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
Project Duration: September 30, 1999-September 29, 2003
Final Evaluation
Phase I
September, 2003
2
Preface
At the beginning of my career several decades ago, I made an intentional choice 
to work with NGOs. At that time it seemed to me, and still does, that our power is 
in being able to try out new, innovative ideas on a small scale, and then, using 
use our community base, and international stature recommend what works at 
scale. Many projects are framed in this way: a pilot portending practical lessons 
for replicability at scale. In the case of the Navoi Child Survival Project, this 
really happened. 
The old cliché “hindsight is 20-20 vision” is the privilege and potential pitfall of the 
evaluator. How easy it is to see what could, should and might have been from 
the vantage point of historical reflection. The greater challenge is to learn the 
lessons of the past and refocus on a clearer vision of a way forward into the 
future. The Project HOPE Uzbekistan team is fully up to this challenge. They 
are as enthusiastic as they are capable, and as ready to learn as they have been 
to share and teach. They work as a team, but each one of them brings 
something special to the collective task. It was my privilege to be part of this 
team for a brief time, and I thank them for their hospitality, openness, and
insights. 
I would also like to thank Dr. Bettina Schwethelm, previous Project Manager and 
Dr. Diaa Hammamy, Project HOPE Director for Central Asia, for inviting me to 
undertake this evaluation. It has been my great pleasure to work with them both 
on this and other projects. 
While two of the four person team—Dr. Mavzhuda Babamuradova previous 
Project Director and Dr. Abdunabi Kuchimov, current Project Director know the 
Project and the context intimately, the other two members, Ms. Sarah Porter, 
new Project HOPE Project Manager and myself were on a steep learning curve. 
The time in the field—just under two weeks—was short, intense, and as always, 
never enough. As such, there are, I am sure, mistakes of fact and interpretation 
in this report. The Project HOPE Navoi team have had a chance to read it 
(albeit not in their own language) as has Ms. Porter and Dr. Hammamy. 
Nonetheless, major findings and recommendations are my own and I hope, 
mostly accurate and helpful.
I commend the Project to USAID and the approval of a four-year extension.
Laurie Zivetz
Washington, D.C.
September, 2003 
3
Table of Contents
Acronyms 5
Executive Summary 6
I. Introduction 10
A. Methodology 10
B. Team composition 11
C. The context 11
1. The health delivery system 12
2. Navoi 12
II. Results and Impact 13
A. Overview 13
1. Data issues 19
B. Results of specific interventions 20
1. Maternal and Newborn Care 20
2. IMCI 23
3. Breastfeeding Promotion 25
4. Child Spacing 26
 C. Adolescent reproductive health 27
III. Crosscutting Issues 29
A. Health Information System 29
B. Training 31
1. Certification 35
C. Supervision 35
D. Drug Supply 36
E. Community mobilization 37
1. Competitions 37
2. Makhalla Committees 38
3. Breastfeeding support group motivators 39
4. Patronage nurses 39
5. Hotline for postpartum women 40
6. Support groups 40
7. Summary and recommendations 40
F. Communication and materials for behavior change 41
1. Mass media 41
G. Capacity building 42
1. Project HOPE/U.S. 42
2. Project management team 43
3. MOH 44
4. National Institutes 44
5. Health facilities and health workers 45
6. Local NGOs 45
H. Impact on national policy and programming 46
I. Sustainability 47
IV. Program Management 48
A. Background 48
B. Planning 49
C. Staff training 49
D. Human resources and staff management 50
1. Leadership 50
4
2. Time management 50
3. Job descriptions and contracts 51
4. Skills mix 51
E. Financial Management 51
1. On site audits 51
2. Fiscal planning 51
3. Reporting systems 52
4. Remuneration for MOH professionals 52
F. Logistics 53
G. Information management 53
H. Technical and administrative support 54
Tables
1. Project HOPE/Uzbekistan-Navoi CS-16 Program-Key Results 15
2. Infant morbidity and mortality in Central Rayonal Hospitals 21
3. Trained health providers and TOT’s 32
4. Trained health providers by discipline 33
5. Master trainers (TOTs) trained by location 34
6. Gifts in Kind from Project HOPE to Navoi Oblast MOH 36
7. External Technical Assistance 54
Annexes 
A. Persons contacted 55
B. Scope of Work for the Evaluation 58
C. Sampling methodology for KPC and HFA 59
D. DIP Matrix 61
E. Items in the Mass Media about the projects 70
5
Acronyms
ARI Acute Respiratory Infection
ADB Asian Development Bank
DIP Detailed Implementation Plan
DOTS Directly observed therapy short-course
HFA Health Facility Assessment
HIS Health Information System
IEC Information, Education, Communication
IMCI Integrated Management of Childhood Illness
KPC Knowledge, Practice, Coverage
MCH Maternal and Child Health
MOH Ministry of Health
MNC Maternal and Neonatal Care
NGO Non Governmental Organization
PEPC Promote Effective Perinatal Care
RH Reproductive Health
SM Safe Motherhood
TOT Training of Trainers
UNICEF United Nations International Children’s Fund
UNFPA United Nations Fund for Population Activities
USAID United States Agency for International Develop
WHO World Health Organization
6
Executive Summary
This report documents the final evaluation of the Project HOPE’s 1999-2003 Uzbekistan 
Child Survival Project, carried out in August 2003. The evaluation considers the Project 
in its role as a field laboratory for testing new innovations in maternal and child health in 
terms of impacts and lessons learned in the two pilot rayons of Navoi Oblast, as well as 
influences on broader thinking, practice and policy in the country and the region. 
This Project arrived at the historical and institutional confluence of a number of trends in 
Uzbekistan and appears to have gauged the situation and timing quite accurately in its 
design. With a well-established health delivery system hungry for new information and 
knowledge, and only a limited tradition of community-based public health outreach, the 
Project began with the delivery system, moving out to the community once it had the 
confidence of public sector leaders. Every new activity began with foundation-laying 
partnership dialogue. The fact that Project HOPE was the only international agency 
working in health in the Oblast, the physical location of the Project office inside of the 
Oblast MOH, and the collegial style of the team, all helped to build trust and a 
partnership with the MOH that propelled the Project forward. Strong, entrepreneurial 
leadership within the Project and a big-picture, positive “never say no” attitude extended 
the purview and impact of the Project well beyond the Oblast.
The cascade approach to provider in-service training, and in particular the way master 
trainers were identified and trained, proved highly effective. Although courses focused 
on specific topics—breastfeeding, IMCI, reproductive health and safe motherhood—the 
cumulative impact of the adult learning, client-oriented, public health approach, appears 
to have catalyzed new behaviors in provider-client and supervisor-subordinate 
relationships. 
Community outreach activities have grown in an organic way from service-delivery 
focused capacity building activities. While issues-based makhalla competitions have 
stimulated interest and enthusiasm, clinic-based community mobilization volunteers and 
the dissemination of IEC materials offer the most promise for widespread and 
sustainable impact at scale.
The Project’s health information system provided only limited data for comparing or 
measuring change or impact. In the next phase, as the Project continues to position 
itself as a laboratory for testing innovations in maternal, child and adolescent health, 
strengthening this aspect of the program merits greater attention. 
Key findings and recommendations are summarized here: 
Safe Motherhood
Findings: 1. Use of the partograph and changes in rooming-in, breastfeeding and 
delivery room procedures represent important achievements.
2. Baby friendly hospitals in both pilot rayons have become the flagship for change in 
maternal and neonatal care (MNC). 
3. Safe Motherhood activities related to emergency obstetric care and IEC were 
delayed. 
4. Maternal nutrition, particularly addressing the high rates of anemia, was anticipated 
in the DIP but not directly addressed in project activities. 
Recommendations: 1. Safe motherhood should be prioritized in the extension project.
7
2. The planned establishment of a Safe Motherhood Center in Navoi should provide a 
focal point for training, monitoring and IEC outreach.
Integrated Management of Childhood Illness (IMCI)
Findings: 1. Probably the most important impact of the Project on national policy and 
practice was in the area of IMCI. 
1. Navoi was designated a pilot site for IMCI under the MOH’s health reform initiative.
2. Project HOPE participated on the national IMCI task force, and made significant 
contributions to IMCI protocols, now used throughout the country.
3. Impact beyond the target rayons is significant, with integration into preservice 
curricula at two prominent medical schools in the country. 
Recommendation:
Quality and sustainability will depend on further attention to institutionalizing monitoring 
and supervision systems and ensuring a consistent drug supply.
Breastfeeding
Findings: 1. Exclusive breastfeeding in the first 4-6 months rose from 9% at baseline to 
78% in final evaluation. 
2. Fifty-three TOTs in Navoi and Medical Institutes. And IEC materials widely 
distributed.
Reproductive Health
Findings: 1. The Project has made significant strides in creating a context in which 
providers and clients expect choice. 
2. A total of 387 providers trained in RH issues. 
3. Formative research was conducted to inform the development of IEC outreach for 
key RH decisionmakers. 
4. Contraceptive availability hampers efforts to offer a range of options to clients.
Recommendations: 1. More information on household spending patterns on 
contraception, would inform the design of appropriate social marketing mechanisms for 
contraceptives. 
2. User pay drug schemes should include contraceptives.
Adolescent Reproductive Health 
Finding: The extension project will add a component focusing on adolescent 
reproductive health. The Project is strategically poised to undertake this initiative, with 
widespread community interest and support. 
Recommendations: 1. Use adolescents to collect data on adolescent knowledge, 
behaviors and preferences; establish an adolescent advisory committee. 
2. Peer networking would be an effective way to disseminate information. 
3. Good supervision is important to ensure correct information is being disseminated.
Monitoring and Evaluation
Findings: 1. Despite the fact that the Project collects a lot of data, information 
management and use was one of the weakest parts of the program. 
2. The KPC and HFA in particular provided little in the way of longitudinal reliability 
because of poorly articulated indicators and a lack of consistency and rigor with the 
instrument. 
3. Despite these drawbacks, the Project has been able to make the case for its 
approach at national level. In a playing field with few other voices, this was possible. 
8
Recommendation: For the Navoi project to continue to play the role of laboratory for 
innovative new approaches in MCH, RH and related areas, information management will 
have to be significantly strengthened. 
Training
Findings: 1. Training was a major Project activity, a method of capacity building and 
institutionalizing new skills in the delivery system. 
2. A total of 1483 providers were trained by the Project.
3. A total of 106 TOTs have been trained ( 32 in the pilot rayons; 62 in the oblast). 
4. The Project has followed the national practice of awarding a certificate to individuals 
when they complete a training course. 
Recommendations: 1. On certificates: provide trainees with a letter of thanks for 
attending Project courses. Award certification after at least 3 monitoring visits (including 
written tests) ascertains a pre-established level of mastery. 
2. On maintaining quality training: the role of the IMCI, RH and soon to be established 
SM Centers in Navoi should include monitoring, to enable identification of refresher 
training needs.
Quality
Finding: Initial delays in implementation did not allow the Project to implement originally 
planned Quality Assurance activities. 
Recommendation: Supervision systems that enable continuous reinforcement of QA 
approaches are critical to ensure sustainable institutionalization.
Drug Supply
Finding: 1.Unavailability of many essential drugs means that in fact consumers are 
forced to buy them from private pharmacies. 
2. Over the life of the Project, Project HOPE donated a total of $641,934 in 
pharmaceuticals. While this filled some gaps in availability, it does not solve the long￾term problem.
Recommendation: Pilot community-based cum clinic-based revolving drug scheme 
approaches in the extension Project.
Community mobilization
Findings: Although community mobilization activities only got underway in the second 
half of the Project, the last year saw significant activity, including 
· Community Competitions
· Makahalla committee involvement and strengthening
· Breastfeeding support group motivators
· Patronage nurse outreach workers
· Hotline for postpartum women
· Support groups
Specific recommendations about each of these approaches are provided. 
Recommendations: 1. Develop an integrated community mobilization/IEC strategy with 
specific targets. 
2. Establish an inquiry framework to monitor and measure the relative and synergistic 
impacts of various approaches. 
9
Communications and materials for behavior change
Finding: The printed materials produced by the Project appear to have been of good 
quality, used by both providers and clients, and widely distributed.
Capacity building
Findings: 1. The Project successfully catalyzed paradigm shift at MOH, facility, and 
community levels through training, exposure, and partnerships supported by the project. 
2. It also served as a fulcrum for connecting national and local stakeholders in ways that 
built capacity and aligned perspectives through jointly initiated activities. 
Impact on national policy and programming
Findings: 1. The Navoi Project design became a model for a project covering two entire 
Oblasts in the country. 
2. Project staff participation on national task forces related to IMCI and reproductive 
health brought lessons from the project to bear on policies being conceived in the 
context of health reform. 
3. Training of trainers and staff from other Oblasts and medical schools multiplied 
exposure and practice to key MCH practices. 
4. Donors, government and international NGO representatives have visited the project 
site or learned about it through interaction with project staff, borrowing ideas, 
curricula, and materials. 
Recommendations: The DIP for Phase II should proactively anticipate the Project’s 
strategic, national role as a laboratory by allocating human resources and designing 
M&E systems and dissemination mechanisms to promote specific, targeted issues. 
Sustainability 
Several aspects of the program portend well for sustainability and scale up:
· The Oblast MOH has embraced all of the new MCH approaches. 
· Oblast officials are invested in health issues.
· Oblast-based TOT’s are able to independently plan and deliver training. They are in 
demand from within and outside of the Oblast.
· Baby Friendly hospital certification set the standard for other facilities and demand 
sustainability of best practice. 
· Local leadership has experience organizing around public health issues.
· Communities in the target rayons have been saturated with information about key 
issues.
Factors that may constrain or hinder sustainability of project interventions include:
· The absence of a supervision and monitoring system which can support quality and 
consistency in new practices. 
· The inconsistent supply of drugs and contraceptives. 
· Provider “migration” to private sector opportunities because of low pay from 
government service.
· MOH lack of budget to reproduce IEC materials. 
· Lack of cogent data demonstrating impact of key interventions.
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I. Introduction
This report documents the final evaluation of the Project HOPE’s Uzbekistan 
Child Survival Project, carried out in August 2003. The report looks not only at 
impact and lessons learned in the two pilot rayons of Navoi Oblast1
 but considers 
also the influence and impact of the Project on broader thinking, practice and 
policy in Uzbekistan. The Project’s models and lessons have already been used 
in the design of USAID’s “Healthy Family” bilateral program covering two other 
oblasts in Uzbekistan and one oblast in Tajikistan, as well as a “sister” child 
survival Project in Kyrgyzstan being implemented by Project HOPE. Because 
the current Project has been granted a 4-year extension to consolidate current 
activities and scale up into two additional rayons, the evaluation process was 
simultaneously retrospective and prospective in its inquiry. The report follows 
the outline format recommended by USAID, with some additional sections to 
consider these aspects of the program. A Scope of Work is provided in Annex 
B.
Recommendations pertinent to specific findings are included in the relevant 
sections to make it easier for the reader to follow the rationale.
A. Methodology
The findings and perspectives in this report rely heavily on in-depth interviews 
and focus group discussions with key stakeholders during the field portion of the 
evaluation (August 21-29, 2003). A KPC and HFA was undertaken at the 
launch, midterm and evaluation points, but much of the data is problematic as 
discussed in Section II.A.1. below. Quarterly, annual, and mid-term evaluation 
reports as well as technical consultant trip reports were reviewed prior to the 
fieldwork. Interviews with Project HOPE/US staff, previous consultants, and 
donor representatives no longer in Uzbekistan with knowledge or previous 
involvement in the Project were undertaken by phone and email. A formal 
debrief with Project HOPE/Navoi was conducted prior to the Team Leader’s 
departure.
Annex A includes a list of people contacted prior to and during the fieldwork. 
Interviews in the field were organized to capture a crossection of representative 
stakeholders in order to effectively triangulate perspectives and information on 
specific issues. Broadly, these stakeholders included:
· Project HOPE U.S. staff and former consultants
· Project HOPE Navoi staff
· Project HOPE staff on the “Healthy Families” and Kyrgyzstan Child Survival 
projects
· Tashkent-based donor agency representatives active in MCH
 
1 1
 The oblast is equivalent to a district that is divided into smaller rayons. The Project was implemented in 
the rayons of Navoi and Kiziltipa in Navoi Oblast. 
11
· Technical Institute representatives (including medical schools) that had 
participated in the Navoi Project
· Ministry of Health representatives at national, oblast, and rayonal levels2
· Senior Oblast Leaders 
· A cross section of providers 
· Clients
· Community leaders
· Community-based volunteers
· Community members—women, men, adolescents
· Project HOPE/Navoi staff
Where possible, at least three representatives of each of these groups was 
interviewed, and in some cases many more. 
The interview instrument included in Annex D served as a starting point as much 
to share priorities and perspectives by email in advance of the field work, as a 
guide to data collection on the ground. As trends and issues surfaced—overall 
or in the context of a specific conversation, additional questions were added and 
pursued.
B. Team composition
The formal team was comprised of
· Team Leader, external consultant, Dr. Laurie Zivetz
· MCH Program Manager, from Project HOPE/US, Ms. Sarah Porter
· Project Director, Project HOPE/Navoi, Dr. Abdunabi Kuchimov
· Previous Project Director and currently Project Manager of the Project HOPE 
“Healthy Family Project”, Dr. Mavzhuda Babamuradova
Other Project HOPE/Navoi staff also participated in some interviews, and all 
Project HOPE/Navoi staff was actively involved in the planning and discussion 
process during the course of the evaluation itself. 
The field team was ably supported by translator Dr. Bakhodir Rakimov, who 
provided not only excellent translation, but perspectives on the medical system 
and broader socio-cultural context as well. Ms. Gulza Khalimova also provided 
translation support in Navoi.
C. The Context
On September 1, 2003 Uzbekistan celebrates its 12th independence day since 
the demise of the former Soviet Union. At its height in the early 15th century, 
capital city, Tashkent, was the center of a major empire under Amur Timerlane 
(Timur the lame) stretching from what is now Turkey to parts of India and north 
into modern day China. Borders have changed, but newly independent 
Uzbekistan is today a country with enormous natural wealth and an educated, 
 
12
hard working population. Although economically struggling following 
independence, the country has very little absolute poverty. A republican, Uzbek 
government has replaced former punitive system once enforced from Moscow, 
and change continues to take place on the basis of edicts—prikaz--from on high. 
