar Districts. The training looked at how to identify markets where dairy products are in high demand. This training was meant to enhance participants’ knowledge on how to start a small family business, with the ultimate aim of increasing their family budget and increasing access to additional micro- and macronutrients year-round. Due to problems with soil and/or irrigation, households in some districts of Khatlon Province cannot cultivate vegetables and fruits in their backyard gardens. As a result, these households rely on income from nonagricultural activities such as carpet weaving and tailoring. In Year Two, THNA conducted a training for households on how to develop a business plan, start a family business, and increase the family budget. With


this increased budget, families could then have access to high-nutrient foods. Trainings in Bokhtar, Jaikhun, and Dusti Districts were conducted with support from a WEEP specialist. To strengthen IGAs at the household level, THNA field coordinators conducted trainings on household budgeting to optimize use of household income. CEs were taught how to impart this knowledge to households to better manage their limited financial resources, so that nutritious foods could be purchased, particularly during the winter months when options are scarce. When CEs conducted educational sessions at the community level, the majority of households reported that they did not regularly record or monitor their income, expenditures, and/or savings. However, most participants did report using credit from local banks, though they never used deposits. Participants learned how to use a provided worksheet to help them compare their monthly budgets with their actual income and expenses. During the community-level educational sessions, it became obvious that households needed more information on savings, bank services, and household budget creation. Therefore, in Year Two, THNA partnered with the nonprofit microfinance organization FINCA to conduct financial literacy training for CEs from the 12 districts of the ZOI. In turn, beneficiaries from FINCA’s training provided cascade training on household budgeting, which reached more than 90,000 people during this reporting period. It should be noted that the overall purpose of the above trainings was to enhance the beneficiaries’ knowledge of how to start small family businesses, which in turn increases family budgets and allows access to micro- and macronutrients throughout the entire year. To help communities increase family income and have access to high-nutrient foods throughout the year, all target groups were taught skills on research management, savings, income, and expenditures of a family budget, as well as management and business enterprise-related issues. Another possible IGA investigated with TAWA was the production of seeds and seedlings. The same aim was to help rural households increase their income to improve nutrition and their overall future prospects. Through the promotion of this IGA, it is possible to improve food security and facilitate low-cost access to food. IGAs can improve family food security when there is sufficient availability of food in local markets, but the impact will vary depending on the distribution of income within the household and the use of that income. In Khatlon Province, the main agricultural activities are conducted by women, so integrating gender issues and promoting theoretical and practical training for women on economic issues would help households increase their family budget and consequently have better access to nutrient-rich food.


IR 3: INCREASED PRACTICE OF HEALTHY BEHAVIORS AROUND MNCH

Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children under two

Capacity development activities for CHEs and village development committees (VDCs) Following short-term technical assistance (STTA) on development of the new behavior change communication strategy, THNA conducted workshops for program staff, including the program’s management, technical staff, regional coordinators, and two field coordinators from each region. The main purpose of the workshops was to connect Activity components including WASH, nutrition, and food security and ensure that the strategy is considered in all project components.

The regional/field coordinators passed the TOT and then trained newly selected CHEs and VDCs in 200 selected villages in the ZOI on:

• Social and behavior change communication (SBCC); • Reinforcing behavior change among community members; • Nutrition, WASH, and food security messages to share; • Community mobilization; • Joint planning and monitoring activities; • Child learning versus adult learning; • Locating and working with support groups; • Cooperation among VDCs, CHEs, medical staff in the villages, etc.; • The importance of connections among THNA components (WASH, nutrition, and agriculture

were discussed among participants several times during the training days using the Active Learning Methodology).

All new CHEs and VDCs were involved in the trainings, which were conducted in two phases. The second phase of the trainings involved a second cohort of participants.

In addition to these capacity development activities, at the beginning of Year Two, all 1,400 CHEs were provided with THNA-branded bags containing IEC materials on all THNA sectors: WASH, nutrition, household budgeting, and agriculture. These materials helped CHEs provide qualified counseling for mothers and pregnant women during household visits in their community. From February to June 2017, THNA conducted refresh trainings on the THNA project goal, its objectives, and the importance of CHEs’ roles and responsibilities within the project. During the trainings, a longer session was included to learn the IEC materials. Groups of two CHEs presented how to conduct proper household/family visits, as well as the methodology behind the counseling of pregnant and lactating women, and women of reproductive age. Each material was read and its meaning explained by CHEs during their presentations. Additional sessions on team-building, CHE roles and responsibilities, and the interrelationship of program elements were also conducted.


The Activity provided training on proper milk consumption (including kefir, cream, and cottage cheese) to 400 CHEs. The focus of the training was to promote the intake of milk products by using a separator to separate the cream (qaimoq) from skimmed milk and further use the whey to produce cottage cheese and kefir, which were not commonly produced prior to the training. The training was also used to explain the constitution of breast milk, as it is made up of watery and fatty portions.

A three-day training for facilitators was held in Jomi District on the Aflateen curriculum, which included information on reproductive health, improved WASH, family planning, HIV, nutrition, budgeting, gender, and other related topics to prepare facilitators to work with adolescent girls in the community. Two people from each village, as well as village leaders, volunteers, teachers, and health workers were involved, totaling 39 participants from 20 villages. The facilitators in turn conducted 20 initial trainings for adolescent girls between 15 to 19 years old. A total of 303 girls were trained in conducting peer-to-peer sessions. Following the initial training, the adolescents then provided cascade training to their peers and reached an additional 2,575 adolescent girls. After conducting trainings in the villages, the girls started woodworking and cooking businesses. In part as a result of this training, the beneficiaries now have a craft and are earning money.

Social and behavior change communication (SBCC) activities

Four outreach campaigns were conducted in four targeted project districts. This activity was linked to the opening of a mother’s room in a rural health center. The events were organized with support from the rural health center, and VDC and CHE representatives. Pregnant and lactating women were the main targets of the campaign, and more than 600 people participated. The main aim of the event was the demonstration of food for pregnant women, which was conducted by community members. During the event, the nutritionists provided advice and demonstrated cooking, encouraging pregnant women to consume food from six to seven food groups. Additionally, there were role-plays, poetry readings, and a question and answer session in which CHEs answered participants’ questions. In all activities, the importance of ANC visits during pregnancy and having a nutrient-rich diet was emphasized. Rural health center representatives gave speeches about the importance of the mother’s room for pregnant women and invited them to come for an ANC visit. Women had the opportunity to go inside the room and see the equipment provided by the project.

In Year Two, THNA conducted various SBCC campaigns on iodized salt. Educational sessions encouraged its proper consumption, and the message was continually reinforced throughout the campaign.

In October 2016, a campaign event promoting iodized salt was organized by THNA in close collaboration with the biggest salt plant in Tajikistan, Yovon Salt Plant, and with support from Yovon’s local government. The more than 300 event participants included local authorities; project beneficiaries from the different villages of the district, including women and children; heads of targeted villages; mahalla leaders; representatives from regional/district health departments; and young volunteers from the district youth center. All


attendees observed a demonstration of several kinds of salt and a determination of iodine content in salt using test kits, and they also participated in role-plays, quizzes, and games. Special attention was paid to pregnant women and children under two. VDCs and CHEs actively participated in the event and facilitated programming of plays, poems, drawings, and songs. All attendees received 100 kg of iodized salt, and the most active campaign participants were rewarded with gifts.

CHEs and VDCs continued to promote the usage and storage of iodized salt through informational sessions during household visits in all project-targeted villages. A total of 2,372 salt test kits have been distributed to CHEs and VDCs in 700 THNA villages.

Tajikistan celebrated the Exclusive Breastfeeding Decade from August 1 to August 10, 2017. The celebration featured the slogan “First 1,000 days of the Beginning of Life – Basis for the Development of the Nation.” The breastfeeding promotional events took place in six targeted districts. The events were attended by representatives from regional and district health departments, primary health centers, and healthy lifestyle centers, as well as by VDCs and members of the respective communities. In total, approximately 200 people participated in each event. About 50% of the participants consisted of women of reproductive age, including breastfeeding and pregnant women. The main goal of these events was to increase local residents’ awareness of the value of breast milk, its benefits to mothers and newborn children, and the social and economic benefits of breastfeeding for the family. According to the program, THNA specialists fully acquainted the participants with:

• The objectives of THNA; • The “First 1,000 days of the beginning of life – the basis for the development of the nation”

methodology; • The consistency of breast milk and its importance to children; • EBF for the first six months; • Supplementary feeding for children over six months of age; • Instructions for proper breastfeeding.

The events included educational sessions highlighting key messages on breastfeeding, quizzes, dances, songs, and poems for mothers. Breastfeeding mothers were celebrated and recognized for their dedication to breastfeeding and the role it plays in developing a healthy child. During the reporting period, THNA staff participated in meetings at target district PHCs, and 64 health workers were counseled about EBF. SBCC materials distribution In collaboration with the project specialists, as well as with project partners Global Alliance for Improved Nutrition (GAIN), UNICEF, Save the Children, the Nutrition Institute of Tajikistan, and TAWA, several materials have been rebranded and distributed in all 700 villages of the THNA project. As a result of the project’s work with the nutrition and WASH team, several banners were developed and used during the events, as well. All materials used in the project were tested in the field before printing and sharing.


Outcome 3.2: Improved sanitation and hygiene-related behaviors

A key element of THNA’s strategy is to reduce stunting by focusing on healthy hygiene and sanitation behaviors, which reduces environment-related threats to health and the prevalence of diarrhea.

Community sanitation activities

THNA hired Navzamin, a local NGO, to pilot the activity on educating communities to independently identify sanitation issues and propose solutions. To implement this activity, four active VDCs were selected in Bokhtar, Jomi, Shaartus, and Balkhi Districts. Navzamin provided a six-month capacity-building plan for VDC members, after discussions with and approval from THNA. VDCs from these districts were expected to submit one project proposal for solving community sanitation problems. During the six months of the pilot activity, the following work was conducted:

• Four selected VDCs found that they did not have good working conditions. Therefore, Navzamin negotiated with jamoats in helping to allocate good working places (offices), renovated and designed with different kinds of relevant corners and boards;

• Each VDC and community conducted a performance review process and some members were re-selected by communities;

• Charters and other VDC documents were improved;

• Capacity-building trainings were conducted according to their approved program;

• Strategic plans were developed by VDCs;

• To learn more in practice, these four VDCs had one exchange visit with other VDCs in Jaikhun District. These VDCs are experienced in solving their community’s problems and are supported by Aga Khan Foundation projects;

• One meeting was coordinated by the Jomi District VDC and was conducted with participation of the other three VDCs, as well as representatives of the district government and jamoats. The main purpose was to bring the sanitation problems to the attention of local authorities, and to address them jointly;

• Writing a project proposal was part of the training, and the four VDCs submitted project proposals to THNA, requesting small grants. The grant process considered contributions from the communities, and each community contributed more than 70% of the total cost for the initiative. This activity involved the provision of supplies by THNA, therefore a bidding process for requesting supplies was conducted and supplies were provided.

This practice will be continued in Year Three, but using a different approach through some subcommittees of VDCs.

SBCC activities on WASH

Various community events were arranged by THNA in Year Two. Community leaders, household/family decision-makers, and in-laws were invited to learn and share their experiences with maternal and infant health, as well as with WASH issues currently facing the communities. In Year Two, WASH promotion events were organized for Global Handwashing Day (October 15) and World Latrine Day (November 19) of 2016. When organizing the events, the project paid special attention to the


villages where hygiene issues were more prominent and prioritized their selection and participation in the events. All events were organized in close collaboration with local authorities, regional healthy lifestyle centers, village leaders, VDC members, and medical staff. To attract a larger audience, the project invited famous actors and comedy groups to participate in the event. A safe latrine drama was presented during World Latrine Day, organized in Bokhtar District. This drama was warmly received by community members, and it was shown in latrine fairs conducted in six other districts as well.

THNA conducted six latrine fairs between June and August 2017 in Sarband, Bokhtar, Jomi, Yovon (two events), and Vakhsh Districts, involving an estimated 480 participants. The purpose of the fairs was to encourage people to improve their latrines for the prevention of infectious diseases. Schoolchildren and their teachers were actively engaged in the events and presented exciting performances for their communities. A drawing competition among teenagers took place, and later, all kids were given hygienic gifts.

