MID-TERM EVALUATION REPORT
“ChildSurvivalandHealthProgramforKvemoKartliandImereti,Georgia”
Cooperative Agreement Number:
GHS-A-00-04-00025-00
October 1, 2004 –September 30, 2009
Submitted to:
US Agency for International Development
USAID/GH/HIDN/NUT/CSHGP
Room 3.7-72B
Washington, DC 20523-3700
Submitted by:
HEADQUARTERS
A Call to Serve International
601 Business Loop 70 West, Suite 113
Columbia, MO 65203
FIELD OFFICE
A Call to Serve - Georgia
7, Vazha Pshavela Ave.
Tbilisi, Georgia 0160
Date of Submission: October 30, 2007
ACTS MTE Consultant: David Newberry
Key MTE Participant Team:
David Newberry, Global Consultants, Inc.
Patricia J. Blair, MD, Headquarters Backstop
Giorgi Tsilosani, MD, PhD, Field Office, Chief Medical Officer
Revaz Tataradze, MD, PhD, CSP Director
Eteri Suladze, CSP Project Manager
Editor: Vicki Leighty, Leighty Consulting Services
A Call to Serve International –Mid-Term Evaluation Page 1
ACKNOWLEDGEMENTS
A Call to Serve (ACTS) International and ACTS Georgia wish to recognize those that directly
contributed or participated as technical or expert resource in this Mid-Term Evaluation.
The Georgia Ministry of Labor, Health and Social Affairs (MoLHSA) participated at every level
of operation during the Mid-Term Evaluation exercise.
Staff from every health facility took precious time from their busy work day to meet with the
team and share experiences, ideas and data during their interviews, as well as valuable
suggestions for working more cohesively with the CSP. All those interviewed expressed support
for the project and a commitment to improve and expand their services to their community.
We wish to thank the professional medical service caregivers and the clinicians and their support
staff for their motivation and dedication to meeting the needs of their patients.
Mothers, infants and children and other community members seeking medical care services in
facilities visited, were strong in their recognition of the quality of services offered, both curative
and preventive.
The community focus groups were inspiring, and their response was proactive and fully
participative for each individual attending.
Finally, the cohort of young children we observed was simply beautiful to see, as happy
individuals with the potential for long healthy lives.
The ACTS Georgia staff serves as a role model for an organized team focused on the important
activities of saving the lives of mothers, infants and children.
A Call to Serve International –Mid-Term Evaluation Page 2
TABLE OF CONTENTS
Acknowledgements....................................................................................................................1
Table of Contents.......................................................................................................................2
List of Acronyms........................................................................................................................4
Summary ............................................................................................................................... 5-6
Assessment of Progress Made Toward Achievement of Project Objectives........................7-27
Technical Approach................................................................................................... 7-12
Brief Overview of Project................................................................................... 7
Progress Report by Intervention Area................................................................. 9
New Tools or Approaches................................................................................. 12
Cross-Cutting Approaches....................................................................................... 13-27
Community Mobilization .............................................................................. 13
Communication for Behavior Change ......................................................... 14
Capacity Building Approach ........................................................................ 18
Project Management ..........................................................................................................28-33
Planning....................................................................................................................... 28
Staff Training ............................................................................................................... 28
Supervision of Project Staff.......................................................................................... 29
Human Resources and Staff Management..................................................................... 29
Financial Management ................................................................................................. 29
Logistics ...................................................................................................................... 30
Information Management ............................................................................................. 31
Technical and Administrative Support .......................................................................... 32
Mission Collaboration .................................................................................................. 32
Other Issues Identified by the Team .......................................................................................34
Conclusions and Recommendations...................................................................................35-36
Results Highlights...............................................................................................................37-41
Action Plan/Revised Work Plan.........................................................................................41-49
A Call to Serve International –Mid-Term Evaluation Page 3
Attachments......................................................................................................................50-126
A. Baseline Information from DIP .............................................................................. 51
B. MTE Survey (LQAS) Report ................................................................................. 53
C. Evaluation Team Members and Titles..................................................................... 70
D. Evaluation Assessment Methodology ..................................................................... 71
E. List of Persons Interviewed and Contacted ............................................................. 73
F. CD with electronic copy of the report in MS Word 2000......................................... 82
G. Special Reports............................................................................................... 83-108
1. Hospital Assessment by Randall Floyd, M.D. and Laura Hillman, M.D...... 83
2. Georgia Diary by Laura Hillman, MD ....................................................... 90
3. ChildRightsProtectionAssociation“ClaritasXXI”Report....................... 94
4. Follow-up Observations on the Integrated Management of Childhood
Illness Report .......................................................................................... 104
5. Summary of Five Hospitals Delivery Log ................................................. 108
H. Project Data Sheet Form ................................................................................109-116
I. References and Resources..............................................................................117-124
1. References ...............................................................................................116
2. Map of Georgia and Intervention Target Regions......................................116
3. Maternity Facility Assessment (MFA)........................................................117
4. Comparison of LQAS MTE Results in Rural and Urban Areas of Focus ... 121
5. Structured interview with Obstetrician ..................................................... 122
6. Structured interview by a Neonatologist .................................................. 123
7. Neonatal Transport Death Chart Audit..................................................... 124
J. Political Structure in Georgia ................................................................................125
K. CSP Relevance to Millennium Development Goals ..............................................126
1. The Government of Georgia is a signer to the UN Millennium
8 Development Goals .............................................................................. 126
2. CSP Relevance to USAID Georgia Mission Strategic Priorities .............. 126
A Call to Serve International –Mid-Term Evaluation Page 4
LIST OFACRONYMS
AAFP AmericanAcad. of Family Physicians
ACTS ACall to Serve
ALSO Advanced Life Support Obstetrics
ANC Antenatal Care
ARI Acute Respiratory Infection
BCC Behavioral Communication Change
BF Breast Feeding
BFH Baby-Friendly Hospital
CDEM Center for Disaster and Emergency
Medicine
CIF Curatio International Foundation
CMO Chief Medical Officer
CORE The Child Survival Collaborations and
Resources Group
CS Child Survival
CSP Child Survival Program
CSHGP Child Survival Health Grant Program
CSTS Child Survival Technical Support
DIP Detailed Implementation Plan
DOSA Discussion-Oriented Self- Assessment
ECD Early Child Development
EOP End of Project
EU European Union
FE FacilityAssessment
FP Family Planning
GMA Georgian MedicalAssociation
GNMC Gudharshi National Medical Center
HIV Human Immunodeficiency Virus
IEC Information, Education, Communication
IMCI Integrated Management of Childhood
Illness
IMR Infant Mortality Rates
JSI T&R John Snow Inc. –Training and Research
Institute
KPC Knowledge, Practice, Coverage
LOE Level of Effort
LQAS Lot QualityAssurance Sampling
M&E Monitoring and Evaluation
MCH Maternal and Child Health
MDG Millennium Development Goals
MFA Maternity FacilityAssessment
MICS Multiple Indicator Cluster Survey
MIS Management Information System
MMR Measles, Mumps and Rubella
MMSG Mother-to-Mother Support Groups
MNC Maternal and Newborn Care
MOH Ministry of Health
MoLHSA Georgia Ministry of Labor, Health and
SocialAffairs
MP Medical Personnel
NCDC National Center for Disease Control
NCDC National Communicable Disease Center
NGO Non-Governmental Organization
OB/GYN Obstetrics/Gynecology
ORS Oral Re-hydration Salt
ORT Oral Re-hydration Therapy
PHR Partners for Health Reform
PVO PrivateVoluntary Organization
RH Reproductive Health
RV Reaction of Vasserman
SDS State Department of Statistics
SO Strategic Objectives
SPSS Statistical Package for the Social Sciences
STI Sexually-transmitted Infection
TRM Technical Reference Materials
UNICEF UnitedNationsChildren’sFund
USAID U.S.Agency for International
Development
VRF Vishnevskaya-Rostropovich
Foundation
WRA Women of ReproductiveAge
WHO World Health Organization
A Call to Serve International –Mid-Term Evaluation Page 5
SUMMARY
A Call to Serve (ACTS) International and its affiliate, ACTS Georgia are in the third year of
implementation of a five-year Child Survival Program (CSP). This is the first CSP in Georgia
and the project targets 37,648 children less than five years and 144,648 women of reproductive
age in the Kvemo Kartli region and in cities of Chiatura and Zestaphoni in Imereti region. Target
populations are mothers, infants and children under five years of age, in the two most
economically depressed areas. Increased mortality among mothers and children occurred after
the 1991 collapse of the Soviet Union.
Thegoalofthe“ChildSurvivalandHealthProgramforKvemoKartliandImereti,Georgia”is
to reduce maternal, neonatal infant and child morbidity and mortality. The goal is being achieved
through three principal objectives:
1. Improved quality of M/C survival services.
2. Improved behavior and maternal and child health practices within households, the
community and among health care professionals and health managers.
3. Increased availability of M/C health care services and increased access to adequate
standard case management.
Interventions include: Maternal and Newborn Care (MNC) 25%, Breastfeeding Promotion
(20%), Nutrition (15%), Case Management of Diarrhea (25%) and Case Management of
Pneumonia (15%), with the latter two combined into one intervention area: Management of
ARI/Pneumonia and Diarrhea (40%). Three crosscutting strategies are being used to achieve
program objectives: (1) Behavioral Communication Change (BCC) approaches; (2) Institutional
Capacity Building; and (3) Partnership Development for Social Mobilization. Integrated
Management of Childhood Illness (IMCI) will be applied in the delivery of childcare services.
Main Accomplishments of the Project
ACTS has implemented the first successful health program in Kvemo Kartli. ACTS selected
Kvemo Kartli at request of the USAID Georgia Mission. Previous health program efforts of other
organizations had failed. The CSP targets 144,648 women of child-bearing age and 37,995
children under five for a total beneficiary population of 182,644. A mass media campaign was
conducted in Kvemo Kartli region (population 535,546). Individual- and community-level
interventions were conducted in focus areas, targeted to underserved minority ethnic groups. In
focus areas, ACTS worked with 9 maternity facilities, 10 polyclinics and 60 ambulatories across
63 sub-districts in two regions (Kvemo Kartli and 2 sub-regions of Imereti).
The CSP has worked in close collaboration with the Georgian Parliament, Department of Public
Health and MoLHSA. As result, successful legislations have been passed that have had positive
impact on improving health in these regions. Fee-based birth registration was eliminated
(Parliament Law passed in 2005), the Universal Iodization of Salt Law was enacted (Feb. 2005
“LawofGeorgiaonPreventionofDiseasesCasesbyIodine,OtherMicronutrientsandVitamins
Deficiency) and a pending law requiring fortification of flour with iron and folic acid is moving
forward, as direct result of ACTS leadership in securing a 3-year, $1.5 million grant from GAIN.
A diverse and broad-based stakeholder network at national, regional and local levels has been
developed. Physicians have been trained in IMCI, breastfeeding and WHO Baby-Friendly
A Call to Serve International –Mid-Term Evaluation Page 6
hospital standards and Rustavi has become the first Baby-Friendly certified hospital in the area.
Social inequality for women is no longer as great a barrier due to FGDs and other innovative
approaches used to engage young mothers.
Overall Progress Made in Achieving Project Objectives
ACTS has made significant progress in reducing maternal, infant and child mortality through
community programs and behavior change interventions. The CSP has successfully reached
underserved and isolated communities and garnered a high level of community support.
Main Constraints, Barriers and Challenges
Unregistered births continue to challenge health care in the region. Transportation is a barrier
that limits access to care. Cultural, language and religious traditions among families in Kvemo
Kartli are diverse and require cultural and religious sensitivity. Women have traditionally been
hard to reach due to social inequality. Training for healthcare professionals is needed on IMCI,
breast feeding and Baby-friendly hospital standards. Lack of equipment at health facilities
impacts quality of care and consumer decision to seek care. Lack of sufficient mortality tracking
data in these rural and remote regions is a challenge. Medical malpractice, including maternal
death is a manner of criminal, not civil law and may effect accurate reporting of these cases.
Capacity-Building Effects of the Project
Capacity building effects as result of the CSP include increased monitoring and evaluation skills
for staff and utilization of a systems-approach. Program staffs have achieved a high level of
competency in KPC, LQAS and other MCH technical skills, and strategic planning capabilities.
Health worker performance, knowledge and skills have also increased.
Lessons Learned
The greatest lesson learned has been engaging populations in health interventions whose cultural,
language, social and religious traditions have isolated them for generations. Developing trust
between diverse communities takes time and committed work. Access to experienced CS peers
throughout the world through the USAID/CORE network is uniquely helpful. Implementing CSP
using rigorous evidence-based USAID CSGHP system (KPC baseline, DIP, MTE independent
review)hasimprovedACTS’abilitytocommunicate results and advocate for change.
Sustainability
Engaging a broad-based network of representative stakeholders from every facet of the
community is essential in achieving long-term sustainability. Creating an educational climate for
young women that is engaging and helpful, while respecting cultural values is critical. ACTS
progress in both arenas has been exceptional.
Conclusions and Recommendations Resulting from MTE
ACTS agrees with the MTE conclusions and recommendations resulting from the MTE and will
utilize the recommendations for future work and focus for the remaining two years of the CSP.
Grantee’sResponsestotheMTEEvaluationRecommendations
See Action Plan/Revised Work Plan on pages 38-45.
A Call to Serve International –Mid-Term Evaluation Page 7
ASSESSMENT OF PROGRESS MADE TOWARD PROJECT OBJECTIVES
TECHNICAL APPROACH
Brief Overview of Project
Thegoalofthe“ChildSurvivalandHealthProgramforKvemoKartliandImereti,Georgia”is
to reduce maternal, neonatal infant and child morbidity and mortality in the Kvemo Kartli region
and in the cities of Chiatura and Zestaphoni in the Imereti region. The total population of the
targetareais535,546.ThisCSPservestwoofGeorgia’smostvulnerablehealthgroups–
mothers, infants and children under five years of age –within the country’stwomost
economically depressed areas. This CSP targets approximately 37,648 children less than five
years of age and 144,648 women of reproductive age, 15 to 49 years of age.
The program goal is being achieved through three principal health objectives:
1. Improved quality of M/C survival services.
2. Improved behavior and maternal and child health practices within households, the
community and among health care professionals and health managers.
3. Increased availability of M/C health care services and increased access to adequate
standard case management.
The interventions include: Maternal and Newborn Care (MNC) 25%, Breastfeeding Promotion
(20%), Nutrition (15%), Case Management of Diarrhea (25%) and Case Management of
Pneumonia (15%), with the latter two combined into one intervention area: Management of
ARI/Pneumonia and Diarrhea (40%). Three crosscutting strategies are being used to achieve the
program objectives: (1) Behavioral Communication Change (BCC) approaches; (2) Institutional
Capacity Building; and (3) Partnership Development for Social Mobilization. Integrated
Management of Childhood Illness (IMCI) is being applied in the delivery of childcare services.
Local partners include:
 A Call to Serve-Georgia (ACTS-Georgia), affiliate of ACTS International, is the key
partner for planning, coordinating, monitoring and evaluating all field activities and
interventions, in consultation with the ACTS headquarters office.
 The Ministry of Labor, Health and Social Affairs of Georgia (MoLHSA) is the key
government partner that works seamlessly with ACTS International and ACTS Georgia
on a national level to assist with coordination and management of the project.
Contributing partners include:
 Claritas XXI assists in implementing program strategies, through a network of trained
community health workers and providers key to child survival, to assure achievement of
sustained improvements in community practices and health care services.
 Vishnevskaya-Rostropovich Foundation (VRF) assists by identifying community leaders and
facilitating mobile teams that will ensure immunization coverage for the region. VRF also
collaborates with ACTS in conducting joint community training.
 Government of Georgia (GOG) is the main ACTS stakeholder. Government administrative
bodies at the regional and local level have been involved in the process of community
mobilization, playing a critical role in the development of networks on the local level. The
long-term sustainability of the CSP depends on the MoLHSA and public health department
A Call to Serve International –Mid-Term Evaluation Page 8
adoption of the CS strategies piloted in ACTS CSP Kvemo Kartli to be piloted nationwide.
Active participation in the pilot has been a learning experience for ACTS, the GOG and
the national Georgian Fortification Program.
MTE Evaluation Process
In preparation for the CSP MTE, the MTE consultant, ACTS Georgia and ACTS HQ Team
determined the process to be taken. A review of previous project documents (Detailed
Implementation Plan [DIP], Annual Reports, and Related Documents) was done. Participatory
roles and responsibilities were assigned and an interview took place with MoLHSA and medical
facilities staff. Stakeholders and partners were invited to serve as evaluation team members. A
participatory approach was determined as the preferred MTE method. A meeting with the
USAID Mission took place. The MTE also involved field visits to MoLHSA facilities, focus
groups, and additional implementations sites; interviews with MoLHSA officials, government
partners, political stakeholders, clinic personnel, ACTS community groups, mothers attending
clinics during facility hours, OB/GYN doctors who attend pregnant women for ANC services
and polyclinic staff; multiple interviews with mothers and focus group participants; the
collection of training data and analysis from agencies, facilities and FGDs; and site assessments
at maternity and clinic facilities to observe deliveries and Caesarian-sections for technique,
equipment capacity, emergency procedures and quality of care. Interviews were conducted with
ANC doctors regarding techniques, protocols, and interactions between patients and physician
was observed. Laboratory support and testing capacity were reviewed. Interviews were
conducted to assess individual knowledge of the CSP. Additional interviews of facility,
administration staff, individual professionals, clinic personal and facility roles and
responsibilities in collaboration were reviewed. Indicators were assessed using an LQAS survey
(Attachment B) conducted with 170 women with a child less than two years of age.
Constraints/Barriers Identified
Constraints and Barriers with the GOG included absence of national standard guidelines and case
management protocols, hence, OB and neonatal care is not performed to a uniform standard.
Physician training and assessments are provided by bilateral funding though NGOs, resulting in
multiple trainings that vary in results. Physicians hold many certificates yet still are unable to
implement standard core practices. Physician salaries are low and often not paid within 30 days.
Government funding is the issue. The results of on-going health sector reform makes it difficult
for the Government to set aside full funding to cover public health costs, while transitioning from
public service to a combined private and public health care system. Greater coordination of
efforts among bilateral and international PVO Programs needs to be addressed. As Georgia
moves into a more sectarian health organization, the number of domestic and foreign
collaborators working in the country has increased. This requires greater organizational
collaboration between all agencies working in a region. Often bilateral development agencies
(U.S., Swiss, Sweden, Japan, Britain) work on related, but uncoordinated programs, putting
strain on regional officials who are required to provide the assistance. ACTS has since 1992 been
a leader conveying cooperation meetings. The GAIN program is an excellent example of one
nationwide program being implemented quickly and cost-effectively because one organization
and one Georgian government agency has streamlined their working relationship. Development
of a regional government system is needed to coordinate program activities to avoid duplication
of efforts and assure that priority needs are being addressed. Lack of regional Georgian
A Call to Serve International –Mid-Term Evaluation Page 9
government health information system limits ability to share information about various groups
working in a region- many PVOS do not readily share successes or failures.
Thenatureofbehaviorchangeinterventionsmakean“evidence-based”approachdifficult to
track. The CSP needs to adopt modifications to improve BCI measurement and provide FGDs,
based on tangible feedback; and modify training sessions at the community level. Limited
evidence-based practices in place (e.g., partographs used just 9% of the time).
The Maternity Facility Assessment (MFA) conducted by ACTS at six Kvemo Kartli maternity
facilities (refer to attachments) documents the need for essential neonatal resuscitation
equipment. Respiratory problems are the leading cause of neonatal death. These finding are
support by an general national survey in 2006 by UNICEF. In both surveys all hospitals
surveyed lacked necessary neonatal resuscitation equipment. These findings point to a
nationwide problem according to UNICEF - Assessment of Perinatal Care in Georgia. The study
found that healthy term babies die each year due to lack of baby warmers in the delivery suite.
Hospitals have no heat, or limited heat, thus healthy babies arrest in shock of a cold environment
disparity of data on mortality needs joint review, with all partners focused on data collection
review and consensus adaptation.
Progress Report by Intervention Area
For the MTE, progress made in each of four CSP intervention areas were measured by
administering an LQAS survey of 170 mothers, with a child less than two years old. In
September 2007, the LQAS survey was conducted in the Kvemo Kartli Region consisting of six
districts: Dmanisi, Bolnisi, Tetri Tskaro, Marneuli, Gardabani and Tsalka.
The sample size was 19 respondents/SA plus three additional SA for Rustavi city. The purpose of
the LQAS survey was to measure progress compared to benchmark data for MCH indicators to:
1) collect MTE data on health and nutrition status of children under five and women of
reproductive age; 2) Identify the impact of implemented interventions on health behavior
patterns; 3) Enhance capacity of ACTS staff in planning, conducting, data collection and analysis
of KPC surveys; and; 4) Revise the DIP and Action Plan based on the results obtained.
ACTS has made significant progress toward reducing maternal, infant and child mortality as
documented by the LQAS data.. Graph 1 shows that in rural villages with focus CSP each of the
seven process and results indicators for each of the four major intervention areas improved to
meet or exceed the MTE benchmarks. Five of the indicators changed to exceed the MTE
benchmark and 2 met the MTE benchmark. In comparison, Table 1 shows the magnitude of the
indicator change in villages with focus (intensive interventions) compared to villages that
received only regional type messages (e.g. mass media, government legislation) nonfocus CSP
intervention. In the focus villages all seven indicators met or exceeded the MTE benchmark
compared to the nonfocus villages where only 3 indicator changes met or exceeded the MTE
benchmark. Additional comparison of indicator changes in focus rural and urban settings are
summarize in Table 2 of the appendix. Each of the seven indicators in focus rural and urban
setting changed to met or exceeded the expected baselines. Significantly higher indicator change
values are observed in the focus urban setting than in the focus villages. Further investigation is
needed to determine actual causes of these differences.
A Call to Serve International –Mid-Term Evaluation Page 10
Chart 1. Baseline-Target-LQAS data for 6 SA of Kvemo Kartli with intensive focus.
Table 1a: Results by Intervention at Mid-Term Evaluation (2007)
Comparison of LQAS MTE Results in Focus and Non-focus Villages
MID-TERM 2007 (LQAS)
INDICATOR
BASELINE
(KPC)
2005
MTE
Target
2007
FOCUS
VILLAGES
rural
NONFOCUS
villages
rural
2009
End of Program
Target
Maternal and Newborn Care
(25%)
Behavior Process Indicator
1.Percent of mothers who could report
4 and more danger signs of pregnancy
5.4% 15% 44.7% 40.6% 30%
Behavior Process Indicator
2.Percentage of mothers who could
report 4 and more neonatal danger
signs
14.7% 30% 56.1% 44.9% 55%
Breastfeeding (20%)
Results Indicator
1. Percent of children aged 0-23
months who were breastfed within the
first hour after birth
Results Indicator
2. Percent of children 0-23months,
who were exclusively breastfeed for 6
months
39.5%
16.5
45%
30%
60.0%
57.2%
40.2%
38.8%
60%
60%
A Call to Serve International –Mid-Term Evaluation Page 11
Nutrition (15%)
Results Indicator
1.Percent of infants aged 6-9 months
who received solid foods with breast
milk;
41.7% 60% 63.0% 50.9% 85%
Pneumonia/Diarrhea (40%)
Behavior Process Indicator
1. Percentage of mothers who could
report at least 2 danger signs of
childhood illnesses
64.2% 75% 75.0% 60% 85%
Results Indicator
2. Percent of Children aged 0-23
months with diarrhea in the last two
weeks who were offered more fluids
56.3% 75% 76% 65.0% 85%
Table 1b: Results by Intervention at Mid-Term Evaluation (2007)
Comparison of LQAS MTE Results in Focus and Non-focus Villages
MID-TERM 2007 (LQAS)
INDICATOR
BASELINE
(KPC)
2005
MTE
TARGET
2007
FOCUS
VILLAGES
rural
FOCUS
CITIES
URBAN
2009
End of Program
Target
Maternal and Newborn Care
(25%)
Behavior Process Indicator
1. Percent of mothers who could
report 4 and more danger signs of
pregnancy
5.4% 15% 59.9% 63.0% 30%
Behavior Process Indicator
2. Percentage of mothers who could
report 4 and more neonatal danger
signs
14.7% 30% 66.2 69.6% 55%
Breastfeeding (20%)
Results Indicator
1. Percent of children aged 0-23
months who were breastfed within the
first hour after birth
Results Indicator
2. Percent of children 0-23months,
who were exclusively breastfeed for 6
months
39.5%
16.5
45%
30%
59.2
57.2%
62.3%
60.1%
60%
60%
A Call to Serve International –Mid-Term Evaluation Page 12
Nutrition (15%)
Results Indicator
1. Percent of infants aged 6-9 months
who received solid foods with breast
milk;
41.7% 60% 75.8% 78.9% 85%
Pneumonia/Diarrhea (40%)
Behavior Process Indicator
1. Percentage of mothers who could
report at least 2 danger signs of
childhood illnesses
64.2% 75% 95.9% 93% 85%
Results Indicator
1. Percent of Children aged 0-23
months with diarrhea in the last two
weeks who were offered more fluids
56.3% 75% 81.3% 91% 85%
New Tools or Approaches
Among the successful innovation techniques developed to engage people and build trust for the
CSP in the targeted regions was the building of a broad-based stakeholder network. This
inclusive stakeholder involvement is new for this region. It is broad-based and includes both
community leaders and religious leaders whom the community knows and trusts. Focus Group
Discussion (FGD) used as a method for qualitative monitoring and it is a new skill that the ACTS
team has gained during this CSP. FGD are new to the young women and grandmothers in Kvemo
Kartli, a historically isolated area where women have never before participated in such activities.
Involvement of the MOH and public health departments in the community-based training was
critical to program success. Community festivals infused with MCH messages were the first
festivals offered since the fall of communism in 1991. The events offered dances, songs, sports
competitions, award ceremony and traditional foods. Participants were diverse, with several
different ethnic groups represented. Three health fairs were held in Kvemo Kartli, with Georgian
military health units and the U.S. Military training and equipment health unit providing medical
staff, equipment and medical testing equipment. Incentives helped to recruit participants to
events and activities. Forms and posters were translated to the Azerbaijan language; and health
care professionals served as interpreters to overcome language barriers.
A Call to Serve International –Mid-Term Evaluation Page 13
CROSS-CUTTING APPROACHES
Community Mobilization
Successes and Lessons Learned:
Community mobilization projects have resulted in empowerment of women through discussion
group activities and education sessions. The discussion groups have encouraged women to use
healthcare services during pregnancy, childbirth and the postpartum period. Discussion groups
have served as a medium for identifying barriers that prevent pregnant women and mothers from
seeking care, such as transportation, cost factors and cultural inappropriateness. They have also
served as a means for learning about the technical competence, methods, and supplies used for
normal deliveries and obstetric emergencies at the health facilities. They provided opportunity
for the promotion of behavior change strategies to prevent medical problems through the early
detection of warning signs, followed by a referral to health facilities for treatment. Information
gathered from these sessions was synthesized to formulate guidance on how to implement
quality assurance systems and partnership agreements between health and referral facilities,
country government, NGOs, international PVOs, and donors.
The possibility of involving males, including fathers, in separate education sessions will be
explored. As influential figures in the households, fathers should be aware of the danger signs
during pregnancy and following delivery. The maternity clinics and hospitals have begun to
permit family members to be present and to participate in the birthing event. It is timely for the
CSP staff to conduct a pilot project to assess the potential for expansion. Regional Coordinators
could recruit local male volunteer as discussion leaders to lead these groups. Community
response in these hard to reach areas has been positive as shown by the large percentage of
mothers attending four or more ANC visits and the active participation in the FGDs. Program
activities continue to be monitored and modified based on data collection and FGD findings.
Constraints/Barriers Identified:
Barriers that CSP staff have encountered in efforts to involve the targeted women in these
communities include cultural restrictions and household decision makers at the village level. In
response, ACTS began forming focus group discussions (FGDs). Over time, this technique has
expanded to include women of reproductive age and interested family members. The FGDs
topics have included pregnancy, gestation, health and wellness, ANC and related behaviors.
Three Power Point presentations were used to show intrauterine fetal development with case
studies,andtwoothermessagesentitled“FiveRecommendationsforPregnantMoms”and
“NineRecommendationsforMotherofChildrenunder-five.”Themembershiphasbeen
expanded to include Mother-to-Mother Support Group and Female Family Member Discussion
Group. The MTE team monitored several of these presentations and found them to be of high
quality, with active participation by all members. To increase the number of births that are
registered, ACTS will explore a partnership with churches and mosques. When women were
asked how many regularly attend church/mosque services, all responded affirmatively. If
churches and pastors get involved in promoting birth registration, the number of births registered
could increase substantially.
A Call to Serve International –Mid-Term Evaluation Page 14
Communication for Behavior Change
Successes and Lessons Learned:
Muchoftheproject’sactivitieshavebeendirectedtobehaviorchangethoughlocalfamilies,
community leaders, political officials and health care staff by increasing knowledge on a variety
of behaviors related to proactive health practices and skills in recognizing illness signs and when
to seek treatment. Community leaders and health professionals have also been trained on IMCI
aspects of wellness and illness in order to be able to participate in the behavior approach
(Attachment G). Experienced mothers and grandmothers are involved whenever and wherever
possible.
