Mid-Term Evaluation Report 
Prepared by: 
Umir Nuri (Rainbow of Life) Child Survival Program 
Counterpart Interntional / Center Perzent / Ministry of Health 
Karakalpakstan, Uzbekistan 
Cooperative Agreement No.: FAO-A-00-00-00027-00 
October 2000 – September 2004 
Submitted to: 
USAID, Bureau for Global Health, Office of Health, 
Infectious Diseases, and Nutrition 
SEPTEMBER 2003 
Written by: 
Arvind Kasthuri, MD 
St Johns Medical College, Bangalore, India 
With editorial assistance from: 
Darshana Vyas, MSW, MPH 
Director, Health Programs, Counterpart HQ 
Washington DC, USA 
Ramine Bahrambegi, MPH 
Program Director, Umir Nuri Child Survival Program 
Karakalpakstan, Uzbekistan 
LIST OF ABBREVIATIONS USED
AIDS Acquired Immune Deficiency Syndrome 
ARI Acute Respiratory Infection 
BCC Behavior Change Communication 
BFSG Breastfeeding Support Group 
CDD Control of Diarrheal Disease 
CHAP Counterpart Humanitarian Assistance Program 
CS Child Survival 
CSCC Child Survival Co Ordination Committee 
CSTS Child Survival Technical Support group 
DIP Detailed Implementation Plan 
HFA Health Facility Assessment 
HIV Human ImmunoDeficiency Virus 
HMIS Health Management Information System 
IMCI Integrated Management of Childhood Illness 
JDA Joint Development Associates 
KPC Knowledge Practice and Coverage Survey 
LOP Life of Program 
MoH Ministry of Health 
MoU Memorandum of Understanding 
MSF Medecins sans Frontiers 
MTE Mid Term Evaluation 
NGO Non Governmental Organization 
ORS Oral Rehydration Solution 
ORT Oral Rehydration Therapy 
SCM Standard Case Management 
TOT Training of Trainers 
TTAP Technical Training Assistance Plan 
CSP (Umir Nuri) Child Survival Program 
UNICEF United National International Children Emergency Fund 
UNDP United Nations Development Program 
USAID United Sates Agency for International Development 
VHC Village Health Committee 
VHW Village Health Worker 
Wtp Willingness to Pay 
WHO World Health Organization 
CONTENTS
Dedication 
Executive Summary 01 
Introduction 05 
Program Overview 08 
The Mid term Evaluation of the UNCSP 12 
Technical Interventions 
Diarrheal disease control 13 
Promotion of Breastfeeding 16 
Pneumonia Case Management 18 
Conclusions 20 
Recommendations 23 
Cross Cutting Interventions 
Community Mobilization 25 
Conclusions 27 
Recommendations 28 
Behavior Change Communication 30 
Conclusions 32 
Recommendations 33 
Organizational Capacity 36 
Conclusions 43 
Recommendations 49 
Networking & Advocacy 51 
Conclusions 52 
Recommendations 54 
Sustainability 55 
Recommendations 56 
The Future 57 
Summary of Conclusions & Recommendations 
Conclusions 59 
Recommendations 72-79 
ATTACHMENTS 
One – The Process of Evaluation, 
and the Evaluation Team 
Two- Selected sections of the DIP with comments 
Three- The Midterm KPC Survey 
Results summary 
Brief Description 
The Questionnaire 
Training schedule for Interviewers and 
Supervisors 
Four- Qualitative assessment tools used 
1
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Executive Summary 
Dedication
This report is dedicated to the memory of two persons who have left an 
indelible mark on the Umir Nuri Child Survival Program. Dr Nuriyah 
Elgondieva was intimately involved with the program from 2001 till her 
untimely demise in January 2003. Dr Damir Babanazarov helped in seeing the 
program through its initial planning and preparatory phases, and was a good 
friend of the program. 
Dr. Nuriyah Elgondieva was born on October 7, 
1975 in Takhiatash, Karakalpakstan. She 
graduated from the Samarkand University as a 
medical doctor with experience in Parasitology, 
Immunology and Infectious disease. 
Nuriyah joined the Umir Nuri Child Survival 
Program at its inception in 2001 and made 
invaluable contributions during the start-up of the 
program and during its subsequent activity 
including BCC workshops, KPC and HFA surveys. 
Starting her work in Counterpart Nuriyah as Field 
Officer in Takhtakupir Rayon, Nuriyah moved on 
to become Health Education Specialist and finally, 
Program Manager. 
Nuriyah’s positive outlook, personal charm, and 
love for Karakalpakstan was combined with a high level of commitment and 
competence at the workplace, which served as a model for everyone who 
worked with her. The UNCSP is coping with her tragic and untimely death by 
carrying on her work and spreading her ideas throughout Karakalpakstan. 
Dr. Damir Babanazarov served as Minister of Health in the Republic of 
Karakalpakstan. He was a man of high virtues, a well-developed personality 
who possessed high levels of 
intellect and talent. He made 
immense contributions to the Health 
Care Delivery System of 
Karakalpakstan. His most notable 
contribution was in establishing and 
improving relations with different 
international agencies and 
organizations who continue to 
contribute to the Health of the people 
of Karakalpakstan. The UNCSP was 
fortunate in being involved with him in its initial stages and has lost a good 
friend in his Passing on. 
His most notable legacy is the name of the program, which he helped 
formulate – Umir Nuri, or “Rainbow of life.” 
2
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Executive Summary 
Executive Summary 
The “Umir Nuri” (“Rainbow of Life”) Child Survival Program (CSP) is a USAID￾supported program located in Karakalpakstan, which is an area 
of Uzbekistan bordering the Aral Sea. The program is 
implemented by Counterpart, an international NGO based in 
Washington, USA, working in partnership with Centre Perzent, 
a local NGO, and the Ministry of Health in Karakalpakstan. The program was 
initiated in December 2000, and the detailed implementation plan submitted in 
April 2001, following baseline assessment. The program is planned over a 4-
year duration, till December 2004. A mid term evaluation was commissioned 
in June 2003. 
The program aims to sustainably reduce mortality among children under five 
years of age in TWO rayons (administrative units) of 
Karakalpakstan – Nukus and Takhtakupir, and to build the 
capacity of the partner NGO, Centre Perzent in the area of 
child survival. The technical interventions of the program are 
directed at THREE broad issues, Control of Diarrheal Disease (35% effort), 
Pneumonia Case Management (45% effort) and Promotion of Breastfeeding 
(20% effort). The objectives of the program are to improve knowledge and 
practice of mothers and caretakers with respect to the three interventions by 
improving access to information and services. The main strategies which the 
program uses include: mobilization of the community by facilitating the 
formation of Village Health Committees, developing and implementing an 
effective Behavior Change communication strategy, building its own capacity 
to train, implement and monitor the program and networking with like minded 
organizations in the area to enhance effectiveness and play an advocacy role. 
In the area of Technical Interventions relating to the Management of Diarrhea 
disease, Pneumonia Case management and promotion 
of breastfeeding, ALL KEY indicators (as stated in the 
DIP) of Knowledge and Practice measured at the mid 
term are estimated at levels HIGHER than the baseline 
level. The proportion of mothers of children under two years of age surveyed 
who knew the danger signs of diarrhea requiring treatment was 87.3% (32.0% 
at Baseline) and the proportion of mothers who could correctly state the 
method of preparation of ORS and use it was 84% (42.3% at baseline). The 
proportion of children who had diarrhea in the two weeks preceding survey 
and who were treated with an acceptable form of ORT was 70.4% (9.1% at 
baseline). The proportion of mothers who knew the danger signs of 
Pneumonia requiring treatment was 96.0% (61.3% at baseline). While no 
mother surveyed at baseline could state the two danger signs of rapid 
breathing and chest indrawing as danger signs of pneumonia requiring 
treatment, 47.0% of mothers surveyed at the mid term could state this 
correctly. The proportion of newborns breastfed within one hour of birth was 
61.3% at the mid term (44.0% at baseline) and the proportion of infants under 
six months of age who were exclusively breastfed was 70.0% (28.0% at 
baseline). However, the proportion of mothers whose children showed 
Program 
Description 
Goal 
Objectives 
Strategies 
Technical Interventions 
-Accomplishments 
3
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Executive Summary 
symptoms of Acute Respiratory Infection (ARI) in the two weeks preceding the 
survey and who took the child to a qualified health care provider on the same 
day was 11.8% (42.9% at baseline). 
The Partnership of Counterpart with the Ministry of Health and with the NGO 
Perzent is a positive outcome of the program, with all partners 
having a clear perception of the program and of their roles. The 
capacity of the NGO Perzent has been enhanced by the program. This is 
evidenced by the availability of technically competent staff, the enhanced 
training ability of the organization and the ability of the organization to 
independently attract funding in the area of Child survival and Reproductive 
health. Even though a Health Facility assessment was not a part of the mid 
term evaluation, the impression from qualitative study was that the health 
facilities and personnel at the facilities have an increased capacity to deliver 
care in the areas of diarrheal disease and pneumonia, and in the promotion of 
breastfeeding. 
18 Village Health committees (VHCs) have been formed at the community 
level. The VHCs appear to have a clear perception of the 
program, and are willing to give time and effort to enhance the 
reach of the program benefits into the community. Other 
community-based groups that have been facilitated by the program are 
breastfeeding support groups, and schools of mothers. At the rayon level, the 
program has established a Child survival co ordination committee in each of 
the two program rayons, which is an effective mechanism for enhancing 
visibility of the program, and for problem solving. 
The program has successfully produced behavior change communication 
(BCC) materials for use by its beneficiaries and its workers, which is 
one of its most visible and major accomplishments. The materials 
have been translated and produced in Karakalpak language, which 
is used locally. The program uses house visits as an important one-to-one 
communication strategy. Other innovative methods used include Puppet 
shows, and street plays. 
The program has had turnover at the level of Project director, and the current 
incumbent is due to complete a year in September 2003. The 
program was unfortunate in having lost its dynamic Program 
Manager, Dr Nuriyah Elgondieva, who died tragically in 
January 2003. But most of the field staff and support staff at 
the program office in Nukus have been with the project since its inception. 
The field staff are an asset to the program, and have developed a good level 
of competence in delivering messages to the community. Training is an 
important activity of the program, and a total of 18 training programs have 
been held since program inception, aimed at a wide variety of audiences, 
ranging from in-house programs for program staff to programs for personnel 
of the Ministry of Health at the health facilities. In House trainers have been 
groomed, and the program can currently handle most of its training on its own. 
Partnership 
Community 
Mobilization 
BCC 
Staff and 
Training 
4
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Executive Summary 
The Health Management Information System (HMIS) has been developed by 
the program for its own use. The system includes a 6-monthly 
collection of indicator-level information, and process-related 
information is collected monthly, as it should be. The staff who 
manage the HMIS are competent, and could improve with training. 
The Networking and advocacy strategy of the program is founded on monthly 
interagency and intersectoral meetings, where like-minded 
organizations come together to discuss matters of mutual 
interest, and to represent issues of concern at the policy 
making level. The present program Director has ensured that the program is 
visible at Karakalpakstan, and in Uzbekistan, and is committed to building a 
good network which will improve effectiveness. 
The Program has done a Willingness-to-pay survey in the area, with the aim 
of establishing Village based pharmacies. This is based on the 
observation that often, health facilities do not have stocks of 
essential drugs, needed for the effective management of 
Pneumonia and other child health problems. This initiative is an 
important step in the area, and has the approval of the Ministry of Health. 
The sustainability of the program is founded on the following: 
- Building the capacity of the NGO Perzent to be able to 
plan and implement a similar program 
- Building the capacity of the Ministry of Health, so that the 
care and services at the Health facilities continue to be good 
- Establishing Village Pharmacies, based on research done which showed 
that communities were willing to pay for drugs of good quality, if available 
at their villages 
- Establishing a firm Community based organizational network in the form of 
VHCs and other organizations of women, so that the community takes 
ownership of the program 
- Effectively communicating for behavior change during the life of the 
program, so that it can be sustained after the program withdraws 
There is a need for Child survival activity to be continued in the region. The 
future of the program, if support for continued Child survival activity is 
available, may be in the following directions: 
- Continuing in the same rayons and expanding the range of issues covered 
to include other health problems like HIV/AIDS control, and Anemia. 
Levels of awareness among mothers regarding HIV has been studied at 
the baseline and mid term, and it shows no change in level over the past 
two years. 
- Expanding into different rayons, replicating the model, with the appropriate 
local modifications. 
In either option, the NGO Perzent could play a larger role in the 
implementation of the program, with Counterpart providing technical advice 
and support. 
HMIS 
Networking 
and Advocacy 
Village 
Pharmacies 
Sustainability 
5
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Executive Summary 
Other important recommendations for the program include: 
º The program may need to quickly research the ARI practice issue to find 
out the reasons for delay in care-seeking and may 
need to design an appropriate strategy. 
º The targets set in the DIP have been exceeded in most cases. Appropriate 
revision would have to be done for the remaining life of the program. 
º The establishment of ORS corners at Health facilities would be a useful 
step to improve further the practice of ORT during diarrhea since the ORS 
corners are a popular concept with the Health facility personnel. 
º Messages relating to feeding during diarrhea and to handwashing practice 
for the prevention of diarrhea could be strengthened, since many mothers 
surveyed did not practice these behaviors appropriately. 
º The practice of early initiation of breastfeeding is another area where more 
input could be given, since many mothers do not practice this. 
º Some of the additional areas for strengthening capacity of Perzent include 
Documentation, Dissemination of information, Lobbying and advocacy to 
secure support for important issues and the HMIS. 
º The program could consider the formation of more womens groups. 
Following the completion of the life of the program, the continued 
dissemination of messages to mothers in communities are best done by 
women, and peers. A Social worker in the program staff could assist in this 
activity. 
º The BCC materials prepared by the project have been well accepted. The 
production of materials in Karakalpak has been a challenge, which has 
been successfully handled. Occasionally, there have been delays in the 
production of materials, due to different interpretations of translated words. 
Such delays must be avoided. 
º The communities met during the evaluation asked that material and 
methods of BCC have more visual content, like television spots, short 
films, videos and leaflets with increased graphic content. 
º Periodic refresher training especially for new recruits is an important task 
which must be given the priority it deserves. 
º The HMIS staff have developed their own tools, and have adapted them to 
suit the requirements of the program. However, the program could 
organize training on HMIS for its staff, to enhance the effectiveness of 
monitoring. 
º The Program could organize scientific conferences / symposiums in the 
region on issues related to Child survival and Reproductive Health. This 
would give an opportunity to present its achievements, learn from similar 
experiences and secure support for the future. 
Recommendations 
6
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Introduction 
Introduction 
Counterpart International (Counterpart) is an international non-profit 
organization headquartered at Washington DC, USA. It was founded in 
1965, working initially in the islands in the South Pacific region. The 
area of activity and geographic coverage have increased over the 
years, and Counterpart currently works in over 60 countries, with 
affiliate organizations in various regions. 
The Core strategy in Counterpart's activity is to build partnerships and 
empower local organizations and communities. To this end, 
Counterpart’s work is categorized into the following divisions: 
o Humanitarian assistance 
o Civil society and governance 
o Food security and sustainable agriculture 
o Environment and Natural resource 
o Small Micro Enterprise 
o Health and Child Survival 
The Health and Child Survival Division of Counterpart implements 
programs in the following domains 
o Child survival 
o Reproductive Health 
o Primary Health Care 
o HIV / AIDS prevention and control 
Some of the unique features of the approach adopted by Counterpart 
include 
o The encouragement of micro enterprise to build capacity 
o The design of programs based on need and demand 
o The building of partnerships with local organizations, aimed at 
their empowerment. 
Counterpart has been present in Uzbekistan since 1993, mainly 
working with Civil Society and Governance, identifying and supporting 
small NGOs in the region. The strategic vision of the organization 
perceived that the presence of Counterpart in the Central Asian region 
was a good foundation for a program aimed at Child survival.(CS) 
The Karakalpakstan autonomous region was identified within 
Uzbekistan as being an area of need based on high rates of Infant and 
Child Morbidity and Mortality and relatively little international assistance 
in Health and Child Survival. At the suggestion of the Ministry of Health 
in Uzbekistan, it was decided to locate the child survival program in 
Karakalpakstan. 
7
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Introduction 
An effort was then launched to locate partners in this area. While the 
Ministry of Health in Karakalpakstan (MoH) was recognized as one 
partner, a suitable Non Governmental Organization (NGO) was looked 
for as being the other. Center Perzent, an NGO of repute in the region, 
was identified as the other partner following a process of assessment 
using, among other methods, the Organizational Assistance Tool and 
the Technical Assistance and Training Plan (T T A P) tool of 
Counterpart. 