Capacity development activities on WASH

Two-day skills trainings for 25 potential community masons and entrepreneurs from Yovon, Jaikhun, Qabodiyon, Dusti, and Sarband Districts were conducted in July and August 2017. During the trainings, participants studied the basics of marketing, cash flow, bookkeeping, and tax regulations. On the second day, the potential community masons were connected with sanitation marketing specialists and with previously trained community stone workers, who showed the participants the slab-and-ring construction technique in detail. All participants were awarded certificates and received sale record books, informative flyers, and modules showing the slab-and-ring construction techniques. After evaluation, the selected masons were given a slab-and-ring construction mold (eight pieces) and informative billboards (three pieces). These newly trained masons will work within their communities to create a demand for ventilated improved pit latrines and to spread the message of their importance.

During the April to August 2017 period, THNA staff trained three groups of sanitation masons who started sanitation businesses in Balkhi, Bokhtar, Sarband, Vakhsh, Dusti, Qabodiyon, Shaartus, Khuroson, Jomi, and Yovon Districts. During a six-month period (April to September 2017), 152 latrines were sold. The project is planning to work more closely with the VDCs to further promote the latrines. Twenty sanitation masons and entrepreneurs from Balkhi, Khuroson, Jomi, Bokhtar, Vakhsh, Shaartus, and Yovon Districts participated in business training in Qurghonteppa to study the basics of product calculation, methods for increasing sales, and marketing and cash flow.

In Year Two, handwashing lessons were replaced by sessions on dystrophic environmental enteropathy.2 THNA conducted 49 trainings on the revised “essential hygiene actions” for 794 new community volunteers and VDC members. The trainings provided information on the connection between hygiene and infectious diseases, ways of preventing infectious diseases, and information about safe latrines, water sanitation, the proper disposal of garbage, as well as the proper use and storage of drinking water. Trained CHEs and VDCs will conduct education sessions in the villages to benefit their respective communities in Year Three. Overall, the purpose of these sessions are to change people’s behavior in relation to proper hygiene and sanitation and to prevent the emergence and spread of diarrhea among the population. Throughout 2017, the environmental enteropathy presentation and module have been used. A total of 399 community volunteers

2 This is a disease caused by proximity to farm animals and a child ingesting animal fecal matter, which obstructs nutrient absorption and increases the chance of stunting.


and VDC members received training in infection prevention and control in 23 sessions led by the director of the Healthy Life Style Center of Khatlon Province. CHEs and VDC members from Cohort I (Dusti and Jomi Districts) and Cohort II (Sarband, Bokhtar, Shaartus, Qabodiyon, Nosiri Khisrav, Jaikhun, and Balkhi Districts) participated in the trainings.

SBCC materials distribution on WASH

The project distributed 15,000 informative brochures to communities, 15,000 informative flyers for masons, 12 new concrete slab-and-ring construction sets with necessary molds for recently trained sanitation entrepreneurs (a third group), and 12 informative billboards for promotion. A total of 8,000 informative flyers about improved pit latrine ventilation were distributed by trained sanitation entrepreneurs and stone workers. Twenty sale record books were distributed by trained sanitation entrepreneurs and stone workers. These books will help THNA staff monitor concrete slab-and-ring sales, and will also help entrepreneurs count sales. Nine informative billboards were put up by newly trained sanitation workers and entrepreneurs to show information about the benefits of improved pit latrine ventilation, the layout of latrines, and telephone numbers for the sanitation entrepreneurs.

THNA also produced two animated videos about clean drinking water and safe latrine use. The videos will be broadcast in Year Three on Tajikistan television. Outcome 3.3: Increased use of health services for MNCH, including nutrition, sanitation, and hygiene

Community-level activities with households

THNA’s multisectoral, tripartite approach for reducing malnutrition by increasing food production, changing behaviors and child care practices, and improving health services maximizes opportunities for reducing the proximal causes of stunting. A paradigm shift is necessary, from treating or curing malnutrition to preventing it altogether. It also may require shifting the focus from rehabilitating children with acute malnutrition to activities to prevent stunting. These interventions are possible only at the household level, working with target beneficiaries. During Year Two, family doctors with support from THNA provided birth planning training for communities to increase referrals of women to PHCs and BPSs. As reported in the 2012 DHS, the majority of complicated cases reported at secondary-level facilities of women in delivery involve those who were not under ANC coverage. One of the main elements of ANC is birth preparation in communities, and for successful implementation of and increases in ANC coverage, close cooperation between PHC workers and CEs is essential. At these trainings, the targeted population learned about the matrix on birth planning, the timely registration of pregnant women in PHC, and also organizing emergency transport from existing taxis in the community. Separate sessions were provided at the PHC BPSs on life skills for expectant mothers to promote ANC within communities. The main topics of discussion were awareness of normal pregnancy and the signs and symptoms of complications. Young mothers in Tajikistan do not make decisions about their own health; decisions are usually made either by either by men or by their mother-in-law. To respond to this challenge, THNA continuously supports training for religious leaders on safe motherhood. The material for the trainings


was printed by USAID in the 2009 module “Muslim Khutbah Guide to Save the Lives of Mothers and Newborns” adapted to Tajikistan. This module is compiled on the basis of the verses of the Qur’an and reflects the principles of Islam regarding the care of mothers and newborns, including ANC. After trainings, religious leaders transfer the core messages about safe motherhood to men during daily prayer in the community’s mosques.

Via its small grants program and to support and increase ANC coverage and referrals to PHC facilities in general, THNA piloted improved “mother’s rooms” for the provision of quality health care to mothers and their children. The mother’s rooms were established in four villages in Shaartus, Bokhtar, Balkhi, and Jomi Districts. The room is placed at the PHC facility level and serves as a counseling point for nutrition and health issues for women of reproductive age in the community. Consultancies are also available for men and adolescent girls. During this year, requested equipment was delivered to the mother’s rooms. Due to the success of this pilot, THNA will continue to expand its support of mother’s rooms in rural PHC facilities in the coming year.

As part of all IMCI programs, THNA provided Community IMCI (C-IMCI) training for CEs. The field coordinators who conducted the follow-up training used interactive/participatory methods, including dolls and visual aids such as pictorial booklets, to illustrate the danger signs outlined in the general IMCI module. Topics on optimal infant and young child feeding practices; EBF; and practices regarding age-appropriate, timely, adequate, affordable, locally available complementary food, were included in the training. Animal-sourced food was promoted in complementary feeding practice explanations. In addition, the seminar drew attention to developmental care, to identifying common signs of illnesses in newborns and young children and the need for timely access to health workers, as well as to the prevention of illness via health worker-administered vaccines and the timetable for vaccinations.

Volunteers were given visual aids/job aids in the form of leaflets and/or booklets to counsel households with pregnant and lactating women and children under two.

Facility-level activities with hospitals To improve the quality of medical care for children, THNA is implementing the WHO Hospital IMCI program. This program includes the introduction of the IMCI pocket guide to improve the management of the most common childhood diseases in resource-limited settings. The hospital IMCI package covers four departments in district hospitals: the pediatric intensive care unit, pediatric somatic unit, pediatric inflection unit, and admission. National experts trained by WHO, in collaboration with local experts trained by the Activity, evaluated the implementation of the WHO pocket guide in facilities and provided on-the-job trainings and recommendations. The Activity also supported the publication of an updated version of the Hospital IMCI pocket guide translated into Tajik and assisted in its introduction in facilities. Following the TOT conducted by the Activity in Year One that established a pool of 24 local trainers, in Year Two, the Activity supported national experts and locally trained experts to train medical staff from Cohort I and II facilities. THNA conducted trainings on hospital IMCI for 20 pediatricians from the pilot Central District Hospitals in Jaikhun, Bokhtar, Qabodiyon, Dusti, Shaartus, Khuroson, Nosiri Khisrav, Jomi, and Sarband Districts, and from Oblast Central Hospital. Post-tests showed an increase in knowledge from 28.6% to 79%,


and although this result is still lower than the expected minimum (85%), it still shows a significant increase (2.7 times). Analyses done by THNA staff and national experts revealed that medical staff in pilot facilities had had no CME in a long time and that they had not been trained on the latest techniques and guidance. The post-tests showed that both additional trainings for health workers and the establishment of CME are needed. The Activity made a plan to provide on-the-job training and mentoring on hospital-level IMCI approaches to ensure medical and nursing personnel are familiar with the latest IMCI recommendations. The training covered technical aspects of hospital care, including patient triage, emergency care, the management of common illnesses, and severe malnutrition. During the training, providers created plans of action to implement the new recommendations in clinical practice and selected QI indicators to monitor specific changes. In accordance with the workplan, MM and SS visits to pilot facilities were carried out every six months. The working group, comprising national experts and local trainers, assessed the quality of care for children in the pediatric departments of the Central District hospitals. The WHO Questionnaire for the Assessment of the Quality of Medical Care for Children was used. During the visits, on-the-job trainings, as mentioned above, were provided on the identified shortcomings. Recommendations to the managers of hospitals were given as follows:

1. Provide children with nutrition; 2. Identify a pediatrician for the admission department; 3. Provide conditions for emergency care for children; 4. Organize 24-hour access to medical care and medicines for sick children; 5. Organize a ward for the treatment of severe malnutrition, including nutrition treatment.

Assessments of health workers in all rayons conducted during SS visits to Cohort I facilities and four facilities from Cohort II to implement the Hospital IMCI program showed increasing levels of knowledge and support from managers (Figure 3).

Figure 3: Implementation of Hospital IMCI Program

2,61

0,85

1,99 1,99

2,94

1,99

3,16

1,8

3,41

3,91

2,5

3,7

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

Jomi Dusti Jaihun Balkhi Sarband Bokhtar

1 SS visit

2 SS visit


For the Hospital IMCI scorecard, each item is evaluated with the information gathered by different sources to reach an overall score, ranging from 0 to 5:

0 = need for structural changes (totally inadequate care and/or harmful practices, with severe hazards to the health of mothers and/or newborns); 1 = need for substantial improvement in the management of all illnesses and related departments; 2 = need for substantial improvement in the management of the majority of illnesses and related departments to reach standard care (suboptimal care with

significant health hazards); 3 = need for a considerable level of improvement; 4 = need for some improvement to reach standard care (suboptimal care, but no significant hazard to health or to basic principles of quality care); 5 = good or standard care.

One of the recommendations from the team of national mentors was to train the remaining doctors and staff on the WHO pocket guide, to provide pocket directories and diagrams, and to organize cross-visits to learn best practices. In the participant list, it is necessary to include various specialists who provide care to children, including surgeons, anesthesiologists, and nurses. Two cross-visits to the Vakhsh Central District Hospital were thus carried out. The first cross-visit was for the deputies of chief doctors for childhood and the second was for the heads of pediatric departments of the Central District Hospital. A special emphasis of the presentation was on the diagnosis and treatment of patients with severe acute malnutrition. The participants actively discussed solutions to the main problems that hinder the implementation of the WHO pocket guide recommendations. The Vakhsh Central Regional Hospital was chosen because it had achieved strong results after the introduction of the WHO pocket guide, such as:

• Over the past two years, more than 110 patients received treatment in this department, including the provision of special therapeutic meals (F-75 and F-100), and those patients recovered and were discharged from the hospital;

• The number of unnecessary examinations and analyses for children was reduced; • The number of unjustified hospitalizations in the last two years was reduced by 40%; • Polypharmacy has been completely eliminated.

These cross-visits served as a platform for creating working relationships among doctors to solve common problems in each of their districts. It was suggested that the next cross-visits be conducted at tertiary-level hospitals, because the material and technical base of rayon facilities is not up to standard. Pediatric departments in district hospitals were not part of the RHFA in May 2016, therefore baseline data were gathered only during MM visits. An assessment of equipment needs was also performed, then lists of essential equipment and disposables were prepared, discussed within each facility, and confirmed by chief doctors. These lists became the basis for grant allocation, and in accordance with the lists, all 12 facilities received medical equipment (See Annex 2 for the list of provided equipment).