BCC strategies are in place in the ACTS CSP. The project is continuously expanding on the
activities used to address major BCC practices. Increasing the immediate registration of new
births, the number of ANC visits per pregnancy, immunizations, facility deliveries and visits for
illness are some of the BCC targets. By expanding the areas for birth registration to churches and
through a voucher program, which rewards mothers for visiting an ANC at least four times with
a delivery at a healthcare facility free of charge development will continue toward BCC goals.
In addition, community-training sessions can be used to explain and encourage the use of
immunization cards, as well as serve as a platform to openly discuss home deliveries. By
addressing the subject of home births and scheduling visits for pregnant mothers to view birthing
areas at hospitals, community members will begin to rely on health facility services more. The
challenge is explaining the benefits of delivery in a healthcare facility without disregarding
traditional beliefs and cultural practices.
Education sessions regarding home deliveries will also focus on standardizing a list of
recommendedmaterialstohaveavailableforahomedelivery“birthingkit”.Similarly,withthe
treatment of childhood illnesses, visits to healthcare facilities are also being promoted, without
disregarding tradition or culture. This is also addressed through education sessions that focus on
health warning signs and symptoms pointing to need for professional care. These education
sessions are targeting men, since they influence decisions made on behalf of children and family
members.
As a result of BCC interventions, comparisons conducted at MTE indicate several improvements
in behavioral problems targeted by the FGD and measured 2007. These surveys found negative
attitudes and opinions related to local physicians and hospitals, fear surrounding the use of
vaccines and concerns regarding breastfeeding. This process of FGD, assessment of results, and
modification of future community sessions will become a standard operating procedure.
Emphasis will be directed to a clearer presentation of why choices in behavior have better or
worseoutcomes.ThisisbasedontheCSP’sapplicationofthebasisofBCC,whichstates
rational and cognitive behavior is stable even when artificial stimulators are of a variable nature,
specifically, participants should be aware of the necessity and benefits of their behavior choices.
The IMCI course is designed to help health workers acquire new skills to manage sick children
more effectively. Health workers may find it difficult to begin using these skills when they see
children in their health facilities. Often they need help in applying what they have learned during
A Call to Serve International –Mid-Term Evaluation Page 15
the course to their work situation. Follow-up after visits are another essential component of the
IMCI training process. A follow-up visit is designed to support the transfer, application, and
reinforcement of new skills acquired during training. At least one follow-up visit is conducted
within four-to-six weeks of the training course in order to assist health workers and health
facilities with the transition to integrated case management. Objectives of the follow-up visits
are: (1) Improvement in accepted clinical skills of the trained medical staff; (2) Identification of
the problems faced by medical staff; (3) Analysis of the results and improvement in
implementation of the program; and (4) Assessment of essential equipment available.
Using the follow-up visits, a trained supervisor can assist health workers to apply their recently
acquired knowledge and skills and overcome workplace challenges. Other follow-up methods
include supervising medical staff during patient visits, reviewing medical records and patient
charts maintained by medical staff, questioning caregivers after their visits, and practice skills
learned if there is time. Follow-up observations are recorded on special forms developed by
WHO that are later used to summarize information on two final reporting forms. An IMCI course
was conducted in 2006, the follow-up conducted between November 6th and 15th of that year
(Attachment G). During the follow-up visit, benefits of the program identified by the doctors
included:
 Easy to understand and use;
 Provides precise diagnoses;
 Details are foreseen by the program;
 Refers patients to hospitals when necessary;
 Reduces the necessity of therapy with antibiotics that are not approved;
 Reduces the frequency of complications and hospitalization;
 Important for children survival; and
 It's economical both for population and state.
Local government officials provide appropriate facilities for training sessions without charge,
with the understanding that ACTS will return to provide advanced training. The local community
invites ACTS to deliver health message at local celebrations and events. To enhance this working
relationship with stakeholders, ACTS asks all stakeholders to review information provided and
includes community representatives in this review process. In addition, stakeholders are provided
with a work plan of activities and invited to participate with ACTS in monitoring the plan. The
stakeholders are supplied with a list of training activities and statistical analysis for child health
from the baseline KPC on which the CSP is based. LQAS standards have been in use for
establishing parameters for both annual reports. ACTS CSP staff has been trained on-line,
through the Johns Hopkins University outreach training in conjunction with CSTS.
Primarily, the CSP engages mothers, mothers-in-law, and pregnant women in-group and
individual sessions based on concerns generated through surveys, the DIP KPC, and issues raised
during community focus group sessions. As the CSP are implemented, additional facets of
knowledge and needs for counseling will become more specific. The second level of counseling
is through partnerships with local and regional level officials regarding the management and
operationalofthepartnership’smutualneedsandcapacity-building aspects. Community-based
focus is based on modified UNICEF IMCI training and standard CSTS components of
empowerment.
A Call to Serve International –Mid-Term Evaluation Page 16
Regional officials engaged in a workshop held in Rustavi, which was attended by about 30 key
persons representing administrative, medical facility staff, USAID, and the ACTS CSP
implementation Team. The various needs for documentation and data have been recognized. A
secondmeetingwouldbebeneficialtofurtherdefinetheCSP’srole,aswellasindividual
contribution and ownership of the program.
The MTE process was not able to develop a format or evaluation mechanism for measuring
either the extent that the partograph is used, or what necessitates its use in the process of
Managing Complications in Pregnancy and Childbirth it might be used. The MTE team,
therefore, recommends this tool be assessed during the next operational year and assessed as part
of the Final Project Evaluation.
ACTS has researched mechanisms for understanding and implementing tasks and strategies
established in the development of the DIP. Their expanded search for communication in
Behavior Change included an exchange visit to Mercy Corps CSP in nearby Azerbaijan. In June,
2006, ACTS Georgia team members, including Drs. Trish Blair, Ketino Shangria, and Nana
Gumbaridze, traveled to Azerbaijan to participate in the Mercy Corps CS Final Evaluation
conducted by Sandy Wilcox. In the fall of 2006, ACTS Georgia CSP leaders, Dr. Rezo Tataradze,
ACTS Georgia CS Director, Dr. Tamar Lobjanidze, district coordinator, Ms. Liana Ushveridze,
financial manager and others traveled to Azerbaijan to observe the Mercy Corps program first
hand and to discuss areas of interest between the two programs.
With respect to data collection on program activities, ACTS Georgia CSP staff, other
implementation partners, and the MoLHSA are making use of findings and decision-making
based on data and collaboration.
ACTS CSPTeaminitiatedthe“HealthyMomsforHealthyKids”festivalwhichwasconducted
in Dmanisi. It was described in the media as an event in which about 2,000 participants learned
about improved healthy practices and behaviors based on themes of nutrition and health. ACTS
Team organized the festival in collaboration with USAID, World Vision, Alliance for Improved
Nutrition of Georgia, Tbilisi Lions Club, and the Dmanisi Administration. The project will be
continued in five remaining regional centers of Bolinisi, Tetritskaro, Tsalka, Marneuli and
Gardabani. Four additional health fairs were conducted in collaboration with the US military.
During these fairs, free examinations and health screenings were provided and healthy behavior
sessions were conducted. These approaches will be expanded and continue to focus on healthy
mom and kids. About 200 women, children and men were given check-ups, training and blood
pressure screening by U.S. Military personnel.
The CSP will add a behavior change marker to the community training sessions. Staff will design
and distribute cards for mothers to return to any health service center they attend. Any service,
either prevention or curative will collect these cards and simply place them where they can be
collected on a monthly basis. The CSP staff will analyze focus groups data to determine
breastfeeding barriers that can be addressed by behavior change modification and motivational
techniques. Concerns raised during the FGDs will be used to determine knowledge gaps on
breastfeedingandtogatherinformationoninfluenceswhichaffectwomen’sdecisionsregarding
A Call to Serve International –Mid-Term Evaluation Page 17
breastfeeding. Formation of male discussion groups focusing on pregnancy and breastfeeding
issues is also being considered.
ACTS has taken the lead in iron and foliate enrichment of flour in Georgia. It was officially
passed into law that such fortification additives become mandatory.
Future Recommendations for the CSP:
The MoLHSA is working with ACTS and other PVOS in the health care sector to identify as a
top priority the development, enactment into law and training for all Georgian physicians on
international standards and guidelines. ACTS successful CSP program should continue to:
 Work with the GOG at national regional and local levels.
 Maintain and nurture the broad-based network of stakeholders in the targeted regions.
 Invigorate the community with community pride and health messages through the
innovative use of the community festival and health fair approach.
Based on findings, data collected, and lessons learned from the implemented program
activities, future objectives for the CSP should include:
 Physician Skills Improvement and Sustainability: Work with the MOLHSA to develop an
evidence-based continuous medical education program for physicians that would include
training follow-up and direct observation of practice.
 Community Education: Improvements in community training session content should be
based on repeated field experiences, continued FGDs, surveys and expanded types and
participants, such as mother-in-law, father, and grandfather education and support groups.
Mother-to-mother BF support groups should be explored.
 Improve Health Issues: In addition to flour fortification program to combat anemia, there
is the need for comprehensive de-worming assessment with funding non-CSP /MoLHSA.
 Protection of Health of Physicians: Advocate for Hepatitis A vaccine to be included in the
Hepatitis B vaccination program that will launch in 2008 by VSP.
 Behavior Changes and Capacity Building: All post soviet countries were part of the same
health care system. Visiting other CSP programs in the former Soviet Union and
developing training and monitoring tools specific to this region where 94% of all
deliveries are hospital-based. Mechanisms for establishing behavioral change measures
and proxy measures conducted as operational research; this is new for many PVOS in
Georgia. CSP should consider additional trainings, such as BEHAVE course using CSTS
and other consultants. ACTS Georgia should continue partnership and dialogue with
MoLHSA, as national health sector reform is designed and implemented. ACTS
International and ACTS Georgia will continue assessing transition of clinical and hospital
facilities from government-owned to private management through facility assessment of
clinical proficiency and essential equipment. The establishment of life-saving conditions
and support with MoLHSA for full-term infants, perinatal, and neonatal aspects should
continue. Full coordination with UNICEF, USAID, WHO and CSP activities should
continue. ACTS Georgia will continue to assess progress and identify problems through
HIS system, LQAS, Focus Group Surveys, additional surveys and track progress on
monthly basis. Management and programmatic decisions will be made on basis of
findings from data collected and analyzed. ACTS Georgia will provide USAID Mission
with routine 3-to-4-paragraph briefing monthly to keep communication flowing.
A Call to Serve International –Mid-Term Evaluation Page 18
Capacity Building Approach
ACTS International and ACTS Georgia are implementing sustainable MCH programs through
improvements in strategic planning, organizational and human resources development, and
management information systems. ACTS is working to improve capacity of its local partner, the
MoLHSA and selected health care facilities of the two target regions, to deliver and sustain the
delivery of effective, high quality MCH programs. Clinical facilities and equipment inventories
were assessed during the MTE by ACTS International. Their findings form a component to the
DIP interventions for savings the lives of mothers and children at birth. Remedial actions for
replacing equipment and other lifesaving essentials will be undertaken by the U.S. Department of
State and ACTS International. Enhanced training and development of protocols will be provided
by MoLHSA. ACTS International established a multi-year contract with Horizon Research
Services (HRS), a U.S.-based private research company, to assist both HQ and field staff in
achieving these goals.
Table 2: Objectives and Indicators for Assessing Success in Achieving Specific Capacity Building
Objectives
Objectives Indicators # Completed
To increase MCH technical knowledge
and skills among staff at all levels.
 No. of HQ staff that have participated in CS
technical workshops and worked on a CSHP project
 No. of field staff that have participated in CS
technical workshops and worked on a CSHP project.
6
10
To increase use of latest CS
technologies.
 No. of ACTS health projects that use CS
technologies, such as the BEHAVE framework
6
Improve data collection and analysis in
health programming.
 No. of programs that replicate methods used in the
implementation of the CSHP (e.g., survey
methodologies and analysis).
1
To scale up/expand successful models.
A CTs is the lead organization with
Georgia Parliament implementing
National Flour fortification.
 No. of health project that include components that
can be scaled up (e.g., social mobilization, volunteer
recruitment and retention, community education,
etc.) the flour fortification program is underway.
national flour
fortification
program is
underway.
Share and integrate lessons learned into
health and child survival programming.
 No. of discussions/seminars arranged at both HQ
and field level to share lessons learned.
10
Progress in meeting these objectives has occurred within ACTS International and ACTS Georgia,
with local partner organizations, in health facilities, with health worker performance and through
training implemented.
Strengthening the Grantee Organization has been accomplished by addressing the goals of: a)
expanding programming capacity in Child Survival, Reproductive Health, and MCH; b)
developing partnerships with other NGOs, particularly those with strong community presence in
the targeted rural areas; and c) building staff capacity to design, implement and evaluate
evidence-based practice in Child Survival and Reproductive Health. Capacity-building progress
within the grantee organization has included the development of monitoring systems, increasing
competence and skill levels of program staff, and establishing a new program office.
A Call to Serve International –Mid-Term Evaluation Page 19
ACTS International and ACTS Georgia have worked in the health arena in Georgia for more than
10 years. ACTS became the first U.S. NGO in Georgia and has worked closely with the
MoLHSA, the Georgian National Center for Disease Control and Public Health, and with U.S.
PVOs working in Georgia. A unique quality of ACTS International and ACTS Georgia has been
its sustained directorship and staffing, resulting in continuity of programming, community
relations, and reliable memory. ACTS Georgia has undertaken a development role in the health
arena (i.e., supporting of the Georgian Medical Association and the National Georgian Family
Physician’sAssociation,providingadvisoryservicestoParliamentaryCommitteesandto the
MOH), as well as in NGO development and establishment of nation-wide health-related
coalitions (Cardiovascular Prevention Committee, Health Promotion Alliance). This phase of
Georgia’sadjustment,whichhascreatedboththeneedandtheopportunityfor ACTS
International to expand efforts in humanitarian aid and development, includes undertakings
toward sustainable, community-based health programs in MCH.
Monitoring systems in place to measure the activities of program staff and CSP include:
 Weekly staff coordination meetings
 Monthly and quarterly reports of the senior program staff to the Program coordinator and
Chief Medical Officer (CMO) and the HQ backstop
 Monthly timesheets to ACTS HQ
 Monthly and Quarterly financial reports to ACTS HQ
 Quarterly Match contributions to ACTS HQ
 Routine constraint identification with cause and effect analysis
To develop the capacity of the staff to measure program change, a three-day staff orientation
workshop was organized between January 12th and 14th, 2005. The objectives of this workshop
included: (1) Discussion and review of activities to determine what worked well and design
strategies to improve weaker areas; (2) Briefing on key objectives and strategies; and (3)
Informing staff about the upcoming KPC survey, timeline, and logistics. The goal of this
workshop was to prepare the staff to effectively implement the project using the key approaches.
Other trainings have included: CORE-based web education, Three-part Monitoring and
Evaluation (LQAS) –on-line access to CSTS quality tools for implementation, management and
measurement of CSP, CORE/USAID/CSTS meetings and training (e.g. Core spring and fall
meetings), BEHAVE training, CSTS operation research training, in-country training by ACTS
HQ staff and consultants and USAID mission coordinating meetings special events and
presentations (e.g. World Health Day).
ACTS International has provided technical expertise to ACTS-Georgia for program evaluation,
building upon well implemented monitoring systems that ACTS-Georgia has developed to track
program outputs. ACTS International will assist its local partner in expanding skills in
quantitative and qualitative data collection for effective program development. ACTS
International will continue to support enrichment of staff through on-the-job training, exchange
visits to other Child Survival projects, participation in U.S.-based public health program training;
and university exchange programs and scholarships to build its skills for maternal and child
health projects and participation in CORE Group activities.
A Call to Serve International –Mid-Term Evaluation Page 20
A Division of Maternal and Child Health has been created, with a non-voting representative on
the ACTS Executive Board through the Division Director, who will participate in all strategic
planning processes undertaken by the full Board and the President. This Division will provide
coordinated oversight for MCH programs generated by ACTS International and ACTS Georgia
for Georgia, as well as for other countries of interest. The major challenge for ACTS Georgia
CSP is linkage with facilities and partners for continued technical support.
Future ACTS Georgia organizational development will be measured by 1) Conducting regular
organizational reviews (Direct Observed Self Assessment [DOSA]); 2) Conducting outcomes
assessments and evidence-based decision making to select program interventions; and 3)
Creating professional development training program based on an annual assessment conducted
jointly by ACTS International and ACTS-Georgia. ACTS International will further expand and
enhance its capacity to plan and implement effective community-based health programs in CS
and health. The transition phase of Georgia's adjustment to its status as an NIS soon will close,
and that is creating the need and the opportunity for ACTS International to expand its efforts in
humanitarian aid and development to include sustainable, community-based health programs in
maternal and child health.
On-going staff activities will include: establishing milestones for the remainder of the CSP based
on the delivery of sustainable components, continued selection of health care and service care
providers on the basis of their capacity to change, inclusion of national, regional, and local
partners and focus on community organizations and groups such as families. Other areas of
specific focus for capacity building will include:
 Increasing capacity to assess CSP progress in implementing DIP interventions
 Improving community and focus groups monitoring supported by the project and to
provide appropriate data sharing numbers and specifics on clients served
 Devising a formal means of sharing and communications with, to and for all partners.
 Web camera communication system to enhance HQ and field communication.
 Website containing all of ACTS CSP document and other useful resources for use by the
ACTS HQ and Field offices and consultant and by special request.
 Visit to the Mercy Corps CSP Azerbaijan program; participation by staff in the final
evaluation of the Mercy Corp CSP Azerbaijan program
A new Georgian field office was leased to increase capacity of ACTS to implement the CSP.
Several factors were considered in selection of an appropriate office space (e.g., size, cost,
security and availability of electricity and telephone services). The central field office is located
in Tbilisi and readily accessible to staff. Within the program area, the field offices were open and
their location was chosen so that they are easily accessible to beneficiaries and partners. Some
basic items were procured, including, computers, printers, radios (HF and/or VHF), furniture,
and stationary. Program vehicles were also purchased at the start of the program with matching
funds. The new office space allowed the CSP to develop a reference library to provide technical
manuals and other publications on child survival, maternal and child health, evaluation and needs
assessment, among other topics (including CSTS, CORE, and the BEHAVE reference materials).
The Maternal and Child Health Resource Library in Georgia is being used by the CSP staff and
by the Tbilisi State Medical School among other Georgian entities.
A Call to Serve International –Mid-Term Evaluation Page 21
Capacity building at the local level is encouraged. Local government officials provide
complementary facilities for trainings, and invite ACTS to provide advance training. The local
community invites ACTS to deliver health messages at local celebrations and events. To enhance
this relationship with stakeholders, ACTS involves all stakeholders in the review process of the
information that CSP staff provides to the community. In addition, stakeholders are provided a
working plan of activities and invited to join ACTS in monitoring the plan. They are also
supplied a list of trainings and statistical reports on which the CSP is based.
MCH technical skill development is achieved through continued professional education
activities. Drs. Tsilosani and Tataradze, supported by the WONCA Bursary Fund for the 17th
World Conference of Family Doctors in conjunction with the American Academy of Family
Physicians (AAFP) Scientific Assembly, attended the Advanced Life Support in Obstetrics
(ALSO) courses in Orlando, Florida in October 2004. The ALSO Provider Course is a two-day
course for all maternity care providers including physicians, nurse midwives, registered nurses,
and other clinicians. Using an evidence-based curriculum, the course provides lectures and
interactive workstations, utilizing pelvic mannequins and other activity-appropriate medical
equipment. A one-day course, the ALSO Instructor Course focuses on specific teaching skills
required for adult learning, including how to teach interactive workstations and workstations
using mannequins and other equipment; and how to give feedback, lecture and teach
workstations using slides. Drs. Tsilosani and Tataradze successfully completed provider and
instructor courses. As result of the training that Drs. Tsilosani and Tataradze received at the
ALSO course, ALSO provider and instructor courses were administered in Georgia in November
2004withintheframeworkof“PhysicianswithHeart,”aPartnership of the American Academy
of Family Physicians, the American Academy of Family Physicians Foundation, and Heart-to￾Heart International. The ALSO training was supported by a grant to ACTS Georgia from USAID
to fund materials and travel for 60 doctors throughout the country to attend this course.
Assistance has also been provided to ACTS by friends and colleagues at World Vision. Thanks
goes to the late Lyndon Brown, MPH and Fe Garcia, MD, MPH who expressed willingness to
provide information and materialsonCSthathavegreatlyimprovedACTS’capacityforprogram
success.
ACTS will establish a resource data bank of MCH-relevant national and regional data, reports,
articles, and program descriptions for use among the network participants. Through conferences,
symposia, training workshops, collaborations, publications, and annual partner meetings, CS best
practices will become integrated into the health and social service programs of Georgian-based
organizations. As a result of participation in the MCH network, member agencies will increase
their capacity to deliver quality MCH programs and integrate MCH into related program efforts.
For example, Claritas has extensive expertise in the BFHI, an initiative that almost exclusively
focuses on breastfeeding; training in BCC principles and the selected MCH interventions can
onlyexpandthecapacityofClaritas’programefforts.
ACTS Georgia is providing leadership in MCH for collaborating partners by giving them the
training and expertise necessary to integratethisproject’sactivitieswiththeirown.Thelong
established and effectively functioning working relationships between ACTS International,
ACTS Georgia, and MoLHSA, along with a history of NGO support, development and
collaboration, makes sustainable programming efforts a reality.
A Call to Serve International –Mid-Term Evaluation Page 22
Strengthening local partner organizations has been accomplished through the continuous sharing
of CSP information, training, and services. In addition to signing a Memorandum of
Understanding (MOU) with the MoLHSA on March 25th, 2005, successfully negotiated
agreements with CSP partners included:
 Ministry of Labor, Health and Social Affairs (MoLHSA) of Georgia and its Public Health
Department
 CRPA/Claritas XXI
 WomenWellnessCareAlliance“HERA”(WestGeorgia)
 Union for SocialProtectionofCitizensofGeorgia“Tanadgoma”
 Vishnevskaia-Rostropovich Foundation (VRF) for the Health and Future of Children in
Georgia (NGO in Kvemo Kartli)
A capacity assessment was completed to determine the training needs of program staff and
partners after agreements were in place. A pre-implementation workshop was held to orient
partners to the program and to encourage commitment from a larger group of stakeholders.
Participants in the two-day workshop included health center staff, rayon (district) health facilities
staff, regional health department staff, district and commune chiefs and representatives from
health-related PVOs working in targeted regions. The workshop informed stakeholders about the
CSP, explained how the program fit with ACTS’othercommunitydevelopmentactivitiesand
helped ACTS gather stakeholder input regarding implementation issues. The workshop was
successful in building participation, cooperation and ownership in the CSP, and provided helpful
feedback for planning early activities, in particular the KPC baseline survey.
Diagram 1: Roles and Responsibilities of the Local Partners
A Call to Serve International –Mid-Term Evaluation Page 23
No changes have been made from the roles and responsibilities outlined in the original DIP.
The MTE found that throughout the first half of the project, partners have been involved in
considerable capacity building activities at all levels, especially through their participation in
Health Facilities/Health Worker Strengthening that included participating in training, quality
improvement, supervision/ supportive supervision, establishing links with the communities,
materials/equipment and strengthening of meetings. Local partner capacities have increased to
meet the organizational objectives and goals throughout the CSP, including expanding skills for
qualitative and quantitative data collection. Challenges faced during the rest of the project will be
the continued monitoring of program activities; however, through the increasing data collection
skills of the local partner organizations should be manageable.
Health Facilities strengthening has occurred throughout the project to examine the equipment
available and used, as well as the staff performance in relation to maternal and child health
procedures. The professional ACTS International MTE Team members conducted their facility
and review (Annex E). Concerns were raised regarding equipment, sterile conditions, and the
physical condition of the facilities visited. While these reports are of professional quality, their
relevance to the CSP is tangential to the DIP implementation and the MTE exercise. ACTS
International and the U.S. Department of State have on-going ventures operative to address
facility equipment upgrades and the replacement of related maternity and infant care and
resuscitation essentials. A Health Facility Survey, results of which will be used during the second
half of the project implementation period, was completed in the following locations:
 Dmanisi Ambulatory and Polyclinic Unit, maternity hospital
 Bolnisi Pediatric Polyclinic and Maternity Hospital
Concerns were raised regarding the health facilities center around a need for a sustainable and
standardized store of equipment. Given that asphyxia accounts for 36% of fetal deaths this must
be the major focus. High risk screening and improved prenatal/obstetrical care are important for
reducing this number, however, the staff must be prepared to resuscitate the infant in any
pregnancy. The ABC of resuscitation must be available. All hospitals had rubber suction bulbs to
help clearairwaysfollowingdelivery.FatherAdam’shospitalwastheonlyhospitalatwhich
suction appeared available, it was a very old soviet portable machine that still worked and that
was carried from the C-section room to the delivery room. For meconium deliveries they had
A Call to Serve International –Mid-Term Evaluation Page 24
suction adaptors for ET tubes. All hospitals, except Dmanisi which had none, seemed to have a
single laryngoscope with some but not all size tubes which in several cases was in a plastic bag
which was taken to each delivery and the nursery as needed.
ACTS has supplied facilities with these materials (through another funding source and program);
and the CSP has focused on promoting the creation of a standardized equipment list. The next
step will be to find sustainable sources to acquire the equipment needed. ACTS will work with
the Department of State and private donors to remedy problems encountered as part of our
response to lessons learned. The community is affected by the capacity of the health facility, as
shown by results of FGDs in the second year of the project. These suggested that women feel
safer with health facilities in larger cities, specifically with the equipment used and the healthcare
staff employed. If standardized equipment becomes available in each health facility in the
program area, community members may gain trust for the services rendered and be more likely
to use the services of local health care facilities.
Strengthening Health Worker Performance has been accomplished through training of medical
personnel in IMCI, BF Hospital, and Breast Feeding has been conducted (See chart that follows).
Table 3: Health Worker Trainings Conducted in Rustavi
Trainings
Conducted of
Medical Personnel
in Rustavi
Quantity Facilities
Category of
Trained
Personnel
Number of
People
Trained
Duration
of
Training
Person Days
of Training
1) Integrated
Management of
Childhood Illnesses
(IMCI)
3 courses
Prophylactic
Centers # 1
& 2
Doctors and
Nurses 137 11 Days 1,507 Person
days
2) Baby-Friendly
Hospital Initiative
(BFHI)
3 courses Maternity
House
Pediatric
Doctors 60 5 Days 350 Person
days
3) Breastfeeding 2 courses Maternity
House
Pediatric
Doctors 60 5 Days 350 Person
days
3 Interventions 8 courses 6 training
sites MDs & RNs 257 21 days
2,207 Person
days of
training
Site visits were used to assess performance of health workers. Assessments of health facility staff
have shown that salary payments are low, but on time, and the staff remains highly motivated
and dedicated to health care service and disease prevention. In addition, the staff provides
thorough reports on incidents of cranial hypertension in infants from cause or causes unknown,
as well as conducting disease surveillance and follow-up on communicable diseases. Site visits
have allowed for open communication between health facility staff and CSP staff, which has
increased the ability of CSP staff to address the issues raised. One example has been recognition
of the inadequate amount of equipment available at some of the health facilities. Through site
visits this problem was observed and strategies to improve the situation were developed. A
standardized list has been developed of essential equipment for child and maternal care. Special
A Call to Serve International –Mid-Term Evaluation Page 25
attention was focused on equipment and procedures needed for infant delivery room resuscitation
and the necessary equipment and physician training.
The project is responding to gaps between performance standards and actual performance by
introducing vigorous training of medical personnel in the field of MCH, using guidelines
developed and/or recommended by the WHO Child and Adolescent Health Department. These
standards are being applied to both preventive health and management of illnesses. IMCI serves
as a main strategic approach to the problem of less than five morbidity and mortality. This
strategy involves preventive and curative components. Following IMCI guidelines contributes to
the improvement of case management skills of health workers through improvement of the
performance of the referral level facilities. As a result of training conducted, health facilities are
using the List of Essential Drugs complying with Eleventh WHO Model List of Essential Drugs
to manage illnesses in lactating mothers.
A four-day seminar for community representatives was held on the basis of Pediatric Clinic of
Rustavi region on November 8th through 12th, 2006. Twenty-eight community representatives
attended the seminar that was held by the trainers: K. Sharangia, M. Beleshadze, and N.
Gumbaridze. Special attention was dedicated to: safe motherhood, breastfeeding, early child
development, healthy nutrition, immunization, diarrhea, cough and cold, and patient rights.
Among seminar participants were representatives of medical staff, teachers, students, housewives
and community counsel. The majority of participants were unaware of the information on the
issues discussed at the seminar. The population became acquainted with state guarantees and
patient rights with special interest. Pre- and post testing was held for the attendants.
