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Implementation Completion Memorandum

Project Number: 46077-001 Grant Number: 9171 November 2018

Tajikistan: Improved Maternal and Child Health

through Connectivity (Financed by the Japan Fund for Poverty Reduction)

CONTENTS

I. BASIC INFORMATION.................................................................................................................... 1

1 – 11 ................................................................................................................................................... 1 II. GRANT PERFORMANCE ASSESSMENT ..................................................................................... 2

12. Background and Description ......................................................................................................... 2

13. Grant Development Objectives.................................................................................................... 2

14. Key Performance Indicators: ....................................................................................................... 3

15. Evaluation of Inputs ...................................................................................................................... 4

A. Project Formulation and Terms of Reference ....................................................................... 4

B. Inputs and performance of the Recipient, EA, and IA .......................................................... 5

C. Inputs and Performance of the Contractor, Consultants, and Suppliers ............................. 5

D. Performance of ADB ................................................................................................................ 6

16. Evaluation of Outputs and Results .............................................................................................. 6

A. Actual Outputs and Quality ..................................................................................................... 6

B. Project Cost, Financing, and Grant Disbursement ............................................................... 7

A. Project Implementation Arrangement .................................................................................... 8

B. Implementation Schedule ........................................................................................................ 8

C. Initial Operation and Sustainability ......................................................................................... 9

D. Impact and Benefit Assessment ........................................................................................... 11

17. Overall Assessment and Rating (HS,S,PS,U) ........................................................................... 13

18. Major Lessons Learned ............................................................................................................... 13

19. Recommendations and Follow-up Actions ................................................................................ 14

20. Additional Remarks, Comments and Suggestions ................................................................... 14 III. PREPARATION AND APPROVAL .............................................................................................. 15

ANNEXES Annex 1. PROJECT FRAMEWORK ...................................................................................................... 16

Annex 2: PHOTOS OF MAJOR PROJECT OUTPUTS ....................................................................... 20

Annex 3: LIST OF MEDICAL EQUIPMENT PROCURED UNDER THE PROJECT ........................ 21

Annex 4. PROJECT COST AND FINANCING ..................................................................................... 23

Annex 5. GRANT DISBURSEMENT ..................................................................................................... 24

Annex 6. ORGANIZATION CHART FOR PROJECT IMPLEMENTATION ....................................... 25

Annex 7. CHRONOLOGY OF MAJOR EVENTS ................................................................................. 26

Annex 8. PROJECT MAP ....................................................................................................................... 29

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JAPAN FUND FOR POVERTY REDUCTION (JFPR)

IMPLEMENTATION COMPLETION MEMORANDUM (ICM)

I. BASIC INFORMATION

1. JFPR Number and Name of Grant:

Grant 9171-TAJ: Improved Maternal and Child Health through Connectivity

2. Country (DMC):

Republic of Tajikistan

3. Approved JFPR Grant Amount:

$2,500,000

4. Grant Type:

● Project / � Capacity Building

5-A. Undisbursed Amount

$8,119.33

5-B. Utilized Amount

$2,491,880.67

6. Contributions from other sources

Source of Contribution: Committed Amount Actual Contributions: Remark - Notes:

DMC Government $386,000 $350,000 for civil works of Component A

Other Donors (please name) $ $

Private Sector $ $

Community/Beneficiaries $47,000 $0 In-kind contributions

7-A. GOJ Approval Date:

12 December 2012

7-B. ADB Approval Date:

7 March 2013

7-C. Date the LOA was signed (Grant Effectiveness Date):

9 April 2013

8-A. Original Grant Closing Date:

31 March 2016

8-B. Actual Grant Closing Date:

30 September 2016

8-C. Account Closing Date:

16 March 2017

9. Name and Number of Counterpart ADB (Loan) Project:

Loan 2196-TAJ/Grant 0154-TAJ: Dushanbe–Kyrgyz Border Road Rehabilitation Project (Phase 2) Loan 2359-TAJ/Grant 0085-TAJ: CAREC Regional Road Corridor Improvement Project

10. The Grant Recipient(s):

Ministry of Finance Mr. Qahhorzoda Faiziddin Academics Rajabov Street 3, Dushanbe Dushanbe, Tajikistan Tel: (992 37) 221-00-82, Fax: (992 37) 222 20 73

11. Executing and Implementing Agencies:

Ministry of Transport Mr. Nurali Arabzoda, Executive Director, Project Implementation Unit Ayni 14, 73046 Dushanbe Tel: (992 37) 221 56 73, Fax: (992 37) 251 02 75 Email: piurr@tojikiston.com

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II. GRANT PERFORMANCE ASSESSMENT

12. Background and Description

The Government of Tajikistan identifies primary health care and Maternal and Child Health as top priorities in its comprehensive National Health Sector Strategy, 2010–2020. Poor child health outcomes in Tajikistan were caused by systemic health sector issues, including chronically limited financing and poor quality health services; poverty, particularly in rural areas; limited knowledge of health-promoting behavior; and poor access to clean water. The general population had insufficient access to health-related information and lacked awareness of the causes of ill health. The project area (Rasht district) is one of the most traditional and conservative areas in Tajikistan. Women from the area were less likely than women from other regions to participate in community activities or seek health services. Both the Infant Mortality Rate and Under-five Mortality Rate were 10%–15% higher in Rasht district compared with other regions. The district is one of the poorest in the country and had the highest rate of food insecurity (11%–18% of the population was classified as extremely food insecure and 74% as moderately food insecure).

At appraisal, the project would support combined and interlinked health and transport interventions to improve the health of mothers and children. The bridge access and road improvement together with health interventions would have multiple synergetic social and economic effects: (i) improved transport services (e.g., availability, frequency, reliability, and costs); (ii) greater accessibility to health care resulting in improved health outcomes for women and children (due to an increased number of people seeking treatment for illness due to reduced travel times); (iii) better access to education opportunities; (iv) uninterrupted flow of agricultural goods and services (such as seed, fertilizer, and crops) across the river; and (v) growth in livestock raising through improved access to veterinary services and better access to market opportunities. The improved accessibility would increase economic opportunities of poor rural households, which in turn would contribute to increased income and, thus, improved health outcomes among women and children. The health information component of the project would increase demand for health services, and the project would support activities to match the demand by increasing the supply and quality of health services. The project would help ensure this supply by enhancing the mobility of health personnel and supplies by reestablishing the bridge and road connection and equipping the rural hospital in Navobod with a safe and operating ambulance.

The Country Partnership Strategy for 2010–2014 emphasized ADB's continuing involvement in the transport sector through investments in domestic and regional road links, and includes gender mainstreaming as a core cross-cutting theme. The project would contribute to achieving MDG 4 (reduce child mortality) and MDG 5 (improve maternal health) in the project area.

13. Grant Development Objectives

The primary objective of the project was to improve maternal and child health results for isolated rural communities of five jamoats in Rasht district,1 one of the poorest regions of the country with the highest rate of food insecurity. Health services were poor and knowledge of health-promoting behavior was limited. The situation had worsened since March 2009 when the only bridge connecting the communities to the district center was destroyed by flooding. Residents had to make a 17-kilometer detour to access the road to the district center. This had seriously constrained access to social services, especially health-care facilities, for communities lacking adequate local health services. The project outcome would be improved access of the marginalized rural poor in five jamoats in Rasht district to strengthened health services. The project would support (i) rehabilitation of the bridge and improvement of the rural road, which is linked to the main road –Central Asia Regional Economic Cooperation (CAREC) corridors 3 and 5; and (ii) increase use of effective health services and nutrition practices in the communities. About 40,000 villagers in 58 communities of the five jamoats would benefit from these interventions.2 The project is highly relevant to the government’s priorities in its comprehensive national strategy and also in line with ADB’s strategy for Tajikistan (sees Item 12).