The status of women, high by international standards, may be eroding in the 
context of a shrinking job market and rising Islamic influences in the country3
. 
1. The health delivery system
A major health reform initiative, underwritten by the major multilateral banks and 
supported by UN and bilateral agencies, is attempting to streamline an 
antiquated, inefficient system with a greater emphasis on integration of now 
disparate services through a network of primary health care sites. Health 
professionals are enormously underpaid (Rural doctors make $25/month with the 
per capita GDP at $2500) as a result of which most have private, parallel 
practices to their government employment. Health reform research being carried 
out by USAID-funded Z’drav Plus is investigating the structural and cost options 
of various public/private sector alternatives. In the context of health reform, 
Navoi was selected by the MOH as a pilot site for Community IMCI, based on 
Project HOPE’s early work in the Oblast.
Cut off from innovations in medical best practice until the 1990s, providers are 
eager to learn and adapt international approaches in medicine and public health. 
The context is ripe for change, and doctors seem willing to cede some of their 
traditional monopoly on information, to a population not only educated but eager 
to learn more about public health issues that are relevant to their lives.
At the time of this evaluation, active discussions were underway among key 
donors, technical agencies and the MOH about prikaz 155, which mandate some 
fairly traditional approaches to maternal and newborn care. Under the prikaz, a 
pregnant woman is required to see her doctor no less than 14 times during her 
pregnancy and to enter the hospital 2-3 weeks before her delivery date. 
The Project cycle coincided with presidentially proclaimed Year of the Healthy 
Generation (2002) and Year of the Community (2003), giving additional profile to 
Project activities.
2. Navoi
Navoi was selected by USAID and MOH because of the relatively high infant and 
mortality rates in the oblast relative to the rest of the country. MMR was 
estimated to be 58/100,000 compared to a national level of 28/100,000 MMR4
. In 
 
3
 See Cooper, Belinda and Isabel Traugott, Women’s Rights and Security in Central Asia, a paper for 
Advocacy
4
 This statistic is taken from the original proposal, based on 1999 government estimates. Both national and 
oblast-level statistics have been dropping since then.
13
an Oblast that generates 46% of GDP with less than 1 million people in a country 
of 23 million, this was clearly an embarrassment. 
In addition to the sixth largest gold mine in the world, Navoi is home to significant 
chemical, pesticide and herbicide industries. Forty-six percent of the cement 
from the Former Soviet Union was produced in Navoi. With this level of 
industrialization, air and water pollution are significant public health issues. 
Interestingly, however, the Oblast Governor (Hokim) reportedly subsidizes 
national contributions to the health delivery system through mandatory 
“contributions” from these factories. According to the Deputy of the Navoi 
Ministry of Health, 84% of the annual Oblast budget for health (some $1 million) 
comes from local contributions. Project inputs and humanitarian assistance are 
in addition to this amount. At the present time, Project HOPE appears to be the 
only International agency with a program in the Oblast, though ADB and the 
World Bank loans will provide infrastructure support in the near future.
The pilot rayons of Navoi and Kiziltepa, selected in consultation with the Oblast
MOH, are more accessible than others in the oblast, and proved a good starting 
point for the Project.
II. Results and Impact
A. Overview
This Project arrived at the historical and institutional confluence of a number of 
trends in Uzbekistan and appears to have gauged the situation and timing quite 
accurately in its design. With a well established health delivery system hungry 
for new information and knowledge, and only a limited tradition of community￾based public health outreach, the Project began with the delivery system, moving 
out to the community once it had the confidence of public sector leaders. Every 
new activity began with foundation-laying partnership dialogue—a multi-agency 
Steering Committee that vetted workplans on a regular basis, orientation 
meetings on new technical approaches with senior decisionmakers, community￾based “makhalla” committee meetings to consider new outreach mechanisms. In 
addition, the fact that Project HOPE was the only international agency working in 
health in the oblast, the physical location of the Project office inside of the oblast 
MOH, and the collegial style of the team all helped to build trust and strong 
partnership that propelled the Project forward. Strong, entrepreneurial 
leadership within the Project and a positive, “never say no” attitude to requests 
for inclusion in training and other activities, effectively extended the purview and 
impact of the Project well beyond the Oblast. 
The cascade approach to provider in-service training, and in particular the way 
master trainers were identified and trained, proved highly effective. Although 
courses focused on specific topics—breastfeeding, IMCI, reproductive health—
14
the cumulative impact of all of these trainings appears to have affected systemic 
changes, particularly related to provider-client and supervisor-subordinate 
relationships. The fact that so many MOH staff benefited from this training, and 
that the Oblast became a focal point for training for other Oblasts and Medical 
Institutes brought further kudos to the Navoi MOH and enhanced the partnership. 
Community outreach activities have grown in an organic way from this 
partnership, seemingly without any government resistance. It also sets the stage 
for an extension in which strategies to address more sensitive issues such as 
adolescent reproductive health, and the involvement of men and grandmothers, 
and potentially support to local NGO’s tackling domestic violence can be 
launched. 
This section reviews results of specific technical foci of the Project based on 
available data and information gathered in the context of the evaluation. The 
goals, objectives, and intervention mix is provided in Annex F. Table 1 
summarizes data from the baseline, midterm and final KPC and HFA’s based on 
indicators from the Detailed Implementation Plan (DIP). For sampling 
methodologies, during the most recent final surveys (July 2003), including 
clusters (makhallas, and health facilities surveyed) please see Annex C. 
Table 1. Project HOPE/Uzbekistan Navoi CS-16 Program – Key Results
Indicator Baseline
April 2000
Mid-term
March 2002
Final
July 2003
DIP Target Source Notes
A. Maternal and Newborn Care
1. % of health staff in target area 
using protocols for delivering 
quality antenatal and post￾services
0% 100% 100% 80% Project 
HIS
“Protocol” was interpreted as prikaz—govt. edict—so 
that it was assumed that 100% of providers were 
following the prikaz. Although there is a protocol 
(algorithm) inside, this was not what was understood. 
2. % of pregnant women 
screened for priority STDs
61% N/A 84% 80% HFA Data shows the % of pregnant women screened for 
syphilis.
3. % of deliveries managed with 
partograph
0% 0% 100% 70% HFA Random sample of records collected from the 3 Baby 
Friendly hospitals in pilot rayons where the partograph 
was introduced after the mid-term review. 
4. % of providers following other 
established protocols for delivery 
and newborn care
0% 100% for BF 100% for 
BF
70% Project 
HIS
Same as #1- interpretation of protocol as prikaz
At the present time there are no prikaz for Safe 
Motherhood, only breastfeeding. 
5. % of health facilities using 
brochures for health education
0% 30% IMCI: 100%
SM: 54%
BF: 92%
RH/FP: 
92%
100% HFA “Health facility use” interpreted as “availability of health 
brochures in clinic” based on HFA observation. At the 
baseline, only the Only limited SM IEC materials were 
available for distribution. 
The midterm only covers availability of Mother Reminder 
Materials (IMCI)
6. % of health facilities providing 
classes for pregnant women and 
their partners and new parents
N/A N/A 66% 50% HFA If either the mother, or mother and a partner (husband 
or mother in law), attended a class, they were counted. 
No prenatal classes were offered before the midterm. 
7. % of women report improved 
nutrition during pregnancy and 
lactation
a. 58%
b. 50%
c. 20%
N/A a. 82%
b. 44%
c. 45%
50% HFA
a. 
Client 
exit 
intervie
w
b. 
Provider 
observati
on
c. 
Provider 
observati
on
The questions in the HFA focused on whether correct 
nutritional advice had been provided, as a proxy for 
improved nutritional status. 
16
Indicator Baseline
April 2000
Mid-term
March 2002
Final
July 2003
DIP Target Source Notes
B. Breastfeeding
8. % of women in baby-friendly 
hospitals breastfeeding within an 
hour of delivery
50% within 
1-8 hours
89% 87% 75% KPC The question changed from the baseline, which asked 
about breastfeeding within 1-8 hours. In the mid-term 
and final the question specified 1 hour after delivery. 
Also, respondents in the final survey were all from Baby 
Friendly hospitals. 
9. % of women breastfeeding 
exclusively for the first 4-6 mo’s 
9% (<4m) 58% (<4m)
42% (<6m)
78% (<4m)
74% (<6m)
30% KPC Interviewed women with children under 2 years
10. % of women with children 
<6m that report breastfeeding on 
demand
N/A 99% 99% 50% KPC The question was not asked in the baseline. Significant 
achievements in this regard are based on intensive 
provider training and community IEC.
11. % of women still 
breastfeeding at 20-23m
N/A 55% 63% 50% KPC The question was not asked in the baseline. Significant 
achievements in this regard are based on intensive 
provider training and community IEC.
12. # of maternity hospitals with 
UNICEF baby friendly 
certification 
0 2 3 2 HIS
13. # of health providers trained 
to provide lactation counseling
0 194 390 60 HIS
14. # of breastfeeding support 
groups (motivators) 
0 16 32 20 HIS 32 active “motivators” working in 4 hospitals (3 maternity 
houses and one children’s hospital) and communities. 
To date, 10, 915 post-partum women have been 
counseled in BF in hospitals alone. 
C. Child Spacing
15. % of facilities in target area 
providing three or more FP 
methods
0% N/A 86% 80% HFA At baseline, three or more contraceptive methods in 
facilities did not exist. At midterm, this subject was not 
observed. 
16. % of women receiving 
FP/child spacing counseling 
during an antenatal visit and/or 
post-partum hospital stay
42% 
(Antenatal 
Visits)
50.7% 
(Post￾partum 
stay) 
96% 82% 
(Antenatal 
Visits)
97%(Post￾partum 
stay) 
70% HFA Midterm averaged antenatal and post-partum visits. 
The mid-term HFA results include “health provider 
discussed the issue of FP/contraception” (results=96%); 
“health provider explained different contraceptive 
methods” (result=87%)
17. % of unmet demands 
decreased
N/A 17% 24% 30% KPC Measurement refers to knowledge of providers. 
Definition of “unmet need” refers to an increase in the 
practice of providers to counsel women on her needs for 
contraception. So: at the mid-term, 24% of women were 
17
Indicator Baseline
April 2000
Mid-term
March 2002
Final
July 2003
DIP Target Source Notes
“told” what to choose, and 76% were able to make an 
informed choice.
The mid-term KPC captured responses from Baby 
Friendly hospitals only. The Final evaluation included 
women delivering in all facilities in the pilot. 
Measurement refers to knowledge of providers. 
The mid-term KPC captured responses from Baby 
Friendly hospitals only. The Final evaluation included 
women delivering in all facilities in the pilot.
D. IMCI
18. % of trained providers at 
SVPs and polyclinics following 
IMCI protocols for sick children
a) all danger signs assessed 
b) prescribed antibiotics when 
not needed
c) nutritional status assessed
d) children’s vaccination card 
checked
e) caretakers were told when to 
return for follow-up
2%
38%
23%
16%
51%
91%
 0%
81%
86%
92%
74%
 0%
88%
32%
63%
80% for 
each 
indicator
HIS 18b) is problematic in the way it was formulated given 
the 80% target. 
Also, data collection and the formulation of questions 
varied for each survey. 
18a) and e) may have spiked at the mid-term because 
this fell immediately after IMCI trainings. 
19. C-IMCI materials in use by 
pediatric and maternity hospitals, 
SVPs, polyclinics, community 
outreach staff, and caretakers
0 30% 100% in 
Health 
facilities. 
98% use of 
caretakers.
N/A HFA
KPC
Use of Mothers’ Reminder Materials
20. % of children aged 12-23 
completely immunized (including 
Hep. B vaccine)
N/A N/A 82% 80% HFA Did not measure at baseline or midterm. Staff feels that 
final survey number would be much higher if Hep B 
were not included in indicator. 
21. % of diarrhea cases among 
children <2 treated with ORS 
and/or recommended home 
fluids
29% N/A 41% 60% HFA Sample size due to seasonality gave insignificant 
results—not enough children with diarrhea. Also, 
community outreach in this area is relatively recent, only 
starting in December, 2002. 
22. % of children under 2 with 
diarrhea in the last 2 weeks who 
receive same or more amount of 
solids
5% 77% 79% 60% KPC The number of actual diarrhea cases identified during all 
surveys was very low due to seasonality, hence the 
results may be invalid. 
18
Indicator Baseline
April 2000
Mid-term
March 2002
Final
July 2003
DIP Target Source Notes
23. At least 50% of caretakers 
provide additional meals to 
children while recovering from 
diarrhea/pneumonia, and other 
diseases
4% 24% 52% 50% KPC At baseline, took average of diarrhea and pneumonia 
cases. At midterm, only examined diarrhea because 
there was an insignificant sample of pneumonia cases. 
For final evaluation, combined both diseases.
No “other diseases” were ever tracked.
24. Mothers reporting 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)
50.9% N/A 83% (2 
practices)
73% (3 
practices)
48% (4 
practices) 
N/A KPC Indicator not in DIP, but nonetheless a proxy for IEC 
impact.
25. Mothers reporting improved 
feeding practices for children 
under five, including Vit. C, Vit. 
A, and iron-rich foods
N/A N/A 63% N/A KPC Indicator not in DIP
26. % of mothers who are able to 
list danger signs for diarrhea and 
pneumonia:
a) high fever
b) fast or difficult breathing
c) sickness getting worse
d) not breastfeeding or drinking
e) blood in stool of children
N/A
86% 
43%
59% 
38%
23%
89%
 5%
48%
16%
29%
70% for 
each 
indicator in 
this 
category
KPC Although indicators “fast and difficult breathing”” or 
“blood in stool of children” are not considered danger 
signs under evidence-based protocols they were 
included in IEC materials to give mothers more 
information about symptoms. 
KPC: Knowledge, Practice, and Coverage; HFA: Health Facility Assessment; HIS: Project HOPE tracking system
1. Data issues
The data presented in Table 1 is problematic in terms of accurately describing 
Project impact. Some of the indicators were either not clearly articulated or 
misunderstood by staff, respondents, or both. The wording of questions changed 
over time and in some cases completely new questions were inserted for some 
indicators. Data was not collected at the mid-term for a number of indicators. 
Many indicators are actually two indicators rolled into one. All of these factors 
make a longitudinal assessment of change challenging if not impossible. 
The right-hand column of Table 1 highlights specific issues with each indicator, 
including caveats to analysis. This has been extensively reviewed with Project 
HOPE Navoi staff. A number of additional indicators, drawing data from the 
Project HIS, have been added to supplement the DIP indicators at the end of 
Table 1.
These findings highlight a number of weaknesses in project planning and 
implementation which internal stakeholders acknowledge merit attention in the 
extension. Specifically:
· Indicators were not clearly articulated or understood by local staff
· KPC and HFA instruments were not carefully pre-tested, or translated 
(and back translated) to ensure accuracy in meaning
· The link and correlation between specific indicators and data points 
from the KPC, HFA as well as the plethora of other HIS data being 
collected in Navoi was not clearly established at the outset
· Project HOPE Navoi staff received insufficient technical assistance in 
Project monitoring to enable them to maximize the use of data for 
decisionmaking.
Having said this, the data in Table 1 is accurate in parts, and, taken in tandem 
with the triangulation of other data sources gives some indication of trends, if not 
impact. Training data, provided in Tables 4 and 5, give an indication of the depth 
and breadth of training activities, which absorbed a significant amount of Project 
attention and resources. The use of formative research mini studies (on 
awareness and practices related to maternal, infant and child health and danger 
sign recognition, contraception and father’s participation on pregnancy, among 
other topics) though methodologically uneven, was nonetheless critical in 
deepening and detailing understanding of knowledge and behaviors related to 
key interventions. This research was, arguably more important in shaping IEC 
materials than statistical data generated from other sources. Unfortunately, 
because it was formative in nature with only tenuous links to the KPC or HFA, it 
provided little in the way of a baseline for monitoring the impact of IEC materials. 
Feedback from the evaluation focused attention on the pilot nature of the Project, 
which will continue to rely on accurate, compelling data to understand the 
potential for new innovations from the Navoi "laboratory" for oblast or national 
20
replication at scale. Project HOPE Navoi staff fully grasps this, and it will be up 
to Project HOPE/US to support them in refining systems and skills for better data 
collection and management in the extension period. 
Recommendations for the extension:
1. Project HOPE should prioritize the provision of technical assistance for data 
management. Technical assistance support should begin with but not be 
limited to DIP development, and should focus on refining and redefining 
indicators and corresponding KPC and HFA and Project HIS instruments. TA 
should ensure that systems, tools and skills within the Project maximize the 
opportunity to measure the impact of specific interventions (in terms of results 
and cost). 
2. Both quantitative and qualitative systems, approaches and skills should be 
supported in this regard and all staff, not just the HIS expert, should 
participate.
B. Results of specific interventions
 In hospitals with Baby –Friendly Certification, new mothers and infants room-in,
 and infants are fed on demand --a radical departure from the past.
1. Maternal and Newborn Care MNC (35%) 
Although the Project made significant impacts in aspects of Newborn care, 
particularly related to clinical and client practices during and immediately post￾partum, Safe Motherhood interventions were only getting started towards the end 
of the project. In part, this may have reflected the absence of Safe Motherhood 
prikaz, which were only issued towards the end of the Project’s life.
Orientation and training, particularly for providers in maternity facilities, has 
clearly precipitated a significant shift in thinking from traditional ways which over-
21
medicalized pregnancy and childbirth. The UNICEF-certified Baby Friendly 
facilities in both pilot rayons have become the flagship for change in MNC 
practice. Use of the partograph (introduced by the Project) is universal in these 
facilities, and doctor’s attribute improved outcomes from labor with their use. 
Similarly, doctors and clients in these facilities attribute drops in mortality among 
infants to new rooming in and breastfeeding practices, which have been 
extremely well received and easily adopted in all facilities. 
The Project was able to help three maternities transition to Baby Friendly status 
in a way that was appropriate and sustainable. This was in part possible 
because existing infrastructure was relatively well established and well 
maintained (although water availability was an issue in one place that was 
visited). The donation of rubber balls and foam mats to aid in delivery, and a 
small budget for decorating the labor room, transformed otherwise sterile, doctor￾centered environments into more welcoming rooms. The legs of cribs have 
been sawed off to allow eye contact with mothers in the wards, and rooming-in is 
the new norm.