Center Perzent (means “progeny”) was established in 1992 as a center 
for reproductive health by Dr Oral Ataniyazova, a committed 
reproductive health clinician. The mission of the organization is to 
improve the health status of the women and children in Karakalpakstan. 
To this end, Perzent runs a reproductive health clinic, implements 
environmental education programs, and is engaged in activities which 
promote safe motherhood. The organization is active in 8 out of 15 
rayons in Karakalpakstan. 
An intense period of planning involving all the partners was then 
initiated which culminated in the launch of the Child survival program in 
December 2000. The main aim of the program is to reduce mortality
among children under five years of age in two rayons of 
Karakalpakstan, Nukus and Takhtakupir, by intervening in three key 
areas that address the major causes of morbidity and mortality among 
children in the region: 
- The control of Diarrheal disease
- Pneumonia Case management 
- The promotion of breastfeeding
The program also aims to build the capacity of the partner 
organization, Perzent, so that the benefits of the program can be 
sustained in the region. 
The program was christened “Umir Nuri” or “Rainbow of life”, based on 
discussions had with the former Minister of Health, the community and 
local Makhalla chiefs. 
The program was unique in the following dimensions: 
o The program is located in Karakalpakstan, which is an area of 
under development within Uzbekistan. Karakalpakstan is the site 
of the Aral Sea environmental crisis, where the waters of the Aral 
sea have receded, leading to large areas of unusable and 
polluted land. 
8
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Introduction 
o It represented a partnership between an international 
organization, a local organization and the Ministry of Health. This 
was a new approach to a health program in Uzbekistan. 
o The partnership was based on a written Memorandum of 
Understanding (MoU), which outlined each partner’s roles and 
responsibilities. 
o The program involved the partners and others including local 
community leaders, doctors from the rayons, NGO 
representatives and others, intensively from the stage of planning 
through implementation and evaluation. 
o Child survival is in itself a unique area of focus in an NGO-driven 
program in Karakalpakstan. 
o The program, in its goals and objectives aims to involve the 
community as an integral part of the program as opposed to 
programs which hand out benefits to be passively received by a 
target group, or others which work directly with health facilities 
without involving the community.
9
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Program Overview 
Program overview 
Location 
The Umir Nuri Child survival program (CSP) is located in 
Karakalpakstan which is in North West Uzbekistan, bordering on the 
Aral Sea. Infant mortality rates are estimated to be higher than the 
nationwide average in Uzbekistan, due in part to the environmental and 
ecological hazards in the Aral Sea region. In 1997-98, the maternal 
mortality rate for Karakalpakstan was estimated to be 48.1 per 100,000 
live births, while maternal mortality in Uzbekistan was only 31.2 per 
100,000. Health problems in Karakalpakstan are largely due to the 
breakdown of health care infrastructure in the region, as well as poor 
sanitation and hygiene practices. It is estimated that the prevalence of 
tuberculosis, cancer, anemia, kidney and liver diseases is significantly 
higher in Karakalpakstan than in other regions of Uzbekistan. 
Karakalpakstan administratively comprises 15 rayons (districts, regions, 
administrative divisions). The Umir Nuri program works in two of these 
rayons – Nukus and Takhtakupir, which were chosen based on the 
high rates of Infant and child mortality, and the commitment of the MoH 
and the organization Perzent to improve the Primary Health Care 
system in the area. 
The leading causes of infant mortality, as well as overall mortality, in 
Uzbekistan include respiratory illnesses (mainly pneumonia) and 
diarrheal diseases. Poor nutrition is a risk factor associated with many 
serious illnesses, including acute respiratory infections (ARI) and 
diarrheal disorders, as it can exacerbate the effects of these diseases. 
Due to the unreliability of health data, the rate of ARI, as also the death 
rate is most likely higher than reported in the official statistics. 
 
Nukus city is the capital of the Karakalpakstan autonomous republic. 
The Umir Nuri CSP office is located in Nukus city. Some of the health 
status indicators for the area are as follows: 
Table 1: Health status indicators in Karakalpakstan and Uzbekistan 
Indicator Karakalpakstan Uzbekistan 
Area 164,900 sq. km. 447,400 sq. km. 
Total population 
Male 
Female 
1,484,069 
712,353 (48%) 
771,716 (52%) 
23,797,500 
11,874,952 (49.9%) 
11,922,548 (50.1%) 
Density (per sq. km) 12 47 
10
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Program Overview 
Indicator Karakalpakstan Uzbekistan 
Number of women of 
reproductive age 
(15-49 years old) 
378,437 (25.5%) 5,973,172 (25.1%) 
Number of children 0-14 
years 
547,636 (36.9%) 9,233,430 (38.8%) 
Live births 31,564 544,500 
Birth rate per 1000 
population 
22.8 29.4 
Infant mortality per 1000 
live births 
Urban 
Rural 
24.9 
27.8 
22.4
45 
Maternal mortality per 
100,000 live births 
48.1 31.2 
Hospital beds per 10,000 
population 
64.7 58.8 
Goals 
The program has TWO goals: 
o To sustainably reduce the mortality rate among children under five 
years of age in the program rayons – Takhtakupir and Nukus 
o To improve the capacity of Perzent (the partner NGO) to plan, 
implement and evaluate child survival programs 
Objectives 
The target group for the program are children under the age of five 
years residing in the area and their caretakers. The program objectives 
are directed at improving knowledge and skills of caretakers of children 
and the capacity of the MoH facilities in the management of three key 
interventions: 
o The control of Diarrheal disease 
o Pneumonia case management, and 
o The promotion of breastfeeding. 
Specific objectives of the program include the following: 
o To Improve breastfeeding practice among mothers of children under 
three in the area 
o To improve management of diarrhea using an acceptable form of 
ORT 
o To improve knowledge regarding danger signs of dehydration, 
dysentery, and persistent diarrhea among caretakers of children in the 
area 
11
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Program Overview 
o To improve the capacity and performance of caregivers in health 
facilities in the project area to correctly assess, treat, and counsel 
caretakers for diarrhea among children. 
o To improve knowledge regarding danger signs of pneumonia 
requiring medical treatment among caretakers of children under five 
years of age in the area. 
o To improve care seeking behavior among caretakers of children 
showing danger signs of pneumonia 
o To improve the capacity of health facilities in the region in the 
management of diarrhea and pneumonia 
o To improve the capacity the NGO Perzent, to sustain activities and 
programs beyond the four-year duration of the program. 
Baseline assessment 
The knowledge and practice of caregivers of children under five 
regarding diarrhea, pneumonia and breastfeeding was assessed by 
means of a rapid Knowledge, Practice and Coverage (KPC) survey. The 
survey was done in January 2001 using the standard methodology 
developed by the Child Survival Technical Support group (CSTS) for 
use by Child survival projects. A Health facility assessment (HFA) was 
also done. The detailed reports of these activities are available in the 
CSP office at Nukus. (See attachment for summary of baseline 
assessments) 
Program strategies 
The important strategies which the program planned to adopt in order to 
achieve the objectives and goals were: 
o Behavior change communication 
This included 
o the design, development and use of material aimed at improving 
caretaker knowledge and practice based on the Behave
framework, and 
o The development and implementation of a training strategy to 
improve capacity of the MoH health facilities in the three 
intervention areas 
o Community mobilization
The program planned to facilitate the development of organizations 
at the community level and at the rayon level. 
At the rayon level, Child survival co coordination committees 
(CSCCs) were to be established, with the Chief doctor/pediatrician 
of the rayon, the Deputy Hakim on women’s issues, and other 
community leaders as its members. These committees would serve 
as an informal process-oriented mechanism for program review. 
12
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Program Overview 
At the community level, Village health committees would be formed 
with members drawn from the local makhalla committees, mothers 
and other interested community members. 
o Capacity building activity
Though not stated as a separate strategy, the building of capacity of 
Perzent, the local NGO partner of Counterpart, was planned as 
being interwoven into the project activity. The building up of capacity 
of the MoH, through its Health facilities, was another important 
activity built into the project. 
o Networking and Advocacy/ Collaboration with other 
International organizations 
The Umir Nuri CS program would build upon the excellent relations it 
has with other international organizations working in the area, such 
as USAID’s mission at Tashkent, Institute of Pediatrics, UNICEF, 
WHO, Peace Corps, Medecins sans frontiers (MSF), Red Cross, 
JDA, Project HOPE and others. Many of these organizations had 
expressed a desire to collaborate with the project, and the Umir Nuri 
program would explore these collaborations. It would raise issues of 
common interest with the Ministry of Health and other policy making 
bodies, and strive to improve the health status of the children in the 
selected rayons in Karakalpakstan. 
The CSP commenced its activity with the submission of its Detailed 
Implementation Plan (DIP) in April 2001.
13
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program MTE 
The Mid term Evaluation of the Umir Nuri Child Survival Program 
The Mid term evaluation of the CSP (MTE) was carried out between 
May and July of 2003. Dr Arvind Kasthuri, MD, Professor, Department 
of Community Health, St Johns Medical College, Bangalore, India 
facilitated the evaluation, at the request of Darshana Vyas, Director, 
Counterpart Health Programs. Dr Kasthuri has conducted similar 
studies for other International agencies including the CS programs of 
Counterpart (India and Turkmenistan), PLAN international and Catholic 
Relief Services. The participation of the Director, Counterpart Health 
Programs and of the CSP staff, led by Ramine Behrambegi, the 
program director, was ensured through the process. 
The Objectives of the MTE were 
º To Assess progress of the programs technical interventions in 
relation to its objectives 
º To Study the strategies used by the CSP in its implementation 
º To Identify areas of strength and weakness in the program 
º To Suggest possible directions for the future of the CSP 
It was ensured that the method used was participatory in nature, 
including a blend of quantitative and qualitative approaches. 
Specific methods used included: 
º Review of documents pertaining to the CSP including the DIP, 
Annual reports, Quarterly newsletters, Reports of workshops, training 
programs and Research activity, May – June 2003 
º Site visit to the CSP program site in Karakalpakstan, June 2003 
which included the following activity: 
º A meeting of all stakeholders of the program on the first day, 
when the evaluation was introduced, and their concerns listed 
and discussed. Participants included the program director of the 
Child Survival program in Navoi, Uzbekistan. 
º A series of group discussions and interviews of Key informants 
had at the field 
º A Rapid Knowledge, Practice and Coverage (KPC) survey, for 
which training, implementation and preliminary analysis were 
completed alongside the qualitative data collection process 
(See attachment 1 for site visit schedule, list of persons met and notes 
on methodology) 
º Development and presentation of the report of the MTE, July 2003, 
with the CSP office and the Director-Health programs, Counterpart 
This document constitutes the report of the evaluation.
14
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Diarrheal Disease 
Technical interventions 
A. Control of Diarrheal Disease 
Comparison with Baseline 
KEY INDICATORS (from DIP) 
Indicator Baseline 
(Jan 2001) 
Mid term 
(June 
2003) 
Target 
(Dec 2004) 
Mothers with children under 2 
yrs of age who are able to state 
at least TWO danger signs of 
diarrhea requiring treatment 
32.0 % 87.3 % 65.0 % 
Children under two years of 
age with diarrhea in the past 
two weeks whose mothers 
report that they were treated 
with an acceptable form of ORT
9.1 % 70.4 % 40.0 % 
Mothers with children under 2 
yrs of age who are able to 
correctly describe the 
preparation of ORS and how to 
use it 
42.3 % 84.0 % 60.0 % 
Key Indicators - Diarrheal Disease
32.00%
9.10%
42.30%
87.30%
70.40%
84.00%
65.00%
40.00%
60.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Baseline
Mid Term
Target
Baseline 32.00% 9.10% 42.30%
Mid Term 87.30% 70.40% 84.00%
Target 65.00% 40.00% 60.00%
Knowledge- danger signs Treatment with ORT Correct ORS use
15
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Diarrheal Disease 
OTHER INDICATORS 
Children under two years of 
age with diarrhea in the past 
two weeks whose mothers 
report that they received 
- same or more liquids than 
usual 
- same or more solids / 
semisolids than usual 
0.0 % 
20.0 % 
51.9 % 
53.8 % 
Children under two years of 
age with diarrhea in the past 
two weeks whose mothers 
report that they sought outside 
help from a qualified source 
during their child’s diarrhea 
36.4 % 48.1 % 
Mothers with children under 2 
yrs of age who say that they 
wash their hands with soap at 
all FOUR important times 
3.7 % 15.3 % 
Activity – Control of Diarrheal disease 
Activities of the project with respect to Diarrheal disease control include: 
The development of educational material related to diarrhea including: 
a. CDD training module for CSP and MOH staff, June 2001 
b. Educational posters and flip charts on all interventions including 
diarrhea 
c. For the MOH staff, VHC members, Mothers, breastfeeding support 
groups, and other caretakers, periodically 
d. Handouts on diarrhea with home management and treatment plans 
at Health facilities, May 2002 
e. “Keep your child from Diarrhea” – leaflet for community distribution, 
July 2002 
f. “What every parent should know about Diarrheal Disease” - a 
booklet on Diarrhea for the community in addition to MoH HF 
personnel, available in July 2003 
Training programs on diarrhea, including 
a. CDD training for staff, especially the Village Health workers of the 
CSP, February 2001 
b. CDD training for 143 participants from the MoH, May 2001 
c. Training of trainers for all CSP staff, and for Village Health workers, 
February 2002 
d. Training of trainers for 21 MoH doctors and mid level staff, May 2002 
e. Refresher training on CDD incorporating the IMCI guidelines, for 
CSP staff and Village Health workers, April 2003 
f. Training on use of BCC materials for CDD and counseling 
16
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Diarrheal Disease 
Community level educational activities, including 
a. Training for VHC members by Village Health workers – where 67 
VHC members were trained 
b. House visiting at the aul level and 1 to 1 education on diarrhea 
c. Education for groups at the aul level like Breastfeeding support 
groups, Mothers’ schools and informal groups of mothers
17
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Breastfeeding 
B. Promotion of Breastfeeding 
Comparison with Baseline 
KEY INDICATORS (from DIP) 
Indicator Baseline 
(Jan 2001) 
Mid term 
(June 
2003) 
Target 
(Dec 2004) 
Newborns breastfed within one 
hour of birth 
44.0 % 61.3 % 60.0 % 
Infants under six months who 
are being exclusively breastfed 
28.0 % 70.0 % 50.0 % 
OTHER INDICATORS 
Mothers with children under 2 
yrs of age who say that they 
gave colostrum to the baby 
during the first three days 
97.3 % 96.7 % 
Children 20-23 months of age 
still being breastfed 
58.3 % 64.7 % 
Activity – Promotion of breastfeeding 
Activities of the project with respect to Promotion of breastfeeding 
include: 
The development of material related to breastfeeding including: 
a. Module on “Basics of child care and breastfeeding” for CSP and 
MoH staff, May 2001 
b. Training of trainers handouts for TOT among CSP and MoH staff, 
February 2001 
Key Indicators - Breastfeeding
44.00%
9.10%
61.30%
70.40%
60.00%
40.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Baseline
Mid Term
Target
Baseline 44.00% 9.10%
Mid Term 61.30% 70.40%
Target 60.00% 40.00%
Early Initiation (<1 hr) Exclusive breastfeeding (<6 mo)
18
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Breastfeeding 
c. Educational posters and flip charts on Breastfeeding for all 
stakeholders, from MoH to community, periodic 
d. Leaflet entitled “Breastfeed your child” for use by the community, 
July 2002 
e. Handouts for Breastfeeding support groups with instructions and 
technical information on breastfeeding, August 2002 
f. Handouts on comparison of “old” and “new” messages on 
breastfeeding for community, older persons (decision makers) and 
MoH, August 2002 
g. Handout on “Proper feeding of the child” based on IMCI for CSP 
staff, September 2002 
h. “What every parent should know about Breastfeeding” – booklet on 
Breastfeeding – available in July 2003 
Training programs on breastfeeding, including 
a. Training on Breastfeeding for CSP staff, June 2001 
b. Training of trainers, CSP staff, February 2002 
c. Training of trainers, Village Health workers, February 2002 
d. Training of trainers, 21 MOH doctors and mid level CSP staff, May 
2002 
e. Training on BCC using the Behave framework, June 2002 
f. Training on breastfeeding for 
- 26 Community nurses 
- 9 midwives 
- 2 Feldshers 
- 6 doctors, and 
- 7 CSP workers – July / August 2002 
g. Refresher training on breastfeeding for CSP staff, July 2002 
Community level educational activities, including 
a. Training for VHC members by Village Health workers 
b. House visiting at the aul level and 1 to 1 education on breastfeeding 
c. Education for groups at the aul level like Breastfeeding support 
groups, Mothers’ schools and informal groups of mothers
19
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
Pneumonia Case Management
C. Pneumonia Case Management 
Comparison with Baseline 
KEY INDICATORS (from DIP) 
Indicator Baseline 
(Jan 2001) 
Mid term 
(June 2003) 
Target 
(Dec 2004) 
Mothers with children under 2 
yrs of age who are able to state 
at least TWO danger signs of 
pneumonia requiring treatment 
61.3 % 96.0 % 75.0 % 
Mothers with children under 2 
yrs of age who are able to state 
the two danger signs of rapid 
breathing and chest indrawing 
as signs of pneumonia 
requiring treatment 
0.0 % 47.0 % 25.0 % 
Key Indicators - Pneumonia Case Management
61.3%
9.1%
96.0%
70.4%
75.0%
40.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Baseline
Mid Term
Target
Baseline 61.30% 9.10%
Mid Term 96.00% 70.40%
Target 75.00% 40.00%
Knowledge- danger signs Knowledge - specific signs (rapid breathing/ chest 
indrawing)
20
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
Pneumonia Case Management
OTHER INDICATORS 
Mothers with children under 2 
years of age whose child 
showed signs of ARI in the past 
2 weeks, and who took the 
child to a qualified health care 
provider on the same day 
42.9 % 11.8 % 60.0 % 
Mothers with children under 2 
years of age whose child 
showed signs of ARI in the past 
2 weeks, and who took the 
child to a qualified health care 
provider on the same day OR 
the next day 
67.3 % 41.2 % 
Children under 2 yrs of age 
who showed signs of ARI in the 
past 2 weeks who were taken 
FIRST to a qualified Health 
care provider 
71.4 % 91.0 % 
Mothers with children under 2 
years of age whose child 
showed signs of ARI in the past 
2 weeks, and who took the 
child to a qualified health care 
provider on the same day or 
next day 
67.3 % 41.2 % 
Activity – Control of Acute Respiratory Infections/ Pneumonia 
Activities of the project with respect to Acute Respiratory Infections 
(ARI) including Pneumonia include: 
The development of material related to ARI including: 
a. Module on “ARI/Pneumonia case management” for CSP and MoH 
staff, September 2001 
b. Training of trainers handouts for TOT among CSP and MoH staff, 
February 2001 
c. Educational posters and flip charts on ARI/Pneumonia for all 
stakeholders, from MoH to community, periodic 
d. “What every parent should know about ARI” – booklet on 
ARI/Pneumonia for the Community, VHCs and MoH – January 2003 
Training programs on ARI, including 
a. Training on ARI for CSP staff, October 2001 
b. Training of trainers, CSP staff, February 2002 
c. Training of trainers, Village Health workers, February 2002
21
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
d. Training of trainers, 21 MOH doctors, and mid level CSP staff, May 
2002 
e. Refresher training on ARI incorporating IMCI guidelines for CSP 
staff, October 2002 
Community level educational activities, including 
a. Training for VHC members by Village Health workers 
b. House visiting at the aul level and 1 to 1 education on breastfeeding 
c. Education for groups at the aul level like Breastfeeding support 
groups, Mothers’ schools and informal groups of mothers 
Conclusions 
 
1. Program effectiveness in terms of interventions 
Although information on incidence of disease and mortality in the 
population was not collected during the Mid term evaluation, the key 
indicators in the KPC survey would appear to indicate that there has 
been considerable progress made in the area of technical 
interventions. 