Upon completion, the grant development objectives were effectively and efficiently achieved. Annex 1 is the Project Framework with results.

1 Jamoat is Tajik for village cluster, the lowest administration division. 2 The five project Jamoats are Navobod, Obi Mehnat, Tagoba, Boki Rahimzoda, and Nusratullo Makhsum.

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14. Key Performance Indicators:

Accomplish-ments Rating

(HS,S,PS,U3)

Evaluation of each Indicator:

i) The 66-meter bridge over the Sarbog river rehabilitated

HS A bridge of 66 meters over the Sarbog River was rehabilitated, including mainly strengthening the barrage and embankment, providing paved deck and guards, and improving approaching roads with barriers, etc.

ii) 18 km of the rural road linking Navobod, Obi Mehnat, Tagoba, Boki Rahimzoda, and Nusratullo Makhsum jamoats and Rasht district center improved

S 10.6 km of road connecting Navobod with district center was improved, including earth works, rock excavation, asphalt concrete pavement, drainage works, and roadside facilities.

iii) Five rural communities provided with basic knowledge, skills, and equipment for conducting day-to-day infrastructure maintenance and minor repair works

HS The road association was established with some equipment for implementing decentralized community participation in road maintenance. Substantial trainings were provided on road/bridge maintenance and village infrastructure maintenance. Road association reported the maintenance road during winter season 2015-2016.

iv) 90% of health workers in health facilities of the target area updated on obstetric and infant care, and Integrated Management of Childhood Illnesses (IMCI)

HS Over 90% of 168 health workers in target jamoats were covered by the training programs under the project, including trainings on “Safety motherhood” and “Care of the newborns” with over 100 participations and on “Reanimation of newborn children” with 80 participations.

v) 20,000 people in the target area covered by the public information campaign to improve health behavior at the household level

HS Campaign on “Behavior change communication” was conducted to improve household health behavior, which covered more than 20,000 populations in the project areas. For the campaign a caravan consisting of health workers and project representatives was formed.

vi) The rural hospital in Navobod provided with the basic essential medical equipment

HS During implementation, needs assessment was carried out, which proposed to establish a Diagnostic Center within Navobod Rural Hospital (NRH) equipped with rehabilitated building and essential medical equipment and laboratory. It was found that the operation of this Diagnostic Center has substantially increased the capacity and service of health care in the project areas, especially to women.

vii) The rural hospital in Navobod equipped with a safe and operating ambulance; and 75% of emergencies reported in the rural health centers referred to the

HS An ambulance, equipped with incubator for newborns and medical testing equipment, was procured and is used by NRH. The hospital medical staff was trained to work on the

3 HS=Highly Satisfactory; S=Satisfactory; PS=Partly Satisfactory; U=Unsuccessful

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central hospital supplied equipment and ambulance equipment usage. The Ambulance is now used about 5-10 times a day for pick-up and drop-off patients.

viii) Quarterly and annual reports on project implementation as well as semiannual environmental monitoring reports, acceptable to ADB, prepared and submitted within 45 days after the end of each related fiscal year

HS During implementation, the comprehensive project work plan, implementation schedule, and guidelines were prepared. Effective construction supervision and fiduciary oversight were in place; required reports, including quarterly and annual progress, and semiannual environmental monitoring reports were prepared and submitted to the MOT and ADB generally on time and of good quality.

ix) The government’s grant completion report, acceptable to ADB, received within three (3) months of physical completion of the project

HS The draft project completion report was submitted timely and reviewed by ADB.

x) Acceptable audited annual financial statements for the project (audit report and management letter) received by ADB no later than six (6) months after the end of each related fiscal year

HS The project financial statements were audited by an independent auditor. All the financial audits were submitted in accordance with schedule and respective statements were accepted by ADB.

15. Evaluation of Inputs

A. Project Formulation and Terms of Reference

The project was formulated in consultation with Ministry of Transport (MOT), the Ministry of Health and Social Protection of Population (MHSPP), local governments, rural communities, and development partners concerned, particularly the Embassy of Japan in Tajikistan and the Japan International Cooperation Agency (JICA), as well as people affected by the project. During project preparation, ADB held several consultations with district authorities, communities, and women's groups to identify primary and secondary stakeholders, their perceptions of current problems, and interest in the project. The project scope and approach had also been discussed with World Health Organization, United Nations Children's Fund, World Bank, GIZ, and Global Funds. All development partners agreed on the importance of the project. The project formulation and design was adequate and met with the requirements of the governments and local residents.

The project was innovative. It would comprehensively contribute to improving people's livelihoods through strong attention and responsiveness to the health needs of the poorest while enhancing benefits that the CAREC road provides to residents of isolated areas. By combining effective and well-targeted interventions for sustainable road and health infrastructure improvement and creating relevant skills and knowledge, the project would ensure better access to quality health services and foster partnerships among local governments, community-based organizations, and health-care institutions in meeting the critical needs of women of reproductive age, mothers, and children.

The project would also pilot an innovative approach, which would help consolidate communities’ resources for addressing their needs, through the introduction of the village (road) maintenance fund for sustaining infrastructure improvement and local capacity created by the project. This approach could be adapted, integrated, or scaled up under other ongoing or upcoming interventions. The United Nations Development Program, which had long-standing expertise in local governance and community mobilization, had established grassroots community-based organizations in most jamoats of Rasht valley. These organizations had contributed greatly to the empowerment of local communities, in particular women, and achieved significant results in social mobilization and community development. Given the level of local preparedness and absorptive capacity of the local communities supported by the United Nations Development Program, potential for the project to be replicated in other communities of the district and region was good.

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It was arranged that the MOT would provide national coordination of the project and disseminate information on project activities to all project stakeholders and partners through consultation workshops, seminars, and public awareness campaigns. The project would build the capacity of key local stakeholders (local government, community-based organizations, and contractors) to carry out community-based maintenance work through participatory planning and mobilizing local resources. The project would rely on a variety of training and awareness-raising channels, including community-based education, counseling, schools, parent-teacher associations, local organizations (i.e., farmer associations, village infrastructure maintenance associations) in developing and implementing behavior change communication activities.

B. Inputs and performance of the Recipient, EA, and IA

The performance of the recipient, the executing agency (EA) and the implementation agency (IA) was highly satisfactory, especially by consideration of that the project was the first of its kind of JFPR financed and ADB managed project in Tajikistan, which requires combined joint efforts of the MOT and MHSPP.

The recipient of the grant was the Ministry of Finance (MOF), the EA was the MOT, and the IA was the Project Implementation Unit (PIU) created under the MOT. The related government agencies, including the MOF, the MOT, and the MHSPP actively participated in the project coordination and supervision. The PIU was well-staffed and worked closely with related government agencies, especially the MHSPP and local government as well as related medical entities in the project area. All project components were successfully implemented. During implementation, the central government provided $350,000 counterpart fund for implementing the civil works of road and bridge. The local government and related medical entities also provided substantially contributions in-kind to the project implementation. The project accounts and financial statements were audited annually by the financial auditors acceptable to ADB, and the audit reports were submitted to ADB as required in the grant agreement. The MOT and the PIU well facilitated and fully supported all ADB review missions during implementation and at completion. During implementation, the related government agencies worked closely and provide sound coordination with ADB, JICA and local government authorities.

C. Inputs and Performance of the Contractor, Consultants, and Suppliers

The performance of the contractors was rated satisfactory by the government. Under the project, two contractors were procured and used for the civil works of the bridge/road and Diagnostic Center respectively. The contractor for the bridge/road rehabilitation was procured using the procedure of international competitive bidding (ICB). The contractor mobilized in September 2014 and completed most of the work by the end of 2015. For completing the additional work, the contract was extended until September 2016. The ADB ICM mission observed that the rehabilitated bridge and road were in good quality. The contractor for the Diagnostic Center was procured locally using the procedure of “shopping”. The rehabilitation and outfitting of the Diagnostic Center was implemented as scheduled and in good quality.