Traditional restrictions on partners in the labor room have eased significantly with 
an understanding about the need for “clean” versus “sterile” environments for 
delivery, and there is much talk and interest in husbands coming into the labor 
room. Interestingly, doctors and women seem more enthusiastic than husbands 
about this prospect. Several doctors mentioned that with the husband in the 
room, there is less likely to be unfounded blame for unforeseen complications 
affecting the mother or the infant. Another advantage, cited by both women and 
providers, is the respect and bonding that sharing this experience evokes. At 
present, mothers’-in-law are more likely to attend a birth, though there is 
definitely a trend towards husbands in attendance. Women also reported that 
providers are more friendly and sympathetic during labor than they were in the 
past. All of these factors are directly attributable to the Project. 
The Chiefs of both the Kiziltepa and Navoi Rayonal maternity hospital provided 
similar statistics, reflecting a drop in infant mortality and morbidity since IMCI 
activities began. Both attribute this to new technical knowledge and client 
awareness. The Chief of the Kiziltepa hospital remarked: “It is good to train the 
common people rather than control them”. Observers also acknowledge that 
new approaches save money. Doctors used to over-proscribe hormones, 
vitamins and unnecessarily long hospital stays. 
Table 2. Infant morbidity and mortality in Central Rayonal Hospitals 
Year Babies in 
ICU--Navoi
Infant mortality--
Kiziltepa
2000 N/A 14%
2001 103 12%
2002 83 12%
2003 34 7%
22
During year 3, over 200 neonatologists and OB/GYNs were trained in Promoting 
Effective Perinatal Care (PEPC) based on WHO guidelines. Nine TOT’s were 
also trained. During this period, a neonatologist from the region conducted an in￾depth assessment of training needs and some initial training in these areas5
. To 
date, 7 TOT’s have been trained in Promoting Effective Perinatal Care (PEPC) 
and others have had some exposure in this area. It is not clear how much follow 
up has been provided, or is available. IEC on these topics has been delayed, 
and the extent of awareness of danger signs in pregnancy among women and 
their families is unknown. 
The other urgent area that received insufficient attention over the life of the 
Project was maternal nutrition, particularly related to anemia, estimated by some 
to be as high as 80% among pregnant women6
. Questions to mothers and 
providers at all levels during the course of the evaluation corroborates the HFA 
data (Indicator 7) that providers in particular lack correct information about which 
locally available foods are iron rich.7
 This is an urgent need, and, given the 
credibility of the Project among providers and communities alike, an informational 
campaign about maternal nutrition is like to have rapid and maximum impact. 
Addressing the issue of anemia through reliance on iron pills, on the other hand, 
may be problematic. Although these drugs are supposed to be free to pregnant 
women, the supplies are so sporadic that in most places they are only available 
at a cost, which is beyond the reach of most families. 
The DIP also anticipated interventions to “introduce the provision of one 
megadose of vitamin A to women immediately post partum and promote the use 
of iodized salt with iodine deficient pregnant women.” No data is available about 
either of these interventions and neither were they mentioned in interviews in the 
field.
The Project took some steps towards addressing the punitive approach to 
maternal mortality review that plagues the health system and prevents learning. 
This is clearly a “current” issue, in which Project staff has participated. Most 
staff and observers describe the system as one in which Doctors are (tacitly) 
encouraged to falsify information because of the unnecessarily severe 
 
5
 National level trainers were brought in for the first round of trainings after which TOT’s were trained, 
including 2 doctors and 1 nurse midwife. 
The 5-day Ob/GYN training covers antenatal care, partogram management, postnatal care and delivery 
management. 
The 4-day neonatologist training includes: newborn care (sick and healthy), asphyxia, newborn 
resuscitation, and breastfeeding. A one-day course for neonatologists and neonatal nurses on breastfeeding 
was carried out previously. 
6
 Personal conversation, Ihtiyar Ochilov, Chief of the Kiziltepa rayonal maternity (a Baby-Friendly 
hospital)
7
 Questions to providers and mothers in the very small sample of evaluation respondents revealed a better￾informed clientele than doctors. 
23
punishments incurred by maternal deaths. A briefing on the topic by the Deputy 
of the Oblast MOH described a process in which patient rights were being 
protected by this review that, in her view, only recommended cases for further 
investigation where the medical review panel considered the health provider to 
have demonstrated blatant neglect to higher authorities. Clearly, more work 
needs to be done to rectify practice and protocols in this regard.
Recommendations:
1. Safe motherhood--particularly upgrading emergency neonatal and obstetric 
care practices, prevention for primary care providers, IEC about danger signs 
among pregnant women and their families, and nutrition education for 
pregnant women—require immediate attention in the extension project.
2. The planned establishment of a Safe Motherhood center in Navoi should 
provide a focal point for training, monitoring and IEC outreach.
2. IMCI (35%)
Probably the most important impact of the Project on national policy and practice 
was in the area of IMCI. Early in the Project, Navoi was designed one of three 
pilot sites for IMCI under the MOH’s health reform initiative. According to the 
Director of the National Pediatric Research Institute, (who chairs the national 
IMCI task force), Navoi is the only site where all three components of the IMCI 
protocol (upgrading provider skills, improving delivery systems and community 
awareness) were developed. Project HOPE participated on the national IMCI 
task force, and made significant contributions to the adaptation and translation of 
IMCI manuals and protocols, now used throughout the country. 
Local impact was also significant, based on a combination of provider training 
and IEC materials dissemination. With a focus on primary care units (SVPs), a 
total of 145 providers were trained in the target rayons, including 11 master 
trainers (TOTs)8
. The Project helped to establish and resource an IMCI Center in 
Navoi City which hosts training, including training for providers and TOTs from 
other oblasts and medical institutes. 
Providers report a transformation in attitudes towards clients, a sentiment echoed 
by the Deputy of the Oblast MOH who recalled how in the past infant diarrhea 
was cause for hospitalization. The IMCI approach helped usher in greater client 
control over knowledge, prevention and care. 
Formative research conducted by Project HOPE in collaboration with the 
National Pediatric Research Institute helped to inform the production of a 31 
page illustrated booklet with information on breastfeeding, child nutrition, home 
treatment of child illnesses and danger signs requiring medical attention. These 
“mother reminder” materials were co-financed with a global grant from 
 
8
 TOT, generically training of trainers, is used in the Navoi Project to refer to the PERSON who has 
received training and certification to train trainers.
24
GlaxoSmithKline, and appear to have been widely disseminated and read in the 
target rayons. The booklet doubles as a take-home record of the child’s 
vaccination and height/weight history, with prompts for the mother about the 
timing of necessary vaccinations. Companion posters were also developed
Impact beyond the target rayons is significant, considering it was not in the 
original planning. IMCI has been integrated into preservice curricula at 
Samarkand and Bukhara Medical Institutes—two prominent medical schools in 
the country. Twenty-eight TOTs remain in place in these two institutions, offering 
the 11-day IMCI training as an adjunct to the normal medical school course, until 
such time as further integration is nationally mandated. 
Providers were unanimous in their enthusiasm for the IMCI approach. One clinic 
even suggested that despite the onerous government reporting requirements 
already in place, they appreciated the IMCI protocols (provided by the Project) so 
much that they were concerned they would run out of forms before a new prikaz
made them available from the government. 
Although the Project has been instrumental in promoting a paradigm shift in 
thinking and practice at service delivery and policy levels, two issues will need to 
be addressed to ensure quality and sustainability:
1. Monitoring and Supervision: IMCI requires not only a shift in thinking about 
prevention and treatment, it requires providers to add new facts to their 
knowledge base, and new approaches to their client interaction repertoire. 
This is never an overnight proposition for adults with entrenched habits, or 
systems with traditional, firmly established ways of operating. Monitoring on￾going supervision and refresher mentoring or training are essential if this new 
approach is to maintain consistent quality. 
The data in Indicator 18a) in Table 1 is instructive in this regard. Many of the 
providers were trained immediately prior to the midterm, which may account 
for the spike in recognition of danger signs (91%). The Project’s protocol 
specifies that TOT’s make supervision and monitoring visits at 1 and 6 
months after their 11-day course. This is an opportunity for trainees to get 
feedback (based on observation) and for TOT’s to collect data on information 
retention (based on written tests). It is noteworthy that by the final 
evaluation, two years after much of the training, and over a year since the last 
monitoring visit, proper assessment of danger signs had dropped to 74%. 
This is still a good outcome, but foreshadowing, perhaps, a further decline in 
quality and consistency. The need to integrate monitoring and supervision for 
IMCI as well as other new approaches in a way that supports, encourages 
and reinforces new practices, is essential. See Section IIIC. for more on this. 
2. Drug supply. IMCI relies on availability of 12 essential drugs. While 
donations from Project HOPE supplemented availability of many of these 
25
drugs, they were not all available during the life of the Project and the 
situation is likely to get worse as donations stop. Systemic alternatives to 
ensuring drug availability are being piloted in the context of broader health 
reform that anticipates a user pay system, as described in Section IIID. below.
The flipside of the drug issue is the fact that over-proscription of antibiotics to 
treat diarrhea and other childhood illnesses has waned significantly (see 
Indicator 18). Though data being collected Z'drav Plus will estimate exact 
figures, this cost savings to the MOH and parents alike is reportedly not 
insignificant. 
3. Breastfeeding promotion (10%)
A significant impact of the Project has been on breastfeeding awareness and 
behavior. Exclusive breastfeeding in the first 4-6 months rose from 9% at
baseline to 78% (<4m) at the final evaluation. Nearly 250 providers have 
received formal training in the pilot rayons, and an equal number in non-pilot 
sites. Seventeen master trainers are now available in Navoi. Maternities have 
been proactive in training all staff in the fundamentals of breastfeeding. In 
tandem with Baby Friendly certification, this seems to have catalyzed a 
transformation in business-as-usual in these facilities. 
The Project produced effective IEC materials for breastfeeding promotion. Many 
of the Maternities visited during the Project displayed innovative posters—
created by clinic staff--exhorting viewers to recognize the advantages of 
breastfeeding. In line with UNICEF requirements, all baby friendly hospitals have 
established hot lines to encourage post partum women or their families to ask 
questions after they leave the maternity. The phone numbers are posted in 
every ward.
Probably the most innovative aspect of the Project’s community outreach 
strategy is the female breastfeeding volunteers—described in more detail in 
Section III E. below. A unique aspect of this approach has been the meaningful 
way in which volunteers have become part of the clinical team, offering regular 
breastfeeding seminars for immediately postpartum women. A series of 
community competitions—including dramas, music and informational quizzes--
have generated additional interest and enthusiasm, engaging a crossection of 
the population in the target rayons. 
IEC interventions appear to have raised awareness far beyond the traditional 
targets (women and men in their reproductive years). Older men who were 
interviewed in the evaluation were unshy about identifying specific advantages of 
breastfeeding with impressive accuracy. The introduction of these “new” 
breastfeeding approaches coincides with a resurgence of cultural re-identification 
in Uzbekistan. Many older informants commented that breastfeeding is 
recommended in the Koran, but that it was “forgotten” during the Soviet time 
when artificial feeding was the norm. The importance of approval from this older 
26
cohort cannot be underestimated, and may be a factor in the rapid acceptance of 
this behavior. 
4. Child Spacing
The Project has made significant strides in creating a context in which providers 
and clients expect choice, and expect to discuss choice based on the individual 
needs and preferences of each client. This is an important development in a 
context in which the IUD and induced abortion9
 were considered the only options. 
Despite the fact that the government offers significant incentives for additional 
children—subsidizing two years of maternity leave for an unlimited number of 
children—birth rates have been dropping nationally for a decade. Community 
members acknowledged this trend, attributing it to the cost of raising a child in 
these tight financial times. Nonetheless, the head of the Navoi Rayonal 
Hospital credits the Project’s reproductive health initiatives with some of this 
drop, noting that in 1996 there were 2600 births/year compared to today’s 1600 
births/yr10. Based on available data, it is impossible to substantiate this view. 
Nonetheless, there is no doubt that the Project has expanded the opportunities 
for informed choice. 
The Republican Reproductive Health Center carried out formative research on 
attitudes and preferences, which informed the preparation of a flyer on 
contraceptive options. In total, 387 providers were trained in RH issues (228 in 
the pilot rayons), about half of them midwives. Last year, the Project arranged for 
13 OB/GYN’s to receive training in minilap procedures, and provided minilap kits 
to oblast and rayonal hospitals11. Some facilities have also undertaken training 
for patronage nurses who do home visits. HFA data indicates that 86% of 
facilities now offer three or more methods. During the project, a UNFPA donation 
of IUD’s, injectables and pills, significantly increased availability, though not 
sufficient to meet demand. 
The Project has been proactive in seeking to understand and engage with key 
RH decisionmakers—husbands and mothers in law. Consistent with changes in 
provider-client relations Project-wide, not only has contraceptive counseling 
increased for ante and postnatal women, but partners have been encouraged to 
participate in these sessions. The forthcoming formative research on the role of 
mothers in law in decisionmaking on reproductive health and maternal and child 
 
9
 According to Dr. Feruza Tulaganovna Fayziev, Director of the Republican Reproductive Health Center, 
there are some 217,000 abortions/year in Uzbekistan. According to the DHS (2002), abortion is actually on 
the rise—at 0.9/woman in 2002, compared to 0.7/woman in 93-96. The DHS (2002) reports 52% of 
contracepting women using the IUD.
10 A senior midwife from one Kiziltepa primary clinic (SVP) also attributed Project inputs to the dramatic 
drop in birth rates from 300 in 1999 to 205 in 2001.
11 There is some concern that Drs. may be promoting sterilization, as an alternative to IUD’s without given 
women enough information on this and other options. More investigation is necessary to ensure this is not 
happening.
27
health decisionmaking more generally will help to target these important 
household “gatekeepers” in supporting appropriate client choice. 
Despite Project efforts, it appears that the IUD is still the contraceptive of choice 
if not least resistance for both providers and clients. Women leaders talk about it 
as the “cheapest and easiest” method, and admit that doctors are still promoting 
it. They prefer a heavy period to none (with the injectable), and most appear not 
to understand the connection with endemic rates of anemia.
One of the DIP objectives was to increase the percent of women who purchased 
a contraceptive method. While this is probably happening irrespective of the 
Project, due to inconsistent availability in government facilities, the reality is that 
contraceptive pills cost the equivalent of half a month’s salary. If the Z’drav Plus 
cost survey reveals trends in this regard, the Project may be able work with the 
Navoi MOH to incorporate these findings into their planning, including piloting 
creative solutions to contraceptive availability.
Recommendations:
1. Contraceptive availability will continue to hamper efforts to offer a range of 
options to clients. Offering information does not necessarily lead to changes 
in consumer behavior unless costs are reasonable. More information on 
household spending patterns on contraception, particularly in light of the drop 
in desired family size, would enlighten the design of appropriate social 
marketing mechanisms for contraceptives. 
2. User pay drug schemes should include contraceptives.
3. Side effects of different methods should be stressed, particularly the 
implications of heavy bleeding on anemia for women entering their 
reproductive years. 
C. Adolescent reproductive health
The extension project will add a component focusing on adolescent reproductive 
health. Funding from Project HOPE/Switzerland will help to do the formative 
research to get this started. The Project is strategically poised to undertake this 
initiative, and communities appear ready to grapple with it as well. 
As in most parts of the world, young men and women are growing up in a socio￾cultural environment that is very different from their parents. Based on interviews 
with parents and grandparents—many of whom are formal and informal 
community leaders--during the evaluation, the resistance to change that is typical 
from the older generation was surprisingly absent. Adults understand that young 
people need more information and guidance before marriage, and appear to 
welcome an outside agent of that information. Indeed, one community leader 
lamented: “Adolescents are 10% of the community, but they are our major 
headache.” To explain, he mentioned that there were not enough cultural things 
to do, that because of large families, adolescents went out without much 
28
restriction, and were difficult to control. Anecdotal information indicates that
premarital sex is on the rise. 
At present the schools offer 5-8 hours/year on health issues12, which touch on 
anatomy and related topics in the teen years. Yet adults and adolescents alike 
acknowledge that reproductive health is not a topic parents and children discuss, 
and adolescents say they prefer to talk to one another about topics that feel more 
intimate. 
Conversations with young people reveal a generation of aware and interested 
youth, thirsty to know more about their peers in other countries, and inform 
themselves about about issues that concern them. Some of the key findings 
from the evaluation that may help in designing the adolescent reproductive health 
strategy are noted here, including several related recommendations:
· Adolescents want to talk to one another—they prefer to get information 
about reproductive health from peers.
· Location is important: adolescents feel more comfortable outside of the 
clinic or school.
· Adolescents read, but they also like to learn from video and movies.
· Some topics that are of particular interest include:
 
12 In forms 1-4 this is taught by the PE teacher; in forms 5-9 it is taught by the biology or chemistry teacher.
· Contraception
· Safe sex
· Mood swings
· Relationships with 
family
· Relationships with 
opposite sex
· Taking care of children
· Issues facing 
adolescents in other 
countries
· Rape
· Domestic violence
· Drugs
Recommendations:
1. Use adolescents to collect data on adolescent knowledge, behaviors and 
preferences. 
2. Peer networking would be an effective way to disseminate information. 
3. Be sure to build referral information and good supervision into the strategy to 
ensure correct information is being disseminated.
4. Appoint an adolescent advisory committee to help in rolling out the strategy, 
and link this committee to the Project Steering Committee. Link also with 
makhallas.
5. Generate good IEC materials for adolescents. Use humor.
6. Pilot approaches, measure outcomes, document processes, share learning.
29
III. Crosscutting Issues
A. Health Information System 
The mid-term review made a number of specific recommendations, many of 
which were not addressed in the second half of the Project. 
Recommendation 10A: “…provide additional training to HIS staff in survey 
methodology.” Project intern Gal Frenkel has a number of HIS objectives in her 
scope of work. Her six-month internship appears to have been only partially 
effective due to language constraints and the press of other demands. In 
addition, the HIS expert who received the bulk of her attention, transferred to the 
“Healthy Family” Project in Year 3 of the Navoi Project, with little transfer of skills 
to the new designate.
Recommendation: 10B: “Prepare indicators and questions for the final evaluation 
in order to ensure comparison of key indicators with baseline and/or midterm 
survey results.” Still problematic, as shown in Table 1.