ALL indicators related to Control of Diarrheal disease have improved 
since baseline, and are currently estimated at levels beyond program 
targets. 
ALL indicators related to Promotion of breastfeeding have improved 
since baseline except the proportion of mothers with children under 2 
yrs of age who state they gave colostrum to their baby during the first 
three days of life, which remains stable at its pre existing high level. 
Levels of Key indicators are currently estimated at levels beyond 
program targets. 
The indicators of KNOWLEDGE of mothers regarding signs of ARI 
show improvement over baseline levels. 
However, the indicators of PRACTICE which measure the proportion 
of mothers taking their child for treatment immediately (on the same 
day) are lower than baseline levels. This could be because 
a. Children with Acute Upper Respiratory Infection can be managed 
at home, which is a message in the BCC related to ARI. The KPC 
indicator referred to above measures practice of mothers whose 
child had ANY kind of ARI, not necessarily Acute Lower 
Respiratory infections. If messages have been effective, the 
indicator may actually be reflective of a greater proportion of 
22
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
mothers who take care of their mildly sick child at home, saving 
resources for the care of severely ill children. 
A study could be done among mothers in the project area to 
probe this issue and find out the reason for a low proportion of 
mothers taking their child who shows symptoms of ARI to a 
doctor on the same day. 
b. The KPC survey was carried out in summer, when the incidence 
of ARI is low. The denominator for the indicator is 17, which is an 
extremely low number. Conclusions drawn based on this number 
must therefore be viewed with caution. 
2. Capacity of Health Facilities with respect to Technical 
Interventions – CDD, Pneumonia and breastfeeding 
The MOH Republican Health System (RHS) is the main health care 
provider in the rural areas, encompassing the 15 rayons in 
Karakalpakstan. When needed, patients are referred to specialized 
hospitals and dispensaries in Nukus City. The RHS provides patient 
care through 3 Republican hospitals, 3 city hospitals, 15 central 
rayon hospitals, 42 polyclinics, 30 SUBs, 68 SVAs, 55 SVPs and 388 
FAPs (explained below). The hospitals include rayon hospitals, 
SUBs, Republican hospitals and specialized hospitals. There are 
3,930 doctors and 15,245 middle medical employees providing 
medical care in the RHS. There are 26.1 doctors and 101.1 midlevel 
medical personnel for every 10,000 people in Karakalpakstan. 
 
The following diagram illustrates the difference between the existing 
rayon health system and the new rayon health system under health 
reform. 
Existing Rayon Health System. 
 
LEVEL I LEVEL II LEVEL III 
The older rural health care system is still in place, with feldshers 
(doctors’ assistants) at FAPs as the first contact point (Level I). The 
second level consists of SVP/SVA/SUB (Level II). The health reform 
initiative supported by the World Bank and USAID is planning to 
replace most FAPs, SVAs and SUBs with SVPs as the primary 
health care center. However, it is expected that some level I FAPs 
will remain in most rural areas of Karakalpakstan. Some rayons will 
FAP 
Doctor’s Assistant 
Midwife 
SVP 
SVA 
SUB 
Doctor
Polyclinic 
Rayon Hospital 
Specialist 
23
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
also operate TB dispensaries and infection hospitals. Below is the 
outline of the new system. 
New Rayon Health System Under Health Reform 
The qualitative data collected from staff at Health Facilities, from 
Village Health Committee leaders and from Mothers would appear to 
indicate that the Health facility staff are currently better equipped to 
deal with children with Diarrhea and Pneumonia. The concepts of the 
staff at the facilities regarding breastfeeding have also undergone 
updating and revision. 
Specific areas of increased capacity include: 
a. Updated knowledge on the technical aspects of the interventions, 
incorporating recent approaches like the IMCI. 
b. The availability and use of educational material at the Health 
facility 
c. Increased capacity as trainers, following the training of trainers 
programs of the CSP. 
d. An increase in confidence of the staff at the facilities, based upon 
their rapport with the community, in those areas where the Health 
facility personnel have a good rapport with the community, by 
being VHC members, for example. 
e. The enhancement of the effectiveness of house visits made by 
health facility personnel. In the words of a VHC member …” 
earlier, they were just filling forms, now they talk to us and 
educate mothers…” 
The Umir Nuri CSP is in the process of conducting a formal Health 
Facility assessment. The documentation of this will provide more 
insight on this issue. 
3. Key Behavior change – findings from qualitative study 
The following were some of the changes in behavior which were 
cited by the various members of the community / Health facility 
personnel 
a. Early referral of children showing danger signs of diarrhea 
b. Use of ORS/ORT in preference to antibiotics or other home 
remedies, like rubbing ash on the abdomen, or giving tea to 
children with diarrhea. 
 SVP 
RAYON 
POLYCLINIC 
RAYON 
HOSPITAL
24
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
c. Initiation of breastfeeding, even when mother is at Maternity 
home 
d. Taking children who show signs of severe ARI for treatment 
4. ARI Practice 
The ARI Practice indicator which measures practice of mothers 
regarding seeking treatment early when their children show signs of 
ARI is estimated at lower levels than baseline. However, the 
indicators of knowledge regarding the danger signs of ARI are 
estimated at higher levels than baseline. 
Recommendations 
 
1. ARI Practice 
Quick research aimed at eliciting the reason for the low level of 
practice relating to taking a symptomatic child immediately for 
treatment, by meeting groups of mothers and other key individuals 
can provide clues as to the reasons behind this. An appropriate 
strategy can then be planned to improve the indicator 
2. Revision of targets 
The targets for indicators of knowledge and practice related to the 
interventions indicated in the DIP must be appropriately revised
since most current estimates exceed target levels. This needs to be 
done as a joint exercise between the partners, including the inputs of 
field level staff. 
3. ORS Corners 
ORS corners at Health facilities are popular with Health workers and 
Village Health workers. These could be promoted to a greater extent, 
since the Health facility personnel appear to be comfortable with the 
concept of ORS corner, have the time and the knowledge to educate 
mothers and provide them with the right messages, at the ORS 
corner. 
4. Messages – feeding during diarrhea 
The messages relating to continued feeding, continued 
administration of liquids, and the feeding of children recovering from 
diarrhea could be emphasized since the indicators of these practices 
show that about half the mothers whose children had diarrhea in the 
2 weeks preceding survey did not practice the same. 
5. Handwashing practice 
The estimated level of the indicator of appropriate handwashing 
practice is still low (15.3%), even if it is higher than baseline (3.7%). 
The project needs to emphasize the prevention of diarrhea in its 
25
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
messages related to diarrhea management. With the high literacy 
level, it should be possible for mothers to read posters, leaflets and 
other material on hygiene. The Poster on hygiene is a good step in 
this direction – it needs to be built upon. 
6. Breastfeeding practice 
The indicators of early initiation of breastfeeding and exclusive 
breastfeeding practice show that there are still mothers who do not 
practice these key interventions. The program has emphasized the 
importance of correct breastfeeding practice, but needs to do more 
to ensure that ALL mothers practice these behaviors. 
Since the place of delivery is usually the maternity home, intensive 
training and support could be provided to staff at maternity homes, 
specifically on early initiation of breastfeeding. 
7. Breastfeeding support groups 
The Breastfeeding support group initiative was not a part of the 
Umir Nuri CSP’s DIP. The experience of the CS program at Navoi, 
coupled with the Community’s response to the BCC on breastfeeding 
encouraged the establishment of the BFSGs. There are currently 6 
breastfeeding support groups, 3 at each rayon. These could be 
promoted further, and extended to cover a wider area. Some 
members of BFSGs are potential trainers themselves and could be 
included in training of trainers’ programs planned for the future.
26
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Community Mobilization 
Cross cutting interventions 
The important cross cutting interventions of the Umir Nuri program 
include: 
A. Community Mobilization 
B. Behavior Change Communication 
C. Organizational capacity 
D. Networking and collaboration with other organizations 
Community Mobilization 
The formation of community-based organizations by NGOs is a 
relatively new concept in Karakalpakstan. 
The Intent behind mobilizing the community was 
o to serve as an entry point into the community 
o to elicit the participation of the community, so that the community is 
able to identify their needs and act upon them 
o to enhance the effectiveness of project staff, by making them part of 
a community program, rather than an NGO program 
o to enhance capacity of the community based organizations to 
independently establish an identity and attract resources 
o build a solid resource base of knowledge and skills to sustain 
benefits of the program 
The Community based organizations, which were formed as part of the 
CSP included the following: 
Aul (Village) level 
a. Village Health committee (VHCs) 
b. Breastfeeding support group 
c. School of Mothers 
Rayon level 
d. Child survival Co ordination committee (CSCC) 
a. Village Health committees 
Village Health committees are informal organizations of about 10-20 
members. There are 18 VHCs in the CSP till this point in time, against a 
target of 20 for the mid term and 40 for the end of the program. 
VHC members are enthusiastic members of the community, who have 
expressed interest in assisting the cause of Child survival. The 
members are generally motivated by the feeling that they are 
contributing to the cause of their own community and their own children. 
27
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Community Mobilization 
The members are usually 
o Active mothers, that is, mothers who are interested and able to 
spend time on educating and motivating others in their own 
communities 
o Local Makhalla leaders 
o Health facility personnel – doctors, nurses 
o Teachers 
o Religious heads – Mullahs 
o Traditional healers (some committees) 
VHCs have been trained by the CSP. Specific areas of training include 
the following: 
o Behavior change communication regarding the project interventions 
o Training on developing project proposals as part of the Community 
Grants program of the Counterpart Consortium. 
o Training on Interpersonal Communication, and 
o Training on Conflict resolution, which were facilitated by the Civil 
society program Division of Counterpart. 
o HIV/ AIDS – an orientation 
VHCs meet once every month. Their activity includes: 
o Discussing activity regarding the CS program 
o Educating mothers and other caretakers at social occasions 
o Representing issues of interest to the CS program at the Hakimiyat 
o Getting groups together for community based activity like group 
health education 
b. Breastfeeding support groups 
Breastfeeding support groups (BFSGs) were formed in 2002 based on 
the experience and sharing of information from the CS project at Navoi. 
They usually comprise 4-6 women, who are active in the communities 
and who have the interest and ability to communicate key breastfeeding 
messages to the young mothers in their community. 
There are 6 BFSGs at this time, 3 in Nukus Rayon, and 3 in Takhtakupir 
rayon. 
c. School of Mothers 
The schools of mothers is an idea based on the discussions had with 
members of Village Health committees, where it was suggested that the 
active women in the community including older women like the mothers 
in law could be involved in propagating messages related to Child 
survival. 
28
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
There are 2 schools of mothers established in Nukus rayon, none as yet 
in Takhtakupir rayon. 
d. Child Survival Co ordination committee 
The Child Survival Co ordination committee (CSCC) is a rayon-level 
organization comprised of the following members: 
o Deputy Hakim, Women’s Issues 
o Chief Doctor, Rayon 
o Chief Pediatrician 
o Chief of the Sanitation / Epidemiologic department 
o Chief of Pharmacy 
o Head of the Education department 
o Makhalla committee leaders 
o Persons from the media 
The CSCC used to meet monthly but currently meets quarterly to 
discuss the issues concerning the CSP. Since many top level officials 
are members, problems faced at field level, when brought to the notice 
of the CSCC, can actually be solved. 
Problems discussed at the CSCC are not necessarily related to Child 
Health alone. Discussions surrounding livelihood issues and 
infrastructure including basic amenities like gas, water and electricity 
are also discussed. 
The Children Defence Day 2003 was celebrated by the CSP on June 1st
2003, with great pomp and gusto. The CSCCs were involved with the 
organization of the celebrations surrounding this event. 
Conclusions 
1. Role of Village Health Committees 
The VHCs represent an attempt at empowerment, and this seems to 
be in evidence as the 18 VHCs of the CSP prepare to play a larger 
role in their communities. One VHC member said “..The program is 
causing a Health revolution, akin to the great October revolution…” 
The members seem to have understood the role which organizations 
like theirs can play in their communities, and appear to be willing to 
take on the responsibility. VHC members approach the Hakimiyat on 
their own for clarification regarding issues concerning the program. 
2. Community Participation 
Community Participation is one of the Key principles of Primary Health 
Care, and the CSP, through its Community mobilization strategy has 
ensured that the community is not a passive recipient of health messages 
29
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
which are handed out impersonally, but is an active participant in the 
process 
3. Role of CSCCs 
The CSCC appears to be successfully playing the role of a rayon￾level supervisory/advisory body. The Deputy Hakim, Women’s issues 
at Nukus Rayon felt that the monthly meeting of the CSCC has now 
been made quarterly, because “…. The VHCs are now doing their 
job at the aul/makhalla level…” and the need for a monthly meeting 
had reduced. 
Recommendations 
1. Inactive VHCs 
It has been reported that there are some VHCs which are not as 
active as others. The CSP should focus on these poor performers 
and find out the reasons for poor performance. Attention should be 
focused on them, in order to build them up to the level of the better 
performing committees. 
2. VHCs – target number 
The target for the end of the project is 40 VHCs. In order to ensure 
quality, it may perhaps be better to identify those areas where 
committed persons are willing to work for their own communities, and 
facilitate formation of VHCs in such areas, even if the total number is 
less than 40. 
3. Traditional healers and religious heads 
Traditional healers and mullahs (religious heads) play an important 
role in some communities. While some VHCs have incorporated 
these individuals in their membership, others have not. It would be 
useful to identify all traditional healers in the area, and ensure that 
they are reached with the messages of the CSP. This could be done 
by 
- organizing a training program for traditional healers on key 
messages and try to get them involved in BCC 
- encouraging their membership at VHCs so that they may be reached 
through the VHC 
4. Breastfeeding support groups and School of Mothers 
The Breastfeeding support groups and the School of Mothers are 
useful initiatives. If they grow to the level of community based 
women’s groups, who are not just involved with health, but also 
social and economic developmental activity like small savings and 
home based income-generating activity like tailoring, they could be 
powerful instruments of social change. 