The inputs and performance of the consultants were highly satisfactory. The project implementation engaged substantial consulting services, including for project detail design, management and coordination, capacity building, environment and social safeguard compliance, benefit monitoring and evaluation, and financial audits. The detailed design was prepared by a local institute. Despite some delays, the consultant completed the design tasks. An international consultant was recruited as technical advisor for ensuring proper management of the project implementation. The technical advisor developed the detailed working plan of indicating specific actions with the purpose of increase of awareness of women's communities including attraction of mass media, women's committees, replication and distribution of information material. The plan of Behavior Change Communication (BCC) prepared by the international advisor envisaged a qualitative and quantitative assessment of the level of awareness on Maternal and Child Heath (MCH) issues among the women of the child-bearing age which is the main target group of the project. The project manager and the health coordinator worked actively on the project management and coordination. The monitoring and evaluation specialist, joint together with other consultants, carried out annual monitoring activities. Upon completion, the consulting service of totally 85.3 person-months was provided to the project implementation, including 3 months for international consultant and 82.3 person-months for national consultants. The consultants provided important contributions to the project implementation and outputs.

The performance of the suppliers was generally satisfactory. The project procured significant number of equipment, including mini dump truck, ambulance and substantial medical equipment. The suppliers fully

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performed their duties and delivered the equipment within the contract schedule. The quality of the equipment met the specifications.

D. Performance of ADB

ADB’s overall performance was satisfactory. The project’s administration was undertaken by ADB’s Tajikistan Resident Mission (TJRM). It made easier to monitor project implementation activities and amend them when necessary. ADB was closely involved in identifying and resolving issues during implementation through (i) tripartite project review meetings between the recipient, the EA, and ADB, (ii) regular project review missions, and (iii) desk works and variety meetings on needed basis. In all, ADB fielded 4 project review missions during implementation. The ADB missions and desk works analyzed implementation issues affecting the project and provided substantial inputs in preparing action plan to expedite the project’s implementation. The ADB project team and experts provided substantial advice and support to the PIU, consultants, and contractors on project formulation and management. Document approval during processing and implementation was timely, and all claims for payment were processed promptly. The role of ADB missions in providing timely advice and technical supports on all aspects of the project was well recognized by the government.

16. Evaluation of Outputs and Results

A. Actual Outputs and Quality

As planned at appraisal, the project has successfully implemented all project components. Upon completion, the main outputs included:

Component A: Improved and sustainable access for isolated communities through bridge and rural road rehabilitation

� A bridge of 66 meters over the Sarbog River was rehabilitated as planned at appraisal. The bridge rehabilitation included mainly strengthening the barrage and embankment, providing paved deck and guards, and improving approaching roads with barriers, etc.

� 10.6 km of road connecting Navobad with district center was improved. The road improvement included earth works, rock excavation, asphalt concrete pavement, drainage works, and roadside facilities. Considering that resources allocated under JFPR projects were not sufficient for full rehabilitation of 18-km rural road, the project aimed at improvement of the road through rehabilitation of the most deteriorated sections. After completion of the detailed engineering design in 2014, it was established that the project budget could accommodate rehabilitation of 9 kilometers of the most urgent sections. During implementation, some grant saving was reallocated to the civil works, which allowed improving further 1.5 km of the road.

� A Joint Association (JA) for road maintenance was established with some equipment for implementing decentralized community participation in road maintenance. The JA is led by a director and participated by several local residents, who are working as volunteers. Upon requested, a mini dump truck was procured under the project for supporting JA’s work and the practice of community participation in road maintenance.

� Substantial trainings were provided to local government, small contractors, and rural communities, which focused on (i) road and bridge maintenance, and (ii) village infrastructure maintenance (VIM). Over 100 representatives of local governments, small contractors, and rural communities were trained. Workshop was also conducted on technical, organizational and financial matters of road and bridge maintenance. The trainees and workshop participants were supplied with handovers and other study material. Meanwhile, a VIM fund was also established.

During implementation, quality control was carried out by the MOT’s PIU with assistance from the consultants recruited under the project. The PIU staff visited the project site regularly to inspect the compliance of the standards and specification in the bridge and road design. During ADB project implementation completion review (ICM) mission in December 2017, it was found that the project bridge and roads were in good quality and provide comfortable ride for the vehicles and pedestrians. The consultations during field visit also confirmed that the JA was working fine and the equipment was used effectively. Photos of the rehabilitated bridge and road are in Annex 2.

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Component B: Improved and increased use of health services and nutrition practices in the targeted communities

� Substantial trainings were provided to the health workers in the five jamoats, including trainings on “Safety motherhood” and “Care of the newborns” with over 100 participations and on “Reanimation of newborn children” with 80 participations. Overall, over 90% of 168 health workers in target jamoats were covered by the training programs under the project.

� Under the detailed plan developed by the international consultant, campaign on “Behavior Change Communication (BCC)” was conducted in the project areas to improve household health behavior. The BCC focused directly on the work with target groups including pregnant women, women of child bearing age and members of their families. Reportedly activities were conducted in all target jamoats, therefore the target indicator for the coverage of 20,000 population was achieved. For the campaign a caravan consisting of health workers and project representatives was formed. The targeted women were invited to the health centers in their respective jamoats where the health workers including a Chief Doctor of Rasht Hospital provided them trainings on the MCH and proper sanitation habits.

� Based on needs assessment during implementation, a Diagnostic Center equipped with rehabilitated building and essential medical equipment and laboratory was established within Navobad Rural Hospital (NRH). The ceremony of the official delivery of the Center with participation of Ambassador of Japan, high ranking representatives of JICA, MOT, MHSPP, ADB country director, and local authorities. The event was widely publicized and broadcasted on National TV.

� An Ambulance for new mothers’ services, equipped with incubator for newborns (humid crib) and the medical testing equipment (ultrasound scanning, tester of blood and urine), as well as the family physician’s bags and the physician assistant’s bags were acquired under this project and delivered to NRH. The hospital medical staff was trained to work on the supplied equipment and ambulance equipment usage.

� Along with training to behavior change the women from the target communities received the illustrated textbooks and specially designed and printed notebooks containing the calendar with illustrated rules of hygiene, danger signs of pregnancy and other useful MCH information. During BCC activities about 5,000 copies of the notebook were distributed in the target jamoats. In addition, substantial medical equipment and tool was procured under the project, which were distributed among the NRH and the health centers of the targeted jamoats.

During ADB ICM mission, the mission member visited the NRH and some health centers. It was found that (i) the health workers and local residents were very happy with the training programs, who gained substantial knowledge and experience from the trainings and campaign, (ii) the Diagnostic Center was working effectively and efficiently with average 30 patients a day, (iii) the ambulance innovated the medical rescue capacity with average use of 5–10 times a day, and (iv) the notebooks and medical equipment were well distributed and used. A list of medical equipment procured under the project is in Annex 3.

B. Project Cost, Financing, and Grant Disbursement

At appraisal, the total project cost was estimated at $2.933 million equivalent, which consisted of the costs for (i) civil works, (ii) equipment and supplies, (iii) training, workshops, seminars, and public campaigns, (iv) consulting service, (v) grant management, and (vi) contingencies. The project cost would be financed by the JFPR grant of $2.500 million (85.2% of the total project cost) and government funds of $0.433 million (14.8%).

