PROJECT HOPE
Increasing the Quality of Child Survival and Maternal 
Care Services in the Navoi Oblast of Uzbekistan
Cooperative Agreement No: FAO-A-00-99-00026-00
MID-TERM EVALUATION
Project Location: Navoi Oblast, Uzbekistan
Project Duration: September 30, 1999 to September 29, 2003
Submitted to:
U.S. Agency for International Development
BHR/PVC/CSH
Washington, DC 20523
Submitted by:
Project HOPE –
The People-to-People Health Foundation, Inc.
Millwood, Virginia 22646
Tel: (540) 837-2100
Fax: (540) 837-1813
April 2002
Contact person:
Bettina Schwethelm, PhD, MPH, Director, Maternal & Child Health Programs
Mavzhuda Babmuradova, CS Project Director, Navoi, Uzbekistan
MID-TERM EVALUATION
Increasing the Quality of Child Survival and Maternal Care Services
in the Navoi Oblast of Uzbekistan
 Implemented by Project HOPE
USAID Cooperative Agreement No: FAO-A-00-99-00026-00
Project HOPE
Millwood, VA 22646
Report prepared by:
Linda Tawfik, MSc, PhD candidate
April 30, 2002
MID-TERM EVALUATION
Increasing the Quality of Child Survival and Maternal Care Services
 in the Navoi Oblast of Uzbekistan
 Implemented by Project HOPE
Mid-term Evaluation Team:
Linda Tawfik, MSc, PhD candidate
Team Leader/External Evaluator
Bettina Schwethelm, PhD, MPH
Director, Maternal and Child Health Programs, Project HOPE/USA
Mavzhuda Babamuradova, MD
Project Director, Child Survival Program, Project HOPE/Uzbekistan
Fakhruddin Nizamov, MD
National Pediatrics Research Institute and 
Child Survival Program, Project HOPE/Uzbekistan
Dalia Shodieva, MD
Head of Center of Adolescent Reproductive Health, Navoi Oblast MOH
Darshana Vyas, MSW, MPH
Director Health Programs, Counterpart International/USA
Nuriyah Elgondieva
Project Manager, Counterpart International/Uzbekistan
Table of Contents
Page
Acronyms
1. Summary ……………………………………………………………………1
2. Assessment of Progress Toward Achievement of Program Objectives…… 2
2.1 Technical approach……………………………………………….. 2 
2.1.1 Overview of the project…………………………………… 2
2.1.2 Progress report by intervention area……………………… 3
2.1.3 New tools and approaches………………………………… 15
2.2 Cross-cutting approaches …………………………………………. 16
2.2.1 Cross-cutting activities used by the project……………….. 16
2.2.2 Community mobilization……………………………………16
2.2.3 Communication for behavior change……………………… 17
2.2.4 Capacity building approach ……………………………… 18
i. Sustaining the PVO Organization ………………… 18
ii. Strengthening Local Partner Organizations ………..19
iii. Health Facilities Strengthening …………………….21
iv. Strengthening Health Worker Performance ………. 21
v. Training …………………………………………….22
vi. Sustainability Strategy …………………………….. 22
3. Program Management………………………………………………………23
3.1 Planning …………………………………………………………….23
3.2 Staff training ………………………………………………………..23
3.3 Supervision of program staff ……………………………………….24
3.4 Human resources and staff management …………………………...24
3.5 Financial management ……………………………………………...25
3.6 Logistics …………………………………………………………….25
3.7 Information management …………………………………………...25
3.8 Technical and administrative support……………………………….26
4. Other Significant Issues …………………………………………………….27
5. Conclusions and Recommendations ………………………………………..27
6. Results Highlight ………………………………………………………… 31
Tables
Table 1 Indicators of and Progress towards Program Objectives
Table 2 Key Findings Indicating Behavior Change among Women who Delivered in 
 Baby-Friendly Maternities, Caretakers of Ill Children, and Providers, Mid-term
 Survey, March 2002
Table 3 Number of Providers and Trainers Trained in Each Technical Area, April 2002
Attachments
A. Baseline Information from the DIP
1. Field program summary
2. Program goals and objectives
3. Program location
4. Program design
5. Partnerships
6. Health Information System
B. Assessment Methodology
C. List of Persons Interviewed
ACRONYMS
ARI Acute Respiratory Infection
CA Contracting Agency
CAR Central Asian Republics
CDC Center for Disease Control
CDD Control of Diarrheal Disease
CRH Central district hospital
CS Child Survival
DIP Detailed Implementation Plan
EPI Expanded Program on Immunization
FAP Feldsher midwife post
FP Family Planning
HIV Human Immunodeficiency Virus
IEC Information, Education, Communication
IMCI Integrated Management of Childhood Illnesses
IMR Infant Mortality Rate
KPC Knowledge, Practice, Coverage
MCH Maternal Child Health
MOH Ministry of Health
MSF Medecins sans Frontieres
NGO Non-Governmental Organization
NIS Newly Independent States
OR Operations Research
ORT Oral Rehydration Therapy
PEPS Promote Effective Perinatal Care
PHC Primary Health Care
PVO Private Voluntary Organization
QA/QI Quality Assurance/Quality Improvement
RH Reproductive Health
STD/STI Sexually Transmitted Disease
SUB Rural community hospital
SVA Rural physician ambulatory
SVP Rural physician post
TOT Training of Trainers
UDHS Uzbekistan Demographic and Health Survey
1
1. Summary 
The goal of Project HOPE’s child survival and maternal care services project in Uzbekistan is to 
decrease maternal and child morbidity and mortality by improving quality of health care. The 
strategy has been to focus on three key interventions—breastfeeding, reproductive health, and 
IMCI—at the oblast level through capacity building of providers and at the community level in 
two pilot rayons of Navoi Oblast (Kiziltepa and Karmana). Summary descriptions of the project 
outlined in the DIP appear in Attachment A.
Data sources for the mid-term evaluation include baseline assessments, periodic surveys, and the 
mid-term survey completed in March 2002. The mid-term evaluation team conducted interviews 
with providers at hospitals and clinics, observed provider-client interactions, and held exit 
interviews with mothers at primary and tertiary care facilities. Discussions were held with 
inpatients in post-natal care departments of maternity hospitals and with breastfeeding support 
group members. The evaluation team observed IMCI training and debriefing sessions, as well as 
a “Best Nurse Competition” and reproductive health “Poster Competition.” 
The findings of the evaluation indicate that the project is extremely successful. It has been able 
to produce cost-effective outcomes in a short time due largely to close collaboration with its 
partners—oblast and rayon Ministries of Health offices and their health facilities; national 
institutions such as the Pediatric Research Institute and Ob/Gyn Research Institute in Tashkent; 
reproductive health centers; international agencies such as USAID, UNICEF, WHO, the World 
Bank; contractors such as Abt Associates; and local and international NGOs such as Counterpart 
International. The Ministry of Health at the national level is in regular contact with the project. 
HOPE has been able to establish national and even regional acclaim in Central Asia with its 
IMCI initiatives. The current leadership of the Project Hope field office in Navoi and the very 
supportive relationship of the director for the project at U.S. headquarters provide high morale 
and serve as a catalyst for positive results. 
Highlights of key measures of effectiveness provide evidence of the project’s success to date. 
A comparison of results from the baseline and mid-term surveys show areas of strength and 
future emphasis. Although the survey methodologies varied, one may infer that the high degree 
of knowledge and behavior change documented in the mid-term survey is predominantly due to 
the project.1
 In the baseline, 8.7% of women said they exclusively breastfeed their child. In the 
mid-term survey conducted in intervention areas, the figure rises to 58.2% for exclusive breast￾feeding during the first 4 months. In May 2000, only 34.7% received postnatal consultation from 
a health provider on STIs and 41.7% on contraception. The mid-term survey indicates 90.5% 
reported receiving a consultation on STIs and 95.8% on contraception. While availability of 
contraceptives has been an issue, 93.8% of women surveyed in the mid-term are currently using 
a method of contraception. Over ninety-five percent (95.8%) of the women said the health 
provider discussed the issue of contraception with them and 87.2% received an explanation from 
the provider regarding contraceptive methods. Another indicator measured by both surveys was 
the degree to which women were providing or would provide some or more food to sick 
 
1 The baseline KPC survey was comprised of a cluster sample, with 30 clusters of 10 
respondents each of mothers with children under two years of age in Navoi oblast. The 
mid-term randomly selected a total of 393 women from the total group of women who gave 
birth in the intervention area “Baby-Friendly” clinics from March 2001 to March 2002; 
309 interviews were actually conducted in the mid-term survey per availability.
2
children.2
 At baseline, 4.7% reported they provided some/more food to their sick child. In the 
mid-term survey in the intervention areas, 47.3% of caretakers said they would increase 
breastfeeding; 24.4% who would offer more food; and 61.3% who would offer more fluid to 
their child during a diarrhea episode. The mid-term suggests that provider knowledge on IMCI 
has increased significantly. Danger sign assessment was completed in 91.0% of cases observed. 
Nutritional assessment was done in 80.6% of cases and counseling in 88.9%. 
To verify findings in the mid-term survey and more fully understand operational issues, the mid￾term evaluation included site visits in both intervention rayons to maternity hospitals, poly￾clinics, SVPs, reproductive health centers and the new IMCI center. Mothers interviewed by the 
evaluation team in the post-natal department of the maternity centers claimed a high degree of 
satisfaction with the services they were receiving currently, but bitterly complained about 
separation from newborn prior to “Baby Friendly” facilities. Women interviewed by the 
evaluation team reported immediate breastfeeding after delivery and all were rooming in with 
their newborns. Providers were using colorful flipcharts to explain alternative contraceptive 
methods during counseling sessions. Historically, the consistent availability of a sufficient 
method mix has been an issue due to shortages and interruptions in contraceptive supplies. 
UNFPA has been a key donor. At the writing of this evaluation plans were underway by the 
German donor KFW to donate large quantities to Uzbekistan. Observations by the evaluation 
team revealed that randomly selected physicians, trained by the project, are following IMCI 
protocols for diagnosing and treating a sick child. The only question omitted by the trained 
providers from the WHO’s checklist dealt with the health of the mother. For a project which 
initiated its first IMCI course only 6 months ago, this is a major achievement. 
Since impact is a function of effectiveness and coverage, the project’s progress in scaling up is 
very important. While the program has been careful to stay on track in terms of improving 
quality of care and health outcomes, it has been able to expand upward through national level 
institutions and outwards across non-intervention rayons and other oblasts. Financial 
sustainability is an area to focus on as the project continues. Its capacity-building function with 
the oblast health department, local government, NGOs, and makhalla committees has been a 
major step forward sustaining achievements. 
2. Assessment of Progress Toward Achievement of Program Objectives
2.1 Technical approach
2.1.1 Overview of the project
This 4-year project aims to improve the quality of child survival and maternal care services in 
Navoi Oblast, with a population of about 769,000, in the central economic region of Uzbekistan. 
The ethnically diverse population, consisting of Uzbeks, Kazaks, Tajiks, and Russians has one of 
the highest maternal and mortality rates in Uzbekistan, despite being characterized by sufficient 
 
2 For questions concerning childhood diarrhea, the baseline survey asked, “Was 
(child’s name) offered less than usual to eat, about the same amount, or more than 
usual to eat?” Due to the limited number of diarrhea cases during the mid-term survey, 
mothers were asked if their child would have diarrhea, “Do you offer less than usual 
to eat, about the same amount, or more than usual to eat?”
3
numbers of medical staff and relatively good access to health services of limited quality. 
Navoi’s population density is very low, and close to 60% of the population is rural, including 
some nomadic Kazakhs. 
At the request of the oblast MOH, the project was initiated in Navoi City and the rayon (district) 
of Kiziltepa. Rich in metals, industry is a major contributor to the GDP of the Navoi oblast, 
followed by agriculture. Navoi City was build several decades ago by the Soviet regime to 
exploit its mineral resources and develop chemical industries. Kiziltepa is one of the eight rural 
rayons of Navoi Oblast and is located between Navoi and Bukhara Oblast. It is approximately 60 
kilometers from Navoi City. Most of the people live close to the center of the rayon, the 
northern and eastern parts of which are desert and difficult to access. The majority of the 
population is Muslim, but religious beliefs and practices are not easily observable in daily life. 
The Navoi Oblast inherited the traditional Soviet health system managed by the public sector. It 
has parallel and vertical systems to manage certain diseases and conditions (e.g. TB, STIs, 
maternity). At the outset of the project, preventive health services and health promotion were 
minimal. Providers did not use modern protocols and lacked essential equipment.
The project is focusing on maternal and newborn care, breastfeeding, child spacing, integrated 
management of childhood illnesses (IMCI), and capacity building. Major activities include: 
Training of health providers in maternal care, lactation counseling, family 
planning counseling, and IMCI, as well as training health facility representatives in 
QA/QI methods.
Development and introduction of protocols and tools to improve quality of
peri/neonatal care and IMCI. 
Developing IEC materials for the community/household level on prenatal and
postpartum care, breastfeeding, danger signs and home management of childhood 
illness.
Capacity-building through establishing a project steering committee of counterpart 
representatives, training of trainers and providers, and supporting the establishment of 
NGOs and other formal and informal entities in project activities. 
2.1.2 Progress report by intervention area
Intervention areas. The aims of the project are to: (1) decrease maternal and child morbidity and 
mortality, (2) promote exclusive breastfeeding, (3) improve sick child management, (4) increase 
women’s knowledge of family planning and (5) develop local capacity.
Activities. The project has organized its activities into five areas: (1) maternal and newborn 
care, (2) breastfeeding, (3) child spacing, (4) IMCI, and (5) capacity building. The initial strategy 
was to focus on activities which could be most readily implemented to ensure success, such as 
breastfeeding and then to develop the more complex interventions. The project initiated 
breastfeeding activities first in the rayons and then at the MOH oblast level. Reproductive health 
training was started throughout the entire oblast and surgical equipment, such as 14 mini-lap kits, 
4
was purchased and training in female surgical contraception is planned for Year 3 of the project. 
The more technically complex area of IMCI was undertaken through a series of activities with 
multiple partners in order to introduce the concept at the national, oblast, and rayon levels, train 
providers, and engage the community. 
There has been a delay in implementing several maternal and newborn care activities (e.g. 
introduction of newborn and delivery care protocols, conducting of a TOT course in 
peri/neonatal care) according to the original workplan. However, the strategy has been to 
concentrate on quality throughout the project and to systematically introduce new activities. The 
minor cost in speed of implementation for maternal and newborn care activities has been more 
than offset in terms of project impact. Maternal and newborn care activities are currently high 
priority with technical assistance being provided within the coming months. 
The progress in implementation of activities is noteworthy given initial staffing delays. The 
initial delay in hiring the first Project Director, and thus hiring of local staff, was compounded by 
having to replace him due to administrative reasons. To overcome this constraint, at the end of 
2000, HOPE hired a well-respected local Project Director with expertise in Reproductive Health 
and experience in managing externally funded projects.
Progress towards intermediate objectives. Table 1 on the next page shows that the project is 
making excellent progress towards program objectives. The table lists indicators of and progress 
towards specific program objectives, along with their baseline values and end-of-project targets. 
Clearly, several end-of-project targets have already been met for those indicators where complete 
data currently exist. Maternal and newborn care will be a focus of the remaining project life in 
order to meet the original objectives by September 29, 2003. Key activities for reaching the 
maternal and newborn care objectives are programmed for years 3 and 4. 
The information system needs to be refined to measure progress towards all the original 
objectives. 
Project effectiveness to date. Data sources also include baseline and mid-term evaluations, 
interviews with providers at hospitals and clinics, observations of provider-client interactions, 
exit interviews with mothers, interviews with mothers in post-natal care departments of 
maternity hospitals, discussion with members of a breastfeeding support group, and observation 
of IMCI training and debriefing sessions. 
5
Highlights of key measures of effectiveness provide evidence of the project’s success to date. A
comparison of results from the baseline and mid-term surveys show areas of strength and future 
emphasis. The survey methodologies varied, however, one can infer that the changes are 
predominantly due to the project.3
 The mid-term survey is attached as a special report. 
In the baseline, 8.7% of women said they exclusively breastfeed their child during the first four 
months of life. In the mid-term survey conducted in intervention areas, the figure rises to 58.2% 
for exclusive breastfeeding. Another indicator measured by both surveys was the degree to 
which women were providing, or would provide, some or more food to sick children. At 
baseline, 4.7% of mothers reported they provided some/more food to their child with diarrhea. 
In the mid-term survey, 47.4% of caretakers said they would increase breastfeeding; 24.4% 
would offer more food; and 61.3% would offer more fluid to their child during a diarrhea 
episode.
Provider knowledge on IMCI has increased significantly. Data from the mid-term survey 
indicates danger sign assessment was completed in 91.0% of cases. Nutritional assessment was 
done in 80.6% of cases and counseling in 88.9%/
Baseline data indicate that in Navoi Oblast in May 2000, only 34.7% of surveyed women with 
children under two years received postnatal consultation from a health provider on STIs and 
41.7% on contraception. By comparison, the mid-term survey indicates that in the project area 
90.5% reported receiving a consultation on STIs and 95.8% on contraception. 
To verify findings in the mid-term survey, monitor providers’ technical competence, and assess 
client satisfaction, the mid-term evaluation included site visits in both intervention rayons to 
maternity hospitals, polyclinics, SVPs, a reproductive health center and the new IMCI center. 
Observations by the evaluation revealed that physicians trained by the project are precisely 
following IMCI protocols for diagnosing and treating a sick child. The only question omitted 
from the WHO’s checklist dealt with the health of the mother. For a project which initiated its 
first IMCI course only 6 months ago, this is a major achievement. 
Mothers interviewed in post-natal departments of the maternity centers in both intervention 
rayons articulated a high degree of satisfaction with care at these “Baby-Friendly” hospitals. 