30
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
A group of women which meets regularly, saves money, and is 
involved with acquisition of skills among its members which will 
increase their income, is a group which can sustain itself. It can also 
serve as an entry point into the community for messages directed at 
child health, and reproductive health. 
The CSP can consider the formation of such groups. 
31
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program BCC 
Behavior Change Communication 
The Behavior Change Communication (BCC) strategy of the CSP is 
based upon the BEHAVE framework. A five-day BCC training was 
conducted by the Director, Health Programs based on this framework. 
Key personnel from the India CS program were invited to share their 
experiences with the Umir Nuri staff, and this resulted in learning from 
experiences, which added to the effectiveness of the BCC strategy. 
The basic tenets of the BCC strategy of the Umir Nuri CSP are: 
a. Technically Updated Messages 
b. Appropriate BCC materials 
c. Innovative BCC strategies 
a. BCC Messages 
The Key messages of the CSP relating to the program interventions are 
as follows: 
i. At the level of the MOTHER 
Diarrheal disease 
º Diarrhea defined as the passage of 3 or more loose stools in a 24 
hour period 
º Diarrhea can cause dehydration in a child, which can lead to death of 
the child 
º The signs of dehydration in a child 
º The child must receive increased fluids during an episode of 
diarrhea, the nature of which can be any of the accepted forms of 
ORT 
º The child must continue to receive solid, semi solid and liquid food 
during diarrhea, and during recovery from diarrhea 
º The child must be taken to a qualified health care provider when the 
child shows signs of dehydration 
Acute Respiratory Infection/ Pneumonia 
º The symptoms of respiratory infection in a child 
º The danger signs of respiratory infection in a child 
º Home care when the child has no pneumonia 
º The child must be taken to a qualified health care provider on the 
same day that the child shows danger signs of respiratory infection 
Breastfeeding 
º Breastfeeding must be initiated early, in the first hour of birth 
º Pre lacteal feeds must be avoided 
º Rooming-in of mother and baby 
º Exclusive breastfeeding for 6 months 
º Breastfeeding on demand 
º Introduction of complementary feeds at 6 months of age 
32
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program BCC 
º Persist with breastfeeding till the age of 2 years 
ii. At the level of the HEALTH FACILITY 
Diarrheal disease 
º Manage diarrhea using standard protocol 
º Acquire training in SCM of diarrheal disease 
º Supervise workers on the SCM of children with diarrhea 
Acute Respiratory Infection / Pneumonia 
º Manage ARI/Pneumonia using standard protocol 
º Check the respiratory rate of children with cough/ difficult breathing 
º Supervise workers on the SCM of children with ARI/Pneumonia 
º Check stocks of Co-trimoxazole periodically 
b. BCC Materials 
The steps involved in the preparation of BCC materials produced by the 
Umir Nuri CSP were 
- development of the material based on technical inputs 
- translation and back translation to ensure correctness 
- extensive pretesting , by involving the personnel from the MoH in the 
Health facilities, community members and Makhalla leaders. This 
ensured that they were culturally appropriate and therefore, effective. 
- Finalization , production and distribution 
The BCC materials produced by the CSP are as follows: 
Diarrheal disease 
º Educational posters and flip charts on all interventions including 
diarrhea 
for the MOH staff, VHC members, Mothers, breastfeeding support 
groups, and other caretakers, periodically 
º Handouts on diarrhea with home management and treatment plans 
at Health facilities, May 2002 
º “Keep your child from Diarrhea” – leaflet for community distribution, 
July 2002 
º “What every parent should know about Diarrhea” a booklet on 
Diarrhea for the members of VHCs, and the community in addition to 
MoH HF personnel, available in July 2003 
Acute Respiratory Infection/ Pneumonia 
º Training of trainers handouts for TOT among CSP and MoH staff, 
February 2001 
º Educational posters and flip charts on ARI/Pneumonia for all 
stakeholders, from MoH to community, periodic 
º “What every parent should know about ARI” – booklet on 
ARI/Pneumonia for the Community, VHCs and MoH – January 2003 
33
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
Breastfeeding 
º Training of trainers handouts for TOT among CSP and MoH staff, 
February 2001 
º Educational posters and flip charts on Breastfeeding for all 
stakeholders, from MoH to community, periodic 
º Leaflet entitled “Breastfeed your child” for use by the community, 
July 2002 
º Handouts for Breastfeeding support groups with instructions and 
technical information on breastfeeding, August 2002 
º Handouts on comparison of “old” and “new” messages on 
breastfeeding for community, older persons (decision makers) and 
MoH, August 2002 
º Handout on “Proper feeding of the child” based on IMCI for CSP 
staff, September 2002 
º “What every parent should know about breastfeeding” – booklet on 
Breastfeeding – under preparation, to be ready by September 2003
c. BCC methods 
The methods used to inculcate behavior change in the community 
include the following: 
º One- to – one education during household visits where the mother is 
individually met and educated 
º Group education sessions 
º Use of flip charts 
º Use of Video/ films 
º Distribution of leaflets and booklets and follow up 
º Innovations like puppet shows, which have been recently introduced 
at the community level and enthusiastically received 
Conclusions 
1. BCC strategy 
The Behavior change communication strategy of the CSP appears to 
have conveyed key messages to mothers in the area, as evidenced 
by the increase in estimated levels of key indicators of knowledge 
and practice. Of particular interest is the fact that the estimated 
levels of indicators measuring knowledge of HIV/AIDS, which is not a 
program intervention, have remained stationary since baseline, while 
those measuring the program indicators have changed. 
Behavior change is difficult to achieve, and the KPC results show 
that the program has indeed accomplished much in a relatively short 
time of 2-1/2 years. The Village Health worker, armed with flip charts 
and posters, has done very well in communicating the BCC 
messages using appropriate methods, and at appropriate venues. . 
34
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
2. Ethnic groups 
The presence of different ethnic groups within the population, 
speaking different dialects of Uzbek, Karakalpak, Russian and 
Kazhakh languages presents a challenge to the communicators of 
the CSP who have to use the appropriate language when necessary. 
3. Translation 
The preparation of materials involves their translation into 
Karakalpak and Russian from English and back translation to check 
for accuracy. The official stance in Uzbekistan is to promote the 
Uzbek language, which is not very widely spoken in the program 
rayons. The CSP, however, has translated most of the BCC 
materials into Karakalpak, and this would represent the correct 
decision in the circumstances. The CSP has also translated IMCI 
guidelines into Karakalpak for use by the MoH. 
The translation of BCC materials into the local language has been a 
major accomplishment of the program. This has resulted in wide 
dissemination of the messages which they contain, and in the 
enhancement of the visibility of the program. 
4. Innovative approaches 
Other innovative approaches suggested towards behavior change 
are 
- Competitions for mothers based on Key Child survival interventions 
- Street plays and puppet shows. These methods were learned by 
the CSP team following an exposure visit to and exchange of 
information between the CS projects of Counterpart at Ahmedabad, 
India and the CSP. 
A puppet show was staged at the Children’s day celebration on June 
1st 2003, and despite reservations as to its cultural acceptance, was 
well received. The CSP plans to use this method to a larger extent in 
its BCC strategy. 
Recommendations 
1. BCC material preparation 
The production of BCC materials by the CSP, as mentioned above, 
can be rated as one of its most major accomplishments, and the 
BCC strategy as being successful. Each step in preparation of BCC 
materials, from the stage of conception of a message, to developing 
a draft form, pretesting it with the community, and finalizing it, has 
been given the importance it deserves by the CSP. The production 
of materials – design and printing – is not an easy task in 
Karakalpakstan, and the CSP has done well in this regard. 
35
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
There has been delay however, in the case of certain materials, and 
such delays must be avoided in future. 
2. BCC Messages 
One of the issues repeatedly encountered during discussions at the 
community level was that messages must be simple and easy to 
understand by mothers, without sounding too technical, if they had to 
be effective. The messages given by workers at Health Facilities in 
the past were cited as examples of complicated messages, while the 
messages given by the CSP were simple and straightforward, in the 
language that mothers would understand. Leaflets and booklets were 
accepted very well in the community, and mothers pointed to the 
simplicity of the language used as a major reason for such 
enthusiastic acceptance. 
The messages of the CSP must continue to retain their simplicity 
while not compromising on technical content. This presents a 
challenge to a communicator. 
5. BCC Methods 
The methods most preferred by most members of the community 
who were met as part of the MTE were dynamic visual media like 
Video, Television and Film. The CSP could explore the possibility of 
º creating educational video films based on local culture, with the 
key messages built in 
º Creating television spots, which could be aired at appropriate 
times, to ensure maximal viewing by members of the target group 
º Even leaflets and booklets must have an increased visual rather 
than textual content in order to be more attractive and appealing. 
Other methods which were perceived as being useful were: 
º Models, especially the breast model which was used to 
demonstrate correct breastfeeding technique 
º Booklets, which were received enthusiastically by the community. 
Since literacy levels in the population are very high (above 90%), 
written material is well received and utilized. 
The leaflets were received with a mixed response, with some saying 
that they were not so useful, and tended to be used as paper 
containers. Even so, they were on display at almost all the facilities 
visited as part of the evaluation. 
6. BCC to special groups 
BCC could be directed towards traditional healers, which is an 
important group in the context of the CSP. While it is good to involve 
36
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
them as part of the Community Mobilization strategy by facilitating 
their membership at VHCs, BCC could also be designed and 
directed towards this important group. 
The other groups which could be focused upon in the BCC strategy 
are those who are decision makers in child health issues: These 
include 
- Mothers-in-law and other older women 
- Fathers and other men 
The CSP has succeeded in making contacts with these groups. 
These are not easy groups to reach and communicate with, but 
considering the rapport the VHWs of the CSP enjoy at the 
community level, it could be tried at this stage in the project. 
7. Reinforcement and Follow-up 
For communication in terms of distributed materials to be effective, it 
must be followed up by interaction and reinforcement. The VHWs of 
the CSP have been reinforcing and interacting with the community at 
every stage, and this is what probably sets them apart from the 
workers at the health facilities, who were perceived as distributing 
materials in a more passive manner. This strength of the CSP is an 
important one, and must be carried forward to the next stage. 
The challenge is to be able to get the members of VHCs and the 
health workers of the MoH to adopt this approach, since it is they 
who will be there when the project comes to an end. Attempts must 
be made to inculcate this value into the workers of the Health 
facilities and to the members of the VHCs.
36
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
Organizational Capacity 
An important goal of the CSP is to build the capacity of the organization 
Perzent so as to enable it to plan, implement and evaluate Child survival 
programs of a similar nature. 
The CSP was initiated as a partnership between Counterpart, Centre 
Perzent and the Ministry of Health in Karakalpakstan. The partnership 
was founded firmly on a written Memorandum of Understanding (MoU), 
which is a unique and important document. The staff of the CSP are 
appointed by Counterpart and Perzent. Capacity has been built into the 
CSP at all levels, from the management and staff of Counterpart, to the 
staff of the CSP from Perzent and the health facility personnel of the 
MoH. Training inputs given to these personnel and to the community 
has played an important role in this building of capacity. 
A. The Partnership 
Counterpart envisages partnership as its core strategy in development. 
In areas where it operates, a suitable partner is identified and capacity 
of the partner is built up ensuring the sustainability of the program. 
The search for a partner was initiated in the Karakalpak area when 
Counterpart identified Uzbekistan as a potential base for a Child survival 
program based on need. The Ministry of Health suggested that the 
program be based in Karakalpakstan, and a suitable partner was 
required, in addition to the Ministry of Health in Karakalpakstan. 
Following a process of shortlisting, and application of the Organizational 
assessment and Technical Training and Assessment Plan tool of 
Counterpart, Centre Perzent was identified as the partner NGO. All the 
partners were involved intensively from the stage of planning through 
implementation and evaluation. 
A formal Memorandum of Understanding (MoU) was signed by all three 
partners prior to the launch of the program. 
B. The Staff of the CSP 
Recruitment of the staff of the CSP was not easy, considering that the 
organization was looking for 
º Ability to speak/understand English, at least at the Office level. 
º Technical competence in the area of child survival 
Potential staff were located by contacting other NGOs in the region, 
through advertisements in the local regional resource center, and by 
word of mouth. 
37
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
The program has had changes in leadership since inception, with 
turnover being an issue. The first Program Director who headed the 
program was Dr Nizam Uddin Ahmed, a physician with experience in 
program management. In September 2001, ten months after the 
inception of the program, Dr Nizam Uddin Ahmed left the organization. 
Dr Roland Abdullo, who was the Program manager managed the 
program, when he left to join the WHO. Ms Kshama Singh from India, 
who was involved with the management of a similar CS program, was 
then appointed temporarily to manage the project for a period of two 
months, as technical advisor. 
Meanwhile, Counterpart Headquarters was looking for suitable persons 
to head the program. Two persons who were shortlisted declined the 
position following the events surrounding the 9th of September 2001 
citing security reasons. Dr Nuriyah Elgondieva, who was initially 
recruited at program inception as Field officer was later promoted to 
BCC specialist. Following training on program management and 
finance, she was asked to take on the role of Project Manager which 
she did, till she left the program in September 2002, to join a position 
with the WHO. Dr Nuriyah returned to the CSP in December 2002, but 
tragically died on Jan 1, 2003. Her death created a void in the program, 
considering that a lot had been done in training her as a program 
manager. 
During this period, Darshana Vyas, the Director, Health Programs at 
Counterpart Headquarters in Washington who manages the Health and 
Child Survival program at its HQ level, visited the program periodically 
and gave constant support and guidance. 
Ramine Behrambegi, the current Program Director joined the program 
in September 2002, and has been guiding its progress since then. 
While the project leadership has witnessed some turnover, the program 
staff and Village Health workers have remained relatively stable. 
The staff of the CSP at the time of the MTE are as follows: 
Name Month/ Year of 
joining 
Designation 
Ramine Behrambegi September 2002 Program Director 
Lilya Kim September 2001 Finance and Administrative 
manager 
Azamat Matkarimov March 2001 Health Communication specialist 
Sagitjan Aitjanov November 2001 Health Information co ordinator 
Nina Nizamatdinova April 2002 Acting Program Manager 
38
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
Name Month/ Year of 
joining 
Designation 
Yulia 
Miroshnichenko 
December 2000 Communication officer/ 
Translator 
Bairam Kamalov January 2001 Driver / Logistics assistant 
Sara Utegenova October 2002 Senior Health Education 
specialist/Trainer 
Gulnara Karabaeva February 2001 Field Officer 
Mirigul Eshmuratova August 2001 Field Officer 
Guljakhan 
Allambergenova 
 Village Health Worker 
Zulfia Baimuratova February 2001 Village Health Worker 
Kurbangul Omarova February 2001 Village Health Worker 
Makhsud Isakov January 2003 Administrative assistant/ 
secretary 
Vasilisa Rotalskaya June 2003 Administrative assistant / 
receptionist 
Kizlargul Esbolova August 2001 Cleaner / Cook 
Rufat Seitimbetov August 2001 Guard 
Jalgas Kalbaev May 2002 Guard 
John Brown April 2003 Senior Technical Advisor 
 
C. Training 
Training has been a major input of the CSP. The organization has 
identified and utilized the services of trainers from a variety of sources, 
including the MoH, other NGOs and the international community. 
The target audience for training includes: 
º The Program staff 
º The field staff, including Field Officers and VHWs 
º Community based organizations like VHCs and BFSGs 
º Active mothers in the community 
º Health workers and Personnel of the Ministry of Health 
The design of training programs of the CSP are based on assessment 
of need, by the trainers in the program, especially the senior Health 
Education specialist. In the case of training for field staff, the actual 
observation of VHWs performance is also used as an input. VHWs are 
also formally evaluated by the Health education specialist to find areas 
of weakness and need. 
