ASSESSMENT OF THE AMERICAN INTERNATIONAL HEALTH 
ALLIANCE (AIHA) PROGRAM IN AZERBAIJAN
Submitted to:
U.S. Agency for International Development/Azerbaijan
In response to: 
USAID Evaluation IQC No. AEP-I-00-00-00023-00 
Task Order No. 842 
Prepared by:
Greg Becker – Team Leader
Ivdity Chikovani, MD – Consultant
Submitted by:
Development Associates, Inc.
1730 North Lynn Street
Arlington, VA 22209-2023
December 2003
Assessment of the American i December 2003
International Health Alliance (AIHA)
Program in Azerbaijan
TABLE OF CONTENTS
Acronyms & Terms ..................................................................................................................ii
Executive Summary................................................................................................................. iii
1. Background ...................................................................................................................1
2. Methodology.................................................................................................................3
2.1 Interviews.........................................................................................................3
2.2 Observations and Field Visits...........................................................................4
2.3 Focus Groups....................................................................................................4
3. Summary of Key Findings............................................................................................4
3.1 Scope of Work Specified Tasks........................................................................5
3.2 Improved Health Outcomes............................................................................10
3.3 Cost Effectiveness and Efficiency..................................................................12
3.4 Focus Areas of the Partnerships.....................................................................12
3.5 Sustainability ..................................................................................................13
3.6 Technical Assistance Outside of Partnership Expertise .................................14
4. Conclusions.................................................................................................................15
4.1 Cooperative Development and Learning........................................................15
4.2 Working With the System ..............................................................................15
4.3 Network Effects - Spread by Attraction .........................................................16
4.4 Systemic Behavioral Change ..........................................................................16
4.5 Sustainability Through Replication................................................................17
5. Recommendations.......................................................................................................19
5.1 Increased Attention to Epidemiological Priorities..........................................19
5.2 Structural Changes..........................................................................................20
5.3 Involvement with Other USAID Programs ....................................................20
Annex A Scope of Work ................................................................................................... A-1
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ACRONYMS & TERMS
AIHA American International Health Alliance
APO Azeri Partnership Organization
GoA Government of Azerbaijan
IDP/R Internally Displaced Person/Refugee
MoH Ministry of Health
NIS Newly Independent States
PHC Primary Health Care
Rayon District
USAID U.S. Agency for International Development
USPO U.S. Partnership Organization
WHO World Health Organization
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EXECUTIVE SUMMARY
BACKGROUND
Greg Becker and Ivdity Chikovani conducted an assessment of the AIHA/Azerbaijan partnership 
program during the period of September 22 to October 22, 2003. In-country field work was 
conducted between October 6 and 18, 2003. The Evaluators examined the three primary
partnerships of Baku-Houston, Baku-Portland, and Baku-Richmond to determine the general
accomplishments, constraints, and shortcomings of the efforts, and to offer advice on possible
future USAID participation in partnership activities in Azerbaijan. 
METHODOLOGY
The evaluation of AIHA’s activities in Azerbaijan was conducted using qualitative research
methods of structured interviews, focus groups, document review, and observation. Limited
quantitative analysis was conducted using secondary source information such as health facility
records, GoA statistical information, and data from bilateral and multilateral donors and
organizations. 
The state of health information in Azerbaijan appears to be more problematic than the norm for 
countries of the NIS. Much data is inaccurate prima facie, and contradictions between data
sources are common. This has made quantification of the impact of the AIHA Partnerships
difficult. 
FINDINGS
The Azeri Health System as a whole appears to be somewhat behind the other countries of the 
Caucasus in its evolution from the Soviet legacy. The greatest deficit in this regard is the
absence of financial reform of the system. The lack poses a significant impediment to the
sustainability of improvements based on material resources, and has a debilitating effect on the
morale of health workers. The most important findings specifically related to the Partnerships
are:
4 The three AIHA Partnerships in Azerbaijan have been effective in achieving
significant improvements to the health of the population of Azerbaijan, particularly 
women and IDP/Refugees: 
· Basic newborn resuscitation training resulted in a major decrease in infant death in
targeted facilities.
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· The creation of a neonatal training unit and capability at the Mir Kasimov center for 
high-risk deliveries provides significantly improved newborn protection for a major
portion1
 of the national population of women at this time of greatest peril.
· The introduction of family medicine practices has resulted in significant measurable
improvements in patient health in the areas of hypertension, gastric ulcers, asthma,
and diabetes.
· The success of the family medicine model has resulted in its official adoption by the
MoH and the establishment of an Azeri post-graduate training program.
· Azeri physicians establishing a Baku-Saberabad partnership have copied the AIHA
Model.
· Local demand for training in cardiovascular care resulted in this training being
developed and delivered without direct partnership support.
· The development of a program to teach breast health to physicians and nurses, and
breast self-examination to women has provided an extremely low cost method of
significantly impacting the pathology of this most prevalent cancer in women.
· The Partnerships have fundamentally changed the power structure of the health
system through the empowerment of area physicians and nurses to provide actual care 
to patients when their traditional roles have been limited to referrals rather than
service delivery.
· Behavioral changes in health workers generated by the Partnerships have been
significant. Morale, comportment, competence, and commitment of participants are
greatly improved. 
4 The Evaluators believe that the Partnership Program in Azerbaijan is both cost 
effective and cost efficient: The impact of these organic changes to the medical
structure of the country reaches more people more effectively than traditional efforts to
bypass the medical establishment or through the externally stimulated development of
NGOs designed to replace the existing structure. Calculations of costs and benefits
should prove that the Partnership Model achieves more in terms of tangible lives saved
and morbidity averted when compared to alternative models where benefits accrue on a
net future value basis.
4 Most of the structural and health outcome impacts of the Partnership Model are 
sustainable by nature: The key factors are that these activities are driven by local
 
1 Presently 2.3% of all pregnancies are delivered at Mir Kasimov Hospital – most referred as high-risk pregnancies. The 
projection of wide coverage of major segments of the population is based on the protective nature of a tertiary care referral 
center. When assessing this coverage, an appropriate analogy is a neighborhood ambulance – all residents of the area have a 
higher level of protection due to the existence of the resource. Measurements of beneficiaries are thus greater than the actual 
number of patients who use the ambulance. 
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demand stimulated by an expanded understanding of the possible, and that they are
implemented through the medical establishment. Programs that are implemented through 
this self-powered mechanism are the essence of local ownership.
4 Epidemiological priorities are not always followed in the selection of Partnership 
activities: The number one scourge of Azerbaijan is cardiovascular disease. It is not
sufficiently addressed. The life expectancy of men is significantly lower than that of
women despite the risks of childbirth and is not addressed by the AIHA program. 
Maternal mortality during childbirth is still a grave problem that is being only marginally
addressed as a part of more diffuse Women’s Wellness Center activities
4 Material resource sustainability is problematic: The Baku-Portland Partnership has 
developed an appropriate mix of basic equipment that sets a rational minimum level of
primary care diagnostic equipment. The Doctor Bags and Nurse Bags provided by the 
partnership to area doctors and nurses moving to the 
medicine model contain the simplest and most essential items necessary for basic
physical examinations. Unfortunately, the bags soon lose some of their value as area
nurses and doctors are not able to procure replacements for their glucometers because of
the $70 per vial cost. Although this raises questions sustainability, in the words of one 
area nurse, “even if we only received the first supply of strips, and never received any
again, there are people who are alive today that would not have been.” A potential value 
of the dearth of strips may be that it will serve as a partial catalyst for further examination 
of financial reform within the system. 
4 The focus on Pap Smears is of comparatively low value: According to local Ob/gyn 
specialists, the same results can be obtained during a more complete colposcopy, which
does not have the recurrent costs of reagents. Given the very small level of mortality due 
to cervical cancer, the considerable effort to introduce this new technique should be re￾evaluated. 
4 There is a need for skills outside of the US Partner areas of expertise: The example of 
glucometer sustainability points to the need for some level of outside collaborative
technical assistance in the areas of structural reform and cost recovery. 
FINDINGS ON THE SUCCESS FACTORS OF THE AIHA MODEL
AIHA is in a unique position among USAID funded projects in its fundamentally different
approach to achieving substantial and sustained health improvements. An examination of these
differences provides a deep understanding of the mechanisms of behavior change and motivation
that are active in health systems development and reform efforts.
4 Changes are demand driven by the partners functioning as peers in a voluntary
helping relationship: Work plans and technical priorities are developed jointly in a give 
and take exploratory process where neither party has moral or financial primacy over the 
other.
4 The process works through the established medical hierarchy: A system that is as 
protocol bound as that of the NIS is the result of long-term adaptation to the environment. 
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It is important to remember that much of the present dysfunction of the system is the
result of radical change in the environment, and that in the past, the health infrastructure
had considerable capabilities and beneficial characteristics.
4 Exchanges of medical professionals between the US and Baku are the sine qua none of 
expanding the world view of participants that makes change possible: The Baku
partners have been able to conceive of changes to the system because of their increased 
understanding and belief in what is possible.
4 The existing medical/technical hierarchy acting under its own volition implements 
system changes: AIHA Partnerships were conceived as primary care efforts, but they
approach the process through the traditional medical power structure rather than
bypassing the hospital centric system.
4 Empowerment of the primary care sector has occurred because the enrichment of area 
doctors and nurses was done with the guidance, direct support, and blessing of the 
medical/technical elite: Training and technical support of providers is of little use if the 
recipients are unable to utilize their increased knowledge because of structural or
environmental constraints.
4 Opinion change and adoption of new processes through the medical/technical
hierarchy is more durable and effective than the equivalent process occurring in the 
MOH structure: Although there are many network ties and common actors between the 
two structures, the MOH’s ability to affect change is subject to political ebb, flow, and 
redirection. Change through the medical/technical hierarchy carries considerable
authority and certitude. 
4 Systemic change moving through the medical/technical hierarchy requires a lower 
level of effort than change creation localized in the lower tiers of the medical/technical 
infrastructure: Change efforts localized at the primary care level of the
medical/technical infrastructure require considerable upwards effort to “buck the
system.” Upper level “believers” pave the way for change to occur.
4 The partnership model is effectively self-replicating: The Baku-Houston Partnership 
has provided an excellent example of the phenomenon of successful strategy imitation by
the Mir Kasimov Republican (i.e. tertiary) Hospital establishing a relationship with the
Saberabad Rayon Medical District. 
4 The attraction principle is conducive to institutionalized change: The Baku-Portland 
Partnership primary care physician skills building activity has achieved improvements to
patient outcomes and physician productivity that have stimulated high level interest in the
program resulting in the creation of an MOH Curriculum and Department of Family
Medicine. 
4 Changes to the power structure stimulates and improves bi-directional communication 
between health workers and administrative authorities: Communication has become 
more intense and constructive as physicians and nurses feel that relationships have been
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established with higher level authorities because of increased interest in the progress and 
problems of care givers.
4 Interest is generated and spread through the Network Hub phenomenon: The term 
“viral marketing” is used to describe interest in a product or service generated through the 
observation of early adopters and word-of-mouth promotion. Sociologists have
recognized the key role of influential individuals in the speed and ultimate success of idea 
or technological spread. 
4 AIHA programs attract participation because of the link to health worker needs
characteristics: People entering (or staying) in the health professions tend to have
comparatively high tendencies towards altruistic behaviors and needs. Enabling them to
satisfy these needs (i.e. cure a patient) provides powerful motivation.
4 The AIHA administrative support structure in Baku and Tbilisi is effective and cost 
efficient: The existing staff are the glue that keep the programs running. 
RECOMMENDATIONS
Qualitative and limited quantitative analyses indicate that the disparity between the IDP/Refugee
population and the general population may have largely disappeared. Unfortunately, this
realignment seems due primarily to a decline in welfare of important segments of the general
population rather than to major improvements in the welfare of the IDP/Rs. The prominent
disparity now appears to be within the IDP/R population as income levels greatly diverge for
individual families much as is occurring in the general population. USAID is encouraged to
carefully monitor this situation and continue adjusting program targeting accordingly.
4 If it becomes possible in the future, the Partnership Program should be continued and 
expanded. Few programs provide this level of benefit for the size of the investment.
4 The AIHA Model should be strengthened through incorporation of outside technical 
assistance from one of the USAID Flagship Programs: Cost Recovery and financial 
reforms are greatly needed in Azerbaijan, and PHRplus or possibly the POLICY Project 
would be appropriate sources for this type of assistance. Technical assistance in cost
recovery on a local basis (theoretical legal authority is already present in the rayons)
would be the essential minimum involvement. If in the future USAID is able to re-invest 
in the AIHA model, an integrated three pronged approach of AIHA model, policy reform, 
and primary sector intervention is highly recommended.
4 Cardiovascular disease should receive increased attention: The severity of the problem 
demands that rapid impact measures be sought in addition to long-term life-style 
interventions and promotion. The present level of mortality is at a crisis stage and must 
be met with primary care level therapeutic interventions. Consideration should be given
to the idea of developing “primary care cardiologists” equipped with simple ECGs for
screening and diagnosis and the development of a self-sustaining (i.e. revolving fund)
medication mechanism.
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4 Women’s Wellness Center focus should be concentrated on the high priority need to 
reduce morbidity and mortality related to child birth: The present level of maternal 
mortality demands that efforts not be diluted by other activities associated with wellness
centers. Other “wellness” activities such as the programs for female staff of Mir
Kasimov should be spun-off as an independent business (possibly not-for-profit).
4 Neonatal Resuscitation Program should be extended and complemented by topics 
addressing common conditions of newborn mortality: The alarming rate of neonatal 
mortality and the faulty status of the referral system for high risk pregnant women and 
newborns indicates that improvements in basic clinical knowledge of medical personnel
at the delivery settings thought country would be of great benefit. 
4 Male mortality in the productive age groups is at a crisis level and, therefore, should 
receive increased attention: Estimates of death in men aged 15 to 60 are very likely low 
by a considerable margin2
. USAID’s commitment to prioritize on the basis of
epidemiological need must take priority over gender preference. AIHA partnerships
should be encouraged to examine this crisis with the medical/technical weight and skill of
its US and Azeri Partners. 
4 Partners should increasingly focus on the wider dissemination of improvements: The 
imitation of partnerships with peripheral health providers as is being done with Saberabad 
should be supported and become a priority for all activities.
4 To the extent possible given available funding, the Model Primary Care Clinic being 
developed in the Narimanov Rayon should be fully assisted by the Baku-Portland 
Partnership, and receive input from the Baku-Richmond Partnership: The dedication 
and level of effort exhibited by the physicians developing the breast health, asthma,
mental health, and other model primary care programs are commendable. The expanded 
profile of Area Physician and Nurse capabilities and areas of practice will result in major 
nationwide improvements in primary care as they are disseminated. Expansion of patient 
and community outreach practices piloted at the clinic are ready for wide scale
dissemination. Full and continued support should be given to the implementation of the
Family Medicine Post-Graduate Training Institute at the Model Clinic.
4 Greater communication and joint actions between the Partnerships is encouraged: 
AIHA and USAID should link the efforts of the Baku-Portland and Baku-Richmond 
Partnerships. Such a linkage at both the Partnership level and at the local Baku Rayon
level would result in significant efficiency gains and increased dissemination of
advances. Duplication of efforts would be minimized and each partner could focus on
different specialty areas. One area for essential collaboration is in the development of the 
Family Medicine Curriculum. 
4 Trauma and cardiac emergencies are likely the leading causes of death in Azerbaijan: 
Creating an Emergency Medical Services Training Center on the AIHA model will result 
 