Diagram 2: Pre- and Post-Test Results
A coordinative counsel was created for each community with access to a doctor, nurse and
community representative. The aforementioned counsels will supervise activities of the
community representatives and actively participate in the process of community education.
Sustainability Strategy: To date, data collection has included an analysis of focus groups of 170
women in order to gather knowledge, practices and the coverage of services concerning maternal
and child health. Findings from these FGDs included concerns about all live births being
registered and reliability of local doctors and maternity facilities. Many women felt that clinics in
larger cities were safer and better staffed. Site visits have taken place to observe the equipment
available for use in healthcare facilities, as managing postpartum hemorrhages and preventing
hypothermia are two main ways to reduce maternal and infant mortality. The current Perinatal
15%
60%
Pre-test
Post-test
A Call to Serve International –Mid-Term Evaluation Page 26
Assessment Survey supported by UNCIF reported that basic supplies and equipment for assisting
in deliveries were available at a majority of perinatal care providers. However, essential items for
newborn resuscitation and life support, such as resuscitation bags and masks, endotracheal tubes,
and umbilical catheters were not found in 7%, 20%, and 23% of cases, respectively. ACTS has
served as a conduit for the import of drugs and medical equipment for healthcare facilities in the
project area. In order to sustain equipment capacity, standardized lists have been created to
display the essential equipment that should be in each facility. This is the first step in regulating
the equipment necessary to perform safe procedures.
The USAID/GH/HIDN/Child Survival and Health Grants Program recommend a six-step process
for sustainability planning and measurement. This process was adopted by CSP and is reflected
in the sustainability plan. The following indicators have been selected to measure sustainability:
 Percent of infants, aged 0-5 months that were fed breast milk only in the last 24 hours
(KPC; LQAS).
 Percent of children aged 0-23 months who were breastfed within the first hour after birth
(KPC; LQAS).
 Percent of children aged 0-23 months with diarrhea in the last two weeks who were
offered more fluids during the illness (KPC; LQAS).
 Percent of mothers who know at least two signs of childhood illness that indicate the
need for referral to health care services (KPC; LQAS).
 Percent of children aged 0-23 months with diarrhea in the last two weeks who were
offered catch-up feeding (KPC; LQAS).
 Percent of households who know how to use and store iodized salt (KPC; LQAS).
Health Service Characteristics
 Number of HF-based providers who receive continued education in IMCI protocol.
Local Organizational Capacity
 Percent of community leaders who will have met at least once per last two months.
 Percent of MMSG who have met at least once per last two months.
Local Organization Viability
 Percent of the community leaders meetings attended by local health providers
 Attrition rate of volunteers for reasons other than death, disability or movement from
project area.
Community Capacity
 Percent of the villages with defined community leaders
 Percent of the villages with defined mother-to-mother support groups
All CSP maternity houses and units will undergo an external assessment process to evaluate the
implementation of a ten-step breastfeeding initiative in the facilities. Primarily, facilities deciding
to become Baby-Friendly Hospitals will conduct a self-assessment and send the results to
Claritas XXI. The representatives of the NGO will review the results and decide if the hospital is
ready for an external assessment. Prior to the assessment, an audit visit will be conducted in the
facility to determine the time to full implementation of the standards and to highlight any weak
areas that need attention. The audit visit lasts a full day and is run by two initiative external
evaluators. It consists of interviews with randomly selected staff, pregnant women, and new
mothers, using the same questionnaires and principles as are used at a full Baby-Friendly
assessment. Findings and recommendations are reported at the end of the visit, as well as in a
A Call to Serve International –Mid-Term Evaluation Page 27
written report. Following the pre-assessment visit, the full assessment is conducted by three
external evaluators over three days. The assessment examines whether the Baby-Friendly
standards are met. Findings and recommendations are again presented. If the health care facilities
do not meet all of the standards, they are given time to implement changes and members of the
assessment team return for an assessment at a later date.
Local staff and partners have been involved with the sustainability strategy. In regards to
personnel and operational project costs, financial planning for the duration of the CSP included
higher start-up costs so that for the tapering of the project, fewer funds will be needed.
Alternative funding options have been examined for certain aspects of the CSPs. Specifically
with the sustainability of essential equipment in health facilities, next steps in the project will be
to determine alternative funding through local partners, so as not to rely solely on ACTS
International. No formal sustainability design methodology was used.
A Call to Serve International –Mid-Term Evaluation Page 28
PROJECT MANAGEMENT
PLANNING
The groups involved in planning are USAID Tbilisi, JSI T&R Institute, Curatio, Abt/CoReform,
VRF,UNICEF,MoLHSA/Parliament,and “Claritas”.Projectobjectiveshave remained
consistent with those listed in the DIP:
1. Improved quality of maternal and child survival services
2. Improved behavior and household health practices, in the community and among health
care professionals and health managers
3. Increased availability of Maternal Child Health (MCH) care services and increased
access to standard case management.
All partners and stakeholders were given copies of objectives. During project start up, two
workshops were conducted for all parties explaining project goals, objectives and strategies. The
translated project outline was distributed and issues were discussed in these workshops.
STAFF TRAINING
The current CSP is the first for the country of Georgia and also the first such USAID grant
project for ACTS. Being the pioneer in this area has required that ACTS train and support the
headquarters and field staff and introduce the project to the Georgian government, including the
MoLHSA, the Georgia Parliament, and newly created Georgian CDC. There are three levels of
training that have been provided. Training has been provided for the ACTS board of directors
and headquarters staff in areas of financial and program reporting requirements to enable
effective project oversight. Headquarters and field staff attended a new grantee orientation
(2004), a private meeting with Liza Buckner, USAID Washington (2004), subsequent meetings
on financial and compliance training (2005-2007). A 2007 financial training was provided for
headquarters accountant by headquarters staff.
Key members of the ACTS field team (chief medical officer, program director and program
manager) have attended specialized trainings, including: USAID/CORE training in KPC/LQAS
(2003), USAID new grantee orientation (2004), Mini-University (2004), Update training (2005).
The field office program manager provides training for Georgia staff and community volunteers
involved in program implementation and evaluation. The KPC survey supervisors (initial survey
in 2005 and for the MTE in 2007) were trained by Eteri Suladze, Program Manager. Eteri was
trained in 2003 in a 2-week intensive USAID CSTS/CORE training in the U.S., along with one
headquarters staff on KPC and LQAS survey technique. In addition, Ms. Suladze provided the
trainings for the focus group leaders. ACTS consultant, Dr. Keti Shrangi has been trained and
certified (maintains this certification at her own expense) by the WHO BF Hospital certification
program. Dr. Shrangi trains ACTS Georgia and local hospital staff in targeted areas.
A Call to Serve International –Mid-Term Evaluation Page 29
SUPERVISION OF PROJECT STAFF
ACTS Georgia staffs have effectively implemented the CSP program in regions of Georgia that
are hard to reach. Historically the Kvemo Kartli area has been difficult to work in for new
programs implementing behavior change interventions. ACTS Georgia has been uniquely able to
engage the population by selecting and training regional staffs that are representative of the local
populations who can deliver excellent and culturally competent programming among the diverse
populations that reside in these areas.
ACTS Georgia has been able to develop a supportive health network of regional coordinators,
community leaders, stakeholders and regional government officials who are working together to
promote, plan and implement local events, such as health fairs, focus groups and education
sessions. Because of the unique needs of the region, but due to limited resources, ACTS focused
geographically on six smaller sub-regions. These sub-regions got results that were at or above the
target zone. The general information has been useful and the KPC results have shown that the
interventions have been useful. The CS program has prioritized its focus on areas of greatest
need so that the project would be appropriate and realistic to the staff capacity and resources
available for the project.
HUMAN RESOURCES AND STAFF MANAGEMENT
All job positions for the CSP are filled, personnel procedures are in place, and job descriptions
are located at HQ. As found during site visits in program areas, personnel are highly motivated
with the program goals. Attention and professional development is provided to staff through
orientations, workshops, and trainings, which is turn assists in the creation of ownership of the
program. Plans for assisting staff with paid positions following the cessation of the CSP duration
will be implemented and followed for the remainder of the program period. Staff turnover has
not been an issue during the program period.
FINANCIAL MANAGEMENT
The MTE Team concludes that the ACTS Georgia CSP is well planned, managed, and
productively supervised. The CSP start-up costs were front-end loaded; therefore operational
costs during the last half of the project will need good management, which is in place as shown
by the Management Plan. The following table displays the CSP position and their LOE.
A Call to Serve International –Mid-Term Evaluation Page 30
Table 4: CSP Staff Positions and Level of Effort
Management Plan
Position No. Affiliation Main Duties LOE
(%)
Paid/
Volunteer
PVO –HQ
Chief Medical
Officer 1
ACTS
Int’l.
Technical oversight and support for project; Lead DIP
preparation, communicates with USAID. 20% Paid
Fiscal Officer 1
ACTS
Int’l.
Processes cash draw downs, transfers cash to the field,
prepare SF269 and monitors country finance and budget. 50% Paid
Administrative
Assistant 1
ACTS
Int’l.
Backstop program management and service point of
contact for program related issues. 50% Paid
Field Office
Project
Coordinator 1
ACTS –
Georgia Provides general oversight for project. 100% Paid
CS Country
Director 1
ACTS –
Georgia Provides project directions and programming guides. 100% Paid
Project
Manager 1
ACTS –
Georgia
Overseeing planning, implementation and evaluation of
the project activities. 100% Paid
Financial
Officer 1
ACTS –
Georgia
General accounting duties, petty cash functions,
completes general ledger. 100% Paid
Office
Manager 1
ACTS –
Georgia Executes routine administrative staff 100% Paid
Project
Director’s
Assistant
1
ACTS –
Georgia
Assists project director and project manager in office
administrative work including all required paper work,
data entry into computer, organization of work meetings
and workshops on the suites
100% Paid
District
Coordinators 4
ACTS –
Georgia
Coordination of project activities at the district level,
development of work plans, coordinating with IMCI and
MNC coordinators, ensuring training facilities and
supplies delivery to training sites.
100% Paid
IMCI
Coordinator 1 Claritas
Training events planning, calendar scheduling,
coordination of materials preparation, adaptation of
curricula, conduction of trainings.
50% Paid
MNC
Coordinator 1 Claritas
Training events planning, calendar scheduling,
coordination of materials preparation, adaptation of
curricula, conduction of trainings.
50% Paid
LOGISTICS
The professional assessment of staff and facilities completed by the two professionals should be
carefully reviewed from the perspective of ACTS International and criteria should be designed
for seeking resources and equipment where possible. While the original DIP did not include
plans for purchase of hospital equipment or facility restoration, site visits prior to and during the
A Call to Serve International –Mid-Term Evaluation Page 31
MTE report findings on the necessity of these expenses. These investments could provide
MoLHSA partners with incentive to restore other facilities outside the CSP area. One challenge
is that the Health Information System (HIS) does not collect data on health worker performance;
however, through routine site visits by CSP and local partner staff this aspect has been observed.
INFORMATION MANAGEMENT
The routine system includes collection of the data by facility-based staff and recorded on
standard reporting forms to public health district level that are sent to higher levels in the system.
Relevant data has been used to monitor and evaluate elements of program performance and
progress towards CSP targets. The advantage of this method is that it uses routine systems and
does not require additional resources. At the same time the official statistical data frequently
differ from data of other surveys, so monitoring cannot be based only on official data, as the
quality of the data is questionable.
The M&E plan is based on a series of data sources and methodologies that are complementary
and will provide information on different levels of health system and community-based
activities. Each project intervention has a particular M&E plan with different information needs
and each uses different M&E instruments and methodologies. Progress toward achievement of
objective outcomes is measured through baseline and final population-based surveys in years 1
and 5. Monitoring surveys continue to be used to evaluate effectiveness of the BCC strategy
efforts. Annual evaluations continue to help refine messages and improve intervention design.
Progress toward program objectives is measured through quantitative and qualitative research
during the project. There are several M&E components. Monitoring systems have been in place
throughout the duration of the program, based on the BASICS HFA tool and LQAS
methodologies. Data generated during the CSP includes a mix of:
 Field visits to MoLHSA facilities, focus groups and various implementations sites;
 Interviews with MoLHSA officials, government partners, political stakeholders, clinic
personnel, mothers attending clinics during facility hours, OB/GYN doctors who attend
pregnant women for ANC services and polyclinic staff;
 Multiple interviews with mothers and focus group participants;
 Training observations;
 LQAS surveys;
 Agencies, facility sources, and FGD qualitative assessments were conducted; and
 ACTS community groups were interviewed for participation and on focus group topics.
The ACTS CSP at MTE will revise strategies to provide community, facility, and service
providers with special assistance to reduce maternal and neonatal mortality and to expand the
training community outreach program using findings from FDGs. Thus, lessons learned from
FGDs will be used to revise community session content. Other strategies will be considered and
focus on improving MTE findings regarding behavior change modifications, and collecting data
related to DIP intervention implementation.
A Call to Serve International –Mid-Term Evaluation Page 32
TECHNICAL AND ADMINISTRATIVE SUPPORT
During the second year of the project, the ACTS team participated in three technical assistance
workshops. They were:
 Two separate web-based, multi-part M & E training sessions by Bill Weiss, JHU and Don
Carlo, Project Hope.
 Quantitative evaluation and operation research training provided by CSTS/CORE and
USAID.
 A behavior workshop led by Bonnie Kittle and coordinated by CORE
ACTS International will build the capacity of its local partner, the MoLHSA and selected health
care facilities of the two target regions, to deliver and sustain the delivery of effective and high
quality MCH programs. Training among all levels of health care personnel, professional medical
organizations, and administrators of health care facilities will occur cooperatively with the MOH
(Resource Improvement, Training, and NGO Development). ACTS International has secured
other donor commitments to cover costs of all commodities for the five-year program. These
costs will constitute a portion of the project proposed 30% cost share.
MISSION COLLABORATION
Project objectives and overall strategy were discussed and negotiated in detail with the USAID
local mission USAID/Caucasus, in Tbilisi, Georgia. Health Program Management Specialist Dr.
Tamar Sirbiladze coordinates relations with the local mission. Denny Robertson, USAID
Mission Director, Bob Wilson, Deputy Mission Director, Khalid Khan, USAID Office Director,
Health & Social Development for Georgia and Azerbaijan and Melinda Pavin, Senior Technical
Advisor Caucasus Mission Health Advisor were also informed about the goals and objectives of
the project. In addition, presentations and discussions were conducted during the USAID health
grantees meetings on November 11, 2004; February 23, 2005; and March 7, 2005.
The main USAID country objective is increased use of health and social services and changed
behavior as Georgia leads the Caucasus region with the highest rate of abortion. Maternal and
child mortality is on the rise.
Table 5: Health Indicators for Infant and Maternal Mortality in Georgia 1999-2004
Maternal
Mortality
per 10,000
Infant Mortality
<28days
per 10,000
Early Neonatal
Mortality <7days
per 10,000
Perinatal
Mortality
per 10,000
# Live births Year
ncdc sds ncdc sds ncdc sds ncdc sds ncdc sds
1999 51.3 22.7 23.4 n/a* 13 n/a* 32.1 n/a* 48,695 46,827
2000 49.2 22.5 21.1 n/a* 12.2 26.0 29.1 n/a* 48,800 46,765
2001 58.2 23.1 20.0 17.7 11.2 n/a 26.4 n/a* 47,459 46,006
2002 46.6 23.6 20.1 18.3 13.6 16.6 28.8 n/a* 46,605 45,033
2003 52.5 24.8 18.5 20.5 12.3 18.4 28.1 n/a* 46,194 44,093
2004 45.3 238 18.0 19.3 12.1 16.5 27.1 n/a* 46,512 47,022
Sources: National Georgia Center for Disease Control (ncdc), State Department of Statistics (sds)
*n/a = data not available
A Call to Serve International –Mid-Term Evaluation Page 33
In order to slow and reverse these trends, USAID/Georgia activities are designed to increase
access and education and improve healthcare for women. ACTS CSP contributes to this objective
by implementing MCH interventions in the targeted areas. USAID mission activities are
intended to also prevent and control the incidence of vaccine preventable diseases, tuberculosis,
HIV, and sexually transmitted infections. Although these issues are non-specific intervention
areas of the ACTS CSP, application of IMCI in the delivery of child-care services should
complement mission efforts. Project objectives and overall strategy are discussed and negotiated
in detail with the USAID local mission USAID/Caucasus, in Tbilisi, Georgia at all key points in
the CSP process. All significant CSP events are coordinated with Dr. Tamar Sirbiladze Senior
health program officer. Her help as well as the insights from the current USAID/Caucasus
mission director, Bob Wilson has been helpful to maintain alignment with the USAID/Caucasus
mission's SOs and IRs. The ACTS CSP is the only current Washington based funded USAID
program in any of the three South Caucasian countries.
Specific times of USAID/Caucasus detailed CSP review have included:
 prior to program proposal submission - November 2003
 the detailed implementation plan (DIP) - April 2005
 field visit of USAID program officer Namita Agravata - July 2005
 HQ backstop field reviews - 2005 and 2006
 the annual reports - 2005 and 2006
 the mid-term evaluation process –2007
USAID mission staffs are invited to all trainings, stakeholders meeting and discussions with
MOLHSA and the health committee of the Georgian Parliament. Their participation has always
been helpful. Selection of the location of the CSP is an excellent example of this working
relationship. In 2003, the USAID/Caucasus advising ACTS on the CSP were Denny Robertson,
USAID Mission Director, Bob Wilson, Deputy Mission Director, Khalid Khan, USAID Office
Director, Health & Social Development for Georgia and Azerbaijan and Melinda Pavin, Senior
Technical Advisor Caucasus Mission Health Advisor and Dr. Tamar Sirbiladze health officer who
directly helps to coordinate the program.
Currently, Bob Wilson serves as the USAID regional director, Dr. Tamar Sirbiladze serves as the
senior health program officer and Dr. Giorgi Khetchenshvili assists her. The MTE planning
process was coordinated with Dr. Tamar Sirbiladze. The orientation that she provided to the MTE
consultant and MTE team was invaluable
A Call to Serve International –Mid-Term Evaluation Page 34
OTHER ISSUES IDENTIFIED BY THE TEAM
There are no other issues identified by the team.
A Call to Serve International –Mid-Term Evaluation Page 35
CONCLUSIONS AND RECOMMENDATIONS
Project Strengths
The ACTS CSP has worked with health facilities, international and local partners and community
members during the implementation of projects aimed at the decrease of maternal and infant
mortality. Throughout the project cycle, the CSP and local partner organization staff have trained
people at the community level, treated people at government facilities, 62 out of 137 women
have taken advantage of the voucher card system, mothers and pregnant women have been
educated on child health issues such as recognizing difficulties during pregnancies and signs of
infant and childhood illnesses requiring treatment by a trained healthcare provider within 24 to
48 hours. In addition, 11 FGDs were arranged to allow women to discuss and learn about issues
related to MCH.
The Mid-Term Evaluation Team followed a rigorous and programmed technical approach, much
of which was based on participatory approaches. The planning stages of the evaluation allowed
for collaboration between MoLHSA officials and partners. During the major assessment period,
the evaluation focus was on observations, client interviews, clinical reviews, record reviews, and
meetings with implementers and beneficiaries.
The LQAS KPC conducted during the MTE found that the behavior change indicators that were
under the control of the mother changed in all regions. The most significant changes occurred in
those regions where the ACTS CSP focused their educational training. In these regions the
changes meet or exceeded the mid-term targets. In the regions where, because of limited
resources, ACTS did not focus the training, the changes were less than the mid-term targets.
Clearly these are the regions that ACTS CSP will focus on the last two years of the program,
while sustaining gains in other regions.
Also noted is that in those situations where the young mother did not have control
(e.g. in this culture taking the baby to the hospital involves the husband and mother-in-law
making the decision) even when the mother knew what was best for the baby she was not always
allowed to take the action. ACTS is considering how best to involve and educate these decision
makers though Grandmothers and Dads clubs.
Challenges
The ACTS CSP Team should continue to focus on the community empowerment aspect of the
project by further developing their discussion, assessment, and analysis for implementation
adjustment process using an on-going basis for quality improvements.
The commitment of the MoLHSA to continue in supporting role as a CSP partner and
implementation agent should be strongly supported and involved with the ACTS CSP
interventions and strategies. It may be necessary to review and update MOU agreements as the
on-going health sector plan is developed. It is suggested that the close communication with
MoLHSA partners and officials continue on a planned basis with a section of the ACTS annual
report devoted to a summary of these collaboration meetings and possible MOU/agreement
adjustment with continued communications.
A Call to Serve International –Mid-Term Evaluation Page 36
The reported degree of growth stunting is at a 15% level and there is a high prevalence of
marginal malnutrition warrants a dialogue with WHO, UNICEF and the MoLHSA regarding the
possibility for adding a de-worming component to the project. This could be done either through
a school program or as a community mechanism for reinforcing health messages through a
practical observable intervention outcome. Treated persons see the expelled worm, which
strengthens trust and increases the validity and credibility to additional health messages. It also
may be feasible to add Vitamin A or other micronutrient components, which could later be
assumed by the ministry.
Measuring BCI changes is a challenge as the concepts are more abstract to study. One possibility
to measure behavior change is for the ACTS CSP Team to design a card system to present to
each family member who has completed the FGD training. These family members would be
instructed to present the cards when attending any clinic for ANC visits, check-ups for infants or
children, or when seeking treatment for an illness. Each facility partner would collect the cards in
a container and give them to ACTS and CSP partners on a monthly basis to measure the
frequency of health center visits for a BCI measurement. Cards could relate to specific services
by varying color.
The amount and type of training probably should be reviewed for application, and especially for
performance. Nearly every partner conducts training but the application of these training sessions
appear fairly unclear. Recommendations are to review the comprehensive reorganization of
training among partners, including the MoLHSA. This will assist in determining who is being
trained for what in view of the national health sector reform.
The MTE findings recommend that a training needs assessment could be done among targeted
cohorts where the intervention group receives training with the intent to improve performance.
An intervention would focus on the clinical partner training needs, performance needed, and
skills in conjunction with the population served and equipment available for use.
The professional assessment of staff and facilities completed by the two professionals should be
carefully reviewed from the perspective of ACTS International and some criteria be designed for
seeking resources and equipment where possible. While, it is not in the purview of the CSP to
purchase equipment or restore aging facilities, it is apparent that improvements made by adding
essential equipment and other clinic level institution needs will save lives and provide our
MoLHSA partner with incentive to restore other facilities outside the CSP area.
A Call to Serve International –Mid-Term Evaluation Page 37
RESULTS HIGHLIGHT
HIGHLIGHT # 1 - INNOVATION AND CAPACITY
COMMUNITY-WIDE FESTIVALS“HEALTHLYMOMS FOR HEALTHLY KIDS”
ACTS CSP sponsored a community-wide festival for celebrating healthy lifestyle messages and
children’sactivities,whileengagingalltheethnicandagegroupswithinthecommunitytobetter
understand healthy lifestyle messages.
Problem Being Addressed:
1. Engage community wide action and acceptance of maternal and child health messages in
a community with diverse ethnic groups and at least one group that restrict the interaction
with and among young women and the communities;
2. Rekindle community pride;
3. Develop community joint actions to empower the community; and
1. Celebrate educational, health and cultural excellence.
Project’sInputToAddressIt:ACTS CSP provided the idea and organization to implement it.
ACTS CSP developed this idea for a community-wide festival and then engaged local
government, health, and school, religious and business groups. Each group was given a task.
They in turn helped engage regional and national leaders. ACTS CSP managed the planning and
implementation, sought out and procured business sponsors and involved a stakeholder village
board as central planning group. The school set up children sports events, provided location for
the teenage peer theater and the young mother healthy life style trivia game. Business sponsors
provided funding for communication, sports trophies and other medals and prizes. Local,
regional and national media covered the event. Religious leaders opened and closed the day with
prayers of thanks while governmentalleadersproclaimedtheeventthe“DmanisiHealthy
LifestyleCelebration.”Theregionalgovernor,parliamentaryrepresentative,Gamkeblia(mayor)
and the city council were on hand to declare the event open and to award sport, dancing, and
singing competition medals.
Magnitude of the Intervention: 2,000participantsweredirectlyinvolvedintheday’smain
activities of: sport competition, young mother trivia games, teen healthy lifestyle theater singing
and dancing groups. The percent of the population touched by the intervention was close to
100% that includes spectators, participants, teachers, organizers, etc.
Results: The Dmanisi City Stakeholders committee voted to make this healthily lifestyle festival
an annual event. The local, regional and national governmental and religious officials have also
asked to make this festival an annual celebration. The schools, churches and mosque have
volunteered their space for next year and the business sponsors have volunteered to sponsor the
festival. In addition, the Gamkebila (mayor) and city councils of other towns have asked the
ACTS CSP to plan similar festivals for their cities.
A Call to Serve International –Mid-Term Evaluation Page 38
HIGHLIGHT # 2 - HEALTH FAIRS IN KVEMO KARTLI
Health Fairs, with a focus on maternal and child care were conducted in villages near the joint
Georgian/U.S. military training site in Kvemo Kartli. Georgian and U.S. military physicians,
nurses and laboratory technicians provided laboratory equipment for blood and urine testing and
calibrated scales for correct weight. Local Georgian physicians, ACTS CSP staff and other
government and health officials were included in the event.
Problem being addressed:
1. Provide additional prenatal evaluation and support for pregnant women, as currently only
57% of young woman in Kvemo Kartli have their first prenatal visit in the first trimester.
2. Engage families and the community in sharing responsibilities for improved aspect of
maternal and child care which they can control.
2. ProvidecommunityoutreachforthemedicalteammembersoftheU.S.Army’s“Train
andEquip”programforGeorgia.
Project’sInputToAddressIt:ACTSCSPorganizedthesefairsafterDr.Tamar’scheck,the
USAID Health Affair Officer, asked ACTS to serve as a liaison between the U.S. and Georgian
militaries and the communities.
Magnitude of the Intervention: Each fair lasted 4-7 hours and provided direct care for 50-80
patients. Percent of population covered by the intervention close to 100% as citizens were
involved a spectators, participants, organizers, etc.
Results: The first three health fairs served 250 mothers and children. Exit interviews with the
young mothers and later FDG document high satisfactory in a majority of women interviewed.
Qualitative data included local physicians expressing appreciation and gratitude to work with the
well trained and well equipped US doctors, nurses and laboratory technicians. Local leaders
voiced approval that their citizens were able to have updated care. Measurement of blood
glucose levels and hemoglobins level of pregnant women was viewed as important by
participants and community leaders.
A Call to Serve International –Mid-Term Evaluation Page 39
HIGHLIGHT # 3 - GRANTEE DEVELOPMENT OF EVALUATION CAPACITY
Problem to be Solved: As a new grantee, development of quantitative evaluation capacity.
ACTS, as an organization who is a new USAID grantee, has benefited and built our headquarters
and field staff capacity to develop indicators, conduct surveys with proper sampling techniques
and analysis, and present the collected data in a meaningful manner. CSP input has been full
participation is all activities offered by CSGHP/CSTS. CSGHP provides a structured approach to
program development with very clear, well-written guidelines at every step from the presentation
of the proposal to debriefing, to designing and conducting the knowledge, practice, coverage
(KPC) surveys, and eventually creating the DIP. In addition, excellent quality technical
assistance is provided by USAID, assisted by CSTS/ CORE. The learning environment of the
USAID/CSTS mini university is the best training experience I have ever encountered. The group
of concerned, invested and knowledgeable peer professionals and organizations is amazing. The
high degree of open, generous sharing of information, techniques, lessons learned and moral
support is extraordinary.
Magnitude of the Intervention: As a new grantee unfamiliar with many of the CSP intervention
three short years ago, ACTS now has a peer group of hundreds of experienced professionals
willing to be contacted and asked about any question that our field teams run into. In addition to
this vast professional network, the CORE electronic network also creates helpful resources.
Overview of the CSP process: During the mini-university, all new grantees are assembled,
presented with excellent evidence based didactic training sessions from experience academics
working in public health fields. ACTS, a new grantee, had three people review our DIP before
the conference and present ACTS with written feedback. An additional learning experience was
that our organization reviewed and presented feed back to another Grantee on their DIP. As a
result of the DIP review, ACTS strengthened our plan and made it more practical and better
suited to the communities where we work.
Results:MoLHSAusedACTS’KPCdatatosubmittoWHO,asrepresentative of regional data.
UNICEP MICS is a country area without regional values. The rigorous development of
indicators with baseline levels and exercise of estimating annual and end of program benchmarks
for both process (behavior change) and results (outcome) indicators provides quantitative data
for evaluation of CSP achievements.
A Call to Serve International –Mid-Term Evaluation Page 40
HIGHLIGHT #4 - CAPACITY DEVELOPMENT FOR LOCAL, REGIONAL &
NATIONAL OFFICIALS
Problem to be solved: Need for evidence-based indicators at a national level to assess across
programs and region.
ACTS Input: The Georgian MoHLSA received ACTS KPC and MTE data and found it
interesting and helpful. Ongoing discussions center of use of KPC and MTE approach across
programs and regions.