They all reported immediate breastfeeding after delivery and were observed rooming in with 
their newborns. The evaluation also specifically identified several multi-parity women who had 
received delivery services for earlier births prior to the project. This was to compare client 
 
3 The baseline KPC survey was comprised of a cluster sample, with 30 clusters of 10 
respondents each of mothers with children under two years of age in Navoi oblast. The 
mid-term randomly selected a total of 393 women from the total group of women who gave 
birth in the intervention area “Baby-Friendly” clinics from March 2001 to March 2002; 
309 interviews were actually conducted in the mid-term survey per availability.
TABLE 1. Indicators of and Progress towards Program Objectives 
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
1. Maternal and 
Newborn Care
- target area use protocols for delivering 
quality antenatal and post-partum services;
80% Not available. To be addressed in years 3 & 4
- 80% of pregnant women screened for 
priority STDs;
80 % Not available.
To be obtained from oblast health dept.
To be addressed in years 3 & 4
- At least 70% of deliveries managed with 
partograph;
70% 0% To be addressed in years 3 & 4
Plan exists to begin training of providers. 
EOP target to be changed to 80% of trained
providers in 2 central rayon hospitals of the
original pilot areas will be trained to use
partograph.
- 70% of providers follow other established 
protocols for delivery and newborn care;
70% Not available.
General resuscitation protocols exist.
Basic treatment protocols for asphyxia, 
hypothermia, jaundice 
To be addressed in years 3 & 4
Redefine this indicator with neonatal consultant
and determine what the Project can achieve.
- Health brochures available at all health 
facilities and used for education;
100% 0%
(Very limited and lots of variability 
between facilities)
Variety of brochures (RH, FP, BF, STIs,
Adolescent health) are currently available in 
100% of health facilities in pilot rayons. Maternal
nutrition posters are available in > 90% hospitals.
Formative research on danger signs in pregnancy
has been completed by Ob/Gyn Institute but
brochures on the topic are limited.
- 50% of health facilities provide classes for 
pregnant women and their partners and new 
parents;
50% 0% 50% of facilities in pilot rayons provide
classes for pregnant women (mothers’ schools).
- 50% of women report improved nutrition 
during pregnancy and lactation;
50% Not available. Not yet assessed.
7
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
2. Breastfeeding - 75% of women in baby-friendly-hospitals 
breastfeeding within an hour of delivery;
75%
0%
(Baby-friendly hospitals did not exist 
at Project outset.)
89.1% of women in baby-friendly hospitals 
breastfeeding within an hour of delivery
(Midterm survey)
- 30% of women breastfeeding exclusively 
for the first 4-6 months;
30% < 4 months: 8.7%
(Baseline KPC survey)
<4 months: 58.2%
<6 months: 41.6%
(Midterm survey)
- 50% of women with children < 6 months 
that report breastfeeding on demand;
50% Not available.
98.6% of mothers delivering in “Baby-Friendly”
hospitals breastfeed on demand
(Midterm survey)
- 50% of women still breastfeeding at 20-23 
months;
50%
Not yet assessed (Midterm survey sample
did not include children 12 – 23 months).
- 2 maternity hospitals with baby-friendly 
policies;
2 0
2 “Baby Friendly” hospitals established
- 60 health providers trained to provide 
lactation counseling;
60
0%
(Not available regarding lactation 
counseling)
169 health providers trained to date on
lactation counseling
- 20 breastfeeding support groups established; 20 0
12 women in Navoi rayon trained
17 women in Kizeltepa rayon trained.
3. Child Spacing - 80% of facilities in the target area provide 
three or more different methods;
80%
Not available for this indicator.
In exit interviews with mothers:
23.2% use no method
58.0% use IUD
7.2% use oral pill
1.4% use condoms
10.2% use other methods
(Baseline KPC survey)
Midterm evaluation team was told at facilities
visited in Navoi rayon that supplies were 
available for at least 3 contraceptive methods. 
UNFPA had just received a shipment which 
had been distributed. 93.8% of mothers who 
had given birth in baby-friendly hospitals
since March 2001 were using a contraceptive
method, including LAM, to avoid pregnancy.
(Mid-term survey)
8
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
- 70% of women will receive FP/child 
spacing counseling during an antenatal visit 
and/or the post-partum hospital stay;
70%
41.7% of mothers reported receiving 
FP/child spacing counseling during 
antenatal visit 
(Baseline KPC survey)
87.2% of mothers reported receiving counseling 
from the health provider regarding contraception.
(Mid-term survey) 
- By project end, unmet demand has 
decreased by 30%; 30% 
decrease
83% in program site who do not want 
another child in the next 2 years, or are 
not sure, are using a modern 
contraceptive method 
(Baseline KPC survey) 
Not yet assessed, since midterm survey focused
on women who had delivered in Baby-Friendly
hospitals during the past year.
4. IMCI - 80% of trained providers at SVPs and 
polyclinics will follow IMCI protocols for 
sick children;
80% 2% of children were assessed by 
provider for all danger signs when 
seeking treatment for ARI, diarrhea, or 
fever;
17% of assessment tasks were 
completed by providers for diarrhea 
cases;
26% of cases with simple diarrhea 
received ORS and 38% received an 
inappropriate antibiotic;
41% of assessment tasks were
completed by the provider for ARI 
cases and only 19% in case of fever;
16% of children had vaccination card 
checked;
24% of children were weighed;
23% had their nutritional status 
assessed;
25%-40% of caretakers were counseled 
on the importance of giving fluid and 
food at home;
91.0% of cases observed had danger signs
assessed;
91.7% of providers examined the child for 
malnutrition/anemia;
100% of cases were correctly assessed for use
of antibiotics and no (0%) of inappropriate
antibiotics were prescribed; 86.1% of providers
checked child’s vaccination status and
completed weight assessment;
80.6% of cases were “assessed” and in 86.1%
of cases providers “inquired” about the child’s 
nutritional status.
86.1% of caretakers were counseled on the
sickness and given guidance on home treatment 
(83.3% on when/how to give fluids, 97.2% on
food, and 44.4% on medication.)
9
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
food at home;
51.4% of caretakers were told when to 
return for follow-up;
37.6% received nutrition advice;
42.8% of caretakers were advised on 
how to prepare ORS.
(Baseline KPC and Health facility 
assessment survey)
94.4% of caretakers were told when to return
immediately to the health facility but only 50%
were informed of danger signs. 
(Mid-term survey)
- Community-based IMCI materials in use by 
pediatric and maternity hospitals, SVPs, 
polyclinics, community outreach staff, and 
caretakers;
0%
IMCI had not been introduced at
baseline.
In process of development .
On basis of formative research, Mother 
Reminder Tools are being prepared by HOPE
in collaboration with the Pediatric Research
Institute for mother with children <5. Plans 
are underway to distribute these materials
through the maternities and the excellent
patronage nurse system and train parents
to 1) use the brochure, 2) identify danger
signs and seek care of a provider. Posters on
danger signs and referral to be placed in pilot
rayon facilities. Agencies involved nationally
in IMCI (including HOPE), have decided
among themselves which agency is responsible
for what type of community IEC materials. The 
agencies update each other on progress made
10
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
and receive input from their partners, so the
tools can be used nationally. This maximizes
available resources and promotes consistency
in messages across Uzbekistan.
- 85% of children 12 - 23 months completely 
immunized (including hepatitis B vaccine); 
80% Not available for this indicator.
(Baseline KPC measured only 
knowledge about immunization.)
Not yet assessed, since the sample did not
include children 12-23 months.
- Vaccination drop-out rates reduced half by 
reducing missed opportunities;
50% 
decrease
Not available. 
86.1% of IMCI-trained providers checked 
immunization status.
- 60% of cases of diarrhea in children under 
two treated with Rehydron (oral rehydration 
salts) and/or recommended home fluids.
60%
28.5% mothers gave ORS during a 
diarrheal episode;
33.7% had correct knowledge on ORS 
preparation.
(Baseline KPC survey)
Due to an insufficient number of diarrheal cases
during the midterm survey this indicator could
not be measured. This should be determined 
during the diarrheal season for the final 
evaluation.
- 60% of children receive the same/more 
solids;
60% 4.7% of mothers provided more food 
than usual (during a diarrhea episode) 
(Baseline KPC survey)
47.3% of caretakers said they would increase 
breastfeeding; 24.4% would offer more food
to their child; and 61.3% would offer more fluid
(during a diarrhea episode).
(Midterm survey)
- At least 50% of caretakers provide 
additional meals to children while recovering 
from diarrheas, pneumonia, and other serious 
50% Not available.
Not yet assessed.
11
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
diseases.
- Mothers will report improved hygienic 
practices at the household level (use of clean 
water for consumption, hand washing, 
appropriate use of latrines, proper disposal of 
stools of young children);
Household hand washing practices:
39.3% before food prep 
42.0% before eating
44.6% before feeding children
77.7% after using toilet
28.6% had soap present
(Baseline KPC survey)
Not yet assessed.
- Mothers will report improved feeding 
practices for children under five, including 
vitamin C, vitamin A, and iron-rich foods;
45.4% of children under two had 
consumed meat, eggs, fish
or poultry during 7 days preceding 
survey 
18.6% of children over 6 months of 
age were given food 3 or more times 
per day
(Baseline KPC survey)
Not yet assessed.
- 70% of mothers will be able to list danger 
signs for diarrhea and pneumonia;
70%
Not available.
(The baseline KPC survey asked about 
the dangers signs of a newborn baby. 
12.7% of women surveyed knew these 
signs. 8.3% of mothers counseled 
during the postpartum period knew 
danger signs of infant illness.)
Mother’s knowledge of danger signs: 
86.2% High fever/fever not going down
43.4% Fast or difficult breathing
59.2% Sickness is getting worse
37.5% Not breastfeeding or drinking
23.0 % Blood in stool
(Mid-term survey)
(1) Develop local project management skills;
(2) Develop a core group of trainers in the 
oblast;
(3) Develop a commitment to quality in the 
health care system;
Cooperative workplanning, implementation, 
monitoring, and evaluation within HOPE and with
its partners continues to develop local project
12
TOPIC INDICATOR [DIP] EOP 
TARGET
BASELINE VALUE AT MIDTERM EVALUATION
(4) Improve critical analysis and problem￾solving skills of counterparts;
(5) Increase the number of informal and 
formal organizations working with the MOH 
on project activities;
(6) Promote the development of local NGOs;
management and problem-solving skills.
Number of TOTs established at the oblast/
rayon level to date:
12 for Breastfeeding, 11 for IMCI, 8 for RH
Provider and client satisfaction articulated
during the midterm evaluation and improved
measures of selected indicators suggest a
commitment to quality in the health care system. 
HOPE is enhancing links between the MOH
and makhalla. MOH conducts most makhalla 
trainings.
HOPE is working with 4 NGOs that have
emerged since the development of the DIP. 
Two are health NGOs with branches in pilot
rayons. With the Bukhara Association of
Pediatricians and Counterpart Consortium in
Bukhara. HOPE supports the establishment of
new NGOs and builds capacities through
proposal/grant writing, workplanning, etc.
13
*The Knowledge, Attitude, and Coverage (KPC) Survey and Health Facility Assessment Survey in Navoi Oblast were completed in April 2000. The Mid-term 
Survey was completed March 2002. 
14
satisfaction now with the past, when the national protocol was to withhold contact between 
mother and newborn for the first three days after birth. 
Providers were using colorful flipcharts to explain alternative contraceptive methods during 
counseling sessions. Historically, the consistent availability of a sufficient method mix has been 
an issue due to shortages and interruptions in contraceptive supplies. There appears to be a 
changing scenerio as the German donor KFW plans to donate massive quantities to the country. 
Since impact is a function of effectiveness and coverage, the project’s progress in scaling up is 
very important. The program has been careful to stay on track in terms of improving quality of 
care and health outcomes. It has simultaneously been able to expand upward through national 
level institutions and outwards across non-intervention rayons and other oblasts. The project has 
been very effective in its capacity-building functions, as indicated in Table 1. The close 
coordination with partners and the transfer of technology, management and technical skills is 
having a clearly demonstrated impact in terms of cost-effectiveness and sustainability.
Changes in the technical approaches outlined in the DIP and rationale. There have been few 
changes in the plan as presented in the DIP. The most significant change is the increase in the 
number and high level of involvement of local partners. Besides the original partners outlined in 
the DIP, the project has gone beyond Navoi Oblast involving trainees from oblasts and rayons 
beyond the original pilots. In Bukhara, it has tapped into a network of NGOs because there are 
strong medical NGOs there which do not exist in Navoi. Also, HOPE is working with the 
Medical Schools in Bukhara and Samarkand, charged with pre-service education and training of 
general physicians on how to integrate IMCI into the training curricula. The rationale for 
involvement of additional new partners and broad networking has been to meet an unmet 
demand with positive health impacts at no extra or minimal cost to the project.
Another highlight which was not planned for in the DIP is the establishment of the new oblast￾level IMCI center. The request for such a center came from within the MOH. A church was 
converted with financial resources for refurbishing coming from HOPE and the MOH. The 
rationale was to fulfill an unmet need for strengthening and expanding IMCI in Navoi and the 
neighboring oblasts.
A foreseeable modification articulated during the mid-term evaluation is the need to reassess the 
concept of breastfeeding support groups. There is interest from these volunteers to learn more 
about broader areas of child health. The rationale for reassessing their role is that: 1) these 
women may have greater impact if they are linked with the makhallas at the community level
rather than maternity hospitals where women have good breastfeeding support from trained 
providers, and 2) with more technical knowledge about child health they may have greater 
impact.
Special outcomes, unexpected successes or constraints. The dynamic nature and strong 
leadership of the project has created a strong interest from several partners within Uzbekistan 
(e.g. the National Pediatric Institute) and within Kazakhstan for the project to serve as a model in 
IMCI. The translation and technical review support of IMCI materials into Uzbek in cooperation 
with Abt Associates has been a major success for meeting the mandates of all actors (e.g. World 
Bank, WHO, MOH, etc.) to introduce IMCI into the national health system. 
15
A systemic issue which potentially affects the project’s child spacing objectives is the 
documented inconsistent availability of contraceptives throughout the republic. Qualitative 
interviews conducted during the evaluation revealed that a moderate level of contraceptives were 
available at the sites visited in Navoi rayon, including at the SVP level and Baby-Friendly 
Hospital. 
 
Next steps. Based on the results of the mid-term survey, the next steps by technical area are to: 
 Reproductive Health
· More deliberately integrate LAM into “Baby-Friendly” clinics and breastfeeding 
trainings to increase effective use of this child spacing method
· Translate materials related to emergency contraception and integrate them into 
reproductive health trainings
· Increase the knowledge of health providers on women’s physiology as a natural 
contraception method
· Underscore the need to counsel women and give them the opportunity to make an 
informed choice regarding contraception
· Stress the need to better inform women on protection methods for STIs
· Conduct focused activities and trainings to further enrich provider knowledge and 
practices. Focused trainings planned for 2002 include: STI, antenatal care/safe 
motherhood, emergency contraception, LAM (potentially with Linkages), female 
sterilization (minilaporotomy)
Breastfeeding
· Integrate antenatal care/safe motherhood and LAM trainings/sessions to further 
increase provider knowledge
· Establish two additional “Baby-friendly” clinics in 2002 on the oblast level
· Conduct monitoring in the “Baby-friendly” clinics every 6 months
· Initiate community activities to promote the knowledge and practice of exclusive 
breastfeeding
· Further disseminate knowledge and utility of women support groups and link with the 
makhalla
IMCI
· In trainings, further emphasize the importance of counseling caretakers on home 
treatment and danger signs
· Produce and distribute Mother Reminder Materials and educate caretakers on danger 
signs
· Encourage health providers to produce their own informative material
· Promote various IMCI issues on the national level
16
Maternal and Newborn Care
· Orient the Oblast Health Department and health providers to the Safe
 Motherhood Initiative
· As a member of the National PEPS working group, take part in the WHO guidelines 
adaptation, planning, and implementation process
· Conduct TOT on antenatal, perinatal, and postnatal care and on neonatal care
· Improve the skills of health providers of two pilot rayons using locally adapted 
guidelines and standards for the management of pregnancy and childbirth
· Implement health education and promotion activities for improving family and 
makhalla attitudes and practices with regard to pregnancy and childbirth 
A detailed discussion of recommendations in section 5 provides next steps in terms of the overall 
project direction. 
2.1.3 New tools and approaches
Coordination and networking. While coordination is not a new approach, rarely has it been 
undertaken with such powerful results as seen in Navoi. Its networking approach to link project 
activities with organizations at all levels has been a strategy to maximize the impact of each 
intervention. For example, through the leadership of Project HOPE the country is in the process 
of scaling up IMCI nationally and regionally. The National Pediatric Institute, which also works 
closely with WHO and Unicef, has been able to translate IMCI materials into Uzbek with Project 
HOPE and Abt’s technical and financial support. HOPE has also conducted the formative 
research for community-level education materials (Mother Reminder Tools) and is in the process 
of developing first draft tools for testing and validation. The Institute and HOPE will now be 
able present the Uzbek facility and household materials at the regional IMCI meeting in 
Kazakhstan. It continues to incorporate IMCI training into its ongoing activities through close 
coordination with the project. 
Collection and translation of training materials. The project has compiled a valuable collection 
of various training materials in Russian and Uzbek. The Uzbek translation of WHO’s IMCI 
modules has been exceptionally useful to many agencies engaged in implementation of child 
programs in Uzbekistan. 
Obstetric and newborn care standards. This is HOPE’s first child survival program with a major 
focus on obstetric and newborn care. To address these technical issues and build headquarters 
capacity, HOPE has established partnerships with the University of Michigan Medical School as 
well as individuals that are assisting with secondary and tertiary obstetric and pediatric programs 
in the past.
Innovative interventions. Simple interventions like cutting the legs of baby cribs, so that 
newborns are at the same level of the mother when rooming in, provide evidence of the openness 
to innovation and an inexpensive way to enhance the bonding between newborns and mothers.
Special studies. Special studies mentioned in section 3.7 have been utilized to guide the project 
in focusing its inputs. 
17
2.2 Cross-cutting approaches
2.2.1 Cross-cutting activities used by the project. “Cross-cutting approaches” refer to 
project activities that further the achievement of many or all of the objectives. These include 
institutional capacity building, training, planning, supervision, information management, and 
behavior change.