2
 Demographic analysis of the Max Planc Institute provides convincing evidence that large inaccuracies in total population 
numbers caused by undocumented out-migration from the Caucasus leads to erroneously low estimates of mortality rates. 
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in major reductions in morbidity and mortality. Funding for this activity should be a
priority for future USAID investment.
4 Clinical Practice Guidelines, Evidence Based Medicine, and Learning Resource
Centers support improved primary care practice: If possible, USAID should reinstitute 
AIHA “Cross-Partnership” programs of guideline development and inter-Caucasus 
collaboration.
4 USAID/Caucasus should combine the AIHA model with policy reform and traditional 
primary care sectoral interventions: USAID/Caucasus (as well as USAID programs in 
many other parts of the world) would significantly increase the effectiveness, efficiency,
sustainability, and depth of impact if a three part strategy was adapted in future
programming.
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ASSESSMENT OF THE AMERICAN INTERNATIONAL HEALTH 
ALLIANCE (AIHA) PROGRAM IN AZERBAIJAN
1. BACKGROUND
The countries of the Former Soviet Union have each faced great challenges in the transition from 
the old coherent system to a resource poor, adaptive system facing severe new challenges. There 
has been much inherent conflict as participants at all levels seek new strategies all the while
clinging to the legacies of the past. 
Within this context, these new countries have made varying levels of progress because of
differing levels of resources and stresses. Azerbaijan had one of the most stressful beginnings
with a pre-independence violent “crack-down” by Soviet troops in Baku, and a post￾independence armed conflict over Nagorno-Karabakh. This ethnic-based struggle resulted in the 
displacement of 650,000 people from their homes and the influx of additional 200,000
Azerbaijani refugees from Armenia. This IDP/Refugee population is only now coming to a state 
of near parity with the general population. Unfortunately, parity is being reached more through a 
decline in the welfare of the general population rather than through gains made by the IDP/R
population.
Equipped with an economy based on obsolete industrial processes and a highly inefficient
petroleum exploitation infrastructure, general standards of living have declined greatly. With
western improvements to the extraction infrastructure, the economy is eventually going to turn
around, but the effects of this investment are not yet widely shared.
Azerbaijan is something of a paradox in its development. Post-independence strife was a period 
of considerable humanitarian need which has slowly calmed. In the meantime, the general level 
of economic and social health has declined. Thus, while the humanitarian emergency can be said 
to have largely ended, the general population is worse off than during the crisis. 
USAID has developed a program of assistance geared to meeting the critical challenges of
economic and democratic transition, and provided humanitarian assistance to the most vulnerable 
groups, especially IDP/Rs. The major vehicle for providing social/health assistance is the
Azerbaijan Humanitarian Assistance Program (AHAP), implemented through an umbrella
cooperative agreement sponsoring programs of seven major US NGOs. Outside the AHAP
framework, three US-Azeri health partnerships within the AIHA program work to upgrade
medical skills and provide Azeri health professionals with exposure to the U.S. health care
system.
In September, 1998, a region-wide agreement, and separate agreements for the Caucasus, Central 
Asia, West/NIS, and Russia were awarded to the American International Health Alliance
(AIHA). USAID concurrently awarded a three-year sub-agreement for the Caucasus, covering
AIHA programs in Georgia, Azerbaijan, and Armenia.
Due to U.S. Foreign Assistance Act Section 907 limitations on direct assistance to the Azeri
Government, the AIHA partnerships faced difficult circumstances in establishing their activities. 
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In addition, the greatest challenge to partnership success and sustainability has been the severe
shortage of public and private resources. The fiscal crisis in Azerbaijan has not abated, and is 
worsening with the passage of time.
AIHA has three established partnerships in Azerbaijan with a forth in the early stages of
development. This assessment has focused on the following three established partnerships, as
defined in the Scope of Work (the full SOW can be found in Annex A).
Baku-Houston: (Established January 2000). Overall goal: to improve medical services to
refugees and IDPs in targeted camps and communities served by the Mir Kasimov Hospital in
Baku and the Sabirabad Rayon Hospital in Sabirabad. Specific objectives include: establish a
neonatal resuscitation center to train health professionals; develop and disseminate practice
guidelines according to international standards; and collaborate with other partnerships in
Azerbaijan to provide education and training in neonatal resuscitation. Also, the partnership
aims at shifting patient-oriented activities to rayon hospitals serving IDP camps in their
catchment areas and establishing a Women’s Wellness Training Center to address maternal and
child healthcare concerns among refugees/IDPs. 
Baku-Portland: (Primary Health Care – Established March 2000) Overall Goal: Develop a
comprehensive, community-based, primary care system designed to meet the basic health care
needs and improve the health status of IDPs and refugees in the Narimanov Health Care District 
in Baku, Azerbaijan. Specific objectives include: Enhance the ability of the Narimanov Health
District to collect, store, organize and analyze basic socio-demographic and health status
information on the IDP/refugee population in the district; enhance and adapt the infrastructure of
the Health District to provide a solid base for primary care; improve the effectiveness of the
nurses serving the IDP/refugee population; and integrate a mental health program into the model
primary care clinic.
Baku-Richmond: (Primary Health Care-Partnership Established March 2000). The overall goal
of the partnership is to improve the health status of the local population including refugees and
IDPs accommodated in the Binagadi District of Baku city through socially oriented, public and
primary health care programs. Specific objectives include: improve the capacity of the Binagadi
Health Department to collect, enter, and analyze data on the health status of the local population 
including refugees and IDPs; improve the quality of medical care provided by area doctors and 
nurses to refugees and IDPs through training in clinical assessment skills and sharing evidence
based medical guidelines, and; to improve the quality of medical information provided to the
population on infectious disease, personal hygiene, sanitation, and general prevention in their
home environment. 
In addition to developing and implementing the above-mentioned partnership programs, AIHA
also supports a number of related activities that facilitate and promote inter-partnership 
communications and synergy, joint partnership initiatives, sharing and dissemination of
information, and replication of centers such as Learning Resource Centers, EMS and Nursing 
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2. METHODOLOGY
The state of health information in Azerbaijan appears to be more problematic than the norm for 
countries of the NIS. Much of the available national data is inaccurate prima facie, and
contradictions between data sources are common. This has made quantification of the impact of 
the AIHA Partnerships difficult at best, and sometimes impossible. Given this constraint, the
team placed a great reliance on qualitative methodologies.
The evaluation of AIHA’s activities in Azerbaijan was conducted using qualitative research
methods of structured interviews, focus groups, document review, and observation. Limited
quantitative analysis was conducted using secondary source information such as GoA statistical
information, and data from bilateral and multilateral donors and organizations. 
Interview informants included health professionals from the MoH including staff from APOs,
directors and participants from the USPOs, staff of AIHA Caucasus, patients, and IDP/Rs. 
Observations were made at MoH facilities including those of APOs, and in IDP/R “camps.” 
Analysis of data and information gathered was conducted using interactive informant feedback
and adjustment, health economics and health management frames, clinical medical review, and
applied complexity science.
2.1 INTERVIEWS
Telephone interviews were conducted with the leadership of the USPOs Baku-Richmond 
(Virginia Commonwealth University), Baku-Portland (Oregon Health Sciences University), and
Baku-Houston (Baylor Medical University). Conducted prior to the team’s arrival in Azerbaijan, 
The focus was to determine the USPO position on the partnerships, to hear their perspective on
achievements and barriers, and to determine the state of institutional commitment. 
Given the early stage at which these interviews were conducted, the focus was split between
gaining a general familiarity with the nature of the partnerships, and with inquiring about the
status and evolution of institutional and participant enthusiasm, commitment, environmental 
adaptation, and learning. 
General questions and responses were helpful in establishing an increased understanding of the
history of these particular partnerships, and in establishing a basic familiarity with the
mechanisms, procedures, and guiding principles employed.
Discussions then focused on the issues of institutional and participant commitment/fatigue. 
Questions covered institutional willingness to contribute to the partnerships at different points
during the life of the programs. Other questions specifically inquired about the level of concern
demonstrated by the institutions’ directors and financial officers over the material, financial,
labor, and administrative costs borne by the USPO. 
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Statistics:
Total population: 8,095,000
Total IDP/Refugee population: 800,000
GDP per capita (Intl $): 2,676
Life expectancy at birth m/f (years):60.7/66.6
Healthy life expectancy at birth m/f (years):50.3/55.4
Child mortality m/f (per 1000): 100/88
Adult mortality m/f (per 1000):253/132
Total health expenditure per capita (Intl $):57
Total health expenditure as % of GDP:2.1
Total of People with Diabetes: 336981
Total pregnant women receiving antenatal care: 140,000 (95%)
Total deliveries in health facilities: 140,000 (95%)
Source: World Health Organization, Geneva, 2003
2.2 OBSERVATIONS AND FIELD VISITS
Field visits consisted of large and small group meetings with facility and local health authority
management and staff. Inspection of facilities included capital and biomedical equipment
condition and maintenance. General sanitary and housekeeping was observed in comparison to
other Azeri and NIS norms3
.
During facility visits, staff, patients, and family members were interviewed on an ad-hoc basis. 
Brief observations of operations were made in most cases. Visits to hospitals, clinics, and a
“Family Practice” serving IDP/R populations involved interviews and observations of
physicians, nurses, patients, and patient families.
2.3 FOCUS GROUPS
The Evaluation Team conducted three focus groups consisting of 8-12 individuals who received 
training in the United States and those who have participated in NIS-wide conferences,
workshops, or seminars through the AIHA program. Focus groups had mixed participants from
all the partnerships and were structured around common interest areas. There was one focus
group comprised of nurses while the other two were made up of physicians from the three
partnerships. Each focus group lasted approximately two hours. 
 
