1 Strategic Objective Close-Out Report USAID/Russia Name: "Improved Effectiveness of Selected Social Benefits and Services” Number: 118-0320 In FY 2002, the new Health SO (#118-0321) was introduced under the Amendment to the Strategy covering the period of FY 2002 - FY 2005. SO Approval date: 1999 SO Completed: 2005 (Final Obligation 2001) Geographic Area: Russian Federation Total Cost: Freedom Support Act (FSA) – $40,346,000 Child Survival and Health (CSH) - $3,542,000 1. Principal Implementing Partners: · American International Health Alliance, for partnerships · World Health Organization, for TB · Centers Disease Control, for TB · Population Services International, for HIV/AIDS · Holt International Children’s Services, for Assistance to Russian Orphans (ARO) · Mercy Corps International, for ARO · Institute for Urban Economics, for social subsidies · Urban Institute, for social subsidies 2. Summary of Overall Impact at SO and IR level SO 3.2 achieved major breakthroughs in adapting and implementing international protocols to combat tuberculosis, and notable successes in the introduction of modern approaches to health care and child welfare. This strategic objective was intended to integrate activities strengthening social service delivery at the local level with those providing models for national replication. Over the years, two distinct program areas emerged. The health portfolio combines efforts to combat infectious diseases — such as HIV/AIDS, sexually transmitted diseases and tuberculosis — with community-based preventive healthcare and assistance to orphans. The local governance portfolio’s activities strengthen the capacity of local governments and communities to address the needs of their constituents for public services. Local Governance This part of SO 3.2 met half of its targets in the Performance Monitoring Plan. However, the validity of these data in adequately capturing the impact of the program is subject to question. Based on what is happening in the local governance sector, and our implementing partner’s central role in these developments, we believe that we have achieved significant results. Russia’s municipalities are the principal level of government for the administration of social assistance and the delivery of social services, operating in a pluralistic regime in which the local legislature, private businesses, and citizens groups have growing influence. If they are to be sustainable, cities must make better use of their assets and improve their delivery of services. Although true reform has come to only a handful of Russian communities, this situation is rapidly changing: with the Government of Russia’s (GOR) re-energized policy development and continued physical deterioration of municipal infrastructure, there is a huge demand for assistance with national- and local-level reforms. USAID’s local governance activities are in the forefront of responding to those needs. Municipal and oblast administrations, federal officials, social service providers, low-income populations, small businesses, housing management and real-estate companies and NGOs are the prime beneficiaries of this work. 2 In July 2001, the government adopted the Mid-term Program for Socio-Economic Development of the Russian Federation: Years 2002-2004 (the “Gref Plan”) which includes sections on land, real estate, housing and communal economy reform based on USAID’s work in the regions, administered by the Institute of Urban Economics (IUE). The government also based its program for reform of housing and communal services sectors for 2002-2010 on USAID’s models. This will have a dramatic impact on fiscal and social policy, and improve targeting of funds to the truly needy. The Gref Plan quickly produced the Land Code, enacted by the Duma in September. The new code provides the first national-level basis for the sale and purchase of non-agricultural land. Again, IUE helped draft the legislation. July 2001 also marked the moment that Cherepovets became the first city in Russia to achieve full cost recovery in its housing communal services. Four other pilot municipalities expanded means-testing in their social services systems and introduced competitive procurement in the delivery of services, to give the truly needy more effective assistance. Analytical tools and treasury systems developed by a USAID public finance activity are helping cities to better manage their budgets and to increase transparency. Health The health program met its targets. Data are not yet available for our key indicator on tuberculosis, but recent trends suggest this target will also be met. The tuberculosis program currently covers the entire population of three oblasts, including both prison and civilian populations. A pilot site in Orel achieved an average treatment success rate of more than 75 percent, the World Health Organization’s (WHO) standard for success, and preliminary results from the other two sites are also encouraging. USAID’s