The training programs conducted by the CSP include the following: 
Training Program Month/ Year Audience 
KPC baseline survey training January 2001 CSP staff, interviewers 
CDD training February 2001 Village Health Workers 
39
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
Training Program Month/ Year Audience 
HFA survey Training February 2001 CSP staff, interviewers 
Training on Counterpart 
Administrative policy/ 
procedures 
March 2001 CSP staff 
CDD training May 2001 MoH staff – 143 
participants 
Promotion of Breastfeeding June 2001 CSP Staff 
Training on formation of VHCs June 2001 CSP Staff` 
ARI training October 2001 CSP Staff 
Training of Trainers (TOT) February 2002 CSP Staff 
Training of Trainers (TOT) February 2002 Village Health workers 
Training on BCC framework April 2002 CSP staff 
Training of Trainers (TOT) May 2002 21 MoH Doctors and 
mid level staff 
Promotion of breastfeeding July – August 
2002 
26 Community Nurses, 
9 midwives, 2 
Feldshers, 6 doctors 
and 7CSPworkers 
Refresher training on 
breastfeeding 
July 2002 CSP staff 
Refresher training on ARI 
incorporating IMCI guidelines 
October 2002 CSP staff 
Refresher training on Diarrhea 
incorporating IMCI guidelines 
April 2003 CSP Staff 
Willingness to pay training February 2003 CSP staff 
KPC Mid Term survey training June 2003 CSP Staff, Interviewers 
Additional inputs in training include the following: 
º Exposure / learning visits to other countries, for example, staff were 
sent to a training program in Cambodia to acquire skills on Behavior 
Change Communication in January 2003 
º The Program Director, Financial Officer and Acting Program 
Manager visited the Jeevan Daan CS program in India to acquire 
knowledge and skills and to share lessons learned on program and 
intervention related issues in April 2003 
º The Finance Officer attended a Financial training program at the 
Counterpart regional office at Almaty, Kazhakstan in July 2001 
º Staff are encouraged to attend local conferences, for example the Co 
ordination meeting on the projects of USAID Tashkent at Charvak in 
June 2003 
º There have been exchange visits of staff working in Counterpart￾supported programs between India and Karakalpakstan, and 
between Turkmenistan and Karakalpakstan The program staff of the 
CS program of Counterpart in India visited the Umir Nuri CSP and 
attended a BCC training session organized by the Director, Health 
40
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
Programs. Also, the India CS program MIS specialist organized a 
five-day HMIS training with the assistance of the Director Health 
Programs for the Umir Nuri CSP team. 
The staff of the CSP provide training to NGOs and others on request 
upon topics in which they have gained expertise, like BCC and Epi Info 
The monthly meetings of staff of the CSP serve as training opportunities 
in addition to being monitoring exercises. In-house training is provided 
to staff in response to needs , either perceived by the program staff, or 
articulated by the field staff. 
D. Monitoring and HMIS 
The mechanisms for monitoring program performance which have been 
built into the program are as follows: 
º The Monthly meeting of all staff which takes place in the last week of 
every month. The monthly meeting is a time to review performance 
of the past month and plan for the month ahead. An agenda is 
prepared for this meeting by the Program director, and is chaired by 
him. Field offices present their reports of activity and the same is 
discussed. 
º Weekly review at the Field offices 
There are two field offices for the CSP, one at Nukus Rayon and one 
at Takhtakupir rayon. Two field officers look after each of these 
offices, and they conduct weekly meetings at the Field offices with 
the VHWs of their rayon. 
º Weekly meet of Field Officers with office staff. 
Each week, the field officers of Nukus and Takhtakupir rayons meet 
with the staff at the CSP office and present their field reports. 
The data gathered periodically as part of program monitoring includes 
the following information, collected as part of the Health Management 
Information System (HMIS) of the CSP. 
º Community Status information, which refers to mothers’ knowledge 
and practice of key behavior regarding the 3 interventions. 
º Health Facility data – pertaining to the health facility, collected at the 
Health facilities of the MoH. The data is collected regarding staff at 
the facility, equipment, stores and space available, sick child 
management, and the physical aspects of the facility. 
º Selected CS indicators from MOH reporting formats –demographic, 
mortality-related and morbidity-related data including information on 
equipment and supplies. This is often not complete, and does not 
41
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
necessarily match the information collected by the program workers. 
An example is the information pertaining to diarrheal cases. The 
definition of diarrhea according to the government includes a stool 
sample, which must have a positive test result for a pathogen. The 
program defines diarrhea clinically, based on the occurrence of 
stools of altered consistency. Hence the number of cases of diarrhea 
in a given population as reported by the VHW and the health Facility 
varies. 
Rapid assessments of health status and its determinants like caretaker 
knowledge and behavior have also been done using tools developed 
indigenously. Rapid assessments have been done in March 2002, 
August 2002 and May 2003 and they focus on the following aspects: 
º Mothers Knowledge/ Practice 
º Health Facility assessment 
º Epidemiologic data analysis 
The reports sent to Counterpart headquarters include: 
º Monthly financial reports 
º Quarterly progress reports and 
º An annual report each year. 
º Periodic newsletters are also prepared, giving highlights of the 
program and important events concerning it. 
Feedback is provided by the Director, Health Programs, Counterpart HQ 
periodically. 
Documentation of the CSP processes and activities is evidenced by 
the reports and documents generated by the program since its 
inception. The following key documents were available during the MTE 
- Baseline assessment reports 
- The KPC survey , Jan 2001 
- The HFA report, March 2001 
- The Detailed implementation plan 
- Training reports 
- HMIS reports 
- Quarterly Newsletters and reports 
- Reports of studies done, including a brief write-up on the Wtp survey 
The website of the program (http://cspnukus.freenet.uz) is under 
construction, and is expected to be updated regularly in the fall of 2003. 
E. Finance 
The system of finances at the CSP is as follows: 
42
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
º Funds are received from Counterpart Headquarters by the 
Counterpart Consortium office at Tashkent 
º Funds are transferred physically to the Nukus office from Tashkent 
every quarter, and are utilized as program expenses 
º Financial reports are sent monthly to Counterpart headquarters 
Training was received by the current financial and administrative 
manager, as an orientation and exposure to the finances and system at 
the CS project at Ahmedabad India, and as formal training at the USAID 
mission at Almaty. Training was also given to the finance and 
administrative manager at Perzent, which has helped in clarifying 
financial aspects of the partnership. All training was given in accordance 
with the procedures and methods recommended by USAID and 
Counterpart International. 
F. Special Research studies 
The following studies have been planned/ executed by the CSP since its 
inception: 
º Baseline assessments 
A. KPC survey, which was done to assess baseline levels of 
knowledge, practice and coverage of Key Program interventions 
among caretakers of children under two years of age in the 
program area in January 2001. 
B. Health Facility assessment survey, which was done to assess 
baseline levels of infrastructure and practice at Health facilities in 
the program area 
º Periodic rapid assessments 
Rapid assessments have been done in March 2002, August 2002 
and May 2003 and they focus on the following aspects: 
º Mothers Knowledge/ Practice 
º Health Facility assessment 
º Epidemiologic data analysis 
º Willingness-to-pay Survey 
The CSP has developed survey questionnaires to assess purchase 
practices and to determine the willingness of residents to pay for 
medicines. This study was done in February 2003 with technical 
expertise from the Research Triangle Institute (RTI), aimed at giving 
shape and direction to the establishment of Village Pharmacies in 
the CSP areas. 
Information about existing pharmacies, needs of population and their 
“willingness to pay” for select pharmaceuticals such as oral 
43
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Organizational Capacity 
rehydration salts, cotrimoxazole, ampicillin, penicillin, amoxicillin, and 
other drugs from WHO’s essential drugs list were compiled. 
Additional recommendations from health authorities, local clinics and 
pharmacies and program staff were incorporated. The end result was 
two questionnaires – Household and Exit Interviews -- reflecting 
current drug prescription and purchase practices in the region. 
Training for interviewers including village health workers, field 
officers and other staff member were conducted during which 
questionnaires were further revised and samples size for the study 
were calculated. Furthermore, target communities were defined and 
schedule of visits were finalized. 
During the first phase of survey implementation, 21 field interviewers 
conducted 802 Household interviews (400 questionnaires in each 
rayon). During the second phase, 17 interviewers interviewed 320 
mothers and caretakers for the Exit interviews (180 questionnaires 
for each rayon). Due to lack of patient referral in the health facilities, 
names and addresses of patients who were referred for medical 
advice in the previous two weeks were collected and interviews were 
conducted at the household level rather than the health facilities 
where the interviews were supposed to be conducted. All completed 
questionnaires were checked at the end of the day by Field Officers 
and other CSPsupervisory staff. Data from questionnaires were 
entered into a database designed on Epi-Info 6.04 and converted to 
SPSS format for data analysis. 
The detailed report of the Wtp study is awaited, but preliminary 
results show that a willingness exists in the residents of the program 
rayons to pay for essential and important drugs and medications. A 
presentation on the survey was made at the USAID conference at 
Charvak in June 2003.
Conclusions 
1. The Partnership 
It would appear that the Partnership between Counterpart, Perzent 
and the Ministry of Health in Karakalpakstan has been a successful 
model. The Memorandum of Understanding which is the written 
basis for the partnership is a unique document. Some of the features 
of the MoU which made the process unique were: 
a. It was among the first partnerships between an international 
organization, a local NGO and the Ministry of Health in 
Karakalpakstan 
b. The MoU was a clear basis or understanding of roles and 
responsibilities of each of the partners. 
44
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
It outlined the same in unequivocal terms. The Ministry of Health 
took time to study the MoU before signing it. 
c. The MoU has since served as a set of guidelines as to 
performance of each partners’ role. 
d. The MoU of the CSP has since been used as a basis for many 
other partnerships which have developed in the region since the 
start of the program. 
The partnership is characterized by an intensive level of involvement 
of all partners. This was initiated form the time of planning, when 
Perzent contributed considerably to the design of the program and 
the DIP, in terms of suggestions regarding geographic areas of 
coverage and the specific issues to be addressed. Suggestions such 
as these were incorporated into program design, and the ultimate 
shape of the project was based on consensus. 
Initially, there did appear to be problems in the partnership between 
Counterpart and Perzent. Currently, however, they share an 
excellent relationship, with the director of Perzent, Dr Oral 
Ataniyazova admitting that the earlier problems were more due to the 
style of functioning of the earlier Program director, than system￾based. 
In the implementation phase, both Perzent and the MoH feel that 
there is a considerable sharing of information and ideas in the CSP. 
The Ministry feels that the gap between the Health facilities run by it 
and the community is being bridged to a great extent by this 
program. The MoH program is not necessarily need-based and 
responsive to felt needs, and the MoH feels that the CSP, which 
works in close partnership with the community, can bridge the gap 
between peoples needs and program interventions. 
The Ministry of Health is perceived by the people as being more 
interested in indicators, rather than in behavior change. Other 
problems it faces are in the area of staff turnover and lack of 
motivation among its workers. The CSP presents a refreshingly 
different approach, with committed staff who work toward behavior 
change. 
2. Staff turnover at the level of Program Director 
The program suffered from instability at the level of Program 
Director, following the exit of the first Program Director, Dr Nizam 
Uddin Ahmed in September 2001. Staff morale was also apparently 
affected in this period because of the restrictive management style of 
Dr Ahmed. The next 12 months, till the appointment of the current 
45
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
incumbent, Ramine Behrambegi, was a difficult period of time for the 
CSP. 
The factors which assisted the program through this period were the 
following: 
a. The intense support given by Darshana Vyas, Director of Health 
Programs from Counterpart headquarters, who made periodic 
visits to the CSP and gave valuable inputs. Her grasp of the 
details of the program is commendable, and this has helped even 
the current Program director establish a pattern of management. 
b. The contribution made by the late Dr Nuriyah Elgondieva, who 
was appointed as Field Officer, promoted to BCC specialist and 
finally Program Manager, was extremely valuable. The various 
persons interviewed as part of this evaluation rate her as a very 
dedicated, resourceful person, who was an extremely important 
and valuable part of the team. The program has indeed lost an 
important resource in her untimely and shocking demise in 
January 2003. 
c. The quality and stability of the staff at the program level and field 
level ensured that even if the leadership position was vacant, the 
interventions and strategies of the program were implemented as 
planned. 
3. Staff Retention 
The Program has had turnover of staff, particularly at the level of 
Program director. But as mentioned above, the field staff and key 
program staff have remained stable. One of the key strengths of the 
CSP has been its ability to retain its field staff. 
The factors which form the basis of this retention strategy could have 
been the following: 
a. A basically participatory style of management brought in by the 
current program director, which presented a refreshing change 
from the earlier director, whose style was more restrictive. 
b. Financially remunerative positions, compared to the usual level of 
salaries in Karakalpakstan 
c. Empowerment of staff and Incentives in the form of training and 
exposure visits to organizations overseas 
4. Staff Profile 
The Staff of the CSP as of today are a good mix of technical 
competence, dedication and ability. 
The current Program Director, Ramine Behrambegi, has established 
an open, participatory style of functioning, which has considerably 
improved staff morale. This is particularly significant considering that 
46
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
he took over at a difficult stage in the life of the program, with an 
absence of a Program director for the previous 12 months. His 
personal style of functioning includes an openness of manner and 
eagerness to meet with new people and share ideas, which is an 
extremely useful attribute in a program of this nature. He is focused 
at this point in time, and has a clear perception that the remaining 
program period is a crucial one. 
However, the balance between task and relationship in dealings with 
staff must be maintained, and there are times when the program 
director has to take quick and apparently harsh decisions. This will 
avoid delays in program functioning in key areas, like, for example, 
BCC material preparation. 
The Senior Health education specialist, Dr Sara Utegenova, is an 
asset to the program. She is a respected member of the Health 
fraternity in Karakalpakstan, having come on board the CSP after a 
stint with the Ministry of Health. She will be a key player in the future 
of the program, with skills in BCC materials, and in training. 
Dr John Brown, the volunteer form the Peace Corps, who will be 
working with the CSP over the next two years, is another potential 
asset. Dr Brown has skills in core technical intervention areas, and in 
the design of material using computers. His ability to focus on a task 
through to completion must be made use of in the remaining life of 
the program. 
The HMIS co ordinator and Communications specialist , Azimat 
Matkarimov and Sagitjan Aitjanov have co authored the abstract of 
the proposed paper on the Willingness to pay study. They are 
persons with considerable skill in the area of Health information, its 
collection, analysis and interpretation. Further training on HMIS 
related issues will enable their skills to be further improved upon. 
The acting program manager, Nina Nizamatdinova and the Finance 
and administration manager, Lilya Kim are other key members of the 
CSP, who appear to have a good grasp on the program. The support 
staff of Yulia Miroshnichenko, Communications officer, Vasilisa 
Rotalskaya, administrative assistant/receptionist, keep the office 
functional. 
The field staff are perhaps the greatest asset of the program. Ably 
headed by a set of qualified and articulate Field Officers, the village 
Health workers appear to have made their mark on the community. 
Judging by the remarks of the various members of the community 
interviewed as part of the evaluation, the VHWs have played an 
47
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
extremely important role in the key areas of BCC and Community 
mobilization. 
The Utilization of the field staff in the remaining part of the life of the 
program must be based on an idea of what the future of the CSP is 
going to be following December 2004. They could contribute very 
valuable inputs to any of the possible directions which the program 
would take 
a. Strengthening the existing program 
b. Diversification into other strategies in the same area, or 
c. Applying the same strategies into different areas. 
5. Training 
The training inputs given by the CSP have been appreciated by the 
Ministry of Health and by Perzent as being need based and effective. 
The Health workers of the MoH interviewed as part of the evaluation 
at the Health facilities state that even if they knew about the 
interventions of the CSP before the program, the training given 
helped in 
a. Updating knowledge 
b. Adding a real component to it by associating it with BCC 
strategies, thereby making it more usable and effective 
An example given by the pediatrician at Nukus rayon was that 
she found that the health personnel for Nukus rayon were more 
aware of the methods to be used in reaching messages to the 
community than workers from other non program rayons during a 
meeting of MoH doctors organized by the MoH. 
6. Capacity - Perzent 
An important goal of the CSP is to build the capacity of the partner 
organizations to enable them to independently plan, implement and 
evaluate a Child survival program. 
The staff of Perzent who are with the CSP have had the training, the 
experience and the first-hand acquaintance of the project. Training 
has been imparted to Perzent staff at Karakalpakstan and by means 
of deputing them to international training programs. At the end of the 
CSP, Perzent will therefore have human resource who are 
technically competent to actually deliver a program directed towards 
child survival. The Field officers, the Village Health workers and the 
supervisory level staff member, Mels Kutlimuratov, have expressed 
confidence in their ability to carry out the interventions and strategies 
of the CSP. 
48
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
The measurement of capacity of an organization would probably be 
based on considerations which include the following: 
a. The ability to independently attract funds by making proposals 
b. The ability to retain staff who are technically competent 
c. The presence of Enthused, willing, motivated staff 
d. The New projects which the organization has developed 
e. The ability of the organization to expand the scope of its existing 
activity 
f. The Presence, within the organization, of trained staff and trainers 
Perzent is currently involved in 8 rayons in Karakalpakstan, and the 
organization is committed to work in the areas of women’s/ 
reproductive health and the environment. The CSP has given it an 
orientation to work in the area of child survival, and the partnership 
has ensured that in addition to the intent, the ability is also present. 