Focus Group 1 was comprised of primary care physicians and examined issues of sustainability
and the potential for fee-for-service. Focus Group 2 was composed of area nurses and examined 
on needs of the profession, the problems of equipment sustainability, and better patient
interaction and care skills. Focus Group 3 was composed of area physicians and physicians
involved with the specialty training areas. 
3. SUMMARY OF KEY FINDINGS
The state of health information in Azerbaijan
appears to be more problematic than the
norm for countries of the NIS. Much data is 
inaccurate prima facie, and contradictions
among data sources are common. To gain
useful information, experience and
qualitative information was used to evaluate
the validity of the various indicators. 
Greater confidence was placed on data
provided directly by the APOs. 
Although Partnerships are helping local 
facilities improve data collection and
reliability, this is a nation wide problem and
 
3
 “Norms” in this case refers to the common or dominant state of upkeep that exists in the region, and does not refer to 
“standards” (preferred or minimum acceptable condition) for these services.
Figure 1 General health statistics provided by WHO
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is best addressed through a national program: The CDC has been very successful in the
development and delivery of these national programs. For example, in Armenia, the data
collection system has been integrated into a highly effective infectious disease surveillance
system. 
In Kazakhstan, the CDC-led effort to improve health data collection found that to the great
surprise of the health system, trauma was the leading cause of death. The extent of the trauma 
mortality rate was masked because of practices in dealing with deaths outside hospitals. When a 
victim was dead in the opinion of whoever represented official authority, they would not enter
the health system through the hospitals or other care facility. Bodies would be taken either to a 
municipal morgue or to a private entity for burial. Thus, large numbers of deaths due to accident 
(and very likely other causes where emergency aid was not summoned) were not recorded by the 
health system. 
 
Azerbaijan may have similar surprises in store, but these will remain unknown until such time as 
the data problem is solved. 
3.1 SCOPE OF WORK SPECIFIED TASKS
The Scope of Work for the Evaluation Team (see Annex A) specified a number of tasks to be 
conducted during the evaluation. The findings related to these tasks are summarized below:
Describe certain categories or types of partnerships that are more effective and productive 
within the Azerbaijan context. Describe what characteristics/factors make them more effective 
and productive.
The three US partners are quite similar – major medical education institutions in cooperative
relationships with Azeri institutions. On the Azeri side however, the nature of the partnering 
institution is wider in range. Although the stated goals of the three partnerships are primarily
related to primary care, the point of entry ranges from the national tertiary care hospital to a rural 
rayon health department.
 
USAID/Baku reports some reticence on the part of the MOH to engage in health care reforms. 
This can be partially attributed to the effect of U.S. Foreign Assistance Act Section 907, but 
given the pervasiveness of this behavior in other countries, it is likely more related to the general 
tendency of centric disassociation 4
 in health reform efforts.
In primary care (PHC), reproductive health (RH), or maternal and child health (MCH) programs, 
the tendency is often to apply technical assistance and provide external financial and material
resources directly at the target. 
 