Facility-level activities with PHCs

To reduce death, illness, and disability among children, combined treatment of major childhood illnesses such as pneumonia, diarrhea, malaria, measles, and malnutrition must be applied. To address this need and to improve health workers’ skills in managing sick children at the PHC level, THNA has adapted and implemented the WHO IMCI Computerized Adaptation and Training Tool In 2012, WHO presented a computerized version of the IMCI package for PHCs, which has a range of advantages:


• Training materials are more accessible; • Training is less expensive (no need to print all modules); • Sustainability is increased (medical workers can learn the training material and refresh their

knowledge on their own). To increase the knowledge of family doctors and nurses and to improve the quality of medical services for children, THNA established the IMCI Computerized Adaptation and Training Tool (ICATT) IMCI Resource Center and supported revision of the ICATT IMCI program. The computerized version of the IMCI program has been amended according to the latest WHO recommendations and translated into the Tajik language. The Center is based in the Qurghonteppa City Health Center and is equipped with eight laptops installed with the updated ICATT IMCI software, a projector, printer, screen, furniture, and Internet access. The Center is accessible to any PHC worker to come anytime for their self-education on IMCI. Moreover, to stimulate the Center’s usage and its effectiveness, THNA in collaboration with the Republican Center of Pediatrics and Pediatric Surgery and local trainers conducted training sessions in the resource center.

To improve continuity of care and the interrelationship between hospital and PHC medical workers, the IMCI program was also introduced at the PHC level by conducting IMCI trainings for 27 PHC workers from Jaikhun, Dusti, Balkhi, and Bokhtar Districts and by employing the ICATT approach. An analysis of the activities of the training center established by the Activity and based in the Qurghonteppa City Health Center showed that 18 family doctors were trained within two months. Results of testing showed that trained health workers improved their knowledge and skills by 60% (pretest – 20% / post-test – 80%). One of the indicators for the quality of work of family doctors is the satisfaction of parents who have a sick child. During interviews with parents, it was found out that:

• 70% of parents know three dangerous symptoms, the detection of which necessitates taking the child to a medical facility;

• 80% know that if child has diarrhea, it is necessary to give more fluids; • 58% know how to give oral antibiotics; • 85% are satisfied with the quality of medical services; • however, only 32% were aware of principles of child care for development.

After analyzing the situation, together with national and regional consultants, the following action items were decided:

• Develop a training program for family nurses (in the next three months); • Conduct a “Child Care for Development” training for family doctors; • Establish an internal monitoring system.

SS visits to implement the IMCI program also covered the PHC level, and during Year Two, these visits were conducted in rayon health centers and in health houses. Supervisors assessed the clinical skills of medical workers, filling out form records, organization of points of oral rehydration, counseling skills, and vaccination with using national assessment tools. The results of SS visits showed that rayon IMCI centers need technical assistance and strengthening the capacity of medical workers with regard to monitoring and QI.


Table 3 shows the differences between medical workers who received training on Hospital IMCI (in Dusti, Balkhi, Bokhtar, and Jaikhun Districts) and those who did not (in Jomi, Khuroson, Sarband, and Yovon Districts). Comparing the knowledge of workers in trained and non-trained facilities, it is clear that the trainings improved clinical and counseling skills, although the quality of services to be provided by oral rehydration points remained the same in some facilities (i.e., Bokhtar and Jaikhun) even after the training. This result is due to the infrastructure of the hospital itself and to external factors, such as lack of access to running water, lack of IMCI record forms, and poor knowledge of the management of diarrhea. Table 3: Quality of Management of Sick Children during Follow-Up Visit

Based on recommendations and analyses from SS and MM visits, in the coming year, THNA plans to expand and emphasize IMCI components at the PHC level, especially targeting the third IMCI component, that of implementing nursing supervision. The third component covers the IMCI nutrition program, which includes: observation by the nurse/feldsher of the interaction between mother and child; determination of how the medical practitioner identifies nutritional problems and provides appropriate recommendations; review of medical charts for correct documentation, including the presence of growth charts; and the provision of feedback and on-site mentoring to the nurses/feldshers on their work and performance. IR 4: INSTITUTIONALIZE EVIDENCE-BASED MNCH SERVICES To institutionalize evidence-based practices, THNA works closely with the MOHSPP and several international donors. In Year Two, good progress was made in terms of increasing the role of regional health authorities and clinical practices guidelines, and increasing capacity for continued improvements. Health system strengthening and collaboration with the Ministry of Health

Following the commitments and agreements between THNA and the MOHSPP in Year One, the project has taken further steps toward institutionalizing an evidence-based approach to MNCH services through technical support at both national and regional levels. All initiatives for moving forward the governmental agenda on MNCH and nutrition and the application of health policy and strategies were implemented in close collaboration with UNICEF, WHO, the United Nations Fund for Population Activities (UNFPA), GIZ, and other partners active at the health policy level. In particular, during the reporting period, THNA actively

Dusti Balkhi Bokhtar Jayhun Jomi Khuroson Sarband YavanClinical skills 50% 75% 62% 86% 24% 22% 15% 29%

Counseling skills 50% 70% 75% 70% 25% 50% 50% 12,50%

Mothers knowledge on care of sick child

80% 75% 70% 77% 36% 50% 60% 37,50%

Quality of the service in oral rehydration point

60% 70% 35% 35% 20% 30% 35% 20%

Quality of vaccination 70% 80% 76% 80% 40% 35% 35% 20%

Quality of filling out form records 35% 40% 36% 50% 18% 20% 21% 20%

Indicator Rayons with trained personnel Rayons with none trained personnel


participated in national-level dialogue through the Donors Coordination Council on health and provided its input on discussions of the most challenging subjects raised at the ministry level.

THNA participated in the TWG on MNCH; one of the significant outcomes for the working group was the endorsement and approval of the Action Plan for implementation of the governmental program on sexual and reproductive health, maternal health, and newborn, child, and adolescent health in the frame of the National Health Strategy 2016-2020. This is a five-year plan aimed at improving MNCH services, including their organization; decreasing the relevant indicators (e.g., maternal and infant mortalities); setting up a system for monitoring and SS; and enhancing clinical practice. However, the MOHSPP will elaborate the Action Plan, as some aspects, e.g., adolescent health, were not addressed in the current document. In Year Three, the MOHSPP plans to set up a working group that will propose a new schedule for revision of the protocols (i.e., the calendar of CPGs). THNA will allocate technical assistance to support the CPG design process and aims to include CPGs on bleeding, physiological delivery, infection control, and others on the list for revision in the near future. In Year Two THNA provided support to the process of revision and followed up with training of health workers in the facilities of the FTF ZOI at both the PHC and hospital level.

During Year Two, THNA was planning to implement activities within the “baby-friendly hospital” initiative launched by WHO and UNICEF in 1991 to implement practices that protect, promote, and support breastfeeding. According on Tajikistan’s National Health Strategy, the baby-friendly approach is to be introduced in all maternities and maternal departments country-wide. THNA was ready to support this initiative within the ZOI, but implementation proved to be very difficult, as capacity is limited. Furthermore, THNA’s work must fit within the nationwide framework and therefore requires input from all health care sectors. For example, to obtain re-certification for maternal departments in district hospitals in the ZOI, the entire district hospital needed to be up to the standards for certification; however, THNA within its mandate supports only maternal and pediatric departments. Recertification is likely to be an involved process and probably beyond THNA’s scope, but during Year Two, THNA did support the MOHSPP with an assessment of the current status of the 14 district maternities and elaborated a plan for re-certification. Certification has lapsed at 12 hospitals receiving THNA support, and the other two were not certified originally. None of the other donors planned to support the baby-friendly initiative in other regions either, so this activity is currently awaiting MOHSPP support within its mandate before progress can be made. The Joint Annual Review of the Health Strategy 2010-2020 implementation was held in January 2017. The event was arranged in close cooperation with the MOHSPP and donor agencies. Four people from the THNA ZOI were funded through the Activity and participated in the discussions at the national level.

Prior to the nutrition forum that took place in July 2017, THNA held a meeting with participation of all partner agencies to propose and discuss the agenda for the event. All agencies jointly approached the MOHSPP committee responsible for the event and discussed the agenda, as well as dates and other logistics. In addition, a follow-up meeting was conducted to review the country’s achievements with regard to nutrition, in line with the goals and objectives established during the last forum and the resolution shared by all involved stakeholders. THNA along with other donors provided technical and financial support for conducting the event.

The booklet (Rohnamo) “Instructions for Mothers’ and Children’s Lives” was approved by the MOHSPP after several revisions. The final version of booklet was translated into the Uzbek language, and a tender for


printing was announced. The Prikaz on implementation of the initiative was drafted, and the districts of the project ZOI were included in the area for piloting. At the national level, the initiative was coordinated by the MOHSPP and the Republican Family Medicine Center, assigned to be in charge of implementation. The initiative includes printing and distributing the booklets and training the relevant staff. The matter of training for PHC staff was discussed with the Republican Family Medicine Center. UNICEF developed guidelines on the use of the booklet and proposed that they be adapted for Tajikistan. UNICEF and THNA were requested to support the MOHSPP with implementation and the provision of technical support in the FTF ZOI. During the reporting period, 60,000 copies of the booklet were printed; of these, 20,000 were given to the MOHSPP and 40,000 will be distributed in the project’s 12 districts. The TOT for counseling on and usage of the booklets was conducted in Khatlon Province, and 10 trainers from the ZOI will provide further trainings to PHC staff.

Following THNA-initiated discussions with the MOHSPP exploring the feasibility of the local production of a micronutrient powder (i.e., Sprinkles) in December 2016, the MOHSPP and THNA team visited two plants to ascertain their potential to produce micronutrients. A feasibility study on the production of micronutrients in the country was initiated and completed; the report was discussed with the MOHSPP and finalized at the end of April 2017. The necessary information was leveraged from the report for presentation to international partners and MOHSPP senior management. In Year Three, THNA will provide support to the MOHSPP to develop a sustainable business plan for the venture and will facilitate discussions with stakeholders about how local production might replace the imports currently supplied via UNICEF. The discussions are ongoing, and further activities for initiating micronutrient production will continue in Year Three.

Two international experts on digital health visited Tajikistan in April 2017 to explore mobile phone communication as a tool to improve health care delivery in communities, particularly between the CHWs being trained by THNA and their local PHC supervisors, as well as information systems for human resources (HR). The experts investigated prior text messaging efforts, the communication infrastructure, and the needs of the health care system in the ZOI. The consultants did not advise to proceed with developing special applications or moving to higher technology such as smartphones or PDAs; however, they did advise enabling CHWs to use their cell phones to make appointments for visits, to text reminder messages to mothers, and to follow up with pregnant women regarding ANC appointments, breastfeeding reminders, and the like. Regarding information systems for HR, the consultants recommended installing or at least piloting smaller-scale, practical applications in the ZOI to address immediate needs and to model approaches for national application. The report recommends the implementation of an HR information system using open source software that provides interoperability with the health management data platform DHIS2. Following the consultancy, THNA was involved in further discussions with European Union and partners on the development of an HR database in Tajikistan.

Collaboration with the Provincial Health Department of the government of Tajikistan (Oblzdrav)


The THNA team arranged and conducted a coordination meeting at the Oblast level on December 8, 2016. The achievements of Year One and the annual plan for Year Two were presented, followed by discussions on the project’s objectives and areas of activity. All agencies involved in MNCH activities in Khatlon Province actively participated in the discussions on the project activities. All partners agreed to meet regularly and to inform each other on their respective activities, as well as to involve the DOH in discussions and decision-making, conveying the messages to health facilities staff. As a result of this meeting, all national and international stakeholders received comprehensive information on the project’s activities and plans, which reinforced coordination and coherence of purpose in the ZOI and reduced the possibility of any duplication or overlap of activities. THNA has initiated the establishment of a working group on health and nutrition at the Oblast level, with special focus on nutrition activities. The working group consists of Oblast-level national institutions and international agencies active in nutrition and health areas in Khatlon Province, including the World Food Programme, the Swiss Agency for Development and Cooperation, JICA, Aga Khan Health Services, Save the Children, and the International Organization for Migration. This working group also serves as a platform for discussing the community-based initiatives on nutrition being implemented by TAWA, as well as other international and national partners.

The terms of reference and map, as well as a list of members for the nutrition TWG, were discussed during the first gathering on April 18, 2017. The group was technically supported by THNA and led and chaired by the head of the DOH, thus ensuring ownership of the initiative by the local government. THNA has initiated and developed a partner activity map for Khatlon Province to support in coordinating activities with all partners, national and international, in the region. The DOH is responsible for arranging meetings and coordinating activities according to the TWG’s terms of reference. THNA will provide the technical support to ensure efficient work of the group at the initial stage: for this purpose, the head of the group who was selected during the last coordination meeting will be supported by the project during the first year. Following a suggestion from the head of the TWG, nutrition trainings were included in the capacity development plan and were provided by the National Institute for Nutrition. During the reporting period, the group held five meetings where representatives of NGOs, both country-based and international, gathered to discuss their current activities, coordinate joint actions, and inform each other of any new initiatives or results of assessments/research. DOH feedback and involvement in discussions is considered a major achievement, as it ensures their ownership and the timely addressing of challenges faced by partners.