The CSP process defined by rigorous requirements is itself an innovative and capacity building
experience. ACTS International and our affiliate field organization, ACTS Georgia works
closely with the Georgian MoLHSA and the Georgian Parliament. Our individual and joint
capacity to provide quantitative baselines and annual and end or program benchmarks improves
monitoring and evaluation of program and decision-making.
Other PVO and bilateral groups from many nations are working in the country of Georgia during
this difficult time of transition. Hundreds of health surveys have and are being conducted. Most
surveys are one time snapshots of a situation. Rarely do any surveys re-assess the situation after
an intervention has been made and then provide MoLHSA with quantitative data. The CSP’s
rigorous demands for ongoing re-assessment and comparison to the baseline survey data makes
this program and its monitoring and evaluation process uniquely helpful to the MoLHSA.
The Georgian Minister of Labor, Health and Social Affairs has been very pleased with the CSP
progress and would like to use its methods in other areas. As the country grows and the health
needs become even more complex, the Ministry hopes to identify its own indicators and begin
requiring all health programs to use the CSP approach of practical measurable indicators, with
mid-term and EOP estimate results, which will be presented to the ministry at the start of all
programs, at the program midterm and at the end of the program. This will for the first time give
the ministry a method of assessing results across different programs and different geographic
areas. With time, this could also provide an assessment of sustainability that would rank
organizations based on the lasting nature of their work. ACTS CSP has been the only program to
introduce this approach in Georgia.
Magnitude of the Intervention: Hundreds of millions of dollars are spent each year on
programs in Georgia. As an example, the British government development agency is completing
a $40 million program implementing family practice in Georgia. How does one measure the
success and sustainability of such large programs if there is no evidence-based approach?
Results: The Georgian MoLHSA includes ACTS CSP KPC data in annual national report to The
World Health Organization (WHO) and is discussion wider use of evidence based indicator
approach.
A Call to Serve International –Mid-Term Evaluation Page 41
RESULTS HIGHLIGHT # 5 - NATIONAL SCALE UP- NUTRITION
Problem to be Solved: How to improve women and children health care on a national level. The
Georgian government has taken several key steps to improve access, availability and quality of
health care through legislation. Still, there remains a need to identify and implement programs
with national impact. Current maternal anemia and spinal cord congenital anomalies are a
problem in Georgia that is correctable by fortification of flour with iron and folic acid. ACTS,
working with the Parliament of Georgia, and using an evidence based approach first learned
through ACTS CSP program, secured a $1,5million, three–year flour fortification program from
the Geneva-based organization Global Alliance for Improved Nutrition (GAIN).
This program adds a vitamin-enriched premix at six flourmills, each milling 100 tons of flour
daily. In 2008, there will be a national scale up to include all flourmills in Georgia. ACTS, as
the lead organization, provides the organization administration and the technical training to add
the pre mix vitamin compound to flour to the six pilot mills. ACTS is also setting up the testing
of iron and folic acid levels in the mill laboratories.
ACTS Input: ACTS CSP provided the capacity and evidence-based knowledge that allowed
ACTS and the Georgian Parliament to win this important Grant. In addition, ACTS CSP
coordinates the healthily nutrition message in both the CSP and GAIN programs. ACTS has a
separate team leading the GAIN grant and no USAID CSP funds or personnel are used in this
separate funded GAIN grant; however, the synergistic messages are coordinate among the ACTS
staff within each program.
Magnitude of the Intervention: With six high volume mills (100 tons per day per mill), starting
fortification in fall of 2007, an estimated 1.4 million people will benefit as a total of 600 tons of
fortified flour will be milled daily. Currently 100% of the populations of the three regions of 11
areaffected.By2009,theentirecountry’spopulationoffivemillionwillbenefit.Also,in2009,
all administrative regions 100% of the population of five million will be affected.
Results:
1. Creation of a Georgian Alliance for Improved Nutrition, including the Parliament of
Georgia and ACTS, as well as a group of large business and government stakeholders,
PVOS and consumers.
2. Passage of A 2007 law that allows the millers to add folic acid and iron to wheat as it
milled into flour
3. Passage of a second law in 2009 is anticipated, following the successful evaluation of the
Georgian GAIN pilot phase
It should be noted that since the GAIN program has awarded countrywide grants to only 18
countries. ACTS received this GAIN grant as a direct result of our increased maternal and child
health programming capacity acquired through CSP.
A Call to Serve International –Mid-Term Evaluation Page 42
ACTION PLAN/REVISED WORK PLAN
Future Recommended Activities for the CSP:
Based on findings, data collected, and lessons learned from the implemented program activities,
future activities for the ACTS CSP will include:
Community-Based Training
 Improvements in community training session education content should be based on
repeated field experiences, continued FGD, surveys and expanded types and participants,
such as mother-in-laws, fathers, and grandfathers.
 Consideration for breastfeeding support groups should be explored.
Monitoring and Evaluation
 Mechanisms for establishing behavior change measures and proxy measures conducted as
operational research need to introduce to MOLHSA routine assessment.
Stakeholder Engagement
 Community stakeholder group will continue to be a prime ACTS CSP communication’
strategy.
 ACTS Georgia should continue partnership and dialogue with MoLHSA, as national
health sector reform is designed and implemented.
 ACTS International and the U.S. Department of State.
 The establishment of life-saving conditions and support with MoLHSA for full-term
infants, perinatal and neonatal aspects will continue.
 Full coordination with UNICEF, USAID, WHO, and CSP activities will continue.
 ACTS Georgia staff will continue to assess progress and identify potential problems
through HIS system, LQAS, Focus Group Surveys, additional surveys and tracking
progress on monthly basis. Management and programmatic decisions will be made on
basis of findings from data collected and analyzed.
 ACTS Georgia will provide USAID Mission with routine 3-to-4-paragraph briefing
monthly. This should be considered an attempt to establish an informal communication
process and should not be viewed as an official reporting obligation.
 Empower and value the anecdotal issue the FGDs identify. Currently, the primary issue is
growing number of cases of worms. ACTS will work with MoLHSA and other partners to
assess the magnitude of the program and develop cost-effective treatment.
Key Recommendations for the remaining 2 years of the CSP:
 Assisting hospitals to become baby-friendly certified.
 Continuing ACTS leadership role in promoting and monitoring the use of fortified flour.
 Collaborating with MOLHSA on adding de-worming facets to all.
 Nutrition projects.
 Monitoring BCC by implementing card system to track visits to ANCs and health
facilities.
 Modifying existing MOU agreements with all partners, as needed.
 Modifying data collection for more in depth daily and weekly counts of services
provided, beneficiaries and BHI measurements.
 ACTS Georgia should provide USAID Mission with routine 3-to-4-paragraph briefing
monthly to establish an informal communication process.
A Call to Serve International –Mid-Term Evaluation Page 43
 Exploring follow on funding to expand this successful CSP program and to continue
activities in the Kvemo Kartli region.
RESPONSE TO MTE RECOMMENDATIONS
Maternal and Newborn Care
Recommendation: The national flour fortification program that will add iron and folic acid to
bread is being implemented in Georgia by ACTS as the leader in cooperation with the
Georgian Parliament. This effective program will reduce maternal anemia and spinal cord
disease in babies. It is recommended that the CSP add the maternal anemia message and the
folic acid important to the community-based messages and that CSP and the GAIN program
join together to sponsor mass media in focus areas where the target has been achieved.
Response: ACTS will continue to lead the flour fortification process. The pilot with six mills
coming on line is completed in 2008. The scale-up involves the entire country in 2009. ACTS
and the Parliament of Georgia will advocate for the passage in 2009 of the law requiring
fortification for all wheat milled in Georgia and all improved wheat.
Recommendation: ACTS should work at the hospital level to develop an affordable method
to assist the GOG in training maternity hospitals in getting and maintaining WHO baby￾friendly hospital certification.
Response: ACTS will work with the MOLHSA to develop cost-effective methods to maintain
the BFH status for Georgian hospitals. Currently, Rustavi Hospital in Kvemo Kartli, as part
of CSP, is the largest and only BFH in Kvemo Kartli. In the past, several hospitals in other
parts of Georgia were certified as BFH under a UNICEF program. All have lost their
certification because the cost of re-certification is not affordable. ACTS will also explore
using the sister medical university relationship between Tbilisi State University and The
University of Missouri School of Medicine to train TSU faculty to become WHO-certified
BFH instructors. There is a modified BHF training program in use in Uzbeckistan and ACTS
will evaluate this with the Georgian MOH and the Georgian WHO representative.
Recommendation: Essential equipment is needed for maternity facilities for neonatal
resuscitation. It is recommended that the equipment essential to neonatal resuscitation be
identified by ACTS and presented to MOLHSA as the standard list of essential neonatal
resuscitation equipment.
Response: ACTS will develop the list of essential neonatal resuscitation equipment required
for each maternity delivery area and will work through another ACTS program/funding
source to secure this equipment and provide instructions for the maternity units.
Recommendation: CSP should monitor BCC by implementing a card system to track visits to
the ANCs and health facilities.
Response: ACTS will develop a plan for implementing a colored-card system to give to all
women attending CSP courses, with instruction to take them to their ANC and give them to
the physician. The card count will be assessed weekly.
A Call to Serve International –Mid-Term Evaluation Page 44
Breast Feeding Promotion:
Recommendation: The MTE target for breastfeeding has been reached in the focus villages,
and it is essential to continue the program of positive messages. ACTS should continue the
successful community-based educational program, monitor the effectiveness of the messages
through focus group and consider adding MMSG.
Response: ACTS will continue the community outreach for young women and will start a
pilot MMSG and assess with FGDs the strengths and weaknesses:
1. Focus discussion groups for expectant mothers to define barriers to breast feeding
could increase better understanding of the barriers.
2. Focus group discussion with the nursing staff that performs the consoling could
provide better understanding about their perceived barriers.
3. Regular training update for the nursing staff to encourage young moms might include:
 Direct observation of the consoling by nurse with suggestions for improvement.
 Exit interviews with the young mother at the time of discharge to assess if she did
start breast feeding within one hour and what, if any, instructions were given by
the nurses; to obtain her self assessment of breast feeding knowledge, where she
obtained her knowledge, and factors that promoted her willingness to breast feed.
These exit interview results can be reported to the nursing staff to help improve
care provided.
Nutrition:
Recommendation: It is recommended that community-based training continue to stress the
importance of correct complementary feeding. This could also be a topic in the mother-to￾mother support groups. Regular training updates for nursing staff should also include
complementary feeding information. Monitor with exit interviews of the young mother.
These exit interview results, can be report to the nursing staff during periodic updates.
Response: ACTS will continue the community outreach for young women and will start a
pilot mother to mother group and assess with FGD the strengths and weaknesses:
1. Focus discussion groups for expectant mothers to define complementary feeding and
gain better understanding of the barriers.
2. Focus group discussion with the nursing staff that performs the consoling could
provide better understanding about their perceived barriers.
3. Regular training update for the nursing staff to encourage young moms might include:
 Direct observation of the consoling by nurse with suggestions for improvement
 Exit interviews with the young mother at the time of discharge to assess if she did
start complementary and what, if any, instructions were given by the nurses; to
obtain her self-assessment of complementary feeding knowledge, where she
obtained her knowledge. These exit interview results can be reported to the
nursing staff to help improve care provided.
Recommendation: Explore source of funding from international antihelmenthic de-worming
groups and open negotiation with MOLHSA on implementing a de-worming component in
all appropriate nutrition programs and projects.
Response: The anecdotal information emerging from focus groups of mothers and physicians
indicate worm infestation is a growing public health problem. The GOG does not consider
this a major cause of anemia. While this important issue is beyond the scope of the CSP,
A Call to Serve International –Mid-Term Evaluation Page 45
ACTS will work with the MOLHSA to better define the problem. Once the situation is better
defined, and if action is needed ACTS will approach donors outside the USAID/ CSP.
ARI/Pneumonia and Diarrhea:
Recommendation: Community-based training for young women should continue to teach the
danger signs of illness; the need for additional fluids during illness, to add the MMSG, and to
include messages about the warning signs of illness and danger signs that indicate the need to
visit the doctor.
Response: ACTS will continue to work with young women in FDG to determine knowledge
and practice barriers and will use MMSG to create similar groups of the other major family
decision makers, Fathers and Grandmothers. Judy Abel Grandmother project will serve as a
reference. These approaches will help identify barriers and develop practical solutions. Exit
interview and FDG will assess the improvement.
Recommendation: Physicians and nursing should be given updated regular training on case
management of pneumonia and diarrhea.
Response: ACTS will:
1. Develop continuing medical standards and medical information updates to be presented
by the MoLHSA, Georgian Medical Association, as part of physician licensing and re￾certification requirements.
2. Nurses will be encouraged to become more effective nurse educators. ACTS will hold
FGD to learn what material the nurse need for teaching and what nurse incentives might
be help. Hospital discharge exit interviews of mothers and direct observation of physician
and nurse interaction with mothers will also be used.
3. ACTS will include in the new MMSG experienced mothers of children. FDG and support
groups will expand to involve family decision makers (e.g., dad, grandmother and
grandfather support groups).
Recommendation: Modifying data collection for more in depth daily and weekly counts of
services provided, beneficiaries and BHI measurements.
Response: ACTS will develop a modified data collection system and chart audit to monitor
results and collect more detailed information.
Community Mobilization:
Recommendation: Continue providing stakeholders with regular information updates that
stress the value of their participation.
Response: ACTS will include relevant data updates and lessons learned from the community
meetings and FGDs.
Recommendation: The CSP program should target remote villages where there is limited
access to health care.
Response: ACTS will explore additional funding resources to allow the CSP to expand
throughout this large region.
A Call to Serve International –Mid-Term Evaluation Page 46
Communication for Behavior Change:
Recommendation: ACTS should continue the effective messages for Behavior Change and
continue using ACTS CSP innovative community approaches of community wide festivals,
health fairs, young mother games and support groups, and FGD incentive system.
Response: ACTS will conduct the community festival in Dmanisi again this year and expand
the community festival approach to two other communities in year four.
Recommendation: Grandmothers and Fathers are key decision makers and need to be
included.
Response: ACTS will develop an educational program for fathers and grandfather focused
on the value of their role in the mother and infant lives and training them to recognize danger
signs. Educational material for men will be developed.
Capacity Building:
Recommendation: Maternal and Child capacity of the GOG would be strengthened through
legislation that mandates national standards for maternal and newborn care. These standards
have been developed by Georgian experts in accordance with international standards.
Response: ACTS will work with the Parliament of Georgia health committee and other
PVOS to advocate for reforms in this area.
Recommendation: Explore cost-effective way for the MoLHSA to establish and maintain
WHO BFHI certification for Georgian hospitals.
Response: ACTS will explore the Sister-Medical School partnership it coordinates between
Tbilisi State Medical University and the University of Missouri to consider a modified WHO
Baby-Friendly Hospital training that could be conducted by faculty.
Recommendation: Regional to ensure sustainability of the positive changes that ACTS CSP
has achieved, it is recommended that ACTS together with the regional governor of Kvemo
Kartli establish a regional information system and set regional priorities to better coordinate
bilateral and other donors.
Response: ACTS will meet with the regional governor and discuss what type of help or
technical assistance is needed.
Health Facilities Strengthening:
Recommendation: ACTS assistance to the MOLSHA is needed to ensure full birth
registration. The lack of full birth registration remains problematic. In 2005, the GOG
eliminated the birth registration fee. However, the registration process still requires a visit by
parents to a distant government office. Parents know the process, but many are unaware that
the fee has been eliminated
Response: ACTS will: 1) conduct focus groups to determine the barriers and work with
MOLHSA to achieve full registration; 2) Recommendation will be made to have birth
registration on site at the hospital. This will eliminate one of the most common barriers; and
3) ACTS will work with MoLHSA to include birth registration information in the four
prenatal visit requirements for physicians and nurses.
A Call to Serve International –Mid-Term Evaluation Page 47
Recommendation: The MTE structured physician interview, MFA and direct physician
practicereviewidentifiedunacceptablegapsbetweenthephysicians’theoreticalknowledge
and practical ability to perform proper neonatal resuscitation. Prime barrier was lack of
necessary and proper size of essential equipment. During the ACTS MTE the physician
assessment team developed the essential equipment list for neonatal resuscitation. ACTS
should seek matching funds or in-kind donations to secure needed equipment and training for
these physicians.
Response: ACTS will work through its donor network to secure, transport, install and train
staff to use this essential equipment list for each of the Kvemo Kartli hospitals. The
associated costs will be secured as matching funds and/or in kind or cash donations. This
essential neonatal equipment list will be shared with MoLHSA and other interested PVOs
and donors to set up sustainable acquisition and training for the nation. This process will be
monitored and evaluated before EOP with a repeat MFA assessment, structured physician
review and direct observations of neonatal resuscitation.
Recommendation: Continue to explore ways to improve staff education, training and
development to increase competence and expertise.
Response: Regular review and self-assessment will identify the topics most needed for
additional training. In 2008, two M and E training workshops will be conducted in training to
include the new BCC card monitoring system and to better prepare regional and local
stakeholders to assume follow up monitoring at the end of this program. Future needs will be
discussed these workshop will concentrate on: 1) ACTS key staff; and 2) new and continuing
local and regional coordinates.
REVISED ACTION PLAN
Table 7: Revised Work Plan for Years 4-5
Project Year Year IV
(2007-2008)
Year V
(2008-2009)
Finalizing and submitting MTE Report
Objective 1: Sustain changes in maternal care giving and care seeking behaviors (maternal and newborn
care/breast-feeding/nutrition/pneumonia management/diarrhea management)
Updating BCC campaign based on MTE & LQAS findings
BCC materials production
BCC materials dissemination
Monitoring BCC through introduction of a card system to track
visits to ANCs and health facilities
Development of three new presentations for fathers and mothers-in￾law with inclusion of musical messages and collaboration with
MoLHSA on adding de-worming facets to nutrition component of
the project
Development of educational TV spots to be aired vial local TV
network
Airing TV spots
Preparation and conduction of Healthy Moms for Healthy Kids
Festival
A Call to Serve International –Mid-Term Evaluation Page 48
Project Year Year IV
(2007-2008)
Year V
(2008-2009)
Objective 2: Sustain improvements in the quality of health services available to children and their
mothers
Conduct training for IMCI protocols among the personal of health
facilities
Follow-up for IMCI protocol implementation
Working with MoLHSA to develop dissemination materials on
evidence-based practice guidelines for maternity care
Selecting HCF for pilot of evidence-based practice protocols
Evidence-based training for identified health care professionals
Semi-annual training updates for physicians/nurses in evidence￾based obstetric practices and IMCI protocols
Organize systematic distribution plan for essential supplies to
support IMCI protocols and evidence-based obstetric interventions
Distribution of IMCI supplies
Objective 3: Improve awareness, collaboration and capacity among public, private and NGO
stakeholders to improve health impact of MCH projects
Train community health workers in BCC messages
Semi-annual BCC updates
In collaboration with Claritas, develop the training plan for district
hospitals, clinics and ambulatory clinic workers in BFH practices
Conduct quarterly meetings jointly with MOH staff and the ACTS￾G CSP staff
Conduct quarterly meetings with ACTS-G CSP staff and
stakeholders
Identify and train Field Staff in BCC
Together with partners, conduct joint quarterly visits to target area
hospitals
Promoting and monitoring the use of fortified flour
Objective 4: Strengthen capacity of ACTS-I and its local partner to implement sustainable maternal
and child health programs
Yearly strategy meeting, facilitated by consultant to conduct
organizational analysis
Develop a strategic sustainability plan
Modifying MOU agreements with Claritas and Institute of Strategic Research
ACTS-I to review and provide extensive feedback on annual BCC and
training plans
Hold annual one-day review workshops for NGO and MOH partners to
evaluate successes and areas for improvement
Attend CORE meetings spring and Fall
Performance Monitoring and Evaluation
Focus Group Discussions
KPC –Final assessment
A Call to Serve International –Mid-Term Evaluation Page 49
Project Year Year IV
(2007-2008)
Year V
(2008-2009)
Modifying data collection for more in-depth daily and weekly counts of
services provided, beneficiaries and BHI measurements
Monitoring survey
Confidential Client Surveys
Operations research
Modified Health Facilities Assessments
Organizational development assessment/DOSA
A Call to Serve International –Mid-Term Evaluation Page 50
ATTACHMENTS
Baseline Information from DIP
MTE Survey (LQAS) Tool
Evaluation Team Members and Titles
Evaluation Assessment Methodology
List of Persons Interviewed and Contacted
CD with electronic copy of the report in MS Word 2000
Special Reports
Project Data Sheet Form
References and Resources
Political Structure in Georgia
A Call to Serve International –Mid-Term Evaluation Page 51
A. Baseline information from the DIP
Nutritional Deficiencies:
Children aged 0-23 months in the target regions were grouped according to the WHO weight￾for-age standards for underweight children (-3SD). The average percentage of underweight
children among the three sub-regions is 4.0%. However, there is a significant difference
between the sub-regions. While the percent of underweight children in sub-region 1 was
4.2%, the same index for sub-region 2 was nearly twice as high at 7.6%. The lowest value
was observed in the sub-region 3, which was 1.4%. On the whole, KPC findings related to
feeding practices for children aged 0-23 months in the target regions revealed comparatively
low levels of malnourishment. They did reveal, however, a relatively high percentage of
moderately underweight children in sub-region 1 and a surprisingly high level of severe
overweight children (+3SD), 43.4% on average, (27.5% in sub-region 1; 42.6% in sub-region
2; and 55.6% in sub-region 3.) These findings justified selecting Nutrition and
Microelements (micronutrients) as one of the project interventions at the 15% level.
Immediate Breastfeeding:
Though the majority (94.1%) of births of 0-23 month olds occurred in maternity hospitals
with 95.3% of deliveries attended by a physician, only 39.5% of newborns were breastfed
within the first hour. Again there is a significant difference between the sub-regions, 48.7% in
sub-region 1; 62.6% in sub-region 2; and just 18.2% in sub-region 3. The significant variance
among the three sub-regions is indicative of the variance across regions for health providers
giving adequate instruction, as well as a weak demand from mothers to breastfeed
immediately. These findings encourage planning of bilateral intervention, both at the health
facility and community levels, with particular emphasis on the Chiatura and Zestaphoni cities
in Imereti region, which exhibited the lowest percentage of children breastfed during the first
hour following birth.
Exclusive Breastfeeding:
The KPC data on exclusive breastfeeding demonstrated that only 16.1% of children up to 6
months of age were exclusively breastfed, 17.1% in sub-region 1; 18.2% in sub-region 2; and
14.0% in sub-region 3. Thirty-two percent of mothers gave their child something to drink
before breastfeeding. Forty-one percent of children age 6-23 months ate meat, fish or poultry,
but not dairy products; 67.7% ate some food from an animal source including dairy products.
Of the 223 mothers who had children in the age range of 0-5 months, 57.4% reported giving
only breast milk to the child during the last 24 hours; 22.9% of infants aged 0-5 months
received fresh fruit and vegetables; 9.4% potatoes; 17.5% grain food (wheat, corn, rice, etc);
17.5% dairy products; 6.3% meat, poultry, fish; 6.3% food prepared in butter, oil or fat; 4.9%
food prepared from vegetables; other kinds of food (pumpkin, carrots, kidney beans, soy)
4.4%. The percentage of exclusively breastfed infants 0-6 months is low and justifies the
breast-feeding promotion intervention in the target areas.
Continued Breast and Complementary Feeding:
Almost 49% of children aged 6-9 months and 30% of children aged 10-23 months were still
breastfed. Of a total of 103 children aged 6-7 months, 43 (41.7%) received at least one solid
food together with breast milk. Approximately 41% (40.7%) of children aged 6-9 months ate
A Call to Serve International –Mid-Term Evaluation Page 52
meat or fish and 67.7% meat, fish, poultry and cheese and 57.8% reported feeding their
children from one-to-seven times during the previous 24 hours with semi-solid food. On
average, children were given this type of food 2.5 times (SD 1.3) per day. From those 520
mothers who pointed to how many times they gave food, 30.25% gave it twice, 28.5% once,
17.9% three times, 16.2% four times and 7.4% more than four times. Sixty-nine percent of
mothers of children 6-11 months indicated that their children ate semi-solid food during last
24 hours.
A Call to Serve International –Mid-Term Evaluation Page 53
B. KPC LQAS Report
Cooperative Agreement Number:
GHS-A-00-04-00025-00
October 1 –October 28, 2007
HEADQUARTERS
A Call to Serve International
601 Business Loop 70 West, Suite 113
Columbia, MO 65203
AFFILIATE
A Call to Serve - Georgia
7, Vazha Pshavela Ave.
Tbilisi, Georgia 0160
Partner Organizations: Ministry of Labor, Health and Social Affairs of Georgia; Georgian
Medical Association, Mother-Child Nutrition and Wellness Association- Claritas XXI, Women
WellnessCenter,UnionforSocialProtectionofCitizensofGeorgia“Tanadgoma”
Authors: Dr. Giorgi Tsilosani, Dr. Revaz Tataradze, Ms. Eteri Suladze,
Under the leadership of Dr. Patricia Blair
Tbilisi, 2007
Lot Quality Assurance Sampling Mid-Term Survey
R E P O R T
October 2007
“Child Survival and Health Program for Kvemo Kartli and Imereti, Georgia
A Call to Serve International –Mid-Term Evaluation Page 54
Acknowledgments
The special recognition should be given to following individuals and organizations whose
support was considered crucial during the planning, implementation and analysis phase of the
KPC assessment: KPC Supervisors: Medea Gegnava, Mzia Klibadze, Tinatin Lomidze (ACTS
Georgia), Interviewers: Nana Ebralidze, Dodo Iashvili, Irma Porchkhidze (ACTS Georgia),
Nunu Latsabidze, Inga Babluani, Liudmila Chernoles (volunteers from Institute of Policy
Studies), Project District coordinators: Dr. Tamar Lobzhanidze, Mr. Amiran Sultanishvili, Mr.
GiorgiDvali;KvemoKartlibasedNGO “Tanadgoma”;DatatabulationMs.NatiaDadiani
(ACTS Georgia). We would like to extend our gratitude to local community leaders and
mobilizers as well as to medical professionals and representatives of local authorities for their
assistance in informing population about the oncoming survey and encouraging them to
cooperate with the survey interviewers.
We wish to thank our project driver Mr. Tengiz Nishnianidze for assisting in development most
optimal logistic plan allowing interviewing maximal number of respondents per day and for his
dedication in transporting various groups of interviewers and supervisors to interview sites.
A Call to Serve International –Mid-Term Evaluation Page 55
Table of Contents
Report
Executive Summary ...............................................................56
Background ............................................................................57
Process and Partnership Building ...........................................59
Methods ..................................................................................60
Results ....................................................................................62
Discussion...............................................................................66
A Call to Serve International –Mid-Term Evaluation Page 56
Executive Summary
Lot Quality Assurance Sampling (LQAS) was used for KPC (knowledge, practice, coverage) survey,
which was conducted in September 25 through October 3, 2007. Total of 171 respondents in nine
supervision areas (SA) have been interviewed. Total of the 99 interview sites, urban and rural, in 6
SA of Kvemo Kartli and three more sites in Rustavi. All the respondents were females. Their age
ranged from 16 to 49 years, mean age being 25.7, SD 5.8. Median is 25 years. 67.2% of respondents
are younger than 25. The sampling frame for the LQAS was used to determine the interview sites in
each SA. They were defined at random using Systematic Sampling approach and the households
within the selected sites were chosen using random drawing of the street names for cities and the
“spinthebottle”methodforthevillages.Thequestionnairewasadapted from baseline KPC survey
and contained only modules related to major indicators and benchmarks of the Project as defined in
DIP. Local partners and stakeholders were consulted to ensure maximal elimination of the possible
obstacles in the process of interviewing. Six interviewers and three supervisors underwent a three￾day training, with the last day devoted to field-testing. Teams consisting of 2 interviewers and one
supervisor were formed and a logistic plan was developed. Average length of the interview was 15-20
minutes; duration of data collection was 7 days. Each team was assigned a schedule for the entire 7-
day period. Supervisors were responsible for the accuracy and completeness of the questionnaires.
The data were analyzed using hand-made tabulation. Summary Tabulation Tables were filled for 6
SA and City of Rustavi; Average Coverage Tables for each indicator and all SA have been compared
with DIP target ones to define the
program priorities by indicator by
SA. The results allowed mapping
the SA where the value of Project
indicator(s) proved to be below
target average coverage and these
findings have been used to update
the Action Plan for the remaining
two years of Project life. Even
though average coverage data for
all indicators for all SA exceed or
are equal to target values as
envisaged by DIP Action Plan,
average coverage values for
individual indicators in various
SA were below targeted values.
The Tables on the right
demonstrated that Gardabani
district has below target average
coverage values for 4 out of 5
indicators. Marneuli district is
next in number of below target
average coverage indicators
number –three out of five; Bolnisi
district –two of five; and Dmanisi
and Tetri Tskaro districts have one
indicator, each which is below
target average coverage.