4
 Centric Disassociation is the author’s term for health reform efforts that focus on the formal decentralization of the health 
care system or other efforts to shift the balance of power, authority, or resources of the established health system without 
adequate attention given to the central health authorities (usually the ministry of health) and their need for role change and 
structural evolution. All too frequently, such reform efforts are perceived as loss dominant by the central authority and are 
thus highly subject to passive or blatant resistance. 
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If impact and system change were linear, these efforts would be more effective. As it is, the
recipients of the intervention establish a direct relationship with the donor organization from
which it receives resources. This link can be considerably stronger than that which exists with
the central authority. This results in a diminishment of ties to the central authority.
The central authority not only does not receive any new resources, but it also loses face to some 
degree because of its comparative impotence. This coupled with the diminished relationship
with the target recipient creates further sensitivities. Often this may only be perceived as vague 
irritation with the reform effort. Because it is difficult to recognize the nature of the irritant (the 
shifts in power, relationships, and resources), the reform intervention itself may become
identified as the problem.
The central authority perceives a loss of power, and in some cases, a loss of its raison d’être. 
The targeted recipient (e.g. the PHC entity) begins to split its allegiances between the traditional
center and the new provider of largess. When required by the donor to act in a manner different 
from accepted norms, it will often do so in hopes of winning the favor of its benefactor. Its 
behavior from the perspective of the central authority thus becomes more distant from the norm, 
and attempts to smooth relations with the center may be seen as duplicitous. 
The Donor sees its role as provider of self-help assistance and desperately needed goods and 
services. It also requires structural changes as part of the intervention. The intention of the
donor is usually beyond reproach. The non-linear impacts of its interventions can, however, be 
counter productive. 
Failure of the central authority to respond favorably to the gifts of technical assistance and
resources often causes a measure of resentment on the part of the donor. Efforts that go directly 
to the targeted recipient bypass the central authority, and thus disrupt the established resource
provision and control systems. Whether it does so intentionally, or as the result of poorly
understood stress, the central authority may begin to resist the intervention. This will manifest
through either not committing centrally controlled resources needed for the counterpart
contribution, or, through outright obstruction of approvals or blocking other channels still under
central control. 
The application of pressure elsewhere in the system (i.e. Mission pressure on the executive
government) is often the only way to slow the self-reinforcement of this “death spiral.” This
resistance to assistance phenomenon occurs all too frequently but is usually misdiagnosed or
attributed to other causes. A careful analysis of the AIHA Partnership Model however, can
provide powerful insight into the behavioral mechanism operational in this paradigm, and, can
provide a solution.
The best way to arrest this tendency in donor interventions is to avoid starting the cycle in the 
first place. The USAID/AIHA program has provided an example of how to do this. By going
through rather than bypassing the traditional structures of the health system, AIHA enlists the
participation of an important segment of the central authority in the development and
implementation of the primary care intervention. Although it is a counterintuitive way to
address primary health care, the efforts of the Baku-Houston Partnership best illustrate this
model. 
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By partnering with the national tertiary care hospital (Mir Kasimov), the Baku-Houston 
intervention was established on the basis of peer-to-peer relationships developed among the top 
echelons of the medical establishment. Although not the same as the Ministry of Health
hierarchy, these two entities share many common members and very strong network
relationships between the traditional power figures. Originating the interventions of the
partnership at this level can avoid creating the perception of bypassing the power structure. 
Working along the principles of “attraction” rather than advising or dictating, the power figures
became involved with the interventions out of personal conviction rather than benign or blatant
coercion. These willing participants thus opened the path for inputs of goods and services
destined for the PHC level. 
This is not to say that the other partnerships are not good models for intervention. They have 
also achieved considerable acceptance. This may likely be due to combined effects of their
relatively high points of entry (another major hospital, and an evidently politically well￾connected rayon health department), and the synergistic effect of the other partnerships. 
The conclusion of the Evaluation Team is that the lesson to be taken from this successful
integration into the power structure is that some level of effort must be directed at and through
the very top of the hierarchy, and that interrelationships among the partnerships can reinforce the 
benefits of this acceptance and support of the medical establishment. This top entry
intervention approach is particularly important when conducting national level activities. The
effects of direct institutional intervention may be sufficient to provide local positive outcomes,
but the generalization and acceptance of a reform effort must be clearly identified as involving
the top of the hierarchy. 
Analyze the appropriateness of external and internal criteria for establishing a partnership.
The criteria presently used by AIHA to identify appropriate partner organizations appear to be 
effective. The Evaluation Team concludes that the selections are appropriate for disparate
interventions. If the AIHA approach is integrated into a macro reform effort (as recommended), 
then the selection criteria become more critical. 
Referring to the explanation of “entry point selection” illustrated above, achieving macro or
systemic level impact requires close attention to the principle of entering and acting through the
established medical hierarchy. 
Analyze what makes partnership inputs unique and how do these activities enhance other 
USAID-funded activities in achieving similar results; thus, resulting in a comparative
advantage for sustainable impact. 
At present, AIHA activities are largely carried out in isolation from the rest of USAID projects. 
This appears to be the result of the common perception that the partnerships are outside of the 
usual range of USAID activities, and are more concerned with generating good will through the 
use of volunteer participants.
Based solely on the review of project documents prior to undertaking this in-depth assessment, 
one might assume that bringing US and NIS experts together through the AIHA partnerships
model does not provide the appropriate expertise and experience necessary to solve the health
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system problems that exist in Azerbaijan and the region. And, further, that the participation
times are too short for the participants to gain the necessary skills and experience to be effective. 
While much of this statement has accuracy, the experience of evaluating the partnerships and
seeing them close up has shown that the basic assumptions of this perspective miss the point. 
The value of the partnerships lies less in the transfer of technology and ideas and more in the 
ability of the partnerships to gain peer entry into the health system and the decision making
hierarchy. 
If one looks at the AIHA partnerships solely from the perspective of technical assistance and
knowledge transfer, then the impact is slight. If however, the partnerships are viewed in terms of 
the establishment of deep relationships based on trust, shared purpose, peer-to-peer exchanges, 
and self-motivated participation and acceptance of learning, then the AIHA partnerships are
without equal. 
Compared to typical USAID programs, the realistic potential for technical assistance value is
moderate. But when compared in terms of integration into the local system and the ability to 
attract self motivated participation, the partnerships appear to be superior. 
If AIHA model partnerships were used in combination with more typical macro or systemic level
health reform programs, the payoff would be huge. The strengths of system penetration of the 
AIHA model would greatly improve the acceptance of the more typical interventions, while the 
more experienced technical assistance and wider targeting of the health reform model would
result in the widening of program impact, very possibly on a rapid national basis. 
Assess the potential for the current programs to be replicated and the extent to which the 
partnerships have had a broader impact on the community, region, or nation.
The question of replication potential is examined later in this section.
The Evaluation Team determined that as long as the confidence level of national statistics is low, 
there is little hope of being able to gain a quantifiable understanding of the larger impact of
AIHA programs. Anecdotal information suggests that impact has been wider than the APOs, but 
the exact extent is impossible to determine. 
When the team examined the neonatal resuscitation program, one indicator showed a broader
impact of this new technology that is interesting to consider for its value in pointing out non￾linear impact. Although the team expected to find a decrease in neonatal mortality, there was a 
concurrent decline in perinatal mortality as well. 
It appears that the conceptual change that was brought about by the introduction of neonatal
resuscitation is broader than just saving newborns that die during birth. The statistics collected 
by Mir Kazimov show a 50 percent decline in the number of “stillborn” infants after
resuscitation was introduced. 
Development Associates, Inc.
Assessment of the American 9 December 2003
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Program in Azerbaijan
Neonatal Mortality: Mir Kasimov Hospital
Year Stillbirth Transfers to
Peds Hosp
Live
Births
Perinatal
Mortality *
Neonatal
Mortality **
1999
2000
2001
2002
2003
(6 months)
1439
1673
1646
1808
1045
46
45
40
38
16
Neonatal Resuscitation Program Implemented 2001
10
9
6
7
3
15.87
11.89
8.47
7.71
5.73
9.03
6.58
4.86
3.87
2.87
* Per 1000 total births
** Per 1000 live births
The determination of “stillborn” is
that the fetus was not viable when
born. The ability to attempt
resuscitation caused a conceptual
shift in defining this viability at birth. 
That means that physicians have
made a considerable mental shift in
deciding whether or not a baby is
born “alive” or not. Clearly the
ability to try to intervene has led to a 
broader appreciation of when it is
possible to intervene. 
 
Figure 2
Analyze the extent to which AIHA special initiatives, including Women’s Wellness, Neonatal 
Resuscitation, EMS Training, Nursing, Infection Control, AIHA central activities such as 
NIS-wide conferences/workshops facilitate individual partnerships in meeting their agreed￾upon goals and objectives. 5
AIHA Special initiatives fill a role similar to a more typical USAID technical assistance
intervention. While the individual partnerships must by nature “reinvent the wheel,” the special
or regional initiatives provide a source of greater experience with appropriate technologies and
approaches. 
Because these initiatives are also participant driven, and they are based on locally developed
experience and expertise, the technical content is highly appropriate and practical, and the impact 
value of the learning experience is reported to be very high.
In Azerbaijan, the trans-Caucasus initiative to develop practice protocols (such as asthma
treatment) was particularly effective in terms of clinical soundness of the products, and because
of the motivational effect of participation in the wide area effort. These types of regional efforts 
are particularly satisfying to participants because of the recognition conveyed with acceptance of
their work, and because of the motivational effect of participants knowing that they are having a 
wider positive impact than they could ordinarily achieve. 
Describe reported changes in health care delivery that are attributable to lessons learned by 
health care practitioners through participating in the partnership programs. In short, what 
are health care professionals and administrators doing differently due to the AIHA program?
 
5 There is a concern on the part of USAID/Caucasus that there are too many activities in sharing Initiatives, conferences, and 
workshops and that it takes a great deal of AIHA/Azerbaijan staff efforts and detracts from implementation of the 
Partnership’s workplans. 
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The most important effect of the primary care focus of the partnerships has been the profound
change it has brought about in the attitudes, comportment, and behavior of primary care
physicians and nurses. The team was consistently told both by participants and non-participant 
informants that the change in these providers has been astounding. 
Prior to the Partnership intervention, the “Visiting Physicians” and “Visiting Nurses” where
considered the bottom of the medical hierarchy, and their role was extremely limited. If any
pathology was found (or suspected) by these care givers, they would refer the patient to
specialists at the polyclinic or hospital. 
These primary care providers were in fact not so much care givers as minimally skilled sentinels. 
With the inception of the AIHA primary care program, the teaching of some very basic
diagnostic skills, and, the provision of the “doctor bags” and “nurse bags,” the actual
performance of these front-line guardians has changed to a degree hard to imagine. Physicians 
and nurses are now actually conducting skilled physical exams and providing appropriate
primary level therapies. 
These physicians, nurses, and their supervisors reported that the change was remarkable, with
both managers and patients showing a level of respect previously unknown. The increased
ability of the care givers to actually provide real care not only resulted in decreased morbidity
and mortality, but it boosted the motivation of the care givers. Their successful attitudes, as well
as their tangible results, have led to increased respect and recognition, which has in turn led to 
further improved performance. Instead of the self-reinforcing “downward spiral” so common in
other interventions, this effort has resulted in a self-reinforcing positive spiral. 
Propose overall recommendations to enhance and focus the effectiveness and impact of
activities performed which demonstrates a comparative advantage and coordinates with other 
on-going activities aiming to achieve comparable results within USAID Strategic Objective. 
USAID Caucasus has an opportunity to achieve great increases in program effectiveness in all
health areas simultaneously through the integration of the AIHA intervention strategy into both
policy/health reform programs, and into traditional primary care sectoral interventions.
As this document has stated, the AIHA strategy has several powerful advantages over the more 
traditional USAID approaches. At the same time, the AIHA method would significantly benefit
from the greater technical depth and experience of the other intervention types.
Assess the local management and administrative capacity of the AIHA country office staff and 
structure and make recommendations to increase overall effectiveness and efficiency.
The AIHA staff in Azerbaijan are high caliber professionals who provide significant value to the 
programs. The sole concern of the Evaluation Team is that any decrease in AIHA administrative 
or managerial funding would significantly jeopardize the value of the programs. 
3.2 IMPROVED HEALTH OUTCOMES
Based on an assessment of AIHA partnership provided data, informant opinion, direct
observation, and a minimal reliance on national and international data, the three AIHA
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Partnerships in Azerbaijan appear to be effective in achieving significant improvements to the
health of the population of Azerbaijan, particularly women and IDP/Refugees: 
4 Basic newborn resuscitation training resulted in a major decrease in infant death in
targeted facilities. Figure 3 shows the example of the Mir Kasimov Hospital. Similar
results can be found at the Saberabad Rayon Hospital. 
4 The creation of a neonatal training unit and capability at the Mir Kasimov center for
high-risk deliveries provides significantly improved newborn protection for a major
portion 6
 of the national population of women at this time of greatest peril.
4 The introduction of family medicine practices has resulted in significant measurable
improvements in patient health in the areas of hypertension, gastric ulcers, asthma, and
diabetes in partner facilities and service areas (i.e., the model family medicine clinic
established in the Narimanov Health District and primary health care providers under the 
Binagadi District Hospital). 
4 The development of a program to teach breast health to physicians and nurses, and breast 
self-examination to women has provided an extremely low cost method of significantly
impacting the pathology of this most prevalent cancer in women.
In addition to these specific examples of improved health outcomes, there are examples of
system improvements that have direct positive health implications for the Azeri population:
4 The success of the family medicine model has resulted in its official adoption by the
MoH and the establishment of an Azeri post-graduate training program.
4 Azeri physicians establishing a Baku/Saberabad partnership have copied the AIHA
Model.
4 Local demand for training in cardiovascular care resulted in this training being developed 
and delivered without direct partnership support.
4 The Partnerships have fundamentally changed the power structure of the health system
through the empowerment of area physicians and nurses to provide actual care to patients
when their traditional roles have been limited to referrals rather than service delivery.
4 Behavioral changes in health workers generated by the Partnerships have been profound
and influential. Morale, comportment, competence, and commitment of participants are
greatly improved. 
 