Recommendation 10C: “…Specifically define indicators to monitor deliveries and 
quality of antenatal and post-partum care.” No evidence this was done.
Recommendation 10D: --- “Change …’20 breastfeeding support groups’ to ‘20 
makhalla establish regular meetings with women’s support groups’.” The Project 
did not adopt this strategy, but neither did it change the indicator (until prompted 
by this evaluation, to make it consistent with the approach that it did adopt. See 
Recommendation 10A.
 ---“Refine the first IMCI indicator to track performance on a
 set of key IMCI protocols” Problem remains.
Despite the fact that the Project collects a lot of data, information management 
and use was one of the weakest parts of the program. As discussed above, the 
KPC and HFA in particular provided little in the way of longitudinal reliability 
because of poorly articulated indicators and a lack of consistency and rigor with 
the instrument. 
The Government demands a lot of information, placing enormous pressures on 
clinical staff that is required, in some cases, to fill out myriad forms for individual 
patients or procedures. MOH officials and facility supervisors alike appear to 
have data on hand, and to use it for supervision and decisionmaking. The 
introduction of new ways of data collection—the partograph, the IMCI checklists 
for instance--have added to not replaced the already onerous information 
gathering system. The situation is likely to change as innovations in Maternal 
and newborn care become nationally mandated, with accompanying changes in 
the national Health Information System.
Although post-training monitoring relied heavily on the Project HIS, and in fact 
this data was probably more reliable and more useful than the KPC and HFA in 
terms of planning, it is not clear that the enormous effort of collecting and 
compiling this data set was optimized. This data has been used by the Project to 
point up areas in need of additional attention in specific clinical contexts. The 
30
extent to which it has been used more systemically to identify rayon-wide or 
Project wide trends, or to find mechanisms for strengthening MOH HIS or 
supervision systems is questionable. 
Special studies, including formative research, were used deepen understanding 
of community attitudes and behaviors to inform new interventions. These proved 
more successful than the KPC and HFA, and the data was used to promote 
Project HOPE’s approach at the national level as well. Specific formative studies 
conducted to date include:
1. Population knowledge level of child health care (n=239)
2. New fathers’ research (n=44)
3. Postpartum services assessment for new/first mothers (n=219)
4. Grandmother’s role in MCH decisionmaking (qualitative).
The concept of formative research is valid, and appropriate for this pilot Project. 
Methodologically, the studies are rather uneven, however, and it is unlikely that 
staff would be able to design their own formative study independent of external 
TA.
Despite these drawbacks, the Project has been able to make the case for its 
approach at national level using data drawn from all of these sources. In a 
playing field with few other voices, and few competing studies on new 
approaches, this was possible. For the Navoi project to continue to play the role 
of laboratory for innovative new approaches in MCH, RH and related areas, 
information management will have to be significantly strengthened. 
Recommendations:
Stress the pilot nature of the Project in DIP formulation of the Project. 
Specifically, the HIS (which includes but is not restricted to the KPC and HFA) 
should be designed to:
· Monitor impacts and learn lessons from new interventions such as 
adolescent RH
· Monitor the process of Oblast-level scale up of key activities and extract 
lessons for national programming
· Identify key data collection approaches and data points which could be 
effectively integrated into MOH HIS systems to cost effectively support 
facilitative supervision and track systemic performance.
31
B. Training
Training was a major Project activity, a method of capacity building and 
institutionalizing new skills in the delivery system. As shown in Table 2 providers 
from Project rayons as well as other oblasts and other institutions all received 
training over the life of the project. The type of provider trained is shown in 
Table 3. In all
· 4 health providers passed 4 different courses 
· 57 health providers passed 3 different courses
· 207 health providers passed 2 different courses
· 1215 health providers passed 1 course
The total absolute number of trained providers is 1483.
The column marked “monit” indicates the number of trainees who were 
monitored—by MOH or Project staff—following the training.
Table 3. Number of trained health providers and conducted monitoring (20.08.03yy.)
RH IMCI Breastfeeding SM/obstetrics SM/Neonatoligist ?-IMCI
newbor
n 
resuscit
ation
Rayons and 
health facilities
trained monit TOT trainedmonit TOT trained monit TOT trained monit TOT trained monit TOT trained monit TOT trained
Kiziltepa rayon 118 21 3 85 81 6 147 43 4 40 0 2 37 0 1 235 182 6 1
Navoi rayon 110 31 6 49 43 5 98 39 4 30 0 4 17 0 1 137 109 5 1
Total in pilot 228 52 9 134 124 11 245 82 8 70 0 7 54 0 2 372 291 11 2
Nurata rayon 12 0 0 20 0 0 9 0 0 0 0 0 0 0 0 0 0 0 1
Kanimeh rayon 23 0 0 4 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1
Total non-pilot 35 0 0 24 0 0 9 0 0 1 0 0 0 0 0 0 0 0 2
Samarkand 
Med.Institute 0 0 0 36 0 18 13 0 0 0 0 0 0 0 0 0 0 0 1
Bukhara 
Med.Institute 0 0 0 22 0 10 0 0 0 0 0 0 0 0 0 0 0 0 0
Total in 
Med.Instites 0 0 0 58 0 28 13 0 0 0 0 0 0 0 0 0 0 0 1
Oblast Maternity 
House 24 3 9 0 0 0 58 13 3 32 0 2 33 0 0 0 0 0 2
Oblast Children 
Hospital 0 0 0 1 0 2 89 0 2 0 0 0 20 0 0 0 0 2 1
Navoi city 31 10 0 23 20 7 19 0 1 7 0 0 0 0 4 27 20 7 0
Total other 
health facilities 
in Navoi city
55 13 9 24 20 9 166 13 6 34 0 2 53 0 4 27 20 9 3
Other rayons 67 0 0 67 0 0 15 0 0 4 0 0 0 0 0 0 0 0 3
Other oblasts 0 0 0 34 0 3 2 0 1 1 0 0 0 0 0 0 0 0 1
Project HOPE 
staff 2 0 2 2 0 2 2 0 2 0 0 0 0 0 1 0 0 0 1
Total 387 65 20 343 144 53 452 95 17 115 0 9 108 0 7 399 311 20 5
Table 4. Trained health providers by discipline
Health providers target other total target other total target other total target other total target other total target other total target other total
Obstetrician/gynecologist 33 52 85 1 2 3 30 28 58 8 1 9 30 41 71
Pediatrician 52 44 96 10 29 39 1
General practitioner 37 37 60 48 108 20 20
Internist 7 4 11 1 1
Infection prevention specialist 2 1 3
Midwifes 120 125 245 48 50 98 1 1 28 30 58
Nurses 38 38 76 185 261 40 39 79 369 24 393
Feldshers 36 36
Neonatologist 1 1 7 17 24 5 14 19 2 9 11
Other specialists 7 18 25 3 3 6
Total trained 228 177 405 152 95 247 205 331 536 53 55 108 59 71 130 372 27 399 2 9 12
Trainees were typically chosen by the MOH, ordered via prikaz. As trainees participated in 
a given course, Project HOPE and other trainers observed them, selecting those they felt 
would make good trainers. These individuals were then given several days more training in 
adult learning techniques, to give them the skills of a TOT. Project staff regularly drops in to 
trainings to give feedback, but are co-facilitating less and less. TOT’s interviewed seem 
confident and capable of planning and delivering training independent of Project staff. TOTs 
have pretests already prepared that help them plan, based on trainee knowledge, and 
posttests are also in place. TOT’s are also responsible for monitoring at regular intervals 
after the training. Project staff continue to conduct monitoring visits in conjunction with 
TOTs. 
As shown in Table 4, the overwhelming majority of trainees were doctors, most of them 
specialists. Because of the current structure of the health delivery system, this is not 
surprising. However, the leaner and more prevention-oriented system of the future is likely 
to rely on lower level staff, and in particular nurses and midwives to provide basic education, 
counseling and primary services. Although some of the trained specialists have made an 
effort to pass their new skills to these staff, the Project should make them a priority as well.
Table 5 provides a snapshot of the numbers and levels of training provided to TOTs. TOT’s 
are scattered throughout participating facilities, and, in addition to performing their usual 
jobs, they are called to deliver training. A total of 106 TOT’s were trained.
Table 5. Master Trainers (TOT’s) Trained by the Project
Number of TOTs who passed….
Rayon
1 TOT 
course 
2 TOT 
courses
3 TOT 
courses
4 TOT 
courses Total TOTs
Kiziltepa rayon 15 - 2 - 17
Navoi rayon 13 1 1 - 15
Total in pilots 28 1 3 - 32
Navoi city 21 3 2 - 26
Other non-pilot 
rayons
4 - - - 4
Other oblasts 42 - - - 42
Project HOPE’s 
staff 
- - - 2 2
TOTALS 95 4 5 2 106
Much has already been said about the impact of training—in terms of technical updates and 
changes in supervision systems and client relations. The introduction of adult learning 
techniques appears to have altered attitudes and approaches both inside and outside of 
preservice training institutes. 
35
1. Certification 
Providers who have successfully completed a training course are awarded a certificate. 
Many have hung them proudly in their examining rooms and offices. While it is certainly 
important to let colleagues and clients know that a given provider has received special 
training, the extent to which these certificates are being used as certification of achievement
is problematic. Passing a course is not the same as mastering a skill. Indeed, IMCI 
trainees receive no less than 3 monitoring visits in the first year to ascertain retention and 
correct practice of new skills. And often, because many of the Project’s courses introduce 
new information and require new behaviors, more training, coaching and mentoring is 
required before genuine certification of mastery is actually appropriate. This is a national 
issue, not isolated to the Project. It has significant implications for quality. The current 
system, in which a final certificate is awarded before practical application is observed, sends 
a message that taking a course is sufficient to acquire the new skill. This is an unfortunate 
message.
Recommendations:
1. Nurses, midwives and general practitioners should be prioritized for future training in 
preventative and primary skills. 
On certificates:
2. Provide trainees with a letter of thanks for attending Project courses. Award certification 
after at least 3 monitoring visits (including written tests) ascertains a pre-established level of 
expertise. 
3. Make the certificate time bound, and award higher certificates for providers who attend 
refresher courses.
On maintaining quality training:
4. The role of the IMCI, RH and soon to be established SM centers in Navoi need to be 
clearly defined for the future. At present they host training. However, they should also 
enable TOT’s to get refresher updates by maintaining rosters of master TOT trainers in 
Uzbekistan and the region and organizing courses with them. The Centers should also 
monitor new developments in their respective fields and have budget to disseminate this 
information through a newsletter or other means. 
C. Supervision
Initial delays in implementation and the press of other demands did not allow the Project to 
implement Quality Assurance activities, which were originally planned. As a result, while 
skills and supervision systems have had benefited from training, supervision systems 
remain more or less as they were, and the institutional framework for reinforcement and 
support of new practices—both technical and supervisory—fragile at best. Indeed in one 
SVP, probing questions about supervision of patronage nurses revealed lingering punitive 
attitudes towards supervision. Staff reported that when a patronage nurse is found to be 
falling short in performance they ask her to “stand up and morning conference so we can tell 
her not to do it.” Clearly, while the good intentions are there, theory has not penetrated 
consistently or completely.
Recommendation for health facilities:
Receptivity at all levels of the health delivery system to a new approach to supervision is 
high, and QA interventions are likely to be quickly absorbed and adapted. Supervision 
36
systems that enable continuous reinforcement of QA approaches are critical to ensure 
sustainable institutionalization.
D. Drug supply 
Table 6 provides information on Gifts in Kind donations provided by Project HOPE over the 
life of the Project
Table 6. Gifts in Kind from Project HOPE to Navoi Oblast MOH
Item $ Equivalent donation
Books 300
Pharmaceuticals 641,934
Medical supplies & equipment 198,774
Other 1,568
Total inventory 841,009
Some of the interventions introduced by the Project rely on a steady supply of drugs to 
maximize their impact. IMCI, for instance, requires some 12 different drugs. Treatment of 
micronutrient deficiencies requires iron folate, vitamin A and other drugs. Greater 
contraceptive choice implies availability of methods. Consistent availability was reported as 
problematic. Although most drugs are supposed to be free to children under 5, women of 
reproductive age and others consistent availability of all of these categories of supplies was 
reported as problematic. Patients are currently paying for iron folate, for instance, because 
supplies are insufficient. The upshot is that only the small number of those who can afford 
these drugs have access. In addition, several Project Steering Committee representatives 
suggested that too much emphasis has been placed on stocking hospitals at the expense of 
Primary Care Units.
Although many drugs are supposed to be free of charge in the current system, unavailability 
of many essential drugs means that in fact consumers are forced to buy them from private 
pharmacies. In the Navoi case, “donations” leveraged from commercial investors, Project 
HOPE, and, in the case of contraceptives, UNFPA during the last 4 years have also helped 
fill the clinic shelves. Over the life of the Project, HOPE donated a total of $641,934 in 
pharmaceuticals. While this filled some gaps in availability, and was highly appreciated, it 
does not solve the problem. 
The system is likely to change with health reform initiatives. A soon to be released study on 
willingness to pay for drugs conducted by Counterpart International indicates that people are 
indeed willing to pay for drugs to ensure availability. Counterpart is piloting an approach to 
clinic-based village pharmacies in Karakalpakstan Oblast. Save the Children has piloted a 
revolving drug scheme in Tajikistan that is slated to be piloted in Uzbekistan under Project 
HOPE’s Healthy Family Project. 
Recommendation: Review alternative models for ensuring drug availability to support 
Project interventions, and consider piloting community-based cum clinic-based revolving 
drug scheme approach in the extension Project. 
37
E. Community mobilization
As capacity in the health delivery system has been upgraded, community outreach activities 
have built upon a solid foundation of trust with the MOH, local and community leaders, and 
well-designed IEC materials. The Deputy MOH cited community engagement and 
awareness of health issues as the most important change resulting from the Project. 
In some senses, the provider training launched the community outreach program, as 
providers began to see their role in informing, advising and educating clients. Adult learning 
methodologies, which underpin all trainings, offered a new participatory, problem-solving 
framework for behavior change. 
At the midterm not much community outreach activity was observable in the Project. The 
last year saw significant activity in this regard. At the end of the Project, the community 
mobilization strategy includes a number of intertwining approaches, each of which bear 
additional investigation in the extension to assess their appropriateness for scaling up. 
In the Oblast level final competition, women perform a skit 
highlighting home-based care of diarrhea.
1. Competitions
To raise the profile of key issues with the community, the Project used a popular event 
format for disseminating its message. Uzbeks seem to revel in competition, and panel 
quizzes on various informational and academic topics are a familiar and fun activity. Using 
the Mother Reminder booklet as the informational basis, the Project sponsored a tiered 
approach to competition, starting at the makhalla (community) level up through the rayon to 
the oblast level. In all, 19 pre-qualifying competitions were held before the final. The 
competition included dramas and fact quizzes. The final, oblast level competition was 
judged by a panel from the Project, MOH and Oblast governor’s office. The prizes: a TV set 
for the winner and tape decks for 3 runner’s up—all will be housed in community buildings.
The competition as an approach appears to have been a high profile, popular event. What 
is less clear is how far its impact has reached, how many people actually engaged in the 
process, and what kind of lasting impact it has had on awareness and behavior change. 
Before replicating it with other messages, in other places, this should be considered in the 
extension. 
38
Recommendation about competitions:
Conduct a quick analysis of the cost and outcomes of competitions based on KPC and 
Project budget data to assess whether this is a viable strategy for replication at scale. 
2. Makhalla Committees
Consistent with the design of many community health projects, the Project identified an 
existing community leadership structure to help garner support and establish legitimacy at 
the community level. The Makhalla is a multi-tiered structure in which community 
representation is elected at the grassroots that then nominates representatives to rayonal 
and then oblast levels. The community makhalla is responsible for oversight of social 
issues—from dealing with alcoholism to managing major religious events, as well as 
oversight of community infrastructure (water, roads etc), and playing a welfare function with 
poorer families. 
In year 3, the Project held seminars to brief the makhalla about key messages. Project 
TOT’s delivered nine seminars for some 128 “makhalla activists” in the pilot rayons. 
Reflecting the sentiments of many older respondents about the Project, one Makhalla 
member commented: “Project HOPE brought some knowledge that our grandparents had. 
They just presented it in a scientific way.” 
In addition to “blessing” Project activities and the informal networking that individual 
members may do, the makhalla has helped mobilize activities. Some members of the 
makhalla, as well as other senior community members, have been recruited as so-called 
IMCI organizers. They gather people together to listen to presentations given by doctors or 
patronage nurses about IMCI related topics. (See below for more about patronage nurses). 
Most of these organizers are older, respected men with the time to be able to do this 
organizing function. There is no information about how many such meetings have been 
held and to what extent these meetings have contributed to community awareness or 
behavior change. Anecdotal information indicates that 10-12 “couples” or came to a 
meeting in one site. 
The fact that makhallas committees at every level are about 99% male13 has it is up and 
down sides: on the one hand, male support for Project initiatives models interest and 
engagement by male leaders. On the other hand, and arguably more importantly, by 
supporting the male-dominated makhallas, the Project may be reinforcing the idea that men 
should drive community decisionmaking. 
Other health issues that makhalla members want information about include:
· Family planning/contraceptives--more
· Healthy baby—more
· Environment, esp. water supply
· Dealing with alcoholism
Recommendations about makhalla committees:
1. Clarify their roles
 
13 Nearly all of the female representatives on the makhallas contacted were designated “secretaries”. Only one makhalla 
was headed by a woman in an elected position, and this was the most grassroots level of makhalla.
39
2. Provide incentives, or at very least positive profiling for female leadership in the makhalla 
committees
3. Continue to keep makhallas informed and engaged, feature them at events, but do not 
expend enormous resources for outreach through this mechanism.
3. Breastfeeding support group motivators
This approach is arguably the most innovative, exciting and sustainable. Like community 
health volunteers in traditional community health projects, “mature” women leaders were 
recruited to disseminate information that reinforced Project messages. In most analogous 
projects, the link between the volunteer network and the health delivery system is tenuous 
or not well defined. In the Navoi Project, the volunteers are very much part of the clinical 
team, spending between 1-3 hours/month on average in the maternity setting where they 
share breastfeeding information with new mothers. Their role in the clinic gives volunteers 
added credibility, access to information, and strengthens referral links. The volunteers also 
disseminate information through informal networking in their neighborhoods, and, by their 
own reports, are seen as a resource and support for pregnant women and new mothers. To 
date, breastfeeding motivators have not been asked to keep a record of the nature and 
frequency of community-based contacts, and it was difficult to get a sense of the extent of 
this function in terms of spread and impact. 