Perzent has moved to a new and larger office in Nukus, and appears 
to have the physical infrastructure to be able to handle a program of 
this nature 
7. Capacity - Ministry of Health 
The capacity of the MoH is difficult to measure, in the absence of a 
formal HFA study. The documentation of the HFA study being 
commissioned by the Umir Nuri CSP will aid in this regard. However, 
discussions had with personnel at the Health facilities would seem to 
suggest that the capacity of the health facilities in the 2 program 
rayons with respect to the program interventions has indeed shown a 
trend for the better. Specific examples cited were: 
a. Facilities were supplied with drugs (Co trimoxazole) and 
equipment. This was facilitated by the CSP involving UNICEF and 
the Counterpart Humanitarian Assistance Program (CHAP) 
b. The process of filling in health related information in cards during 
house visits by health personnel has become a more intensive 
activity, probably because of better communication skills acquired 
during BCC training. 
c. Health workers at the facilities now compete with Village Health 
workers of the project in their community based activities 
The BCC materials and methods used at the health facilities have 
improved considerably since the start of the project. BCC material 
relating to the program interventions were found at almost all the 
facilities. While this was encouraging to note, true empowerment of 
the MoH facilities will be in evidence when the MoH creates its own 
BCC materials which are attractive and educational. Even if funds 
and resources within the MoH are needed for this to happen, the 
CSP has shown a direction for its partner to take. 
49
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
Recommendations 
1. Health Management Information system (HMIS) 
The HMIS could be developed further to make it a sensitive 
mechanism for detecting areas of need, both in terms of training and 
in terms of program interventions and activities. 
The HMIS was collecting information pertaining to indicators of 
knowledge and practice at a monthly frequency. This proved to be a 
time-consuming laborious exercise, which took time of the VHW 
away from important, BCC related activity. Following a review of this 
mechanism, the amount of information collected was reduced and 
the frequency made once six-monthly, which is a more reasonable 
frequency for indicator-related information. Process-related 
information is still collected monthly, as it should be. 
The HMIS staff have developed most of the instruments used 
themselves, which is commendable. But there is a need for formal 
training of the HMIS staff on methods designed to make the 
collection and use of data a more useful and active exercise. 
Training of the MoH staff on HMIS would further build capacity. 
2. Refresher training 
The system of periodic assessment of VHW performance by the 
Health Education specialist is a good basis for designing refresher 
training. The Rapid assessments which are done by the HMIS staff 
of the CSP should help identify need for refresher training for the 
Health facilities as well. 
Motivation and communication skills are two additional areas of need 
for training of MoH staff. 
Newly recruited staff should receive some form of orientation training 
so as to make them feel one with the rest of their peers.
3. Capacity of Perzent 
Discussions with Dr Oral Ataniyazova, Director, Perzent, would 
appear to indicate that her organization is expressing confidence in 
their ability to handle a program of a similar nature. She suggested 
that in the future, Counterparts role could be more facilitatory and 
supportive, with Perzent being involved in the actual grassroot level 
implementation. 
Additional areas where there was a need felt for capacity building in 
Perzent were the following: 
50
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
a. Lobbying / advocacy, where skills were required in trying to 
secure support for issues which need to be addressed 
b. Documentation 
c. Dissemination of information relating to programs and activities 
d. Health Management Information systems 
51
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program 
 Networking & Advocacy 
Networking and Advocacy 
Counterpart has been an active member of the International NGO 
community in Uzbekistan since 1993. The work of Counterpart in 
Uzbekistan ranges from Civil society and governance programs to 
Health. 
Some of the International NGOs with whom the CSP has a relationship 
include: 
o Medecins sans Frontiers, which is involved with the DoTS program 
in Tuberculosis control in all rayons of Karakalpakstan. Initially, MSF 
was also involved with programs for Diarrheal disease control and 
Acute Respiratory Infections, but is not involved in these issues since 
the start of the CSP. 
The CSP has collaborated with MSF in the DoTS program in the two 
rayons of Nukus and Takhtakupir. The VHWs of Counterpart were 
involved in the DoTS program. Also, the CSP was involved with 
Health education on the World TB day, which MSF organized. 
o Project HOPE, with its Child survival program at Navoi, is involved in 
similar interventions in another area of Uzbekistan. Collaboration is 
in the areas of technical information / initiatives exchange. For 
example, the breastfeeding support groups initiative and the idea of 
competitions for mothers and health workers on child survival issues. 
o The Progress Educational and Development center, which is a 
UK-supported initiative to promote the learning and use of English. 
The Health Families Club, an initiative supported by UNICEF and the 
CSP is an area of collaboration. 
o Red Cross, who is involved with a food distribution program for TB 
patients. The CSP was involved in the organization of the 
ceremonies on World TB day in collaboration with the Red Cross and 
MSF. 
o The Counterpart Consortium in Karakalpakstan which is involved 
mainly with civil society and governance-related programs. Even 
though the parent agency (Counterpart) is the same, the offices of 
the consortium agency and the CSP are different, and they work as 
independent bodies. Collaboration has been in the areas of sharing 
of space, and training facilities. VHC members from the Umir Nuri 
CSP have been trained on proposal development and management 
by the Counterpart Consortium, and have received funds from the 
organization. 
52
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
o UNICEF, with whom the CSP has collaborated in the area of drug 
distribution to health facilities. 
o Counterpart Humanitarian Assistance Program (CHAP) in the 
leveraging of resources, through which the CSP facilitated the 
equipping of Health facilities in the program rayons with essential 
infrastructural items. 
Formal mechanisms of networking have been established by the CSP. 
They are: 
o Interagency meetings, which take place once monthly on 
Saturdays. These meetings, which are a pioneering initiative by 
the Umir Nuri CSP, are semi-informal where the various 
international agencies operating in the Karakalpakstan region get 
together for a 2-3 hour discussion on issues of common interest 
at the CSP office. 
o Intersectoral meetings which are convened at the Ministry of 
Health, where the agencies meet with the MoH, and get a chance 
to discuss issues with the government. The intersectoral meetings 
started following a feeling that the interagency meetings lacked 
the official backing necessary to actually affect policy. The CSP 
plays a convener role for both these meetings. 
Conclusions 
1. Networking and advocacy strategy - basis 
The Networking and advocacy strategy of the CSP is founded on the 
following principles 
a. Regular interagency and intersectoral meetings help in getting 
like- minded organizations together, and in giving them a forum to 
interact with the Ministry of Health. 
b. Excellent public relations, especially with the current Program 
Director, Ramine Behrambegi, helps in getting people together, 
and in getting them to articulate their views on issues of common 
interest 
c. Finding common areas of interest and assisting in whatever way 
possible (for example – World TB day) is a good way of making 
and keeping friends. 
2. Networking and advocacy - benefits 
Networking and advocacy helps the CSP and Counterpart in the 
following ways 
53
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Conclusions 
a. Deciding and marking out geographic territories of involvement 
b. Enhancing the visibility of the program and the organization 
Counterpart in the area and the development community in the 
region 
c. Avoiding of duplication of efforts directed at a common purpose 
by discussing plans and strategies at interagency and 
intersectoral meetings 
d. Discovering potential areas of collaboration and partnerships 
between organizations 
MSF has discussed possibilities for collaborative research in the 
future on areas like 
º Persistent organic pollutants and risk communication 
º Anemia, especially in women and children 
º Building of capacity of educational institutions in doing 
research on issues related to environmental health 
e. Learning from each others experiences which are shared at 
interagency and intersectoral meetings 
f. Advocacy for issues of common interest by presenting a stronger 
voice to policy makers 
3. Donor visibility 
The visibility of the donor – USAID – has also been enhanced in the 
Karakalpak region because of the CSP program, which is the only 
health program supported by USAID in the region. The CSP enjoys 
an excellent relationship with the USAID mission at Tashkent. 
The US ambassador to Uzbekistan visited the CSP office in May 
2003. 
4. Support from headquarters 
Counterpart Headquarters has also been very supportive to the 
program, especially through its Director, Health Programs, Darshana 
Vyas. Specific areas of support and facilitation by Ms Vyas include: 
a. Three training programs, on BCC, ARI and HMIS 
b. The ensuring of participation in international training programs 
and seminars to enable upgradation of skills 
c. The Design of BCC strategy and materials 
d. The periodic feedback on reports and information sent to 
Headquarters 
e. The incentives provided as part of the staff retention strategy 
f. A two day retreat and training on team building and conflict 
resolution 
The CSTS unit has helped with technical information and advice 
when sought. 
54
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
Recommendations 
1. Scientific Conference 
The CSP has already taken the lead in organizing interagency and 
intersectoral meetings on a regular basis. A further step towards 
emphasizing the identity of the program would be to organize a 
scientific conference, or seminar, or symposium centered around 
Child Survival issues of relevance to the region. Besides contributing 
to the knowledge base on Child survival in the region, it would serve 
as an excellent platform for all stakeholders – donors, policy makers 
and communities to come together on a scientific platform and 
exchange information and views relating to child survival. The 
achievements of the program could also be presented to the group 
and their suggestions on future directions be solicited. 
55
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Sustainability 
Sustainability 
What happens after December 2004 ? 
The question of sustainability is high on the minds of all stakeholders of 
the CSP – the donors, the partners, the staff, the community and the 
network of collaborating organizations among others. 
The objectives related to sustainability as stated in the DIP include the 
following: 
a. Health facilities improve their skills and quality of care in the areas of 
CDD, PCM, breastfeeding and interpersonal communication 
b. Makhalla and village health committees have the capacity to 
implement health education interventions 
c. Service – seeking behavior is increased 
d. Local institutions are established which are capable of sustaining 
positive changes in behavior 
e. CS interventions are continued beyond the LOP by instituting 
alternative funding and cost recovery systems 
One of the major strategies towards sustainability will be the building of 
capacity of the partner organization, Perzent. This increased capacity 
could result in the continuation of child survival interventions in the 
existing rayons, or the expansion of the program into other rayons. The 
capacity of Perzent and of the MoH has been discussed in the previous 
section. 
Apart from this, evidence that some of these objectives are being 
fulfilled at the mid term includes: 
a. Health Facility/ MoH 
Expressions of confidence among personnel at the health facilities 
met as part of the MTE that they are capable of delivering care in the 
program intervention areas to mothers in the community. This feeling 
was also echoed by the members of the Ministry of Health who were 
met who said that their facilities have benefited from the inputs given 
by the program and that they are better equipped to deliver 
intervention-related care 
b. Village Health committees 
Village Health Committee leaders and members who were met as 
part of the MTE expressed their satisfaction at the program and 
expressed willingness and confidence in their ability to talk to 
mothers in their communities regarding program interventions 
56
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program Recommendations 
In addition to this VHCs have been exposed to the unique 
Community Grants program, where training was imparted to some of 
them on the development of project proposals aimed at improving 
the situation in their communities by means of some development 
initiative. 
VHCs who attended this program have prepared some project 
proposals directed at common health issues like anemia, 
breastfeeding promotion and fortification of commonly consumed 
foods with iron. 
This skill imparted to the VHCs will enable them to independently 
secure funds for their own development, which will pave the way for 
their independence and empowerment. 
c. Care seeking behavior 
The KPC indicators which measure care-seeking behavior in 
diarrhea and in ARI have improved since the baseline. Though the 
indicator which measured immediate care seeking was estimated at 
a level less than baseline in the case of ARI, the indicators of 
seeking care form a qualified health care provider were estimated at 
levels higher than baseline for both diarrheal disease and ARI. 
Recommendations 
1. Local institutions – womens organizations 
The VHCs are strong community based organizations which have 
been created by the CSP. Being voluntary bodies, who are not being 
paid by the program, VHCs will play a key role in the future of the 
program. 
BFSGs, School of mothers and the Village health workers of the 
CSP who reside in the community can be the starting points to 
establish solid community based institutions which will continue to 
exist beyond the LOP. Ideally, organizations of women will be the 
best source of health related knowledge for newly weds and young 
mothers. They may be a better source than a VHC, which has an 
“official” nature as compared to the “woman next door” nature of 
local women organizations. 
The CSP must aim to establish women’s groups through the VHCs, 
BFSGs and Schools of mothers. These groups must receive training 
from the CSP on the interventions of the program and on social 
issues, since they will also be social organizations where women can 
join and discuss social issues of common interest, maybe even start 
a small savings program. 
57
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program The Future 
This can be the source of a revolving fund through which items 
necessary for women and children at the village such as ORS and 
drugs can be purchased. 
2. Village Pharmacies 
The groundwork for the Village pharmacy initiative has been done in 
the shape of the Willingness to pay study, though this is an initiative 
which should be accelerated. 
 
The Village pharmacy promise to be a good legacy to leave behind 
after the LOP. Since the initiative is based upon solid research, the 
chances of success are high. In this initiative, it is proposed to 
establish village pharmacies, which will receive an initial stock of 
drugs as a grant. Sale of these drugs will lead to the creation of a 
revolving fund, which will then be used to get more drugs. The 
management of the pharmacy will be in the hands of the local 
community. The VHCs could play a role in this, thereby ensuring 
their continued existence. 
3. Health Facilities 
The support required for the HF in the remaining part of the program 
will relate to the following areas: 
o Support with BCC materials and educational aids, and, more 
importantly, training to enable the MoH to produce and use 
innovative materials 
o Training for the newly recruited staff and refreshers for the 
existing staff 
o Creating cadres of trainers by organizing more training of 
trainers programs.. 
The Future 
The Future of the CSP, if it continues to be supported in 
Karakalpakstan, could be in one of two broad directions: 
1. Expanding the scope of the activity and consolidating the presence 
of the program in the same rayons. 
In this scenario, the program will continue o work in Nukus and 
Takhtakupir rayons, but will expand the scope of activity to include 
such issues as 
a. Other Child health issues like Nutrition, Iodine deficiency 
disorders 
b. Reproductive Health issues, particularly anemia 
c. HIV/AIDS, which has been reported as being a “silent” crisis in 
the region 
58
The Mid Term Evaluation of the Umir Nuri 
Child Survival Program The Future 
d. The building of the capacity of schools and educational 
institutions, the use of school teachers as potential trainers in the 
community 
2. Replicating the successes of the CSP in other rayons, by initiating 
similar programs 
This is the scenario which the MoH would like to see, so that as 
much of Karakalpakstan, if not the whole of it, receives the benefits 
of the program interventions. 
Either of the possibilities can be actually implemented by Perzent, with 
Counterpart playing a technical advisory role. Perzent has indicated its 
willingness and ability to be involved with the grassroot level functioning 
of any future child survival initiative, with Counterpart providing technical 
support. The resources of Perzent, in the form of its new office and 
trained manpower could be used to share costs with the organization in 
the next phase. 
The excellent networking skills of the CSP will result in possible areas of 
collaborations and areas of cost sharing with other international 
organizations. MSF has indicated potential areas of collaboration. 
The Umir Nuri Child Survival program is a working model which 
has the potential to improve health status, while empowering local 
communities at the same time. In the period upto December 2004, 
the program must consolidate, refocus and plan for the future, 
which has exciting possibilities. 
 Conclusions & Recommendations 
59
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS 
CONCLUSIONS 
A. Technical Interventions 
1. Program effectiveness in terms of interventions 
Although information on incidence of disease and mortality in the 
population was not collected during the Mid term evaluation, the key 
indicators in the KPC survey would appear to indicate that there has 
been considerable progress made in the area of technical 
interventions. 
ALL indicators related to Control of Diarrheal disease have improved 
since baseline, and are currently estimated at levels beyond program 
targets. 
ALL indicators related to Promotion of breastfeeding have improved 
since baseline except the proportion of mothers with children under 2 
yrs of age who state they gave colostrum to their baby during the first 
three days of life, which remains stable at its pre existing high level. 
Levels of Key indicators are currently estimated at levels beyond 
program targets. 
The indicators of KNOWLEDGE of mothers regarding signs of ARI 
show improvement over baseline levels. 
However, the indicators of PRACTICE which measure the proportion 
of mothers taking their child for treatment immediately (on the same 
day) are lower than baseline levels. This could be because 
a. Children with Acute Upper Respiratory Infection can be managed 
at home, which is a message in the BCC related to ARI. The KPC 
indicator referred to above measures practice of mothers whose 
child had ANY kind of ARI, not necessarily Acute Lower 
Respiratory infections. If messages have been effective, the 
indicator may actually be reflective of a greater proportion of 
mothers who take care of their mildly sick child at home, saving 
resources for the care of severely ill children. 
A study could be done among mothers in the project area to 
probe this issue and find out the reason for a low proportion of 
mothers taking their child who shows symptoms of ARI to a 
doctor on the same day. 
b. The KPC survey was carried out in summer, when the incidence 
of ARI is low. The denominator for the indicator is 17, which is an 
 Conclusions & Recommendations 
60
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
extremely low number. Conclusions drawn based on this number 
must therefore be viewed with caution. 