LQAS Findings Demonstrating the sites and indicators requiring
additional LOF at Community Level
Indicator.
Percentage of Mothers who knew at least 2 signs of childhood illnesses
that indicate the need of referral to health care services
Supervision Area Baseline Target LQAS data Difference
Marneuli 57.89% - 17.10%
Gardabani 63.15% -11.84%
Tsalka
64.2% 75%
68.42% -6.57%
Indicator
Percentage of infants who were exclusively breastfed
Supervision Area Baseline Target LQAS
data
Difference
Gardabani 16.2% 30% 26.31% -3.68%
Indicator
Percentage of children aged 0-23 months who were breastfed within the
first hour of birth
Supervision Area Baseline Target LQAS data Difference
Dmanisi 42.10% -17.8%
Bolnisi 21.05% - 38.94%
Tetri Tskaro 42.10% -17.8%
Marneuli 36.84% -23.15%
Gardabani
39.3% 60%
42.10% -17.8%
Indicator
Percentage of infants aged 6-9 months who received breast milk and solid
food within the last 24 hours
Supervision Area Baseline Target LQAS
data
Difference
Bolnisi 47.36% - 12.63%
Marneuli
41.7% 60%
57.89% -2.10%
Indicator
Percentage of infants aged 0-23 months with diarrhea in the last two weeks
who were offered more fluids during illness.
Supervision Area Baseline Target LQAS data Difference
Bolnisi 63.15% - 11.84%
Tetri Tskaro 68.42% -6.5%
Gardabani
56.3% 75%
68.42% -6.57%
A Call to Serve International –Mid-Term Evaluation Page 57
Background
GeorgiaissituatedinthecentralandwesternregionofCaucasus.It’sborderednorthbyRussia,east
by Azerbaijan, south by Armenia, southwest by Turkey, in west there is Black Sea. The territory of
Georgia is 69.5 thousands sq. km. Total length of the border is 1968.8 km, land –1,660.4 km, see
borders- 308.4 km. In geographic terms Georgia belongs to neither Europe nor Asia. In cultural terms
it is neither West nor East. It has distinct language, customs and traditions. The 90ies were the most
critical years in the latest history of Georgia since they marked the period of fundamental changes in
political, economic and social life of the country.
The region of Kvemo Kartli consists of six rayons or districts: Gardabani, Marneuli, Tetri Ttskaro,
Bolnisi, Dmanisi and Tsalka. The administrative centre of Kvemo Kartli, Rustavi, is situated just 25
km from the Georgian capital, Tbilisi, and the towns of Marneuli and Gardabani are also close to the
capital (at distances of 39 km and 42 km respectively). The western rayons of Kvemo Kartli
(Dmanisi, Tetri Tsqaro and Tsalka) are not only more remote from Tbilisi geographically, but are also
rather mountainous; the town of Tsalka is situated approximately 1,500 meters above sea level. The
three principal national minorities concentrated in Kvemo Kartli are Azerbaijanians, Armenians and
Greeks. Azerbaijani are by far the most numerous of the three sub-regions; according to the 2002
census, 284,761 Azerbaijanians live in Georgia (6.5% of the population) and 78.9% of these live in
Kvemo Kartli. According to the same census, Azerbaijanians form an absolute majority of the
population of Marneuli, Bolnisi and Dmanisi rayons and more than 40% of the population in
Gardabani rayon.
Vegetable growing is the main economic activity and potatoes are the main crop. One source
estimated that 126,000 tons of potatoes were produced in Kvemo Kartli in 2000, which made up
41.8% of all potatoes produced in Georgia. According to this source, in the same year, Kvemo Kartli
produced 25.4% of all vegetables produced in Georgia.2 Fruit and grain (mainly wheat and maize)
production is also significant, particularly in the Gardabani and Marneuli rayons. Livestock breeding
also plays an important role in the local economy, especially in the mountainous regions where
hayfields make up a large proportion of agricultural land. As for poverty in Kvemo Kartli, 78 percent
(3/4) of the population lives under the poverty line and 1/3 in extreme poverty1 Adequate financing in
the health sector of Georgia is a major challenge and stems in large measure from the collapse of
Soviet-style health systems. Before the 1990s, central budgeting had dominated the policy and
practice of provider reimbursement in the health care sector of Georgia. Under the old system,
production capacity (e.g., hospital beds, staff) and utilization of services (e.g., number of inpatient
days or outpatient visits) drove the financing of health care providers. The financing system did not
contain incentives for higher workloads, better management, or clinical and technological innovation.
1
Progress Report, Economic Development and Poverty Reduction Program (EDPRP), Tbilisi, January 2005
A Call to Serve International –Mid-Term Evaluation Page 58
The supply of health care resources (physicians and hospital beds) continued to grow and reached an
excessive level in the economy. Total health care system productivity has been on the decline since
the mid-1960s and, to make matters worse, scarce budgetary resources have been diverted to
redundant capital investment in defense programs. After the dissolution of the Soviet Union, the
rapid disintegration of the old centrally controlled economy and a civil war left Georgia with a
collapsed economy. The system underwent enormous upheaval and was no longer uniform or as
highly regulated. In 1995, in response to this economic crisis that brought public expenditures on
health to a level of less than US$1 per capita, the GOG launched an ambitious health sector reform
program. The vision of the future health system was a social insurance model, maintaining the
principles of solidarity and equity. However, the reality was that scarcity of state financing shifted the
financial burden to the population. Underdeveloped private insurance is not yet able to meet existing
"needs", to pool available private resources and to increase the volume of prepaid funds for health
care funding. That’swhy,seekingalternativesolutionsbecomesofprimeimportanceforGeorgia.In
the Georgian health sector, the problems posed by lack of adequate resources are compounded by
lack of knowledge about the optimal pattern for reallocating existing resources or applying new
resources. There have been significant, recent advances in the state of knowledge in this area. The
GOG has shown its commitment to improving maternal and child health through legislation and
policydocumentssuchas“LawonHealthCarewhich defines the rights of mothers and children; The
LawonPatients’Rights,whichgrantspregnantandnursingwomentherighttoinformationabout
possible effects of planned medical interventions on a fetus or infant: The Law on Promotion of
Breastfeeding and Regulated Use of Artificial Food, which governs the state activities promoting
breastfeeding and complements a law regulating the sale of infant formula. In addition the GOG has
entered into several international agreements touching on perinatal care, such as the International
Conference for Population and Development (ICPD) Plan of Action, the Convention on the Rights of
a Child (CRC), the Convention on Elimination of All Forms of Discrimination against Women
(CEDAW) and the Millennium Declaration. Currently GoG is implementing several reforms related
tomaternalandchildcarerangingfrom developingafamilydoctors’institutetoreorganizing
hospitals and their financing and accreditation. Currently, the health care system of Georgia is
divided into primary, secondary and tertiary levels of care. However, there is no policy that clearly
delineates service by level of care. In terms of facilities, the maternal and child health care sector of
Georgia’shealthcaresystemconsistsof685ambulatories,180 polyclinics, 19 antenatal clinics, 50
maternity houses and 47 maternity wards at hospitals. Of those in Kvemo Kartli are 7 maternity
hospitals, 65 ambulatories, 8 polyclinics, 3 Ambulatory-Polyclinic Unions.
As a signatory to the Millennium Development Goals the GoG has pledged to decrease infant and
under-five mortality by two-thirds and maternal mortality by three-fourths relative to its year 200
statistics by the year 2015. The GoG seeks to achieve these goals through several public policies
including four free antenatal checkups for pregnant women, a vouches system that offers subsidized
delivery services at select maternity facilities, additional subsidized care for high-risk pregnant
women and subsidized hospital care for children from birth to age three.2
Project Goals and Objectives
Project Goals is: Sustained reduction of under five mortality, infant and maternal mortality rate in
Kvemo Kartli Region
2 Curatio International Consulting, Assessment of Perinatal Care in Georgia, Georgia, 2006
A Call to Serve International –Mid-Term Evaluation Page 59
Project Objectives are:
 Improved Quality of M/C survival services and increased quality of care on household level;
 Improved Behavior of community, health care professionals and health managers on
maternal and child health;
 Increased Accesses to M/C health care services and increased accesses to adequate standard
 Case management
Intervention Activities
Areas of intervention of the project were defined as follows:
 Maternal & Newborn Care
 Breastfeeding
 Nutrition
 Pneumonia
 Diarrhea
Intervention activities related to intervention area include:
 Improving Quality of M/C survival services and quality of care at household level
 Improving Behavior of community, health care professionals and health managers on
maternal and child health.
 Increasing Accesses to M/C health care services and accesses to adequate standard case
management
Objectives of the KPC Survey
Measuring progress compared to benchmark data for maternal and child health indicators including:
 Collection of MTE data on the health and nutrition status of children under five and women
of reproductive age;
 Identifying the impact of implemented interventions on health behavior patterns;
 Enhance the capacity of ACTS staff in planning, conducting, data collection and analysis of
KPC surveys
 Revising DIP and developing Plan of Action based on the results obtained.
Process and Partnership Building
Successful conduction of any survey especially health related KPC requires cooperation at various
levels such as governmental, local administration and community. Considering the above said from
the very beginning of the Project Implementation ACTS team compiled a Project Description
document in Georgian and distributed it to various departments of MoLHSA, Public Health
Department of Georgia and Parliament Commission for Medical Issues, NGO Georgian Medical
Association. This was followed by meetings and consultations with the Minister of Labor, Health and
Social Affairs and his deputies and the heads of relevant Departments. As a result of these meetings
and consultations ACTS concluded Agreement on Cooperation within the Framework of the Project
with MoLHSA and Public Health Department of Georgia. This significantly helped in establishing
close partnership relationships with Kvemo Kartli administration as well as with district
administration and local medical professionals. As a result all administrative bodies at regional and
A Call to Serve International –Mid-Term Evaluation Page 60
rayon levels as well as health facilities were involved into the process of community mobilization. A
three year experience of project implementation demonstrated that a network of local volunteers
including local nurses, physicians and representatives of local authorities are playing a crucial role in
selection and recruitment of most active community representatives to serve as conveyors of CS
major messages to the community members. The above stakeholders alongside with district
coordinators actively assisted in recruitment of the representatives of target groups for focus group
discussions, community meetings and development of logistic plan to conduct baseline cluster KPC
and mid-term LQAS surveys. At the same time they served as bridges between the CS team and
target population increasing trust and encouraging population participatory attitudes.
Methods
In September 2007, the LQAS survey was conducted in the Kvemo Kartli Region consisting of
six districts: Dmanisi, Bolnisi, Tetri Tskaro, Marneuli, Gardabani and Tsalka. The sample size
was 19 respondents/SA plus three additional SA for Rustavi city as described below in
“SamplingDesign”section.
 Questionnaire
The LQAS survey questionnaire was adapted from baseline cluster survey questionnaire. The
baseline survey questionnaire was significantly shortened and contained only the modules, allowing
to measure the efficiency of project implementation in relation to the major indicators identified in
DIP. Local partners and stakeholders were consulted to ensure maximal elimination of the possible
obstacles to the process of interviewing. The questionnaire consisted of 26, mostly closed questions.
 Sampling Design
The entire region of Kvemo Kartli was divided
into 6 supervision areas (one per each district of
the region) plus three supervision areas in the
central city of the region – Rustavi. Such
decision was made because Rustavi does not
belong to any of the districts of Kvemo Kartli
region being its administrative center. A simple
random sample of 19 randomly selected
individuals per SA was used to judge whether
the major project indicators are below average or
have reached a performance benchmark. To
calculate a coverage proportion for the
catchment area, the individual samples of 19 are
added together and an average is calculated. In
the household survey, lists of the catchment
population within each village were obtained
from data from the Georgian 2002 Census. A
two-stage sampling plan: first randomly selected
villages with total number of 19 interviews for
each SA have been defined (Appendix 1). The
second step randomly selected a household
within the village (spin the bottle method).
LQAS Indicators
a) Prenatal care:
 Percent of mothers who could report 4 and more
danger signs of pregnancy
 Percent of children aged 0-23 months
exclusively breastfed for 6 months;
 Percent of children aged 0-23 months who were
breastfed within the first hour after birth
b) Healthy nutrition
 Percent of infants aged 6-7 months who received
solid foods with breast milk;
 Percent of mothers of children 0-23 months of
age who were asked and explain proper
breastfeeding and complementary feeding
practices.
c) ARI/Pneumonia and Diarrhea
 Percent of mothers knowing that the must offer
more fluids and food to sick children.
 Percentage of mothers who could report at least
2 danger signs of childhood illnesses
 Percentage of mothers who could report 4 and
more neonatal danger signs
A Call to Serve International –Mid-Term Evaluation Page 61
The following were supervision areas:
SA District SA District
1 Dmanisi 6 Tsalka
2 Bolnisi 7 Rustavi Central part
3 Tetri Tskaro 8 Rustavi Right side of Mtkvari River
4 Marneuli 9 Left Side of Mtkvari River
5 Gardabani
 Training
The interviewers and supervisors participating in baseline KPC survey have been selected for mid￾term LQAS survey. Three day training of interviewers and supervisors has been conducted before
starting LQAS survey. Six interviewers and three supervisors participated in the training. The Agenda
of Training is provided in Appendix 2.
Data Collection:
 Average length of interview
Average length of interview varied between 15 –20 minutes;
 Number of days for data collection
After identifying interview sites the logistic plan has been developed and interviewers have been
assigned to relevant interview locations. With due regards to the geography of the region in
question, accessibility and distances between the interview locations the optimal route for two
cars with interviewers and supervisors has been developed and duration of the survey with 6
interviewers and 3 supervisors was determined as 7 days.
 Major constraints/field problems
The major field problem was accessibility of the respondents in Azeri villages. Considering the
fact that LQAS survey was conducted in the beginning of the fall and it is Azeri women that are
working in the fields, while their husbands are watching them, it proved rather time-consuming
to find the household with a mother of a child aged 0-2 years. Considering this constraint the
LQAS team tried to use rainy weather days to visit Azeri villages.
 Quality-control procedures
One supervisor was appointed to watch two interviewers each. Total of three supervisors were
supervising the activities of six interviewers. By the end of day a supervisor and interviewer had
to fill a special Daily Report Forms as well as tabulate the data obtained. Hand-made tabulations
have been used and to control the quality of and accuracy of data tabulation a team of three
participants - a caller, a recorder, and a verifier has been formed. A Tabulation Quality Checklist
has been used to ensure correct estimation of average coverage for each indicator per SA and
catchment area on the whole.
Data Analysis
 Method of data analysis
A Call to Serve International –Mid-Term Evaluation Page 62
As has been mentioned above hand made data tabulation was used to analyze the data. The
interviewers/supervisors training schedule involved special sessions on hand-tabulation
technique. A Summary Tabulation Table (Appendix 3) was used to summarize the results of the
analysis. The following team members participated in data management analysis:
interviewers/supervisors, project manager and maternal and child health director. The data
obtained were compared with the data collected in the course of Focus Group Discussions as
well as with the data collected from the mothers visiting medical facilities. Confidence Intervals
were calculated using the formula:
P=pz * SQRT((p*q)/[n/Deff])
Where P = the actual rate/proportion in general population
p = the survey estimate
q = 1- p
z = 1.96 (with a confidence level of 95%)
n = sample size
Derff = 1
Results of LQAS Survey
INDICATOR NUMERATOR DENOMI
NATOR PERCENT CONFIDENCE
LIMITS
 Percent of mothers who could report
4 and more danger signs of
pregnancy
87 171 50.8% 43.16% to 58.84%
 Percent of children aged 0-23 months
exclusively breastfed for 6 months; 18 45 48.5% 35% to 62%
 Percent of children aged 0-23 months
who were breastfed within the first
hour after birth
86 171 50.2% 37% to 64%
 Percent of infants aged 6-9 months
who received solid foods with breast
milk;
14 22 63.7% 51% to 77%
 Percent of mothers knowing that the
must offer more fluids and food to
sick children.
139 171 81.3% 71% to 92%
 Percentage of mothers who could
report at least 2 danger signs of
childhood illnesses
129 171 75% 63% to 86%
 Percentage of mothers who could
report 4 and more neonatal danger
signs
96 171 56.1% 43% to 69%
The LQAS survey documented certain changes in target indicator values. These changes
correlated with the interventions their intensity being higher in the districts where interventions
were more vigorous. There were two kinds of interventions –at medical personnel level and at
A Call to Serve International –Mid-Term Evaluation Page 63
the community level. As a result of the first type of intervention total of 157 medical
professionals (OB-Gyns, pediatricians, nurses) have been trained in IMCI, Breast Feeding, and
BFHI. The second type of interventions was conducted on community level and included
community meetings to train the community mobilizers, Health Fairs conducted jointly with US
Navy Medical personnel acting within the framework of Georgian Sustainment & Stability
Operations Program, MOLHSA Public Health Department within the framework of the
Programs:”ActiveDetectionofMorbidityandMedicalPreventiveExaminationofPopulation”,
“SupportofHealthyLife,ActiveDetectionofDiseasesandPrevention of Socially Dangerous
Diseases”.ThreeHealthFairshavebeenconductedinKvemoKartliRegioninGachianiand
Koda villages (Gardabani district) and Irganchai village (Dmanisi district). In the course of
screening all women of fertiule age and particularly pregnant women and mothers of children 0-5
years of age have been counseled on safe motherhood and child care by the joint team of ACTS
Georgia child survival staff, US Navy medical personnel and Georgian physicians. Total of 650
women of fertile age received Cs messages both in verbal and printed forms. Another kind of
community level interventions was organizing Health Festivals in the region with active
involvement of local population and support from local authorities and medical professionals.
More than2000residentsofDmanisidistrictparticipatedintheFestival“HealthyMomsfor
HealthyKids”heldinMay2007.
The Charts 1 and 2 (below) demonstrates the progress in average indices by the end of the 3rd
year of project implementation in six districts (SA) of Kvemo Kartli (Chart 1) and three rayons
(SA) of Rustavi city (Chart 2).
Chart 1. Baseline-Target-LQAS data for 6 SA of Kvemo Kartli
A Call to Serve International –Mid-Term Evaluation Page 64
Chart 2. Baseline-Target-LQAS data for SA Rustavi, Kvemo Kartli Region
5.4
64.2
14.7 16.1
39.5 41.7
56.3
15
75
30 30
60 60
75
63.2
75
56.1
64.9 64.9 65
91
0
10
20
30
40
50
60
70
80
90
100
Baseline
Target
Achieved
For six SA of Kvemo Kartli region one indicator has been found to be below target average
coverage:
 Percent of children aged 0-23 months who were breastfed within the first hour after birth;
At the same time, the same indicator for Rustavi city was even higher than target average coverage
value. Considering the fact that ACTS conducted intensive medical personnel training in Rustavi city
such dramatic increase from baseline 39.5% value to 64.9% (which is 4.9% higher than target 60%
value) can be assumed to be the result of the training and i8ndicative of behavior change among the
maternity hospital personnel.
However analysis of each indicator separately by supervision areas demonstrated that several
indicators were below target average coverage. Thus, percentage of Mothers who knew at least 2
signs of childhood illnesses that indicate the need of referral to health care services was below
average coverage in Marneuli, Gardabani and Tsalka districts of Kvemo Kartli (Table 1)
Table 1. Percentage of Mothers who knew at least 2 signs of childhood illnesses that indicate the
need of referral to health care services
Supervision Area Baseline Target LQAS data Difference
Dmanisi 84.21% + 9.21%
Bolnisi 84.21% + 9.21%
Tetri Tskaro 89.47% + 14.47%
Marneuli 57.89% - 17.10%
Gardabani 63.15% -11.84%
Tsalka 68.42% -6.57%
Rustavi
64.2% 75%
75.0% 0%
In Marneuli and Gardabani districts it was even lower than baseline value for Kvemo Kartli
region.
Percentage of infants who were exclusively breastfed was below target average coverage only in
Gardabani district, though the value of this indicator is significantly higher than the baseline
value.
A Call to Serve International –Mid-Term Evaluation Page 65
Table 2. Percentage of infants who were exclusively breastfed
Supervision Area Baseline Target LQAS
data Difference
Dmanisi 63.15% + 33.15%
Bolnisi 42.10% + 12.10%
Tetri Tskaro 31.57% + 1.57%
Marneuli 42.10% +12.10%
Gardabani 26.31% -3.68%
Tsalka 52.63% +22.63%
Rustavi
16.2% 30%
64.9% +34.9%
The most unfavorable situation is with the [percentage of children who were breastfed within the
first hour after birth –this indicator proved to be below average coverage in 5 districts of Kvemo
Kartli –Dmanisi, Bolnisi, Tetri Tskaro, Marneuli, and Bolnisi (Table 3). However in all these
districts except Bolnisi and Marneuli districts there is a certain increase of average coverage
compared to baseline value.
Table 3. Percentage of children aged 0-23 months who were breastfed within the first hour of
birth
Supervision Area Baseline Target LQAS
data Difference
Dmanisi 42.10% -17.8%
Bolnisi 21.05% - 38.94%
Tetri Tskaro 42.10% -17.8%
Marneuli 36.84% -23.15%
Gardabani 42.10% -17.8%
Tsalka 73.68% +13.68%
Rustavi
39.3% 60%
64.9% +4.9%
Percentage of infants aged 6-9 months who received breast milk and solid food within the last 24
hours was below target average coverage in Bolnisi and Marneuli districts, though in both cases
the LQAS survey values were higher than baseline ones (Table 4).
Table 4. Percentage of infants aged 6-9 months who received breast milk and solid food within
the last 24 hours
Supervision Area Baseline Target LQAS data Difference
Dmanisi 63.15% +3.15%
Bolnisi 47.36% - 12.63%
Tetri Tskaro 78.94% +18.94%
Marneuli 57.89% -2.10%
Gardabani 78.94% +18.94%
Tsalka 42.10% +12.10%
Rustavi
41.7% 60%
65% +5.0%
Among Diarrhea and ARI management indicators Percentage of infants aged 0-23 months with
diarrhea in the last two weeks who were offered more fluids during illness was below target
average coverage in SA 2, 3, 5 (Table 5).
A Call to Serve International –Mid-Term Evaluation Page 66
Table 5. Percentage of infants aged 0-23 months with diarrhea in the last two weeks who were
offered more fluids during illness.
Supervision Area Baseline Target LQAS data Difference
Dmanisi 89.47% +14.47%
Bolnisi 63.15% - 11.84%
Tetri Tskaro 68.42% -6.5%
Marneuli 78.94% +3.94%
Gardabani 68.42% -6.57%
Tsalka 89.47% +14.47%
Rustavi
56.3% 75%
91% +16%
At the same time average coverage values for two indicators: Percentage of Mothers who knew 4
signs of danger during pregnancy and Percentage of Mothers able to report 4 and more neonatal
danger signs are significantly higher than target average coverage in all SA (Table 6 and Table
7).
Table 6. Percentage of Mothers who knew 4 signs of danger during pregnancy
Supervision Area Baseline Target LQAS
data Difference
Dmanisi 31.57% + 16.57%
Bolnisi 52.63% + 37.63%
Tetri Tskaro 31.57% + 16.57%
Marneuli 57.89% + 42.89
Gardabani 47.36% + 32.36%
Tsalka 47.36% + 32.36%
Rustavi
5.4% 15%
63.2% + 48.2%
Table 7. Percentage of Mothers able to report 4 and more neonatal danger signs
Supervision Area Baseline Target LQAS
data Difference
Dmanisi 36.84% + 6.84%
Bolnisi 57.89% + 27.89%
Tetri Tskaro 47.36% + 17.36%
Marneuli 78.94% +48.94%
Gardabani 63.15% +33.15%
Tsalka 52.63% +22.63%
Rustavi
14.7% 30%
56.1% +26.1%
Discussion
Of all supervision areas SA 5 (Gardabani district) has most indicators, which proved to be below
target average coverage (4 out of total of 5 indicators, which were below target average coverage
in the Region). Hence it is necessary to focus ACTS CS on Supervision Area 5 to improve these
indicators.
A Call to Serve International –Mid-Term Evaluation Page 67
By the end of the project, 85% of mothers shall know at least 2 signs of childhood illnesses that
indicate the need of referral to health care services. By year 3 of Project implementation this
indicator should be 75%.
LQAS result for SA 4, 5, 6: 58%, 63%, 68% of mothers knew at least 2 signs of childhood
illnesses that indicate the need of referral to health care services in
each of SA respectively.
Conclusion: Specialattentionintheproject’sinterventionsintheabovesupervisionareas
willbepaidtoincreasingmothers’knowledgeoftheaboveissueand
practicing adequate behavior.
By the end of the project percentage of infants who were exclusively breastfed shall be 50%. By
year 3 of the Project implementation this value shall achieve 30%.
LQAS results for SA 5: 26% of infants were exclusively breastfed.
Conclusion: Hence the messages advocating for exclusive breastfeeding shall be more
pronounces in this supervision area and more effort shall be focused on this
issue to improve this indicator.
By the end of the project 85% of children aged 0-23 months shall be breastfed within the first
hour after birth. By the end of year, this indicator shall be 60%.
LQAS result for SA 1, 2, 3, 4, and 5: Only 42%, 21%, 42%, 37% and 42% of children aged 0-23
months were breastfed within the first hour after birth in
these supervision areas, respectively. This can be explained
by the fact that trainings of the medical personnel have
been conducted only in Rustavi where this indicator was as
high as 70%.
Conclusion: The data obtained indicate that the project did not achieve its objective in four
supervision areas. It is necessary to train maternity hospitals personnel in
remaining supervision areas, starting from SA 2 (average coverage = 21%), then
SA4 (average coverage = 37%), SA 1, 3, 5 (average coverage = 42%). At the
same time at the community level it seems reasonable to encourage future
mothers to demand from maternity hospitals personnel to bring a newborn for
breastfeeding within the first hour after birth. By the end of the Project 85% of
infants aged 6-9 months shall receive breast milk and solid food within the last 24
hours. Year 3 benchmark is 60%.
LQAS result for SA 2 and 4: 47% and 58% of infants aged 6-9 months received breast milk and
solid food within the last 24 hours.
Conclusion: In SA 2 and 4 the community meeting interventions shall specifically stress the
benefits of correct complementary feeding for the children aged 6-9 months.
A Call to Serve International –Mid-Term Evaluation Page 68
By the end of the Project 85% of children with diarrhea aged 0-23 month shall receive more fluids during
the illness. By the end ofYear 3 this indicator shall be as high as 75%.
LQAS result for SA 2, 3 and 5: Among the ARI/Pneumonia and Diarrhea indicators the percent
of infants with diarrhea who received more fluids during illness
was 63%, 68% and 68%, respectively.
Conclusion: Additional efforts shall be applied to educate mothers on the necessity of
providing more fluids to the children with diarrhea. Special attention shall be paid
to education of mothers-in-law in Azeri families.
Other studies
In addition to LQAS survey 11 focus group discussions have been conducted in Kvemo Kartli region.
The FGD guide was the same as in 2006 so that it was possible to compare the results. The FGD of
2007 demonstrated that several behavioral problems evident in the course of 2006 FGD are not
observed any more, that is certain attitudes towards various issues have been changed, which
unequivocally is a positive phenomenon. However knowledge about the benefits of exclusive
breastfeeding in the age of 0-6 months is still insufficient. Compared to previous year mothers are
better informed about the benefits and necessity of exclusive breastfeeding. Their behavior changed
with increase of the information quality –compared to the previous year the number of mothers who
are exclusively breastfeeding their children increased though some of them still believe that the child
below 6 months of age should be given water, and/or juice in addition to breast milk. Some of the
respondents even insisted that breast milk was not enough and infants need some complementary
semi-solid foods.
 We canassumethatmothers’behaviorchangeswiththeincreaseofinformationdelivery
level if such change does not require additional expenses. This observation testifies that with
more aggressive advocacy of exclusive breastfeeding the results are likely to improve
significantly.
Another problem that persisted was self-treatment of a child which is well reflected in LQAS survey
average coverage for percent of mothers who knew at least 2 danger signs of childhood illnesses that
indicate the need of referral to health facility.
 Analysis of the FGD demonstrated that alongside with the fear for the health of a child the
decision to refer to medical institution is also effected by the system of priorities established
inmothers’perceptionofdangersigns.
To a less extent was expressed the problem related to providing more fluids during diarrhea in
children aged 0-23 months. However a few mothers stressed that they believed that a child should be
restrictedinfluidsandfood“nottoirritatethebowelsandstomach”.Atthesametimethemajorityof
mothers disagreed with that statement and said that they had information that contrary was true. The
proportion of those who spoke in favor of giving more fluids during diarrhea was significantly higher
in 2007 FGD compared with the participants of 2006 FGD.
Exit interviews
In parallel with FGD and LQAS survey ACTS CS team developed a short questionnaire and
interviewedthewomenaftertheirvisittowomen’sconsultationorpediatricpoliclinic.Totalof250
interviews were made in 5 districts of Kvemo Kartli region. The questions asked were: 1) Have you
attended or heard of some meetings, workshops or trainings during last 12 months which have been
A Call to Serve International –Mid-Term Evaluation Page 69
dedicated to the issues of safe motherhood? If yes, have they changed your attitude and/or behavior
in relation to the issued discussed?