Based on discussions with the DOH, THNA developed a roadmap for capacity-building of DOH management staff. The plan and topics for training were discussed and endorsed by the DOH. Cohort I health managers were trained in April 2017 via a THNA sub-award to BDO, a consulting company, which adapted existing management training program to the health care sector. The goal was to improve the managerial and strategic planning capacity of the DOH staff and, with DOH support, the capacity of the hospital managers themselves, whose deficiencies have been well documented in facility assessments. In addition to trainings, the meetings and working discussions at the Oblast level served as a solid platform for improving the managerial and strategic planning capacity of DOH staff.


The TWG members, led by the DOH, conducted a nutrition forum at the Oblast level on September 13, 2017, mirroring the activity implemented at the national level. The main purpose of the forum was to bring government and development partners together to discuss their commitment to eradicating malnutrition among women and children in Khatlon Province through a multisectoral approach involving health, agriculture, food security and safety, education, economic development, water, and sanitation.

The head of the MNCH department of the MOHSPP of Tajikistan and the deputy head of the DOH in Khatlon Province chaired the forum. The Deputy called upon all stakeholders to combine efforts to further address nutrition challenges. Approximately 60 local and international partners and practitioners from Khatlon Province, development agencies, NGOs, civil society, and the media attended the forum to review progress made and to present and validate new evidence. Participants also discussed policy and program implications to address the challenges that malnutrition creates for children and their families in Khatlon Province.

The initiative on establishing a nutrition corner was discussed with other partners involved in nutrition-related activities at the hospital and PHC levels. During the second and third quarters, all e-versions of the approved IEC materials on nutrition were collected from UNICEF and the MOHSPP. All materials were distributed to the newly opened mother’s corners in Dusti, Jomi, and Balkhi PHCs.

Collaboration with the international community

To prepare for the STTA on developing an HR database for the country, during the reporting period, the project met with the CEO of IT IDEAS to discuss automation and the development of software for health facilities. The company is very new, but already well-known in the country and has implemented several successful projects, including development and deployment of software for the UNDP regarding tuberculosis, HIV, and malaria control at the hospital level; development of an automated system for family medicine centers; and development of cross-platform software to train medical staff for UNICEF, among others. The project sees some potential in this company and might consider piloting an automated system for family medicine centers in one of ZOI districts. However, before taking the first step, the matter of sustainability will be discussed with the Republican Family Medicine Center to determine if this institution can make a commitment to further sustain and manage the system.

STTA on a computerized and integrated HR information system was completed in April 2017. During the assessment, the THAN team and consultants analyzed the HR situation by meeting with national, provincial, and district government officials, project staff, and international organizations in Tajikistan. The purpose of the meetings was to understand the current situation, the work undertaken to date, the relevant policy and its direction, and the future needs of HR information systems in the country.

Following the consultancy, THNA was involved in further discussions with European Union partners on the development of an HR database in Tajikistan. When approved by the MOHSPP, the initiative will be supported in the ZOI, and the project will contribute to the implementation process through participation in a preliminary, baseline survey. The modeling of the survey is ongoing, and THNA is taking part in discussions at the national level.

As a member of SUN (Scaling Up Nutrition) in Tajikistan, the THNA focal point participated in two international teleconferences arranged by Global SUN. During these meetings, developing the country’s


framework for implementation of SUN initiatives was discussed. UNICEF, as a lead agency of the initiative, hired an international consultant to support the development of a Common Results Framework (CRF). The next step in the process would be a joint meeting with all stakeholders, including various ministries, to discuss the Framework.

MONITORING AND EVALUATION

During the reporting year, THNA’s indicators were revised to accommodate changes to FTF’s worldwide indicators, and the results from the MNCH end line evaluation were used to set baselines and targets for THNA. The updated Activity Monitoring and Evaluation Plan was approved by USAID in the first quarter.

Several surveys have been completed in Year Two:

1. In February 2017, THNA completed a qualitative study on nutrition behavior. This study explored decision-making in households. Questions included: Who makes food and nutrition decisions in the household? Why is it that person and how does that person decide? The findings showed that some common assumptions are not accurate. For example, earlier inquiries showed men make food purchase decisions; however, as often as not, they work from a list provided by the mother or grandmother and do not actually make decisions.

2. Two rounds of the Recurring Household Survey (RHS) have been completed, one in November 2016 and the other in May 2017. RHS is an effort to measure the results of FTF activities in the ZOI—gathering data on DHS indicators from FTF households to isolate the impact of USG interventions. The first round perfected the method of collection and confirmed the accuracy of available statistics. The second round isolated FTF households and began to compare findings to national rates. The third round will verify the findings of the second round through paneling of results. The findings are presented in the Activity Implementation Summary section.

3. Finally, in September 2017, the Survey on Economic Growth to measure the priority outcome indicator “EG.3.2-17. Number of farmers and others who have applied improved technologies or management practices with USG assistance” was conducted. The results showed that 75.5% of respondents were applying the improved agricultural technologies on which they had been trained. This result was observed by enumerators and certification of application showed that 48% of respondents applies those technologies. The majority of these were canning and preservation techniques. Extrapolating these data to the total number of beneficiaries means that 121,010 people in the FTF zone are applying the improved technologies. This figure is so much higher than the target for Year Two that the target value for Year Three will be adjusted accordingly.

As field coordinators transitioned from the paper-based reports of the MNCH project to the tablets, introduced in January 2017, used for data collection in THNA, some data inaccuracies in reporting have been observed. Although there was staff training, field monitoring by the Monitoring and Evaluation (M&E) unit discovered omissions in data collection and submission, and there continue to be challenges. As these were employees of Mercy Corps, the issue was raised with the Mercy Corps country office. Extensive field work by the M&E unit took place in June 2017 and through the remainder of the period, which resulted in significant


improvement of accuracy in data collection and submission. Two consecutive data quality verifications conducted in July and August 2017 showed next to no omissions and inconsistencies in submitted data from field and regional coordinators.

At the end of Year Two, the M&E unit started the process of hiring an additional M&E/database officer who will be based in the QTP office to ensure the collected data are submitted in a quality and timely manner.

Progress towards Targets Table 4

Purpose / Output Indicator Total for

FY17 FY17 target

Progress toward target

Output (IR 1, 2 & 3)

HL.9-4: Number of individuals receiving nutrition-related professional training through USG-supported programs 2,339 1,500 156%

Output (IR 2 & 3)

HL.9-1: Number of children under five reached by USG-supported nutrition programs 116,619 112,000 104%

Output (IR 2)

EG.3.2-17: Number of farmers and others who have applied improved technologies or management practices with USG assistance 121,0103 8,000 n/a

Output (IR 2)

EG.3.2-1: Number of individuals who have received USG-supported short-term agricultural sector productivity or food security training 250,169 240,000 104%

Output (IR 2 & 3)

EG.3-1: Number of households benefiting directly from USG assistance under Feed the Future 87,006 150,000 58%

Output (IR 1, 2 & 3)

HL.9-3: Number of pregnant women reached with nutrition interventions through USG-supported programs 34,563 20,000 173%

Outcome (IR 3)

HL.8.2-6: Percentage of households in target areas practicing correct use of recommended household water treatment technologies 99% 92% 7%

Output (IR 3) HL.6.6-1: Number of cases of diarrhea treated in USG-assisted programs 17,900 17,000 105%

Output (IR 1)

HL. 6.2-1: Number of women giving birth who received uterotonics in the third stage of labor through USG-supported programs 31,149 24,000 131%

IR: Intermediate result; EG: Economic growth (indicator)

COMMUNICATIONS AND KNOWLEDGE MANAGEMENT Communications play a significant role in nutrition decision-making as well as behavior change in the ZOI. In recognition of this fact, in Year Two, THNA used an intentional approach that places awareness of beneficiaries into every activity. Thus, the highlighted activities below represent key communications achievements completed during the reporting period. 3 The reason this target was low was that it was uncertain as to what extent these trainings would impact the target communities, as they were mostly out of the scope of the THNA. In addition, though not new in FTF, it was a new indicator for the Activity and to be on the safe side, the target was set to be absolutely achievable. Survey was conducted to calculate people applied promoted technologies using Beneficiary Based Guide. As a result, survey showed that 48% of people applies those technologies. Taking this into account, 121,010 was extrapolated from 48% of 250,169 of EG.3.2-1 indicator. In light of this year’s success, the target figure for FY18 will be adjusted accordingly to reflect this information.


In Year Two, Cohort II facilities received medical equipment via sub-awards. Two handover ceremonies were broadcast on nationally televised news stations, and local authorities of the MOHSPP and representatives of USAID attended the ceremony. The communication specialist, in close collaboration with the senior nutrition specialist, produced short, five-minute videos on nutritious recipes for children under five and pregnant women. These videos are to be distributed to community members during cooking demonstration sessions or home visits by CHEs, as well as aired during community events in the ZOI upon approval by the MOHSPP. In Year Three, six more videos will be produced.

THNA financed the publication of the third quarter of the Healthy Life Style Center’s quarterly magazine Ganji Sino, which included an article on nutrition developed by the Institute of Nutrition together with the THNA MCNH Technical Specialist on Child Health and Nutrition Advisor.

In the third quarter, two animated videos were developed and produced in Tajik and Uzbek with English subtitles on the topics of safe water and ventilated improved pit latrines. These videos were tested on members of the target audience and approved by USAID and IntraHealth’s branding and marketing departments. The sanitation and hygiene-themed videos were approved by the MOHSPP in August 2017 and will be broadcast on national television through the end of October 2017. The videos can be viewed at:

• https://www.youtube.com/watch?v=pJR_ZAFqDUQ • https://www.youtube.com/watch?v=Qanw7FymyUo

A billboard developed for promoting proper nutrition among children under five and tested on the target audience was approved by the USAID branding and marketing department in July 2017. The billboards will be distributed and displayed in over 50 health centers in the THNA ZOI by the end of October 2017. Additionally, THNA was active in creating awareness of healthy eating and appropriate nutritional intake during the first 1000 days’ window during farmers’ market and latrine fair outreach campaigns in the FTF ZOI, as well as at the national-level nutrition forum. In collaboration with the MOHSPP and other stakeholders, THNA conducted a number of events to raise awareness during World Breastfeeding Week, celebrated from August 1-7, 2017. For more information, please visit https://spark.adobe.com/page/5Q7bBPSZG9SyI/.

A story about Usmonali Gafurov, a ventilated improved pit latrine mason from Yovon District, was published in USAID’s monthly newsletter in September 2017, as well as on IntraHealth’s VITAL blog (https://www.intrahealth.org/vital/safer-toilets-bring-better-health-new-business-tajikistan).

A professional photographer was recruited to take pictures of local children and women during implementation activities in health facilities. Consent was obtained for the use of these pictures in SBCC materials to highlight the positive consequences of adopting healthy nutrition behaviors.

https://www.youtube.com/watch?v=pJR_ZAFqDUQ

https://www.youtube.com/watch?v=Qanw7FymyUo

https://spark.adobe.com/page/5Q7bBPSZG9SyI/

https://www.intrahealth.org/vital/safer-toilets-bring-better-health-new-business-tajikistan


During the reporting period, the communication specialist and nutrition advisor participated in a two-day nutrition workshop organized by GAIN for mass media representatives. As GAIN is phasing out, this activity will be continued by THNA, and another workshop for journalists is planned for Year Three. This activity will enhance knowledge about nutrition, and THNA will use this opportunity to promote nutrition through mass media by involving journalists.

A report of the opening ceremony of four mother’s rooms in the FTF ZOI was published in USAID’s monthly newsletter in September 2017.

THNA submitted three success stories to USAID during the reporting period. (Annex 7: Success Stories) The development of IEC materials and their dissemination at the household, community, and facility levels among health workers has been one of the main amplified efforts during Year Two. A list of IEC materials produced and/or printed by THNA is presented in Annex 8.

Together with the Annual Report, a high-definition DVD with 20 pictures taken at THNA events will be provided to the Mission.