campaign to combat HIV/AIDS is increasing awareness of HIV and sexually transmitted infections among young people and other high-risk groups. One site reports both dramatic reductions in needle-sharing among drug users and increased use of condoms. The Ministry of Health has recommended active collaboration between obstetrician-gynecologists, specialists in skin and venereal diseases and neo￾natologists in the prevention and diagnosis of congenital syphilis, based on a USAID-supported study by the Centers for Disease Control and Prevention. Research is improving service delivery in treating other sexually transmitted diseases in Moscow. Given high rates of sexually transmitted infection and increasing drug use, youth in Russia are at particular risk for HIV infection. During 2001, targeted HIV/AIDS prevention activities reached an estimated 30,000 youth in Moscow and 28,500 in Saratov. In addition, a weekly radio program "Minus Virus" in Saratov reaches about 70,000 young people with HIV and other reproductive health information. Federal mass media messages targeting youth reached about 3.4 million viewers. An innovative Internet￾based campaign reached an estimated 1.8 million youth nationally, of whom an estimated 30 percent live in Moscow. Quality assurance programs use a problem-solving approach to introduce changes in service delivery related to specific health problems. Pilot projects in Tula and Tver on hypertension, pregnancy induced hypertension, and perinatal respiratory distress syndrome improved health outcomes and cut costs significantly. For example, in Tver the Oblast targeted quality improvement resulted in a 64 percent reduction of early neonatal mortality and a 77 percent reduction in hospitalizations due to Pregnancy Induced Hypertension (one of the major causes of maternal death in Russia.) This led to 87 percent reduction in the cost of care for women with the disease. In three years, regional authorities have embraced these techniques and during 2001 clinicians spread them oblast-wide. The Ministry of Health is implementing a national program using the methodology and the innovations have been implemented in 30 regions in Russia. Building upon the success of 15 hospital partnerships, the seven primary health care partnerships are fostering more effective and efficient delivery of community-based health services, focusing on family medicine, women’s and infant health, STIs (Sexually Transmitted Infections) and HIV, infection control, and management of chronic diseases. During 2001, partnerships developed programs that resulted in more than ten new primary health care facilities over the next two years. A 2001 regional evaluation documented the AIHA program’s success. As a result of U.S. technical assistance under USAID’s women and infant health activity, the Ministry of Health issued national breast-feeding policies that bring Russia into conformance with WHO’s standards to promote healthier babies. Target sites have restructured their services to meet WHO’s standards in mother and child care, while research is showing the impact of high quality post-abortion care. More than 5,000 children and 3,000 families have benefited 3 from assistance in more than 20 regions under USAID’s Assistance to Russian Orphans program. Initiatives in Tomsk, Novgorod, Primorskiy Kray and Magadan have led governments to seek partnerships with NGOs to improve child welfare practices. Local governments and businesses have pledged to fund some of these services after USAID’s program ends. Child Welfare In 1999, the number of abandoned and institutionalized children in Russia reached 680,000, a level that poses a threat to the national social stability. Following an extensive assessment of needs in Russian child welfare, USAID initiated a $6 million, three-year project, Assistance to Russian Orphans-1 (ARO1) to support alternatives to institutionalization and promote community integration of orphans and children at risk of abandonment. As the result of ARO1, which ended in 2002, out of over 10,000 most vulnerable children served, 1,403 children remained in families, 144 projects implemented by 84 NGOs and their partners in government sector in 26 regions of Russia, including Vladimir, Novgorod, Tomsk, Perm, Nizhnii Novgorod, Tyumen, Rostov, Magadan, Altay, Krasnodar and Primorskiy Kray, developed innovative child welfare services to help families in crisis and foster families (e.g. regional foster care model in Primorskiy Krai), support programs for children with special needs (e.g. regional system of early intervention in Novgorod oblast), social hostels for orphanage alumni and family reunification for children at-risk. The federal 2002 – 2006 nation-wide government-funded program “Children of Russia” adopted ARO-developed models and policies, in particular, the foster care model. The implementing partners were Holt International Children Services and Mercy Corps International. Building on success of ARO1, USAID initiated ARO2, a four-year $11 million effort to facilitate the development of regional child welfare reform and establish an efficient regional abandonment prevention model. 