The outstanding reputation of the project at all levels, from national to community, has been a 
major accomplishment. The National Pediatric Institute utilizes the knowledge and materials 
shared with the project to replicate IMCI at the national level. Training of trainers courses, and 
technical trainings in IMCI, reproductive health, and breastfeeding have improved the 
knowledge of multiple providers to effectively deliver quality services. The cascade approach to 
training has resulted in a diffusion of skills to areas beyond Navoi and Kizeltepa because trainers 
were invited from other oblasts such as Sardaria. The supervisory practices established by the 
project are implemented through the oblast Ministry of Health. Data is collected and shared by 
Project Hope in cooperation with its partners. This collaboration means that project objectives 
can be achieved while building institutional capacity. The child survival program has received 
the trust and support of all partners involved, including doctors, nurses, and mothers in the 
intervention areas; Ministry of Health staff; donors, international and bilateral agencies. Project 
HOPE is currently looking at ways to expand working with medical schools such as the 
Samarkand Medical School and the Medical Institute in Bukhara to further meet project 
objectives.
2.2.2 Community mobilization
Community mobilization activities are in a nascent stage and gaining momentum. The project 
has trained 12 women in Navoi rayon and 17 women in Kizeltepa rayon to serve as the 
foundation for 4 Women’s Support Groups for breastfeeding mothers. On the basis of formative 
research, the project is in the process of developing community-based brochures in the Uzbek 
language for women with children under age five. These “Mother Reminder Tools” are part of a 
9-country activity being undertaken with funding from Glaxo-Smith Kline and technical support 
from BASICS II and CHANGE. Sessions are held with makhalla to keep communities abreast 
of new health information. Poster competitions are periodically held to communicate key health 
messages.
There was a limited presence of health NGOs in Navoi Oblast at the writing of the DIP. The Red 
Crescent Society, with about 8,000 volunteers at that time, had worked in schools and makhallas. 
Healthy Generation, supported by the state, had a small clinic and ambulatory unit in Navoi with 
some community outreach and women’s groups. In the past, the government stance towards such 
organizations and the weak financial base to establish them had been barriers. The project has 
spurred NGO development through roundtable meetings of emerging organizations from Navoi 
and Bukhara Oblasts. Several health NGOs now exist in Navoi Oblast as the total number in all 
sectors has increased to 27. According to Olga Sashema, Director for Social Adaptation, 
“Project HOPE’s influence in the community is well-felt…The first meeting was only thanks to 
Mavzhuda.” By involving the Bukhara Association of Pediatricians in IMCI training (an oblast 
with a well-developed establishment of 120 NGOs), the project has helped to catalyze the NGO 
community into forming networks with those from Navoi.
18
There are several other contextual factors will likely contribute to community mobilization in the 
long-run. First, the project is following national health policy guidelines established by the 
President under the Cabinet. This written policy is followed uniformly and contributes positively 
to project implementation. Secondly, mass media, initially in the form of newspaper articles 
about the program, has enhanced awareness and acceptance of initiatives. These articles initially 
only mentioned Project HOPE in Navoi; now they refer to specific MOH facilities or doctors 
who are doing the work There have been several articles in the national newspaper: coverage 
about the deputy of a hakim (mayor of the oblast) speaking of an SVP opening, and an article on 
an IMCI orientation meeting. These favorable promotions support community mobilization and 
advertise key health messages. Public figures from the government are attending ceremonial 
events, such as the “Best Nurse Competition” and “IMCI Center Opening”. The involvement of 
political figures demonstrates linkages and support between the MOH and community, thereby 
serving as a motivational force. 
2.2.3 Communication for behavior change
The results of the mid-term survey and mid-term evaluation indicate that the program’s approach 
to behavior change is appropriate and effective. Health workers (doctors and nurses) continue to 
be the primary source of information for the population and are utilized extensively for this 
purpose by the project. Community education materials and the media are also receiving 
increasing support. Providers’ and clients’ knowledge and skills are improving in pilot rayons as 
suggested by comparative survey and mid-term evaluation findings presented in section 2.1.2. 
Highlights of behavior changes are shown in Table 2 below.
Table 2: Key Findings Indicating Behavior Change among Women who Delivered in Baby￾Friendly Maternities, Caretakers of Ill Children, and Providers, Midterm Survey, March 
2002
Reproductive Health Breastfeeding IMCI
80.7% of women take part in 
decision￾making on type of contraceptive 
to use
92.4% of women giving birth used 
the Kangaroo method*
Nutritional assessment was 
conducted in 80.6% of cases and 
counseling in 88.9% of cases
88.3%-94.5% of women are 
familiar with LAM but only 
40.8% know the
3 LAM criteria
91.4% of women were rooming-in 
with their newborns within the first 
hour after delivery*
In case of a diarrheal episode, 
47.7% of caretakers would increase 
breastfeeding, 61.3% would 
increase fluid intake, and 24.4% 
would increase food
74.9% of women prefer to have 
their next child more than 2 
years from now
99.7% of mothers who delivered 
were breastfeeding*
54.7% of caretakers know that tea 
has a negative effect on iron 
absorption
93.8% of women (among those who 
delivered in a baby-friendly facility 
within the past year) use contraception
41.6% of mothers exclusively 
breastfeed infants under 6 months 
of age
Providers assessed danger signs in 
91.0% of cases observed
19
There is a recognized need to link more closely with the makhalla over the remainder of the 
project. The potential exists to involve them in the use of these data to promote other behavioral 
changes.
2.2.4 Capacity building approach
i. Sustaining the PVO Organization
Project HOPE in Uzbekistan is actively building its organizational capacity. First, it has created 
a highly competent and well functioning staff. The Navoi office staff has acquired skills in 
management, English, wordprocessing, EPI-Info, training, survey research.4
 HOPE headquarters 
has submitted a proposal to USAID for a child survival project in Kyrgystan which would be 
mentored and receive technical oversight by the Navoi-based Project Director, Dr. Mavzhuda 
Babamuradova. Secondly, the office is supported by state-of-the-art systems and procedures as 
described in section 3 under Program Management. The office has internet access and copy 
machines which make production of materials in a short period feasible. Thirdly, the increased 
competence of the field office and partners has laid the foundation for project sustainability. Its 
reach has also created a high demand within and outside the oblast for involvement in HOPE 
activities. A most striking indication of the breadth and depth of the organization is the respect 
earned from all local, national, and international organizations in Uzbekistan.
HOPE headquarters has been gaining experience in the region. The organization is in the 
process of expanding its consultant base and partnerships to cover obstetric and newborn care 
because of its Uzbekistan project. Curricula and protocols covering essential and emergency 
obstetric care and newborn care have been acquired in the Russian language. The project is 
currently working on approaches, guidelines, and protocols to improve neonatal mortality. This 
is particularly important for a region with relatively high neonatal mortality rates. HOPE has 
developed a second child survival project for Kyrgystan based on lessons learned in Navoi. The 
MCH Director at headquarters, Dr. Bettina Schwethelm, has provided valuable guidance to the 
project. In the process, she has developed experience in the region which is faced by vastly 
different health challenges and opportunities than HOPE CS projects in the Americas or Africa
along with other headquarters professionals who have provided short-term technical assistance.
2.2.4 Capacity building approach
ii. Sustaining the PVO Organization
Project HOPE in Uzbekistan is actively building its organizational capacity. First, it has created 
a highly competent and well functioning staff. The Navoi office staff has acquired skills in 
relevant technical topics, management, English, wordprocessing, EPI-Info, training, and survey 
 
4 All questionnaires for the mid-term survey on RH, BF, and IMCI were discussed with 
local team in Navoi with input from Project HOPE headquarters. The survey team was 
comprised of HOPE personnel, RH/BF/IMCI trainers and past RH/BF/IMCI trainees from the 
Central Rayon Hospital of both Navoi and Kiziltepa rayons. Surveyors were trained and 
conducted role-plays prior to conducting the survey. Supervisors discussed findings 
daily with project director. All data were analyzed and entered in Epi-Info version 
6.04d.
20
research.5
 HOPE headquarters has submitted a proposal to USAID to develop a similar CS 
project in Kyrgystan that would be mentored by HOPE’s project in Navoi and with an expanded, 
more regional role of the current Project Director. Secondly, the office is supported by state-of￾the-art systems and procedures as described in section 3 under Program Management. The office 
has internet access and copy machines which make production of materials in a short period 
feasible. Thirdly, the increased competence of the field office and partners has laid the 
foundation for project sustainability. Its reach has also created a high demand within and outside 
the oblast for involvement in HOPE activities. A most striking indication of the breadth and 
depth of the organization is the respect earned from all local, national, and international 
organizations in Uzbekistan.
HOPE headquarters has been gaining experience in the region. The organization is in the 
process of expanding its consultant base and partnerships to cover obstetric and newborn care 
because of its Uzbekistan project. Curricula and protocols covering essential and emergency 
obstetric care and newborn care have been acquired in the Russian language, and the project is 
expanding its focus on neonatal and maternal care in the remaining months. This is particularly 
important for a region with relatively high neonatal mortality rates. HOPE has developed and 
submitted a second child survival project for Kyrgystan based on lessons learned in Navoi. The 
MCH Director at headquarters, Dr. Bettina Schwethelm, has provided valuable guidance to the 
project. In the process, she has developed experience in the region along with other headquarters 
professionals who have provided short-term technical assistance.
ii. Strengthening Local Partner Organizations
The project has excellent working relationships with its partners: the Navoi oblast and pilot 
rayons MOH, the Center for Reproductive Health in Navoi, health facilities in the two pilot 
rayons (Navoi/Karmana and Kiziltepa), emerging local NGOs, makhalla committees, the 
National Institute of Pediatrics and its Center of Reproductive Health, and the Ob/Gyn Research 
Institute in Tashkent, USAID, Unicef, WHO, the World Bank, Abt Associates, Counterpart 
International. Certain project interventions aim to strengthen health services and local capacity 
oblast-wide, while others focus on intense implementation in the pilot rayons. 
The Project HOPE office in Navoi is housed in the Oblast Ministry of Health building. All 
planning and operations in the oblast are undertaken jointly with this partner. This results in 
direct transference of skills and monitoring of program activities. The program is viewed by the 
Chief of the oblast MOH as a joint endeavor. On April 6, 2002, the project established an IMCI 
Center which now serves Navoi and neighboring oblasts as a model resource and training center. 
The Center for Reproductive Health was established in January 2001 and started its activities, 
reproductive health training and service provision for the oblast, in March 2001. HOPE assisted 
the Center in its planning and by conducting TOT workshops for midwives, ob/gyn’s, and 
general practitioners. HOPE has also served as a bridge between the Navoi Center for 
 
5 All questionnaires for the mid-term survey on IMCI, RH, and Bf were discussed with 
local team in Navoi with input from Project HOPE headquarters. The survey team was 
comprised of HOPE personnel, RH/BF/IMCI trainers and past RH/BF/IMCI trainees from the 
Central Rayon Hospital of both Navoi and Kiziltepa rayons. Surveyors were trained and 
conducted role-plays prior to conducting the survey. Supervisors discussed findings 
daily with project director. All data were analyzed and entered in Epi-Info version 
6.04d.
21
Reproductive Health and the Ob/Gyn Research Institute in Tashkent. The Navoi Center for 
Reproductive Health delivers workshops for the makhalla with project support. The Center 
began this year to provide reproductive health training for adolescents. This adolescent training 
includes use of contraceptives, STI prevention, drug and smoking addiction, gender identity, etc. 
Their work has reached approximately 70% of students in grades 8-10 in Navoi City, and has 
expanded to at least three colleges. Because its facilities are limited, the Reproductive Health 
Center needs additional inputs to upgrade its capacity. 
Two “Baby Friendly” hospitals have been established through the project, one in Navoi and one 
in Kiziltepa. Staff from other pilot rayon facilities (e.g. polyclinics and SVPs) are being trained 
in IMCI and reproductive health to provide quality services to their respective coverage areas. In 
addition, HOPE is providing assistance to the oblast maternity to become certified as “Baby￾Friendly.” 
As mentioned previously in section 2.2.2, the project has supported the establishment of local 
NGOs in Navoi and is networking with those in other oblasts to expand their role. 
Project Hope coordinates with all of the key international agencies: WHO, Unicef, and World 
Bank. WHO has been a key player for all work in IMCI and will be embarking on Safe 
Motherhood initiative. Unicef has been assisting in the project’s breastfeeding activities. The 
World Bank and HOPE have interfaced on the integration of new curricula into the training of 
providers and on preparation of materials.
The project is financially supported by USAID/Washington, but regular coordinating meetings 
are held with the USAID mission. At the local level, the project coordinates closely with two 
USAID-funded organizations, Abt Associates and Counterpart International. Abt Associates is 
the contractor for USAID’s Health Reform Project. Counterparts International, an NGO with 
headquarters in Washington, D.C., has its field office in Karakalpakstan Oblast where it is 
develops its child survival initiatives at the makhalla-level. 
Project Hope has taken a lead role in the introduction of IMCI in Uzbekistan through its 
partnership with the National Pediatric Institute in Tashkent, which also coordinates closely with 
WHO and Unicef. By June 1999, Kazakhstan and 30 other countries had reached the early 
implementation phase of IMCI implementation, whereas IMCI was just being introduced into 
Uzbekistan, Kyrgyszstan, Tajikistan, and Turkmenistan (WHO IMCI Information 1999).
HOPE has supported the Institute in practical IMCI training, the translation of IMCI materials 
into Uzbek, and the development of baby-friendly health instruments and mother reminder tools. 
The Institute will introduce IMCI materials developed by Project Hope in Navoi at an upcoming 
regional conference in Almaty, Kazakhstan. 
The key challenge to further capacity building is the size of the Project HOPE staff and the 
current level of effort needed to maintain ongoing activities. The emphasis on coordination and 
networking is one means of meeting this challenge.
22
iii. Health Facilities Strengthening
There are currently two facilities in Navoi which have been certified as internationally 
recognized “Baby Friendly” hospitals due to the inputs of the project. Training of medical 
personnel from SVP’s and polyclinics in maternal and child health supports and complements 
these efforts at the tertiary care level. 
There are certain other facilities which could benefit from additional financial inputs, namely the 
Center for Reproductive Health in Navoi. Space is limited and the building needs to be
refurbished, or more ideally, changed.
The project has conducted health facility assessments at baseline and at mid-term. Thirty sites 
were selected randomly for the baseline from a list of SVPs, SVAs, SUBs, polyclinics, and 
hospitals. Methods included observations of providers and interviews of providers and clients. 
The project adapted the BASICS HFA and the WHO Reproductive Health Assessment For the 
midterm survey, 27 facilities were assessed to monitor facilities where doctors had been trained 
in IMCI and/or Reproductive Health. Results from the midterm health facility assessment 
indicate that a majority had a functional weighing scale and timer (92.6% and 85,2% 
respectively), a working refrigerator (88.9%), and an IMCI protocol folder. However, only 
66.7% had a separate oral rehydration therapy corner. Most facilities did not have reminder 
materials or IMCI record forms (only 29.6% and 25.9%, respectively had these forms). Most 
vaccinations were available (between 88.9% and 96.3%) with the exception of flu and mumps 
vaccine, neither of which has been available for the last five to six years. IMCI drug availability 
ranged widely from 0.0% for Gentian violet, 3.7% for Chloramphenicol, to 81.5% for 
Paracetamol and 92.6% for ORS. 
iv. Strengthening Health Worker Performance
The project has devoted major resources to strengthening health worker performance with its 
cascade approach to training. This has been very effective as shown in the results of the mid￾term survey on provider knowledge and skills discussed in 2.1.2. Training has been carried out 
at all levels of the project including orientation meetings at the national and oblast level, provider 
training at the oblast and rayon levels and with mothers. Partner organizations have been invited 
to both TOT and technical courses.
Initially, some technical assistance was received from WHO Kazakhstan for IMCI training. 
Now all IMCI, breastfeeding, and reproductive health training is done by master trainers from 
the MOH, HOPE/Navoi, and its partners. Technical assistance in maternal and newborn care 
will soon be provided by international experts. The evaluation team observed that the training 
methodology being used for IMCI training was excellent, and the achievement of benchmarks 
for number of providers trained is high as shown in Tables 1 and 3. Aspects of training activities 
are discussed further in other sections of this report (2.1.3 and 2.2.2).
The program is establishing new performance standards with the introduction of protocols for 
each of the technical areas. The continual feedback mechanisms being developed through pre 
and post-tests, workshop debriefings, and special surveys serve to address any gaps between 
standards and actual performance. Supervisory checklists are part of the project’s routine 
supervisory system. In addition, special surveys have been conducted to observe and interview 
23
providers and clients in the two target pilot rayons. Specifically, these tools have focused on 
IMCI for health providers, IMCI for caretakers, IMCI for health facilities, RH and BF for 
women. Questions were adapted from the KPC 200+ and BASICS tools. The questionnaire 
included specific program-oriented questions.
v. Training
The training strategy is based on a cascade approach in which master trainers train trainers, who 
in turn train providers and community members (e.g. breast-feeding support groups). This has 
been very effective in stimulating the program to expand to oblasts beyond the intervention areas 
at basically no extra cost. In this way, Pediatric and Ob/Gyn Institute staff are involved in the 
master training workshops in Navoi and then can transfer the technologies through training of 
staff in Navoi and other oblasts.
Table 3 provides a list of training of providers and trainers, by technical area, to date. 
Table 3: Number of Providers and Trainers Trained in each Technical Area, April 2002
Topic No. of providers trained No. of trainers trained
Breastfeeding 194 (from 2/2001) 12
Reproductive Health 162 (from 3/2001) 8
IMCI 72 (from 9/2001) 11 
As already mentioned, Table 1 shows how these training activities have contributed towards 
progress in meeting the objectives. Table 2 indicates that provider and client knowledge and 
skills have resulted in new ways of doing things due to the project’s training.