Training for motivators has, to date, depended on the clinic they are attached to. In some 
cases, volunteers received only one hour of briefing about breastfeeding. In other clinics, 
they get regular, quarterly updates. All have access to written materials, and are literate. 
Volunteers want (and need) training, not just about breastfeeding but also about other 
related health issues. Issues mentioned include: how to care for newborn, childcare, how to 
deal with their husbands.
Like health volunteers in other parts of the world, the breastfeeding support motivators are 
motivated as much by the desire to help other women with vital information, as they are the 
accolades that accrue to them for the service they provide. Several recounted with 
considerable fervor how the experience and knowledge about exclusive breastfeeding had 
transformed their lives—and the health of their children. The desire to share this 
experience and information with other women was powerful. In addition, many clinics offer 
volunteers priority treatment in appreciation for their services. 
Recommendations about community volunteers:
1. Standardize volunteer training and make it more frequent, adding new topics and 
refreshing old ones. Provide reference materials.
2. Develop simple matrices to allow volunteers to record their networking activities.
3. Open a “drop in” counseling “room” in a strategic location that can be staffed by 
volunteers and serve as a focal point for education and dialogue on health issues for 
pregnant women and new mothers (as well as adolescents at different times?). The 
center could also stock basic drugs, vitamins and even contraceptives. This idea was 
proposed by a volunteer and echoed by a member of the Steering Committee. 
4. Patronage nurses
An established part of the health delivery system, patronage nurses have been the 
traditional link between the clinical and household setting. When a woman goes home with 
her new baby, she can expect a visit from the patronage nurse on a daily or biweekly basis. 
40
The patronage nurse—who functions somewhat like a barefoot doctor--is not only a source 
of information and advice, but in the past was also responsible for checking on the hygiene 
of the household. Typically, one patronage nurse is responsible for 50 households. In 
addition to their house-to-house role, patronage nurses have given community seminars and 
been very involved in supporting local makhallas in preparation for Project-sponsored
competitions.
Patronage nurses have received 3 days of training in reproductive health, and 3 days in 
basic IMCI. There is a plan to provide a similar module for Safe Motherhood. Patronage 
nurses are armed with Project brochures that they distribute to each household. 
Recommendations about patronage nurses:
1. Patronage nurses have an important role to play in community health education. They 
should be given more training to upgrade their skills in specific health messages, 
counseling, and basic home based treatments of childhood illnesses.
2. The link between community volunteers and patronage nurses needs to be clarified in 
the context of overall health reform that may redefine the role of the patronage nurse. 
Patronage nurses may, for instance, be the first referral link in some cases that 
volunteers come to know about. Patronage nurses may also supervise and support 
volunteers with information. 
5. Hotline for postpartum women
Every baby friendly hospital has opened a hotline for women after they go home with their 
new babies. The phone numbers are posted in all maternity wards. An average hotline 
receives 250 calls every year. Hotlines may prove a useful component for the adolescent 
reproductive health strategy.
6. Support groups
Using its own initiative to reach out to the community, the Kiziltepa regional hospital has 
established support groups for adolescents and one for DOTs patients (in TB treatment). 
Fifty volunteers organize these meetings. Although this initiative appears to have predated 
the Project, the head of the hospital reports a change in presentation methods (from lecture 
to participation) based on learning’s from the Project. 
7. Summary and recommendation about Community Mobilization
Although the Project started community outreach activities late, it has generated a number 
of interesting models. Since community health is so new in Uzbekistan, these have already 
attracted considerable attention. Community engagement is high at the moment, including 
MOH and makhalla leadership support. Maintaining, monitoring and institutionalizing this 
level of engagement remain a challenge for the Project. 
As a next step, the Project needs a coherent community mobilization/IEC strategy with 
specific targets. Since this is a pilot, it will be important to establish an inquiry framework 
including, possibly, control sites, indicators, and simple information collection systems that 
can monitor and measure the relative and synergistic impacts of various approaches. Cost 
and human resource considerations should be factored into this inquiry framework. It 
should generate data and lessons that allow the Project to adjust approaches and make 
national-level recommendations over time. 
41
 IEC Materials had a significant impact on the highly literate population
F. Communication and materials for behavior change
The printed materials produced by the Project appear to have been of good quality, used by 
both providers and clients, and widely distributed. The Mother's Reminder Booklet 
referenced above was available in maternities and distributed to every household with a 
pregnant or new mother. It serves as a reference and record for mothers, and a point of 
discussion between providers and clients. 
The leaflet on reproductive health was available in primary clinical and maternity house 
settings and was distributed to households by patronage nurses. With a highly literate 
population with little to read, these materials appear to have been read not only by women 
in their reproductive years, but by partners, grandmothers, and adolescents. 
A poster competition between participating clinics and hospitals helped to reinforce 
breastfeeding, reproductive health and IMCI messages, and generated some very 
innovative, creative posters that now adorn the walls of the clinics and hospitals where they 
were produced. Posters created by the Project also brighten the halls of clinics and 
hospitals. 
New materials on MCH-related issues are being generated in many parts of Uzbekistan, 
underwritten by a number of donors. To date, there is no one standard set of IEC materials 
for any of the technical areas covered by the Project. The Project has made some important 
attempts to network with the other agencies that have produced alternative materials, and
reciprocal review processes have helped maintain quality if not a measure of healthy 
competition. 
1. Mass media
As shown in Annex F, the Project received attention in major local and national newspapers, 
due, in large part to proactive placement by Project staff. The use of mass media for 
dissemination of key messages has been hampered by bureaucracy constraints. While the 
Project has gotten some TV airtime, it seems like this was mostly “talking heads” and not a 
major part of the IEC strategy.
Recommendations: 
1. Sustainability: looking to national impact, scale, and the inevitable question of covering 
the recurrent costs for reproducing IEC materials beyond the life of the Project, continued 
liaison with other Projects and the MOH will be essential.
42
2. Since mass media is a part of most people’s lives, and an inexpensive way to 
disseminate information widely, the extension should prioritize investigation of print, 
television and radio to place key IEC messages. Creative, humorous approaches should be 
considered.
F. Capacity building
Much has been said above about the paradigm shift, which the Project has achieved at 
MOH, facility, and community levels. The Project has also served as a fulcrum for 
connecting national and local stakeholders in ways that built capacity and aligned 
perspectives through jointly initiated activities. For a small Project like this, this is no minor 
feat. The Project set out in the DIP to build the capacity of six key groups of stakeholders 
and stakeholder agencies:
· The Navoi Project management team
· The cadre of TOTs
· The health care system as a whole—particularly related to quality
· The Oblast MOH—particularly related to problem solving
· Agencies currently or potentially linked to the MOH
· Local NGOs—still nascent at the time of the DIP
This section considers the extent and nature of the Project’s impact on these and several 
other institutions and stakeholder groups, as well as Project HOPE itself. More details on 
the Project HOPE teams in Navoi and the U.S. are included in Section IV. 
1. Project HOPE/US
Project HOPE launched a number of Child Survival initiatives during the period 1999-2003, 
but this was its first and by many accounts its most successful. The Project gave HOPE an 
opportunity to reach into new sectors including maternal and newborn care, and gave the 
agency greater depth of understanding and valuable networks in Uzbekistan. The design 
has informed other Projects including the larger bilateral Family Health Project in Uzbekistan 
and Tajikistan, as well as the Kyrgyzstan Child Survival initiative, which began a year after 
Navoi. The cluster of programs in Central Asian Republics (which also includes a major TB 
eradication program) also enabled Project HOPE to standardize personnel and other 
procedures for the region. 
There has been a total turnover of staff from the Project HOPE side, with regional and 
deputy regional managers as well as the technical manager all changing over the life of the 
Project. Despite this, field staff appears to feel that Project HOPE has been supportive of 
their efforts.
43
Project HOPE Navoi Staff with Evaluators
1
st row Laurie Zivetz, Sarah Porter, Dilorom Allabergenova, Ravshan 
Alimov, Abdunabi Kuchimov; 2nd Row Nasiba Bozorova, Nigora Muratova, 
Mavzhuda Babamuradova, Lilya Djelilova, Nuriddin Shaimanov, Liza 
Bogovich, Vicky Bulatova, Komiljob Boboyev
2. Project management team 
All old and new staff acknowledge how much they have learned and grown (and enjoyed the 
process) as a result of their work on the Project. Not only were technical areas new, but the 
style of working (introduced primarily through the efforts of Dr. Babamuradova) as well. 
Learning can be seen in two major areas—a) technical—all staff have gained new 
knowledge and skills in key Project areas through training, monitoring and application, and 
b) management--Navoi staff remarked that they have never worked in such a collegial way 
before. Staff has understood and internalized fundamental principles of participation, 
ownership and partnership in the way that they conduct themselves as a team, implement 
their program, and relate to partners. 
Significant turnover among the local staff has also occurred, much of in the last 6-8 months. 
New staff has been smoothly integrated, vouching for the strength of the team norms and 
management systems for application.
Most of the members of the Navoi team demonstrate solid leadership skills in their own 
areas of responsibility, but there is also a team ethic (which may be cultural as well) to 
respect and follow the broader leadership of the Director. This, coupled by a dynamic 
leader for the last 2.5 years, has allowed the team to operate at a highly functional level, 
where each member of the team shined and felt at the same time supported by colleagues 
and a leader. 
44
3. MOH
The Project appears to have struck just the right balance in its partnership with the MOH. 
Several factors contributed to this:
· The introduction of new training topics was preceded by orientation briefings at 
every level—oblast, rayon, and makhalla before the training was undertaken14
. 
· The fact that the Project office is housed within the MOH contributed to daily, 
collegial interaction.
· The Project actively sought to inform and engage senior political officials at the 
Oblast level.15
· The Project kept MOH informed and actively sought senior decisionmakers' input 
via monthly Steering Committee meetings.
· MOH staff was involved in all monitoring activities.
· The Project spotlighted Oblast MOH achievements through its participation on 
national level task forces.
Says Professor Dilbar Makhmudova, Direct of the National Research Institute of Pediatrics, 
“Usually the Ministry of Health would like to take full credit for achievements, but in the case 
of the Health Authority in Navoi, they give credit to Project HOPE.” Indeed, Project staff 
report that even the Chief of the local health authority has been known to contribute to 
seminar preparation efforts, staying with the job until it was finished. MOH staff does 
likewise. 
The Project leave behind a cadre of MOH master trainers who even now are in demand 
outside of Navoi (see Tables 3 and 4). The Deputy of the Oblast MOH reports that the 
oblast has started using the “Project HOPE” methodology to train providers in other places, 
and appears confident that the MOH could continue to replicate training independently in 
future. 
4. National Institutes
The Project did an outstanding job of linking with several national level institutes, thereby 
multiplying the impact on capacity manyfold. Agencies like the National Institute for 
Pediatric Research and the Reproductive Health Institute benefited significantly by being 
part of the inception of the strategies relevant to their sectors. Partnerships with key 
national Institutes also paid off in terms of the Project’s potential for policy impact. 
Subcontracts were provided to conduct formative research provided financial and logistical 
support for national level academics to get into the field, and participate in a grassroots-level 
laboratory at a time of significant national level programmatic change. 
Samarkand and Bukhara Medical Institutes benefited significantly from the Project as well. 
In all, nearly 100 staff were trained, including 28 TOT’s. IMCI is now part of preservice 
training in both Institutes as a result of the Project. The exposure to participatory adult 
learning techniques has also had an impact on teaching styles. 
 
14 In the early days of the Project, HOPE sponsored a study tour for senior MOH officials to the Ferghana Valley where 
Z’drav Plus was implementing baby friendly IMCI approaches. This appears to have given the initial impetus for change. 
Interestingly, Navoi has now become such a study tour destination as well.
15 The deputy Governor, the most senior woman in the Oblast, participated on the porject steering committee, and as a 
judge in oblast-level Project-sponsored competitions.
45
While the DIP did not anticipate training beyond the target rayons, there is no doubt that by 
including providers from these Institutes, and indeed supporting training on site there, the 
Project significantly extended its impact and sustainability. Training built and multiplied 
capacity. The Bukhara Medical Institute, for instance, trains 150 students/year. Fifty of the 
1500 questions on the state test in Samarkand are now directly related to IMCI. The 
relationship with these Institutes helped establish the Project’s credibility, which is in no 
small measure responsible for the national profile of the Project and Project HOPE. Says
Professor Karimova, President of the Association of Ob/GYN’s and based at Samarkand 
Medical Institute: “It is easier to work with Project HOPE than other agencies. They never 
say ‘no’.” 
5. Health facilities and health workers 
Health workers interviewed during the evaluation were universally and unequivocally 
effusive about training they had received during the Project and the transformations they 
attribute to Project interventions. Starved for up-to-date information in their specialty areas, 
the Project infused the system with new ideas and energy. 
Participating facilities have strengthened their links with communities through their 
involvement in outreach activities described above, as well as more sympathetic attitudes 
towards clients. The visual impact of the Project on maternities in particular is tangible, with 
posters and displays on breastfeeding produced by maternity staff adorning walls and 
tables. Head of the Navoi Rayonal MOH, Dr Ergashev Yusef says that breastfeeding 
training was so important that they insisted all maternity hospital staff, including cleaners 
and drivers, have exposure to the key messages.
Importantly, supervisors and staff all report significant changes in the way they relate to one 
another and clients, as mentioned above. The Chief Doctor in one primary clinic (SVP) says 
he divides his work life into two parts—before and after Project HOPE. Staff in this clinic 
talked openly about how the training they received transformed the way they work as a 
team—the supervisor doesn’t feel the need to be right every time, but can problem solve 
with other staff. The group also talked about the way they treat their patients, mentioning 
that now they consider psychological factors as important to diagnosis and treatment. 
In addition to the public sector service delivery system, the Project invited representatives of 
the better-endowed mining company system to briefings on IMCI and safe motherhood. The 
mining company, with its head office in Navoi and 57,000 employees nationwide, offers 
private service to its employees. The chief pediatrician indicated an interest in procuring 
training for mining company doctors from the project, or Project trained TOTs.
6. Local NGOs
When the Project began in Navoi, there were very few NGOs and those that existed were 
young, and fragile. Today, there are 46 NGOs in the Oblast, and an NGO newsletter. One 
of the lead NGOs is active on issues related to women’s employment and advocacy on 
domestic violence and trafficking. The Director of this agency credits the growth and 
development of local NGOs in large measure to the Project HOPE Project. In the early days 
of the Project, HOPE supported an NGO exhibition in which local agencies were able to talk 
46
about their programs with local officials and talk about public-private sector partnerships. 
The project gave this event legitimacy as the only INGO. Project HOPE has continued to 
participate in NGO events and has invited NGOs to Project briefings and trainings. 
The project has been instrumental in lending its credibility and resources to strengthen ties 
between Navoi-based NGOs and the local government. As community activities take off in 
the extension, these linkages and Project HOPE’s continued support will be critical.
Recommendation about local NGOs:
The Project needs to partner with local NGOs on community activities as mutually 
appropriate. Collaboration should be designed to strengthen local NGO capacity, and affirm 
relationships with government. 
G. Impact on national policy and programming
Much is said in other parts of this report about the project’s impact on national policies and 
programming. The Navoi Project design became a model for a project covering two entire 
Oblasts in the country. Project staff participation on national task forces related to IMCI and 
reproductive health brought lessons from the project to bear on policies being conceived in 
the context of health reform. Training of trainers and staff from other Oblasts and medical 
schools multiplied exposure and practice to key MCH practices. Donors, government and 
INGO representatives have visited the project site or learned about it through interaction 
with project staff, borrowing ideas, curricula, and materials. 
The DIP does not anticipate any activities related to national policy or health reform. Indeed 
it is questionable whether the objectives that remain unaddressed could have been 
achieved had not attention been focused solely on Navoi. The IMCI expert, for instance 
spent an entire six months translating the curriculum from Russian into Uzbek. While this 
went a long ways towards meeting the broader objective of introducing an important new 
approach into the country (not to mention creating a positive, collaborative relationship with 
donors and the MOH), the question of whether this was the best use of project resources is 
there. 
Recommendation:
1. The project is in a strategic position to continue to impact on government programming in 
the context of national health reform. This should be proactively anticipated in the DIP 
by allocating human resources, designing M&E systems, dissemination mechanisms to 
promote specific, targeted issues. 
2. In particular, the Project should find ways of regularly networking with other agencies 
working on MCH-related issues (National Research Institutes, Z’drav Plus, Counterpart 
International, the Healthy Family Project, the World Bank and ADB projects16) in the 
context of task force work and outside. Networking should not only serve to share 
lessons from Navoi, but enhance Navoi activities through lessons from other places. 
 
16 All of these projects have manyfold times more resources, including technical professionals who may be of assistance 
to the Project.
47
I. Sustainability 
Several aspects of the program portend well for sustainability and scale up:
· The Oblast MOH has embraced all of the new MCH approaches piloted by the Project, 
and is already implementing many in non-Project rayons. 
· MOH officials, as well as individual providers appear empowered by new approaches.
· Oblast officials are invested in health issues.
· Oblast-based TOT’s are able to plan and deliver training without assistance from the 
Project. 
· TOT’s are in demand from within and outside of the Oblast.
· Baby Friendly hospital certification carries a lot of pride with it. To maintain certificate 
status, maternities must maintain best practice. Baby friendly hospitals set the standard 
for other facilities.
· Oblast MOH and local NGOs appear to have forged good avenues for dialogue and 
cooperation.
· Local leadership is well informed about some issues, and has experience organizing 
around public health issues.
· Communities in the target rayons have been saturated with information about key 
issues—breastfeeding, danger signs, and, to a lesser extent, contraceptive choice. This 
information may seep down to younger people, and across rayonal lines.
· IEC materials, particularly the Mother Reminder Booklets, are in the possession of many 
households, and can be used and read by the whole family.
Were the Project to stop today, much would remain behind that would continue have an 
impact for this generation at very least.
Factors that may constrain or hinder sustainability of project interventions include:
· The absence of a supervision and monitoring system that can support quality and 
consistency in new practices. 
· The inconsistent supply of drugs and contraceptives. 