6 Presently 2.3% of all pregnancies are delivered at Mir Kasimov Hospital – most referred as high-risk pregnancies. The 
projection of wide coverage of major segments of the population is based on the protective nature of a tertiary care referral 
center. When assessing this coverage, an appropriate analogy is a neighborhood ambulance – all residents of the area have a 
higher level of protection due to the existence of the resource. Measurements of beneficiaries are thus greater than the actual 
number of patients who use the ambulance. 
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Comparative Life Expectancy Male - Female
Source: Gender in Transition
58.0
60.0
62.0
64.0
66.0
68.0
70.0
72.0
74.0
76.0
Male
Female
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Although the data available in Azerbaijan is particularly problematic, direct observation of
provider behavior, environment, comportment, and physician/patient interaction indicates that
the self-reported achievements of the partnerships are valid, and that a good level of confidence 
can be given to the reported data. The conclusions of these direct observations are supported by 
comparative observations in non-partnership provider institutions. 
3.3 COST EFFECTIVENESS AND EFFICIENCY
The Evaluators believe that the Partnership Program in Azerbaijan is both cost effective and 
cost efficient: The widespread nature of the health improvements provided by the AIHA
Partnerships and the appropriate level of technical knowledge sharing have achieved actual
reductions to morbidity and mortality that are more tangible than most programs.7
 The impact of 
these organic changes to the medical structure
of the country reaches more people more
effectively than traditional efforts to bypass
the medical establishment or through the
externally stimulated development of NGOs 
designed to replace the existing structure. 
Although they were outside of the scope of
this evaluation, calculations of costs and
benefits should prove that the Partnership
Model achieves tangible lives saved and
morbidity averted at a higher rate per dollar
invested than alternative models where
benefits accrue on a net future value basis. Figure 3. World Bank Comparative Mortality Study
3.4 FOCUS AREAS OF THE PARTNERSHIPS
Epidemiological priorities are not always followed in the selection of Partnership activities: 
Although it is uncertain because of the lack of statistical data, it is likely that cardiovascular
disease is the number one scourge of Azerbaijan. However, it is not sufficiently addressed. 
Despite the risks of childbirth and is not addressed by the AIHA program, the life expectancy of 
men is significantly lower than that of women.8
 (see Figure 3)
The Max Planc Institute in Germany conducted a demographic study in Georgia and Armenia to 
determine if mortality rates were reliable. Their findings were that because of very heavy
undocumented out-migration, the official estimates of total population were significantly too
high. 
 
7 This is pure speculation at this point by the author. Experience with USAID health programs in 25 countries since 1977 forms 
the basis of this conclusion. This cost effectiveness question deserves further examination and should be performed soon by 
USAID as the potential benefits of greater use of this model are believed to be significant.
8
 This conclusion is supported by the World Bank’s Gender in Transition Study, the WHO statistical information for Azerbaijan 
and the Caucasus, and, USAID/Baku’s own publication on development and humanitarian assistance.
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Although the reasons were slightly different in the two countries, there were sufficient
similarities to lead to a reasonable conclusion that rates in Azerbaijan are incorrect as well. A
disturbing conclusion of the study is that given these errors in total population, mortality rates,
especially those for men between the ages of 15 and 60 were in reality much higher than official 
estimates. 
Given that the official estimates are highly worrisome, an increase in this rate as projected by the 
study is at the magnitude of an epidemiological crisis. 
Maternal mortality during childbirth is still a grave problem that is being only marginally
addressed as a part of more diffuse Women’s Wellness Center activities.
The focus on Pap Smears is of comparatively low value. According to local Ob/gyn specialists, 
the same results can be obtained during a more complete colposcopy, which does not have the 
recurrent costs of reagents. Given the very small level of mortality due to cervical cancer, the
considerable effort to introduce this new technique should be re-evaluated.
3.5 SUSTAINABILITY
Most of the structural and health outcome impacts of the Partnership Model are sustainable 
by nature: The key factors are that these activities are driven by local demand stimulated by an 
expanded understanding of the possible, and that they are implemented through the medical 
establishment. Programs that are implemented through this self-powered mechanism are the 
essence of local ownership.
Material resource sustainability is problematic: The Baku-Portland Partnership has developed 
an appropriate mix of basic equipment that sets a rational minimum level of primary care
diagnostic equipment. The Doctor Bags and Nurse Bags provided by the partnership to area 
doctors and nurses moving to the family medicine model contain the simplest and most essential
items necessary for basic physical examinations. 
Despite great care to keep material support to a sustainable level, total adherence to this principle 
is impossible if lives are to be saved. There is a point of technical resource poverty below which 
even the most gifted physician, nurse, or even public health expert cannot provide assistance to 
those in need. The Baku-Portland Partnership has found an appropriate level for this minimum
rational material resource bottom. 
Anecdotal evidence of the life saving value of these bags is plentiful. Early problems with non￾local procurement of contents has been corrected under AIHA Baku guidance. Unfortunately,
the bags soon lose much of their value. At $70 US per vial of fifty test strips, the nurses and 
doctors are not able to procure replacement strips for their glucometers. Some strips have been 
purchased out of Rayon funds for a couple of physicians, but the majority are now without. 
Careful consideration was given to this situation by the Evaluators (including finding and
purchasing strips for an IDP/R area nurse) as to whether the inclusion of glucometers is a
sustainable item, and if not, should they be discontinued in future bags. 
The answer to this question is difficult under present circumstances, and leads to larger questions 
about AIHA’s relationship to the total health reform effort. The immediate answer is that the
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demonstrated benefit of these machines is sufficiently high as to warrant their appellation as an
essential basic device. In the words of one area nurse, “even if we only received the first supply 
of strips, and never received any again, there are people who are alive today that would not have 
been.” A potential value of the dearth of strips may be that it will serve as a partial catalyst for
further examination of financial reform within the system.
3.6 TECHNICAL ASSISTANCE OUTSIDE OF PARTNERSHIP EXPERTISE
There is a need for skills outside of the US Partner areas of expertise: The experience with the 
glucometer sustainability issue points to the need for considering outside collaborative technical
assistance. During one of the focus groups, the question of trying to recover the cost of replacing 
the glucometer strips from patients was discussed in depth. 
The idea in general is contrary to the lamented aspects of the Soviet system, and is heavily
colored by the perception of this practice as “bribery” or “corruption.” It was interesting that
after 30 minutes of discussion, about half of the focus group members were convinced that the
situation demands such efforts no matter what one would prefer. The other half however, could 
not make the emotional leap past “what was good” and “what was right” about the old system. 
Despite having a clear, first hand understanding of the consequences of being without essential
supplies, they were unable to move past “what should be.” 
The potential for successful cost recovery will remain low while the present perspective of 
“bribery” is dominant: The lack of financial restructuring poses a significant impediment on the 
sustainability of improvements based on material resources. More importantly, the lack of
financial and structural reform poses a large burden on the morale of health care workers. 
Extremely low salary levels make the collection of under-the-table payments for health services 
inevitable. The lack of drugs and materials means that in all but the most desperate of cases,
patients must purchase all needed supplies before procedures can be performed. 9
 
The level of stress and sense of personal failure caused by this monetary problem is debilitating. 
Patients refer to all such payments (whether for the purchase of essential supplies or for
physician income) as “bribery.” The health workers are in a double bind because of the
desperation that necessitates actions seen as personally reprehensible, and, because of the vocal
condemnation of some patients when faced with such fees. In the worst of circumstances,
physicians must demand that supplies be purchased by patient families because absolutely none 
are available in the system, and the family’s inability to pay results in the death of the patient.
Even those health workers who are able to see the necessity of cost recovery in some form
perceive it in terms of greater or lesser evil. Given the present framing of the debate, the
question is whether or not “bribery” is necessary. In this frame, the health worker is placed in a 
lose-lose situation. Under the present mental model, even if the government was to actively
implement a program of cost recovery, it would be effectively sanctioning a “bad” thing. A
change in the framing of the issue is urgently needed. 
 
9
 There is much anecdotal information that indicates that there is a true “needs assessment” basis for the collection of payments. 
Greater efforts are made to find alternative sources of resources for the most at-risk patients.
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4. CONCLUSIONS
AIHA is in a unique position among USAID funded projects in its fundamentally different
approach to achieving substantial and sustained health improvements. An examination of these
differences provides a deep understanding of the mechanisms of behavior change and motivation
that are active in health systems development and reform efforts.
4.1 COOPERATIVE DEVELOPMENT AND LEARNING
Changes are demand driven by the partners functioning as peers in a voluntary helping 
relationship. Work plans and technical priorities are developed jointly in a give and take
exploratory process where neither party has moral or financial primacy over the other. Either
party may increase or decrease its level of participation, and neither is fundamentally at serious
risk if negotiations fail. Interestingly, it appears that in the case of the three Azeri Partnerships, 
the initial expectations of the Baku partners were focused on material support. The Azeri
Partners entered into the relationships believing that they had little or no need for technical
advice from the US partners, but they were very anxious to gain desperately needed equipment, 
supplies, and drugs. They entered the partnerships through the desire for material gain, and soon 
were being exposed to medical paradigms that they were completely unaware of. Seeing new
structures and processes that they previously did not know of, they became curious. Seeing the 
outcomes on patients (and providers) of these new paradigms made them interested in learning
more. Thus, the entire process was based on attraction rather than imposed mandate or advice.
Exchanges of medical professionals between the US and Baku are the sine qua none of
expanding the world view of participants that makes change possible: The Baku partners have
been able to conceive of changes to the system because of their increased understanding and
belief in what is possible. This factor is critical. When one lives in an environment where
certain constraints are dominant, perspectives of alternative paradigms will rarely develop. 
4.2 WORKING WITH THE SYSTEM
The process works through the established medical hierarchy: Although the AIHA
Partnerships were conceived as primary care efforts, they approached the process through the
traditional medical power structure rather than bypassing the hospital centric system. 
Fundamental changes may occur in a human system through evolution and learning adaptation,
or, through revolution or phase change during punctuated equilibrium (a major change in a
population through extinction or other radical change that provides a rapid and fundamental
modification to the status quo). In other words, fundamental change can happen comparatively
easily with the cooperation of the structure of the system, or, with difficulty, disruption, or not at 
all when attempted through bypassing the established structures. 
It is very important to note that there are effectively two major power structures in a national
health system (and arguable several more). The visibly dominant system is the official power
structure, in the form of the ministry of health. This is the structure that provides the titular
leadership of the health care system, and tends to dominate the governance of provider facilities 
and organizations. 
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The second major power structure in a health system is the medical/technical hierarchy. These 
are the physician leaders who set the norms of the system and determine what is and is not
appropriate activity. In most countries, this hierarchy is dominated by the medical specialists of
the tertiary care level and possibly by the academic level. This is particularly true in countries of 
the NIS where decision making and behavioral control of the entire system is dominated by this 
elite. 
The AIHA approach enters into the health system at the higher levels of the medical/technical
hierarchy, and relies on attraction and suasion to move changes on through to the primary care 
levels. Traditional USAID projects often avoid this hospital based hierarchy and proceed either 
through the titular hierarchy (MOH) or bypass both power structures and intervene directly with
the primary care level. Empowering the primary care level is a laudable goal, and it is achieved 
much more easily with the blessing of the power establishment.
4.3 NETWORK EFFECTS – SPREAD BY ATTRACTION
The attraction principle is conducive to institutionalized change: The Baku-Portland Partnership 
has demonstrated a highly sustainable occurrence of institutionalized reform through the success
of the primary care physician skills activity. Improvements to patient outcomes and physician
productivity have been sufficient to stimulate high level interest in the program, and to want to
implement it on a national basis. The Chief Doctor of the Narimanov Rayon was appointed to 
head a new MOH department of Family Medicine. This appointment and the beginning of the
post-graduate program in Family Medicine were brought about through the interest generated by
the success of the practice model and the attractiveness of the benefits of the model to the power 
structure of the health system.
Interest is generated and spread through the Network Hub phenomena: The term “viral
marketing” is used to describe interest in a product or service generated through the observation
and word-of-mouth of early adapters. Sociologists have recognized the key role of influential
individuals in the speed and ultimate success of idea or technological spread. These early
adopters will very greatly lead acceptance if they are well connected socially. Rather than
simple popularity, these opinion leaders are influential because of widely respect for their
opinion or status. Looking at local social systems as networks, these opinion leaders function as 
hubs with established connections to their peers and associates. Because the AIHA model works 
with the medical/technical hierarchy, the high correlation between elite status and hub status
means that the ideas and technologies that are accepted and adopted will be more likely to be 
embraced by others in the network.
Attractiveness of the AIHA generated behaviors is high because of the link to health worker
needs characteristics: People entering (or staying) in the health professions tend to have
comparatively higher tendency towards altruistic behaviors and needs. Providing 
opportunities/mechanisms to satisfy these higher level needs will likely result in reinforcing
behavior.
 