A consistent need articulated by the partners is for integration of state-of-the-art protocols into 
medical and nursing schools. While post-graduates are gaining knowledge via training courses, 
entire cadres of health sector human resources are entering the field. This is a window of 
opportunity in which the project is already participating in Samarkand and Bukhara.
vi. Sustainability Strategy
All project activities are taking place within the context of a larger health reform in Uzbekistan, 
with Navoi one of the three pilot oblasts. At the time of this midterm evaluation plans were still 
underway to reduce the number of providers at the tertiary care level and expand the role of the 
SVP’s to encourage a primary health care approach. Long-term reforms require changes in the 
curricula of medical institutions and in the certification of medical personnel. Doctors and 
nurses already in practice need continuous upgrading of skills in the latest child survival and 
maternal health technologies and protocols. As the World Bank’s loan money is been channeled 
to equip rural points and train teachers from the three pilot oblasts in IMCI, breastfeeding, and 
pre and post-natal care, HOPE has been assisting by helping prepare for training in Bukhara and 
Samarkand Institutes. 
The evaluation team does believe that if the project were to end, that many of the technical 
interventions have been institutionalized in the pilot areas and would continue at some level. 
24
An exit strategy has not been formally formulated by HOPE with local partners. All individuals 
met during the course of this mid-term evaluation clearly prefer the project to continue with 
more inputs.
The project has not yet implemented programs to build financial sustainability. There is limited 
local level financing, no cost recovery, and no significant resource diversification or corporate 
sponsorship for the oblast MOH. The oblast receives its financial support from the government 
and has not been engaged in fund-raising. Financial contributions to the public sector by 
corporations would require a major paradigm shift. The oblast MOH had approached several 
large enterprises such as the chemical factories and mining enterprises but apparently they were 
not interested in public health care financing. The money from these industries goes directly to 
the central government, resulting in what one could call a “negative flow” from the oblast for 
health care financing. Industries are currently not considering funding of public health care 
beyond their defined coverage targets because they have their own hospitals for their own 
employees. Sources of financial support from collective farms, mining industries, chemical 
factories, cement manufacturers, and food industries are estimated to account for only about 1% 
of the current oblast health budget. In terms of financial sustainability for NGOs, discussions 
were underway during the mid-term evaluation with NGO’s on how the project might assist in 
organizing grant-writing workshops. 
3. Program Management
3.1 Planning
All program planning has been accomplished in cooperation with the major local organizational 
partners, including the National Institute of Pediatrics in Tashkent, the Navoi oblast MOH, the 
new Center for Reproductive Health, health facilities in the two pilot rayons (Navoi/Karmana 
and Kiziltepa), emerging local NGOs, and makhalla committees. There are few individuals not 
involved and data is shared and analyzed across the project. For example, the Medical Council, 
an oblast-level Board of Health works with the project to examine each maternal death case in 
the project area. Together the organizations discuss results and determine recommendations for 
Project HOPE to conduct its activities. 
HOPE interfaces with the various international and bilateral organizations to plan specific 
activities related to their joint missions. 
3.2 Staff training 
English language and computer skills have been clear priorities for all staff since the start of the 
project. With the help of a HOPE intern, the entire team was trained in Microsoft programs and 
certain staff in EPI info. Instruction in English began for each member of the project team who 
needed to upgrade their language skills, with instruction being given twice per week. The 
HOPE/Navoi pediatrician who came to the project with significant clinical neonatal experience is 
now one of the key trainers in IMCI and breastfeeding at the national level; she has developed 
research skills through conducting the baseline survey and health facility assessment. The 
HOPE/Navoi obstetrician with 5 years of clinical experience has expanded her skills in training 
25
in IMCI, reproductive health, and breastfeeding. Project HOPE’s physician in charge of the 
management information system has mastered EPI-info and gained on-the-job training in survey 
research methodologies. All technical staff attended WHO’s monitoring and evaluation course. 
The Project Director, an ob/gyn by training, came to the position having worked for several 
international organizations (e.g. AVSC, JHPIEGO) and with strong skills in reproductive health 
and training. During her tenure on the project, she has expanded her experience in IMCI and 
program management. She has visited the University of Michigan Medical School for 
observations and discussions of maternal and neonatal health.
3.3 Supervision of program staff 
Supervision of staff by the Director of MCH Programs at HOPE headquarters and by the Project 
Director in Navoi is exceptional. Staff are enthusiastic about their work and challenged by it. In 
fact, the key thought to consider for the future is the balance between work and time off. There 
is a strong team relationship among all members of the project who work long hours. Effort will 
be required to maintain the current momentum and yet avoid burn-out with the limited size of the 
team. This will be especially necessary if the role of the Project Director is expanded to include 
regional responsibilities. The technical staff spend a great deal of time engaged in training 
activities in the field and working with the partners and often meet afterward at the Navoi office.
The MOH conducts supervisory visits for IMCI trainees according to a project schedule. 
Currently, trainees are followed up one month and at six months after training. The evaluation 
team recommends that the supervisory visits needs to be extended and more regular as the 
project becomes institutionalized. The MOH takes action based on its monitoring and 
supervisory visits, indicating that a feedback system is in place. Certain technical areas require 
more emphasis. Supervision of breastfeeding activities at the polyclinics, for example, has not 
yet been integrated into the supervisory system. 
3.4 Human resources and staff management
When the initial project director was terminated, there was a lag time before qualified individuals 
could be identified to fill all technical and administrative positions. The field office and 
headquarters worked closely together to examine existing staff qualifications against project 
needs. Job descriptions were reviewed in January 2001. There were clear needs in the area of 
information systems and IEC. Given the shortage of qualified human resources for the IEC 
position, despite advertising Samarkand, Bukhara, and Tashkent medical schools, nobody could 
be found to fill the position. Ultimately, the Pediatric Institute agreed to share Dr. Fakhruddin 
with the project 50% time, an arrangement which ultimately facilitates coordination.
Technical staff, administrative staff, and drivers are actively involved in a team approach which 
provides strong cohesion and motivation. The evaluation team found the administrative systems 
of HOPE extremely well organized. Human resource management is a high priority. A 
conscious effort is made to develop staff knowledge, skills, and experience. Job descriptions are 
written for each HOPE staff. 
26
3.5 Financial management
Each HOPE project is staffed with an administrator/accountant at the field level who is 
responsible for the compiling and reporting the local currency expenses vis-a-vis approved 
budgeted line items to the Project Director. Once the monthly Profit and Loss statements and 
related financial documents are approved by the Project Director, this information is sent to 
HOPE Center in Millwood, Virginia for review by the Assistant Regional Director of Finance. 
The Assistant Regional Director, Finance reviews the financial reports and enters the financial 
data into the General Ledger, provides for imprest reimbursement to the field offices, requests 
payment from funders, and provide the necessary reports to funders as stipulated in the 
agreements. 
HOPE’s commissioned multi-functional Financial Assessment Team in late Spring 2001 made 
recommendations for re-engineering its financial delivery systems in order to improve decision￾making at all levels of the organization. A major focus of this group was improving the 
accessibility and interactivity of HOPE’s financial data base for international field staff in a way 
that better reflects the organization’s desire to increase field responsibility and accountability for 
program activities. HOPE has already installed a new accounting and reporting system centrally. 
The focus is now on standardizing and automating the field accounting systems to better capture 
local data needs, while training field staff to interact with the central database through Internet 
links for real-time processing, analysis, and performance feedback.
3.6 Logistics
The project has a well-defined logistics system for bringing humanitarian supplies into the 
country at limited cost to the project. Once medicine and equipment arrive from overseas 
delivery is within two weeks. A letter is sent to the Cabinet and once a reply is received from 
Customs, HOPE arranges delivery through its office based in Tashkent. This office manages the 
logistics of all HOPE goods brought into the country, some of which come to the Navoi child 
survival project. It coordinates transport of goods to Navoi through the oblast MOH. Project 
HOPE in Navoi checks inventory with the oblast MOH when it arrives at destination. 
The project’s Steering Committee invites pharmaceutical company representatives to its 
meetings to discuss quantities of available supplies and allocations for each rayon. The oblast 
health department distributes humanitarian supplies according to need, which is determined by 
various organizations (e.g. the Mining Company). HOPE monitors drug distribution, use, and 
reporting for donated pharmaceuticals. Humanitarian supplies include drugs such as 
amoxycillin, penicillin, and multivitamins. Project HOPE/Navoi owns a vehicle and rents 
additional cars if necessary.
3.7 Information management
The information system for the project includes a system operated by the Ministry of Health and 
a system within the HOPE field office. The MOH system is comprised of two systems: 1) a 
medical system, and 2) a civil registration system. The government collects data on a variety of 
indicators, but for certain ones it follows strict requirements to focus on the project’s target 
27
interventions. These indicators include number of deliveries, maternal deaths, perinatal deaths, 
and infant deaths. Death rate information is sensitive because investigations are made on 
practitioners whose patients are not surviving. The definition of a live birth is changing from the 
Soviet system definition to that of WHO. Because the WHO definition of perinatal death is a 
death which occurs after 28 weeks of pregnancy and within six days of post-delivery, it becomes 
critical to distinguish between cases of spontaneous abortion, stillbirth, and perinatal deaths and 
the medical reasons for each. The increased rate of maternal mortality in the oblast has been a 
red flag for mismanagement during delivery. Punitive measures are taken for practitioners who 
are judged to be technically questionable or incompetent. For example, measures range from a 
memo to the files for a first time breach of quality care, to salary cuts, to dismissal. 
Information is collected and shared between HOPE and the MOH. Key information system 
activities are carried out jointly to monitor and evaluate the child survival project. These have 
included a baseline Knowledge, Practice, Coverage (KPC) survey6
, a health facility assessment, 
a list of providers trained in each technical area with pretest and posttest scores, and the mid￾term survey7
. The project has also conducted formative research and mini-studies to explore 
particular issues. In August 2000, technical assistance was provided to conduct a “Postpartum 
Services Assessment for New/First Mothers in Navoi Oblast, Uzbekistan.” In 2001, population 
surveys and focus group discussions were carried out on IMCI topics in preparation for 
developing the Mother Reminder Tools to determine knowledge levels and practices among the 
target population of beneficiaries.8
 Routine data is collected on provider performance using 
supervisory checklists to make sure the project is on track and to feedback information into 
training sessions. 
3.8 Technical and administrative support
The project has received technical assistance from its partners and outside organizations such as 
WHO/Kazakhstan. The project anticipates it will need additional assistance in the remaining 
years in maternal and neonatal health care from institutions such as the University of Michigan 
Medical School, USAID CAs, and independent consultants. The project has received several 
supervisory and technical support visits per year from persons stationed at Project HOPE’s 
headquarters, including the Regional Director and the Director for Maternal and Child Health.
 
6 KPC instruments were comprised of 58 questions based on a state-of-the-art instrument developed by 
CORE/CSTS. The instrument was translated into Russian and Uzbek and pretested.
7
 Data for the mid-term survey was collected in the two pilot rayons, including Navoi City, using two methods: 1) 
observation of providers, and 2) interviews of clients and providers. See attachment 1for complete methodology.
8
 The population survey randomly selected 48 households in Kiziltepa rayon and 42 households in Navoi. A total 
of 239 individuals (104 from Navoi rayon; 135 from Kiziltepa rayon) were interviewed; 66.9% were women and 
33.0% were men. Four focus groups were selected in each rayon and were divided into primary and secondary 
groups based on their role in family life: 1) mothers with children under five years of age, 2) health providers, 3) 
men, 4) mothers-in-law and their representatives.
28
4. Other Significant Issues/Strategic Opportunities 
The end of the Soviet control of Uzbekistan coincided with a time period when the influx of new 
knowledge became limited. While Uzbekistan was part of the Soviet Union, people could move 
free of charge between the republics for in-service training, refresher training, post-graduate 
courses. After independence in the early 1990s, the borders opened up but travel became a 
financial issue. Suddenly state-of-the-art technical materials are beginning to flow into the 
health sector and people are thirsty for the materials in the Uzbek language. The current era is 
seen as a window of opportunity to establish new protocols which meet international standards. 
Other republics in the region are likely experiencing the similar motivation to absorb the latest in 
technology and health care advancements. There appears to be a regional interest in sharing 
materials and lessons learned as the newest medical and health information becomes available. 
The experience gained in child survival and maternal care in central Asia by the project offers a 
unique opportunity to expand lessons learned to other republics. This strategy is being pursued 
by HOPE for a project in Kyrgyzstan.
5. Conclusions and Recommendations
This section summarizes findings and recommendations, most of which are described elsewhere 
in the report.
Finding 1: Outstanding reputation of project. The credibility of Project HOPE is exceptionally 
high with the partner organizations. This is crucial to the support, expansion, and 
institutionalization of the project at all levels. HOPE’s close coordination and the respect it has 
achieved with each of the partners accounts for the open flow of communication and unified 
project identity.
Recommendation 1A: Maintain this reputation as project by maintaining quality as new 
technical interventions are undertaken and as coverage is extended. This may require 
additional HOPE staff, changes in job descriptions, new or extended networks of NGOs, 
etc. 
Recommendation 1B: Continue to provide humanitarian aid.
Finding 2: Well implemented in terms of effectiveness. The project has been largely successful 
in implementing its workplan. It has already achieved some of its end-of-project benchmarks at 
midterm and has placed as high priority those activities which were initially delayed. 
Recommendation 2A: Continue to implement the program according to the values and 
management style used to date.
29
Recommendation 2B: Coordinate with KFW to target RH training to those facilities 
being supplied with contraceptives.
Finding 3: Well implemented in terms of coverage. Due to the successful implementation in 
the target areas, particularly with providers at the facility level, emphasis should continue in 
deepening the roots of the program at the community level. Moreover, a demand for project 
interventions has been created in other oblasts and rayons who are inspired by the state-of-the art 
technical protocols and behavior changes. 
Recommendation 3A: Extend and replicate the project in other oblasts and rayons which 
have no foreign assistance or limited inputs. In order to achieve equity, certain 
geographical areas require project assistance. The decision on where to extend should be 
based on criteria such as population size, commitment and interest of the oblast/rayon 
MOH and/or NGOs, cost to the project, potential for impact. 
Recommendation 3B: Establish a full-time cadre of master trainers for IMCI in order to 
scale up. They can be based at the IMCI center.
Finding 4: Community mobilization. Community mobilization activities are in a nascent stage 
and gaining momentum. The project is making major headway at the community level by 
supporting the establishment of local NGOs. The political support and attendance of high profile 
figures at project competitions and ceremonies reinforces awareness and acceptance of new 
initiatives among the general population. 
Recommendation 4A: Place more emphasis on the makhalla as a project resource. For 
example, link breastfeeding support groups/volunteers to makhalla committees, reach 
men/fathers through the makhalla, etc.
Recommendation 4B: Reassess the role of breastfeeding support groups in terms of the 
potential role of this cadre of volunteers. With the influx of additional IEC materials and 
an interest in broader child health topics, these volunteers could have a greater impact. 
Discuss the role of the makhalla and formal health system in supervising volunteers.
Finding 5: Limited technical and IEC materials There is a limited supply of technical resources 
for providers and for communities in the local language. The inadequate availability of reminder 
tools in health facilities and IMCI record forms emphasizes the fact that nobody has claimed 
responsibility for their provision. On the national level, Project HOPE is making an effort to 
improve this situation with the IMCI Steering Committee. On the regional level, HOPE 
coordinators are urging health facilities to produce their own posters. It is expected that the 
Mother Reminder Materials being produced by the project will be incorporated in the health 
facilities. There is a need for audio-visual materials for the central rayon hospitals and 
communities. Previous attempts at the use of television have been costly and short-term.
30
Recommendation 5A: To the extent possible, identify more literature in Russian and 
Uzbek for project-related resource centers and libraries. Produce a HOPE brochure and 
an annual report in the local language.
Recommendation 5B: Further explore the use of mass media (e.g. radio, television, etc.) 
to disseminate health messages.
Recommendation 5C: Identify and request donations of audiovisual equipment for each 
rayon hospital, especially for Central Rayon Hospitals. Find videos from the Central 
Asian region (e.g. Kazakhstan) which can be utilized in Uzbekistan. Particular topics of 
interest are well-child care and anemia.
Finding 6: Sustainability. Institutional development has been a cornerstone strategy. For 
added value, the project can effectively upgrade and replicate its activities through existing and 
new institutions. Financial sustainability is an area which needs to be addressed further.
Recommendation 6A: Assist the Center for Reproductive Health in Navoi with 
refurbishment, provision of equipment, and other reproductive health supplies to make it 
a model center.
Recommendation 6B: Open two more Baby-Friendly hospitals.
Recommendation 6C: Build oblast capacity in (and explore the possibility of establishing 
a center for) adolescent health.
Recommendation 6D: Have project staff participate in more national and international 
workshops.
Recommendation 6E: Assist in linking emerging NGOs with donors. Involve the MOH 
and NGOs in proposal preparation and grant writing and/or coordinate with other 
organizations for this purpose.
Finding 7: Training and supervision At the policy level, oblast and rayon chiefs need to be 
oriented to the project’s supervision policy in order to upgrade knowledge and skills over the 
medium- and long-term. The cascade approach to training is successful and there is an interest 
from oblasts/rayons outside the current project coverage area to participate in training sessions. 
Within the project area certain providers and technical areas need to be addressed further.
Recommendation 7A: Orient policymakers to the role and techniques of supervision in 
managing quality services, particularly those involved in IMCI. Hold workshops on 
effective supervision for managers and trainers.
Recommendation 7B: Invite trainers and providers from areas beyond the current pilot 
areas to begin training in breastfeeding, reproductive health, and IMCI. Develop criteria 
for selection so that there is a critical mass of trained providers at each facility and rayon 
31
to develop supervision systems. The approach should be system-wide rather than 
sporadic training of individuals who will not be supported by the public health system.
Recommendation 7C: Integrate IMCI training into medical schools in neighboring 
oblasts by working on this issue with the National Pediatric Institute. 
Recommendation 7D: Focus more input and attention on training of midlevel
providers. 
Recommendation 7E: To increase dissemination of state-of-the-art knowledge while 
motivating high performance, attract international trainers and provide study tours as 
opportunities and budget allow. 