· Provider “migration” to private sector opportunities because of low pay from government 
service.
· MOH lack of budget to reproduce IEC materials. 
· Lack of cogent data demonstrating impact of key interventions.
A note on the Sectoral Centers that the project established is relevant here. To date, the 
Project has resourced the establishment of IMCI and RH training Centers in the Oblast, with 
plans to support the establishment of a Safe Motherhood Center in the next phase. While 
these Centers are well equipped for training, they appear to be understaffed and 
underutilized, with an equal number of trainings being conducted inside of facilities. Center 
Directors liase with and support project activities. 
The Centers were established with the blessing of the Oblast MOH. However, the 
evaluation did not explore to what extent the Oblast MOH is committed to supporting the on￾going, recurrent costs of maintaining the Centers, or, most importantly, what they envision 
as the Centers’ role in the future. This report argues that the Centers have a role to play as 
focal points for technical excellence, if they house libraries, disseminate new information, 
employ staff who do spot technical “audits” (to compliment on-going monitoring), identify 
48
training and refresher training needs, and organize TOT and provider courses etc. Before 
investing in more stand-alone Centers, however, the Project will need to clarify the roles and 
resource requirements of such Centers and the commitment of MOH to agree to both.
Although some of the constraining factors are not directly within the extension Project’s 
purview, they are issues that the Project can address in Oblast and national level fora where 
the broader context for health reform is considered. 
IV. Program Management
Many of the management issues related to Project HOPE’s partnership with MOH, facilities, 
National and local Institutes, NGOs and community groups have been covered in the 
previous section. This section focuses on the management of the Project by HOPE and the 
local Project HOPE team. While all of the findings and recommendations relate specifically 
to the extension Project, many of the recommendations are generic and may also apply to 
other Projects in the Central Asian Republic region or globally.
A. Background
The Project got off to a rocky start under the leadership of an expatriate Team Leader from 
Bangladesh. Following some administrative and fiscal irregularities, he was terminated in 
August, 2000. There was then a lapse of some 5 months during which time not much 
happened, although two Peace Corps Volunteers located in the Project office and did 
provide some support in this interim period. At the end of 2000, Project HOPE hired Dr. 
Mavzhuda Babmuradova who had previously represented EngenderHealth (then AVSC) in 
Uzbekistan. Dr. Babmuradova started work in January 2001. Her arrival rapidly boosted 
the low morale and lagging staff momentum, and by all accounts propelled the Project to 
where it is today. In recalling that time, veteran staff talk about how they learned about 
working as a team, began a genuine partnership with the MOH, and took hold of their 
individual technical responsibilities. MOH, National Institute informants and providers 
across the spectrum similarly credit Dr. Babmuradova’s leadership and vision as 
instrumental in achieving the Project’s considerable results in such a short period of time. 
In September 2002, with Project HOPE’s successful bid for the USAID bilateral Health 
Family Project, Dr. Babmuradova was invited to move to this program. There began a 
search for a replacement for Navoi, resulting in the hiring of Dr. Abdunabi Kuchimov, then 
the international relations manager for the GP training program at Samarkand Medical 
Institute. After a two-week handover in Navoi, Dr. Babmuradova moved to Tashkent, 
continuing to contirubte15% of her time to the Child Survival Project. During this period she 
provided both technical and administrative support to the new leadership, ensuring its 
smooth transition in the final Project period. 
None of the original staff from Project HOPE/U.S. are still with this Project, most of them 
having left the agency. Continuity in technical support from Dr. Bettina Schwethelm who was 
involved in the inception and left Project HOPE in early 2003 was a critical element in its 
success. About half of the Navoi staff is new, many having been hired in the last 12 months. 
Despite the considerable changes and late de facto start up of the Project, a retrospective 
look reveals quite significant accomplishments given the time and resources available to the 
Project. In addition to numbers of people who directly benefited from training, materials, and 
49
activities, the Project has effected a transformation in thinking and practice among MCH 
providers and their clients that has permeated beyond the pilot rayons into the target Oblast 
and beyond. It has impacted on national policy and programming through targeted 
interventions and modeling innovation. This is due in large measure to the hard work, and 
solid management of a highly committed, motivated team in the field. Importantly, the 
leadership and functioning of the team modeled the cooperative, participatory, respectful 
problem solving approach that it promoted in the field. In short: the team walked the talk in 
terms of the way the Project was implemented.
B. Planning
Staff who were involved in the development of the DIP report using this framework for 
planning their specific activities. Sound planning is reflected in the sheer number of 
activities carried out by the Project by the relatively small cadre of staff. 
Project activities were carried out in a way that maximized participation of stakeholder 
agencies. The role of the Steering Committee—with senior representatives from key 
participating agencies--was critical in achieving cooperation of major gatekeepers. The 
input of key national Institutes in planning major components of the Project was similarly 
critical in garnering a sense of joint ownership of Project outcomes. 
C. Staff training
There is no doubt that every staff member has acquired valuable, practical new skills as a 
result of the Project. All professional staff have upgraded their technical and training skills. 
All of the veteran staff have had English and computer training. However, several, newer 
staff lack these skills. 
Like everyone in the health system in Uzbekistan, Project HOPE staff have squeezed every 
opportunity—whether a training, a consultant visit, the intern or Peace Corps volunteer who 
were with the Project for several months, or seminars in Tashkent—to expand their skills 
base. Most training was on the job, informally structured, or a brief mentoring relationship 
with a short-term consultant. Interestingly, although Navoi drew international and national 
observers, only one staff study tour (to the other IMCI pilot in Ferghana valley) was 
reportedly conducted during the Project. A recommendation put forward in this regard from 
the mid-term review is still pending, and important. Similarly, no staff aside from the 
Director attended conferences or trainings outside of Uzbekistan. 
As the Project begins to institutionalize, scale up and broaden its focus in the extension, 
staff urgently need training and exposure in some very specific areas related to:
1. Monitoring and evaluation/data for decisionmaking
2. Community mobilization
3. Maternal nutrition
4. Safe Motherhood
5. Time management.
Recommendations: 
1. For the extension phase: all staff have access to English and computer skills and all 
professional staff be required to achieve a certain level of proficiency in both areas. 
50
Project HOPE earmark funds to enable quality training for staff in this regard (a local 
NGO offers both types of courses).
2. TA and study tours be organized to enhance staff skills in key areas. Specifically:
· TA: Priority should be placed on the identification of regional (Russian speaking) TA 
providers. This will maximize impact for non-English speaking staff as well as 
partners, and is, obviously, more cost and culturally effective.
· Study tours should be organized in such a way that staff have a chance to meet 
counterparts in and observe analogous programs in Uzbekistan and the region. They 
should be structured to encourage critical thinking about adapting existing models to 
the Navoi context. 
3. Staff be supported to participate in international conferences or training, as appropriate to 
their jobs.
D. Human Resources and Staff Management
The mid-term report observes that the “technical staff, administrative staff and drivers are all 
actively involved in a team approach which provides strong cohesion and motivation.” This 
remains the case. Three issues related to human resource management merit mentioning:
1. Leadership
As discussed above, outstanding Project management and leadership—from Project HOPE 
and in Navoi-- was a major factor in the Project’s success. Both Dr. Schwethelm and Dr. 
Babmuradova adopted a style that was collegial, trusting and encouraged hard work and 
creativity. They led by example. Dr. Babmuradova, commenting on the support she 
received from Dr. Schwethelm, said: “She always gave me options but let me make the 
decision. I never felt my hands were tied or that I did something wrong." This approach 
appears to have permeated all levels of the Project. 
This kind of leadership was possible in large part because all professional staff are 
educated, trained health providers (and all but one a doctor). Nonetheless, it marked a 
significant departure from the traditional, punitive, top-down management style of the 
government that staff were used to. 
The recent transition to new leadership in the Project inevitably marked a change in style. It 
has taken some time for the team to make the transition and begins to trust themselves and 
their instincts, having depended in a myriad of ways on Dr. Babmuradova for vision and 
direction.
2. Time management
The mid-term evaluation raises the issue of staff burn out in the context of the targets ahead 
of the Project and its momentum at that point in time. Although there has been some staff 
turnover since that time, the issue remains a relevant one. Staff work long hours and 
weekends without complaint or compensation. Morale is high and there is no doubt that 
efforts have paid off in terms of results and impact. Staff cohesion and a team spirit is 
palpable in the office—an oft heard comment was that that although individual staff have 
jobs, they could count on one another for help, and that often they work together on one 
another’s jobs. What is not as clear is whether the long hours are a result of too few staff 
stretched too thin, or inefficiencies in work style. On the other hand, perhaps staff are trying 
51
to do too much for the MOH, and not letting go of key functions at opportune moments? 
These points bears further investigation, and more attention going into the extension phase. 
3. Job Descriptions and contracts
Although job descriptions exist for each position, they appear to be outdated and do not 
serve as a baseline for performance review17. There is a fairly comprehensive staff manual, 
which was prepared for all offices in the CAR. Missing from this manual, however, is 
discussion of how performance is appraised, how salary raises are calculated, and whether 
an appeals process is available to staff.
Although staff sign government mandated agreements which are sent to the Ministry of the 
Interior when they are initially employed, these contracts do not appear to be linked to work 
scopes or transparent salary markers. 
4. Skills mix
At the present time, all of the professional staff are trained doctors with the exception of one 
midwife. In addition, most of the staff, trainees, researchers and other participants in the 
project are MOH employees by virtue of the system that still remains where all professionals 
work for the State. Both of these factors limit the potential diversity of disciplinary 
perspectives on the team, and possibly the opportunities for team creativity and innovation. 
As the project moves more into community activities, medical degrees may be less 
important than they have been when technical training was the major emphasis of the 
project.
Recommendations: 
1. Consider staffing levels against targets and activities in the development of the DIP for 
the extension.
2. Prioritize time management training in upcoming technical assistance or training for staff. 
3. Review all job descriptions before the extension begins, based on requirements of the 
DIP.
4. Project HOPE should generate and disseminate a clear policy for staff performance 
appraisal, and salary increases.
5. New hiring should focus on diversifying the skills base within the staff. 
E. Financial Management
Each Project HOPE project is staffed with an administrator/accountant at the field level who 
is responsible for compiling and reporting the local currency expenses vis-à-vis approved 
budgeted line items to the Project Director. 
1. On site audits
In the spring of 2001 Project HOPE made some changes to its accounting system, which 
slowed the process for a period of time. To that point, financial information had been sent 
directly to Millwood. Following the changes, a financial monitor was installed in Project 
HOPE’s regional office Almaty, and reports were sent to her and checked before forwarding 
them to Millwood. This does not appear to have had a significant impact on efficiencies one 
way or another from the Project’s point of view. 
 
17 The job description for the driver, for instance, drafted in the time of the first Team Leader, notes that when the driver is 
not performing his duty as a driver he should sit and read the paper!
52
Navoi was lucky to have a competent person in this position, who managed the books in a 
meticulous way. Regional oversight from a skilled Project HOPE Manager has also 
provided closer support and oversight. A cursory review of financial systems raise a number 
of broader, generic issues which are put forward here for consideration18
.
What is anomalous is the fact that following the termination of the first Team Leader and the 
efforts involved in untangling fiscal issues in the wake of this termination, that Project HOPE 
did not take steps to adjust its system to be able to catch such issues earlier. It raises 
questions about whether an on-site audit, or the anticipation of such, might have precluded 
some of these difficulties?
2. Fiscal planning
Although not a chronic problem, in the final months of the Project, the Director was advised 
that he had less money in the budget than he’d previously understood. While this is likely to 
be more the result of transitions in headquarters staff than a pattern, it nonetheless raises 
concerns about how budgets are interpreted and how information is shared with the field. 
3. Reporting systems
It was noted that the Project accountant keeps two sets of manual ledgers in addition to the 
Project HOPE international Quickbooks system, which is backed up on a zip drive. It is not 
clear whether the hard copy steps are necessary or mandatory in the current system. 
Finally, the mid-term review anticipated a new system in which “field staff (could)…interact 
with the central database through Internet links for real-time processing, analysis, and 
performance feedback.” (pg 26). There was no evidence that this objective had been 
achieved.
4. Remuneration for MOH or Institute professionals
As with many Projects, striking a balance between engaging good professionals from within 
a government system and remunerating them in a way that is both fair and sustainable was 
a challenge for this Project. This was particularly challenging since nearly all professionals 
are employed by the government. Project HOPE’s commitment to sustainably 
institutionalizing a training capacity within the MOH made it important to establish a cascade 
training system that could, eventually, function on its own steam.
Project HOPE has been meticulous in establishing guidelines that disallow Project funds to 
be paid to professionals who are already salaried with the government. When Project 
HOPE Navoi recruited TOT’s (all employees of the MOH or National Institutes) to implement 
research or training in the Project area, no salary was paid in the early days of the project. 
Later on a per diem was given. When TOT’s and other TA providers were recruited to work 
in other Oblasts (and other countries—for instance, for the CS Project in Kyrgyzstan) a letter 
was sent to their office requesting their services for a specified period of time. It was 
assumed in this case that the person’s salary would be cut for the requested time, so that 
 
18 Financial issues are always extremely sensitive. These observations and recommendations are based entirely on 
interviews, and in no way reflect a comprehensive review of HOPE’s financial systems that was beyond the purview of 
this evaluation and indeed the evaluator’s skills. 
53
Project HOPE could remunerate the person for both time and per diem. The services of a 
50% time IEC specialist from the Institute of Pediatric Research was negotiated in this way. 
Project HOPE is to be commended for this approach which is at once pragmatic, 
transparent, and ultimately more sustainable. A good indication of this, is the fact that 
many of the project’s trained TOT’s continue to provide training on behalf of MOH and 
Medical Institutes without any external funding.
Recommendations:
1. Project HOPE should consider instituting an on-site audit at least once in a Project cycle.
2. The local Project Director needs to have complete and consistent information about the 
Project budget and anticipated spending timetables.
3. Since the current Navoi-based accountant will be leaving the Project this month, it might 
be a good moment for Project HOPE to review the manual entry practice and 
recommend whether the extra steps are necessary.
4. Project HOPE should continue its current approach to requesting the services of 
Government employees. 
F. Logistics
Project HOPE has decades of experience in the distribution of humanitarian assistance, 
which appears to have been handled effectively in the case of Navoi. The contribution of 
pharmaceutics and equipment were acknowledged and appreciated by the Oblast MOH and 
facility representatives. 
The Project has its own vehicle and rents other vehicles as needed. Coordination of 
vehicles—often a challenge to implementation for a complex Project like this one—appears 
to run smoothly.
G. Information Management
Information management is arguably the weakest technical skill among Project staff, and, 
based on the data collected since the Project’s inception appears to have been an Achilles 
heal since then. While staff understand MOH procedures, none are statisticians or social 
scientists (which in any case are few and far between in the countries of the Former Soviet 
Union). The KPC and HFA were not only foreign tools, the concepts behind them were 
equally unfamiliar. Technical assistance from Project HOPE appears to have fallen short of 
what was necessary to conceptualize useful indicators, collect and track data, and 
particularly analyze data in a meaningful way for decisionmaking.
 Recommendations:
1. Project HOPE provide immediate, intensive support to strengthen staff capacity in the 
design, collection and analysis and use of quantitative and qualitative studies for Project 
management and design. Training should also help staff make use of data to promote 
Project innovations.
2. Local, mentoring support be identified to enable this process (e.g. M&E advisors with the 
Healthy Family or Z’drav Plus projects).
3. The extension continues to use the formative research approach to explore new issues 
(adolescent reproductive health, safe motherhood) but intentionally build local capacity 
(staff and local NGO) in the process.
54
H. Technical and Administrative Support
A number of the external technical inputs provided over the life of the Project have been 
referred to in previous sections. Table 7 lists the TA provided by consultants to the Project. 
Project HOPE staff Dr. Bettina Schwethelm, and Juan Carols Alegre provided technical 
inputs as well. 
Table 7. External Technical Assistance
Topic Person Dates
Investigations on 
SM/MCH/Childcare in facilities
Erika Latchis May, 2000
Staff training in Epi-Info Gal Frenkel January-July 2002
Postpartum services assessment 
for new/first mothers
Stella Aslanyan August, 2002
Assessment of neonatal and 
perinatal care
Dr. Andro Shilakadze March, 2002
Assessment and training in 
emergency obstetric care
Dr. Erika Latchis May, 2002
Minilaporotomy training for 13 
providers
Dr. Makenjian 
Musuraliev
June, 2002
Essential newborn care and 
Newborn Resuscitation course
Dr. Andro Shilakadze June, 2002
Training Oblast OB/GYNs in 
antenatal care
Dr. Frank Anderson, U 
of Michigan
May, 2002
EFM, partograph and prenatal 
education training
Dr. Erika Latchis January, 2003
Grandmothers and other actors in 
MCH decisionmaking
Judi Aubel June, 2003
 
As mentioned above, all of the TA appears to have been highly useful as the Project 
developed. The use of volunteers certainly represented cost savings to the Project. 