3. Summary of Activities and Success Stories USAID’s exclusive breast feeding campaign is one example of a success story. One hospital used thousands of dollars, previously spent on infant feeding formula to finance a revenue-generating maternity ward. Other international health practices provide immediate improvements in health and lead to policy changes and cost savings. USAID has had particular success in treating and controlling tuberculosis (TB). With its partners - WHO, the U.S. Centers for Disease Control and Prevention (CDC), and Russian counterparts – USAID demonstrated for the first time that international protocols on TB can work in Russia. Two groups of patients treated using a protocol adapted for Russia exceeded WHO’s regional standard for treatment success. USAID’s vigorous leadership has led to increased political will and commitment to reform in the previously intractable arena of TB science in Russia paving the way for improved services. During FY 2000, governors of all three USAID TB regions issued declarations supporting the program’s approach. One of the highlights of USAID’s assistance to vulnerable children activities has been the establishment of Russia’s first regional system of early intervention centers for children up to three years of age with special needs (Novgorod oblast). The USAID-developed model has been incorporated in the federal guidelines on development of services for children with severe disabilities. Another entirely new type of rehabilitation services – a play library for mentally retarded children - has been set up due to USAID’s assistance and licensed by the Federal Education Ministry as the state-standard set of developmental and treatment equipment for pre-school municipal child care providers. Through these forms of assistance, over 7,000 children will be able to grow up within their birth families and not be placed in institutions. Achievements and Challenges Greater opportunity exists to replicate successful models in women and infant’s heal and the orphans’ program because of increasing global attention to the Russian population’s basic needs and declining health, the demonstration value of successful programs, and greater receptivity of leaders and increased participation of civil society at the local level. 4. Prospects for the Future Evaluations of these activities documented dramatic achievements. Much of the poor state of Russia’s health indicators can be laid to individual lifestyle choices and the low priority given to preventive health practices. To make major gains in health, a new activity will target the major causes of elevated mortality 4 in Russia and pursue approaches using the Internet and other communication strategies to further disseminate successful models and intensify our focus on youth. A new strategic objective emerged from SO 118-0320, SO 118-0321, Use of Improved Health and Child Welfare that reflects an increased Mission emphasis on health. The health program continues to meet its targets, continuing the progress achieved under the previous SO. The program consolidated many successful models in primary health care delivery of services, improving the quality of services, combating infectious diseases, and restructuring women’s and infants’ health care services. The Russian government took great strides in response to USAID’s ground-breaking assistance to orphans, and a new program was designed to support emerging child welfare reforms. Healthy Russia 2020 streamlined the health portfolio, increasing resources to disseminate successful models. Based on extensive consultations and analysis, USAID/Russia concluded that it needed to put more emphasis on unhealthy lifestyles that account for a significant portion of morbidity and mortality from non-communicable diseases. Designed and launched in 2002, Healthy Russia 2020 is an innovative, comprehensive and strategic health education and behavioral change program with the overarching goal of bringing Russian health indicators to West European levels by the year 2020. It is the first major activity in the region dedicated to health problems in industrialized countries. The heart of Healthy Russia 2020 is a membership association based in Moscow that will unite all organizations with an interest in improving the health of Russians. Through technical assistance, training, coaching, and gradual transfer of implementation and managerial authority, USAID, its implementing partner and Russian colleagues will work on communication and advocacy through the Healthy Russia 2020 NGO. Outcomes are designed to result in an effective, sustainable member-driven coalition that oversees the dissemination and adoption of evidence-based information and service-delivery models throughout the country. These outcomes will be capable of influencing policy and practices on a national, local and individual level; respond quickly to emerging health needs with high-quality communication, advocacy, or capacity-building programs; work in powerful combination with public sector programs; and have a direct impact on ordinary Russians’ behavior and expectations about their health. 