Upon completion, the actual cost for the whole project was $2.842 million, which is about 3.1% lower than that estimated at appraisal. Among the actual project costs, the cost for civil works and trainings increased by 20.1% and 41.6% respectively, which were fully covered by the cost contingency. Meanwhile, the cost for grant management reduced by 45.8%.4 The government’s contribution was actually $350,000, which was used for implementing the civil works of bridge and road. Upon completion, the project financing was revised slightly to be 87.7% from the JFPR fund and 12.3% from the government fund. Annex 4 compares the details of the project costs and financing at appraisal and completion.

4 Substantial government contributions were provided to the project by the central and local governments, which

were in-kind, like office, furniture, supplies, staff cost, etc., which is not able to be converted into money term.

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The grant was approved on 7 March 2013, signed on 9 April 2013, and made effective on 9 April 2013. All disbursements of the grant were carried out in compliance with ADB’s Loan Disbursement Handbook (2012; as amended from time to time). The JFPR grant was channeled from ADB to the imprest account, which was established, managed, replenished, and liquidated by the PIU. Direct payment procedure was applied for civil works and international consulting services. Statement of Expenditures (SOE) procedure was used for reimbursement of eligible expenditures and to liquidate advances for the payment not exceeding $5,000. During implementation, the grant proceeds were reallocated twice upon requests from the government, which mainly reallocated the contingencies and grant savings to civil works and trainings.5 Meanwhile, the grant closing date was also extended by six months from original 31 March 2016 to 30 September 2016 for completing the additional work of the road improvement. Upon grant financially closing on 16 March 2017, total grant proceeds of $2,491,881 were disbursed. The remaining unutilized grant balance of $8,119 was cancelled on the same day.6 The annual grant disbursements are in Annex 5.

C. Project Implementation Arrangement

As arranged at appraisal, the MOT was the EA for the project through the PIU. The PIU, established for previous ADB financed project, was headed by an executive director with the responsibility for overall project management and implementation, who was supported by a group of professional and administrative staff with expertise in financial accounting, civil engineering, construction supervision, social and environmental safeguards and contract management. A project manager was designated specially for implementing the project and was in responsible for day-to-day supervision of the project implementation. For the component B (Improved and increased use of health services and nutrition practices in the targeted communities), The MHSPP actively participated in the project design and implementation. The director of Department of Maternal and Child Health Care and Family Planning of the MHSPP contributed substantially to the project. For supplementing existing PIU resources, additional staff was recruited, including a project engineer, an accountant, and a secretary and translator. Meanwhile, several consultants, including one international expert were engaged to assist the project management, provided variety consulting services in technical advices, monitoring and evaluating project benefits, and assistance in capacity building and other activities of the project implementation. An organizational chart of the project implementation is in Annex 6.

During implementation, the comprehensive project work plan, implementation schedule, and guidelines were prepared and attached to the grant implementation memorandum; the project funds for each component were utilized efficiently and transparently; effective construction supervision and fiduciary oversight were in place; required reports, including quarterly and annual progress, project completion report, semiannual environmental monitoring reports, and poverty impact assessments were prepared and submitted to the MOT and ADB generally on time and of good quality. The project financial statements were audited by an independent auditor and audited reports were submitted to ADB. For monitoring the project achievements and impacts, annual monitoring and evaluations were conducted. The monitoring reports were submitted to ADB timely.

The project was the first of its kind of JICA and ADB financed project in Tajikistan, which requires combined joint efforts of the MOT and MHSPP. During implementation, these government agencies worked closely and provided sound coordination with ADB, JICA and local government authorities. Such a project implementation arrangement and adequate coordination ensured successfully implementation and good performance of the project.

D. Implementation Schedule

The project was approved by the Government of Japan on 12 December 2012 and the grant was approved on 7 March 2013 (ADB Grant JFPR 9171-TAJ). At appraisal, the project was planned to be implemented over 3 years, tentatively from March 2013 to March 2016. After the grant effective in April 2013, the project started implementation. However, the project implementation experienced initial delays due to recruitment of design consultants and arisen design issues while preparing the detailed design. The project scope for Component A (bridge and road) had to be revised according to available budget. The revised scope for civil works was approved by the Minutes of Meeting on 20 January 2014. Then, the procurement for civil works of bridge and

5 ADB letter to Ministry of Finance. 13 October 2016. JFPR 9171-TAJ: Improved Maternal and Child Health

through Connectivity – Approval of Final Reallocation of Grant Proceeds. TJRM 6 ADB Fax. 23 March 2017. JFPR 9171-TAJ: Improved Maternal and Child Health through Connectivity – Final

Cancellation and Actual Grant Closing Date. TJRM

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road started in 16 May 2014 and the contract with selected contractor was signed on 5 September 2014. The bridge over Sarbog river was rehabilitated as scheduled, however the bank enforcement works were completed with slight delay due to seasonal rise of water in the river. The bank protection works at the bridge location were completed by November 2015. Due to extra works for road rehabilitation (additional 1.5 km), the road subcomponent was fully completed by 30 June 2016.

The implementation schedule for the capacity building program under Component A is summarized below:

� The trainings for road maintenance and community participation were conducted in 22–26 May 2015.

� The JA, named ”Shahraki Navobad” was approved and formally established on 7 September 2015. A workshop was conducted in 28–31 October 2015 as part of implementation process of establishing the JA.

� The procured mini dump truck was delivered on 31 December 2015.

The procurement of the civil works for the Diagnostic Center started on 30 June 2014 and the contract was signed with the selected local contractor on 18 July 2014. The implementation took five months and completed on 20 December 2014. A ceremony of the official delivery of the Diagnostic Center took place on 22 May 2015 with participations of high rank representatives. The Ambulance purchased under the project was delivered to NRH on 16 September 2014. The procured medical equipment was delivered to NRH in July to September 2014.

The implementation schedule of the trainings and campaign under Component B are summarized below.

� The trainings on “Safety motherhood” and “Care of the newborns” were conducted in May 2014.

� The trainings on “IMIC” were conducted in October 2014.

� The training for health workers on interpersonal relations were undertaken in August 2015.

� The trainings on “Reanimation of new born children” was conducted in 29 May to 4 June 2016.

� The BCC was undertaken in July 2014 to December 2015.

Although the project activities started with the 5 months’ backlog from the initial schedule due to difficulties with recruitment of essential staff and detailed design, the project implementation was generally completed on time. From time to time the implementation schedule was reviewed and revised to reflect the actual progress achieved in the project implementation and amended implementation plan. The impacts of initial delays were minimized due to timely amendments, good cooperation and efforts of project management. For facilitating the project implementation and fully achieving the anticipated project benefits, the grant closing date was extended by six months.

The chronology of major events of the project is in Annex 7.

E. Initial Operation and Sustainability

Project bridge and road

The rehabilitation of the bridge and road was fully completed in June 2016, which was followed by defect liability period (DLP) of six months. During the DLP, no serious quality issue was reported. Under the project, a JA for road maintenance was established, which is led by a director and composed of several maintenance workers. While establishing the JA, several units of road maintenance machinery and equipment were pooled among the five jamoats.7 The project also contributed a mini dump truck to enhance the capacity of the JA. Currently, the JA takes the responsibility of routine road condition inspection and basic road maintenance (adding gravel, clean land sliding, and snow removing). The operation fund comes from donations of local residents. For large road maintenance and damages, like potholes sealing and patching, the JA needs to report it to the MOT’s regional road maintenance depot for repairs. Such community-based road maintenance has increased the awareness of road asset protection and maintenance, and also ensured timely maintenance of the road. However, operation fund is a serious challenge. The project bridge and road is located in poverty

7 Currently, the Joint Association has total seven road maintenance equipment, like grader, excavator, loader,

and the mini dump truck procured under the project.