2) Have you attended or heard of some meetings, workshops or trainings during last 12 months,
which have been dedicated to the issues of child health? If yes, have they changed your attitude
and/or behavior in relation to the issued discussed?
Total of 84 (33.6%) respondents responded positively to both questions. Of interest is the frequency
of positive answers by SA.
Marneuli –2 respondents;
Gardabani –16 respondents;
Bolnisi –12 respondents;
Tetri Tskaro –13 respondents;
Dmanisi –41 respondents.
General Conclusions:
This survey determined that the overall average coverage level for Project Indicators at
Household/Community level is consistent with and in some cases exceeds the target levels. However five
supervision areas had coverage levels below the target level for 5 indicators, the number of indicators
below average coverage varying from SA to SA. The information obtained from this survey combined
with the data obtained from two other smaller studies (focus group discussions and exit interviews at the
women consultations and pediatric policlinics (total of 250 interviews) was used to revise the Action Plan
for remaining 2 year period and redistribute LOF at the community and household level to achieve
improvement in behavior and develop appropriate strategies for achieving target benchmarks by the end
of the Project.
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C. Evaluation Team Members and their titles
David Newberry, MTEConsultant, Global Consultants, Inc, Associate - Department of
International Health, Johns Hopkins University,
Patricia Blair, MD. PhD, President, ACTS International, CMO CSP
Dr. Giorgi Tsilosani, President of ACTS Georgia, Field CMO CSP
Dr. Revaz Tetaradze, CSP Program Director
Ms. Eteri Suladze, ACTS, CSPProject Manager
Tamara Lobgandze, CSP District Coordinator
Ms. Tiko Lomidze, ACTS, MCH Division Director Assistant
Dr. Randall C. Floyd, Associate Professor and Director, Division of Maternal-Fetal Medicine,
University of Missouri, Columbia
Dr. Laura Hillman, Professor of Child Health, Division of Neonatology, University of
Missouri
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D. Evaluation Assessment Methodology
Technical Approach
The consultant, the ACTS Georgia and the ACTS HQ Team exchanged e-mails and
participated in a site visit preliminary MTE planning action. Telephone conversations to
delineate steps and actions required were documented and follow up assignments arranged.
These steps included the following in regards to the MTE.
1. Review of DIP, two annual reports and other related documents.
2. Participatory roles and responsibilities were assigned
3. The close collaboration and implementation of this Child Survival project with the
MoLHSA medical facilities in the project areas required numerous interviews with key
ministry and facility-based professional staff
4. A List was completed of the key stakeholders that need to be interviewed and assessed
5. A List of possible invitees, stakeholders and Partners who would then possibly serve as
evaluation team members
6. Discussion and agreement on the tools to be used for the MTE
7. A strategic meeting with USAID Mission was completed
8. A participatory approach was established as the most important tool for objectivity and
increased ownership
MTE Overview
1. Extensive review of total project documentation and various reports
2. Field visits to MoLHSA facilities, focus groups and various implementations sites
3. Interviews with MoLHSA officials, government partners, political stakeholders, clinic
personnel, mothers attending clinics during facility hours, OB GYN doctors who attend
pregnant women for ANC services and polyclinic staff
4. Multiple interviews with mothers and Focus Group participants
5. Training data and analysis
6. LQAS survey was conducted with 170 women with a child less than two years of age
were interviewed. A simple 10 question LQAS interview form was utilized.
7. Data were collected from various sources including agencies, facility sources and focus
group qualitative assessments were conducted.
8. ACTS community groups were interviewed for participation and on content of their focus
group topics.
9. Annual Reports were reviewed and other assessments reviewed to determine indicators
related to either behavior change or evidence-based findings related to the DIP targets.
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Description of Survey tools
Tool Name Source of Data Sample Size Comments
1. Maternity Facility
Assessment (MFA)
Structured interview
and observation
6 1 regional maternity
hospital
3 maternity wards
2 out patient centers
2. Obstetrician interview
with obstetrician
Structured interview 9
3. Neonatolgist
interview with
Neonatologist
Structured interview 23
4. Obstetrician / direct
observation by MTE
obstetrician
Direct observation 6
5. Neonatologist direct
observation by MTE
Direct observation 6
6. Hospital Delivery
records/log audit
Audit review 6
7. Neonatal Transport
Chart Audit
Chart audit 1
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E. List of Persons Interviewed and Contacted
Review of ACTS Georgia DIP Baseline Survey –2005
Completed by Dr. Nana Sumbadze
DIP KPC
Three ethnic and religious groups were included:
 Christian –314 respondents
 Muslim –285 respondents
 Imereti
Methodology: 900 interviews were conducted in 8 districts according to the CORE survey
methodology.
The Baseline Survey findings were established as the basis for ACTS Georgia Interventions.
Among the most important facets of the ACTS Child Survival DIP is the close and nearly
seamless coordination and collaboration between the Ministry of Labor, Health and Social
Affairs with a community to an institutions-based service implementation and delivery
system enabled.
MTE Plan of Action
 A Mid-Term Evaluation schedule was established
 A global review and interviews of the partners, stakeholders, community and legislative
contributors will be undertaken.
 The impact of the current Georgian Health Sector Reform was analyzed and the positive
and potential negative realities were carefully discussed with members within the reform
group to improve communications during this critical period.
Visit to Rustavi (regional center of Kvemo Kartli Region)
Governor’sOffice
1. Mr. Zurab Melikishvili, Governor of Kvemo Kartli Region
2. Mr. Zakharia Darchiashvili, First Deputy Governor of Kvemo Kartli
3. Mr. Amiran Sultanishvili, district coordinator of ACTS CSP
Field Visit and Interviews
Rustavi Treatment and Diagnostic Center #2
Dr. Manana Kapanadze, Head of the Center
Dr. Rusudan Adamia, Head of the Pediatric Clinic
Rustavi Maternity Hospital
Dr. Zaza Shengelia –Deputy Director of the Hospital
Dr. Laura Mirashvili, Head of Obstetrical Department of the Hospital
Dr. Ketino Dugladze, Head of Pediatric Department
Dr. Eteri Tabatadze, Neonatologist of the Hospital
A Call to Serve International –Mid-Term Evaluation Page 74
Findings:
 Rustavi serves a large patient load, with about 70,000 persons, of which, 40% are
children 0-16 years of age, about 3,000 are less than 3 years of age while 5,000 fall into
the less than 5 year old age group.
 Children present with ARI, pneumonia and diarrhea most frequently
 The“paymentVoucher”systemresultsinmostwomenattendingfourormoreANC
visits.
 There are about 200 staff total.
 Pay was late –usually delayed about a month or more.
 These administrators and staff interviewed are obviously highly dedicated and
motivated. They state their approval and support for the ACTS partnership and
linkages. The focus on training and working with pregnant women was viewed as
directly supportive of their mission and they support a strong, continued collaboration.
The ACTS CS ownership could be observed as one shared by regional MoLHSA and
political partners at all levels, including the Georgia MoLHSA Minister at the national
level.
 Supplies, equipment and pharmaceuticals were available with no outages reported.
 The Governor and his staff are fully supportive of the ACTS partners and the DIP
implementation.
 The most impressive observation was the obvious dedication, commitment and
proficiency of the service staff.
Rustavi Diagnostic Center - Pediatric Department
Indicator 2004 2005 2006
Morbidity –Total 4491 5218 6126
Morbidity –0-12
months 1586 1677 1777
Morbidity –1 year￾3 years 1126 1475 1724
Mortality 0.5 0.3 0.2
Patient Visits 6838 7299 8418
Patient Visits –
Total 8581 10818 13743
Home Visits 1178 707 1043
Immunization 5296 4064 3654
Specialist Referral 1449 2247 1832
Rustavi Maternity Hospital visit
This facility has about 1,600 births per year. Staff can recall one maternal death due to
hemorrhage - during the last 3 years. ACTS request qualitative and quantitative data from all
partner facilities regarding patient loads, collaboration resulting from the ACTS CSP. Issues
raised by the maternity staff included:
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1) Fiscal recovery processes for services
2) Human staff resources available in terms of patient load
3) Institutional resource in terms of their physical facility (POOR)
4) Protocols –are being modified as part of the Health Sector Reform and will require
specific consideration during the start-up period
5) Low salaries, 24 hours of staff coverage and patient load
6) The physical plant is in disrepair and plans are underway to rebuild.
7) Training and in-service applications are a joint responsibility of MoLHSA and ACTS.
Staff expressed great satisfaction with the ACTS CSP and staff.
Visit to Georgia USAID Mission
 Tamar Sirbiladze, MD, Health Program Management Specialist, Office of Health and
Social Development
 Dr. Giorgi Khechinashvili, MD, MS, Health Program Management Specialist, Office of
Health and Social Development
Dr. Tamar Sirbiladze reviewed the background, history and role of the Tbilisi USAID Office.
The geographic areas of USAID projects are defined by the mission. Criteria are based on
needs, and political importance. Measurement of Behavior Change through modification is
challenging at best and costly. ACTS was praised for being both responsive and responsible.
JSI has a reproductive Health project funded by USAID in a site, which slightly overlaps the
CS project. The project provides ANC services, which are featured. There is good
coordination between partners and USAID with national and local network partnerships
including the MoLHSA through facility partners.
Dr. Giorgi Khechinashvili is the USAID Mission expert working with the GOG in
collaboration of the current Health Sector Reform reconstruction process.
JSI has been awarded Reproductive Health grant and their focus is Family Planning (FP) and
ANC and health care service
 ACTS continues to work as described in the DIP implementation process in
collaboration with all partners
 USAID expressed confidence in the ACTS as an organization and as a CS project
implementation partner.
 USAID provided a lucid description of the Georgia national Health Sector Reform. It is
obviously a design in flux, changing from day-to-day.
 One of the key USAID concerns expressed is that of sustainability.
 The ACTS CS project has promise of empowerment because of its strong MoLHSA
collaboration, BCC focus and community implementation strategy.
 The unique structure and function of implementation through a variety of partners with
the strongest being the MoLHSA ministry was never quite raised.
 The project will continue to function and in the training of agents, collaboration
partners, and basic health knowledge sessions in locations covered by the projects while
keeping pace with the rapidly changing health sector reform modifications. At the
present time there are structure adjustments taking place!
A Call to Serve International –Mid-Term Evaluation Page 76
 USAID Mission has an overarching responsibility in monitoring multiple projects with
avarietyof“owners”,whichmustprovideconsistentcomponentsthatmeetUSAID’s
short and long term Georgia country outcomes.
 CDC has provided technical expertise in reproductive health and epidemiologist
training.
 The continued USAID Mission participation with the ACTS Child Survival project was
assured.
The MTE conducted a field visit to an ACTS Georgia project implementation site at Dmanisi
in the Kvemo-Kartli Region of Georgia.
Field Visit to the Dmanisi Outpatient Clinic and Interviews with Dr. Nana Onanashvili,
Head of Public Health Unit, and Madona Butskhrikidze, Administrative Nurse in
Kyemo-Kartli Region
Representing ACTS CS Dmanisi Office:
1. Dr. Ramaz Urushadze, Head of Regional Management Department of National Center
for Disease Control and Public Health
2. Dr. Tamar Lobjanidze, Chief District Coordinator
3. Spiridon Mosashvili, Head of Self-governance Unit (sakrebulo)
The ACTS Georgia implementation Team has a staffed office with a district Coordinator
resident. This facility is arranged to accommodate focal group training. Approximately 20
expectant and new mothers were assembled for a group training session, which covered
gestation, Five useful tips for Moms, and Nine useful tips for mothers with Children 0-5
years Old.
The participants were engaged in the materials and information being provided. They asked
questions while collecting printed summaries of all materials presented. There may be
cultural bias about signing in on the focus group roster but eight ladies signed while 20
participated. ACTS staff has since indicated that time was the key factor and generally all
participants“signin”.Asaresult,itmightbeworthconsideringaddingashorteducation
message on intestinal parasites in a community of ethnic diversity, with nutritional
deficiencies and anemia.
In addition, a visit to the local Polyclinic staff was arranged. We found two excellent
administrative professionals at work: Madona Butskhrikidze: Polyclinic Nurse and Nino
Onanashvili, Physician Public Health Representative. They shared information freely and
intelligently. They manage an operation that includes about 37 staff members that provide
service to about 1200 patient visits per year. The overall population-base of Dmanisi is about
29,000. Services include public health following the normal mission of surveillance focused
on preventing disease, disability and death through prevention means, e.g. full immunizations
and BCC education. An estimated breakdown of the patient demographic revealed that adults
presented with the normal variety of illness and symptoms. Women sought health care during
pregnancy but often deliver at home with local birth attendants. The most common
complaints for children were diarrhea, respiratory and fever of morethanoneday’sduration.
Women completed four (4) or more ANC visits routinely. They also manage the patient
A Call to Serve International –Mid-Term Evaluation Page 77
Voucher system for government reimbursement for delivery services. Men presented most
commonly with hypertension. Low employment resulted in greater alcohol consumption but
negative social impact of this component was not assessed.
Meeting with Facility Staff:
 Staff reported that 70% of pregnant participated in at least one ANC visit and unless
some warning or danger sign noted these women did not return on a routine basis.
 No maternal deaths were reported in recent history.
 The staff does report an unusual incidence of cranial hypertension in infants from cause
or causes unknown.
 They conduct careful disease surveillance and follow-up on any condition with a
potential for spread.
ACTS CS community Focus Group Discussion
ACTS community focus group session
 Twenty attendees with 4 infants
 Slide show presentation
 Five tips for pregnant women
 Nine tips for moms with children
 Slide show on gestation from fertilization to term
 ANC prenatal care covered in detail with focus on the benefits.
 Consider adding de-worming?
Meeting of ACTS Child Survival Implementation Team
Review of Health Information System
 Various data available for 2004, 2005 were identified. It was noted that few data were
available for 2006
 The abortion rate for Georgia is 90,000 because it is used as a form of birth control. The
current birth rate is below population replacement
 C-Section percentage is about 30%
 Low birth weight births is about 6%
 Low birth rate appears to be related to economic factors
 Key birth issues continue to be focused on home delivery versus facility births
 Accurate IMR and MMR rates are difficult to establish because of poor denominators,
low level of birth registration and other death reporting issues
 Immigrants and births registrations are issues that need to be explored during the
 ACTS interventions were reviewed carefully from the prospective of the staff and
client. It was determined that measurements will be done through both quantitative and
qualitative means.
A formal Linkage has been established and clarified with the following:
 MoLHSA at all levels
 Clarities, Partner PVO
 Community partners by location
 Medical facilities and service providers
A Call to Serve International –Mid-Term Evaluation Page 78
 Primary health care and referral systems
 Supervision at all levels and community empowerment
 Careful linkage at the local, district, regional and national levels
 Communication linkages at all organizational levels with strong referral system
 UNICEF strong interest and partnership
 USAID, JSI, ACTS, MoLHSA, WHO, and others
 Project discussed the IMCI by program and by history
 Two major roles for ACTS involve professional and community participant training and
supervision as required for implementation.
Issues
 The major challenge for the intervention measurement is to obtain and document
evidence-based findings, which determines the current status –is the project on-course
and can we make reasonable recommendations as needed.
 Determining accurate denominators will be a real challenge for valid findings. Behavior
change through knowledge modification is very difficult to monitor or show cause and
effect from program activities (interventions).
 There are significant diverse ethnic and religious clusters in the ACTS project
geographic areas, which add to the challenge of project implementation.
 It was agreed to look carefully at the level of effort required to produce measurable
change. How much effort does it take to produce a 15% or any measurable change?
 A question raised is that of a possibility for adding a de-worming component to the
project. This could be important to consider where the nutritional status is so fragile and
stunting prevalence is high.
 Irion deficiency has been a long-term concern of the MoLHSA and ACTS. Anemia is a
very common finding. ACTS Georgia and ACTS International have undertaken a close
collaboration with key MoLHSA officials and national legislators to initiate an iron,
foliate enrichment of flour law. This was passed and signed into law during September
2007. ACTS staff will also assist the GOG develop ransom sampling procedure for iron
in flour at key distribution locations.
 One issue briefly discussed was the role of males in decision making for health and
treatment options. Should ACTS look into an educative focus group for men?
The USAID MTE requirements were reviewed:
 Baseline data and information are related to interventions
 Carefully select monitoring components for project implementation and for measuring
progress of interventions
 Tools are needed for better modifying Intervention targets or amount of effort
 Selection of Health care and service institutions to be assessed:
1. Capacity change
2. National partners
3. Local partners
4. Community organizations and ownership
A Call to Serve International –Mid-Term Evaluation Page 79
The major issue is how to best assess progress in implementing the interventions from the
ACTS Georgia DIP:
1) Assess HIS data gathered
2) Describe community-based monitoring supported by the project
3) Main topic requirements are as follows:
 Technical Approach
 Problem Statement
 Strategy
 Surveys –KPC, Focus Group qualitative interviews and LQAS
 Baseline findings
 Identify Problems and provide implementation Interpretation
 Interventions (Emphasis on how to best establish Behavior Change modification)
 Partnerships and their achievements. How to retrieve and to obtain counts and
frequencies related to CS
Rustavi Coordination Meeting
The Rustavi coordination meeting was organized by the government of the Kvemo Kartli
Region and attended by representatives from the international organizations implementing
projects in the region. Mr. Gulashvili, Deputy Representative of the President in Kvemo
Kartli region introduced the aim of the meeting. The meeting began with an exchanging of
information, analysis of the implemented, and introduction of relevant projects and
recommendationsfortheRegionalAdministrator’sprincipledirectionto supportthe
economical and social development of Kvemo Kartli.
Meeting with Dr. Ketevan Sharangia, IMCI National Coordinator, General Manger and
WHO Consultant on IMCI
The excellent cooperation and coordination between the MoLHSA and the ACTS project was
reconfirmed. We discussed training, Baby-Friendly hospital designation, data, strengths and
weaknesses of the Georgia IMCI.
Meeting with Mr. Zaza Bokhua, Advisor of the Minister of Labor, Health and Social
Affairs (Stakeholder from MoLHSA).
Reconfirmed support for the CSP through overlapping services and extended collaboration
for as long as the project continues.
Meeting with Mr. Levan Baramidze, Deputy Director, National Center for Disease
Control and Public Health
Attendees
1. Giorgi Tsilosani, MD, PhD, President, ACTS Georgia, CMO of CSP
2. Revaz Tataradze, MD, PhD, MCH Division Director of CSP
3. David Newberry ACTS, Consultant
The interview reconfirmed previous observations regarding the obvious fact that the
ACTS/MoLHSA linkage is seamless in every respect. The National GOG is deeply
A Call to Serve International –Mid-Term Evaluation Page 80
committed to the ACTS Child Survival Project and will provide high lever support to ACTS
on a quid pro quo basis. The Ministry officials knew the project; they recognize the
challenges; they agree on major implementation difficulties because these are their own as
well. All partners are fully aware that behavior change modification (BCI) is difficult to
measure and more difficult to monitor.
Capacity development and community development are two very reasonable expectations the
GOG holds for this project. It is possible that the MoLHSA may use the new baby outreach
home visitation activity as a means of conducting some form of community Focus Group
Discussion for training.
The ministry is impressed with the intensity and thoroughness of the ACTS Child Survival
project. The connection with health care service and treatment facilities was found to be
given a very high priority by the government. The ministry is committed to provide services
as needed to assure that the Child Survival Project is successful for reaching the DIP goals
and project objectives. The individual participating facilities and their attendant staff are
further committed to a longer-term assumption many of the outreach tasks presently being
conducted through ACTS and implementation partners.
Meeting at the Ministry of Labor, Health and Social Affairs
Attendees:
1. Mr. Vladimer Chipashvili, Minister of Labor, Health and Social Affairs
2. Mr. Zaza Bokhua, Advisor of the Minister of Labor, Health and Social Affairs
(Stakeholder from MoLHSA)
3. Mr. Otar Toidze, Member of Parliament, Member of Parliamentary Health Committee
4. Giorgi Tsilosani, MD, PhD, President, ACTS Georgia, CMO of CSP
5. Revaz Tataradze, MD, PhD, MCH Division Director of CSP
6. Ms. Eteri Suladze, Project Manager
7. David Newberry, Consultant
The ministry and legislative body of Georgia are committed to provide services as needed to
assure that the Child Survival Project is successful for reaching the DIP goals and project
objectives is the overall objective of the MTE.
Meeting with Mr. Nick Nutsubidze, Consultant, Reproductive Health Survey in
Georgia.
A very cordial meeting was conducted modeled on previous meetings. Roles and
responsibilities, as well as various input support required by all the partners was concluded
by agreement.
Meeting (Informal) with Mr. Edwin T. Collins, Major, GaARNG Bilateral Affairs
Officer, US Office of Defense Cooperation.
A Call to Serve International –Mid-Term Evaluation Page 81
Major Edwin T. Collins expressed his personal and professional admiration for the ACTS
Child Survival project, its officers, managers, and ability to produce results. He committed to
support the project in every way possible.
Meeting with UNICEF PO Health Officer Tako Ugulava
A meeting with the UNICEF PO Health Officer: Tako Ugulava. We discussed many issues
related to medical doctors following and complying with the revised ministry of health
protocols for treatment, births, quality and procedures for delivery and many related service
requirements. These quality and protocol enhancements have begun to be used by the
government to assure quality services and as a medical education (CME) requirement needed
to be licensed in Georgia. In addition, we discussed data and various reports that UNICEF
had taken the lead on in collaboration with the MoLHSA, and the Centers for Disease
Control and Prevention. Tako Ugulava sent confirmation of her commitment to share
information and continue collaboration with ACTS Georgia. ACTS will follow up on
strengtheningthiscollaborationandtorevisetargetsinrelationtotheaccreditationof“Baby￾Friendly”hospitalsorconductingthefulltrainingrequired.
Meeting with Honorable Lado Chipashvili, Minister of Health of Georgia.
The Honorable Minister provided a short history of the ACTS/MoLHSA Child Survival
project. He and his ministry are committed and highly supportive of the project. The current
Health Sector reform has made the normal function of his ministry a series of ups and down
but they are making both progress and using mistakes to improve the revised Department.
The Honorable Minister will support the ACTS Georgia Child Survival project and continues
to serve as an implementation partner through MoLHSA facilities and outreach programs.
Georgia Project MoLHSA Structure
Partners
Community
Central Hospitals
(III Level)
Primary
Health Care
Regional
Hospitals
Regional Public
Health Department
Regional Health
Care Department
MoLHSA & Public Health
Department
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F. CD with electronic copy of the report
A CD with all required documents is enclosed with this submission.
A Call to Serve International –Mid-Term Evaluation Page 83
G. Special Reports
1. Hospital Assessment by Randall Floyd, M.D. and Laura Hillman, M.D.
Cesarean Delivery Observation
A repeat cesarean section in a patient noted to have had 2 previous cesarean sections is
observed. The operating room is noted to be open with no airflow control. There is an
open electrical circuit box on one side of the room near the infant resuscitation table.
There is no infant warmer available. The suction for neonatal resuscitation is a portable
unit in suspect repair. The basic sanitary condition of the room is unknown but the floor
has open cracks and the plaster is cracking with peeling paint. During the course of
preparation the instrument table was laid out by a surgical assistant who was not wearing
gloves. The instruments were laid out from stainless containers which appeared to be
sterilized. The medication cabinet appears to be relatively well stocked but the inability to
read the labels hampers evaluation. No electrocautery is available. No suction is available
on the operative field. Suture for the procedure is stored in a glass jar that is apparently
reused from case to case. It is unknown whether this is sterilized between cases (this is
doubtful as the jar of chromic suture would not tolerate steam sterilization). Reusable
needles which are obviously not optimally sharp are used. The caliber of the suture
utilized is larger than necessary. The anesthesia machine appeared to be in some disrepair
but functioned adequately to all appearances. Oxygen was supplied from the single wall
line which did not have a standard color-coded handle. No automatic ventilation was
available and the patient was ventilated manually throughout the procedure. There was no
scavenging apparatus available for anesthesia gases and the odor of halothane was
obvious throughout the procedure. Gloves were used only by members of the actual
operating team (surgeons, scrub nurse and anesthesia provider).
The patient was positioned and her abdomen prepped with an iodine solution. An
indwelling urinary catheter was placed and drained (open) into a jar under the table
through IV tubing, the catheter was previously used. The patient underwent induction of
anesthesia with IV diazepam and ketamine, maintenance anesthesia was
halothane/oxygen and fentanyl was administered following cord clamping. Ceftriaxone
was administered following cord clamping. The procedure was performed through a
midline incision through the previous incision scar. The uterine incision was low
transverse. The amniotic fluid was noted to be stained with meconium at the time of
delivery. The uterine incision was closed in three layers with chromic/vicyl/chromic. A
hematoma was ligated with chromic. The peritoneal cavity was inspected but not
irrigated. The fascia was closed with interrupted chromic suture stitches. The skin layer
was closed with large gauge silk suture using interrupted mattress stitches.
Major concerns include: the facility and its condition, the lack of sterile technique during
the preparatory stages, the condition of the anesthesia equipment, the lack of fetal
resuscitation equipment. Other concerns include the use of an open system for drainage
of the bladder and the use of reusable equipment which appears to be in suboptimal
condition. The suture material used should be reevaluated.
Hospital Review Questions
A Call to Serve International –Mid-Term Evaluation Page 84
Rustavi
1. Number of deliveries –1600, 130/month,
a. Number operative vaginal –?
b. Is anesthesia available –yes, local only
c. Other intrapartum pain control modalities –none
2. Number of cesarean deliveries –20% (20-30/month) general anesthesia is utilized. The
OR is observed and is substandard secondary to sanitary issues.
3. Transfer to higher level of care –none
4. Criteria for transfer –N/A
a. Neonatal distress –N/A
b. Rh isoimmunization –yes, unclear to where. Rhesus negative patients are few at a
rate of 3-4/month
c. Other
5. Receiving hospital notified –N/A
a. How
b. Who
6. What routine prenatal laboratory studies are done
a. Serology, hgb/hct, Rh, ABO, HIV, Hepatitis B; no glucose challenge is used to
screen for gestational diabetes; a fasting blood sugar alone is measured. Rubella
screening is not done
b. No blood bank or storage capabilities are available in any of the hospitals. The
hospital laboratory is evaluated and appears to be rudimentary but is likely
adequate for the services performed. Equipment needs to be reviewed and
upgraded.
7. What routine admission laboratory studies are done –Hb/Hct, urine protein
8. What type of intrapartum monitoring is utilized –occasional auscultation
a. No monitoring was observed in the two laboring patients noted on the ward at the
time of observation. Electronic fetal monitoring is not available.
9. What routine postpartum laboratory studies are done –urinalysis, Hb
10. What routine neonatal laboratory studies are done
11. Are neonatal Apgar scores and weight recorded - yes
a. Where
i. Apgar scores are recorded in the maternal and neonatal records
ii. Weight is recorded in the maternal/neonatal records and birth record
12. What are typical congenital malformations and at what rate –not reported. Alcohol use
during pregnancy is not felt to be a problem but smoking is felt to be problematic
13. What equipment is available -
a. Ultrasound
i. Yes, available but possibly for those who can pay
b. Fetal monitor
i. None
c. BP cuff
i. Yes
d. Stethoscope
i. Yes
e. Scale
A Call to Serve International –Mid-Term Evaluation Page 85
i. Maternal
ii. Infant
f. Infant warmer
i. Yes, in the delivery room
g. Incubator - no
h. Heat and/or air conditioning for the hospital –unsure but none obvious
14. Birth registration/record in the hospital
a. Yes,patient’sname,dateofadmission,timeofandtypeofdelivery,neonatal
gender/weight/length, doctor/hcp involved
15. Are stillborns recorded - yes
16. Definition of stillborn - WHO
17. Medications available
a. IV fluids –yes, patients do not routinely receive IV fluid for spontaneous
deliveries. It is unclear how much IV fluid is administered at the time of cesarean
section.
b. Oxytocin - yes
c. Magnesium sulfate –yes, dosage is nonstandard from western perspective and is
administered only after delivery. It is unclear what the loading dose is but the
maintenance dosage is standard
d. Antihypertensive –there is no hydralazine available. Nifedipine is available and is
used for hypertension, as is methyldopa. It is again concerning as nifedipine is a
CCB and if used in conjunction with Magnesium Sulfate may be synergistic with
increased possibility of respiratory compromise
e. Antibiotics –Ceftriaxone appears to be the primary antibiotic. Ampicillin and
gentamicin are available
f. Rh immune globulin –is available and utilized in the postpartum period if the
patient purchases it. It is not administered for threatened abortions and at 28
weeks gestation.
g. Pain medication
i. Local anesthetics - Lidocaine is available, it is unclear what other
medications are available.
ii. General anesthetics –Ketamine, Halothane and thiopental
iii. Postoperative pain medications (?)