5. Lessons learned for application to other SOs In 2002, a new SO (118-0321) was developed with a revised set of intermediate results and indicators. In measuring the effectiveness of the health program soon after (2003-04), it became clear that: 1) Some indicators were developed to measure the outcomes of the programs which were graduating shortly after the framework was developed (or the future of which was not clear at the time). For example, the programs focusing on the improvement of quality of primary health care (implemented by AIHA, URC) were entering their final year. The indicators and the targets for these programs therefore were relevant only for a very short period. 2) In the case with a new activity - Healthy Russia 2020 - at the time of the framework finalization, it was unclear what exactly this newly launched program would implement, as it had a broad focus (HIV/AIDS, TB, RH/FP, and healthy lifestyles for youth). The SO indicators were developed and finalized before the actual program took shape. Later experience showed that the original indicators were ineffective as the focus of the program narrowed and the expected results were specified according to the new focus. Based on this experience, we have learned that it is important to have a certain degree of flexibility in developing performance measurement tools for the whole SO. This helps offices to make adjustments when necessary (e.g., when new activities are launched/or refocused), and set targets when time permits to measure their achievement. 6. Summary of indicators and their usefulness for performance management 5 The Mission continues to struggle with how to measure and communicate our significant achievements in a country as vast as Russia. National statistics change slowly and often do not reflect regional differences and the dynamics at the sub-national level. While this measurement problem is not uncommon, perhaps no other country in which USAID works is as vast and diverse in geography and population. Tuberculosis treatment success rates in pilot sites Unit of Measure: treatment Success rate = (Patients cured + patients completing treatment)/Total number of patients starting the treatment course. Summary: Outcome data are only available six to nine months after treatment begins. Reductions in repeat abortions in selected sites Unit of Measure: Percentage of abortion clients who terminated a prior pregnancy by abortion within the last two years. Summary: Lags in facility reporting, data analysis and monitoring results. For instance, 2000 interim data was not available till after the second quarter of 2001. Increased exclusive breastfeeding rate (0-3 month-olds) in selected sites Unit of Measure: Number of infants 0-3 months of age completed months of exclusive breastfeeding. Summary: Lags in facility reporting, data analysis and monitoring results. For instance, 2000 interim data was not available till the second quarter of 2001. New approaches to child welfare service delivery adopted Unit of Measure: Increase in the number of child welfare services providers using effective child abandonment prevention practices. Summary: Russia-wide, 143 innovative child welfare models have been developed and implemented including services to families in crisis and foster families, support programs for children with special needs (for example, regional system of early intervention in Novgorod oblast), services for deaf children, children with autism and other disabilities, social hostels for older orphans and children at-risk. Throughout Russia, 63 state institutions and local administrations are adopting new child welfare policies and practices developed by NGOs in the program. Twenty-six distinct social partnerships between non￾governmental and governmental service providers have been established. The expertise and skills of more than 500 municipal specialists have been improved through 54 training workshops. 7. Appendix Reports Results Report and Resource Request (R4) 1999 Results Report and Resource Request (R4) 2000 Key Contacts USAID Betsy Brown Office Director, Health USAID/Russia 2004- bebrown@usaid.gov PARTNERS Holt International Children Services/Eugene Daniel Lauer, Associate Department Director, International Programs PO BOX 2880 (1195 City View) Eugene Oregon 97402 Tel: (541) 687-2202, fax: (541) 683-6175 E-mail: danl@hltintl.org 6 Website: www.holtintl.org Mercy Corps International/Portland Mark Ferdig, Program Officer 3030 SW First Avenue, Portland, OR 97201-4796 Tel: (503) 796-6809, fax (503) 796-6844 E-mail: mferdig@mercycorps.org Neal Keby-Guyer, CEO Tel: (503) 796-6800, fax (503) 796-6843