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areas of Tajikistan. Raising fund is not an easy task. During the site visit of the ADB ICM mission, it was told that a loader needed to replace 4 tires. But, the JA could raise the fund enough only for 2 tires. To be sustainable, the government might establish a special fund and provide more technical assistance to the community-based road maintenance.

The project road connects the main road to Navobad with total distance of 18 km. It is also the only road for the five jamoats to connect with the district center. At project appraisal, considering that resources allocated under JFPR projects were not sufficient for full rehabilitation of all 18 km road section the project aimed at improvement of the road through rehabilitation of the most deteriorated sections. After completion of the detailed engineering design in 2014, it was established that the project budget could accommodate rehabilitation of 9 kilometers of the most urgent sections. Later, during project implementation some grant saving allowed improving further 1.5 km of the road. Before the project, the road was in very bad condition, most of road surface was gone with a lot of potholes, the bridge was seriously damaged, and there was a lot of land sliding along the road. The road was sometimes disconnected during raining season and the vehicle could only take detour by taking another river crossing about 6 km away. The rehabilitated road was in two sections (6 km and 4.6 km). The rest sections remain poor condition. It was noticed by the ADB ICM mission that the vehicles run about 60–80 km/hour on the rehabilitated sections, whilst only 20–30 km/hour on the un-rehabilitated sections. Furthermore, there is about another 40 km of feeder roads from Navobad to some jamoats in the project area, but also in very bad condition. That is, the project could only rehabilitate part of the roads in the project areas. For being sustainable and maximizing the project benefits, whole section of the road, including the section from the main road to Navobad and from Navobad to all jamoats need to be rehabilitated.

Along with the fast socioeconomic development, the traffic in the project areas, including that on the project road, increased fast in recent years. It was told that the average daily traffic on the project road was about 300–500 vehicles.8 Most of the vehicles are small passenger cars or vans. It is a fact that most of the families in the project areas own cars due to poor public transport provision. But, many cars are not used due to low income and affordability for fuel. Along with fast economic development and income increase, the traffic on the project road will have a fast growth in near future. The rehabilitation of the road promotes the use of vehicles due to reduced vehicle operation cost and less traveling time (see economic benefit assessment for more). The government should also encourage and/or foster public transport in the project areas, which may provide reliable and low cost transport to the local residents, especially to the poor.

Meanwhile, it was also noticed that the vehicles intended to run at fast speed on the project road, which is a potential of road accidents. Although the road incidents at Rasht-Navobad road decreased by 25% in 2015 in comparing that in 2014, the government should enforce the traffic law and implement measures to control the vehicle speed. Campaigns on road safety should be also carried out to local residents, drivers, students, and children.

Diagnose Center and medical equipment

Under the project, a medical Diagnostic Center was established within NRH, which was completed in December 2014. The NRH is located in Navobad and provide basic medical care to the local residents in the five jamoats. Currently, the NRH has about 70 doctors and nurses, 30 beds, average 50 patients a day. The operation of the Diagnostic Center has substantially improved the NRH capability and service. Now, about 30 people have diagnostic checking at the Diagnostic Center, most of them are women. Due to advanced equipment and excellent service, the people of other jamoats also come to the NRH from long distance for health checking. With the rehabilitated facilities and new purchased equipment, the capability and service for month and children care have substantially improved. The monitoring survey indicated that more than 50% of pregnant women in the project deliver babies in the NRH. Up to the ADB ICM mission, total 287 babies were born in the NRH this year.

The Ambulance procured under the project now takes important role in urgent medical rescue in the project areas. In comparing with the old ambulance (a normal poor van), this Ambulance is equipped with first aid equipment, electricity outlets, moving bed, etc. It was told that this Ambulance is used about 5-10 times a day to pick-up and drop-off patients. Most of equipment purchased under the project is now well used and maintained. The medical bags for family doctors have well distributed and used among the health centers. The ADB ICM mission also visited some of the health center at jamoats. Each health center has about 3 medical

8 No official traffic counts are available for the project road.

11

workers and provides first aid to the local residents. Whenever needed, the health center communicates with the NRH for further checking and treatments.

The operation and maintenance budgets for the NRH and health centers come from two sources. The salaries for health workers are from fiscal allocation of the central government. The cost of operation and maintenance of the health facilities and equipment is covered by district government. No serious sustainability issue was identified. However, more supports are needed from the governments, in terms of budget and technic supports. The health workers are happy with the trainings provided by the project. It is expected more trainings will be provided, especially for the health workers of the health centers. During discussion with the representative of the MHSPP, it was requested that ADB and JICA may design and finance similar projects in other areas of the country.

F. Impact and Benefit Assessment

The project area covers five jamoats with total population of 40,000 people. Navobad is a center town of the five jamoats. The rehabilitation of the project bridge and road has significantly improved the connectivity and mobility in the project area. The operation of the Diagnostic Center and improvement in medical condition has remarkably increased the capacity and quality of health care in the project area. Substantial socioeconomic benefits have been generated by the project.

Economic Benefits

Due to improvement of road conditions, the vehicles now drive at much faster speeds on the improved road, from average 20–30 km/hour before the project to 60–80 km/hour after the project, which has led to substantial economic benefits in the project areas. The major economic benefits included:

� Savings in vehicle operation cost (VOC). The un-rehabilitated road section is in poor condition and has almost no asphalt surface with many potholesand water logged. The international roughness index (IRI) is at least 15 or above. The rehabilitated road section is with asphalt concrete pavement and significant road facilities. The IRI is about 4–5 based on the ADB ICM mission’s observation. Such road improvement can generally lead to at least 25% reduction in the VOC.

� Savings in passenger travel time costs. Due to faster vehicle speed, the passenger travel time on the project road section reduced substantially. Assuming the average vehicle speed was 25 km/hour before the project and 60 km/hour now, the average passenger time saving is about 15 minutes by using the rehabilitated road sections.

� It was told that the bridge/road was sometimes disconnected before the project due to flooding, land sliding, and heavy snows. The vehicles needed to take another river crossing in about 6 km away. The rehabilitation of the bridge now can avoid the detour and save substantial VOC and passenger traveling times.

� Promoted economic development and increased working opportunity. The rehabilitation of the bridge and road make the traveling easier with lower VOC and traveling time. It can effectively facilitate and promote local economic development. It can been seen that many gas stations and road side business have established, which provide more working opportunity to the local people.

� The operation of the Diagnostic Center and the use of the equipment purchased under the project have increased capacity and service of health care in the project area. Now, the residents can better access required health care and medical treatment, which has reduced the time for local residents to go to further hospitals. This can lead to savings in patient’s traveling time and cost.

Social Impacts and Benefits

During project implementation, four surveys were undertaken with the purpose of investigation of basic conditions and for measuring of the progress resulted from project activities.

� Needs assessment survey was conducted in 9–13 October, 2013 and covered 400 representatives of main target group and health workers of target jamoats. The survey collected base-line data at the project area and served for detailed planning of Component B activities.

� The base-line data collected in February 2015 before starting the BCC activities. The base-line survey was undertaken among the women of child-bearing age (from 20 to 50 years old) and having children

12

aged up to 1 year. Totally 468 of women were interviewed.

� In February 2016, the survey was undertaken within the same target group with 500 of respondents interviewed. The same questionnaires were used. The changes in values were used to measure the achievement after the BCC activities.

� The final survey was conducted in August–September 2016 with the questionnaires used for “Needs assessment survey” conducted in 2013. The obtained results were used for measurements of project outcomes and overall project assessment.

Based on the survey data, assessment reports were prepared with detailed analysis of measured results and planning of further activities. The final assessment reports included recommendations for activities after project completion in order to ensure the sustainability of results. The monitoring reports indicated that the implementation of the health component had significantly increased the medical care condition to and health awareness of local people, especially the women. Following are major findings of the surveys.