4.4 SYSTEMIC BEHAVIORAL CHANGE
The Chief Doctor from the Mir Kasimov Republican Hospital and the Baylor Partners came up 
with the idea to pilot a Partnership Model relationship between Kasimov Republican and the
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Saberabad Rayon hospitals. Mir Kasimov has a pre-existing mandate to provide
specialty/tertiary services to the entire country. This role has traditionally been performed
through regular visits of Kasimov Specialists to the various rayon hospitals throughout the 
country. These visits were conducted in a manner where the specialists would examine the
referred local patients, and then make the decision to treat on the spot or send to Baku for
hospitalization. 
The old modality of this “visiting experts” regime is very much in keeping with the legacy soviet 
“refer up” process where each level of physician passes along all but the simplest cases. The
effect on this model has been devastating over the years of its use. Major flaws of this system
include:
4 Concentration of clinical expertise at the top of the system: Rather than tertiary
specialists being a resource of last resort, they become the dominant authorities in the
delivery of all care of modest to high complexity.
4 Lack of clinical authority at all but the highest levels: Primary care physicians and local 
specialists from hospitals and polyclinics lose the clinical authority to make decisions.
4 Demoralization/apathy in the primary and secondary care levels: Without the authority 
to take clinical actions, the tendency is to lose interest and no longer try to effect patient 
outcomes.
4 Skills deterioration: As skills are not used, they are lost. This is evidenced in the
therapists that require remedial training in conducting basic physical exams. It is also 
evident in secondary specialists that not only lack the technology to 
The new Partnership Model offers the technical ability and authority to perform. Changes to the 
power structure stimulates and improves bi-directional communication between health workers 
and administrative authorities: Communication has become more intense and constructive as
physicians and nurses feel that relationships have been established with higher level authorities
because of increased interest in the progress and problems of care givers.
4.5 SUSTAINABILITY THROUGH REPLICATION
The partnership model is effectively self-replicating: The Baku-Houston Partnership has
provided an excellent example of this phenomena of imitation of successful strategies. The Mir
Kasimov Republican (i.e. tertiary) Hospital had an established relationship with the Saberabad
Rayon Medical District through its visiting specialists role. With the support of the Baylor
Partner and the encouragement of AIHA Baku, the Mir Kasimov Hospital decided to form its 
own partnership with Saberabad along the AIHA model. Successful initiatives such as the
Neonatal Resuscitation program and the Women’s Health activity were taken to Saberabad and 
presented by the Baku Partners. As in the original partnership, local demand soon brought about 
additional activities that were not planned or financially supported by AIHA. The Saberabad
partners have a huge need for increased capabilities in managing cardiovascular disease. Their
request, and the agreement of the Mir Kasimov partners resulted in the design and delivery of
cardiovascular training and support efforts.
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There is concern that the Saberabad example is the exception rather than the rule in terms of
auto-generated replication of AIHA initiatives, and that the deepening financial crisis makes it
difficult to obtain government support for continued or expanded initiatives. This begs a
fundamental question: How much behavioral change or program implementation is possible
given the absence of resources?
Because of the literal life and death nature of health sector activities, health professionals,
particularly those in the service of international donors feel a strong moral imperative to keep
seeking improvements and changes, no matter what the realistic availability of human, financial,
or capital resources. 
The NIS has the good news/bad news situation of not fundamentally understanding the cost of
human resources. If people are employed at an organization, the perceived marginal cost for
their labor is zero. Therefore, it is comparatively easy to get staff assigned to new initiatives as 
long as their absence from their previous duty is not too disruptive. Efforts to replicate AIHA
initiatives, or any other health reform initiatives should emphasize activities that rely primarily
on human labor and have small material, financial, or capital costs. 
That said, there are few activities that are truly free from non-labor costs. Initiatives that
function mainly on the motivation of participants and are limited in financial requirements will
soon find that motivation disappears if material resources are absent. Even the most basic of
curative or preventive services and activities have important non-human cost components. 
Altruistic drive will motivate healthcare workers to keep trying for significant amounts of time,
but there is a point where such futile efforts end.
Since real financial resources in Azerbaijan are not zero, those that are available are allocated on 
the basis of perceived return (not necessarily a common good). Two fundamental strategies will 
encourage the investment of those scarce resources on AIHA or other health activities.
The first strategy is showing a demonstrable return for the investment. This is not always framed 
in social terms but is frequently based on the inherent network power structures of the system. 
The demonstration of benefit must be evident to the decision makers, and it must be based on
their criteria rather than an external metric. The AIHA model of attraction is inherently suited 
for this as it is dependent on the participants determining need and priority (criteria for
determining benefit). The important point is to make sure that to the degree possible, the actors 
in the system that control resources (both directly and indirectly) are included as participants. 
Saberabad works because the people who control the resources (at least those needed) are the 
people who participate and see the value of the activity. As stated previously, the medical
hierarchy is not exactly the same as the official government hierarchy, but it is close in terms of
common members and social influence. The logical way to increase participation of resource
decision makers is to figure out who they are and target them for inclusion.
The Family Medicine initiatives in the Narimanov Medical District are able to receive
government resources both because of the limited resources controlled directly by the Director,
but also because of the influential position held by the Director in the Ministry of Health and the 
national government. 
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The second principle that is critical to this strategy is to increase the amount of resources
available. Cost Recovery and health financing reform is essential. The AIHA model does not
have a comparative advantage in this technical area, but, it could provide an entry point into the 
decision power structure vastly superior to the typical reform project mechanism. When the
AIHA model is integrated with the health reform model, there is a realistic possibility of
breaking the taboo that holds back this critical reform. 
5. RECOMMENDATIONS 
Qualitative and limited quantitative analyses indicate that the disparity between the IDP/Refugee
population and the general population may have largely disappeared. Unfortunately, this
realignment seems due primarily to a decline in welfare of important segments of the general
population rather than to major improvements in the welfare of the IDP/Rs. The prominent
disparity now appears to be within the IDP/R population as income levels greatly diverge for
individual families much as is occurring in the general population. USAID is encouraged to
carefully monitor this situation and continue adjusting program targeting accordingly.
4 The Partnership Program should be continued and expanded as part of USAID’s 
future strategy: Few programs provide this level of benefit for the size of the
investment.
5.1 INCREASED ATTENTION TO EPIDEMIOLOGICAL PRIORITIES
Cardiovascular disease should receive increased attention: The severity of the problem
demands that rapid impact measures be sought in addition to long-term life-style interventions
and promotion. The present level of mortality is at a crisis stage and must be met with primary
care level therapeutic interventions. Consideration should be given to the idea of developing
“primary care cardiologists” equipped with simple ECGs for screening and diagnosis and the
development of a self-sustaining (i.e. revolving fund) medication mechanism.
Women’s Wellness Center focus should be concentrated on the high priority need to reduce 
morbidity and mortality related to child birth: The present level of maternal mortality demands 
that efforts not be diluted by other activities associated with wellness centers. Other “wellness”
activities such as the programs for female staff of Mir Kasimov should be spun-off as an
independent business (possibly not-for-profit).
Neonatal Resuscitation Program should be extended and complemented by topics addressing 
common conditions of newborn mortality: The alarming rate of neonatal mortality and the 
faulty status of the referral system for high risk pregnant women and newborns indicates that
improvements in basic clinical knowledge of medical personnel at the delivery settings thought
country would be of great benefit. 
Male mortality in the productive age groups is at a crisis level and, therefore, should receive 
increased attention: Estimates of death in men aged 15 to 60 are very likely low by a
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considerable margin.10 USAID’s commitment to prioritize on the basis of epidemiological need 
must take priority over gender preference. AIHA partnerships should be encouraged to examine 
this crisis with the medical/technical weight and skill of its US and Azeri Partners. 
Cardiac emergencies and trauma are likely the leading causes of death in Azerbaijan: 
Creating an Emergency Medical Services Training Center on the AIHA model will result in
major reductions in morbidity and mortality.
5.2 STRUCTURAL CHANGES
Partners should increasingly focus on the wider dissemination of improvements: The
imitation of partnerships with peripheral health providers as is being done with Saberabad should 
be supported and become a priority for all activities.
If present funding permits, the Model Primary Care Clinic being developed in the Narimanov 
Rayon should be fully assisted by the Portland Partnership, and receive input from the Baku￾Richmond Partnership: The dedication and level of effort exhibited by the physicians
developing the breast health, asthma, mental health, and other model primary care programs are 
commendable. The expanded profile of Area Physician and Nurse capabilities and areas of
practice will result in major nationwide improvements in primary care as they are disseminated. 
Expansion of patient and community outreach practices piloted at the clinic are ready for wide
scale dissemination. Full and continued support should be given to the implementation of the
Family Medicine Post-Graduate Training Institute at the Model Clinic.
Greater communication and joint actions between the Partnerships is encouraged: AIHA and 
USAID should link the efforts of the Baku-Portland and Baku-Richmond Partnerships. Such a 
linkage at both the Partnership level and at the local Baku Rayon level would result in significant 
efficiency gains and increased dissemination of advances. Duplication of efforts would be
minimized and each partner could focus on different specialty areas. One area for essential
collaboration is in the development of the Family Medicine Curriculum.
Clinical Practice Guidelines, Evidence Based Medicine, and Learning Resource Centers 
support improved primary care practice: USAID should reinstitute AIHA “Cross-Partnership” 
programs of guideline development and inter-Caucasus collaboration.
5.3 INVOLVEMENT WITH OTHER USAID PROGRAMS
The AIHA Model should be strengthened through incorporation of outside technical assistance
from one of the USAID Flagship Programs: Cost Recovery and financial reforms are greatly
needed in Azerbaijan, and PHR Plus or possibly the POLICY Project would be appropriate
sources for this type of assistance. Technical assistance in cost recovery on a local basis
(theoretical legal authority is already present in the rayons) would be the essential minimum
involvement.
 