BUDGET VS. EXPENDITURE ANALYSIS Activity spending was still slow in the first half of Year Two, but picked up significantly in the latter part of the year (See Table 5). Overall, the Activity spent 99% of the budget allocated for Year Two. Spending will continue to be on target, moving into Year Three of THNA’s implementation. Table 5. Project to Date Obligation and Burn Rate

Project to Date Obligation: Burn Rate

Current Obligation $ 7,481,568

Actual Funds Spent $ 5,127,446

Burn Rate: 69%

The breakdown of expenditure by program element/funding source is presented in Table 6 below. Table 6. Obligation vs. Expenditures by Result Area

FY17 Expenditures by Result Area Description Year Two

Result Area 1: Improved quality of health care services for MNCH. $875,012


Result Area 2: Increased access to a diverse set of nutrient-rich foods. $667,360

Result Area 3: Increased practice of healthy behaviors around MNCH. $1,596,911

Result Area 4: Evidence-based MNCH services. $502,740

Total for FY17 $3,642,023

SUB-GRANTS

THNA awarded and delivered 13 in-kind sub-grants totaling $458,437 during the reporting year:

1. Procurement of an assortment of basic medical equipment. Total: $26,034

2. Local sanitation solutions: support four VDCs in a pilot effort to mobilize local resources to address WASH issues. Total: $10,430

3. Hospital IMCI: equipment for ZOI district hospitals. Total: $88,671

4. Cohort II equipment: filling needs identified in the facility assessments. Total: $115,747

5. Infection control I: autoclaves. Total: $24,700

6. Infection control II: dry heat sterilizers. Total: $22,680

7. Medical equipment for the maternity department of the Dusti Central Hospital through sub-grant support. Total: $40,504.25

8. Capacity-building in management for health care facility managers. Total: $11,603

9. Equipment for mother’s rooms in four pilot districts in Khatlon Province. Total: $5,444

10. Procurement of medical equipment for the maternity department of Shaartus District Central Hospital. Total: $28,800

11. Procurement of medical equipment for the maternity department of Qabodiyon District Central Hospital. Total: $34,640

12. Procurement of medical equipment for the maternity department of Nosiri Khisrav District Central Hospital. Total: $20,180

13. Printing materials for distribution in the community. Total: $29,003.12

CHALLENGES ENCOUNTERED AND ACTIONS TO OVERCOME

In the first quarter, there was a problem with the deliveries of equipment to the hospitals: no supplier had delivered on time. The three different firms had used highly unreliable suppliers. For the Dusti District equipment grant, THNA chose a fourth firm and added a penalty clause to the contract. In subsequent quarters, this issue was resolved, as other suppliers were selected and proved to be more responsible.


Infection control remained a challenge at health care facilities and an obstacle in achieving QI standards. The main constraints to implementing effective perinatal technologies in these facilities are the absence of heating systems, sewerage, water supply, recycling, and sterilization. While many of these are infrastructure needs and outside of THNA’s grant mandate, the Activity is able to provide equipment, and in the coming year, a competitive grant award will be considered that will include this area of need.

The transition from MNCH to THNA continued to be challenging. By the end of the first quarter, despite previous communications of expected burn rates, Mercy Corps remained considerably underspent on their funding, with a burn rate of 6%. As the prime, IntraHealth reduced Mercy Corps funding for the year and outlined spending targets. Mercy Corps staff understanding of and commitment to the required technical shifts from the MNCH to a more targeted strategic THNA approach remained inadequate. During the workplan retreat, which included team-building sessions, some attitude shifts began to take place. In the fourth quarter, senior activity leadership continued with extensive group discussions while the subsequent workplan development meetings to help staff begin to appreciate and understand the technical strategy and approach of THNA. However, ultimately, the greatest opportunity for change came with the announcement to terminate the Mercy Corps sub-agreement. This termination permitted THNA to carefully plan a transition of staff to IntraHealth—staff who were willing to try to undertake a different approach to the work. Staff capacity-building in evidence-based technical strategies, critical analysis of the root causes of a problem, and interpreting and applying data to the design and implementation of interventions will continue to be required. In the fourth quarter, THNA leadership began to make strides toward increased staff capacity and setting a tone of critical analysis of interventions and data.

Knowledge of the causes and implications of undernutrition and its importance as a determinant for health and development is a barrier at all levels in the ZOI. The intersectoral approach to nutritional issues sometimes led to situations where no group took responsibility or advocated effectively, as nutrition was observed to be only the purview of agricultural and health sectors. Furthermore, overloading community volunteers with a variety of trainings on different topics negatively impacted their work, and by trying to cover a wider array of factors that affect nutritional issues, their focus on nutrition itself was weakened.

To address these challenges, THNA is planning modify its approach to work at the community level, which will increase its impact and provide greater results. In evaluating the work of the CEs over the past two years, shortcomings have also been identified. A principal finding is that the CEs are working with communities on too many subjects, ranging from hygiene to canning to business planning. In addition, the evaluation found that 28% of CEs were acting as health workers but did not have the requisite training or skills. As a result, THNA proposes in Year Three to focus the attention and efforts of the CEs on food security, life skills, and sanitation and to introduce a new community-based volunteer who would give full attention to nutrition and health. While both CEs and the new Community Health Promoters (CHPs) will work with communities, the two would have very different, complementary roles and responsibilities. In the future, the CHPs would become the link between the community and the health system. Dividing the roles and responsibilities of the volunteers working at the community level will enable each cadre of volunteers to focus on achieving a limited set of objectives. More details about this effort are described under IR 4 and the


“Priorities for Next Year” section of this report, as well as in the Concept Note on Community Health Promotion model in THNA’s Year Three workplan.

GENDER

In Year Two, THNA mainstreamed gender-related activities by incorporating gender-sensitive approaches into its nutrition-specific and sensitive interventions. The project continued strengthening its targeted approach to women by enhancing their role in creating opportunities for livelihoods and savings through the agriculture sector and by focusing on men as household providers and purchasers of nutrient-rich food. These activities were supported by the THNA nutrition strategy developed in Year Two, which was based on the nutrition behavior study.

In response to these two documents, THNA has changed its approach to addressing the nutrition-specific gender issues by targeting women of reproductive age who were more at risk of micronutrient deficiencies and of having malnourished children. According to the study, both men and women influence the target beneficiaries, therefore identifying the roles and responsibilities for both helped to include gender-sensitive approaches and activities in agricultural, nutrition, sanitation, and health activities.

In agricultural educational activities, targeting women was a means of strengthening the link between gender and nutrition by establishing women’s substantial contributions in the areas of food collection, preservation, and preparation. Poultry farming afforded women the opportunity to stay at home to look after both children and chickens. This transformative learning resulted not only in the provision of nutrients and protein for the household but also a means of income generation. This extra income contributed to women, especially female-headed households, having access to more nutritious food, and their savings gave them the means to purchase non-food items that would otherwise not be available to them.

Typically, the purchase of food items is reserved for men in the household; however, some households are headed by women, particularly mothers-in-law. Thus, in Year Two, the project also sought to reach these female-headed households with messages to purchase nutrient-rich food. These messages were promoted during outreach campaigns at farmers’ markets, open field days, and during consultations in mother’s rooms.

Self-efficacy is still a challenge in the ZOI, as it is in Tajik society more broadly. Parents, elders, or husbands are the sole decision-makers in every aspect of life, therefore shifting away from these norms remains challenging. THNA trained religious leaders on Khutbah, a collection of teachings from the Qur’an about safe motherhood, breastfeeding and complementary feeding, and the rights of women to make health decisions. Religious leaders spread this information among men during the five times daily prayer in mosques. THNA remains committed to conducting purposeful inquiry into gender, behavior change, and the applicability of a sustained, group-based delivery of life skills lessons. These lessons are aimed at supporting women and their role in the development of positive social norms in their communities, and they illustrate THNA’s commitment to reaching every individual regardless of age or gender.

MANAGEMENT AND STAFFING

Year Two of THNA’s implementation incurred some major challenges in term of staffing and management. In the last two quarters, due to a conflict of interest, one senior staff member resigned, and the Chief of Party (COP) was denied reentry into the country. However, the Activity’s work continued uninterrupted with


support from the in-country senior THNA team and the senior project manager from IntraHealth HQ. Furthermore, an interim COP was placed in the Dushanbe Office, while THNA was actively recruiting for the permanent position. During the first part of Year Two, several key positions were filled. A senior policy advisor came on board to lead activities related to THNA’s IR 4: Institutionalize evidence-based MNCH services through national-level policies and standards, as well as a program manager for the Qurghonteppa office to liaise and work with the Mercy Corps team in implementing IR 2 and IR 3. In addition, an expat nutrition advisor from Nigeria joined the team in Qurghonteppa in early 2017. In the third quarter, a new grant manager and a communications specialist joined to complete the THNA team in Dushanbe. During the last quarter, the THNA project underwent a number of changes, including the restructuring of the office, project activity responsibilities, and management. The events leading up to the restructuring were the COP’s denial of reentry into the country, and the termination as of September 30, 2017, by mutual agreement, of the sub-award between IntraHealth and Mercy Corps. To address the staffing and program changes, steps were undertaken to expand both the Dushanbe and Qurghonteppa offices, while continuing field activities without interruption. The first steps were the restructuring of the office, the reassignment of some duties, and the hiring of additional staff (Annex 9, revised organizational chart). The positions of operation manager and financial manager along with IT and HR were advertised in late July 2017. By mid-September 2017, all but the IT positions had been filled; two internal staff were selected for the finance and operations positions, and an experienced HR manager was chosen to ensure a smooth transition of Mercy Corps staff as well as the recruitment of additional regional office staff. The HR manager will further ensure effective management and training of the larger staff (up to 50 by early November 2017), in line with the Tajikistan Labor Code and Practices. 1. Restructuring the THNA offices: A regional manager was hired for the Qurghonteppa office in the final

quarter of Year Two to manage the expanded community activities previously implemented by Mercy Corps and added to the IntraHealth THNA portfolio for Year Three implementation. The Mercy Corps technical staff members based in the Qurghonteppa field were transitioned from Mercy Corps to IntraHealth to start on October 1, 2017. Additional positions in the field office and Dushanbe are under recruitment, including for an M&E officer. The senior policy advisor was promoted to director of community programs/policy, which includes oversight of the Qurghonteppa office and activities. By the end of September 2017, to accommodate the large staff, THNA had moved into a new office in Qurghonteppa. THNA is committed to a rapid orientation of all new staff members to IntraHealth structure, policies, and procedures and to their duties and responsibilities with regard to the Activity strategy. It also aims to minimize disruption in operations to ensure activities are implemented according to the Year Three workplan.

2. Team-building and workplan planning: In July 2017, a workplan retreat was held for all THNA project staff in Norak, Khatlon Province under the joint leadership of the HQ senior program manager and the deputy COP for the THNA project. The purposes of the retreat were twofold: to brainstorm and draft the Year Three workplan and to build a strong and productive team. Team-building was accomplished by working collaboratively on the workplan and through twice daily team-building exercises intended to


build a better interpersonal understanding of all team members and their respective roles. The new CHP model was discussed and developed with active involvement of the THNA team, and following the meeting, a concept was developed and shared with USAID and HQ. This concept is now part of the approved Year Three workplan.

3. Training and on-boarding (new) staff: In the latter part of September 2017, a two-day team-building/technical workshop was organized in Dushanbe for all THNA staff to introduce and work on a common and integrated approach to address challenges, and to learn how to work as a team to reach THNA goals. The workshop was led by Dr. John Tomaro, a consultant with experience in nutrition and community involvement. The workshop focused on how THNA technical units (clinical, nutrition—including livelihoods and food security—and sanitation) and implementation teams (ministry of health staff and community volunteers [CEs and CHPs]) might organize their activities to facilitate collaboration across the domains and to achieve project results/outcomes in the villages and households of Khatlon Province. Follow-up team meetings will be held periodically in Year Three under the leadership of the community program director. An all staff/all-day meeting on IntraHealth’s policies and procedures, including HR, ethics, and compliance is scheduled for October 11, 2017 in the new Qurghonteppa office.

4. Hiring the new COP: THNA advertised and identified a new COP, who will take up his position in January 2018. During the transition period, in addition to the acting COP, both the senior program manager and the finance business partner are providing adequate program oversight, continuity, and fiscal austerity. The acting COP will be part of the orientation and transition when the new COP arrives to the country.