55
Annexes: Final Evaluation Report
Increasing the Quality of Child Survival and Maternal Care Services in Navoi Oblast of 
Uzbekistan
Annexes 
A. Persons contacted
B. Scope of Work for the Evaluation
C. Sampling methodology for KPC and HFA 
D. Evaluation protocol
E. DIP Matrix
F. Items in the Mass Media about the projects
56
Annex A
Persons Contacted
Outside of Uzbekistan
Bettina Schwethelm, Former Project Manager, Project HOPE/US
Diaa Hammamy, Regional Manager, CAR, Project HOPE/US
Debbie El Anani, Deputy Regional Manger, CAR, Project HOPE/US
Juan Carlos Alegre, M&E, Project HOPE/US
Judi Aubel, Consultant
Erika Latkis, Project HOPE Women’s Health Advisor
Anara Doolotova, Project HOPE CS Manager, Kyrgyzstan
Susan Youll, USAID
Aigul Kuttumaratova, WHO/Europe
Project HOPE Navoi Staff
Abdunabi Kuchimov
Nigora Muratova 
Dilorom Allabergenova
Nuriddin Shaymanov
Lilya Djelilova
Nasiba Bozorova
Lisa Bogovich
Vicky Bulatova
Komil Boboev
Ravshan Alimov
Program Manager
OB/GYN specialist 
Pediatric specialist 
HIS specialist
IEC specialist
Midwife
Administrator
Secretary
Driver
Driver 
Steering committee members
1.Abdurahmon Nosirov 
2.Musallam Ibragimova
3.Yunus Avezov
4.Tanzila Ravshanova
5.Muazzam Bozorova
6.Orif Jumaev 
7.Yusuf Ergashev
8.Gulyam Aslonov
9.Nizam Sidikov
10.Gulsin Karimova
11.Nurmuhammad Alhamov
12.Project HOPE technical staff 
Chief of the Oblast Health Department 
Deputy of the Oblast administration
Deputy of the Chief of Oblast Health Department
Deputy of the Chief of Oblast Health Department on MCH and Head 
pediatrician
Head OB/GYN
Chief of the Kiziltepa Central Rayon Hospital 
Chief of the Navoi Central Rayon Hospital
Chief of the Navoi Oblast Maternity House 
Chief of the Navoi Oblast Child Hospital 
Chief of the Navoi Oblast RH Center 
Director of the IMCI training Center, Deputy of the Chief of Oblast Child 
Hospital 
Tashkent
Klara Yadgarova, Deputy Director, MOH
Andreas Tamberg, USAID/Uzbekistan
Prof. Dilbar Makhmudova, Director, National Pediatric Research Institute
Doug Palmer, Bahtiyar, Yuldosh, Fahriddin, Healthy Family Project
Feruza Tulaganovna, Director, National Reproductive Health Center
Zakir, WHO
57
Asta Maria Kenney and Ulugbek Buriev, Z’drav Plus
Andro Shilakadze, UNICEF
Farkhad Fuzailov, World Bank
D. Navoi
Bahriddin Murtazaevich Ruziev, Governor of Navoi Oblast
Tanzila Ravshanova, Deputy Oblast Health Dept.
Ergashev Yusuf, Chief, Navoi Rayon Central Hospital
Istat Himmatova, Deputy, Navoi Rayonal Hospital (MCH)
Nurmatova, Chief Navoi rayon Baby friendly hospital
Gulom Aslanov, Chief Baby friendly hospital in Navoi Oblast
Orif Jumaev, Chief, Kiziltepa Central rayonal hospital
Dilbar Akramova, Deputy Chief Doctor, Kiziltepa Rayonal hospital
Ihtiyar Ochilov, Chief Kiziltepa Baby friendly hospital
Ramine Bahrambegi, Program Director, Counterpart International’s Child Survival Project, Karkalpakstan
Olga Sashina, Navoi NGOs
Sabohat Salmova, Deputy Chief, Mining Co. hospital
Mariyana Bahrieva, Chairwoman, Red Crescent, Navoi Oblast
Prof. Nodira Juraeva, Chief GP training center, Bukhara Medical Institute
In addition, providers, TOTs and outreach workers and makhall committee members as follows:
SVP Madaniyat 
SVP Zarafshan 
SVA Ibn-Sino 
Malikrabod policlinic 
Yangi-arik makhalla 
Argun makhalla. Navoi rayon 
Ok-oltin village. Kiziltepa rayon 
SVP Zarmetan. Kiziltepa rayon 
Vangozi village. Kiziltepa rayon 
E. Samarkand
Prof. Karimova, President, Association of OB/GYNs
Klara Dilmuradova, Dean, Samarkand Medical Institute
58
Annex B
SCOPE OF WORK
PROGRAM: Child Survival Project, Navoi, Uzbekistan
POSITION: Final Evaluation Consultant
POINT OF CONTACT: Project HOPE Center: Program Manager, Russia Eurasia
On-site: Program Manager, Navoi CS
PURPOSE: Conduct Final Evaluation for Child Survival Project in Navoi, Uzbekistan
Activities Prior to arriving in Uzbekistan
ÿ Review background documents and baseline
ÿ Design pre-evaluation inquiry for Navoi Team
ÿ Design evaluation instruments with feedback 
Specifically, the evaluation will look at the following aspects of the project:
- impact in target sites
- potential for sustainability in target sites
- impact of project on national programming/policy direction
- replication/scale within the project period
- groundwork laid for extension/scale within the Oblast
- groundwork laid for added components anticipated in the cost extension
- community mobilization, and particularly appropriateness and capacity building of CBOs and 
sustainability of CBOs
- availability and appropriateness of technical and IEC materials for impact, cost, replicability, and scale
- training and supervision, particularly related to quality and scale up 
- quality of care
- HIS
SPECIFIC OBJECTIVES:
1. Provide methodology and conceptual framework for final evaluation of Navoi SC project. 
2. Lead inquiry and evaluation team.
3. Write the final evaluation report. 
4. Ensure final evaluation focuses on lessons learned and sustainability and potential for scale in terms of 
institutional and community commitment, capacity, cost, and the integration of project components into planning 
at the community, Oblast, and national levels. 
5. Carry–out 2 stakeholders meetings to brief participants on the preliminary results of the final evaluation for local 
stakeholders in the Navoi Oblast and national stakeholders in Tashkent. 
59
Annex C
Sampling Methodology
Knowledge, Practice, and Coverage (KPC) Survey
Universe: 190,294 inhabitants in Kiziltepa and Navoi Rayons
Sampling size: A simple random 30-cluster sampling method was used. For the purpose of the KPC survey, one cluster 
equals one makhalla. Ten interviews per cluster were obtained. In addition, parallel sampling was used to better 
understand the knowledge, practices, and coverage of mothers with children aged 0-23 months, women of fertile age (15-
49), and youth aged 16-18 years old. Thus, slightly different questionnaires were used for each group. The sample sized 
used gave a total of 300 interviews per age group, or a grand total of 900 interviews for the total area of the project 
(Kiziltepa and Navoi Rayons).
The following makhallas were included in the sampling methodology for the KPC Survey:
Rayon Makhalla Population Rayon Makhalla Population
Kiziltepa Kalayiazizon 2319 Navoi Vark 2,902
Uzlishkent 2725 Katta machit 3,013
Khasancha 2642 Shibzon 3,839
Gamkhur 3556 Allon 2,371
Mayta 2612 Umarov 4,130
Khusharti 1999 Pakhtaobod 3,011
Khamrabod 2500 Dustlik 3,920
Bulakrabod 3323 Khoncharvok 2,496
Kasrishurak 2715 Yangiobod 2,828
Ayronchi 2764 Degaran 2,011
Pakhtaobod 1848 Azamat 2,188
Okmachit 3006
Khavkarien 3172
Zarmetan 3547
Vorazun 2816
Khusbidin 2924
Konsurun 3070
T.Khamid 2340
Gulzor 2265
The above makhallas (30) were randomly selected out of all makhallas in each rayon. The random selection was based 
on population size for each makhalla. 
60
Health Facility Assessment (HFA)
The sampling frame and survey sample for the Navoi Oblast is the following:
Navoi Oblast
Sampling Frame for Navoi Oblast
Health Facility Kiziltepa Navoi Total
Central Rayon Hospital 1 1 2
Central Rayon Hosp. branches 2 -- 2
Central Rayon Child Polyclinic 
Polyclinic
1 -- 1
Central Rayon Polyclinic 1 1 2
SVP 21 14 35
SVA 5 1 6
Baby-friendly hospitals -- 2 2
Total 31 19 50
Survey Sample for Navoi Oblast
Health Facility Kiziltepa Navoi Total
Central Rayon Hospital 1 1 2
Central Rayon Hosp. branches 1 -- 1
Central Rayon Child Polyclinic 
Polyclinicc
1 -- 1
Central Rayon Polyclinic 1 1 2
SVP 4 4 8
SVA 2 1 3
Baby-friendly hospitals -- 1 1
Total 10 8 18
A total of 18 health facilities were assessed in the two pilot rayons. All Central Rayon Hospitals were 
surveyed, along with all Polyclinics. Four SVPs in each rayon, and a total of three SVAs (two in Kiziltepa and 
one in Navoi) were also surveyed. In addition, one of the baby-friendly hospitals in Navoi City was also 
included in the sample. 
61
Annex D: DIP Matrix 
Interview questions for key stakeholders: Navoi CS Evaluation
Tashkent
Question Notes
Donors, MOH, Other development agencies These are one on one 
interviews
1. What do you know about this project?
2. Have you visited Navoi?
3. What aspects of the project have informed your work? Probe for specifics
4. How do you think this project has impact on national programming in health? 
Are there aspects that have been adapted at scale?
5. How has it impacted on national policy in health?
6. What role has project HOPE played in the development of national programs 
or policies in health?
Probe for specifics
7. Are you using any of HOPE’s training or IEC materials in your program?
8. Are there aspects of the program that you would suggest could be improved?
9. Are there specific issues related to the implementation of the project that you 
would like more information about?
-For MOH (in addition to the above)
1. Do you perceive a change in the way the Navoi MOH performs as a result of 
this project? How?
2. How do you plan to interface with this project in future?
-For other PVOs/development agencies (in addition)
1. What type of technical cooperation have you had with Project HOPE over the 
last 4 years related to the Navoi project? 
2. Looking back, what have been the key benefits and challenges?
3. What if any type of cooperation do you envision in the future?
Navoi
Question Notes
Project Steering Committee Focus group 
1. Let’s do a short history of the project. What were the most important events 
in the project, and what changes did they make? 
Historical timeline (4 yrs) with 
key events and changes in the 
project and in the oblast. Paper 
with years drawn on it. 
Stickies with key events and 
then draw arrows to why, how, 
who.
2. What do you see as the most important achievement of the project? Individual responses then pass 
to front and read.
3. What do you think your biggest success as a Steering Committee has been?
4. If you could go back in time and change one thing about the project, what 
would it be?
5. If you could change one thing about the Steering Committee what would it 
be?
 For 2-5: make 2 columns on 
the flipchart: one for each 
language (so 2 scribes will be 
good) 
62
Oblast and Rayon Chiefs Individual interview
1. What have been the major achievements of this project in your 
oblast/rayon?
-in terms of changes in health status or practices
-
One on one interviews
Probe for changes in health 
status, management, and MOH 
‘culture’
2. What have been your biggest challenges?
3. What do you see as your biggest challenges to keep achievements on course 
in the future?
4. What role do you think this project plays in national policy or programming in 
the health sector?
5. What other projects or agencies play an important role in health delivery in 
your oblast/rayon? What role do they play? How does the HOPE project 
interface with them? 
6. Ask about any anomalous changes in key indicators from the KPC or HFA… TBD based on data
7. Iron and folate supplementation?
8. How is health information data collected? How do you use statistical data to 
make decisions? Is this different from the past? 
Oblast stat. Dept/Rayon stat chief (?) Individual interview
1. Describe how data is collected analyzed and shared in the oblast and rayons 
and with the national MOH.
2. Has this changed during and as a result of the project? If so, how? DIP anticipates “data for 
action”, computerization and 
analogous approaches at oblast 
and rayon levels.
3. Can you suggest 3 things you would like to do to further improve the Health 
Information System in Navoi?
Heads of baby friendly hospitals One on one
1. Size of hospital, services, no. staff, no. of deliveries, pop served etc.—basic 
stats.
2. How did your hospital come to be a baby friendly hospital—history?
3. What have been the biggest changes you had to make for this hospital to 
become a baby friendly hospital? 
Note: DIP anticipated:
-breastfeeding edu during 
mothers’ stay
-home visits in lactation support
-removal formula cans from 
facilities
-mother’s cards
4. Which changes were easiest? Probe—why?
5. Which were most challenging? “ “
6. How have project interventions changed the way staff are supervised inside 
the hospital and in tertiary facilities?
Following 4 and 5, probe using 
6-10 if these issues are not 
naturally raised.
7. What protocols are you using? How do you ensure staff are following them?
8. Has the project changed the way the hospital views and interacts with patients 
and their families? How?
9. How do you know whether your patients/clients are satisfied with your 
services?
10. What are the most important skills that hospital staff have gained as a result 
of project inputs?
11. As a result of the project, have you changed the way you collect or manage 
data?
63
data?
12. Looking back, what would you advise an administrator of another hospital 
that wants to achieve baby friendly status to do and not to do in this process?
Heads of non baby friendly hospitals One on one
1. What do you know about the project?
2. What benefits has your hospital received from the project—training, 
materials, equipment, medicines?
3. Do you expect more? If so, from where? If not, how will you sustain these 
inputs in years to come?
4. Have supervision procedures changed in your hospital since the project 
started? How? What was the best thing about this change? What was the 
most challenging? 
5. What protocols are you using for maternal and neonatal care? How do you 
ensure staff are following the ones you are using?
6. What have been the most important skills that the project has provided staff at 
the hospital through training? How do you ensure that your staff are using these 
new skills? Do you have plans to train other hospital or clinic staff in these 
skills? 
7. How do you know whether your patients/clients are satisfied with your 
services?
8. Do you plan to apply to be registered as a baby friendly hospital? If so, why? 
What will you need to do to get this registration? What systems will you have to 
change?
Supervisors/TOT’s Can be one on one interviews, 
but if there are 3-4 in one place, 
I’ve designed a short exercise 
we could also carry out (see 2. 
below)
1. What is your position? Has this changed since before the project started in 
Sept 1999? 
2. What kind of training did you receive? What were the 3 most important things 
you learned in the training? What were the 3 most challenging things you 
learned?
If this is in a focus group, could 
write on paper individually and 
then post/share and discuss.
3. How do you plan training now? How do you identify training needs? Select 
trainees? Organize training’s? Evaluate? How many training courses have you 
done without project support? Does the MOH support you on this?
 “ “
4. How do you define Quality? What are 3 indicators/ways of knowing or 
measuring quality in the health system according to you?
Same process, post, cluster, list 
across top of a flipchart (column 
heads) then ask 5.
5. What does the health system have to do to achieve and maintain these 
aspects of quality? 
Same process, cluster 
responses for rows, then ask 6.
6. Using a scale of 1-10 with 10 outstanding and 1 terrible, how would you rate 
yourselves (oblast/rayon) at the moment? 
Participants fill in the boxes. 
Important to probe for why—in 
terms of why they scored that 
and causal factors. In this 
discussion, the conversation is 
as important as the score.
7. Have supervision procedures changed in your area since the beginning of the 
project? If so, how? What have been the biggest successes in this regard? 
What has been the most challenging?
Address this if it has not already 
come up in the previous 
discussion.
64
8. Do you use a supervision checklist? What do you do with the 
information?
Providers One on one interviews as well 
as observation when the 
opportunity presents itself
1. What is your job?
2. What kind of training or other support have you received as a result of the 
project?
3. What were the 3 most valuable things you learned in the training? Ask this Q if the person has 
received training
4. What has been the most challenging thing you learned to actually implement?
5. Has your relationship with your supervisor or the way you are supervised 
changed since the project started? If yes, how? How do you get feedback on 
your performance? 
Probe for details.
6. Have you changed the way you communicate or relate to your patients/clients 
changed since the project started? If yes, how?
 “ “
7. What protocols do you use for maternal and infant care? Where do you go if 
you have a question about these protocols? Who supervises you?
8. What do you think are the 3 most important changes in the health system as 
a whole in Navoi since the project started?
Details
EXPLORE some of the findings from the HFA and KPC as appropriate here.
9. What important issues do you think remain to be addressed in the health 
system in Navoi in future?
Details
Navoi (community)
Question Notes
Makalla committees F. Focus group discussion
1. What is your function in the community?
2. Venn part 1: who are the most important decisionmakers with respect to the 
health of a mother and child? List all of the decisionmakers on individual stickies. 
Place them near the picture of the mother and child based on how important 
they are. Then draw arrows between those who may interact in ways that also 
benefit the mother and child. 
Draw a mother and child in the 
middle of a large piece of paper. 
Participants place stickies around 
it. Be sure that the health system 
is broken down into component 
parts—hospital, clinic, specific 
types of providers etc, not put up 
as one large unit.
For key decisionmakers, ask 
how? And note on the paper. Help 
participants to think about the 
connections between 
decisionmakers, and draw arrows 
where appropriate. 
3. Venn part 2: looking at this diagram, which decisionmakers has the project 
helped make more informed decisions or improved services to women and 
children? How?
Talk about what the project has 
done for key decisionmakers 
(providers, fathers, the committee 
itself, mothers) and note this on 
the flipchart near the name of the 
decisionmaker. 
4. What has been your role as a committee in the project? If this did not come up in 3., raise 
it and add.
5. What do you see as your role in future?
65
Red Crescent Visiting Nurses Focus group or 1:1. I would like 
to talk with the head of the Red 
Crescent in Navoi (oblast and/or 
rayon) as well.
1. What is your job?
2. Has your job changed as a result of the project? If so, how?
3. What training or other inputs did you receive?
4. What have been the best parts of this new work? 
5. What have been the most challenging parts?
6. How do you interface with the health system?
Breastfeeding support group volunteers Focus group
1. Background on individuals, work, no. kids, age.
2. Who organized this group and what is its role? How long have you been 
meeting? How many women have you reached?
3. Where do you get information? Where do you go if you need information? Note: we could also do the Venn 
exercise, as above.
4. What other types of information do you think would be helpful to pass along to 
pregnant women or women with infants or young babies?
Community members: female NOTE: NEED TO REVISE THIS 
BASED ON GROUP 
COMPOSITION, SEE MY Q 
ABOVE.
1. Background on individuals: age, work, no. children, where children delivered 
(BF or not).
2. Did you notice any differences in your experience in x hospital this time than 
previous deliveries? IF so, what were they?
For women who delivered at BF 
hospitals. 
Brainstorm and make list on 
flipchart.
3. What do you know about hospital x and the procedures for birthing and 
postpartum care? What do you think about that?
For women who did NOT deliver 
at BF hospitals.
4. Venn exercise part #1. Note: could also do the Venn 
exercise, as above.
5. What kind of contraception do you use? Where do you get it? Is this your 
method of choice?
Explore some of the findings from the KPC and HFA as appropriate.
Community members: male Focus group
1. Background as above with females.
2. Venn exercise part #1. Probe particularly on role of 
fathers in decisionmaking.
3. 
3. What new information, if any, have you learned about pregnancy, birthing, 
infant or child health over the last 4 years? From whom?
4. What additional information would you like on these topics?
Community members: adolescents
1. What was the most valuable thing you learned in the training?
2. What would you like more information about?
66
Navoi (NGOs)
HOPE staff
1. Timeline of major events Probe for how’s and why’s
2. What have been the major successes of this project? Challenges? Individual and then list/cluster
3. What would you do differently in the extension?
4. Partnerships Venn for how important to project 
meeting its objectives: role of each in; 
probe for why?