Recommendation 7F: As noted in recommendation 9A below, provide additional 
training to HIS staff in survey methodology.
Finding 8: Maternal and neonatal care. The project is in need of capacity building in maternal 
and neonatal care. The disproportionate number of neonatal and maternal deaths in the oblast 
requires continued investigation into the causes and steps to ameliorate the problem. 
Recommendation 8A: Provide technical assistance using experts from abroad in neonatal 
and maternal care, as planned. The project can then use its existing mechanisms for 
transferring the knowledge of such medical specializations to national medical 
institutions and geographical areas beyond Navoi.
 
Recommendation 8B: Implement international classification of “live birth” with approval 
from the MOH.
Recommendation 8C: Conduct training for providers in antenatal, postnatal, and neonatal 
care after upcoming technical assistance consultation by international expert. 
Finding 9: Special studies. There are several research topics which need to be studied. In light 
of new protocols and an unstable, insufficient supply of pharmaceuticals at public health delivery 
points, there is a need to understand drug availability, use and compliance. The involvement of 
fathers at the starting point of delivery and post-natal care has been an unexplored area. 
Currently fathers have extremely limited contact with the newborn, and in fact, spend much of 
the early days outside the hospital. There is an interest within the oblast MOH to research 
adolescent reproductive health in Navoi, because adolescent pregnancies appear to be on the rise.
This topic should be considered for potential research.
Recommendation 9A: Conduct an operations research study on drug availability,
 use, and compliance related to IMCI.
Recommendation 9B: Conduct qualitative research on the role of fathers during
Delivery and during post-natal periods to assess how to involve them in bonding
and early child care.
32
Recommendation 9C: Consider research into adolescent reproductive health
issues in Navoi and link it with project objectives. 
Finding 10: Utility of health information system. The health information system is critical for 
measuring project outcomes and gauging impact. There is currently a lack of comparison data
between baseline and midterm surveys. In order to maximally evaluate the project during the
final evaluation several steps need to be taken. This can also help to improve monitoring and
feedback into training and supervisory systems. Indicators for maternal and newborn care have 
not yet been developed. There is no indicator and no information available for several objectives 
outlined in the DIP. Staff need additional training in survey methodology to upgrade knowledge 
and skills.
Recommendation 10A: As noted in recommendation 7F, provide additional 
training to HIS staff in survey methodology.
Recommendation 10B: Prepare indicators and questions for final evaluation in order to 
ensure comparison of key indicators with baseline and/or midterm survey results. Collect 
and/or compile data from existing sources. For the Child Spacing indicator which reads, 
“By project end, unmet demand had decreased by 30%,” in the final evaluation sample 
women with children under age two for unmet need. 
Recommendation 10C: Develop indicators for maternal and newborn care using Safe 
Motherhood guidelines. Specifically define indicators to monitor deliveries and quality of 
antenatal and post-partum care.
Recommendation 10D: Redefine indicators as follows—
-- Change last Breastfeeding indicator from “20 Breastfeeding support groups
 established” to “20 makhalla establish regular meetings with women’s support
 groups.”
-- Refine the first IMCI indicator to track performance on a set of key IMCI protocols. 
6. Results Highlight
Key findings indicating behavior change from the Mid-term Survey, March 2002, are highlighted 
in section 2.1.2 in Table 2. The complete Mid-term Survey document is available from Project 
HOPE headquarters in Millwood, Virginia.
33
ATTACHMENT A1: Program Description
FIELD PROGRAM SUMMARY
PVO/Country: Project HOPE Uzbekistan Program duration (9/1/1999 – 8/31/2003)
Site: Kyziltepa Rayon and Navoi City, Municipality (Total population 252,000) 
1. ESTIMATED PROGRAM EFFORT AND USAID FUNDING BY INTERVENTION
Intervention % of Total Effort (a) USAID Funds in $ (b)
Immunization % $
General Nutrition % $
Vitamin A % $
Micronutrients (other than Vitamin A) 10% $
Breastfeeding Promotion 10% $
Control of Diarrheal Disease % $
Pneumonia Case Management % $
Control of Malaria % $
Maternal and Newborn Care 35% $
Child Spacing 10% $
STI/HIV/AIDS Prevention % $
IMCI – Health Facility and Community 
Level
35% $
Total 100% $
2. PROGRAM SITE POPULATION: CHILDREN AND WOMEN (C)
Population Age Group Number in Age Group
Infants (0-11 months) 6,800
12-23 Month Old Children 6,460
12-59 Month Old Children 25,580
Total 0-59 Month Olds 32,380
Women (15-49 years) (d) 60,480
Data collected for UDHS rates and Government of Uzbekistan population data for target sites.
t Estimated annual number of live births in the site 6,800
t Sources of the population estimates above: MOH Oblast Administration 
34
Attachment A2: Program Goals and Objectives
OBJECTIVES MAJOR ACTIVITIES INDICATORS MEANS OF VERIFICATION
Child Survival and Maternal Care Objectives
1. Maternal and Newborn Care
(1) Improve the quality of antenatal and 
postpartum care.
(2) Increase the capacity of physicians 
and midwives to provide quality basic, 
essential, and emergency obstetric care.
(3) Increase the capacity of physicians
to provide quality newborn care. 
(4) Increase provider capacity to 
diagnose and appropriately treat/refer 
pregnant and post-partum women and 
neonates with danger signs.
(5) Increase knowledge of families about 
danger signs during the pre-natal, post￾partum, and neonatal period that require 
immediate and appropriate care seeking.
(6) Improve maternal nutrition during 
pregnancy and lactation.
(7) Increase the number of women provided 
with iron folate during pregnancy and 
lactation
(8) Introduce the provision of one 
megadose of vitamin A to women 
immediately post-partum.
(9) Promote the use of iodized salt with 
iodine-deficient pregnant women.
- Review and update the existing mother-baby 
package and protocols for basic health 
services;
- Train health providers to promote good 
maternal nutrition;
- Provide iodine to deficient women;
- Supplement all pregnant and lactating 
women with iron folate;
- Screen and treat pregnant women for STDs;
- Supplement all women with vitamin A 
immediately post-partum;
- Train providers in improved management of 
deliveries;
- Train physicians and other providers in 
basic newborn care (neonatal resuscitation, 
provision of oxygen, hypothermia, management 
of asphyxia, prevention and treatment of 
neonatal infections, and immediate 
breastfeeding);
- Develop health education materials on key 
topics for women and their partners 
(maternal nutrition, pregnancy and post￾partum danger signs, preparation for 
delivery, etc.);
- Develop curricula and implement classes 
for pregnant women and their partners and 
new parents; 
- Promote the involvement of men during the 
prenatal, perinatal, and postpartum period;
- Conduct ongoing case reviews of all 
maternal deaths in the target area with key 
oblast health staff.
- 80% of health staff in target area use 
protocols for delivering quality antenatal 
and post-partum services;
- 80% of pregnant women screened for priority 
STDs;
- At least 70% of deliveries managed with 
partograph;
- 70% of providers follow other established 
protocols for delivery and newborn care;
- Health brochures available at all health 
facilities and used for education;
- 50% of health facilities provide classes 
for pregnant women and their partners and new 
parents;
- 50% of women report improved nutrition 
during pregnancy and lactation;
- KPC survey at baseline 
and project end; 
- Provider observations 
and review of patient 
charts through ongoing 
supervision;
- Patient exit interviews 
- annual, - Dietary recall 
for pregnant and lactating 
women at project baseline 
and end; 
35
OBJECTIVES MAJOR ACTIVITIES INDICATORS MEANS OF VERIFICATION
2. Breastfeeding
(1) Increase the percent of newborns that 
are breastfeed within one hour of birth.
(2) Increase the percent of newborns that 
are rooming in with their mothers after 
birth.
(3) Increase the percent of infants under 
six months that are exclusively 
breastfed and receive no other liquids or 
solids, with the exception of drops or 
syrups consisting of vitamins, mineral 
supplements, or medicines.
(4) Increase the percent of women that 
report breastfeeding on demand;
(5) Increase the percent of women still 
breastfeeding at 20-23 months.
- Assist maternity hospitals in the target 
area to establish baby-friendly hospital 
procedures.
- Train OB/GYNs, pediatricians, hospital and 
community health nurses in lactation 
counseling.
- Promote the development of breastfeeding 
support groups.
- Conduct qualitative research on barriers 
to exclusive breastfeeding during the first 
six months.
- 75% of women in baby-friendly-hospitals 
breastfeeding within an hour of delivery;
- 30% of women breastfeeding exclusively for 
the first 4-6 months9;
- 50% of women with children < 6 months that 
report breastfeeding on demand;
- 50% of women still breastfeeding at 20-23 
months;
- 2 maternity hospitals with baby-friendly 
policies;
- 60 health providers trained to provide
lactation counseling;
- 20 breastfeeding support groups 
established;
- KPC survey at baseline 
and project end;
- Project Information 
system - quarterly;
- Baby-friendly hospital 
patient records -
quarterly;
- Research report (once).
3. Child Spacing
(1) Increase women's knowledge about 
advantages and disadvantages of 
contraceptives other than the IUD.
(2) Increase the number of facilities 
that provide a range of modern 
contraceptives.
(3) Decrease unmet need for 
contraception;
(4) Increase the percent of women who 
purchased a contraceptive method.
- Focus group study to determine reasons for 
contraceptive preferences of women and their 
partners;
- Provide needs-based training to providers 
in all methods and client counseling;
- Include family planning/child spacing 
education as an essential component during 
the prenatal and post-partum period;
- Train staff in delivery hospitals to 
counsel women and offer methods during the 
hospital stay; 
- Develop/adapt and disseminate brochures 
for women and men with advantages and 
disadvantages of all major methods, 
including surgical contraception and LAM;
- Develop materials and IEC approaches that 
target young women that might be interested 
in delaying pregnancy.
- 80% of facilities in the target area 
provide three or more different methods;
- 70% of women will receive FP/child spacing 
counseling during an antenatal visit and/or 
the post-partum hospital stay;
- By project end, unmet demand has decreased 
by 30%;
- KPC survey at project 
onset and end;
- Provider observations 
(quarterly);
- Client exit and client 
satisfaction interviews 
(annually); 
- Maternity hospital 
statistics (quarterly);
- Special reports.
 
 9The UDHS reports exclusive breastfeeding for the first four months. The project will collect information for the first four and the first six months and follow MOH policy.
36
OBJECTIVES MAJOR ACTIVITIES INDICATORS MEANS OF VERIFICATION
4. IMCI
- Improve the integrated management of 
the sick child (i.e., diarrhea, ARI and 
severe disease management skills, EPI, 
and nutrition assessment and counseling 
skills);
- Improve the quality of well-child 
visits;
- Improve the health system's capacity to 
provide sick and well-child services 
(logistics, procurement, training and 
supervision);
- Improve family and community child 
health and nutrition practices.
- Train IMCI trainers;
- Assist IMCI trainers in the training of 
SVP and polyclinic health providers;
- Train SVP staff and public health nurses 
in educating parents about good child health 
and nutrition household practices;
- Train providers in hepatitis B and vaccine 
application;
- Assist the MOH in the development of 
community-based IMCI materials.(e.g., 
brochures for new parents on 1. diarrheas 
(promoting hygienic practices at the 
household level, knowledge of danger signs, 
use of ORT, and good nutritional 
management); 2. ARIs (recognition of danger 
signs of pneumonia, prompt care seeking, 
nutritional management, and compliance with 
antibiotic treatment); 3. EPI (immunizable 
diseases and vaccination schedule); and 4. 
Nutrition (good breastfeeding and 
complementary feeding practices, 
complementary feeding practices, and 
essential micronutrients).
- Conduct qualitative research on local 
beliefs and practices related to the 
recognition of pneumonia and dehydration 
danger signs, care seeking, and home 
management;
- Assist the MOH to receive low-cost/donated 
Hepatitis B vaccine for the protection of 
children under one and health care workers;
- With MOH, identify pockets of low vaccine 
coverage and target promotional efforts to 
providers and families;
- 80% of trained providers at SVPs and 
polyclinics will follow IMCI protocols for 
sick children;
- Community-based IMCI materials in use by 
pediatric and maternity hospitals, SVPs, 
polyclinics, community outreach staff, and 
caretakers;
- 85% of children 12 - 23 months completely 
immunized (including hepatitis B vaccine);
- Vaccination drop-out rates reduced half by 
reducing missed opportunities;
- 60% of cases of diarrhea in children under 
two treated with Rehydron (oral rehydration 
salts) and/or recommended home fluids.
- 60% of children receive the same/more 
solids;
- At least 50% of caretakers provide 
additional meals to children while 
recovering from diarrheas, pneumonia, and 
other serious diseases.
- Mothers will report improved hygienic 
practices at the household level (use of 
clean water for consumption, hand washing, 
appropriate use of latrines, proper disposal 
of stools of young children);
- Mothers will report improved feeding 
practices for children under five, including 
vitamin C, vitamin A, and iron-rich foods;
- 70% of mothers will be able to list danger 
signs for diarrhea and pneumonia;
- KPC survey at baseline 
and project end;
- Health facility 
statistics (quarterly);
- Project HIS (quarterly);
- Special reports.
37
OBJECTIVES MAJOR ACTIVITIES INDICATORS MEANS OF VERIFICATION
Capacity-Building
(1) Develop local project management 
skills;
(2) Develop a core group of trainers in 
the oblast;
(3) Develop a commitment to quality in 
the health care system;
(4) Improve critical analysis and 
problem-solving skills of counterparts;
(5) Increase the number of informal and 
formal organizations working with the MOH 
on project activities;
(6) Promote the development of local 
NGOs;
- Set up project steering committee with 
counterpart representatives;
- Identify potential trainers throughout the 
project and provide additional training in 
adult education;
- Train representatives of health facilities 
in QA/QI methods and provide support to QA 
investigations in the oblast;
- Teach counterparts in other analytical 
methods (e.g., COPE, supportive supervision, 
analysis and use of qualitative and 
quantitative information, etc.);
- Explore establishing a Project HOPE NGO in 
Uzbekistan;
- Actively involve and seek participation of 
other formal and informal public and private 
entities in project activities;
- Steering committee meets quarterly and 
provides input to project;
- Oblast MOH office has a list of experienced 
trainers to draw on for future training;
- Providers will report increased concern and 
involvement in quality of care issues;
- MOH actively coordinates with other local 
entities on MCH issues;
- Health facility staff apply analytical and 
problem-solving skills;.
- Steering committee 
minutes-quarterly;
- Project health 
information system -
quarterly;
- Focus group discussions 
with providers and key 
informants at project 
beginning, midterm, and 
end;
- Project final 
evaluation;
- Quality assurance final 
report.
38
Attachment A3: Program location: 
1. Description of the Project Target Area
Project HOPE’s Child Survival project is located in the Navoi Oblast of Uzbekistan (see Annex VI.1 for a 
map of the country, oblast, and rayon). Uzbekistan is the most populated country in Central Asia with a 
population of about 23.5 million (World Development Report 1999/2000, World Bank 1999) with about 
71% of the population being ethnic Uzbeks and 88% Muslim (World Bank OP 3.10 Annex D, June 1997). 
Life expectancy in 1996 was 67.8 years for men and 72.7 years for women. Literacy rates are very high, 
with an average of 11 years of schooling, and high secondary and tertiary school enrollment for men and 
women. According to the UDHS, 99.2% of women 15-49 completed primary education and 78.6% of girls 
6-12 are attending school. Water and sanitation services are clearly inadequate in Uzbekistan: Only 22.6% 
of households have flush toilets or VIP latrines, and 15.2% of the population lives further than 15 minutes 
from safe water supply (UDHS, 1996). After the pronatalist policies of the former Soviet Union,
Uzbekistan has remained the country in the region with the highest fertility rate (TFR = 3.3 children). 41% 
of the population is under age 15 (UDHS). 
All political power in Uzbekistan rests in the hand of the President who appoints all top-level officials in 
the central government and in the oblast administrations. Staffing changes appear to be relatively frequent. 
Uzbekistan is also affected by non-convertibility of the local soum, for which there is an official, a bank, 
and a black market rate, affecting Uzbekistan’s ability to assure a consistent supply of pharmaceuticals, 
medical equipment, and consumables. With USAID’s assistance a new law supporting nonpolitical NGOs 
was issued in 1999, but there are still few international and local NGOs operating in Uzbekistan.
The Navoi Oblast, with a population of about 769,000, is located in the central economic region of 
Uzbekistan. While one of the largest geographic regions with 8 rayons, more than a third of the land is 
dessert. Navoi’s population density is very low, and close to 60% of the population is rural, including some 
nomadic Kazakh populations. Rich in metals, industry is a major contributor to the GDP of Navoi, 
followed by agriculture. Navoi City was built several decades ago by the Soviet regime to exploit its 
mineral resources and develop chemical industries. Pollution and contamination by these industries are 
clearly visible throughout the City. Navoi City was linked directly with Moscow with its local airport 
(currently not operational) and was completely isolated from the rest of the country and off-limits to all 
outsiders. HOPE’s Project Director is only the second expatriate living there for an extended period. A 
Peace Corps volunteer, teaching economics, and her students have been subjected to much harassment from 
local officials, and two other Peace Corps volunteers left, because they were unable to live under similar 
circumstances. Given the strong controls exercised in this region, independent initiative (NGOs, 
businesses, etc.) have not yet entered this oblast.
The ethnically diverse population, consisting of Uzbeks, Kazakhs, Tajiks, and Russians has one of the 
highest maternal mortality and infant mortality rate in Uzbekistan. In 1996, 57% of Navoi’s health care 
expenditures were allocated to inpatient care and only 44% to outpatient health services, and the population 
averaged 7.9 physician visits per year, 42.8% of these to specialists (MOH, UNDP Human Development 
Report, 1997). The majority of the population is Muslim, but religious beliefs and practices are not easily 
observable in daily life. In Region 2, (containing Navoi), only 39.7% of women with children under six 
were working, and their children were cared for in daycare (25.2%), by an older female child (21.5%), or 
others (UDHS). According to the HOPE KPC survey, mother-in-laws are the most common child care 
provider when the mother is out of the home (59.6%). 