Throughout the year, the project staff received hands-on training and mentoring through STTA from IntraHealth HQ and regional staff (as described elsewhere in the report), as well as online training on policies and procedures, ethics, and cyber security. The senior program manager provided technical assistance during the workplan development. The finance business partner continued to provide mentorship and oversight regarding financial systems.

PARTNERS

The sub-agreements with Abt Associates and Mercy Corps continued in Year Two. These sub-agreements outline the anticipated responsibilities over the five-year life of the Activity. Annual modifications are made detailing the annual workplan and budget in line with the approved workplan. With their long history of experience in the country, the sub-awardees, Abt Associates and Mercy Corps, bring extensive connections to THNA. However, despite several efforts by the THNA project management team to discuss and reorient Mercy Corps to the objectives and goals of THNA, their work was a continuation of the previous approaches used in their MNCH project, without a strong consideration for the integrated yet targeted nature of THNA. At the end of July, Mercy Corps expressed its intention to terminate the sub-agreement, and a mutual agreement was reached. IntraHealth issued a revised modification to the sub-award with a new end date of October 31, 2017 with the understanding all field activities would be transferred to IntraHealth as of October 1, 2017. Collaboration with FTF activities


THNA continued to actively collaborate and coordinate with other FTF activities to facilitate the smooth and timely implementation of initiatives on nutrition, with the goal of preventing stunting by addressing its proximal causes. During year Two, THNA targeted efforts to assist and promote an increase in nutrition-sensitivity through multisectoral coordination and programming efforts with other FTF programs working in the ZOI. THNA is positioned to collaborate within the FTF portfolio of Activities to ensure that nutrition outcomes are primary in programming decisions, activities, and materials. With good working relationships established and clear understandings of each Activity’s roles and objectives, the FTF teamwork is more integrated, with THNA acting as the lead for maternal and child health care, nutrition, and WASH. TAWA supported THNA with dietary diversity trainings on the importance of nutrient-rich foods for pregnant women and children aged six months to two years old; with training on canning and safe storage of products; and with training on land preparation and crop rotation in advance of the planting season via TOT and cascade training. During Year Two, THNA field staff received a TOT from a TAWA extension specialist that resulted in cascade trainings of CEs and that focused on the goals of crop rotation, conserving and building organic matter and nitrogen, and disease control.

A number of joint farmers’ markets and fairs with TAWA and its extension agents and resident economists were conducted at the community level to demonstrate the proper preservation and storage of food products. The activities, which included competitions and exhibitions, were carried out to promote local products and crops, as well as products promoted by TAWA, and to show proper storage and preparation techniques. THNA also participated in TAWA’s Open Fields project and participated in a cooking demonstration of broccoli, cabbage, and okra. THNA’s nutrition specialist developed and promoted a few complementary feeding recipes by testing the recipes with mothers. Economic growth events were conducted as part of the ongoing collaboration with WEEP and Save the Children, which deliver direct training sessions on household economics. To coordinate activities and rationalize efforts, THNA and TAWA hold monthly coordination meetings for field staff. Other FTF partners (e.g., WEEP and Farmer to Farmer) frequently attend. These are working meetings at which the activity calendars of each Activity are reviewed in detail and adjustments are made to closely coordinate work and to find efficiencies and complementarity. Continuing its collaboration with GAIN, THNA technical staff participated in the regional summit “Fortify Our Future” in Almaty, Kazakhstan. This event advocated for five Central Asian countries to take the next step toward establishing and/or enforcing mandatory wheat flour fortification in their countries. At the hospital level, THNA technical staff members have also been working closely with GAIN technical experts on spina bifida topics. This effort includes raising health workers’ awareness of how to reduce the incidence of spina bifida and hydrocephalus by tackling the issue of anemia in pregnancy through folic acid intake. In Year Two, THNA signed a memorandum of understanding with the International Potato Center for collaboration in the process of adapting 15 varieties of orange-fleshed sweet potato seedling into in vitro


seeding, and then growing in the nursery. The initiative was presented to farmers at one of the demonstration plots in Khatlon Province. These collaborations will continue in Year Three. Collaboration with the international community THNA has the most prominent role of any FTF activity in the international community. As one of only two projects to join the coordination committee of international donor organizations, THNA is leading the effort to raise the profile of nutrition in Tajikistan. Described in detail under IR 4, THNA’s has served to substantially raise the FTF profile and the promotion of improved nutrition in Tajikistan. The COP delivered a presentation on the latest scholarly research into the causes of stunting; he aligned the findings of the research with the structure of the FTF portfolio in the ZOI. THNA collaborates with the international community in training events as well. In the third quarter, THNA was supported by WHO and UNFPA in preparing and delivering ten-day training on EPC. THNA’s clinical director enrolled the EPOS project, funded by KfW, in refining the WHO assessment tool used in the RHFA. Branding and Marketing A communications and knowledge management specialist ensured that all communication documents for the Activity (banners, fact sheets, posters, PR, etc.) during the reporting year were designed and approved by the USAID communications office. PRIORITIES FOR NEXT YEAR The interventions at the community level through CHEs and their village-based activities, which were introduced by the USAID-funded, Mercy Corps-led MNCH project, have been integrated into THNA. However, the approaches used by the CEs to encourage the adoption of behaviors that promote health and prevent illness have achieved some important but limited results. CHEs responsible for informing communities and mobilizing them to adopt a very wide range of health and nutrition-related behaviors—pertaining to health, food security, nutrition, water, sanitation, and hygiene—were “overloaded” and unable to discharge all of their responsibilities. Therefore, THNA is planning to split the responsibilities of community volunteers between CEs (the new name for CHEs) and CHPs. In the new structure, it is proposed that CHPs focus on delivering messages on health and nutrition and on referring those needing clinical care to health facilities. In contrast, CEs would have a reduced workload (but would be encouraged to have a longer time of service) and would focus on delivering messages relevant to the other interventions being implemented by the project. Both types of volunteers would work at the village level, would coordinate their activities with guidance from the district coordinator, and would serve as links between the community and health services or other assistance. THNA will train 797 volunteers in six districts: Jomi, Bokhtar, Khuroson, Sarband, Dusti, and Balkhi.


In Year Three, THNA will continue utilizing innovative approaches to address the maternal and child nutrition priorities of FTF and the government of Tajikistan. THNA will continue a holistic set of program activities focusing on nutrition. Communities and households within the ZOI will receive evidence-based interventions designed to change behaviors around nutrition, including water and sanitation. Interventions will cover all 12 districts at the community and health facility levels. The Activity will increase quality health care for pregnant and lactating women and neonates at the hospital and PHC levels. This increase will be accomplished by strengthening the capacity of health workers and supplying the necessary equipment for services, as well as by promoting improved nutritional practices. At the community level, CHPs will reinforce messages from health workers, refer clients to health facilities, and conduct community-based nutrition education and counseling interventions. THNA activities planned for Year Three are in compliance with the National Health Strategy of the Republic of Tajikistan 2010-2020; the Maternal, Newborn and Child Health Action Plan; and the Nutrition and Physical Activity Strategy 2015-2024. These activities and strategies aim to institutionalize improvements via the capacity development of national experts, evidence-based decision-making, and sustainable linkages. In Year Three, THNA will focus its set of program activities to address the causes of stunting at the individual and household levels. Multisectoral efforts will continue addressing stunting through nutrition-sensitive interventions to protect vulnerable households from and mitigate the undesirable consequences of food security threats. Based upon the evidence generated in the first two years of the activities, THNA is adapting its approach to community involvement. To ensure the sustainability of the initiative, the Community Health Promotion model, which is based on past achievements and lessons learned through the MNCH project, will be introduced. This new model will allow the Activity to conduct more focused interventions on nutrition and related health issues by reaching the target beneficiaries. By using the enhanced data on the households most in need of interventions—data established at the initial stage of the implementation—the Activity can increase its targeting efficacy. An mHealth and EHealth will be introduced on a pilot/experimental basis, as proposed in the consultants’ reports, and will be thoroughly assessed to document relevance, impact, and long-term financial sustainability. Discussions with the MOHSPP and international partners on further development of micronutrient production in Tajikistan will also take place in Year Three. The Activity will continue to focus resources on the households where signs of poor nutrition are found and will bring messages and support directly to where they are needed. Although the activities are intended for all communities, a targeting process will identify priorities for specifically targeted interventions. Services to new and soon-to-be mothers will be a particular focus in Year Three. CHPs will reinforce messages from the health workers in the PHCs and district hospitals and will refer clients to appropriate health facilities. CHPs will also monitor children with nutrition-related disorders (moderate acute malnutrition, severe acute malnutrition, etc.) who have been discharged from hospitals to eliminate repeated cases of hospitalization through close mentorship and timely referral to PHCs.


Annexes Annex 1: Activities planned vs. actual for the year

KEY ACTIVITIES YEAR TWO STATUS

Completed

Partially completed

Not completed

IR 1: Improved quality of health care services for MNCH Outcome 1.1: Improved quality of health care services being provided in the Feed the Future (FTF) Zone of Influence (ZOI) 1.1.1 Hospital-level activities

a) Conduct supportive supervision (SS) training of trainers (TOT) for 20 providers on effective perinatal care (EPC) using clinical practice guidelines (CPGs) developed under IR 4, approved by the Ministry of Health and Social Protection of the Population (MOHSPP)

X

b) Conduct EPC training for 20 health care providers (OB/GYNs, neonatologists, and midwives), including topics such as emergency obstetric and newborn care (EmONC) at the maternity level from Cohort I and II using national EPC trainers

X

c) Conduct mentoring and monitoring (MM) visits for EPC implementation (covering intrapartum and postpartum care, healthy newborn care, sick newborn care, neonatal resuscitation, and infection prevention and control) using national EPC mentors

X

d) Provide SS to continue to improve maternity providers’ maternal, newborn, and child health (MNCH) clinical practices, with an emphasis on EPC training and clinical skills updates

X

e) Pilot e-based biweekly online conferences between supervisors and mentors and facilities from Cohort I to provide continuous and sustained SS to health care providers on EPC

X

f) Provide in-kind sub-awards to Cohort II facilities to address basic equipment needs as identified in the assessments X

g) Conduct quality improvement (QI) training for ten providers from Cohort I X h) Develop action plans with Cohort II facilities on improving quality health care at the

maternity level X

i) Produce two algorithms and internal protocols based on a cross-analysis of data on the prevention and treatment of peripartum infection and others in subsequent years X

j) Provide TOT for 20 hospital-level workers on the new or updated CPGs and protocols developed and approved under IR 4 X

k) Develop MNCH database with indicators common for all district hospitals as well as specific, internal QI indicators X

1.1.2 Primary health care-level activities a) Provide SS TOT for 20 providers on antenatal Care (ANC) based on IR 4’s CPGs approved

by the MOHSPP X

b) Train 60 providers on ANC in the FTF ZOI at the primary healthcare center (PHC) level, preferably from Cohort I and II, to improve the quality of antenatal services for women X

c) Have national ANC and family doctor mentors conduct MM visits on ANC implementation (covering nutrition issues during pregnancy such as folic acid intake in the first trimester; improved management of anemia in pregnancy; and improved quality of prenatal counseling, including danger signs, physiological changes, postpartum contraception, breastfeeding, and decreased use of non-evidenced-based drugs)

X


d) Provide SS to continue to improve primary health care practices, with an emphasis on increasing the number of women screened for preeclampsia during each ANC visit and disseminating key ANC counseling messages

X

e) Train 80 PHC providers (mostly family doctors) on nutrition issues during the 1,000 days’ window using the CPGs developed under IR 4 X

f) Conduct QI training for ten providers at the PHC level X g) Support and/or provide grants (as is feasible) to PHC facilities to improve the quality of

antenatal services for women at the PHC level X

Outcome 1.2: Improved patient access to health care services in the FTF ZOI due to improved quality 1.2.1 Hospital-level activities

a) Carry out a 3 day training on updated Prikaz on Infection Control Prikaz 1119 for 40 health workers in selected districts to improve infection control practices in existing EPC pilot facilities depending on IR4's Infection Guideline TWG

X

b) Facilitate MM by national trainers on infection control to ensure that providers follow infection control practices and sterilization and disinfection procedures X

c) Apply a sub-grant sequence for effective implementation of infection control guidelines to decrease septic complications among newborns and postpartum women (include equipment for sanitation and sterilization as needed)

X

d) Pilot “mother’s corners” at selected maternities to promote appropriate postnatal care for women and newborns and immediate early and exclusive breastfeeding X

1.2.2 Primary health care-level activity: Carry out a three-day training on the updated Prikaz on Infection Control (Prikaz 1119) for 40 primary health workers in selected districts to improve infection control practices in pilot facilities

X

Outcome 1.3: Stronger facility and provider networks 1.3.1 Hospital-level activities

a) Conduct training on EmONC for 40 health care providers from all 14 maternities to introduce management of postpartum bleeding and baby breath programs on newborn resuscitation and essential care for small baby programs.