18. What is method of diagnosing preclampsia –blood pressure and proteinuria criteria are
used. BP 160 systolic
19. Treatments for preeclampsia/hypertension –Magnesium sulfate and nifedipine, no
hydralazine is available
20. What is method for diagnosing DVT –no answer is given; this is not felt to be a problem,
as it does not happen at this hospital. Laboratory studies available include prothrombin
time and thromboplastin time; it is unclear what standards are used for these tests.
21. Treatments for DVT –fraxiparin and heparin may be purchased for administration
22. Breastfeeding complications
a. Mastitis rate
b. Treatment for mastitis
A delivery was observed in this hospital. The delivery was spontaneous in the squatting position
with no complications. Oxytocin was administered IM at delivery of the placenta. The infant was
A Call to Serve International –Mid-Term Evaluation Page 86
placeduponthemother’schestwithskin-to-skin contact. It was dried and assessed in that
position. No recommendations are noted.
Hospital Review Questions
Father Adams (Maternity Hospital #3)
23. Number of deliveries - 1200
a. Number operative vaginal - 400
b. Is anesthesia available –yes, local
c. Other intrapartum pain control modalities –epidural, spinal
24. Number of cesarean deliveries –20% (250?), general anesthesia is utilized in at least
50%
25. Transfer to higher level of care –Approximately 10 transfers are reported
a. Where transferred
i. Children’sHospital,Gudashuari
b. How transferred
i. Ambulance/emergency vehicle - ambulance
ii. Personal transportation
c. HCP accompanied (physician/nurse) - ?
d. Vehicle equipment - ?
i. Oxygen
ii. Pediatric life support
e. Length of transport
f. Success of transport
g. Infant/mother discharged alive
26. Criteria for transfer
a. Neonatal distress –neonatal complications
b. Rhisoimmunization –yes, unclear to where
c. Other
27. Receiving hospital notified
a. How
b. Who
28. What routine prenatal laboratory studies are done
a. Serology, hgb/hct, Rh, ABO, HIV, Hepatitis B; no glucose challenge is used to
screen for gestational diabetes; a fasting blood sugar alone is measured.
b. No blood bank or storage capabilities are available in any of the hospitals
29. What routine admission laboratory studies are done
30. What type of intrapartum monitoring is utilized
a. No monitoring was observed in the two laboring patients noted on the ward at the
time of observation. Electronic fetal monitoring is reported as available (one
machine) but no paper is available to record the tracings.
31. What routine postpartum laboratory studies are done
32. What routine neonatal laboratory studies are done
33. Are neonatal Apgar scores and weight recorded
a. Where
i. Apgar scores are recorded in the maternal and neonatal records
ii. Weight is recorded in the maternal/neonatal records and birth record
A Call to Serve International –Mid-Term Evaluation Page 87
34. What are typical congenital malformations and at what rate –not reported. Alcohol use
during pregnancy is not felt to be a problem but smoking is felt to be problematic
35. What equipment is available
a. Ultrasound
i. Yes, but it is in poor/nonworking condition
b. Fetal monitor
i. One is available but there is no recording paper
c. BP cuff
i. Yes
d. Stethoscope
i. Yes
e. Scale
i. Maternal
ii. Infant
f. Infant warmer
i. Yes, one is noted in the private wing of the hospital
g. Incubator -?
h. Heat and/or air conditioning for the hospital
36. Birth registration/record in the hospital
a. Yes,patient’sname,dateofadmission,timeofandtypeofdelivery,neonatal
gender/weight/length, doctor/hcp involved
37. Are stillborns recorded - yes
38. Definition of stillborn - WHO
39. Medications available
a. IV fluids - yes
b. Oxytocin - yes
c. Magnesium sulfate –yes, dosage is nonstandard from western perspective.
Dosage is 4gm IV then 2gm IM q6h (vs. 5gm IM q6h)
d. Antihypertensive –there is no hydralazine available. Nifedipine is available and is
used for hypertension. This is concerning as it is a CCB and if used in conjunction
with Magnesium Sulfate may be synergistic with increased possibility of
respiratory compromise
e. Antibiotics –Ceftriaxone appears to be the primary antibiotic. Unasyn is used for
prophylaxis at the time of cesarean delivery and used continuously for 2-3 days.
Augmentin, metronidazole and gentamicin (?) are available
f. Rh immune globulin –is available and utilized in the postpartum period. It is
unclear if it is administered for threatened abortions and at 28 weeks gestation.
g. Pain medication
i. Local anesthetics - Lidocaine is available, it is unclear what other
medications are available.
ii. General anesthetics –Halothane was utilized in the cesarean delivery
observed
iii. Postoperative pain medications (?)
40. What is method of diagnosing preeclampsia –blood pressure and proteinuria criteria are
used. BP 160 systolic
A Call to Serve International –Mid-Term Evaluation Page 88
41. Treatments for preeclampsia/hypertension –Magnesium sulfate and nifedipine, no
hydralazine is available
42. What is method for diagnosing DVT –no answer is given, this is not felt to be a problem
as it does not happen at this hospital
43. Treatments for DVT
44. Breastfeeding complications
a. Mastitis rate
b. Treatment for mastitis
Hospital Review Questions
Bolnisi
45. Number of deliveries - 750
a. Number operative vaginal –not known, forceps deliveries are performed
b. Is anesthesia available –yes, local
c. Other intrapartum pain control modalities –epidural, spinal
46. Number of cesarean deliveries –20% (75-80), general anesthesia is utilized in at least
50%
47. Transfer to higher level of care –Transfers are rare secondary to distance
a. Where transferred
i. Children’sHospital,Gudashuari
b. How transferred
i. Ambulance/emergency vehicle - ambulance
ii. Personal transportation - no
c. HCP accompanied (physician/nurse) -?
d. Vehicle equipment -?
i. Oxygen
ii. Pediatric life support
e. Length of transport
f. Success of transport
g. Infant/mother discharged alive
48. Criteria for transfer
a. Neonatal distress –neonatal complications
b. Rh isoimmunization –yes, unclear to where
c. Other
49. Receiving hospital notified
a. How
b. Who
50. What routine prenatal laboratory studies are done
a. Serology, hgb/hct, Rh, ABO, HIV, Hepatitis B; no glucose challenge is used to
screen for gestational diabetes; a fasting blood sugar alone is measured.
b. No blood bank or storage capabilities are available
51. What routine admission laboratory studies are done –hb, blood group, proteinuria
52. What type of intrapartum monitoring is utilized
a. No monitoring was observed as there were no laboring patients on the ward at the
time of observation. Electronic fetal monitoring is not available.
53. What routine postpartum laboratory studies are done –hb, urinalysis
A Call to Serve International –Mid-Term Evaluation Page 89
54. What routine neonatal laboratory studies are done
55. Are neonatal Apgar scores and weight recorded - yes
a. Where
i. Apgar scores are recorded in the maternal and neonatal records
ii. Weight is recorded in the maternal/neonatal records and birth record
56. What are typical congenital malformations and at what rate –not reported. Alcohol use
during pregnancy is not felt to be a problem but smoking is felt to be problematic
57. What equipment is available
a. Ultrasound
i. Yes, in working condition
b. Fetal monitor
i. None is available
c. BP cuff
i. Yes
d. Stethoscope
i. Yes
e. Scale
i. Maternal
ii. Infant
f. Infant warmer
i. Yes, one is noted in the OR, one in the delivery room
g. Incubator –yes, there are two in the nursery, there is no bilirubin light in the
hospital
h. Heat and/or air conditioning for the hospital, yes, new central heat is noted
58. Birth registration/record in the hospital
a. Yes,patient’sname,dateofadmission,timeofandtypeofdelivery,neonatal
gender/weight/length, doctor/hcp involved
59. Are stillborns recorded - yes
60. Definition of stillborn - WHO
61. Medications available
a. IV fluids - yes
b. Oxytocin - yes
c. Magnesium sulfate –yes, dosage is standard from western perspective. Dosage is
4gm IV then 2gm IV/hr
d. Antihypertensive –there is no hydralazine available. Nifedipine is available and is
used for hypertension. This is concerning as it is a CCB and if used in conjunction
with Magnesium Sulfate may be synergistic with increased possibility of
respiratory compromise
e. Antibiotics –Ceftriaxone appears to be the primary antibiotic. Ampicillin and
gentamicin are available
f. Rh immune globulin –is available and utilized in the postpartum period. It is not
administered for threatened abortions and at 28 weeks gestation.
g. Pain medication
i. Local anesthetics - Lidocaine is available, it is unclear what other
medications are available.
ii. General anesthetics –Halothane
A Call to Serve International –Mid-Term Evaluation Page 90
iii. Postoperative pain medications
iv. Atropine, diphenhydramine, thiamine, pyridoxine and multiple other
medications were noted in the medicine cabinets.
62. What is method of diagnosing preeclampsia –blood pressure and proteinuria criteria are
used. BP 160 systolic
63. Treatments for preeclampsia/hypertension –Magnesium sulfate and nifedipine, no
hydralazine is available
64. What is method for diagnosing DVT –no answer is given, this is not felt to be a problem
as it does not happen at this hospital
65. Treatments for DVT
66. Breastfeeding complications
a. Mastitis rate
b. Treatment for mastitis
The overall impression of the hospital is favorable. The obstetric floor is very clean and well
organized. The patients (7 postpartum) appear well and comfortable. The infants are well and do
not appear jaundiced or otherwise unwell.
2. Georgia Diary by Laura Hillman, MD
Date: 9/20/07
Initially met with Father Adams, head obstetrician, Dr. Floyd, DR. Blair, and
Nelly interpreted. Mainly discussed obstetrical care.
Main points: Rh incompatibility no longer goes to a separate hospital. Rogam has
been used since soviet times and sensitization is low. Mothers are typed and screened. If
infants need exchange go to the children’shospital.Mothershavefastingglucose
checked and if abnormal have GTT. No screening GTT. Did not acknowledge significant
number of Gestational Diabetes in non-obese.
Metinroomwithabout8“neonatologists”Aftermedicalschooltheyspentone
yearatoneoftwohospitalswhotrained“neonatologists”.Thentheycametothis
hospital. Everyone there was working on this day shift. There were more on at night.
There was a head neonatologist (Locli Drlidzie) and an older woman who was in charge
today (Marina Gelashrili) and carried the resuscitation bag to deliveries I attended, CS
and vaginal. One, who said she had been working here for 10 years, became the group
informally appointed English speaker (Rino Aleksishrili). Another similarly experienced
woman who I think understood English but spoke less was Zhuzhuna Otarashviei. Two
probably newly trained and very interested younger woman who I think understood but
didn’tspeakEnglishwereIngaGogishvieiandSopoTashvier.
They wanted to know our resuscitation protocol. Luckily the one I gave matched
their training that was on the wall in this office. We were then called to go to a C-section.
The infant had been out for 2 minutes and was still without respirations and being
suctioned. They had suctioned for meconium but found none. They said they used an ET
tube with suction but I never saw as they quickly took infant into delivery room where
there was a warmer (none in C-section room). Infant then swaddled and taken to nursery
where put on a second very old and inefficient warmed. I then got to look in the plastic
bag which contained a laryngoscope, a box with ampoules of epinephrine and other
A Call to Serve International –Mid-Term Evaluation Page 91
meds, the ambu bag (small but stiff with pop off-? O2
connection), ET tubes in drawer,
suction attachments for meconium.
In nursery was isolet not servo with piped in O2
from wall. Also rigid hood on
table (wood) with O2
blender and humidifier. Need O2
analyzer. One old suction machine
in delivery room (? CS room). One very old white light biliruben light (in second on floor
below)
Discussed their use of Glucose for IDM, LGA, SGA asphyxia (no glucometer) No
Ca or electrolytes but CBC. Want lab and blood gas analyzer.
Use amp + gent no cefataxime. Need IV phenobarbital (only have PO), use
Valium for seizures. Have everything for IV but need infant IV pumps. Need sterile
VAC/UVC kits.
Wish list:
IV pumps for low flows
New warmers-servo, if possible
Servo isolet
O₂monitors
Pulse oximiters
Suction machine (s)
Ambu bags with O2
regulators
Laryngoscopes ĉsmallblades+ETtubes
More masks
Blue biliruben lights x2
Glucometer
Lab to do Ca + electrolytes?
Blood gas analyzer
VAC kits
Blanket warmers
IV Phenobarbital
“Nebulizer”?
Date: 9/21/07
We went to Maternity Hospital in Restavi south of Tbilisi, a city built by the soviets to be
an industrial city however none of these industries have been able to function out of the
Soviet Union larger system. City is large number of multi floor, multi apartment cement
buildings in poor shape.
We first visited the delivery hospital where one woman had been admitted for
delivery. She was laboring bouncing on a large rubber ball and looked quite comfortable.
She was only 3cm so wewentintothedoctor’sofficeandRandyFloydquestionedthe
head obstetrician about obstetrical care practices. We were then told that the woman was
ready to deliver and went to the room. She was sitting on a berthing stool pushing very
hard. She quickly delivered and the infant immediately cried and was placed on the
abdomen and suctioned. The cord was eventually tied with a gauge tie. Infant was
exceedingly alert. Mother was lifted up to the table where a vaginal repair was done.
A Call to Serve International –Mid-Term Evaluation Page 92
Infant was placed closer and closer to the breast and eventually began to nurse. Mother
and infant were covered by a blanket. Warmer was present but was not set up for
resuscitation.Iaskedthe“neonatologist”whereequipmentwasandagaintherewasonly
one ambu bag not connected to O2 thatcamefromanotherplasticbagwith“everything”.
I asked where there was O2
and was taken down a very long hall to a place where they
said O2 was in a large canister below and a tube came out of the floor up wall and down
hall to nursery where it went to one isolet, relatively new without servo, and one warmer
old but working. There was a very old non-working ventilator but they seemed to want a
CPAP system, bag or prongs, to stabilize the infants while they waited for the transport
team to arrive from Tblisi. She wanted a new pulseoximeter. They had one very old set of
blue (?) biliruben lights which sat on top of a reasonable non-servo isolet which they
wheeled around the hospital as needed and she wished for another biliruben light. Had a
very old infusion pump that did work but needs another.
We then went to the wards where there were 4 to 6 woman in a room with
mothers’bedsandafew babiesincribsandmostinmothers’beds.All were tightly
swaddled and were placed on back but propped to side. I gave the pediatrician with us
andthe“neonatologist”abrieflectureontheimportanceofplacingtheinfantsontheir
backs, not sides. They all know not to place on stomachs because of SIDS but did not
know that sided had twice the risk of back. Some women were being discharged with
tightly swaddled infants. Need to find out if mothers really do the swaddling and if so for
how long. Swaddled in side position, probably very dangerous.
Went to see laboratories that did Hematology, clotting studies biliruben, glucose,
but not electrolytes. There was no bacteriology laboratory. We saw a relatively new
ultrasound which was privately owned but could do scans for non-private patients and get
governmentreimbursement.Theyalsodid“headultrasounds”of the newborns if the
neonatologists”felttherecouldbepathology/bleeds.
We then left and went to a newly constructed beautiful outpatient clinic for both
Pediatrics and adults. It was the only one built in country as a result of a competition and
opened last month. There were 20 Pediatricians in 7 rooms. Each Pediatrician saw
patients in the clinic for 3 hours then they left and did home visits for patients for 3 hours
and second did a clinic for 3 hours then a third for 3 hours: 9-12, 12-3, 3-6. All of the
recordsforthesethreedoctors’patientswerekeptintheroomorganizedbyyearofbirth.
Records were paper books about 6 x 8 with hand written entries. Doctors and a
nurse would go to see newborn for three days after discharge in infants home and provide
training. They would also make home visits to their patients if they were too sick to come
to clinic and decide whether to send to hospital. Another example of overabundance of
doctors, especially pediatric doctors in this country. However this may change quickly
because fewer students are applying to medical school largely due to very low pay of
physicians. Medical school is also about to be taught by a single faculty, not just a
pediatricfacultyand“familypractice”willbeencouraged.Pediatricand“neonatal”
residencies will become longer. Practicing pediatricians are being asked to begin care for
adults.
A Call to Serve International –Mid-Term Evaluation Page 93
Neonatal Essential Equipment for Neonatal Resuscitation in Delivery room
Ambu bags
CPAP bags
? NCPAP set up
Pulseoximeter
O
2 monitor
O
2
blender
Humidifier
Laryngoscope ĉsmallblade
ET tubes
HR/apnea Monitor
Biliruben lights x2
Way to get O2
into rooms?
Infusion pumps
Warmer
Suction
Date: 9/22/07
Went to Bolini to visit a private maternity hospital that had just been rehabilitated.
7obstetricianshadputtheirownmoneytogetheralongwitha“Moscowinvestor”fora
total of $100,000 to fix the plumbing, electricity, heat, floor, walls, and furniture. They
deliver about 700 infants a year. There were about 12-15 beds in rooms from doubles to
quads. The operating room was new with a newer table but the anesthesia equipment was
poor. The delivery room had good delivery tables and a marginal infant warmer. Ambu
bag and laryngoscope was in a box in the nursery as were medications. It would be
helpful to have another set in the delivery room. There was only one neonatologist in the
hospital; she was older and very experienced and exceedingly well known in the
community. There were two isolets in the nursery, one that never was servo and the other
a servo for which they never had a prob. There would like newer ones; however their
main request was for a biliruben light for which they did not have. (Need to look into cost
of biliruben lights and explore billiblankets) The nursery had wall O2 into the isolets but
no blenders, humidifiers, oxygen analyzers, or Pulseoximeter.
Wevisitedwithseveralmothers’whohadtheirinfantsnotswaddled.Thedoctors
and nurses were trying to convince the mothers not to swaddle the infants however at
least two mere unwilling and swaddled the infants themselves. We do not know how long
the swaddled the infants so tightly and what if any the consequences are. Dr. Blair says
that they often have to take the babies to therapists who massage the arms. The infants are
not taken out of the house for 60 days. The infants were all on their backs.
The director of the hospital was well aware of the ACTS Child Survival Program
and credited it and other education with the marked improvement innobstetrical care that
they were able to give. She said that more women were getting prenatal care and that they
were seeing far less complications. Her staff had been trained by ACTS several years ago
and had just been retrained by the John Snow Institute. I did not explore the nature of that
training.
A Call to Serve International –Mid-Term Evaluation Page 94
We went to a 5th century church where Scott was able to take pictures inside. The
head Ob, the neonatologist and other women all went to the church and after they held a
large supper for us at a local restaurant. Both the head obstetrician and the neonatologist
would be excellent candidates to come to the U.S. except neither seems to understand any
English. Neonatologist Manana Abuladze.
Wish List:
Biliruben light or biliblankets
Better infant warmer for DR
Better isolets
Second set of Laryngoscope, tubes the right size
Better Ambu ?
Pulse oximiters
Date: 9/26/07
We went to Dmanisi that is past Bolini very close to the Armenian border. We met
with the mayor of the town then toured the museum of prehistoric artifacts. We then went
to the hospital to deliver supplies, and entire van full for all areas of the hospital. We
briefly went to the maternity ward. The entire hospital was in very poor shape and we
were told that they were making no repairs because they would have a new hospital in 2
years and that this hospital would be destroyed.
We were not able to see the original delivery room because the ceiling was falling
down and it was not safe so that they had moved the deliveries into a room that had an
old but functional classical delivery table. A table was set up for the infant with an
operating room light focused on it to provide heat. Under a cart for the mother there was
an Ambu bag with an adult mask which they said was also for infants. They said they
didn’thavealaryngoscopeor ET tubes. There was no O2
evident but they said they had
small tanks somewhere in the hospital. No suction was evident.
There was a sink, but it was unclear whether or not there was running water as
during a later delivery the obstetrician washed her hands with water provided from a
basin. We then saw the nursery where there was an old isolet without cuffs to keep in the
warmth or O2
. When I asked how they gave O2
they said through the Ambu bag. The staff
said they had triplets born at home at 1430, 1350, and 1050 gms who needed O2
. I
assumed that they were transported to another hospital however, the translator says they
went home after a few days. There was no biliruben light. In the medicine cabinet there
was nothing I could recognize except KCl. The neonatologist we were talking to then was
called to delivery and we went along without a translator. The delivery was not
progressing and we had the mayor waiting, so we left. We had lunch and then we headed
for the archaeological dig.
3. Child Rights ProtectionAssociation“ClaritasXXI”Report
ChildRightsProtectionAssociation“ClaritasXXI”inAprilandMay,2006beganthe
trainingactivitieswithintheframeworkoftheproject“ImprovementandExpansionof
Child Survival Strategies in Kvemo Kartli Region:PilotProject”implementedbyACTS
A Call to Serve International –Mid-Term Evaluation Page 95
International and ACTS Georgia funded by the Child Survival and Health Grant program
to the office of Health, Infectious Diseases and Nutrition, Bureau of Global Health,
USAID Washington D.C.
The training courses "IntegratedManagementofChildhoodIllnesses"(3courses),“Baby
FriendlyHospitalInitiative”(3courses)and“Breastfeeding”(2courses)werecarriedout
in Rustavi.
Integrated Management of Childhood Illnesses (IMCI)
The IMCI training courses, three courses, were carried out on the basis of Rustavi
Treatment at the Prophylactic Center #2.
a. First training course for medical staff of Rustavi region was held from April 5 through
April 15. The seminar was attended by 20 representatives of the Rustavi Treatment –
Prophylactic Center #1 and #2. The seminar was held by the trainers: K. Nemsadze,
M. Khochava, I. Shalamberidze, T. Bakhtadze, and N. Gumbaridze.
b. Second training course for medical staff of Rustavi region was held from April 25 to
May 5. The seminar was attended by 20 representatives of the Rustavi Treatment –
Prophylactic Center #1 and #2. The seminar was held by the trainers: N. Nucubidze,
T. Bakhtadze, N. Kiknadze, T. Obgaidze, and N. Nareklishvili.
c. Third training course for medical staff of Rustavi region was held from May 8 to May
18. The seminar was attended by 20 representatives of the Rustavi Treatment –
Prophylactic Center #1 and #2. The seminar was held by the trainers: M. Khochava, I.
Shalamberidze, N. Nucubidze, N. Gumbaridze, and T. Obgaidze.
The seminars were opened by the program coordinator with an introductory lecture in
which she recognized the necessity of program elaboration. Seminar participants were
divided into four groups and pre-tested. The average pre-test score was 30%.
In the process of seminars the attendants discussed the signs of danger, the evaluation
signs of five basic diseases, the new national calendar of injections, and the main aspects
of treatment. Many of the attendants did not previously know the signs of chest
retraction, skin flexibility, or sense of thirst. Also the majority of attendants didn't know
O.R.S. composition, the principles of the correct preparation of the solution or signs of
administration of medicine. During the seminar, special attention was paid to the
mistakes made in the testing. Seminars were held daily from10:00am until 6:00pm. The
training course induced great interest of the attendants. Each symptom and criterion was
an issue of discussion and evaluation. The clinical course was carried out with special
interest and held daily, from 10:00am until 2:00pm in the borders of which 46 patients of
outpatient clinics and 58 stationary patients were given classification and evaluation. The
attendants evaluated: danger signs, such as vomiting after taking any food or drink;
convulsion; frequency of breath; chest retraction; wheezing; skin flexibility; pale palms;
and correspondence of age and weight. The attendants classified: hard pneumonia or very
severe diseases; pneumonia; possible bacterial infection; sustained fever; no low weight
and no anemia is revealed. The scheme booklet was approved by the participants that
contain the all he necessary information for patient evaluation.
A Call to Serve International –Mid-Term Evaluation Page 96
Technical seminars were held to cover acute respiratory infection, diarrhea diseases,
neonatal diseases, fever conditions, feeding, and anemia. At the end of the seminars
discussions were held on issues that the attendants were interested in.
At the end of the seminars post-testing was carried out. The results equaled mainly 85%
though there were the cases of 100% results. Trainers were invaluable in the increased
knowledge of the participants.
Pre- and Post-test Results
Photographs from the Training Sessions
30%
85%
0%
20%
40%
60%
80%
100%
Pre-test Post-test
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Baby Friendly Hospital Initiative (BFHI) Report
The training seminars on the BFHI were held in the delivery house of Rustavi during
April 5th through 9th, 10th through 14th, and 25th through 29th, 2006. The purpose of the
seminars was to help the medical staff improve their knowledge and practices on
breastfeeding management issues, which are necessary for implementing the 10 steps of
BFHI principles and breastfeeding in the delivery house.
The seminars were held according to the preliminarily worked out day timetable. Each
seminar was held by 4 trainers. The seminars were led by the master-trainers certified on
BFHI issues:
1. Medea Beleshadze
2. Luda Lomia
3. Maya Kherkheulidze
4. Tamar Bakhtadze
5. Nino Kiknadze
6. Nani Kavlashvili
7. Neli Khurtsilava
8. Nana Sapanadze
Bymeansofpreliminaryestimationoftheparticipants’knowledgethoughpretestsand
brainstorming method results it was revealed that the one part of the delivery house staff
was acquainted with lactation management methods, BFHI requirements, and partly used
them in practice; however, many serious gaps were found in their knowledge and in their
position toward the BFHI principles. The participants also were not informed about the
International CODE of Breast milk Substitutes and that the Georgian law worked out on
Code base and adopted by the Georgian Parliament. It was found that there is confirmed
usage of prelactation food and artificial feeding products, as well as pacifiers and teats.
The preliminary estimation confirmed the necessity of conducting of the seminars.
A Call to Serve International –Mid-Term Evaluation Page 98
The first day of the seminar was dedicated to the pre-history, achievements in BFHI
implementation, and the future plans. Requirement of BFHI were discussed, mainly the
importance of continuous education of medical staff, antenatal management, and the
methodologyofpregnantwomen’spreparation,thebenefitsofbreastfeedinganditsearly
initiation. In the process of the mentioned issues presentation the trainers were revealing
the knowledge level of the participant and supplying them with proper information. A
majority of the participants recognized the benefits and priorities of breastfeeding, they
could understand the importance of educating pregnant women, and the importance of
early start of breastfeeding, although inpracticetheydidn’tofteninitiatebreastfeeding
immediately following birth, skin-to-skin contact, and they used the artificial feeding.
The conversation with mothers was limited to the necessity and importance of
breastfeeding. They were less informed about the BFHI principles. The trainers
underlined the importance and necessity of improving the mentioned deficiencies,
explained the role of medical staff in starting breastfeeding early and correctly and the
importance of perfect preparation of the pregnant women in promoting the BFHI
implementation process.
On the second day the intranatal management exclusive breastfeeding, rooming-in, and
the importance of on-demand feeding was discussed. A majority of the participants were
acquainted with the mentioned issues and more-or-less tried to implement them, although
as they noted they have problems about rooming-in because of mother being tired. The
participants were told to try and solve this problem. The preparation of mothers and
conversation with them about the importance of being together and also the necessity of
assisting them were underlined. The special attention was paid to the issue of correct
attachment to the breast, which assists in avoiding many problems.
As for the on-demand feeding principle, the majority of the participants shared and
implemented it in practice, though they paid less attention to the night feeding, which
were explained properly by the trainers. Together with supplying theoretical information
the practical exercises took place by means of demonstrating right attachment signs and
baby’srightpositionstowardthemother’sbody.
On the third day the participants were educated on frequent and rare problems of
breastfeeding (mastitis, nipple sore, milk insufficiency, cleft palate, cleft lip, etc.) and
how to manage them. As the participants noted, concerning the breastfeeding program
implementation in the maternity house, there are no mastitis cases although there are
cases of nipple soreness that, as they thought, were caused by the poor attachment to the
breast and about what they got ensured at the seminar. As for the milk insufficiency
syndrome,totheparticipantsmindtheycouldn’tcorrectlyestimateitsexistenceornon￾existence,becausetheydidn’tknowthecriterionnecessary for its revelation. Trainers
explainedthatthemajorityoftheproblemsweren’tcontradictionofbreastfeedingand
supplying the baby with expressed milk. The trainers represented the medical negative
contradiction of breastfeeding. They underlined the fact, that every such case must be
confirmedandexplainedinthenewborn’shistory.Attheendoftheday,role-plays about
the mentioned issues were held.
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The forth and fifth day were dedicated to the condition of BFHI implementation in
Georgia and the issue of awarding the title. The international code of marketing of breast
milk substitutes and Georgian Law was discussed in depth. Exercises and role-plays also
occurred.
By estimating the results of the seminars the important increase of theparticipant’s
knowledge level (60%-70%) was revealed and their motivation towards BFHI principles
and for gaining the title was sharpened.