At the request of the oblast MOH, the project will be initiated in the rayon of Kyziltepa and Navoi City. 
Kyziltepa is one of the 8 rural rayons (district) of Navoi Oblast and is located in between Navoi and 
Bokhara Oblast. It has borders with Navoi, Navbahaor and Konimeh rayons of Navoi Oblast. It is 
approximately 60 kilometer from Navoi City and it takes about an hour from the City to the center of the 
rayon by taxi. Most of the people live close to the center of the rayon. The northern and eastern parts of 
the rayon are mostly desert. The desert areas are hard to access. The total area of the rayon is 221 square 
kilometer and the population is 109,819. The density of population is 4.7 per km2
. The rayon has 140 
kishlaks (villages). The population is predominantly Uzbek with some Kazakh and Tajik. Most of them 
39
are Muslim. The economy of the rayon is dependent on agriculture. The rayon produces cotton, wheat and 
fruits. In the desert area, the farmers are engaged in cattle rearing. Like other parts of Uzbekistan the 
literacy rate is high, with most of the people having primary education. In the rural area women work 
mostly at home and take care of the children.
Navoi City is the main city of the Navoi Oblast and the center of the Oblast. All Oblast level offices and 
facilities are located here. It has a population of about 142,000. The city was built in the early sixties by 
the Soviet when they started mining the region for gold and uranium. The city was built like a small Soviet 
city with most of the facilities available. The area of the city is approximately 1366 sq.km. The density of 
population per km2
 is 103.9, the highest density in the region. The population of Navoi City was once 
predominantly Russians, but they are gradually replaced by Uzbek populations. After the independence in 
1991, most Russians left for Russia, and only 10-15% of the total city population remains Russian. The 
city is divided into 18 units called micro-rayons and has an old and new area. The older part, called 
Karmana, contains mostly native Uzbek Muslims, and has limited access to water, sanitation and modern 
facilities, like telephone. The new part contains most of the facilities like shops, schools, park, hospitals, 
piped hot and cold water, telephone, etc. Most people live in apartments. The city has the following 
factories: Navoi Mining, Navoi Cement, Navoi Hydro-Electric, Navoi Chemical Factory and Navoi 
Nitrogen Plant. Approximately 15,000 people are employed in these factories. These factories have their 
own medical facilities which provide care to their employees and families. Unlike in the rural areas, the 
lifestyle in Navoi City is more European. Most of the women work and there are no religious restrictions 
on women’s movement or dress. 
Given relatively good access to health services of limited quality, within a context of high levels of 
nutritional deficiencies, the project will target all women of reproductive age and children under five in the 
rayon and the city. 
The Navoi Oblast inherited the traditional soviet health system managed by the public sector. It has 
parallel and vertical systems (facilities and providers) to manage certain diseases and conditions (e.g., TB, 
STIs, maternity). Preventive health services and health promotion is minimal. Providers do not use 
modern protocols and lack essential equipment. The types of facilities and the services they provide are 
described in more detail further on in the text. 
The Navoi Oblast health system is divided into four components: the Oblast Health System of the MOH, 
the City Health System, the industrial, and the private sector. The MOH provides most of the care in the 
region while the industrial health system provides health care to their employees. The private sector is a 
new phenomenon, mostly confined in cities. There are no real NGOs in Navoi. Two semi-public 
organizations the project will work with include the local branch of the Red Crescent Society and Healthy 
Generation, a government sponsored agency. Their activities are mostly limited to health promotion, first 
aid, and humanitarian assistance to poor families, very large families, and/or families with handicapped 
children. 
 
Figure 1. Navoi Oblast Health System
Rural (rayon) 
Health System
City Health 
System
Industrial 
Health 
System
Private 
Sector
Oblast
Referral Hospitals 
Dispensaries
Centers
40
The MOH Oblast Health System is the main health care provider in the rural areas, encompassing the eight 
rayons. When needed, patients are referred to specialized hospitals and dispensaries in Navoi City. The 
Oblast Health System provides patient care through 40 hospitals, 135 polyclinics, 40 SVP, 43 SVA and 143 
FAP. The hospitals include rayon hospitals, SUBs, regional hospital and specialized hospitals.
There are 1,615 doctors and 6,668 middle medical employees providing medical care in the Oblast Health 
System. Of them 306 doctors and 2,881 midlevel medical personnel work in urban areas. There are 21 
doctors and 85 mid-level medical personnel for every 10,000 population.
Navoi Oblast Health Department. Oblast Health Department plans and implements the national health 
programs, including preventive and curative services. It works closely with the Oblast Hokimiyat and the
Ministry of Health for allocation of funds and its annual plan. The Oblast Health Department operates two 
specialized hospitals for children, ophthalmology and a General Hospital (also contains Oblast blood 
transfusion and pathology department, and provides specialized care to the entire Oblast. However, more 
than 60 percent of the patients are directly from Navoi City. In addition, there are also five specialized 
dispensaries (oncology, narcology, dermato-venerology, psychiatry, endocrinology), and the Oblast TB 
dispensary, providing care for TB patients from the entire region. 
Rayon Health System. The Navoi Oblast is divided into eight rayons. Each rayon health system provides 
preventive and curative health care to its population through a network of rural health posts, polyclinics and 
hospitals.
LEVEL I LEVEL II LEVEL III
Fig 2. Existing Rayon Health System
The older rural health care system is still in place, with Feldshers at FAPs as the first contact point (Level 
I). The second level consists of SVP/SVA/SUB (Level II). The health reform supported by World Bank 
and USAID is planning to replace most FAPs, SVAs, and SUBs with SVP as the primary health care 
center. However, it is expected that some level I FAPs will remain in Navoi’s most rural areas. Some 
rayons also operate TB dispensaries and infection hospitals. 
LEVEL I LEVEL II LEVEL III
Fig 3. New health system under health reform
FAP
Feldsher
Akusherk
a
SVP
SVA
SUB
Doctor
POLYCLINIC
RAYON 
HOSPITAL
Specialist
SVP RAYON
POLYCLINIC RAYON
HOSPITAL
41
Table 1 lists the oblast health facilities by rayons, with Kyziltepa indicated in bold.
Table 1. Health facilities by Rayon
Sl. 
no.
Name of 
Rayon
Central 
Rayon 
Hospital
Rural 
Hospitals 
(SUB)
SVAs SVP FAP TB 
Dispensary
Infection 
hospital
01. Navoi 1 0 6 5 0
02. Novbohor 1 0 8 5 4
03. Kyziltepa 1 0 11 8 9 1
04. Khatyrchi 1 1 8 9 53 1 
05. Konimeh 1 3 1 3 26
06. Nurata 1 5 7 4 9 1 1 
07. Tomdy 1 4 0 3 25
08. Uchkuduk 1 5 1 1 17 1 
Total 8 18 43 40 143 3 2
Doctors and mid-level medical personnel. Table 2 gives the total number of mid-level medical personnel 
in different rayons. Khaterchi has the highest number of personnel followed by Nurata, Navbohor, 
Kyziltepa, Konimeh, Navoi, Tomdi and Uchkuduk respectively.
Table 2.Mid-level Health by Rayon
Rayon
Number Percent
Navoi 420 10.2
Tomdi 221 5.3
Uchkuduk 70 1.7
Kyziltepa 503 12.2
Khaterchi 1214 29.6
Konimeh 434 10.5
Nurata 659 16.0
Navbohor 575 14.0
Total 4096 100
Source: Oblast Health Department (1999)
42
Figure 4. Distribution of health personnel
Figure 4 gives the distribution of health personnel in different health care facilities in the rayons: 45% of 
all mid-level health personnel are working in hospitals, 22% in polyclinics, and 25% in 
SVPs/SVAs/SUBs/FAPs.
Distribution of mid-level health personnel in Rayons of Navoi 
Oblast, Uzbekistan (1999)
Nurse
44%
Junior Nurse
36%
Others
3%
Akusherka
9%
Feldsher
8%
Distribution of mid-level medical personnel in Rayon Health 
Facilities of Navoi Oblast, Uzbekistan (1999)
Hospital
45%
SUB
3%
PC
22%
SVA
7%
SVP
5%
FAP
11%
IH
4%
SES
3%
43
Table 3. Mid-level medical personnel per 1000 population in the Rural Areas of Navoi 
Oblast (1999)
Specialty Number Per 1000 
population
Feldsher 343 0.7
Akusherak 371 0.7
Nurse 1776 3.7
Junior Nurse 1492 3.1
Others 114 0.2
Total 4096 8.7
Health System of the City Council (Hokimyat)
The city health system is supported by the city council (Hokimyat). It operates the city polyclinic and the 
city SES. The Oblast General Hospital is the referral center for the city polyclinics.
Health care institutions of the city council (Hokimyat) in Navoi Oblast
 Hospital/clinic Navoi Zarafson Uchkuduk
Polyclinic 5 1 1
City TB Dispensary 0 0 1
SES 1 1 0
In Navoi City there are four polyclinics, and one for skin and STIs. The other three are for children and 
adults. The city also runs a first-aid ambulatory station, with ambulance service
Industrial Health System
Mining in the Kyzylkum desert started in 1958. Currently, the biggest government company, the Navoi 
Mining and Metallurgical Complex, popularly known as Gorne Mettullergy Kombinet (GMK), operates 
four uranium sites and two gold mining sites (including the largest gold producing mine and mill in the 
world). A plant for processing uranium and gold is located at one end of the city, at the edge of the desert. 
Apart from GMK, the Newmont Mining Company of USA and another British company are also engaged 
in gold mining. Navoi also has a plant for production of cut and polished marble.
The GMK employs around 55,000 people and manages a parallel health care system for their employees 
and their dependents (approximately 130,000 beneficiaries). Its system of polyclinics and hospitals 
(Medical Sanitary Department, MEDCENCHAS, provides preventive and curative services to children and 
adults in three cities (Navoi, Zarafson and Uchkuduk). MEDCENCHAS has approximately 1,000 beds in 3 
hospitals (400 each in Navoi and Zarafson and 200 in Uchkuduk), 7.6 beds per 1000 population, as well as 
laboratory facilities in all three locations, with a unit of Sanitary and Epidemiological Station (SES). 
Although covered under a different decree of the government of Uzbekistan, the GMK medical system 
works closely with the Oblast Health Department and provides information on a regular basis. The 
information system of GMK is computerized and produces a wide range of statistics of morbidity and 
mortality. MEDCENCHAS also assists the Oblast Health Department with medicines, vaccines and 
equipment. 
Other Factories in Navoi City. The other big factory is the Navoi Nitrogen Plant (Navoi AJOT), with 
7,000 employees, which operates a polyclinic and a hospital for adults of the employee families. Children 
under 14 years are served by the city polyclinic. Three other state owned smaller factories, the Navoi 
Cement Factory, Chemical Plant, and Hydroelectric plant located around Navoi City employ about 10,000 
44
people. They have polyclinics for their employees only, and the employees’ dependents are served by the 
Oblast and City Health System. 
Brief Description of Health Facilities
Facility Services Provider
Child Health 
Maternal Health
FAP EPI 
ANC/PNC
FP
Feldsher/Akusherka
SVP EPI, Curative care 
ANC/PNC
FP
Akusherka/Nurse/Doctor
SVA/SUB EPI, Curative care 
ANC/PNC, Delivery
FP
Akusherka/Nurse/Doctor
Central Rayon 
Poly- Clinic
Curative care, EPI, referral 
ANC/PNC, referral
FP
Akusherka/Nurse/General 
Physician/Physician/Specialist
s
Central Rayon 
Hospital
Referral 
Referral, Delivery
Specialists
Regional Hospital
Children, Maternity
Referral 
Referral
Specialists
Dispensary Specialized care Specialists
FAP (Feldsher-Akusherka Station). The FAP is the most basic health care facility in the rayons. Each 
FAP is staffed by a Feldsher (doctor’s assistant), a Akusherka (midwife), a nurse, and a cleaner. They are 
responsible for about 150-200 households in their catchment area. FAPs provide preventive (e.g., 
vaccination) and curative services. Akusheraks see mostly women of reproductive age and provide care to 
pregnant and lactating women, as well as family planning services. They are also capable of providing 
primary care to the patient. They work in the FAP till lunch and then conduct home visits in the afternoon. 
About 15-20 patients visit a FAP on an average day.
ORGANIZATION OF FAP
The SVA is the next level of health care. The average SVA is staffed with 5 doctors (2 therapists, 2 
pediatricians, and, 1 OB/GYN), 5 nurses, 2 midwives, 2 feldshers, a lab nurse, and 2 cleaners. Each SVA 
serves an average of 2,000 - 3,000 people. In addition, a pediatrician, a dentist, and two nurses work in the 
local school. The SVA also generally has ambulance service, with a driver and a nurse available on a 24-
hour basis to provide emergency transport.
AKUSHERKA
CABINET
FELDSHER
CABINET
NURSE
CABINET
45
ORGANIZATION OF SVA (KHATERCHI RAYON)
The SUB is a small rural hospital with about 10 beds (5 for women, 2 general medicine, and 3 for children). 
A SUB is headed by a chief doctor, and staffed with a pediatrician, a dentist, and 14-15 nurses, including 
three midwives. Each SUB serves approximately 2,000-3,000 people. The SUB also provides 
vaccinations. There is a small lab that conducts some basic tests. In a day, 50-60 patients are seen, half of 
them for lab tests. 
 
EXAMPLE OF A SUB (RURAL HOSPITAL)
The SVP is the new primary care center established under the Uzbek health reform. The average SUB is 
staffed by a therapist, a surgeon, a midwife, a dentist, a laboratory technician, a physio-therapy nurse, two 
nurses for conducting home visits, one nurse for patient registration, a nurse to provide preventive health 
services, and a nurse for medical procedures. The small lab provides basic tests (blood, urine, stool). The 
SVP is supposed to serve about 3,000 people within a radius of 20 km. On an average day, approximately 
40 patients are seen, 40% for lab tests. Each SVP also has 5 beds for day observation and treatment. The 
physiotherapy room also has 2-4 beds for treating patients.
ORGANIZATION OF SVP (KONIMEH RAYON)
AKUSHERAK￾GYNECOLOGY
PEDIATRICS LABORATORY THERAPIST
PROPHYLAXIS
(VACCINATION)
PROCEDURE
ROOM
REGISTRATION
CHIEF
DOCTOR’S
CABINET
AKUSHERKA￾GYNECOLOGY
CABINET
PEDIATRICI
AN/
THERAPIST
CABINET
DENTIST
CABINET
PROCEDURE 
ROOM
PROPHYLAXIS
(VACCINATION) 
ROOM
BEDS (10) LABORATORY
AKUSHERKA
CABINET
LABORATORY OBSERVATIO
N BEDS
PROCEDURE 
ROOM
DRUG 
STORE
PROPHYLAXIS
(VACCINATION)
ROOM
CHIEF 
DOCTOR’S
CABINET
DENTIST 
CABINET
PHYSIOTHERAPY 
CABINET
SURGERY 
CABINET
46
Attachment A4: Program design
1. Program Description
The project will operate at the oblast and rayon level through capacity building of providers and at the 
community/household level in the experimental areas through extensive IEC activities and work with 
muhalla committees, Red Crescent volunteers, and schools.
Oblast level. An overall project steering committee, including the Oblast Health Chief, the Chief 
OB/GYN, Chief Pediatrician, Chief Nurse and HOPE staff will develop and review the project workplan. 
This committee will meet quarterly to review progress, adjust the workplan to changing needs and 
opportunities, and approve training plans. No formal agreements will be developed at this time at the 
oblast and rayon level, because all agreements would have to be processed and approved at the central level 
and a “prikaz” law issued.
The project will develop a core team of master trainers/trainer-of-trainers/supervisors at the oblast and 
rayon level to assure that the MOH will be able to replicate activities developed by the project in the 
experimental rayon. These trainers will provide regular follow-up and facilitative supervision to the 
individuals they have trained. Major emphasis will be placed on establishing evidence-based and 
internationally accepted protocols for managing maternal and child health problems and provider 
interpersonal communication and counseling skills.
The project will follow following steps in implementing its training and IEC activities to bring about 
behavior change of the target population:
- need assessment
- recruit trainers/educators
- develop training/IEC materials/curriculum
- conduct TOT
- participatory training courses
- follow-up and on site supervision
- continued education
- quality improvement
- audit/evaluate
Based on the results of the health facility assessment, the project has developed a list of priority 
interventions/topics that will be addressed by this project:
t Management of high and low-risk pregnancies
t Essential and emergency obstetrics
t Newborn and post-partum care
t Micronutrient deficiencies in women and young children (anemia and iodine deficiency)
t Baby-friendly maternities and exclusive breastfeeding during the first six months
t Integrated management of childhood illness
t Adult education techniques and counseling, and
t Consumer health education and mobilization
For each topic/intervention, project staff will determine whether the information collected to date is 
sufficient, or whether additional information needs to be collected through focus group discussions, 
observations, key informant interviews, surveys, OR, or others methodologies. With the support of 
collaborating public agencies (e.g., the Institute of Reproductive Health, Institute of Pediatrics) and 
international donors and NGOs (e.g., GTZ, AVSC, UNICEF, Peace Corps), available curricula will be 
identified and adapted with local consultants and staff. 
Several of the listed agencies have assured Project HOPE that they will make their staff available for 
training, as long as Project HOPE will cover their travel and per-diems. The original trainer-of-trainers 
47
course will involve project staff and 3-4 trainers from the oblast level, and a similar number from the rayon. 
One of the first courses will cover adult education methodologies, with trainers from Peace Corps, AVSC, 
JHPIEGO, and other agencies as available. The master trainers at the oblast and rayon level, will be 
expected to replicate the training activities, at the rayon level with technical and logistical support from 
Project HOPE. With AVSC support, Project HOPE staff and the local master trainers will also be trained 
in facilitative supervision by an AVSC consultant. Supervision checklists will be developed for each 
technical area and assess the extent to which protocols are being followed and clients educated and 
counseled. 