2. Capacity of Health Facilities with respect to Technical 
Interventions – CDD, Pneumonia and breastfeeding 
The MOH Republican Health System (RHS) is the main health care 
provider in the rural areas, encompassing the 15 rayons in 
Karakalpakstan. When needed, patients are referred to specialized 
hospitals and dispensaries in Nukus City. The RHS provides patient 
care through 3 Republican hospitals, 3 city hospitals, 15 central 
rayon hospitals, 42 polyclinics, 30 SUBs, 68 SVAs, 55 SVPs and 388 
FAPs (explained below). The hospitals include rayon hospitals, 
SUBs, Republican hospitals and specialized hospitals. There are 
3,930 doctors and 15,245 middle medical employees providing 
medical care in the RHS. There are 26.1 doctors and 101.1 midlevel 
medical personnel for every 10,000 people in Karakalpakstan. 
 
The following diagram illustrates the difference between the existing 
rayon health system and the new rayon health system under health 
reform. 
Existing Rayon Health System. 
 
LEVEL I LEVEL II LEVEL III 
The older rural health care system is still in place, with feldshers 
(doctors’ assistants) at FAPs as the first contact point (Level I). The 
second level consists of SVP/SVA/SUB (Level II). The health reform 
initiative supported by the World Bank and USAID is planning to 
replace most FAPs, SVAs and SUBs with SVPs as the primary 
health care center. However, it is expected that some level I FAPs 
will remain in most rural areas of Karakalpakstan. Some rayons will 
also operate TB dispensaries and infection hospitals. Below is the 
outline of the new system. 
New Rayon Health System Under Health Reform 
FAP 
Doctor’s Assistant 
Midwife 
SVP 
SVA 
SUB 
Doctor
Polyclinic 
Rayon Hospital 
Specialist 
 SVP 
RAYON 
POLYCLINIC 
RAYON 
HOSPITAL
 Conclusions & Recommendations 
61
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
The qualitative data collected from staff at Health Facilities, from 
Village Health Committee leaders and from Mothers would appear to 
indicate that the Health facility staff are currently better equipped to 
deal with children with Diarrhea and Pneumonia. The concepts of the 
staff at the facilities regarding breastfeeding have also undergone 
updating and revision. 
Specific areas of increased capacity include: 
a. Updated knowledge on the technical aspects of the interventions, 
incorporating recent approaches like the IMCI. 
b. The availability and use of educational material at the Health 
facility 
c. Increased capacity as trainers, following the training of trainers 
programs of the CSP. 
d. An increase in confidence of the staff at the facilities, based upon 
their rapport with the community, in those areas where the Health 
facility personnel have a good rapport with the community, by 
being VHC members, for example. 
e. The enhancement of the effectiveness of house visits made by 
health facility personnel. In the words of a VHC member …” 
earlier, they were just filling forms, now they talk to us and 
educate mothers…” 
The Umir Nuri CSP is in the process of conducting a formal Health 
Facility assessment. The documentation of this will provide more 
insight on this issue. 
3. Key Behavior change – findings from qualitative study 
The following were some of the changes in behavior which were 
cited by the various members of the community / Health facility 
personnel 
a. Early referral of children showing danger signs of diarrhea 
b. Use of ORS/ORT in preference to antibiotics or other home 
remedies, like rubbing ash on the abdomen, or giving tea to 
children with diarrhea. 
c. Initiation of breastfeeding, even when mother is at Maternity 
home 
d. Taking children who show signs of severe ARI for treatment 
4. ARI Practice 
The ARI Practice indicator which measures practice of mothers 
regarding seeking treatment early when their children show signs of 
ARI is estimated at lower levels than baseline. However, the 
indicators of knowledge regarding the danger signs of ARI are 
estimated at higher levels than baseline. 
 Conclusions & Recommendations 
62
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
B. Community Mobilization 
5. Role of Village Health Committees 
The VHCs represent an attempt at empowerment, and this seems to 
be in evidence as the 18 VHCs of the CSP prepare to play a larger 
role in their communities. One VHC member said “..The program is 
causing a Health revolution, akin to the great October revolution…” 
The members seem to have understood the role which organizations 
like theirs can play in their communities, and appear to be willing to 
take on the responsibility. VHC members approach the Hakimiyat on 
their own for clarification regarding issues concerning the program. 
6. Community Participation 
Community Participation is one of the Key principles of Primary Health 
Care, and the CSP, through its Community mobilization strategy has 
ensured that the community is not a passive recipient of health messages 
which are handed out impersonally, but is an active participant in the 
process 
7. Role of CSCCs 
The CSCC appears to be successfully playing the role of a rayon-level 
supervisory/advisory body. The Deputy Hakim, Women’s issues at Nukus 
Rayon felt that the monthly meeting of the CSCC has now been made 
quarterly, because “…. The VHCs are now doing their job at the 
aul/makhalla level…” and the need for a monthly meeting had reduced. 
C. BCC 
8. BCC strategy 
The Behavior change communication strategy of the CSP appears to 
have conveyed key messages to mothers in the area, as evidenced 
by the increase in estimated levels of key indicators of knowledge 
and practice. Of particular interest is the fact that the estimated 
levels of indicators measuring knowledge of HIV/AIDS, which is not a 
program intervention, have remained stationary since baseline, while 
those measuring the program indicators have changed. 
Behavior change is difficult to achieve, and the KPC results show that the 
program has indeed accomplished much in a relatively short time of 2-1/2 
years. The Village Health worker, armed with flip charts and posters, has 
done very well in communicating the BCC messages using appropriate 
methods, and at appropriate venues. 
9. Ethnic groups 
The presence of different ethnic groups within the population, 
speaking different dialects of Uzbek, Karakalpak, Russian and 
 Conclusions & Recommendations 
63
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
Kazhakh languages presents a challenge to the communicators of 
the CSP who have to use the appropriate language when necessary. 
10. Translation 
The preparation of materials involves their translation into 
Karakalpak and Russian from English and back translation to check 
for accuracy. The official stance in Uzbekistan is to promote the 
Uzbek language, which is not very widely spoken in the program 
rayons. The CSP, however, has translated most of the BCC 
materials into Karakalpak, and this would represent the correct 
decision in the circumstances. The CSP has also translated IMCI 
guidelines into Karakalpak for use by the MoH. 
The translation of BCC materials into the local language has been a 
major accomplishment of the program. This has resulted in wide 
dissemination of the messages which they contain, and in the 
enhancement of the visibility of the program. 
11. Innovative approaches 
Other innovative approaches suggested towards behavior change 
are 
- Competitions for mothers based on Key Child survival interventions 
- Street plays and puppet shows. These methods were learned by 
the CSP team following an exposure visit to and exchange of 
information between the CS projects of Counterpart at Ahmedabad, 
India and the CSP. 
A puppet show was staged at the Children’s day celebration on June 
1st 2003, and despite reservations as to its cultural acceptance, was 
well received. The CSP plans to use this method to a larger extent in 
its BCC strategy 
D. Organizational Capacity 
12. The Partnership 
It would appear that the Partnership between Counterpart, Perzent 
and the Ministry of Health in Karakalpakstan has been a successful 
model. The Memorandum of Understanding which is the written 
basis for the partnership is a unique document. Some of the features 
of the MoU which made the process unique were: 
o It was among the first partnerships between an international 
organization, a local NGO and the Ministry of Health in 
Karakalpakstan 
o The MoU was a clear basis or understanding of roles and 
responsibilities of each of the partners. 
 Conclusions & Recommendations 
64
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
o It outlined the same in unequivocal terms. The Ministry of Health 
took time to study the MoU before signing it. 
o The MoU has since served as a set of guidelines as to 
performance of each partners’ role. 
o The MoU of the CSP has since been used as a basis for many 
other partnerships which have developed in the region since the 
start of the program. 
The partnership is characterized by an intensive level of involvement 
of all partners. This was initiated form the time of planning, when 
Perzent contributed considerably to the design of the program and 
the DIP, in terms of suggestions regarding geographic areas of 
coverage and the specific issues to be addressed. Suggestions such 
as these were incorporated into program design, and the ultimate 
shape of the project was based on consensus. 
Initially, there did appear to be problems in the partnership between 
Counterpart and Perzent. Currently, however, they share an 
excellent relationship, with the director of Perzent, Dr Oral 
Ataniyazova admitting that the earlier problems were more due to the 
style of functioning of the earlier Program director, than system￾based. 
In the implementation phase, both Perzent and the MoH feel that 
there is a considerable sharing of information and ideas in the CSP. 
The Ministry feels that the gap between the Health facilities run by it 
and the community is being bridged to a great extent by this 
program. The MoH program is not necessarily need-based and 
responsive to felt needs, and the MoH feels that the CSP, which 
works in close partnership with the community, can bridge the gap 
between peoples needs and program interventions. 
The Ministry of Health is perceived by the people as being more 
interested in indicators, rather than in behavior change. Other 
problems it faces are in the area of staff turnover and lack of 
motivation among its workers. The CSP presents a refreshingly 
different approach, with committed staff who work toward behavior oht prorogra followD
0 wbased. 
 Conclusions & Recommendations 
65
The Mid Term Evaluation of the Umir Nuri
Child Survival Program
incumbent, Ramine Behrambegi, was a difficult period of time for the 
CSP. 
The factors which assisted the program through this period were the 
following: 
a. The intense support given by Darshana Vyas, Director of Health 
Programs from Counterpart headquarters, who made periodic 
visits to the CSP and gave valuable inputs. Her grasp of the 
details of the program is commendable, and this has helped even 
the current Program director establish a pattern of management. 
b. The contribution made by the late Dr Nuriyah Elgondieva, who 
was appointed as Field Officer, promoted to BCC specialist and 
finally Program Manager, was extremely valuable. The various 
persons interviewed as part of this evaluation rate her as a very 
dedicated, resourceful person, who was an extremely important 
and valuable part of the team. The program has indeed lost an 
important resource in her untimely and shocking demise in 
January 2003. 
c. The quality and stability of the staff at the program level and field 
level ensured that even if the leadership position was vacant, the 
interventions and strategies of the program were implemented as 
planned. 
14. Staff Retention 
The Program has had turnover of staff, particularly at the level of 
Program director. But as mentioned above, the field staff and key 
program staff have remained stable. One of the key strengths of the 
CSP has been its ability to retain its field staff. 
The factors which form the basis of this retention strategy could have 
been the following: 
a. A basically participatory style of management brought in by the 
current program director, which presented a refreshing change 
from the earlier director, whose style was more restrictive. 
b. Financially remunerative positions, compared to the usual level of 
salaries in Karakalpakstan 
c. Empowerment of staff and Incentives in the form of training and 
exposure visits to organizations overseas 
15. Staff Profile 
The Staff of the CSP as of today are a good mix of technical 
competence, dedication and ability. 
The current Program Director, Ramine Behrambegi, has established 
an open, participatory style of functioning, which has considerably 
improved staff morale. This is particularly significant considering that 
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he took over at a difficult stage in the life of the program, with an 
absence of a Program director for the previous 12 months. His 
personal style of functioning includes an openness of manner and 
eagerness to meet with new people and share ideas, which is an 
extremely useful attribute in a program of this nature. He is focused 
at this point in time, and has a clear perception that the remaining 
program period is a crucial one. 
However, the balance between task and relationship in dealings with 
staff must be maintained, and there are times when the program 
director has to take quick and apparently harsh decisions. This will 
avoid delays in program functioning in key areas, like, for example, 
BCC material preparation. 
The Senior Health education specialist, Dr Sara Utegenova, is an 
asset to the program. She is a respected member of the Health 
fraternity in Karakalpakstan, having come on board the CSP after a 
stint with the Ministry of Health. She will be a key player in the future 
of the program, with skills in BCC materials, and in training. 
Dr John Brown, the volunteer form the Peace Corps, who will be 
working with the CSP over the next two years, is another potential 
asset. Dr Brown has skills in core technical intervention areas, and in 
the design of material using computers. His ability to focus on a task 
through to completion must be made use of in the remaining life of 
the program. 
The HMIS co ordinator and Communications specialist , Azimat 
Matkarimov and Sagitjan Aitjanov have co authored the abstract of 
the proposed paper on the Willingness to pay study. They are 
persons with considerable skill in the area of Health information, its 
collection, analysis and interpretation. Further training on HMIS 
related issues will enable their skills to be further improved upon. 
The acting program manager, Nina Nizamatdinova and the Finance 
and administration manager, Lilya Kim are other key members of the 
CSP, who appear to have a good grasp on the program. The support 
staff of Yulia Miroshnichenko, Communications officer, Vasilisa 
Rotalskaya, administrative assistant/receptionist, keep the office 
functional. 
The field staff are perhaps the greatest asset of the program. Ably 
headed by a set of qualified and articulate Field Officers, the village 
Health workers appear to have made their mark on the community. 
Judging by the remarks of the various members of the community 
interviewed as part of the evaluation, the VHWs have played an 
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extremely important role in the key areas of BCC and Community 
mobilization. 
The Utilization of the field staff in the remaining part of the life of the 
program must be based on an idea of what the future of the CSP is 
going to be following December 2004. They could contribute very 
valuable inputs to any of the possible directions which the program 
would take 
a. Strengthening the existing program 
b. Diversification into other strategies in the same area, or 
c. Applying the same strategies into different areas. 
16. Training 
The training inputs given by the CSP have been appreciated by the 
Ministry of Health and by Perzent as being need based and effective. 
The Health workers of the MoH interviewed as part of the evaluation 
at the Health facilities state that even if they knew about the 
interventions of the CSP before the program, the training given 
helped in 
a. Updating knowledge 
b. Adding a real component to it by associating it with BCC 
strategies, thereby making it more usable and effective 
An example given by the pediatrician at Nukus rayon was that 
she found that the health personnel for Nukus rayon were more 
aware of the methods to be used in reaching messages to the 
community than workers from other non program rayons during a 
meeting of MoH doctors organized by the MoH. 
17. Organizational Capacity - Perzent 
An important goal of the CSP is to build the capacity of the partner 
organizations to enable them to independently plan, implement and 
evaluate a Child survival program. 
The staff of Perzent who are with the CSP have had the training, the 
experience and the first-hand acquaintance of the project. Training 
has been imparted to Perzent staff at Karakalpakstan and by means 
of deputing them to international training programs. At the end of the 
CSP, Perzent will therefore have human resource who are 
technically competent to actually deliver a program directed towards 
child survival. The Field officers, the Village Health workers and the 
supervisory level staff member, Mels Kutlimuratov, have expressed 
confidence in their ability to carry out the interventions and strategies 
of the CSP. 
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The measurement of capacity of an organization would probably be 
based on considerations which include the following: 
a. The ability to independently attract funds by making proposals 
b. The ability to retain staff who are technically competent 
c. The presence of Enthused, willing, motivated staff 
d. The New projects which the organization has developed 
e. The ability of the organization to expand the scope of its existing 
activity 
f. The Presence, within the organization, of trained staff and trainers 
Perzent is currently involved in 8 rayons in Karakalpakstan, and the 
organization is committed to work in the areas of women’s/ 
reproductive health and the environment. The CSP has given it an 
orientation to work in the area of child survival, and the partnership 
has ensured that in addition to the intent, the ability is also present. 
Perzent has moved to a new and larger office in Nukus, and appears 
to have the physical infrastructure to be able to handle a program of 
this nature 
18. Organizational Capacity - Ministry of Health 
The capacity of the MoH is difficult to measure, in the absence of a 
formal HFA study. The documentation of the HFA study being 
commissioned by the Umir Nuri CSP will aid in this regard. However, 
discussions had with personnel at the Health facilities would seem to 
suggest that the capacity of the health facilities in the 2 program 
rayons with respect to the program interventions has indeed shown a 
trend for the better. Specific examples cited were: 
a. Facilities were supplied with drugs (Co trimoxazole) and 
equipment. This was facilitated by the CSP involving UNICEF and 
the Counterpart Humanitarian Assistance Program (CHAP) 
b. The process of filling in health related information in cards during 
house visits by health personnel has become a more intensive 
activity, probably because of better communication skills acquired 
during BCC training. 
c. Health workers at the facilities now compete with Village Health 
workers of the project in their community based activities 
The BCC materials and methods used at the health facilities have 
improved considerably since the start of the project. BCC material 
relating to the program interventions were found at almost all the 
facilities. While this was encouraging to note, true empowerment of 
the MoH facilities will be in evidence when the MoH creates its own 
BCC materials which are attractive and educational. Even if funds 
and resources within the MoH are needed for this to happen, the 
CSP has shown a direction for its partner to take. 