� By improved connectivity and mobility, the local residents now can go to variety services by vehicles. The last survey revealed that the number of respondents reaching the health facilities on foot reduced from 95 % to 45% compared with that in 2013.

� Trainings to the health workers have remarkably increased the knowledge and skill. The campaign to the local people has substantially increased the awareness in health care, especially the women. It also significantly increased the empowerment of women in the project area.

� The project improved awareness about adequate nutrition practices and successfully promoted appropriate breastfeeding. The ratio of respondents aware about exclusive breastfeeding period of 6 months increased from 46% to 79%. The percentage of women giving antibiotics to children in the case of ARI increased from 43% to 48%.

� Over 79% of pregnant women in the project area now are covered by prenatal care. The percentage of women receiving prenatal assistance increased from 32.8% in 2013 to 63% in 2016. Percentage of women giving medicines received from health facilities to sick children made up 78% compared to 45.8% in 2013.

� The project has changed the attitude of many women to family planning and use of contraceptives. The percentage ratio of respondents considering 3-year interval between child-deliveries as optimal increased from 11% to 22%.

� The advanced capacity of NRH allowed to women from remote jamoats to seek for services in Navobad instead of travelling to Rasht.

� The purchased Ambulance transports patients in response to emergency calls and when it is required. By the last survey, the run of the Ambulance already exceeded 50,000 km providing health services in the project area.

� Compared to base-line data the percentage of women using mobile phone increased from 24% to 28%

� The representative of Rasht Traffic Police Department informed that quantity of traffic incidents at the Rasht-Navobad road section decreased in 2015 by 25% compared to 2014. No accidents with lethality were reported.

Environment Impacts

At appraisal, the due diligence confirmed that the project would not pass through any environmentally sensitive areas and would not result in significantly negative environmental impacts, and therefore, for environmental safeguards the project was classified as category B. The MOT prepared an initial environmental examination (IEE) according to ADB's Safeguard Policy Statement (2009) and national legislation and regulations. The IEE was disclosed on ADB website on 24 September 2012. The IEE included an environmental management plan (EMP) to minimize the project's potential environmental impacts.

During implementation, the MOT, assisted by an environmental expert, was in responsible for implementing the EMP and submitting to ADB semi-annual monitoring reports. For enhancing the compliance of environment policy and implementation of the EMP, an environmental specialist was engaged by the PMO. The ADB missions and the PIU monitored the environment compliance closely, promptly detected the

13

violations of the approved EMP, and implemented corrective measures if any related issues found. According to regular sampling and laboratory tests, the quality of environmental components such as water, air and soil in the zone of project influence were within the tolerance limits established by the government. The environmental monitoring reports also indicated that the contractors implemented the proposed actions on regular basis. No significant environmental impacts were reported during report coverage period. Minor environmental impacts were timely and efficiently mitigated. No complaints relating to environmental issues were reported during implementation.

Moreover, the dusting from the traffic in the villages along the rehabilitated road sections practically stopped that has significantly improved the air quality in the project area. It is especially important for Nusratullo Maksum jamoat possessing. According to IEE, there are a number of sensitive sites (school, hospital) in vicinity to project road. In addition, the rehabilitated road drainage structures has significantly reduced erosion process and eliminated standing pools of water, reduced surface and groundwater pollution

Social Safeguards

The project was categorized C for potential involuntary resettlement (IR) and indigenous peoples (IP) impacts since no land acquisition and impacts on IPs were foreseen. All project activities would be conducted in the existing Right of Way (ROW) and other available land with no IR impacts. A due diligence mission to the project site was fielded and a report was prepared accordingly. During preparation and implementation of the project, no ethnic minorities that fall under the definition of ADB SPS (2009) on Indigenous Peoples were identified in the project site.

Visibility

The project implementation had significantly attracted wide public attention in the project areas. The contribution of the Government of Japan and ADB in supporting the project was widely recognized. During implementation, the project made significant efforts on this and major events were covered by local mass media. The JFPR and ADB logos were well used in publications, training programs, workshops, and any other materials produced under the project. All press releases issued by ADB and local news media for the JFPR project activities acknowledged the financial and technical contributions of the Government of Japan following the Guidance Note of Visibility of Japan. The high level representatives of Japan Embassy and JICA attended the official opening ceremony of the Diagnostic Center rehabilitated under the project. The BCC activities have also well promoted the visibility and local awareness of the JFPR project.

17. Overall Assessment and Rating (HS,S,PS,U)

The project is rated highly successful (HS). The project is highly relevant to the government’s priorities in its comprehensive national strategy. The project was designed appropriately and implemented without major changes in scope. The project is rated effective and efficient in achieving its outputs and outcomes. The project achievement demonstrates that it was an effective intervention that substantially improved the connectivity and medical care condition in the project areas. The routine maintenance of the project bridge and road is in place to keep the bridge and road in good condition. The Diagnostic Center and the equipment procured under the project are now fully functional and well used with proper maintenance. The trainings and campaigns have significantly increased the skill and awareness of health care in the project areas. However, the resources allocated were not sufficient for full rehabilitation of 18-km rural road and the project could aim at improvement of the road through rehabilitation of the most deteriorated sections.

18. Major Lessons Learnt

� Considering that resources allocated were not sufficient for full rehabilitation of 18-km rural road, the project aimed at improvement of the road through rehabilitation of the most deteriorated sections. After completion of the detailed engineering design in 2014, it was established that the project budget could accommodate rehabilitation of 9 kilometers of the most urgent sections. During implementation, some grant saving was reallocated to the civil works which allowed improving further 1.5 km of the road. The ADB ICM mission noticed that the un-improved road sections were in poor condition, which is negative to overall performance of the project road. In future projects, the project cost estimation should well consider the road deterioration trend and reserve adequate contingency for price escalation and fluctuation of the exchange rate.

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� At appraisal, it was planned to provide basic essential medical equipment to the rural health centers in five jamoats. During implementation, needs assessment was carried out, which proposed to establish a Diagnostic Center within NRH equipped with rehabilitated building and essential medical equipment and laboratory. It was found that the operation of this Diagnostic Center has substantially increased the capacity and service of health care in the project areas, especially to women. In future projects, such consultation and assessment should be carried out as early as possible, which may make the project design more suitable to local needs.

19. Recommendations and Follow-up Actions

� During implementation, only about half of the road was improved. Rehabilitating full road section may substantially improve the overall performance of the road. JICA, ADB, and the governments might jointly design and implement a follow-up project to fully rehabilitate the whole road section.

� A JA for road maintenance was established for inspecting the road condition and providing quick maintenance of the project road. However, the JA has weak capacity with limited equipment and budget. JICA, ADB and the government should promote such community-based road maintenance practice by providing more supports.

� The project has remarkable socioeconomic impacts to the local people. Some benefits can be realized several years after project completion. Follow-up monitoring and evaluation program should be properly designed and implemented, which may fully capture the socioeconomic benefits brought by the project. Lessons learnt can be well summarized and adopted by other similar projects in the country as well as in other developing countries.

� The project is highly successful in its design and implementation. The socioeconomic impacts and benefits are remarkable, especially to the poor. The government (MHSPP) is seeking more supports from the Government of Japan and ADB to disseminate and duplicate the practice of the project design and implementation.

20. Additional Remarks, Comments and Suggestions

None

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Annex 1. PROJECT FRAMEWORK

Design Summary Performance Targets and Indicators with Baselines

Achievement

Impact Improved child and maternal health results in five isolated jamoats in Rasht district

By June 2019, maternal mortality rates decreased in the project areas by 15% relative to 2011 data By June 2019, child mortality rates decreased in the project areas by 10% relative to 2011 data By June 2019, household income increased in the project area by 10% relative to 2012 baseline data

Maternal mortality rate in country decreased from 59.8 in 2011 to 44 per 100,000 in 2013. U5 mortality rate in the country decreased from 50.9 per 1,000 in 2012 to 44.8 per 1,000 and infant mortality reduced from 43 to 39 per 1,000 in 2015. The achievement of target may be impeded by the decrease of remittances.