5. What has surprised you the most in your experience in this project?
Individual interviews: HOPE
1. What has been your role?
2. Most gratifying; most challenging part.
3. What changes have you seen in the MOH system over the life of 
the project in your area?
4. What have you learned that has been most valuable?
Explore data
HIS: 5. How has project monitoring data been collected over time? 
How is it used? 
6. Describe the MOH HIS system. Has it changed as a result of the 
project? How? Is data being used in a different way now than it was 
before?
IEC: 7. How did you develop the msgs for your materials? 
8. Who pretested and how?
9. Intermediate measures of impact?
10. Distribution? Sustainability?
11. Use of mass media and challenges?
Red Crescent management
1. Overview of visiting nurses program.
2. How has this worked in the Navoi program?
3. What do you think has been the major achievement of your 
program in the context of the HOPE project?
4. What lessons have you built upon for the larger program?
5. Has this collaboration built capacity in your organization? If so, 
how?
Mining company
1. Describe your health facilities and its relationship, if any to the 
MOH.
2. Do you do any public health education in addition to the clinical 
services you provide?
3. How much do you know about the HOPE project?
4. What has been your relationship with the project? DIP expected provider participation in 
technical updates.
5. Have you received any benefits from the project?
6. Do you think your organization has contributed to the success of 
the project or any transformations in the MOH health delivery 
system? How?
67
7. What is your policy on rooming in for newborns?
8. Do providers give mothers information on breastfeeding? Care of 
diarrhea in young children? Danger signs? 
9. What kinds of contraception do you provide?
Navoi NGOs
1. Background on the NGO and their overall program.
2. What has been your relationship with the project?
3. What have been the 3 most important contributions you have 
made?
4. How has your organization benefited from this project or this 
association?
5. What were the 3 biggest challenges you faced?
6. What do you think your greatest contribution to maternal and child 
health can be over the next 3-5 years?
Outside Navoi
HOPE staff in new rayons
1. What is your current job?
2. What was your role in the previous project, if any? 
3. How much do you know about the previous project?
4. What are the major elements of the new project that are similar to the previous 
one?
5. What are the main elements that are new? Probe on partnerships, 
community outreach, IEC.
6. What do you expect to be the biggest challenges to implementing the new 
project? 
7. How will you maintain achievements in the old rayons while launching in the 
new ones?
8. What do you see as your role in national policy making?
9. What do you see as the role of the new project in the HOPE MCH/RH project? 
Other HOPE projects?
10. What is your relationship with MOH Navoi?
Explore data—their ideas.
MOH Rayonal Director in Extension Rayons
1. What has your involvement in the previous project been?
2. What do you know about the previous project?
3. What were the most important accomplishments from the previous project?
4. What do you think the most important lessons were—what to do this time, 
and what not to do?
5. What do you expect to be the benefits in your rayon of the new project? Probe for specifics--
components
6. How do you expect these benefits to be sustained over the longer term, after 
the project is finished?
7. What do you anticipate as your biggest challenges?
TOT”s from non-project rayons
1. What is your job?
2. What kind of training did you receive?
4. What were the 3 most important things you learned in the training?
3. What kind of training have you delivered?
68
4. What have you found most challenging in delivering the training?
5. What other types of training would help you?
6. Are you doing supervision in addition to training?
7. How has that changed as a result of project training?
8. Have you faced any challenges in the rayon in implementing the training?
9. Where do you go if you have questions about subjects covered in the new 
training?
Medical school reps from Bukhara and Samarkand
1. What contributions has the project made to universities?
2. Why did you approach HOPE for these inputs?
3. How effective have they been?
4. What other aspects of the program that you know about would you like to see 
incorporated into your curriculum?
U.S.
Bettina Schwethelm
1. Contact info for WHO/Copenhagen and who is best to talk to?
2. Abt? WB? Unicef?
3. Steering committee—role anticipated; role played?
4. Most successful aspect of community component?
5. Most successful aspect of natl policy work?
6. Relationship with Kyrgestan CS project?
7. Most challenging aspect of the training of providers?
8. How have supervision systems in the project changed as a result of the 
project?
9. HIS?
10. Role of U. of Michigan? Worth talking to?
11. Special studies—which, where?Who determined what special studies to 
do? Who conducted? Available in English?
12. How has this project strengthened the capacity of HOPE/US or 
HOPE/Uz?
13. Management issues: reasons? impact? 
14. Most important changes in MOH capacity as a result of the project?
15. Challenges of institutionalizing aspects of the project—e.g. midterm says 
govt. not “claiming responsibility” for providing IEC materials. 
16. What 3 things would you do differently or will you do differently in the 
extension? 
Debbie El Anani
1. Historical perspective on management issues. 
2. How did the Navoi project inform development of the Kazakhstan design?
3. What other projects has it informed?
Anara, Kyrgestan CS Project
1. How has the Navoi project informed or influenced the design and 
implementation of the Kyrgestan CS project. Can you give me specifics 
and details.
2. Are there specific lessons learned in Navoi that influence the way you are 
implementing your project?
3. What kind of contact has there been between the staff of each project?
4. Is there anything you would like to know more about the Navoi project that 
would help you in your project, that we could investigate in the evaluation? 
69
Erika Latkis
1. What was the role of U. of Michigan? 
2. What impact did they have on thinking and practice in the Oblast? 
Nationally?
3. What have been the most impt. Changes in the areas of safe motherhood in 
terms of practice in the oblast? Nationally? 
USAID Sent to Susan Youll who 
agreed to circulate to relevant 
people in USAID/DC; will also 
contact Andreas Tamberg in 
Tashkent
1. Can you give me some background on your involvement of and knowledge 
about this project? What was the period of your involvement? How often 
did you meet with HOPE staff during the Project’s implementation? Have 
you visited the project in the field? 
2. This project formed the basis of the larger MCH/RH bilateral initiative for 
Uzbekistan and Tajikistan, also being implemented by a consortium led by 
Project HOPE. In your view, what were the key aspects of the CS project 
that recommended it for replication and scale up?
3. Aside from these factors, what would you say have been the major 
achievements of this project? To what do you attribute these successes?
4. What would you say have been the major challenges in implementing the 
project, and to what do you attribute these challenges?
5. Are there any issues, or themes you believe are particularly important for 
investigation or individuals or stakeholder groups who may merit particular 
attention in the upcoming fieldwork phase of the evaluation (August 21-
29)?
Other doc’s to review and items to check on
G. Special studies H. Sarah and Bettina will gather/send
Mid term recommended curricula and protocols covering 
essential and emergency obstetric and newborn care in 
Russian/Uz—done?
Mothers’ cards and any other IEC materials
I. Oblast IMCI Center
J. Drug availability
70
Annex E
Items in the Media about the Project
Name of 
newspaper
Edition Date of 
edition
Name of article Short description of 
the article
Author of the 
article 
Salomatlik Oblast 
news￾paper
06.02.2001 “Project HOPE’s 
new plans”
Seminar concerning 
Breastfeeding, 
Reproductive Health 
and IMCI in 
collaboration with 
Oblast Health 
Department was 
conducted.
Dustlik bayrogi Oblast 
news￾paper
20.03.2001 “For health of 
your child”
Project HOPE in 
collaboration with 
Oblast Health 
Department conducted 
an Orientation meeting 
on Breastfeeding, Work 
with population, 
Creating of a working 
group.
Dustlik bayrogi Oblast 
news￾paper
12.04.2001 “The first steps” Project HOPE – an 
international 
organization working in 
Navoi Oblast. Its 
activity directed on 
improvement of mother 
and child care. Project 
HOPE is working with 
health providers on 
improvement of health 
staff’s training.
Dustlik bayrogi Oblast 
news￾paper
12.04.2001 “If newborn baby 
feels thirsty or it’s 
no need to give a 
child a nipple”.
Breast milk is one of 
the most important 
components for growth 
and development of a 
child. Some useful 
vitamins like A, B, C, 
iron and other you can 
find in breast milk. It is 
necessary to 
breastfeed a child till 4-
6 months not giving 
boiling water, tea, juice. 
Health providers do not 
recommend to give a 
nipple to child because 
nipple can be a cause 
of different 
gastrointestinal 
Babamura￾dova M., 
Muratova N.
71
diseases, wrong 
development of jaw and 
different infectious 
diseases.
Salomatlik Oblast 
news￾paper
16.04.2001 “Project HOPE’s 
purposes”
Project HOPE’s 
purposes and main 
directions were 
discussed during 
meeting with NGOs of 
Navoi Oblast.
Khotamov J.
Znamya drujbi Oblast 
news￾paper
01.06.2001 “Project HOPE in 
action”
Monitoring on usage of 
health items and after 
training were 
conducted. New 
direction of the Project. 
Orientation meeting on 
IMCI that took place on 
May 2001.
Babamura￾dova M.
Dustlik bayrogi Oblast 
news￾paper
14.09.2001 “Humanitarian 
assistance”
Project HOPE rendered 
a technical assistance 
on amount of $105 
thousands – medicines.
Oybuvi 
Ochilova
Dustlik bayrogi Oblast 
news￾paper
01.01.2002 “Basis of Baby￾friendly status”
Talk with chief of 
maternity department in 
Navoi CRH – Oybibi 
Nurmatova. She told 
about preparation of 
maternity complex to 
“Baby-friendly” 
certification . Health 
providers were trained 
on seminar about 
Breastfeeding with 
assistance of Project 
HOPE. 
Oybuvi 
Ochilova
Salomatlik Oblast 
news￾paper
01.01.2002 “Happy New 
Year”
Interview with Oblast 
Health Department’s 
chief Nosirov A.M. 
about getting of 
UNICEF/WHO “Baby￾friendly” certificate in 2 
CRHs of Kiziltepa and 
Navoi rayon. 
Congratulations on 
getting “Baby-friendly” 
certificate.
Oyla Jamiyati 
(Family 
society)
Republic
an news￾paper
23.01.2002 “A child have to 
grow with 
mother’s love”
Interview with chief of 
department in Navoi 
rayon CRH’s – Oybibi 
Nurmatova. The clinic 
is preparing for “Baby￾friendly” certification. 
Maternity House has 
115 beds. Women 
conducting talks about 
meaning of 
Breastfeeding. 
Assistance is rendering 
Oybuvi 
Ochilova
72
Assistance is rendering 
with technical 
assistance of Project 
HOPE.
Oyla va 
jamiyat (Family
society)
Repub￾lican 
news￾paper
23.01.2002 “A child growing 
with mother’s 
love”.
The article about 
getting of “Baby￾friendly” certificate by 
Navoi rayon’s clinic.
Oybuvi 
Ochilova
Dustlik bayrogi Oblast 
news￾paper
01.02.2002 “IMCI” Some activities on IMCI
on WHO’s program 
were conducted. Since 
2001 training of health 
providers on IMCI is 
taking place in Navoi 
Oblast. Opening of 
IMCI Center.
Babamura￾dova M.
Dustlik bayrogi Oblast 
news￾paper
15.02.2002 “People’s health” An Orientation meeting 
on IMCI in Buchara 
Medical Institute. The 
article about conduction 
of a round table with 
health workers of 
Buchara Medical 
Institute and Oblast 
Health Department. 
Nodira Sharipova –
representative of GP 
faculty.
Oybuvi 
Ochilova
Salomatlik Oblast 
news￾paper
01.05.2002 “Concerning to 
Project HOPE’s 
program”
In Toshrabod of 
Kiziltepa rayon was 
conducted “The best 
nurse” competition. On 
the 5th of April 
competition on 
Breastfeeding was 
conducted where 7 
health nurses took a 
part. The article 
describes the 
competition conduction 
and talks with 
population also.
Dustlik bayrogi Oblast 
news￾paper
21.05.2002 “Safe 
Motherhood”
Creating of IMCI 
Center, technical 
support to the Center. 
Program on 
Reproductive Health. 
Conduction of seminars 
on Breastfeeding, 
Reproductive Health, 
IMCI. Preparation to 
meeting on Safe 
Motherhood.
Oybuvi 
Ochilova 
Health System 
in Uzbekistan
Republic
an news￾paper
23.07.2002 “Analyses of 
health knowledge 
on main skills on 
child care”.
The article about 
conduction of 
population’s 
interviewing on 
childcare. Conduction 
of meetings in focus 
Babamura￾dova M.
73
of meetings in focus 
groups and conduction 
of researches among 
Population. 
Vestnik of 
NGOs
Oblast 
news￾paper
01.10.2002 “Project HOPE in 
Navoi Oblast”
The article contents a 
short story about 
general activity of 
Project HOPE and 
about done work of 
Project HOPE since 
2000.
I.Alek￾sandrova
Znamya drujbi Oblast 
news￾paper
19.11.2002 “Keeping the 
most valuable”
The article contents 
interview of Project 
HOPE’s coordinator￾Abdunabi Kuchimov. 
He told about Project 
HOPE’s program, 
tasks, achievements for 
the last time. He also 
noted that our “Child 
Survival” program 
directed to 
improvement of Child’s 
and Mother’s health 
condition. Project 
HOPE’s main directions 
are: Safe Motherhood, 
Reproductive Health, 
Breastfeeding, 
prophylactics of child’s 
diseases. Project 
HOPE’s staff is 
realizing the program 
by conducting training 
seminars, monitoring 
and preparing of 
trainers from health 
providers and nurses 
and also organizing 
different meetings with 
makhalla activists, 
pregnant and women 
having children under 
5. During Project 
HOPE’s activity 2 
hospitals got “Baby￾friendly” status.
I.Tudvasev
Dustlik bayrogi Oblast 
news￾paper
14.01.2003 “On the way to 
recovering of 
population”
On November 2, 2002 
a joint meeting with 
Oblast Health 
Department’s 
collaborators and 
working group on work 
with population. The 
meeting was headed by 
Oblast khokim’s deputy 
Ibragimova M.A. On the 
O.Mu￾Rodullaeva
74
meeting was created a 
plan on work with 
population in 2 pilot 
rayons. Mavzhuda 
Babamuradova and 
Abdunabi Kuchimov 
told about Project 
HOPE’s activity. 
Salomatlik Oblast 
news￾paper
16.01.2003 “Oblast Maternity 
complex got 
“Baby-friendly” 
status”
Collaborators of Oblast 
Maternity complex 
carefully prepared to 
getting of Baby-friendly 
status. Their knowledge 
and efforts were 
evaluated by an 
international experts. 
Project HOPE rendered 
a great assistance to 
Oblast Maternity 
complex in getting of 
Baby-friendly 
certificate. During 
handing the certificate 
Oblast khokim’s deputy 
Ibragimova Musallam 
Adizovna and Oblast 
Health Department’s 
chief Abdurakhmon 
Nosirov, chairwoman of 
“Red cross” Oblast 
society Bakhrieva M.A. 
and Mavzhuda 
Babamuradova.
J.Akhtamov
Dustlik bayrogi Oblast 
news￾paper
14.02.2003 “Increasing of 
health knowledge 
among 
population”
Orientation meeting on 
IMCI - third component 
(Work with population) 
was conducted in 
Kiziltepa and Navoi 
rayons. Oblast khokim’s 
deputy Ibragimova M.A. 
emphasized necessity 
of introducing “Work 
with population” 
program in prosperity 
year for makhalla. 
Kuchimov A. told about 
purposes of the 
program and got 
acquainted participants 
with introductory steps 
of the program to 
population. 
O.Mu￾rodullaeva
Dustlik bayrogi Oblast 
news￾paper
28.03.2003 “Health 
generation –
health future”
During Steering 
meeting on Safe 
Motherhood conduction 
was discussed issue 
on creating of Oblast 
Center on Safe 
O.Mu￾rodullaeva
75
Motherhood.
Dustlik bayrogi Oblast 
news￾paper
18.04.2003 “That a child to 
be healthy”
The article is about 
conduction of 
competitions on 
makhalla level on topic 
“That a child to be 
healthy” in 2 pilot 
rayons.
O.Mu￾rodullaeva
Navoi avozi Rayon 
news￾paper 
30.05.2003 “Such a 
wonderful 
brochure”
Population of Navoi 
rayon approved issuing 
and creating of “That a 
child to be healthy” 
brochure.
Kenjaeva N.
Dustlik bayrogi Oblast 
news￾paper
05.06.2003 “Purpose –
creating of a 
healthy family”
Steering meeting was 
conducted in Navoi 
Oblast and programs 
“Organization of 
Reproductive Health in 
health facilities” and 
“Issues of creating a 
healthy family on 
makhalla and family 
level” were made out
Namozova D.
Salomatlik Oblast 
news￾paper
12.06.2003 “Purpose –
creating of a 
healthy family”
Collaborators of Project 
HOPE and Oblast 
Health Department 
organized meeting 
where Reproductive 
Health issues were 
discussed. On the 
discussion were 
collaborators of Health 
Ministry of Uzbekistan 
K.Yadgarova and 
Oblast Health 
Department’s chief 
Abdurakhmon Nosirov.
Namozova D.
Khamshira Oblast 
news￾paper
06.2003 “Is it important 
consulting of 
patients?”
All 8 pages of the 
newspaper are devoted 
to consulting on 
Reproductive Health 
and family planning.
M.Murodova
Dustlik bayrogi Oblast 
news￾paper
17.06.2003 “Project HOPE’s 
collaborators in 
kindergarten”
Project HOPE’s 
collaborators on 
Children defense 
holiday visited 
kindergartens in 2 pilot 
rayons. Due to the 
holiday children got 
presents and Project 
HOPE conducted 
meeting with 
kindergarten’s 
collaborators and 
mothers on topic 
“Health generation￾health future” also.
O.Mu￾rodullaeva
Tumaris Oblast 07.2003 “Opinion of Mrs. In many makhallas of Sh.Zoirova
76
news￾paper
from America” pilot rayons were 
conducted meetings 
with Judi Aubel. Judi 
Aubel highly evaluated 
traditions of our people, 
relationship of young 
and old generation, role 
of grandmothers in 
family. 
Dustlik bayrogi Oblast 
news￾paper
21.08.2003 “People’s health 
– Country’s 
health”
in the article is written 
about Project HOPE’s 
activity and 
development of Project 
HOPE from starting the 
project and about 
Breastfeeding week 
and final evaluation
O.Ochilova