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E. Networking and Advocacy 
19. Networking and advocacy strategy - basis 
The Networking and advocacy strategy of the CSP is founded on the 
following principles 
a. Regular interagency and intersectoral meetings help in getting 
like- minded organizations together, and in giving them a forum to 
interact with the Ministry of Health. 
b. Excellent public relations, especially with the current Program 
Director, Ramine Behrambegi, helps in getting people together, 
and in getting them to articulate their views on issues of common 
interest 
c. Finding common areas of interest and assisting in whatever way 
possible (for example – World TB day) is a good way of making 
and keeping friends. 
20. Networking and advocacy - benefits 
Networking and advocacy helps the CSP and Counterpart in the 
following ways 
a. Deciding and marking out geographic territories of involvement 
b. Enhancing the visibility of the program and the organization 
Counterpart in the area and the development community in the 
region 
c. Avoiding of duplication of efforts directed at a common purpose 
by discussing plans and strategies at interagency and 
intersectoral meetings 
d. Discovering potential areas of collaboration and partnerships 
between organizations 
MSF has discussed possibilities for collaborative research in the 
future on areas like 
º Persistent organic pollutants and risk communication 
º Anemia, especially in women and children 
º Building of capacity of educational institutions in doing 
research on issues related to environmental health 
e. Learning from each others experiences which are shared at 
interagency and intersectoral meetings 
f. Advocacy for issues of common interest by presenting a stronger 
voice to policy makers 
21. Donor visibility 
The visibility of the donor – USAID – has also been enhanced in the 
Karakalpak region because of the CSP program, which is the only 
health program supported by USAID in the region. The CSP enjoys 
an excellent relationship with the USAID mission at Tashkent. 
The US ambassador to Uzbekistan visited the CSP office in May 
2003. 
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22. Support from headquarters 
Counterpart Headquarters has also been very supportive to the 
program, especially through its Director, Health Programs, Darshana 
Vyas. Specific areas of support and facilitation by Ms Vyas include: 
a. Three training programs were conducted by her, on BCC, ARI 
and HMIS 
b. The ensuring of participation in international training programs 
and seminars to enable upgradation of skills 
c. The Design of BCC strategy and materials 
d. The periodic feedback on reports and information sent to 
Headquarters 
e. The incentives provided as part of the staff retention strategy 
f. A two day retreat and training on team building and conflict 
resolution 
The CSTS unit has helped with technical information and advice 
when sought. 
F. Sustainability 
Evidence that the program objectives related to sustainability are being 
fulfilled at the mid term includes: 
23. Health Facility/ MoH 
Expressions of confidence among personnel at the health facilities 
met as part of the MTE that they are capable of delivering care in the 
program intervention areas to mothers in the community. This feeling 
was also echoed by the members of the Ministry of Health who were 
met who said that their facilities have benefited from the inputs given 
by the program and that they are better equipped to deliver 
intervention-related care 
24. Village Health committees 
Village Health Committee leaders and members who were met as 
part of the MTE expressed their satisfaction at the program and 
expressed willingness and confidence in their ability to talk to 
mothers in their communities regarding program interventions 
In addition to this VHCs have been exposed to the unique 
Community Grants program, where training was imparted to some of 
them on the development of project proposals aimed at improving 
the situation in their communities by means of some development 
initiative. 
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VHCs who attended this program have prepared some project 
proposals directed at common health issues like anemia, 
breastfeeding promotion and fortification of commonly consumed 
foods with iron. 
This skill imparted to the VHCs will enable them to independently 
secure funds for their own development, which will pave the way for 
their independence and empowerment. 
25. Care seeking behavior 
The KPC indicators which measure care-seeking behavior in 
diarrhea and in ARI have improved since the baseline. Though the 
indicator which measured immediate care seeking was estimated at 
a level less than baseline in the case of ARI, the indicators of 
seeking care form a qualified health care provider were estimated at 
levels higher than baseline for both diarrheal disease and ARI 
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RECOMMENDATIONS 
A. Technical Interventions 
1. ARI Practice 
Quick research aimed at eliciting the reason for the low level of 
practice relating to taking a symptomatic child immediately for 
treatment, by meeting groups of mothers and other key individuals 
can provide clues as to the reasons behind this. An appropriate 
strategy can then be planned to improve the indicator 
2. Revision of targets 
The targets for indicators of knowledge and practice related to the 
interventions indicated in the DIP must be appropriately revised
since most current estimates exceed target levels. This needs to be 
done as a joint exercise between the partners, including the inputs of 
field level staff. 
3. ORS Corners 
ORS corners at Health facilities are popular with Health workers and 
Village Health workers. These could be promoted to a greater extent, 
since the Health facility personnel appear to be comfortable with the 
concept of ORS corner, have the time and the knowledge to educate 
mothers and provide them with the right messages, at the ORS 
corner. 
4. Messages – feeding during diarrhea 
The messages relating to continued feeding, continued 
administration of liquids, and the feeding of children recovering from 
diarrhea could be emphasized since the indicators of these practices 
show that about half the mothers whose children had diarrhea in the 
2 weeks preceding survey did not practice the same. 
5. Handwashing practice 
The estimated level of the indicator of appropriate handwashing 
practice is still low (15.3%), even if it is higher than baseline (3.7%). 
The project needs to emphasize the prevention of diarrhea in its 
messages related to diarrhea management. With the high literacy 
level, it should be possible for mothers to read posters, leaflets and 
other material on hygiene. The Poster on hygiene is a good step in 
this direction – it needs to be built upon. 
6. Breastfeeding practice 
The indicators of early initiation of breastfeeding and exclusive 
breastfeeding practice show that there are still mothers who do not 
practice these key interventions. The program has emphasized the 
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importance of correct breastfeeding practice, but needs to do more 
to ensure that ALL mothers practice these behaviors. 
Since the place of delivery is usually the maternity home, intensive 
training and support could be provided to staff at maternity homes, 
specifically on early initiation of breastfeeding. 
7. Breastfeeding support groups 
The Breastfeeding support group initiative was not a part of the 
Umir Nuri CSP’s DIP. The experience of the CS program at Navoi, 
coupled with the Community’s response to the BCC on breastfeeding 
encouraged the establishment of the BFSGs. There are currently 6 
breastfeeding support groups, 3 at each rayon. These could be 
promoted further, and extended to cover a wider area. Some 
members of BFSGs are potential trainers themselves and could be 
included in training of trainers’ programs planned for the future. 
B. Community Mobilization 
8. Inactive VHCs 
It has been reported that there are some VHCs which are not as 
active as others. The CSP should focus on these poor performers 
and find out the reasons for poor performance. Attention should be 
focused on them, in order to build them up to the level of the better 
performing committees. 
9. VHCs – target number 
The target for the end of the project is 40 VHCs. In order to ensure 
quality, it may perhaps be better to identify those areas where 
committed persons are willing to work for their own communities, and 
facilitate formation of VHCs in such areas, even if the total number is 
less than 40. 
10. Traditional healers and religious heads 
Traditional healers and mullahs (religious heads) play an important 
role in some communities. While some VHCs have incorporated 
these individuals in their membership, others have not. It would be 
useful to identify all traditional healers in the area, and ensure that 
they are reached with the messages of the CSP. This could be done 
by 
- organizing a training program for traditional healers on key 
messages and try to get them involved in BCC 
- encouraging their membership at VHCs so that they may be reached 
through the VHC 
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11. Breastfeeding support groups and School of Mothers 
The Breastfeeding support groups and the School of Mothers are 
useful initiatives. If they grow to the level of community based 
women’s groups, who are not just involved with health, but also 
social and economic developmental activity like small savings and 
home based income-generating activity like tailoring, they could be 
powerful instruments of social change. 
A group of women which meets regularly, saves money, and is 
involved with acquisition of skills among its members which will 
increase their income, is a group which can sustain itself. It can also 
serve as an entry point into the community for messages directed at 
child health, and reproductive health. 
The CSP can consider the formation of such groups. 
C. BCC 
12. BCC material preparation 
The production of BCC materials by the CSP, as mentioned above, 
can be rated as one of its most major accomplishments, and the 
BCC strategy as being successful. Each step in preparation of BCC 
materials, from the stage of conception of a message, to developing 
a draft form, pretesting it with the community, and finalizing it, has 
been given the importance it deserves by the CSP. The production of 
materials – design and printing – is not an easy task in 
Karakalpakstan, and the CSP has done well in this regard. 
There has been delay however, in the case of certain materials, and 
such delays must be avoided in future. 
13. BCC Messages 
One of the issues repeatedly encountered during discussions at the 
community level was that messages must be simple and easy to 
understand by mothers, without sounding too technical, if they had to 
be effective. The messages given by workers at Health Facilities in 
the past were cited as examples of complicated messages, while the 
messages given by the CSP were simple and straightforward, in the 
language that mothers would understand. Leaflets and booklets were 
accepted very well in the community, and mothers pointed to the 
simplicity of the language used as a major reason for such 
enthusiastic acceptance. 
The messages of the CSP must continue to retain their simplicity 
while not compromising on technical content. This presents a 
challenge to a communicator. 
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14. BCC Methods 
The methods most preferred by most members of the community 
who were met as part of the MTE were dynamic visual media like 
Video, Television and Film. The CSP could explore the possibility of 
º creating educational video films based on local culture, with the 
key messages built in 
º Creating television spots, which could be aired at appropriate 
times, to ensure maximal viewing by members of the target group 
º Even leaflets and booklets must have an increased visual rather 
than textual content in order to be more attractive and appealing. 
Other methods which were perceived as being useful were: 
º Models, especially the breast model which was used to 
demonstrate correct breastfeeding technique 
º Booklets, which were received enthusiastically by the community. 
Since literacy levels in the population are very high (above 90%), 
written material is well received and utilized. 
The leaflets were received with a mixed response, with some saying 
that they were not so useful, and tended to be used as paper 
containers. Even so, they were on display at almost all the facilities 
visited as part of the evaluation. 
15. BCC to special groups 
BCC could be directed towards traditional healers, which is an 
important group in the context of the CSP. While it is good to involve 
them as part of the Community Mobilization strategy by facilitating 
their membership at VHCs, BCC could also be designed and 
directed towards this important group. 
The other groups which could be focused upon in the BCC strategy 
are those who are decision makers in child health issues: These 
include 
- Mothers-in-law and other older women 
- Fathers and other men 
The CSP has succeeded in making contacts with these groups. 
These are not easy groups to reach and communicate with, but 
considering the rapport the VHWs of the CSP enjoy at the 
community level, it could be tried at this stage in the project. 
16. Reinforcement and Follow-up 
For communication in terms of distributed materials to be effective, it 
must be followed up by interaction and reinforcement. The VHWs of 
the CSP have been reinforcing and interacting with the community at 
every stage, and this is what probably sets them apart from the 
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workers at the health facilities, who were perceived as distributing 
materials in a more passive manner. This strength of the CSP is an 
important one, and must be carried forward to the next stage. 
The challenge is to be able to get the members of VHCs and the 
health workers of the MoH to adopt this approach, since it is they 
who will be there when the project comes to an end. Attempts must 
be made to inculcate this value into the workers of the Health 
facilities and to the members of the VHCs 
D. Organizational Capacity 
17. Health Management Information system (HMIS) 
The HMIS could be developed further to make it a sensitive 
mechanism for detecting areas of need, both in terms of training and 
in terms of program interventions and activities. 
The HMIS was collecting information pertaining to indicators of 
knowledge and practice at a monthly frequency. This proved to be a 
time-consuming laborious exercise, which took time of the VHW 
away from important, BCC related activity. Following a review of this 
mechanism, the amount of information collected was reduced and 
the frequency made once six-monthly, which is a more reasonable 
frequency for indicator-related information. Process-related 
information is still collected monthly, as it should be. 
The HMIS staff have developed most of the instruments used 
themselves, which is commendable. But there is a need for formal 
training of the HMIS staff on methods designed to make the 
collection and use of data a more useful and active exercise. 
Training of the MoH staff on HMIS would further build capacity. 
18. Refresher training 
The system of periodic assessment of VHW performance by the 
Health Education specialist is a good basis for designing refresher 
training. The Rapid assessments which are done by the HMIS staff 
of the CSP should help identify need for refresher training for the 
Health facilities as well. 
Motivation and communication skills are two additional areas of need 
for training of MoH staff. 
Newly recruited staff should receive some form of orientation training 
so as to make them feel one with the rest of their peers.
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19. Capacity of Perzent 
Discussions with Dr Oral Ataniyazova, Director, Perzent, would 
appear to indicate that her organization is expressing confidence in 
their ability to handle a program of a similar nature. She suggested 
that in the future, Counterparts role could be more facilitatory and 
supportive, with Perzent being involved in the actual grassroot level 
implementation. 
Additional areas where there was a need felt for capacity building in 
Perzent were the following: 
a. Lobbying / advocacy, where skills were required in trying to 
secure support for issues which need to be addressed 
b. Documentation 
c. Dissemination of information relating to programs and activities 
d. Health Management Information systems
E. Networking and Advocacy 
20. Scientific Conference 
The CSP has already taken the lead in organizing interagency and 
intersectoral meetings on a regular basis. A further step towards 
emphasizing the identity of the program would be to organize a 
scientific conference, or seminar, or symposium centered around 
Child Survival issues of relevance to the region. Besides contributing 
to the knowledge base on Child survival in the region, it would serve 
as an excellent platform for all stakeholders – donors, policy makers 
and communities to come together on a scientific platform and 
exchange information and views relating to child survival. The 
achievements of the program could also be presented to the group 
and their suggestions on future directions be solicited. 
F. Sustainability 
21. Local institutions – womens organizations 
The VHCs are strong community based organizations which have 
been created by the CSP. Being voluntary bodies, who are not being 
paid by the program, VHCs will play a key role in the future of the 
program. 
BFSGs, School of mothers and the Village health workers of the 
CSP who reside in the community can be the starting points to 
establish solid community based institutions which will continue to 
exist beyond the LOP. Ideally, organizations of women will be the 
best source of health related knowledge for newly weds and young 
mothers. They may be a better source than a VHC, which has an 
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“official” nature as compared to the “woman next door” nature of 
local women organizations. 
The CSP must aim to establish women’s groups through the VHCs, 
BFSGs and Schools of mothers. These groups must receive training 
from the CSP on the interventions of the program and on social 
issues, since they will also be social organizations where women can 
join and discuss social issues of common interest, maybe even start 
a small savings program. This can be the source of a revolving fund 
through which items necessary for women and children at the village 
such as ORS and drugs can be purchased. 
22. Village Pharmacies 
The groundwork for the Village pharmacy initiative has been done in 
the shape of the Willingness to pay study, though this is an initiative 
which should be accelerated. 
 
The Village pharmacy promise to be a good legacy to leave behind 
after the LOP. Since the initiative is based upon solid research, the 
chances of success are high. In this initiative, it is proposed to 
establish village pharmacies, which will receive an initial stock of 
drugs as a grant. Sale of these drugs will lead to the creation of a 
revolving fund, which will then be used to get more drugs. The 
management of the pharmacy will be in the hands of the local 
community. The VHCs could play a role in this, thereby ensuring 
their continued existence. 
23. Health Facilities 
The support required for the HF in the remaining part of the program 
will relate to the following areas: 
o Support with BCC materials and educational aids, and, more 
importantly, training to enable the MoH to produce and use 
innovative materials 
o Training for the newly recruited staff and refreshers for the 
existing staff 
o Creating cadres of trainers by organizing more training of 
trainers programs.. 
G. The Future 
The Future of the CSP, if it continues to be supported in 
Karakalpakstan, could be in one of two broad directions: 
I. Expanding the scope of the activity and consolidating the 
presence of the program in the same rayons. 
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In this scenario, the program will continue o work in Nukus and 
Takhtakupir rayons, but will expand the scope of activity to include 
such issues as 
a. Other Child health issues like Nutrition, Iodine deficiency 
disorders 
b. Reproductive Health issues, particularly anemia 
c. HIV/AIDS, which has been reported as being a “silent” crisis in 
the region 
d. The building of the capacity of schools and educational 
institutions, the use of school teachers as potential trainers in the 
community 
II. Replicating the successes of the CSP in other rayons, by initiating 
similar programs 
This is the scenario which the MoH would like to see, so that as 
much of Karakalpakstan, if not the whole of it, receives the benefits 
of the program interventions. 
Either of the possibilities can be actually implemented by Perzent, with 
Counterpart playing a technical advisory role. Perzent has indicated its 
willingness and ability to be involved with the grassroot level functioning 
of any future child survival initiative, with Counterpart providing technical 
support. The resources of Perzent, in the form of its new office and 
trained manpower could be used to share costs with the organization in 
the next phase. 
The excellent networking skills of the CSP will result in possible areas of 
collaborations and areas of cost sharing with other international 
organizations. MSF has indicated potential areas of collaboration. 
The Umir Nuri Child Survival program is a working model which 
has the potential to improve health status, while empowering local 
communities at the same time. In the period upto December 2004, 
the program must consolidate, refocus and plan for the future, 
which has exciting possibilities.