10 Demographic analysis of the Max Planc Institute provides convincing evidence that large inaccuracies in total population 
numbers caused by undocumented out-migration from the Caucasus leads to erroneously low estimates of mortality rates. 
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USAID/Caucasus (as well as USAID programs in many other parts of the world) would
significantly increase the effectiveness, efficiency, sustainability, and depth of impact if a three
part strategy was adapted in future programming. 
The AIHA approach has clearly demonstrated that it can achieve a depth of impact and cost
efficiency beyond the norm because of the principles of “attraction” and entry through the
medical hierarchy. It is not however, a total health sector strategy. Certain policy level issues 
are clearly needing to be addressed (such as cost recovery) in order for the program to achieve 
maximum lasting benefit. 
In addition, a broader arsenal of proven PHC strategies needs to be applied in the target areas. 
While AIHA has achieved significant impact with the national adaptation of “family practice,”
there are highly developed approaches that have been implemented by USAID cooperating
agencies in other parts of the world. These strategies would be mutually reinforcing if combined 
with AIHA methods.
AIHA is an effective program, and provides important lessons that are essential for the broader 
USAID to adopt. The future USAID Health Sector Strategy should be built around a three￾pronged approach based upon the AIHA model and more traditional policy reform and primary
health care interventions. 
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ANNEX A
SCOPE OF WORK
I. PURPOSE
The primary purpose of this assessment is to assess the effectiveness, accomplishments and
impacts of AIHA’s activities in Azerbaijan. A secondary purpose is to assess how/whether these 
activities both build upon the network of USAID-funded health activities as well as contribute to 
the wider accomplishments that other donors and the GOAZ are striving to achieve in the health 
care sector. 
This analysis supports the current Strategic Objective 3.1 – Reduced Human Suffering in
Conflict-Affected Areas, and Intermediate Result (IR) 3.1.1.3 – Communities have access to 
better quality services. This analysis will help inform USAID/Caucasus/Baku as it prepares its 
strategy for the period after FY 2004. 
II. BACKGROUND
Economic trends worsened for most people after Azerbaijan obtained independence from the
Soviet Union. This decline was exacerbated by the armed conflict over Nagorno-Karabakh that 
resulted in the displacement of 650,000 people from their homes and the influx of additional
200,000 Azerbaijani refugees from Armenia. The maternal mortality rate increased four-fold 
between 1990 and 1998 from 9.3 per 100,000 live births to 41 per 100,000 live births (Statistical 
Yearbook of Azerbaijan 1999). Unofficially, rates are quoted as 78-80 per 100,000 live births. 
The overall under-five mortality rate was 38 per 1000 in 1997, which is high compared with
western standards of an average of 6 per 1,000. Morbidity and mortality rates appear to have 
ceased their upward spiral and the infant mortality rate has been stable at 20 per 1000 live births 
since 1997, according to the State Statistical Committee. This figure is considered unusually low
due to Azerbaijan not using the international standard for classifying live births. 
Since 1993, USAID has assisted Azerbaijan in meeting the critical challenges of economic and
democratic transition, and provided humanitarian assistance to the most vulnerable groups,
especially IDPs and refugees. Health initiatives in Azerbaijan comprise a small but important
component of the Mission’s assistance portfolio. The major vehicle for providing social/health
assistance is the Azerbaijan Humanitarian Assistance Program (AHAP), implemented through an
umbrella cooperative agreement sponsoring programs of 7 major US NGOs. Outside the AHAP 
framework, three US-Azeri health partnerships within the AIHA program work to upgrade
medical skills and provide Azeri health professionals with exposure to the American health care 
system. 
As a result of a free and open competitive process, cooperative agreements (a basic agreement, a 
regional-wide agreement, and separate agreements for the Caucasus, Central Asia, West/NIS,
and Russia) were awarded to AIHA in September 1998. When the basic agreement was
awarded, USAID concurrently awarded five separate three-year sub-agreements for activities in
individual countries or parts of the NIS. These separate cooperative agreements included a
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three-year agreement for the Caucasus, covering AIHA programs in Georgia, Azerbaijan and
Armenia.
Due to the rigorous socio-political conditions and Section 907 limitations the AIHA partnerships 
have been implemented under extremely difficult circumstances in Azerbaijan
11. At that time USAID selected the partnership model as one of the components in its program 
to foster more effective and efficient delivery of health care services in Azerbaijan. The greatest 
challenge to partnership success and sustainability was and remains to be, the availability of
public and private resources. This challenge has been exacerbated by the deepening fiscal crisis 
in Azerbaijan.
The original 3-year cooperative agreement contained a provision for a two year extension. AIHA
requested this extension in January 2001 and the cooperative agreement was extended for an
additional two years. The Caucasus agreement is currently scheduled to end on September 30, 
2003 and has a Total Estimated Cost of $20,537,273 with $4,755,000 comprising the Azerbaijan 
portion The basic agreement also included a provision for an option for a 5-year extension of all 
agreements issued under the basic agreement. AIHA has already expressed interest in exercising 
the extension option. 
As of May 2003, AIHA had established three partnerships in Azerbaijan: 
Baku-Houston: (Established January 2000). Overall goal: to improve medical services to
refugees and IDPS in targeted camps and communities served by the Mir Kasimov hospital in
Baku and the Sabirabad Rayon hospital in Sabirabad. Specific objectives include: establish a
neonatal resuscitation center to train health professionals; develop and disseminate practice
guidelines according to international standards; and collaborate with other partnerships in 
Azerbaijan to provide education and training in neonatal resuscitation. Also, the partnership
aims at shifting patient-oriented activities to rayon hospitals serving IDP camps in their
catchment areas and establishing a women’s wellness training center to address maternal and
child healthcare concerns among refugees/IDPs. 
Baku-Portland: (Primary Health Care – Established March 2000) Overall Goal: Develop a
comprehensive, community-based, primary care system designed to meet the basic health care
needs and improve the health status of IDPs and refugees in the Narimanov Health Care District 
in Baku, Azerbaijan. Specific objectives include: Enhance the ability of the Narimanov Health
District to collect, store, organize and analyze basic socio-demographic and health status
information on the IDP/refugee population in the district; enhance and adapt the infrastructure of
the Health District to provide a solid base for primary care; improve the effectiveness of the
nurses serving the IDP/refugee population; and integrate a mental health program into the model
primary care clinic.
 
11 Until FY2003, all U.S. Government-funded activities in Azerbaijan were subject to the provisions of Section 907 of the 
FREEDOM Support Act (FSA). Section 907 states that, “United States assistance under this or any other Act may not be 
provided to the Government of Azerbaijan until the President determines, and so reports to Congress, that the Government of 
Azerbaijan is taking demonstrable steps to cease all blockades and other offensive uses of force against Armenia and 
Nagorno-Karabakh.” In FY 2003, the President exercised the authority provided in the FY 2003 Appropriations act and 
waived Section 907.. 
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Baku-Richmond: (Primary Health Care-Partnership Established March 2000). The overall goal
of the partnership is to improve the health status of the local population including refugees and 
IDPs accommodated in the Binagadi District of Baku city through socially oriented, public and
primary health care programs. Specific objectives include: improve the capacity of the Binagadi
Health Department to collect, enter, and analyze data on the health status of the local population 
including refugees and IDPs; improve the quality of medical care provided by area doctors and 
nurses to refugees and IDPs through training in clinical assessment skills and sharing evidence
based medical guidelines, and; to improve the quality of medical information provided to the
population on infectious disease, personal hygiene, sanitation, and general prevention in their
home environment. 
In addition to developing and implementing the above-mentioned partnership programs, AIHA
also supports a number of related activities that facilitate and promote inter-partnership 
communications and synergy, joint partnership initiatives, sharing and dissemination of
information, and replication of centers such as Learning Resource Centers, EMS and Nursing
Training Centers. 
III. GOAL
The goal of AIHA/Azerbaijan partnership program assessment is to analyze the general
accomplishments of the project--successes, constraints and failures, and to set the stage for future 
USAID participation in partnership activities in Azerbaijan. The team’s findings and
recommendations will be used by USAID/Caucasus/Baku as a tool in decision making and
planning of future health partnership strategies. 
IV. OBJECTIVES AND TASKS
As stated above, the independent assessment team will assess the current AIHA partnership 
portfolio. In addition, the team will review AIHA country office administrative capacities and 
structure. 
Focal issues for the assessment are:
· Accomplishments of the AIHA Partnership/Volunteer Program.
· Contribution to USAID social/health sector goals.
· Demonstrable impact in the field.
· Value of contribution relative to level of investment.
· Sustainability.
· Replication.
· Effectiveness of AIHA implementation and management.
The team will assess partnership activities to identify which activities demonstrate a comparative 
advantage in its technical field and provide recommendations on how to build upon and focus 
these activities for future expansion. Under this objective are the following tasks: 
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ÿ Describe certain categories or types of partnerships that are more effective and productive
within the Azerbaijan context. Describe what characteristics/factors make them more
effective and productive.
ÿ Analyze the appropriateness of external and internal criteria for establishing a partnership.
ÿ Analyze what makes partnership inputs unique and how do these activities enhance other
USAID-funded activities in achieving similar results; thus, resulting in a comparative
advantage for sustainable impact. 
ÿ Assess the potential for the current programs to be replicated and the extent to which the 
partnerships have had a broader impact on the community, region, or nation.
ÿ Analyze the extent to which AIHA special initiatives, including Women’s Wellness, 
Neonatal Resuscitation, EMS Training, Nursing, Infection Control, AIHA central activities
such as NIS-wide conferences/workshops facilitate individual partnerships in meeting their
agreed-upon goals and objectives.12
ÿ Describe reported changes in health care delivery that are attributable to lessons learned by
health care practitioners through participating in the partnership programs. In short, what
are health care professionals and administrators doing differently due to the AIHA
program?
ÿ Assess the tool through which AIHA staff monitors and evaluates the adequacy and
appropriateness of staff being selected for training.
ÿ Propose overall recommendations to enhance and focus the effectiveness and impact of
activities performed which demonstrates a comparative advantage and coordinates with
other on-going activities aiming to achieve comparable results within USAID Strategic
Objective. 
ÿ Assess the local management and administrative capacity of the AIHA country office staff
and structure and make recommendations to increase overall effectiveness and efficiency.
Specific issues to be addressed per each partnership entail, but are not limited to:
Baku-Houston Partnership:
· What progress has been made in establishing a neonatal resuscitation center to train 
health care professionals? How many health care professionals have been trained? To
what extent have the services provided by the trained professionals improved? What are 
they doing differently since completing the training? What additional training (in terms of
content or pedagogical techniques) do they believe they need for improving their
services? What has been the impact on the beneficiaries?
· Have practice guidelines (according to international standards) been developed and
disseminated? How many professionals have received the guidelines? To what extent
have they used them to improve the services they provide? Examples? Are the guidelines 
appropriate for the services they provide? How could they be improved?
· To what extent has there been collaboration with other partnerships in Azerbaijan to
provide education and training in neonatal resuscitation? 
 