Baby Friendly Hospital Initiative (BFHI) Schedule
First Day
1000
-1030
- Registration, pre-testing
1030
-1130 –BFHI (pre-history, achievements, future perspectives)
1130
-1145 –Coffee
1145
-1230 –BFHI Policy and the methods of its implementation (I step)
1230
-1300 –methodology of the continues education of the maternity house staff and its
importance (II step)
1300
-13
45 –Pregnant women education, antenatal management (III step)
1345
-1445 –Lunch
1445
-1545 –BFHI and health of the baby (benefits and priorities of breastfeeding)
1545
-1600 –Coffee
1600
-1700 –Early start of breastfeeding (importance, implementation methods (IV-V)
steps)
Second Day
1000
-1030 –Intranatal management
1030
-1145 –Coffee
1145
-1215 –video-films(“firstattachment”,“Assistmotherstostartbreastfeeding”)
1215
-1300 –“Exclusivebreastfeeding”explanation,itsimportance,mechanisms(IVstep)
1300
-1345 –Importance of rooming-in after delivery (VII step)
1345
-1445 –Lunch
1445
-1545 –“Ondemandbreastfeeding”(importance,mechanismsVIIIstep)
1545
-1600 –Coffee
1600
-1700 –Mother support group (X step)
Third Day
1000
-1030 –Breastfeeding frequent problems
1130
-1145 –Coffee
1145
-1245 –Video-film(“Motheristhebest”)
1230
-1345 –Breastfeeding rare problems
1345
-1445 –Lunch
1445
-1545 –Video-films(“Birthdefects”,“MotherKangaroo”)
1545
-1600 –Coffee
1600
-1700 –Role-plays
Forth Day
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10
00
-1030 –Situation about BFHI implementation in Georgia
1130
-1145 –Coffee
1145
-1245 –Main activities necessary for gaining the BFHI title
1245
-1345 –International Code Marketing of breast milk substitutes
1345
-1445 –Lunch
1445
-1545 –Discussion about the exercises of the Code implementation revealed as a
result of monitoring
1545
-1600 –Coffee
1600
-1700 –Exercises (individual and group work)
Fifth Day
1030
-1130 –ExplanationofthemainprovisionsofGeorgianLaw “OnProtectionand
Promotion of BreastfeedingandRegulatedUseofArtificialFood”.
1130
-1145 –Coffee
1145
-1245 –Mechanisms of working of the law of Georgia
1245
-1345 –Responsibility of medical staff toward the law
1345
-1445 –Lunch
1445
-1545 –Role-play by means of demonstrating the examples of the violation of law
1545
-1600 –Coffee
1600
-1700 –Pre-tests, estimation of the results
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Child Healthy Nutrition Report
Training seminars on Child Health and Nutrition were held in Rustavi during May 8th and
12th, 13th and 17th, 2006. Each seminar was led by 4 trainers. The seminars were held by
certified master-trainers:
1. Medea Beleshadze
2. Luda Lomia
3. Maya Kherkheulidze
4. Tamar Bakhtadze
5. Nino Kiknadze
6. Nani Kavlashvili
7. Neli Khurtsilava
8. Nana Sapanadze
The trainings started with preliminary pre-testingoftheparticipants’knowledge.Each
participant represented the information about breastfeeding and preventing factors in their
area. The frequency of breastfeeding has increased in Rustavi over the past few years.
The feeding percent is about 50-70%. Though means of giving additional questions to the
participants it was found out that exclusive breastfeeding is implemented until six
months;howevernotineverycase.Thecausesofthatinclude:thelowlevelofmothers’
knowledge, traditions,andmothers’work/theirstudyatthehighestuniversities.Several
delivery houses were indicated, among which there was Tbilisi delivery house where
there were problems with newborns breastfeeding, unprepared mothers, and the usage of
artificial feeding products, which to their mind was the cause of the arisen problem on the
clinic level.
The first day of the seminar covered the issue of breastfeeding benefits; mechanisms of
breastfeeding, anatomy/physiology of the nipples, and correct attachment signs were
discussed. All the participants learned about the benefits of breastfeeding for baby as well
as for mother. They learned a few signs of inadequate breastfeeding, right attachment
signs, and its importance. They greeted the demonstration of the consultation methods.
On the second day the participants were represented antenatal and intranatal management
issues, optimal breastfeeding principles, exclusive breastfeeding and on-demand
breastfeeding, peculiarities of preliminary breastfeeding, sudden infant death syndrome
(SIDS) and SIDS prevention. The participant indicated the fact, that in the last years they
haven’tparticipatedinantenatalmanagementaccordingtoexistingstandardsorspoke
with pregnant women. They were given this information by the trainers that as the results
of recently carried our reforms of healthcare; the doctors would interfere in this process
which was more beneficiary for pregnant women and promote their motivation toward
breastfeeding. The participant confirmed that breastfeeding on-demand is mostly
implemented and almost no mother uses the hourly regime. The participants discussed
the particulars of complementary feeding and the variety of foods to use, the necessity of
providing complementary feeding to infants.
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On the third day the lactation amenorrhea method (LAM), milk expression technique,
several breastfeeding problems (milk sufficiency, refusal to the breast), and nipple
conditions were discussed. The majority of the participants knew that breastfeeding could
decreasethepossibilityofbecomingpregnantfollowingdelivery;however,theydidn’t
know that this is possible only in exclusive breastfeeding conditions (LAM) and by
means of protecting the optimal breastfeeding principles. Topics discussed were when it
is possible to use additional (and what kind) contraceptives to protect themselves from
pregnancy; milk expression technique and its importance for managing the various
problems were described by the trainers; milk sufficiency syndrome and the criterions by
which usage it is possible to reveal real milk sufficiency. The fact was underlined that in
manycasesmilkadequacyisthemother’ssubjectivefeelingandveryfrequentlyitis
confirmed by the medical person by mistake. The negative results of pacifiers and teats
usage were highlighted, which can cause the baby to refuse the breast. It was noted that
while estimating the nipples it is necessary to persuade mothers that in almost all cases it
is possible to implement breastfeeding in spite of its size and shape. It was noted that the
only problem may be an inverted nipples, although this is rare. At the end of the day role￾plays were held by using the consultation methods.
On the forth day, trainers discussed the frequent and rare breastfeeding problems,
relactation methods and the particulars of the physical development of breastfeeding
baby. A participant indicated that after implementing frequent and on-demand
breastfeeding it is rarity to have mastitis and abscess cases. As it was revealed by talking
with them most used various ointments to cure by using this method and oiling the
expressed milk on the nipples and drying them on the air gives high effected result. The
trainers were educated on physical development and placing the estimation methods of
weighed baby every month on the map. The proper exercises were done.
The fifth day was dedicated to the particulars of mother and child feeding, BFHI main
principles, artificial feeding issues, and the international marketing code of breast milk
substitutes and the discussion of the main provisions of Georgian proper law. Special
attention was paid to the role of medical staff by means of working and keeping the law
and the sanctions foreseen by the law were underlined in case of its breaking.
At the end of the seminar the post-testing results were quite high (70-80%). The trainers
noted the importance of the seminars in implementing their activities effectively and
indicated that in spite of being informed and having enough experience about the
breastfeedingmanagementissues,they’veincreasedtheirknowledgebymeansofthe
seminars and estimated the existing knowledge defaults and would use the new
information in practice by all means.
Child Health and Nutrition Training Schedule
First Day
1000
-1030
- Registration, pre-testing
1030
-1130 –Importance of breastfeeding
1130
-1145 –Coffee
1145
-1230 –Existing practice of breastfeeding
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1230
-1300 –Breastfeeding mechanisms
1300
-1345 –Breastfeeding estimation methods (attachment, position)
1345
-1445 –Lunch
1445
-1545 –video-film - <First attachment, assist mother to start breastfeeding>
1545
-1600 –Coffee
1600
-1700 –Practical exercises
1700
-1730 –Consultation methods, exercises, role-plays
Second Day
1000
-1030 –Antenatal management
1030
-1145 –Coffee
1145
-1215 –Intranatal management
1215
-1300 –“Exclusivebreastfeeding”(explanation,itsimportance,mechanisms)
1300
-1345 –Management after delivery
1345
-1445 –Lunch
1445
-1545 –“Ondemandbreastfeeding”(importance,mechanisms)
1545
-1600 –Coffee
1600
-17
00 –Peculiarities of complementary breastfeeding.
1700
-1730 –Causes and prevention of sudden infant death syndrome.
Third Day
1000
-1030 –Lactation amenorrhea method
1130
-1145 –Coffee
1145
-1245 –Milk expression technique
1230
-1345 –Refusal to breast
1345
-1445 –Lunch
1445
-1545 –Milk sufficiency syndrome (causes, signs, management methods)
1545
-1600 –Coffee
1600
-1700 –Estimation of nipple condition (revelation of the problems, management);
1700
-1730 –Role-play by using consultation methods
Forth Day
1000
-1030 –Frequent breastfeeding problems
1130
-1145 –Coffee
1145
-1245 –rare breastfeeding problems
1245
-1345 –Practical exercises, discussion of situational history
1345
-1445 –Lunch
1445
-1545 –Relactation methods
1545
-1600 –Coffee
1600
-1700 –Breastfeeding and physical development map
1700
-1730 –Exercises, video-film <mother is better>
Fifth Day
1030
-1130 –Medical demonstrations of artificial feeding and management
1130
-1145 –Coffee
1145
-1245 –Pregnant and breastfeeding mothers
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1245
-1345 –BFHI principles
1345
-1445 –Lunch
1445
-1545 –International code marketing of breast milk substitutes
1545
-1600 –Coffee
1600
-1700–Georgianlaw“OnProtectionandPromotionofBreastfeedingandRegulated
UseofArtificialFood”.
1545
-1600–Discussion, answeringtotheparticipants’questionsandpost-testing.
4. Follow-up Observations on the Integrated Management of Childhood Illness Report
According to the project component of IMCI, the follow-up observation activities were
held later than scheduled. Originally, observation activities were scheduled four-to-six
weeks following the trainings. Follow-up observations were carried out after five months.
Itwasincorrectprocedureaccordingtotheprogram’srequest. These activities were held
between November 6th and November 15th in treatment prophylactic center #2 of Rustavi
by the curators: I. Shalamberidze, M. Khochava, T. Obgaidze N. Nucubidze and T.
Bakhtadze.
The goals of the observation were:
1. Reaffirm recommended clinical habits among medical staff;
2. Reveal the problems that prevent the utilization of the IMCI program; and
3. Find the ways to solve the problems.
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The forms used by supervisors during the post-training observation included:
1. Records of sick child between two and five years and sick infants between one
week to two months;
2. Form of observation on medical staff members;
3. Interviews of mothers;
4. Record assessments;
5. Form on the quality of patient management;
6. Assessments of outpatient clinics and policlinics; and
7. Form on the basic indicators of the IMCI program.
The training course in Integrated Management of Childhood Illnesses for the medical
staff of outpatient clinics of Rustavi region was held in April-May, 2006. Forty doctors
work in treatment-prophylactic center #2 and participated in the training course. All
passed the training course. The doctors were situated in conference hall because of the
renewal activities of the building.
The center also has the registration and vaccination book, Scales. The clinic hours are
10:00am to 4:00pm daily. It is 15-20 minute walk away from the stationary. Owing to the
stateofemergency,theassessmentofthecenter’sequipmentwasnotcarriedout.
There is a corner for vaccinations in the conference hall. Vaccinations are held everyday.
Vaccines are stored on the principle of "cold chain" in special boxes. The following
medicines are available at the clinic: Amoxicillin, Paracetamol, Oral Rehydration
Solution packages. Medicine is kept in a closed and dry place. During the post-training
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observation the supervisors had a chance to immediately observe 25 patients and the
record forms were examined.
The following was revealed from the record examinations: every patient is estimated on
the signs of danger, 90% of patients are seen for main symptoms, and none of the patients
are examined on feeding problems or their immunization status. Supervisors pay special
attention to the latter, as well as to the provision of medicine for the outpatient clinic.
During discussions with the supervisors, the medical staff of the clinic gave positive
descriptions of the program, especially on the completeness of the record forms.
Post-training observations revealed that the medical staff prepared by the program works
according IMCI, which means that patient estimation and management is carried out
using the scheme booklets, forms of records are filled in, and mothers' consultations are
held using remembrances.
According to the first regional summarizing schedule, which contained the relevant
information about the quality of patient management, the following have been revealed:
1. General signs of danger have been estimated for 50 patients up from 40;
2. Basic signs (cough, diarrhea, fever, ear, and throat problems) were diagnosed in 50
patients from 30;
3. Forty-five patients were examined for cough, fever, and diarrhea;
4. Patient weight was estimated with 18 from 50;
5. None of the statuses were fixed with 14 patients from 50;
6. No critical patients were received;
7. Anti-bacterial medicine was administrated correctly in 6 cases from 10;
8. The complete course of anti-bacterial medicine was taken by all 6 patients with
pneumonia;
9. Bronchodilatator was not administered;
10. Patients with dysentery were not received; and
11. Patients with moderate dehydration were not received.
According to the second regional summarizing schedule, which concerns the problems
about supporting the program at medical facilities, the following was revealed:
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1. Medical facilities possess: scales, timers, IMCI booklets, IMCI record forms,
mothers' remembrances, patients' individual cards, individual immunization cards,
registers;
2. Immunization is carried out everyday according to plan;
3. Outpatient clinic works according to schedule from 10:00am until 4:00pm;
4. Records in individual cards are not complete; and
5. 100% of doctors are prepared according to the program in the facilities were the
post-training observations have been held.
Doctors were given relevant instructions about the errors revealed while filling in the
record forms. They were assured on the necessity of correcting mistakes made in the
process of management by providing them information using scheme booklets. With
active participation of doctors the basic issues of past material was carried out. To support
and encourage recommended medical habits situational skills, role-playing was used. At
the same time during the post-training observation period the positive parts of the
program were revealed by supervisors. These positive parts are mentioned by the doctors,
namely:
 The program is easy to understand and use;
 Provides precise diagnoses;
 Details are foreseen by the program;
 The program refers patients to hospitals when necessary;
 Reducesthenecessityoftherapywithantibioticsthataren’tapproved;
 Reduces the frequency of complications and hospitalization;
 Important for children survival;
 It's economical both for population and state.
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5. Summary of Five Hospitals Delivery Log
Rustavi
Maternity
Hospital
Bolnisi Dmanisi Marneuli Gardabani Tetritskaro
1. total # births
2006 Jan- Dec
2007 Jan - Sept
1370
1261
690
544
177
129
915
824
404
378
99
82
2. still born births
2006 Jan- Dec
2007 Jan - Sept
28
11
17
14
3
0
10
5
6
4
0
0
3. # of newborn transferred to
Tbilisi
2006 Jan- Dec
2007 Jan - Sept
12
10
14
14
3
1
0
0
0
0
2
3
4. # maternal deaths
2006 Jan- Dec
2007 Jan - Sept
0
1
0
0
3
1
1
4
0
1
0
0
5. # early neo natal death <7 days
2006 Jan- Dec
2007 Jan - Sept
2
8
0
0
0
1
2
3
1
1
0
1
6. # of newborn transferred to
Tbilisi
2006 Jan- Dec
2007 Jan - Sept
2007 Death post transport*
(national transport
program data from chart review)
74
58
12
17
0
0
0
3
2
2
0
0
0
9
8
1
2
2
2
7. Rh complications
2006 Jan- Dec
2007 Jan - Sept
0
1
0
0
0
0
0
1
0
0
0
0
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H. Project Data Sheet Form
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I. References and Resources
1. References
1. National Medical Center Neonatal Transport DataBase ( unpublished personal
Communication) Kakhaber Chikhradze, M.D.
2. Asatiani, Tenginz, MD, PhD, et al. (2006).UNICEF Assessment of Perinatal Care in
Georgia
3. Healthy Women in Georgia Scaling Up for Success 2006 USAID
4. UNICEF MICS conducted in 2005 has not been released October 2007.
5. Builidng a World Fit for Children UNICEF 2003
6. Millenniunm Development Goals -The Earth Institute at Columbia Univeristy
2. Map of Georgia and Intervention Target Regions
Map of Georgia and Target Regions
Zestaphoni and Chiatura
–two mining towns in
the region of Imereti
located in Western
Georgia –collapse of
manganese mining and
processing resulted in a
staggering
unemployment rate
(65%).
Kvemo Kartli –most
ethnically diverse
region bordering both
Armenia and
Azerbaijan in East
Georgia.
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3. Maternity Facility Assessment (MFA)
QUESTIONS Regional Maternity
Hospital (1) Maternity Ward (3) Outpatient Center (2)
1. Which of the following items are available and in working condition at the maternity facility
1.1 general condition of
building
fair 1 excellent
1 good
1 poor
1 excellent
1 fair
1.2 General Cleanliness good 1 excellent
1 good
1 poor
2 good
1.3 Hot running water in
delivery room
present present in 2 present in 2
1.4 Cold running water
in delivery room
present present in 2
absent in 1
present in 2
1.5 Soap/ Antiseptic
(unsatisfactory if
bar soap;
satisfactory if liquid
soap or antiseptic)
satisfactory satisfactory in 2
absent in 1
n/a
1.6 Wall clock with
Second timer
present present in 2 n/a
1.7 Air thermometer absent absent in 3 n/a
1.8 Oxygen (central of
tank)
present present in 2 n/a
1.9 Central Sewage present present in 3 present in 2
1.10 Heating (satisfactory
if central heating;
unsatisfactory is
electrical heating)
unsatisfactory satisfactory in 1
unsatisfactory in 2
satisfactory in 1
unsatisfactory in 1
1.11 Toilet present present in 3 present in 2
1.12 Refrigerator present present in 3 present in 2
1.13 Generator absent present in 1 present in 1
1.14 Sterilization room present present in 3 n/a
QUESTIONS Regional Maternity
Hospital (1) Maternity Ward (3) Outpatient Center (2)
2. Which of the following items are available and in satisfactory condition
Registers/ documentation
2.1 Clinical Care
Management
Guidelines for
Maternal/Child
Health CARE
MOLHSA 2002
(satisfactory if
available to the
physicians)
present present in 3 present in 2
2.2 Ministerial decree on
maternal and
newborn referral
present present in 3 present in 2
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QUESTIONS Regional Maternity
Hospital (1) Maternity Ward (3) Outpatient Center (2)
Basic Equipment
2.3 Blood pressure
apparatus
present present in 3 present in 2
2.4 Stethoscope - adult present present in 3 present in 2
2.5 Stethoscope - peds absent present in 1
absent in 2
absent in 2
2.6 Infant weighing
scale
present present in 3 present in 2
2.7 Adult weighing
scale
present present in 3 present in 2
2.8 Protective Clothing present present in 3 present in 2
2.9 Speculum - various
sizes
speculum - one size speculum in all 3 -
one size
speculum - various
sizes
2.10 Obstetric forceps
(absolute minimum
equipment for
delivery)
present present in 3 n/a
2.11 Scissors present present in 3 n/a
2.12 Suture needles and
suture material
present present in 3 n/a
2.13 Needle holder –long
(absolute minimum
for C section)
present present in 3 n/a
2.15 Adult ventilator present - old soviet
model
present 3
2 new Japanese
2 old soviet
n/a
2.16 Operating table with
light
present present 3 n/a
2.17 Laryngoscope -adult present present 3 n/a
2.18 Laryngoscope -peds absent absent 3 n/a
2.19 Endotracheal
tubes(different
sizes)
n/a
2.19 Where is equipment
stored (locked or
unlocked)
unlocked unlocked 3 n/a
Education materials
2.20 On postpartum care,
newborn care or
breast feeding
yes yes in 3 Yes in 2
2.21 Leaflets/ poster/
promoting artificial
feeding
no no in 3 no
2.22 Leaflets/ poster on
family planning
no no in 3 no
2.23 Leaflets/ poster on
sexually transmitted
diseases/HIV/ AIDS
yes no
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QUESTIONS Regional Maternity
Hospital (1) Maternity Ward (3) Outpatient Center (2)
3. Postpartum/neonatal room/neonatal ICU
3.1 Cold running water yes yes in 2 yes
3.2 Hot running water yes yes in 2 yes
3.3 Soap/ Antiseptic
(unsatisfactory if
bar soap;
satisfactory if liquid
soap or antiseptic)
satisfactory satisfactory in 2
unsatisfactory in 1
n/a
3.4 Air thermometer absent present in 1
absent in 2
n/a
3.5 Newborn exam table present present in 3 n/a
3.6 Neonatal intensive
care
Not at any of these hospitals. There is national referral center in Tbilisi and
an ambulance transport. 50% of the newborn transport deaths are from
remote Kvemo Kartli.
QUESTIONS Regional Maternity
Hospital (1) Maternity Ward (3) Outpatient Center (2)
4. Neonatal resuscitation area in the delivery room
4.1 Neonatal exam table
with radiant
warmers
yes, but warmer not
producing adequate
temperature
yes in 1
no in 2
n/a
4.2 Cloth towel to dry
baby
yes yes in 3 n/a
4.3 Clinical
thermometer
yes yes in 3 n/a
4.4 Soft anesthesia bag
for resuscitation
no no in 3 n/a
4.5 Mask for infant
various size
no no in 3 n/a
4.6 Laryngoscope for
infant with size
appropriate blades
no yes in 1
no in 2
n/a
4.7 Endotracheal tubes
various small size
uncuffed
yes yes in 1
no in 2
n/a
4.8 Wall oxygen
immediate available
dedicated for baby
close to exam table
no yes in 1
no in 2
n/a
4.9 Incubator no yes in 2, but not
complete and not able
to retain in and oxygen
properly
no in 1
n/a
A Call to Serve International –Mid-Term Evaluation Page 120
QUESTIONS Regional Maternity
Hospital (1) Maternity Ward (3) Outpatient Center (2)
4.10 Suction immediately
available in close
proximity to the
neonatal
resuscitation are
no yes in 1 n/a
4.11 Bulb for suction yes yes in 3 n/a
4.12 Oral catheter yes yes in 3 n/a
A Call to Serve International –Mid-Term Evaluation Page 121
4. Comparison of LQAS MTE Results in RURAL and URBAN AREAS of FOCUS
MID-TERM 2007 (LQAS)
INDICATOR
BASELINE
(KPC)
2005
MTE
TARGET
2007
FOCUS
VILLAGES
rural
FOCUS
CITIES
URBAN
2009
End of Program
Target
Maternal and Newborn Care
(25%)
Behavior Process Indicator
1. Percent of mothers who could
report 4 and more danger signs of
pregnancy
5.4% 15% 59.9% 63.0% 30%
Behavior Process Indicator
2. Percentage of mothers who could
report 4 and more neonatal danger
signs
14.7% 30% 66.2 69.6% 55%
Breastfeeding (20%)
Results Indicator
1. Percent of children aged 0-23
months who were breastfed within the
first hour after birth
Results Indicator
2. Percent of childen 0-23months,
who were exclusively breastfeed for 6
months
39.5%
16.5
45%
30%
59.2
57.2%
62.3%
60.1%
60%
60%
Nutrition (15%)
Results Indicator
1. Percent of infants aged 6-9 months
who received solid foods with breast
milk;
41.7% 60% 75.8% 78.9% 85%
Pneumonia/Diarrhea (40%)
Behavior Process Indicator
1. Percentage of mothers who could
report at least 2 danger signs of
childhood illnesses
64.2% 75% 95.9% 93% 85%
Results Indicator
2. Percent of Children aged 0-23
months with diarrhea in the last two
weeks who were offered more fluids
56.3% 75% 81.3% 91% 85%
A Call to Serve International –Mid-Term Evaluation Page 122
5. Structured interview with Obstetrician
Structured interview documented that the Obstetricians understood:
- how to identify a high risk pregnancy
- How to treat Rh incompatibility most had Rhogam available
- When needed
- How to treat post partum hemorrhage
- How to treat post partum retain placenta
- Indication of C –section
- How to identify preclampsia and eclampsia
- Know that Magnesium was drug of choice
- For treatment but none of the obstetrician knew the correct dose of
- Magnesium , universally they thought 50% of the dose was adequate (it should be
noted that this lower inadequate dose was the dosage used during the Soviet times)
- All obstetrician interviewed had received IMCI training and the last 2 years
- And 50% had received training either Advance Life Support for Obstetrics (ALSO) or
WHO BFH Training
- Partographs were rarely used
- They identified lack of working modern equipment as the number one barrier to
- Providing care to their patients.
- Lack of sterile gloves often prevent all team member from wearing gloves
- Blood for transfusion was not available in any of the Kvemo Kartli hospital
- But all had access to a blood bank in an emergency
- Signs of danger for the neonatal that would necessitate transfer to Tbilisi
- Were known The transport time are long
- C section rate of 20-25% is common in all facilities
- Skin to Skin contact was understood and practiced.
- The concepts of exclusive breastfeeding and breast feeding within first hour were
know and supported
- Salaries remain low and often are delayed in arriving.
The Georgian Obstetrics and Gynecologists Association is the main professional
organization that is working to set practice standards. Interview conducted with Dr.
Tengiz Asatiani, M.D, PhD Georgian Obstetrics and Gynecologist Association.
The Importance of continuous quality assurance standard, ideas and implementation
was recognized but no active regular chart and case review or morbidity and mortality
conference were taking place in any of the Kvemo Kartli hospitals.
In Soviet time maternal death case review was a required practice that was done by an
active board of experts including representatives of the Ministry of Health.
Direct observation of deliveries documented that
- Proper care of the patient and standard acceptable deliver principles were followed in
all facilities
- Anesthesia for vaginal deliveries is limited
A Call to Serve International –Mid-Term Evaluation Page 123
- Hand washing (scrubbing) was done with liquid soap and running water
- Just outside the delivery room in all but one case; in this case there was no running
water in or near the delivery room and hot water from a pitcher was poured over the
OB’shandafterlatheringwithbarsoap
- Use of Epidural is rare due to lack of syringes/anesthetic
Understanding
- While neonatologists are present all most/all deliveries suction, oxygen were not
immediately available for the infant in the all delivery rooms. Oxygen was available
on the same floor as the delivery room.
6. Structured interview by a Neonatologist
Of the Neonatologists interviewed:
 All had received training with the last 12 month on neonatal resuscitation and could
each describe the steps for resuscitation, what equipment was needed and the
indication for resuscitation.
 Less than 50% has actually preformed a resuscitation within the last 6 months or had
been presented at a resuscitation.
 All knew that the babies should sleep on their back to avoid Sudden Infant Death
Syndrome (SIDS).
 There are a large number of neonatologists on each of the staff of the maternity
hospital and working in the ward of the maternity hospital.
Review of the delivery room and direct observation of the care of routine deliveries noted
that:
 While bulb suction was available, wall suction was not
 Oxygen was not immediately available
 Radiant Warmers were present in one hospital and those warmer did not provide
adequate heat levels
 Wall thermometers were missing
 Incubators were present in 2 hospitals, but neither of them had proper set up for
allowing the infant to receive supplemental
 Oxygen while in the incubator
Also noted was that:
 One hospital had bili lights to treat neonatal jaundice by the apparatus and it was
difficult to correctly position in relation to the baby
 Only one hospital had blankets loosely over the baby; The other had the baby tightly
wrapped papose style. The baby could not move in this tight wrap.
 In the one hospital where the loose blankets were in use, the physician reported that
the mother frequently requested to wrap the baby tightly or they themselves would
wrap the baby.
 12 months ago, the physician reported wrapping the baby in a clear plastic saran wrap
light material and placing that under the blanket to maintain body heat in the unheated
maternity hospital and wards. FDG with physicians and mother were conducted by 7.
ACTS to change this behavior. Health Statistics for Infant and Maternal Mortality in
Georgia 1999-2004
A Call to Serve International –Mid-Term Evaluation Page 124
7. Neonatal Transport Death Chart Audit
Maternal
Mortality
per 10,000
Infant Mortality
<28days
per 10,000
Early Neonatal
Mortality <7days
per 10,000
Perinatal
Mortality
per 10,000
# Live births Year
ncdc sds ncdc sds ncdc sds ncdc sds ncdc sds
1999 51.3 22.7 23.4 n/a* 13 n/a* 32.1 n/a* 48,695 46,827
2000 49.2 22.5 21.1 n/a* 12.2 26.0 29.1 n/a* 48,800 46,765
2001 58.2 23.1 20.0 17.7 11.2 n/a 26.4 n/a* 47,459 46,006
2002 46.6 23.6 20.1 18.3 13.6 16.6 28.8 n/a* 46,605 45,033
2003 52.5 24.8 18.5 20.5 12.3 18.4 28.1 n/a* 46,194 44,093
2004 45.3 238 18.0 19.3 12.1 16.5 27.1 n/a* 46,512 47,022
Sources:
National Georgia Center for Disease Control (ncdc)
State Department of Statistics (sds)
*n/a = data not available
A Call to Serve International –Mid-Term Evaluation Page 125
J. Political Structure in Georgia
Home
Structure of Labor Health and Social Affairs System
A Call to Serve International –Mid-Term Evaluation Page 126
K. CSP Relevance to Millennium Development Goals
1. The Government of Georgia is a signer to the UN Millennium 8 Development Goals.
Goal four is to reduce child mortality and goal 5 is to improve maternal health
significantly by 2015. The ACTS Child Survival Program is assisting Government of
Georgia to measure and meet these key goals.
2. CSP Relevance to USAID Georgia Mission Strategic Priorities. ACTS CSP goals,
program indicators and results are aligned with USAID Georgia Mission plans which are
identified as the following strategic objectives (S.O.) and intermediate results (I.R.):
SO 3.4 Increased use of social and health services and changed behavior;
IR 3.4.2 Increased knowledge of health promoting practices;
IR 3.4.3 Improved quality of health services; and
IR 3.4.4 More effective health support system.