In addition to developing a group of master trainers, HOPE will also strengthen obstetric and neonatal care 
in the Navoi City referral facilities. After conducting verbal autopsies of maternal deaths and neonatal 
deaths in Navoi City and Kyziltepa, retrospectively, as well as on an ongoing basis, specific areas to be 
strengthened will be determined and local/international consultants identified to provide training. Specific 
areas that might be included are management of pregnancy-induced hypertension, management of obstetric 
emergencies and post-abortion complications, neonatal resuscitation, management of premature and/or 
small for gestational age newborns; etc. Protocols and curricula for some of these topics are already 
available in Russian from HOPE programs in Kazakhstan and Georgia and will be adapted.
Rayon. At the recommendation of the MOH Oblast Chief, Project HOPE will initiate its activities in 
Kyziltepa, one of the rayons not to be served by the World Bank project. Project HOPE will set up a rayon 
coordinating committee with the rayon health chief and his chief OB/GYN and pediatrician to plan, 
implement, and monitor the rayon activities. In this rayon, HOPE will work with health providers at all 
levels, from the FAPs to the rayon hospital, depending on the specific project intervention. Building on the 
abundance of health providers in the region, which allows time from problem analysis and OR approaches. 
QA/QI methods will be introduced at the health facility level. Given AVSC’s strong presence in the 
country and the fact that its director has been trained in COPE, (a QI tool). HOPE is considering requesting 
AVSC assistance in using COPE for introducing health-facility based problem analysis and problem￾solving. In addition, HOPE may also consider experimenting with peer training and role-modeling, using 
PCI’s approach developed for vaccinators in Indonesia. Given that access in the region is not a real issue, 
the key to reducing maternal and child mortality and morbidity is an increased focus on evidence-based 
methods and quality.
Navoi City. In Navoi City the project will work closely with the city polyclinic, children hospital and the 
maternity unit of the regional hospital. A set of core trainers from these institutions will be developed. The 
maternity unit will serve as the center for reproductive health and the children polyclinic will be the focal 
point for IMCI activities. The TOTs will be conducted at the city polyclinic and the maternity unit of the 
regional hospital. Apart from the MOH, in Navoi City the project will also work closely with the mining 
industry and implement IMCI and maternal health activities in their setting. However, the project will 
negotiate and examine the feasibility of these interventions beforehand with the medical department of the 
mining complexes.
Community/Household Level. A further key to health improvements in the region is increasing 
consumer/client active participation in health. HOPE will work with mahalla committees, schools, and 
community-based volunteers of the Red Crescent Society. In addition, the project will develop information 
materials for women of reproductive age and children under five, with an emphasis on increasing 
knowledge and active consumer participation in healthier lifestyles. Given the importance of other adults 
(husbands, mothers-in-law, etc.), IEC activities will also target these key decision-makers. As part of a 
larger project, complementing existing CS projects, HOPE (in coordination with UNICEF, BASICS, 
PAHO, and WHO) will develop a Mother’s Card, providing key information on danger signs necessitating 
timely care-seeking, home management of basic conditions, and feeding advice. Two cards will be 
developed, one for the neonatal period, and a second for children under two years of age.
All women of reproductive age and children under five will automatically be part of the target group and 
accessed through the project and counterpart providers. It is unlikely that more than a small proportion of 
high-risk families would be missed, given the comprehensive outreach of the local health care system and 
the vast majority of women delivering within the formal health care setting.
48
In order to reach the communities a series of advocacy meetings will be held at the rayon and community 
level (Kishlak level) in Kyziltepa. While in the city these meetings will be held at the microrayon level of 
the city unit. The existing administrative structure of the Rayon and its various level will be sensitized and 
mobilized to support project activities.
Simultaneously, the current linkage between household and the health care provider will be strengthened, 
particularly during prenatal and postnatal visits by the Akusheraks and doctors. Their role will be extended 
from IPC to form support groups and provide group health education at the community level.
The other existing resource is the school nurse who comes in contact with school children on a regular 
basis. The nurses will be utilized to promote nutrition, hygiene and the community component of IMCI 
through children.
Before implementing community interventions, the lessons-learned by the Health Reform Project of 
Abt/USAID in reaching and mobilizing communities in Fargana will be examined. The project will work 
closely with the reform project in utilizing its first hand experience.
2. Choice of Interventions and Strategies
Generalizing broadly, the introduction and systematic use of evidence-based modern protocols and active 
consumer participation in health maintenance and improvement are the two key strategies of the project for 
reducing unnecessary mortality and morbidity in women of reproductive age and children under five in the 
target area. Within this context, the following key technical interventions were selected based on health 
statistics, baseline survey results, and MOH priorities:
ß Maternal and Newborn care
ß IMCI
ß Breastfeeding
ß Family planning
ß Iron and iodine deficiency
In addition, the project will be responsive to the issue of lack of drugs, supplies and equipment, in great 
part due to the non-convertibility of the local currency. Project HOPE will work with international donors 
to improve the availability of basic antibiotics and contraceptives, and assist the oblast with targeted 
donated product. The drug supply management module developed by Management Sciences for Health will 
be introduced at the Oblast and Rayon level.
The project will build on the strengths of the local health care system, the abundance of human resources 
and a strong system of community outreach and visitation.
Project HOPE’s local staff is highly motivated, but lacks professional experience in evidence-based 
protocols and adult education methodologies. HOPE staff will participate in all trainer-of-trainer courses 
and receive additional in-service education through the Project Director to be able to serve as role models
and mentors of counterpart staff. 
3. Changes, Additions or Deletions of CS Interventions between the Agreement Program 
Description and those Discussed in the DIP
As mentioned above, the project is adding a focus on iron deficiency anemia and iodine deficiency, given 
the importance of these micronutrient deficiencies in the target area.
4. Innovations, New Methods, Strategies, or Materials 
Most of the project methods, strategies, and materials are new in the project area. For example, Uzbekistan 
is still finalizing its facility-based IMCI approach and a community-based approach has not yet been 
49
developed. Project HOPE serves on the national taskforce for the facility-based IMCI and develop 
materials for community/household IMCI. Modern protocols for managing deliveries (e.g., partograph) or 
child illness (IMCI) have not been introduced to the target area. In addition, adult teaching/learning 
methodologies differ significantly from the traditional teaching style of lecturing. 
As perinatal makes up a major portion of the IMR, emphasis will be given to case management of 
newborns and the neonates. Standard protocols on case management of these babies will be introduced 
following WHO guidelines. All neonatal deaths will be evaluated using verbal autopsy and audit of medical 
records. Efforts will be made to develop collaboration with American International Health Alliance and US 
based institutions to utilize expertise in the area of neonatal health. 
Facilitative supervision and QI methods at the health facility methods (e.g., COPE) have not yet been used 
in Navoi. IEC materials at the health facility level are very rare (usually only hand-made posters for the 
wall with non-standardized health messages are available) and absent for the family/household level. The 
project will develop a Mother’s Card with the major danger signs indicating the need for care-seeking, 
home-based care advice, and basic child feeding and nutrition information. This Mother’s Card will be 
dove-tailed with the health-facility-based IMCI approach. The developed methods and materials will be 
shared with the Institutes of Reproductive Health and Pediatrics, as well as other interested organizations in 
Uzbekistan for replication and scaling-up purposes.
5. Operations Research Activities 
Operations questions requiring operations research will be identified throughout the course of the project 
and may include the following:
t Impact of IMCI training on the appropriate use of antibiotics for ARIs and diarrheas;
t Impact of use of the partographs on the use of C-sections and drug interventions;
t Comparison of various IEC approaches on changes in knowledge and behavior;
t The use of QI methods by health facilities on quality of care.
t Changes in the quality of care of the providers after introduction of protocols for ANC/PNC and 
newborn care.
The following additional issues will be explored:
 
Risk factors for not exclusively breastfeeding
Quality of IMCI services at the polyclinics
Effectiveness of ORT campaign in the project area
Barriers to family planning in the target area
Beliefs and practices during pregnancy and postpartum period
Complimentary feeding practices in children 6-24 months
Feeding pattern during illness (ARI, diarrhea and fever)
IUD users and problems associated with IUD use 
6. Process Undertaken to Select and Involve Relevant In-Country Organizations in the Design and 
Implementation of the Program
The project worked with the MOH Oblast Health Chief, the Chief OB/GYN and Deputy Chief of the oblast 
Health Department in the selection of the priority interventions and to a limited extent in the development 
of this plan. At their recommendation, the project will strengthen its focus on micronutrients (iron and 
iodine deficiency), work with community committees (Makhalla committees) and community leaders, the 
Red Crescent Society, Healthy Generation, teachers, doctors, and other health providers. At the oblast 
level, the MOH would like to see a core group of master trainers and TA to the oblast and eight rayon 
hospitals, and increased community participation in health in the experimental rayon. 
Increasing the active participation of the oblast and rayon MOH also will be part of the capacity-building 
component of the project. The experimental rayon was not involved in the development of this DIP, since 
50
the decision that Project HOPE should initiate activities in Kyziltepa was not made by the oblast 
administration until mid-May. The health facility assessment included exit interviews with clients and the 
information they provided was taken into account. People in the oblast are not yet accustomed to 
participate in participatory planning processes and freely provide their opinions or ideas.
In addition, the Project Director has developed a network of professional contacts that will enhance project 
implementation and technical assistance to the project, including the Institutes of Pediatrics and 
Reproductive Health of the MOH, Peace Corps, AVSC, GTZ, and UNICEF.
7. Program Fit with the USAID Mission Strategic Objective (SO) 
The project has been in periodic communication with the USAID Mission. Cheri Vincent, Health Advisor 
accompanied Dr. Siddiqi to Navoi on his first trip and has assisted with contacts and recommendations. 
The project contributes to the CAR Mission’s goal of Healthier Central Asian Populations and its IR 3.2.3 
of Increased quality of health care and IR 3.2.4. Better informed citizenry about personal health care rights 
and responsibilities. 
USAID Collaborating Agencies. USAID is in progress of negotiating the Central Asia Quality Health Care 
Project, which includes Uzbekistan, to support technical assistance, training, and limited equipment and 
commodity to “increase select populations’ equitable access to quality primary health care.” This project 
will include health policy inform, the development and replication of existing successful general 
medicine/family medicine health care delivery models, and consumer awareness raising in preventive 
health care, health care rights, and responsibilities. The project will be first implemented in Tier I oblast 
and be replicated in Tier II oblast. Navoi is a Tier II oblast. IMCI and reproductive health are highlighted, 
among other activities, in the USAID RFA. Project HOPE will coordinate with USAID’s contractor to 
assure that the CS project will link and enhance these new USAID/CAR activities by keeping the 
contractor apprised of lessons-learned in Navoi and in determining activities that can be replicated in the 
target area. Other contractors include AIHA, CDC, and Project HOPE (TB activities). 
8. Other Bilateral or Multilateral Organizations
Other donors, currently active in Uzbekistan include:
The World Bank (Health One project) with the purpose of 1. Strengthening rural primary health care 
facilities; 2. Pre- and in-service training of health professionals in general/family medicine; and 3. 
Strengthening of finance and management system. While Navoi is one of the three oblasts involved in this 
project, activities have focused on Fergana, and the perceived impact in Navoi is limited. To date, the 
World Bank has supported the construction of 12 SVPs and a one-year retraining course for 40 doctors in 
general medicine (ongoing, with assistance from the British Know-How Fund). The training of additional 
doctors, nurses, and managers of SVP is planned. The World Bank is working in two experimental rayons, 
Nurata and Konimeh, with Kyziltepa and Khaterchi as controls. 
· EU/TACIS started a project in 1999 to complement World Bank and USAID activities to promote 
preventive health care policies, develop preventive medicine programs, assist in reorganizing the 
public health care system; and assist in upgrading the management system in the same oblasts. 
· The Know-How Fund – retraining of physicians as GPs
· The Peace Corps has assigned a volunteer to share her time between the oblast hospital and Project 
HOPE and is considering the placement of additional volunteers to support the project activities.
· CDC is working with the USAID Mission and Project HOPE on the implementation of the TB DOTS 
program. Project HOPE is not currently working on TB in Navoi, because of Mission concerns that 
two USAID funding sources could be mixed. However, TB is a high priority for Navoi health 
officials, and HOPE will encourage the Mission to revisit this issue later on.
· MSF/Holland, WHO, and UNICEF, with some support of the Government of Japan, are working in 
the Autonomous Republic of Karkalpakastan on such areas as TB DOTS implementation, ARI, CDD, 
IMCI, and iodine deficiency
51
· GTZ/EPOS, UNFPA, CMS of USAID (recently completed), and UNAIDS are working in different 
areas of the country on reproductive health issues. GTZ has already shared its reproductive health 
materials with Project HOPE, and a HOPE trainer participated in GTZ’s reproductive health training 
course in mid-May 
· AVSC (supported by UNFPA) has trained providers in family planning and counseling and is willing 
to share expertise in reproductive health, facilitative supervision, and QI methods (e.g., COPE). 
9. Special Health Initiatives in Uzbekistan
IMCI is the major new health initiative in Uzbekistan. According to the Director of the Pediatric Institute, 
charged with IMCI implementation oversight, IMCI is in the final stages of adaptation. However, in a 
meeting on 5/12/2000, Project HOPE staff also met a WHO consultant charged with conducting OR for the 
food box of IMCI. According to the Director, IMCI is currently stagnating due to the fact that the World 
Bank has not been forthcoming with funding the trip of the two WHO staff from Copenhagen to review the 
adapted IMCI materials. Given the IMCI experience of Project HOPE’s CS Project Director, Navoi was 
selected as one of the three pilot implementation oblasts sites for IMCI, and the CS Project Director serves 
on the national IMCI taskforce.
The MOH is conducting surveillance activities on poliomyelitis. Routine immunization with OPV is in 
place, and the current coverage levels are very high. At present there is no mass campaign like NIDs in 
place. Last year, no cases of polio were reported in the Navoi region. 
10. Participation of Community Leaders, and Community Groups 
Given the local environment, community leaders have not yet been included in the design and 
implementation of activities. Community members participated in the health facility assessment through 
exit interviews and in the KPC survey. They will also be included in the development of IEC materials 
through focus group discussions and other qualitative methodologies. In addition, the project will work 
with the mahallas committees. The Mahalla Committees holds the administrative and political power base 
at the Kishalak level. They are representatives of their communities and share their concern with the Rayon 
Hokimyat, which is the highest body in the rayon. These committees are represented by various senior 
citizens and groups in the community. The project plans to mobilize them for its activities through a series 
of advocacy meetings with them.
The project plans to explore collaboration with the school system using two strategies, the training of 
school nurses in RH and CS issues within the context of health provider training, and training courses for 
teachers in reproductive health. The development of curricula and training of select school teachers will be 
scheduled in the third year.
11. Local Government Organizations Involved with Primary Health Care 
See Section B.2, for a detailed description of the local government involvement in PHC.
12. Other US and International PVOs
There are no other U.S. and international PVOs in Navoi. As described earlier, the project area is still 
suffering the long term consequences of past isolation. The project has made excellent contacts with other 
international donors and NGOs located in Tashkent and will bring their expertise to the target area. 
Counterpart International was recently awarded a CS-XVI grant. The project will provide lessons-learned 
and explore sharing international TA with Counterpart.
13. Private Sector
The existing private sector in Navoi consists of physicians mostly providing dental care, and care for heart 
diseases and physiotherapy. These specialists are not providing child or maternal care at present, thus 
limiting their inclusion in the project activities. However, the project will monitor the private sector and its 
52
development on a regular basis and will look for opportunities to incorporate it within the project activities 
as appropriate. 
14. NGOs
NGO involvement in health care is very limited in Navoi. Healthy Generations and the Uzbekistan Red 
Crescent are the two organizations outside the main health system providing first aid and health promotion 
to the population in the region.
The Red Crescent Society provides support mostly through its volunteers in the schools and Mahallas. It 
has about 8,000 volunteers nationally who are trained in first aid. It also provides food to families in need 
whenever it receives humanitarian assistance from other countries. The Government of Uzbekistan, 
International Red Cross and Red Cross Societies of different countries support the Red Crescent. In Navoi, 
the Red Crescent Society has a staff of seven, and about 3-5 paid individuals in each of the rayons, as well 
as about 100 volunteers. They work with pensioners and have trained about 500 students and workers in 
first aid. The volunteers teach school children and recently conducted a competition on hygiene and 
sanitation. The Red Crescent works with about 3,000 families in Navoi, selected by the mahalla 
committees, because families are either very large or have a disabled child. In the target rayon, there are 25 
volunteers working. The Red Crescent Society is very interested in working with the project and 
participate in some of the training. In addition, their beneficiary families are clearly at elevated risk for 
poor health status.
Healthy Generation is a relatively a new organization mostly supported by the state. It has a nationwide 
network and offices. In Navoi, it operates a small clinic and an ambulatory unit which provides medical 
care and medicines, mostly free of charge. Healthy Generation also reaches out to the communities and 
organizes seminars for the women groups on various health issues and publishes health promotion 
materials for people.
Another organization that works on a very limited scale in Navoi is called The Fund for Disabled. It 
receives limited support from Save the Children/UK and works with 8,000 children that have lost one or 
both parents. Their Director indicated her willingness to collaborate, where feasible.
As the Navoi oblast is becoming more open to the outside world, it is expected that existing national NGOs 
will branch out to this oblast (e.g., women’s groups) and that new NGOs will form. The project will be 
open to developing a working relationships with groups that share common goals or have access to the 
beneficiary group of the project. This also includes professional groups of medical providers and teachers, 
as they begin to establish local chapters.
 
53
Attachment A5: Partnerships
STRENGTHENING LOCAL PARTNER ORGANIZATIONS
1. Local Project Partners
The project will work with the Oblast Health Department (including the health care system of the mining 
and industrial sector), the Kyziltepa Rayon Health Department, the Red Crescent Society, Healthy 
Generation, and the mahalla committees.
2. Capacity of Local Partners
The available human resources of the Oblast, city and rural health care system have been described in detail 
in section B.2 and E. As pointed out in the HFA, facilities at all levels lack essential pharmaceuticals, 
supplies, and equipment, and often patients are requested to purchase prescriptions in the local pharmacy. 