12 There is a concern on the part of USAID/Caucasus that there are too many activities in sharing Initiatives, conferences, and 
workshops and that it takes a great deal of AIHA/Azerbaijan staff efforts and detracts from implementation of the 
Partnership’s workplans. 
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· What progress has been made in shifting patient-oriented activities to rayon hospitals
serving IDP camps in their catchment areas and establishing a Women’s Wellness
Training Center to address maternal and child healthcare concerns among refugees/IDPs? 
To what extent have these activities resulted in improving services? What are some of the 
perceptions of the beneficiaries regarding improvements in services?
Baku-Portland Partnership:
· What progress has been made in developing a comprehensive, community-based, primary 
health care system?
· To what extent has the new system resulted in meeting the basic health care needs and 
improving the health status of IDPs and refugees in the Narimanov Health Care District? 
What are some of the perceptions of the beneficiaries regarding improvements in
services?
· What progress has been made in enhancing the ability of the Narimanov Health District
to collect, store, organize and analyze basic socio-demographic and health status
information on the IDP/refugee population in the district? To what extent has the
information collected been used for decision-making? Examples? 
· What progress has been made in enhancing and adapting the infrastructure of the Health
District? What changes have been made? How has it made a difference in meeting the
basic health care needs and improving the health status of IDPs and refugees in the
District? What are some of the perceptions of the beneficiaries regarding improvements
in services?
· To what extent has the effectiveness of the nurses serving the IDP/refugee population
been improved? Examples? What are some of the perceptions of the beneficiaries
regarding improvements in services?
· What progress has been made in integrating a mental health program into the model
primary care clinic? What efforts have been made in establishing a mental health
program that is built on the Azerbaijan culture and the mental health needs of the
beneficiaries? To what extent has this program been used by beneficiaries? What has
been the impact on the beneficiaries? What are some of the perceptions of the
beneficiaries regarding the services provided in this program?
Baku-Richmond Partnership:
· To what extent has the health status of the local population including refugees and IDPs 
improved since the beginning of the partnership?
· What progress has been made in improving the capacity of the Binagadi Health
Department to collect, enter, and analyze data on the health status of the local population 
including refugees and IDPs? To what extent has the information collected been used for 
decision-making? Examples?
· What progress has been made in providing area doctors and nurses training in clinical
assessment skills and sharing evidence based medical guidelines? How many doctors and 
nurses have been trained? How many have received the guidelines? To what extent has
the quality of their services improved? Examples?
· What progress has been made in improving the quality of medical information provided 
to the population on infectious disease, personal hygiene, sanitation, and general
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prevention in their home environment? What are some of the perceptions of the
beneficiaries? To what extent can they understand the information provided on these
issues? To what extent has it made a difference in their health practices?
AIHA’s Partnership Strengthening Activities:
· What activities have been implemented that facilitate and promote inter-partnership 
communications and synergy? What has been the impact? Examples of changes in
communication and synergy?
· What activities have been implemented that facilitate and promote joint partnership
initiatives? How many new initiatives have begun? What is the quality and
appropriateness vis-à-vis health needs of the new initiatives?
· What activities have been implemented that facilitate and promote sharing and
dissemination of information? To what extent has this information been used?
· What progress has been made in replicating centers such as Learning Resource Centers, 
EMS and Nursing Training Centers?
V. METHODOLOGY
Information will be collected mainly through personal and/or telephone interviews with key
informants from AIHA field representatives, GOAZ officials, Azerbaijan-based AIHA partners,
other USAID-funded implementing partners, U.S.-based partners, and USAID/Caucasus staff. 
Focus group discussions should be held with small groups of returned trainees from the United
States and those who have participated in NIS-wide conferences, workshops, or seminars. 
Interviews and group discussions will collect descriptive data on AIHA’s organizational and
management capabilities, and the technical outputs/impacts of partnership exchanges and
participation in conferences, workshops, and seminars. 
Team will also conduct field trips to selected activity sites in Azerbaijan to observe project
implementation, verify reported information, and assess performance and progress towards
accomplishment of program results and strategic objectives. Team will talk to health
professionals who were recipients of trainings, to identify how their performance, attitude and/or
provided services have been changed. During field trips, the team will also talk to beneficiaries 
to find out how services have been improved or not. 
US partners not present in Azerbaijan at the time of the assessment should be interviewed by
phone prior to the teams departing for Azerbaijan. In the even that the consultants are located 
close to one of the US partners, they may arrange personal interviews before leaving. As
additional questions may arise in Azerbaijan in the course of the assessment that require
clarification with US partners, the team should remain in e-mail contact with the US partners
while in Azerbaijan. USAID/Caucasus staff member(s) may accompany the review team while
in Azerbaijan as observer(s) throughout the assessment, as necessary.
The Team Members will then assess the outcomes of each set of interviews and group
discussions, synthesize the results, and provide/develop a set of findings, lessons learned, and
recommendations for future partnership activities. A final briefing near the end of the
consultancy will be made to the USAID/Caucasus/Baku Coordinator’s Office management staff. 
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Interim briefings, as appropriate, may take place in Baku with Mission staff participating on the 
assessment team.
VI. PERSONNEL AND LEVEL OF EFFORT REQUIRED
The team will consist of two consultants. All team members will be approved by
USAID/Caucasus/Baku. Experience within the former Soviet republics, especially the Caucasus 
region will be an added advantage.
The team will require two specialists. Based upon qualifications, a Team Leader will be named 
and shall be responsible for the successful management of the assessment and the production of 
all deliverables. The Team Leader must have USAID assessment experience. Experience with
USAID programs and with assessments are important, but not mandatory, qualifications for the
other team member.
Program Analyst
The program specialist will be responsible for assessing the management effectiveness of the
AIHA program, as well as of the monitoring and evaluation plan.
Recommended Qualifications - Technical expertise and experience in monitoring and evaluation
tools and methods, organizational management, and partnership models. Azeri or Russian
language capability and experience in analysis in the former Soviet Union is desirable.
Health Analyst
Recommended Qualifications: Technical expertise and experience in delivering and managing 
health activities and in international health program planning and management. Knowledge of
the health system of the former Soviet Union is also required. An MPH is preferred, as is Azeri 
or Russian language capability and experience in analysis in the former Soviet Union.
VII. DELIVERABLES
The activity will be undertaken from 09/23/2003 to 11/21/2003. Prior to the team’s departure to 
Azerbaijan, preliminary briefings will be scheduled at USAID/Washington and AIHA
headquarters in Washington, D.C. The draft report will be presented to USAID/Caucasus - Baku 
before leaving the country. USAID will provide comments and suggestions within ten days of
receiving the draft. The Final Report, incorporating the Mission comments (4 bound copies and 
an electronic version in Word on a c.d. rom) will be provided to the Mission shortly thereafter 
but not later than ten days. The report should be concise, not exceeding 25 pages plus
appendices, as needed. The team leader will be responsible for completing the report on time 
and submitting it to the Mission. The final report should include the following sections:
Executive summary; Background; Methodology; Description of activities; Summary of key
findings; Conclusions; Recommendations; Annexes.
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VIII. LEVEL OF EFFORT (TENTATIVE)
The level of effort will be approximately as follows:
Washington interviews&Background Reading 4 days
Travel Days 4 days 
Interviews/Discussions and report writing in Azerbaijan 12 days 
Analysis & Final Report Writing 6 days 
Total number of working days: 26 days 
IX. ADMINISTRATIVE AND LOGISTICAL ARRANGEMENTS
Valerie Ibaan and Gulnara Rahimova, Humanitarian Project Management Specialists will be the
official contacts for the team in Azerbaijan. Air Travel to and from Baku, Azerbaijan is
authorized. USAID/Baku will provide support in scheduling meetings and site visits. 
Office space and equipment. Because office space is limited, the team will not be provided 
with temporary workspace at USAID Baku. The team leader will be required to have a personal 
computer and should arrange temporary workspace and other assistance with the local
administrative/logistical support providers, as needed. No access to USAID Azerbaijan services 
or facilities will be provided.
Transport. Local transport and per diem will be reimbursed at the USAID rate for Azerbaijan
on a daily basis. Airline tickets will be reimbursed on a cost basis, upon submission of official
receipts.
Work week: A six-day workweek is authorized, without any premium pay.
X. EXPECTED RESULTS
USAID/Caucasus is looking for pragmatic and actionable advice and recommendations based on
the team’s assessment in Azerbaijan. The Mission will be the primary user of the information to 
assist in decision making on future partnership strategies. Given the limited USAID resources in 
the health assistance area in Azerbaijan, USAID/Caucasus needs to know where the greatest
potential for effective and sustainable partnerships exists. The assessment results will be
disseminated to AIHA for similar decision making processes.
XI. REFERENCES
1. Report of the Continuing Evaluation Panel, “The American International Health Alliance
Partnership/Volunteer Program in the Newly Independent States and Central and Eastern
Europe”– June 30, 2001
Development Associates, Inc.
Assessment of the American A-8 December 2003
International Health Alliance (AIHA)
Program in Azerbaijan
2. LTG Associates, Inc. and TvT Associates, Inc., “Social and Health Assessment of Residents, 
Refugees and Internally Displaced Persons in Azerbaijan” – February, 2002
3. International Medical Corps, “Two Part Baseline Survey on Primary Health Care and
Population Health Needs and Utilization of Health Care Services” - August 2000.
4. USAID Azerbaijan Strategic Plan, 2001-2003, May 2000.
AIHA Program in Azerbaijan.doc/EvaIQC-35