X

b) Assess “baby-friendly hospital” status in 14 maternities and elaborate plan for recertification X

c) Support facilities in achieving “baby-friendly hospital” certification, as feasible X d) Mentoring of HCW in Cohort facilities (mentorship by THNA staff) X e) Organize and implement exchange visits and forums to other facilities to learn best

practices in MNCH X

1.3.2 Primary health care-level activities a) Support health care facilities’ work with volunteers to promote use of delivery plans X b) Have volunteers distribute UNICEF booklets with antenatal supplement after the

revisions noted under IR 4 X

c) Improve clinical practices by supporting health workers through ongoing SS and mentoring, in partnership with the MOHSPP X

IR 2: Increased access to a diverse set of nutrient-rich foods throughout the year Outcome 2.1: Diversified food consumption during the growing season and beyond 2.1.1 Recruit and hire a program manager for nutrition to work in the field office to serve as

the nutrition expert for THNA and other FTF activities X


2.1.2 Conduct staff training for all field coordinators to build a basic understanding of nutrition concepts; training is to be led by Dr. Azonov of the Institute of Nutrition under the Ministry of the Economy in part to help THNA start building relationships with Tajik institutions and resources

X

2.1.3 Complete THNA coverage of all villages in the ZOI a) Add 200 communities; due to the low population density in some areas, this is likely to

be 225 villages consolidated into 200 communities X

b) Graduate 200 communities; the criteria for graduation are a functioning village development committee (VDC) with regular meetings and linkages, active volunteers, and health workers

X

c) Foster ongoing capacity-building of all community volunteers X 2.1.4 Promote diversified food consumption for new communities to provide the same core training as done under the MNCH

project a) Conduct trainings in the new communities on dietary diversity for 320 participants

(including 200 health workers from the district health centers) X

b) Train 400 CHEs on canning/safe food preservation with TAWA and distribute existing DVD; conduct cascade training to 3,000 people X

c) Include 12 TAWA home economists in the dietary diversity trainings X 2.1.5 Conduct a household survey of nutrition behavior and decisions to enable THNA to

propose crops to TAWA for promotion and to create effective and influential social and behavior change communication (SBCC) activities to improve nutrition

X

2.1.6 Field a “Farmer-to-Farmer” volunteer to assist in TOT on food preparation for winter X 2.1.7 Conduct rapid cascade training on food storage for winter X 2.1.8 Conduct a sequence of demonstrations and trainings for VDCs/community leaders on

methods of improved storage of pumpkin, cabbage, carrots, and other root vegetables X

2.1.9 Conduct 12 joint farmers’ markets and fairs with TAWA and its extension agents and home economists to showcase proper nutrition behavior via competitions and exhibits X

2.1.10 Prepare two short-format videos on nutrition and air them on local TV; also offer selections from the FTF video library THNA is developing in IR 3 X

2.1.11 Design and deliver training to 100 household farmers to promote improved irrigation; conduct a sequence of trainings and follow-up visits over a two-month timeframe X

2.1.12 Develop plan in collaboration with TAWA and the International Potato Center to improve household gardening more directly to address water and soil deficiencies in food-poor households

X

Outcome 2.2: Nutrition integrated into agriculture-focused programs and linked to value chains supported through FTF activities 2.2.1 Deploy an STTA nutrition expert to develop a nutrition strategy for THNA activities to

enable THNA to lead other FTF activities in nutrition-related areas X

2.2.2 Improve participants’ ability to grow nutritious food (“availability”) a) Conduct joint training with TAWA for THNA staff on the care and feeding of poultry via

improved pens, feed, and vaccinations and then conduct cascade trainings in Sarband, Yovon, and Jomi Districts

X

b) Conduct supplementary poultry management training on the financial aspects of maintaining poultry via TOT and cascade training X

c) Produce a DVD on poultry management with multiple copies distributed to all community volunteers X

d) Develop a training curriculum on drying fruits and vegetables, beginning with TAWA’s apricot video X

e) Explore with TAWA a sustainable approach to providing vaccination services for poultry, dairy animals (including sheep, cows, and goats) X


f) Conduct training (primarily direct training) in 300 communities on the technical aspects of drying fruit X

g) Conduct joint training (primarily direct training) with TAWA on small-scale dairy production X

h) Conduct joint training with TAWA on land preparation and crop rotation in preparation for the planting season via TOT and cascade training X

2.2.3 Improve the ability to buy nutritious food (“access”) a) Enable FINCA to conduct financial literacy training X b) Investigate additional linkages to promote savings and bank accounts with IMON

International and private banks X

c) Collaborate with WEEP and Save the Children to deliver direct training on household economics X

d) Conduct trainings on household budgeting to optimize use of household income, considering data from the “cost of diet” survey deployed in the new communities X

2.2.4 Promote income-generating activities (IGAs) as a means to increase incomes to buy nutritious food a) Conduct training on fruit drying as an IGA X b) Conduct training on small-scale dairy production as an IGA X c) Coordinate with private sector partners for IGAs in carpet weaving and tailoring X d) Design and implement a pilot IGA with TAWA on a safe herbicide application service X e) Investigate along with TAWA the feasibility of small-scale distribution of agricultural

inputs such as improved seeds and fertilizer as an IGA X

2.2.5 Assess IGA activity in the ZOI and revise next year’s approach X IR 3: Increased practice of healthy behaviors around MNCH Outcome 3.1: Increased consumption of nutrient-rich foods among adolescent girls, women, and children under two 3.1.1 Apply the approved nutrition strategy to SBCC activities and align campaign elements,

activities, and media X

3.1.2 Complete formative research to inform improvements and changes to the SBCC approach and train THNA staff X

3.1.3 Implement a series of three one-day trainings on community mobilization, adult learning, and nutrition topics for the 400 new volunteers and 200 VDCs in THNA’s new communities

X

3.1.4 Conduct direct training of 1,400 community volunteers: focus on THNA objectives; explain the interrelationship of program elements and the community volunteers’ role; distribute materials and branded bags; lead team-building exercises

X

3.1.5 Implement capacity-building and coaching for regional and field coordinators to help them focus community volunteers on the THNA objectives of nutrition, improved patient care, food security, and sanitation in transition from the MNCH project

X

3.1.6 Execute SBCC campaign on iodized salt: educate the population, encourage proper consumption, enable access to the product, and reinforce the messaging

a) Collaborate with the Global Alliance for Improved Nutrition (GAIN) and UNICEF to prepare printed materials for educating the target audience X

b) Produce a short-format video for broadcast on regional television X c) Create print and video material for volunteers to use in encouraging people to seek out

and demand iodized salt X

d) Guide volunteers in preparing an outreach campaign to enlist VDCs in encouraging households to demand iodized salt X

e) Engage with salt wholesalers to ensure proper supply of quality assured product X


f) Obtain rapid tests and distribute to volunteers, VDCs, and shopkeepers X 3.1.7 Execute SBCC campaign on healthy food: educate the population, encourage purchase and consumption of a diverse diet,

enable access to food products, and reinforce messaging a) Develop additional recipes to educate people about crops promoted by TAWA X b) Produce videos to broaden and reinforce cooking demonstrations X c) Produce educational materials about dairy, animal source protein (poultry), and others

to supplement MNCH materials X

d) Create print and video materials for volunteers to use in encouraging people to seek out and consume nutritious food—include general guidance and the special needs of adolescent girls

X

e) Produce a flipchart booklet and dishes with TAWA to show production and cooking of nutritious food in one combined reference X

f) Guide volunteers in preparing an outreach campaign to enlist VDCs in encouraging households to consume nutritious food, with an emphasis on adolescent girls, pregnant and lactating women, and children

X

g) Work with TAWA farmers to enable supply by improving the marketing of locally produced dairy foods in remote communities X

h) Promote dairy consumption through demonstrations of preparing kefir and other milk products; conduct TOT for 28 field coordinators and cascade training to 400 volunteers and 6,000 participants

X

3.1.8 Execute SBCC campaign on nutrition for pregnant women: educate the population, encourage commitment to exclusive breastfeeding (EBF) through six months, and reinforce messaging

a) Develop a targeted social marketing campaign for this segment to complement the broader “nutritious foods” campaign X

b) Implement the action steps (to be specified) in the targeted campaign X с) Distribute booklets to the community on nutrition for women of reproductive age and

during pregnancy in particular X

3.1.9 Execute SBCC campaign on EBF: educate Oblzdrav staff on their role in the national campaign, encourage active implementation, enable access to communities, and reinforce messaging

a) Support Oblzdrav’s media and outreach efforts through coaching and printing required materials and collaborate with the MOHSPP to develop public service announcements to promote EBF to be aired during World Breastfeeding Week.

X

b) Encourage Oblzdrav staff to be more actively engaged in promoting EBF X c) Facilitate Oblzdrav meetings with VDCs and community leaders to promote EBF X d) Encourage PHC workers to be more actively engaged in promoting EBF by counseling and

distributing materials X

e) Facilitate PHC workers in meetings with VDCs and community leaders to promote EBF X 3.1.10 Execute SBCC campaign on complementary feeding: educate mothers and mothers-in-law, encourage households to

change infant and young child feedings practices, and reinforce messaging a) Develop a targeted social marketing campaign for this segment to complement the

broader “nutritious foods” campaign, including collaboration with the Red Cross spina bifida material

X

b) Implement the action steps (to be specified) in the targeted campaign X c) Encourage PHC workers to be more actively engaged in promoting complementary

feeding by counseling and distributing materials X

3.1.11 Broaden and focus experience with Alfateen into a life skills for nutrition and health program to reach a wider audience with gender messaging around nutrition and maternal health

a) Deliver TOT on Aflateen to new THNA communities to ensure the new villages have the same basis for capacity-building as those from the MNCH activity; conduct 20 trainings X


for 300 adolescents

b)

Extract useful Aflateen modules and combine them with new life skills topics for gender equitable and effective decision-making, as well as positive health and nutrition behaviors via improved agency and self-efficacy

X

c) Write new life skills for nutrition and health curriculum with three complementary modules—one each for young women, mothers-in-law, and men X

d) Pilot delivery method options (direct workshops, video, and/or care groups) X e) Evaluate pilot results X f) Complete a plan to scale up effective channels of delivery considering the relative

strength of influencers, the division of authority, the duration of life skills training with regard to its effectiveness, etc.