The vast majority of health providers have also not participated in training in the project interventions in 
the previous year and need to be trained in the use of international management protocols and patient 
education and counseling. 
The industrial health care system receives additional resources from its profits. As a result, its facilities are 
better stocked and equipped. Since providers are paid higher salaries, the industrial health care system 
draws the brightest and most motivated health care workers. Even at first glance, there are more patients 
awaiting services at the visited health facilities; providers appear busy and occupied with patient care; and 
the available equipment is more modern.
However, providers in both types of settings have expressed great interest to participate in technical 
updates through the program.
With respect to management capabilities, supervision visits do not assess the quality of care provided by 
individual health workers, with constructive feedback and incentives on how to improve performance. 
Supply and logistics are driven by the number of population covered, rather than by actual local needs. The 
current information system is loaded with data that are hardly used. The data collection methods are poor as 
is the quality of data. The health reform project will be working on the improvement of health information 
system and develop a population-based computerized data base for the Oblast. 
Given national health reform efforts managed by the GOU with the World Bank, USAID, and other 
partners, the project does not plan to become involved in health care financing issues at this point in time.
3. Program Approach to Strengthening the Capacity of its Partners
Technical Strengthening. The project will develop a TOT team at the oblast and rayon level. This team, 
with assistance from project staff, will be responsible for the training of all providers involved in 
reproductive and child health, counseling and patient education, as well as for post-training follow-up and 
supervision. In addition to technical training, the TOT team will receive training in adult education 
methodologies and facilitative supervision. Prior to each new technical training, a training needs 
assessment will be conducted with a sample of the targeted providers, and the findings integrated into the 
curriculum. In addition, providers at the referral hospitals (rayon and Navoi City) will be trained in 
essential and emergency obstetric care and newborn critical care. 
Since the rayon and city health team has little understanding of primary health care management a one 
week course on primary health care management spread over a period of 4 months will be developed for 
the managers of the centers.
54
Quality Improvement Methodologies. To improve quality of care, the project will strengthen technical and 
management skills at the health facility level, using a variety of QI methods. Given the current top-down 
approach of management, the project considers it unwise to introduce more democratic, analytical problem￾solving approaches until the latter part of the second year. Introduction to participatory teaching 
approaches, novel interactive approaches to supervision, and training in customer counseling and education 
will provide the foundation for health-facility wide analysis and planning, that will involve provider and 
customer perspectives about current health service delivery and system improvements. The project plans to 
work with AVSC and other organizations in the region to develop a commitment to QI at the health facility 
level. A small manageable number of health facilities will be included in the first phase. As these facilities 
complete their first QI projects, health staff from additional facilities will be invited to listen to their 
experiences, findings, and improvements. In the second phase, successful health facilities will be invited to 
send staff to assist in the training of the second group 
Information System. The project will work to strengthen the current information system and will introduce 
the concept of “data for action”. The project will work with the Oblast Statistical Department to 
computerize their data and produce meaningful tables and graphs of the collected data. Similarly, at the 
Rayon level, the data will be analyzed and presented in a compatible format with the Oblast level. Later on, 
when the Health Reform Project gets on board, the project will work closely to ensure that the staff 
managing the health information system in the Rayon and the City get appropriate training like in the other 
intervention areas.
Coordination. All activities will be made in consultation and coordination at the central level with the 
MOH and various institutions particularly on IMCI and reproductive health. All development partners will 
be coordinated through the inter agency health meeting held at USAID on a bimonthly basis. At the local 
level the project will coordinate on a regular basis with the World Bank Project Implementation Unit, 
TACIS and the Health Reform Project of USAID. 
4. Jointly Developed and Signed Agreements
Project HOPE has a Country Agreement (see Annex III), but does not intend to develop formal agreements 
with its local partners at this time. All agreements have to go through the central level formal approval 
process, which would be cumbersome and potentially stall the implementation of project activities. 
Through the steering committee, the project will developed mutually agreed upon annual and quarterly 
workplans with its partners. The issue of developing formal agreements at the project level will be 
revisited periodically and assessed for feasibility.
STRENGTHENING THE PVO
1. Strengthening of Project HOPE
This is Project HOPE’s first CS project in Uzbekistan and USAID-funded CS project in the CAR. While 
HOPE headquarters and field staff can draw on lessons-learned through previous and current activities in 
the NIS (foremost humanitarian assistance and TB DOTS training and implementation), this oblast 
partnership to improve child and reproductive health presents new challenges. 
At the headquarters level, the program will be managed by Project HOPE’s maternal and child health staff 
and regional team. This team has worked in developing countries in the Americas and Africa and has 
limited experience in the NIS. This is also HOPE’s first CS program with a major focus on obstetric and 
newborn care. To address these issues and build headquarters capacity, HOPE is developing new 
partnerships to benefit this CS project (e.g., University of Michigan Medical School, and consultants and 
HOPE volunteers that have assisted with secondary and tertiary obstetric and pediatric programs in the 
past). The rigors and M & E activities associated with the implementation of BHR/PVC CS projects will 
also benefit HOPE’s other programs in the region, by increasing knowledge and skill levels of technical 
and administrative staff in the region for monitoring health programs.
2. Monitoring and Measuring Increased Capacity of HOPE
55
Current Capacity. 
t No ongoing CS/MCH/RH project in the NIS.
t Other programs in the region are weak in the areas of formal workplans, results indicators, M & 
E systems, including external evaluations.
t HC CS staff lacks experience in the region.
t Limited headquarters expertise in obstetrics and neonatal care.
Capacity at Project End
ß Expanded consultant base to cover obstetric and newborn care needs of CS projects.
ß Increased attention to obstetric and newborn care in new CS proposals in regions with high neonatal 
mortality rates.
ß Curricula and protocols covering essential and emergency obstetric care and newborn care in 
Russian/Uzbek.
ß Procedure and guidelines for assessing neonatal mortality through verbal/social autopsies developed.
ß A second CS project proposal developed in the region and submitted for funding to a donor, based on 
lessons-learned in Navoi.
ß At least one technical MCH staff with experience in the region.
ß M & E strengthened in other projects in the region.
56
Attachment A6: Health Information System
Monitoring:
The program will monitor its progress, both internal and external, by tracking inputs, outputs and activities 
according to the project workplan. During the forth quarter of the first year project staff will break down 
the activities in the work plan into sub-activities called “tasks”, and assign these to specific members of the 
project team or to collaborating organization team members as well as setting a schedule for their execution 
and completion. This will be done in a participatory fashion to produce maximum buy-in by both staff and 
counterparts. Subsequently project staff will meet monthly to review progress in completing tasks and to 
modify or adjust schedules as external or internal factors cause changes. 
On a quarterly basis, as described in Section 1.E Program Design, the overall Project Steering Committee. 
including counterparts, will meet to similarly review progress. Staff members and managers will prepare 
quarterly progress reports using the task completion targets as the basis for those reports. Where external 
factors had been identified which interfered with completion of tasks, and which were related to Oblast or 
Rayon health system factors, this quarterly meeting will provide the opportunity to discuss these barriers 
and to collaboratively plan strategies and related activities to overcome them. 
 An annual meeting, with the addition of USAID representatives and those of other relevant organizations, 
will be carried out in similar fashion, but will provide a formal review of the strategy of the project, and 
allow adjustments to be made as appropriate. This detailed Task-Based Workplan and monthly summaries 
will provide feedback and reminders to project staff regarding upcoming tasks as well as those in process of 
implementation. If appropriate, separate meetings will be held with rayon and muhalla leaders and 
counterpart staff, with the same review and updating of objectives, activities, and tasks relative to the 
particular rayon/community in mind.
The program will also monitor results of its activities in terms of changes in behavior of providers and 
households/families/women, and changes in conditions in health facilities. Provider behaviors are expected 
to become more similar to national/international protocols as the result of training and supervisory follow￾up after training. A baseline HFA has provided data regarding patient care practices, including the results 
of both direct observation of providers giving care to sick children and pregnant and post-partum women, 
and exit interviews of the clients. Newborn and delivery care will be assessed during the second half of 
Year 1 and the beginning of Year 2. While a full HFA/Situation Analysis will be repeated only for the final 
evaluation, observation s and exit interviews will be carried out during post-training supervisory visits. The 
results of these will be fed back to the providers, in groups and individually, and progress toward behavior 
change documented.
Quality of care, and quality of other activities such as clinical and adult training, will be monitored and 
improved using Quality Improvement methods, such as COPE, supervision checklists, and other methods 
(e.g., participatory definition of standards in critical areas of behavior, self-assessment or mutual 
assessment of performance, analysis of data and of causes for non-quality performance, development and 
implementation of interventions, assessment of the effectiveness of the interventions in bringing about 
improved quality, and replanning as needed for further improvement). These quality improvement 
activities will be documented using standardized forms based on relevant case management or training 
guidelines and protocols/algorithms as well as the supervisory checklists being used in an ongoing fashion, 
and compiled by the project as documentation of progress in improving quality. The QI methodology 
involves teams of persons involved with particular processes (e.g., pediatric staff at a PHC facility) to be 
the ones working through problems associated with those processes, hence has the element of participation 
which is critical to eventual acceptance of changes in the processes under examination.
Changes in conditions in health facilities, for example availability of selected essential drugs, will be 
monitored by supervisors using a checklist of items including some selected from the overall HFA, as well 
as by the staff of the facility itself. Supervisors will seek to move toward a facility managed system of 
ongoing internal supervision and checking to improve the sustainability of these efforts. 
57
The project will facilitate the carrying out of audits of neonatal and maternal deaths, both to determine their 
medical cause and to explore the steps leading up to the death. A doctor or other provider will be assigned 
to investigate the death using a standardized form, and the situation will be reported to a group of 
providers, either at the facility, rayon, or oblast level and discussed with the objective of determining how 
to avoid similar deaths in the future. The oblast and rayon health systems will be encouraged to make 
these audits on their own (and include deaths beyond the neonatal period), to allow for sustained 
improvement activities after the HOPE project is no longer present.
The project will experiment with LQAS type sampling and survey method to monitor changes in maternal 
knowledge and practices in areas in which the program is known to have carried out activities. Where 
results of these samples suggest that coverage may be deficient according to targets set in advance (e.g. % 
of mothers who recognize signs of pneumonia, % of mothers who can recite signs of dehydration, % of 
mothers who know danger signs in newborns), further investigation will be carried out to more definitively 
assess the deficiency as well as to determine how to overcome it.
A detailed list of indicators and monitoring/evaluation data gathering methods is listed in Section 1.D of 
this DIP as part of the table entitled PROGRAM GOALS AND OBJECTIVES. This table would be 
applicable to both monitoring and evaluation activities.
Evaluation
The project will carry out a mid-term and final evaluation as shown in the workplan. The midterm 
evaluation will review documents, carry out focus group discussions and in depth interviews, and examine 
data from the project database. We anticipate that this midterm evaluation will be a slightly more detailed 
review of progress and activities than the annual monitoring review described above, involving the use of 
external persons to obtain a more objective view of the project’s internal and external relationships and 
functioning, and providing an opportunity for a more in-depth discussion of possible changes in strategy as 
needed to reach the project’s targets and objectives in the time remaining. Full participation of counterpart 
staff at oblast and rayon/municipality level will be emphasized for the midterm evaluation (as well as the 
final evaluation), both to facilitate acquisition of the skills in this kind of assessment as part of capacity 
development, and to facilitate an active response to the results of the evaluation on the part of local officials 
and staff. This will facilitate preparation of the Action Plan for implementing the recommendations of the 
evaluation team, which may well involve changes in both the project and the host country sponsored 
activities and inputs. 
As already noted, the Final Evaluation will involve a repeat of the KPC survey, the HFA for child health 
activities, and a combination of the Reproductive Health Assessment and the Situation Analysis for 
delivery and newborn care assessment. In addition the evaluators will carry out focus group discussions, 
in-depth interviews, and reviews of documents as in the midterm evaluation. The team will involve 
external consultants, project staff and counterpart staff, and representatives from other relevant agencies in 
an attempt to include all stakeholders in the project. Instruments will be modified and adapted to answer 
strategic questions particular to the Uzbekistan and Navoi situations. 
Changes in the Project Evaluation Guidelines
Project HOPE proposes that the midterm evaluation be conducted in October of 2,001 to give the project 
additional time to recover from a slow start-up period and to take advantage of the somewhat cooler months 
in the fall.
With respect to the Midterm evaluation guidelines, Project HOPE proposes that the external evaluation 
consultant and HOPE staff spend 1-2 days prior to the evaluation on reviewing the status of the Uzbek 
health reform. This information should be taken into account when making recommendations about 
modifications to the workplan for the final two project years.
58
The final project evaluation should also address the achievements of the project within the context of the 
larger health reforms, and to what extent the health reform stalled or moved along the project objectives 
and how project activities have/have not complemented health reform efforts.
Dissemination of Monitoring and Evaluation Results
The project will emphasize the use of results from both monitoring and evaluation in its management, as a 
learning organization. Monitoring results, as noted, will be shared directly with those involved with the 
processes, and at the quarterly and annual review meetings these will be used as the basis for consideration 
of shifts in project emphasis or strategies. Monitoring and evaluation results will also be shared with HQ 
backstopping staff, who will contribute from their perspective to the planning and replanning which will 
follow the availability of those results. Evaluation results will be more formally written up in summary or 
paper fashion, and circulated widely among stakeholder organizations and other partners, as well as 
prepared for publication as appropriate. 
59
Attachment B: Assessment Methodology
This mid-term evaluation report is based on a two week field investigation of the project by the evaluation 
team and is supported by baseline assessments and periodic surveys. The field investigation occurred April 
2-12, 2002. The evaluation team and process was organized by Project HOPE according to the written 
guidelines for mid-term evaluations provided by USAID. It was a participatory evaluation process that 
included representatives from the key stakeholders in the project, with an external team leader. 
The team was centered in Navoi, Uzbekistan, where the project office is located, and made day trips to 
many sites where the project is being implemented. Due to the size of the team and the number of people 
to meet, two sub-teams were sometimes formed. The mid-term evaluation team conducted interviews with 
providers at hospitals and clinics, observed provider-client interactions, and held exit interviews with 
mothers at primary and tertiary care facilities. Discussions were held with inpatients in post-natal care
departments of maternity hospitals and with breastfeeding support group members. The evaluation team 
observed IMCI training and debriefing sessions, as well as a “Best Nurse Competition” and reproductive 
health “Poster Competition.” Informal discussions and a meeting were held prior to the end of the 
evaluation to share and synthesize observations and reports. A final day was spent together developing 
findings and recommendations. 
The entire process was extremely well organized. In offices in Tashkent and Navoi, and at the various 
facilities the evaluation team was welcomed with enthusiasm and a celebratory atmosphere. The project 
staff worked very hard and spent long hours to make the time of the evaluation team productive.
60
Attachment C: List of Persons Interviewed 
Tashkent
 1. Dilbar Makhmudova Director of National Pediatrics Institute
 2. Mekhmon Akhmedov Deputy of National Pediatrics Institute,
Chief of the National IMCI Center, Tashkent
 3. Mark McEuen Abt Associates, Project Director
 4. Irina Stirbu Abt Associates, IMCI Coordinator
 5. Farkhad Fuzailov World Bank Health Project Coordinator
 6. Andreas Tamberg USAID/Tashkent Health Advisor
 7. Asomidin Kamilov Deputy Minister, MOH
 8. Vladimir Verbitskiy Head of WHO Mission in Uzbekistan
 9. Stafania Avanzini WHO Coordinator for MCH Programs
10. Feruza Fazilova Chief of the RH Center, Tashkent
Navoi City
OBLAST HEALTH DEPT
 1. Nasirov Abdurakhmon Chief of Oblast Health Department
 2. Nuriddin Shaymanov Chief Pediatrician of Navoi Oblast
 3. Bozorova Muazzam Chief Gynecologist of Navoi Oblast
TOT TEAM
 4. Allabergenova Dilorom Project HOPE Pediatrician/IMCI &BF Trainer
 5. Muratova Nigora Project HOPE Gynecologist/BF & RH Trainer
 6. Eshankulov Yuldosh Kiziltepa Coordinator, IMCI & BF Trainer 
 7. Gaybullaeva Nigora IMCI Trainer
 8. Ashurova Lola IMCI Trainer
 9. Sharapova Solikha IMCI Trainer
 10. Kalimbetov Ravshan IMCI Trainer
 11. Ibragimova Ibodat IMCI Trainer
 12. Karimova Gulsun RH Trainer
 13. Khamroeva Makhfuza RH Trainer
 14. Gulyamova Aziza RH Trainer
 15. Shodieva Dilya RH Trainer
 16. Khalimova Manzura BF Trainer
 17. Shaymanov Nuriddin IMCI Trainer
 18. Bozorova Muazzam BF Trainer
 19. Kodirova Zarifa BF Trainer
 20. Ruzikulova Nodira BF Trainer
 21. Bakirova Anisa BF & IMCI Trainer
 22. Asadova Gulchekhra IMCI Trainer
 23. Askarova Dilbar IMCI Trainer
 24. Bokieva Mavluda BF Trainer
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 Chiefs of Hospitals from Other Rayons 
 1. Khalilov Shavkat Chief of Nurata
 2. Norbaev Erdon Chief of Kanimekh
Local NGO Representatives
 1. Olga Sashina Women’s Adaptation Center
 2. Kamila Association of RH
 3. Larisa Yurikova Association of Business Women
 Chiefs of Pilot Rayons
 1. Orifjon Jumaev Kiziltepa Rayon
 2. Askarova Dilbar Chief Pediatrician of Kiziltepa Rayon
 3. Kuvvatova Oliya Chief OB/GYN of Kiziltepa Rayon
 4. Ochilov Ikhtiyor Chief Deputy of Kiziltepa Rayon
 5. Yusupjon Ergashev Navoi Rayon
 6. Jeliliva Lilya Chief Deputy of Navoi CRH
 7. Khimmatova Istat Chief Pediatrician of Navoi Rayon
 8. Nurmatova Oibibi Chief OB/GYN of Navoi Rayon