Outcome Improved access of the marginalized rural poor in five jamoats in Rasht district to strengthened health services.

By January 2016, travel time to health care facilities reduced in the project area by 30% relative to 2012 baseline data By January 2016, the number of families practicing IMCI in five targeted jamoats increased by 30% relative to 2012 baseline data Births at health facilities increased from 45% in June 2012 to 70% by January 2016 in five targeted jamoats Number of women of five targeted jamoats completing the required

The safe speed at the rehabilitated road sections increased by 57% from 40km/h to 70km/h. The amount of taxi rides increased by two times, while the ratio of women going to health facilities on foot, notably decreased. The target is achieved for communities in vicinity to the rehabilitated road. The target is achieved as confirmed by several performance indicators. Awareness of target group increased for the most of indicators by over two times. The percentage of women receiving prenatal assistance increased from 32.8% in 2013 to 63% in 2016. Postnatal assistance was provided in 2016 to 57.8% of young women compared to 28.3% in 2013. Percentage of women giving medicines received from health facilities to sick children made up 78% compared to 45.8% in 2013. Over 79% of pregnant women in the project area now are covered by prenatal care. This indicator is slightly lower in three remote jamoats. According to final survey the women who gave birth in health facilities make up 59.5 % of interviewed. The target indicator for prenatal visits is achieved in average and in

17

number of prenatal visits increased from 20% in June 2012 to 50% by January 2016 Number of women practicing exclusive breastfeeding for 6 months in five targeted jamoats increased from 45% in June 2012 to 60% by January 2016

target jamoats except remote Obi-Mehnat settlements. The postnatal visits achieved 63% in 2016. The true knowledge about prenatal care during pregnancy and required visits to the health specialists demonstrated 63% of respondents compared to 42% during past survey Target indicator is achieved. According to survey about 70% of women practicing exclusive breastfeeding for 6 months.

Outputs 1. 58 communities in Rasht valley have improved access to transport and social facilities

By June 2015, 66-meter bridge over the Sorbog river rehabilitated By June 2015, 18 km of rural road from the bridge to the Rasht district center access road improved Five rural communities provided with basic knowledge, skills, and equipment for conducting day-to-day infrastructure maintenance and minor repair works by June 2015

The bridge is rehabilitated and passed to the MOT at the beginning of 2016. The rehabilitation of road sections according to amended design is completed by the end of 2015. Road is passed on to the MOT in January of 2016. The road association is established in August 2015, workshop and training undertaken in October 2015. Road association reported the maintenance road during winter season 2015-2016.

2. Targeted communities effectively use health services and nutrition practices

By June 2014, 90% of health workers in the health facilities of the target area updated on IMCI By June 2014, 90% of health workers provided with training on obstetric and infant care By June 2015, 20,000 residents of the target area covered by the public information campaign to improve household health behavior By March 2014, rural health centers

The four trainings on update of IMCI approach including obstetric and infant care were conducted. Totally over 90% of health workers were covered The target indicator is achieved. From October 31 until November 29, 2015 BCC activities to increase public awareness with regard to the possible ways to prevent and control malnutrition and related diseases were performed in five target jamoats. Campaign on “Behavior change communication” was conducted to improve household health behavior, which covered more than 20,000 populations in the project areas. In August 2014 completed delivery

18

in five jamoats provided with basic essential medical equipment By February 2014, rural hospital in Navobod equipped with a safe and operating ambulance, and 75% of emergencies reported in the rural health centers referred to a central hospital

of medical equipment and ambulance. Ambulance services are fully conducted it transfers patients from jamoats to hospitals level. The need to referral of patients to Rasht hospital decreased because of improvement of NRH

3. Effective project management, monitoring and evaluation of results

Quarterly and annual reports on project implementation as well as semiannual environmental monitoring reports, acceptable to ADB, prepared and submitted within 45 days after the end of each related fiscal year The government’s grant completion report, acceptable to ADB, received within three (3) months of physical completion of the project Acceptable audited annual financial statements for the project (audit report and management letter) received by ADB no later than six (6) months after the end of each related fiscal year

Project progress reports and semi-annual environmental monitoring reports were submitted in accordance with schedule. The draft project completion report was submitted and reviewed by ADB. The financial audits were completed, and respective statements were accepted by ADB.

Activities with Milestones 1.1 Improvement of 18 km of rural road from bridge (Navobod town)

to the Rasht district center 1.1.1 Civil works contract awarded by August 2013 1.1.2 Civil works completed by June 2015

1.2 Rehabilitation of bridge over Sorbog river 1.2.1 Civil works contract awarded by August 2013 1.2.2 Civil works completed by June 2015

1.3 Fostering community-based maintenance practices 1.3.1 Representatives of local governments, small contractors,

and rural communities trained on bridge and road maintenance by October 2014

1.3.2 Establishment of VIMFs by February 2015 1.3.3 Essential safety and road maintenance tools procured and

delivered to road associations by June 2015 2.1 Improve capacity of health centers to deliver quality MCH and

nutrition services 2.1.1 Assessment of the training needs of health workers,

conducted by August 2013 2.1.2 Training programs for health workers on obstetric and infant

care and IMCI designed and delivered (design by December 2013, delivery by June 2014)

2.1.3 Basic essential medical equipment provided to the health medical facilities (study by October 2013, delivery by March 2014)

2.1.4 Basic renovation provided to the health facilities (needs assessment by January 2014, delivery by August 2015)

Actual Inputs JFPR Financing $2,491,881 among which: Civil works $1,682,017 Equipment and supplier $130,420 Training and campaign $108,593 Consulting service $501,070 Grant management $69,780 Government Financing $350,000 among which: Civil works $350,000 Total project cost $2,841,881

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2.2 Facilitate behavior change among individuals and communities for better health outcomes 2.2.1 Assessment of current practices, beliefs, and perceptions

for awareness-raising activities, conducted by September 2013

2.2.2 Behavior change communication activities developed and implemented (design by December 2013, delivery by January 2016)

2.3 Establish a responsive emergency referral system and transportation 2.3.1 Purchase of new ambulance by February 2014 2.3.2 Effective referral system with responsive ambulance

service functioning by March 2014 3.1 Effective monitoring and evaluation of results

3.1.1 Baseline data on a set of quantitative and qualitative indicators collected and analyzed by August 2013

3.1.2 Midterm evaluation survey conducted by September 2014 3.1.3 An independent audit timely conducted (annually) 3.1.4 Final evaluation survey conducted by December 2015 3.1.5 Project completion report submitted by February 2016

ADB = Asian Development Bank, BCC = behavior changes communication, IMCI = integrated management of childhood illnesses, JFPR = Japan Fund for Poverty Reduction, MOT = Ministry of Transport, U5 = under age 5 Source: the ADB project implementation completion review mission

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Annex 2: PHOTOS OF MAJOR PROJECT OUTPUTS

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Annex 3: LIST OF MEDICAL EQUIPMENT PROCURED UNDER THE PROJECT

№ Description Specifications Quantity

1. Bag of family medical doctor

1. Book "manual of family doctor" (in Russian language) 2. Otoscope 3. Ophthalmoscope 4. Stethoscope 5. Fetoscope 6. Tonometer 7. Calendar-ring for pregnancy calculation 8. Lantern-pen light 9. Reflex hammer 10. Tape (sm) for measuring of stomach of pregnant ladies

15

2.