X

3.1.12 Create a complete library of FTF video materials for volunteers to use in communities X Outcome 3.2: Improved sanitation and hygiene-related behaviors 3.2.1 Improve community sanitation via a new program to support local sanitation solutions: a pilot program to empower and

support VDCs as leaders of local sanitation and hygiene behaviors a) Select three to four pilot villages with energetic and organized VDCs X b) Issue tender for a capacity-building grant to find a Tajik organization with community

development and/or strategic planning qualifications X

c) Allow the Tajik organization to guide the VDCs through an inclusive and participatory process of planning local sanitation solutions X

d) Issue small grants to support sanitation programs designed and supported by the local planning teams X

e) Assess the effectiveness and the process of the local sanitation solutions pilot X f) Collaborate with Multi-Input Area Development (MIAD, an Aga Khan Foundation activity)

to compare processes, best practices, and lessons learned X

3.2.2 Pilot a new approach for sustaining improved sanitation via an IGA for improved latrines and as a structured test of an IGA as a partial solution

a) Support World Latrine Day (Nov. 19) X b) Provide skills training in slab-and-ring masonry in two pilot regions (Dusti and Jomi)

starting with already trained businesses X

c) Provide business training to the masons, including marketing and sales X d) Promote improved latrines as a sanitation option in eight to ten areas within the pilot

districts using the MNCH project’s sanitation marketing research X

e) Conduct financial literacy training in target markets, including improved latrines as an example of planned savings and installment payments X

f) Facilitate sales visits of masons to target markets X g) Evaluate the pilot X

3.2.3 Train the 200 new communities in the essential hygiene actions of MNCH to ensure a solid base for all THNA communities (400 community volunteers and 400 VDCs from the 200 communities)

X

3.2.4 Incorporate environmental enteropathy in hygiene messages X 3.2.5 Conduct a media campaign on water and sanitation hygiene (WASH); design the

campaign in the second quarter and air a short-form video in the third quarter X

3.2.6 Conduct infection prevention control training for community volunteers and VDCs in Cohort II districts X

3.2.7 Develop a plan with TAWA for interventions with water users’ associations X 3.2.8 Explore new approaches to engaging influencers of youth opinion based on MNCH’s X


Child-to-Child activities and design a new intervention set

Outcome 3.3: Increased use of health care services for MNCH, including nutrition, sanitation, and hygiene 3.3.1 Community-level activities

a) Support Global Handwashing Day (Oct. 15) X b) Train PHC staff in the draft Prikaz on volunteers and on the concept/role of volunteerism X

c) Hold regular meetings of community volunteers and PHC staff for collaborative linkages and support functions as identified in the assessments X

d) Conduct birth planning training for communities led by family doctors with community volunteers to increase referrals of women to PHCs and birth preparedness schools via cascade training to 2,000 participants

X

e)

Conduct five-day trainings on the IMCI Computerized Adaptation and Training Tool (ICATT) / Integrated Management of Childhood Illness (IMCI) at the PHC level in selected rural areas of districts for 24 PHC workers and with involvement of community volunteers

X

f) Conduct a one-day training on community-based IMCI for community volunteers and field coordinators in the FTF ZOI with involvement of PHC workers, and provide community materials for distribution

X

g) Conduct expectant mother life skills workshops in PHC birth preparedness schools for community volunteers to promote ANC within communities X

h) Mentor PHC providers and community volunteers on interpersonal communication and community mobilization skills for preventive actions and treatment for diarrhea and pneumonia by staff

X

i) Train religious leaders on safe motherhood (200 people in ten meetings) X j) Produce a video on dangerous symptoms during pregnancy X k) Promote care-seeking using the “dangerous symptoms” video and conduct TOT and

cascade trainings via community volunteers X

l) Pilot the Aga Khan Foundation model of community financing of urgent health care X

m) Deploy a University of North Carolina Fellow to assess community health planning activities of the MNCH activity and enhance them with global best practices X

3.3.2 Build specific competencies in selected community volunteers to create a corps of volunteer community health workers (CHWs)

a) Compile a database of volunteers X

b) Apply STTA from an international expert in CHW programs (20 days, remote w/no travel) X

c) Identify initial districts; recruit and select candidates from the volunteers; complete written agreements with the CHWs X

d) Meet with PHC staff in pilot areas to familiarize them with the program, gain support, and solicit input for revising and making additions to the training plan X

e) Complete training materials X f) Conduct the first trainings of CHWs X g) Continue the training sequence, targeting four pilot areas with six trainings each in Year

Two X

h) Monitor the performance X 3.3.3 Facility-level activities with hospitals

a) Conduct a five-day cascade training on hospital IMCI for 20 hospital workers in districts from Cohort I and partially from Cohort II X

b) Provide essential IMCI equipment to the facilities from Cohort I and II to support IMCI X


implementation at the hospital level in Khatlon Province

c) Apply SS and mentoring to continue to improve the quality of hospital care for children (hospital IMCI) X

d) Enable cross-visits to other hospitals in other regions to study best practices in implementation of hospital IMCI X

3.3.4 Facility-level activities with PHCs

a) Establish resource centers at the Oblast and districts levels for ICATT/IMCI to improve the knowledge and skills of providers and to promote and deliver appropriate treatment and full supportive care for children under five

X

b) Conduct two five-day trainings on ICATT/IMCI at the PHC level in Jomi and Dusti Districts for 24 PHC workers at the Oblast-level resource center X

c) Reprint and distribute the nationally approved IMCI pocket guide for trained providers to implement the IMCI approaches to acute malnutrition X

d) Mentor family doctors to promote community volunteers to refer women to PHCs and birth preparedness schools, with wide distribution of ANC brochures for the population X

3.3.5 Integrate patients and facilities

a) Assess the status of birth preparedness schools in the 12 districts at the PHC level X

b) Organize roundtable discussions to improve PHC receptivity to community volunteers and referrals to strengthen PHC linkages, as community volunteers take on health care facility support functions as identified in the assessments

X

c) Design, publicize, and implement a training on patient services at the PHC level X

d) Pilot improved mother’s rooms at the PHC level via a grant to install life skills and other elements of improved service X

e) Pilot a simpler birth preparedness school model at the PHC level, including capacity-building of family doctors on nutrition issues for women of reproductive age and during pre- and postnatal care

X

f) Train 400 CHEs in new communities to conduct learning sessions for mothers-in-law to promote health-seeking behaviors and the recognition of danger signs during pregnancy X

g) Conduct a one-day training on C-IMC for 200 health workers in the new communities X IR 4: Institutionalize evidence-based MNCH services through national-level policies and standards Outcome 4.1: Ensure cadres of academics and national/regional clinical trainers are skilled in teaching evidence-based clinical practices for MNCH 4.1.1 Hire a senior policy advisor to liaise with the MOHSPP and Oblzdrav to promote actions

at the government level to improve nutrition and the health of mothers and children X

4.1.2 Determine a capacity-building approach for Oblzdrav staff on nutrition issues X 4.1.3 Print and distribute extensively existing materials on nutrition X 4.1.4 Conduct peer-to-peer mentoring among health care facility staff—a structured approach

to institutionalize the connections formed in IR 1 X

4.1.5 THNA staff actively mentor four key Oblzdrav staff X 4.1.6 Support Oblzdrav participation in trainings such as the Joint Annual Review as they arise

throughout the year X

4.1.7 Pilot a new approach to skill-building among hospital managers via a grant-supported test of using management improvement methodologies in a health care setting to improve hospital operations

X


4.1.8 Recruit partner institutions (e.g., Pediatric Institute, Center of Evidence-Based Medicine, or similar) to co-design and implement efforts to promote nutrition; deliver capacity-building as required

X

4.1.9 Work with the Donors Coordination Council on raising the government of Tajikistan’s awareness of nutrition issues, and conduct the second annual nutrition forum X

4.1.10 Implement a series of short-term terms of reference in support of MOHSPP priorities, such as assessing the feasibility of local production of micronutrients, revising schema, revising maternal and child nutrition recommendations, preparing a nutrition training curriculum and TOT, addressing the nutrition needs of adolescent girls, and similar activities to be determined

X

4.1.11 Support Exclusive Breastfeeding Decade in collaboration with donors and key stakeholders at the PHC and hospital levels to strengthen the capacity of MNCH specialists and to complement community campaigns

X

4.1.12 Pilot a new approach to improve the overall quality of patient care via a grant to support a test of interpersonal relationship training for health care providers X

4.1.13 Promote the use of delivery plans as a concrete and sustainable way for PHCs and community volunteers to work together, possibly by joining the rounds of family doctors in the communities

X

4.1.14 Collaborate with UNICEF on supplementing the “Instructions for Mothers’ and Children’s Lives” booklet with an antenatal supplement for distribution by community volunteers X

4.1.15 Co-design a retreat for CHWs and Oblzdrav and MOHSPP staff to contribute to the Year Three plan for capacity-building of CHWs and emphasizing their role in the unified health care system outlined in the 2005 Prikaz (open space workshop)

X

4.1.16 Deploy a University of North Carolina Fellow to outline appropriate continuous medical education modules based on state-of-the-art information and research to improve health worker knowledge and performance

X

Outcome 4.2: Ensure sustainability of evidence-based approaches for MNCH, including nutrition, sanitation, and hygiene 4.2.1 Develop a district-level action plan to strengthen linkages between volunteers and PHC

family doctors X

4.2.2 Support TWGs in reviewing and updating existing MNCH CPGs and standards on postnatal bleedings and infection control, as well as initiating new guidelines and standards (some IR 1 activities are dependent on this outcome)

X

4.2.3 Support TWGs in elaborating a new strategic plan for mother, women, newborn, children, and adolescent care and deliver a draft plan X

4.2.4 Support Technical Working Groups (TWGs) to review, update, and initiate two new MCH CPGs and Standards X

4.2.5 Prepare an evidence-based paper for national standards based on a cross-analysis of data on the prevention and treatment of peripartum infection X

4.2.6 Deploy a University of North Carolina Fellow to prepare a journal article on the rapid health facility assessment (RHFA) process and use X

4.2.7 Engage the private sector to fund volunteers (e.g., FINCA, salt wholesalers, and others) X 4.2.8 Present data from the MNCH database to Oblzdrav and the MOHSPP on a regular basis X

4.2.9 Collaborate with the Japanese International Coordination Agency (JICA), Kreditanstalt für Wiederaufbau (KfW), and the Aga Khan Foundation to “lobby” the MOHSPP for improved support for equipment maintenance

X

4.2.10 Assess the status of the “baby-friendly hospital” initiative and develop an action plan X 4.2.11 Support the “Beyond the Numbers” (BTN) effort of the MOHSPP by arranging cross-visits to share best practices

a) Prepare an action plan and hold a roundtable discussion in Khatlon Province X


b) Conduct two BTN trainings of 24 hospital staff X

c) Lead two cross-visits to operational BTN facilities X 4.2.12 Organize quarterly roundtables of partners, stakeholders, and religious leaders to

address challenges and prepare action plans for local implementation X

Outcome 4.3: Improve linkages across sectors supporting poverty alleviation, agriculture, nutrition, and health 4.3.1 Host two Donors Coordination Council meetings to discuss nutrition awareness activities X 4.3.2 Support Oblast-level monthly advisory MNCH meetings with stakeholders, donors, and

government officials to coordinate activities and to ensure appropriate messaging on nutrition for health workers

X

4.3.3 Support Oblzdrav multisectoral coordination committees and facilitate the meetings that Oblzdrav convenes X

4.3.4 Support national-level, quarterly advisory MNCH meetings at the MOHSPP as needed X 4.3.5 Pilot a new community planning process with a few VDCs via a grant to a local NGO for

capacity-building and planning to identify priority community sanitation needs and to support their solutions (see also IR 3.2)

X

4.3.6 Conduct the second national nutrition awareness conference in collaboration with UNICEF and echo its messages in the communities X

4.3.7 Monitor and support 700 religious leaders, including mosque staff, in promoting care-seeking messages to communities, especially to men; standardize monitoring and checklists

X

4.3.8 Advance digital health applications via development of a user-friendly registry database a) Conduct a needs assessment and feasibility study of a registry of facilities (hospitals,

PHCs, and village clinics) and personnel (census, qualifications, certifications); include in-country analyses and international web conferences, and co-design with Tajikistan experts (~15-20 days of STTA)

X

b) Collaborate closely with WHO and Swiss projects on a workforce database and related activities (~15-20 days of STTA) X

4.3.9 Design a two-way, mobile phone-based communication system that uses basic text messaging to connect hospitals, health workers, and the MOHSPP using simple talk-and-text mobile devices with no 3G required and no license fee; use MNCH’s mHealth evaluation

X

4.3.10 Address knowledge and information deficiencies by designing an interactive vernacular audio/video-guided mobile application that provides an accessible e-library X

Monitoring, Evaluation, and Learning

MNCH baseline X Recurring Household Survey X Nutrition Attitudes Survey X Survey on Economic Growth Indicators X Cohort I monitoring to update the facility scorecard X

All THNA four-day planning retreat X Formative assessment to help inform SBCC strategy X


Appendices

Annex # Description Link

2 List of provided equipment in Year Two

Annex 2 List of equipment for Year II.d

3 Score cards of healthcare facilities of Year Two

Annex 3 Score Cards of Facilities in Year Tw

4 Hospital level structure

Annex 4 Hospital Level Structure THNA.p

5 PHC level structure

Annex 5 PHC Structure THNA.pptx

6 Nutrition Strategy of THNA

Annex 6 Nutrition Strategy for THNA.doc

7 Success stories

Annex 7 Success Stories.pdf

8 List of publications and IEC materials

Annex 8 List of publications and IEC m

9 THNA Organizational Chart

Annex 9 Org Chart THNA (Oct17).pdf

FEED THE FUTURE TAJIKISTAN HEALTH AND NUTRITION ACTIVITY

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