Bag of family medical doctor’s assistant

1. Otoscope 2. Stethscope 3. Fetoscope 4. Tonometer 5. Calendar-ring for pregnancy calculation 6. Lantern-pen light 7. Reflex hammer 8. Tape (sm) for measuring of stomach of pregnant ladies

40

3. Ultrasonic scanning unit

Main technical specifications: • Resolution Power: lateral 2mm , longitudinal 1mm • Probe multi frequency conversion мульти-: 5 segment

frequency • Scanning and mapping mode: B , 2B , B / M , M , 4B , ZOOM ;

In real time mode: zoom; 3D option • Picture direction: Up / Down / Right/ Left • Function: False color • Zoom: 10 Ratio , 1.5, 2.0, 2.5 , 3.0, 3.5 , 4.0, 4.5 , 5.0 , 5.5, 6.0 • Motions : 64, 128, 256, 512, 1024 shots (by users) • Storing: Big capacity of local storing and USB storing, pictures

and motions, result of measuring and report. • Probe slot: 2 • terminal out : VGA , video out PAL -О • Power : AC 100- 240V, 50/60Hz , 150VA

1

4. Blood analyzer

Selection mode of one appropriate from 3 modes for testing: all settings WBC/HGB, RBC/PLT Automatic dilution of sample, applying of reagent, mixing Automatic cleaning of sampler Automatic control of residual volume of reagents Integral thermo printer, connectivity of internal printer Color LCD display

1

5. Urine analyzer

Measurable parameters - blood - glucose - рН - specific weight - bilirubin - urobilin gene - ketones - albuminе - nitritew - white blood cells - ascorbic acid

1

6. Electric suction device for

Vacuum abort, pressure regulator 20 - 98 кПа, Productivity on liquid, l/min not less than 3

1

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№ Description Specifications Quantity abortion Minimal residual pressure in storage tank, кПа not high than 20

Limits of control of residual pressure, кПа from 20 to 98 Full power, not high than 130

7. Thermo dry cabinet

capacity 80 l; temperature mode 50/200 0С; time of continuous running 16 hours; power 220V; power consumption not high than 2,5 КВт

1

8.

Set of first aid kit for obstetrician-gynecologist

1. Gynecological speculum 2. Set of dilators of different sizes (from 3 to 24) for getting of access to chanel of uterine neck. 3. Hysterometer for assessment of depth of uterine cavity. 4. Gynaecological curet for implementation of diagnostic scrapes from uterine mucous. 5. Double-sided spoon for intake of trials discharges. 6. Syringes and extractor for insertion and extraction of Lipps loops (spiral intrauterine contraceptive). 7. Syringes for intrauterine wetting and infusions, as well as for insertion in uterine cavity of intrauterine contraceptive.

3

9. Baby balance scale

Electric 4

10. Gynaecological chair

Exanimated 1

11. Medical couch 1 12. Table Laboratorial 1 13. Chair Laboratorial 1 14. Cabinet Laboratorial 1

Source: The Project Implementation Unit

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Annex 4. PROJECT COST AND FINANCING

Table 4.1: Comparison of Project Cost and Financing at Appraisal and Actual (US Dollar)

Appraisal Estimate Actual by Components

Total by Components

Total items A B C A B C

A. JFPR Grant Financing

1 Civil Works 1,350,000 50,000 1,400,000 1,635,635 46,382 1,682,017

2 Equipment and Supplies 10,000 120,000 1,900 131,900 9,987 119,512 922 130,420

3 Training, Workshops, Seminars, and Public Campaigns

5,500 71,200 76,700 5,402 103,191 108,593

4 Consulting Services 100,000 230,550 187,680 518,230 73,472 237,417 190,181 501,070

5 Grant Management 128,800 128,800 69,780 69,780

6 Contingencies 244,370

JFPR Grant Total 1,465,500 471,750 318,380 2,500,000 1,724,496 460,120 260,883 2,491,881

B. Government Fund Financing

1 Civil Works and Project Management 350,000 36,000 386,000 350,000 350,000

2 Project Management at Site 1,000 10,000 36,000 47,000

Government Fund Total 351,000 10,000 72,000 433,000 350,000 350,000

Total (A+B) 1,816,500 481,750 390,380 2,933,000 2,074,496 460,120 260,883 2,841,881 Component A: Improved and sustainable access for isolated communities through bridge and rural road rehabilitation Component B: Improved and increased use of health services and nutrition practices Component C: Project management, monitoring, and evaluation JFPR = Japan Fund for Poverty Reduction Source: ADB grant financial information system, the Project Implementation Unit

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Annex 5. GRANT DISBURSEMENT

Table 5.1. Annual and Cumulative Grant Disbursement

year

Annual Disbursement Cumulative Disbursement

Amount % of Total

Amount % of Total

($) ($)

2013 116,258 4.7%

116,258 4.7%

2014 747,222 30.0%

863,481 34.7%

2015 853,302 34.2%

1,716,782 68.9%

2016 777,097 31.2%

2,493,879 100.1%

2017 -1,999 -0.1%

2,491,881 100.0%

Total 2,491,881 100.0%

Source: ADB grant financial information system

Figure 5.1. Annual and Cumulative Grant Disbursement ($)

Source: ADB grant financial information system

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Annex 6. ORGANIZATION CHART FOR PROJECT IMPLEMENTATION

ADB = Asian Development Bank, JICA = Japan International Cooperation Agency MOT = Ministry of Transport, MHSPP = Ministry of Health and Social Protection of Population

Source: the Project Implementation Unit

Financial Auditor

Government of Tajikistan

MOT MHSPP

JICA ADB

PIU Project Manager

Engineer Accountant

Secretary / Translator

Rasht District / Jamoats

Navobad Rural Hospital / Heath Center

Health Coordinator Health Advisor

Contractor for Bridge and Road Component

Contractor and Suppliers for Health Component

Environment and Monitoring

Consultants

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Annex 7. CHRONOLOGY OF MAJOR EVENTS Date Main Event

2013

7 March Grant approval

9 April Signing of the Letter of Agreement for the grant

9 April Grant effective

2 August Contract signing with the Design Institute for Detailed Design

12 August Contract signing with the Project Manager (local)

12 August Contract signing with the Health Coordinator (local)

16 August Contract signing with the Accountant (PIU Staff)

1 October Contract signing with the Engineer (PIU Staff)

9–13 October Baseline survey for social impacts and benefits

11 November Contract signing with the Translator (PIU Staff)

15 December Completion of the detailed design

17 December Contract signing with the Health Technical Advisor (International)

23–31 December ADB project inception mission

2014

20 January Minutes of technical meeting

22 January Submission of the report of baseline survey to ADB TJRM

22 February Introductory seminar in Navobod hospital

12 – 24 May Training on “safe motherhood” and “care of the newborn infants”.

16 May Bid announcement for the contract “Improving of road Rasht-Navobod and reconstruction of the 66-meter bridge over the Sorbog river”

29 May Pre-bid site visit

30 May Pre-bid meeting

30 June The final date of bid submission, opening bids

1 July Contract signing for Delivery of Ambulance

14 July Contract signing for Delivery of Medical Equipment

18 July Contract signing for the improvement of Diagnostic Center building of Rural Medical Facility in Jamoat Navobod (Rasht District)

8 August Submission to the ADB of the report and bid evaluation report for the contract of “Improvement of the road Rasht-Navobod and rehabilitation of the existing 66 m bridge over the Sorbog River”

25 August ADB approval of the bid evaluation report for the contract of “Improvement of the road Rasht-Navobod and rehabilitation of the existing 66 m bridge over the Sorbog River”.

28 August Negotiations for the Contract “Improvement of the road Rasht-Navobod and rehabilitation of the existing 66 m bridge over the Sorbog River”

5 September Contract signing for “Improvement of the road Rasht-Navobod and rehabilitation of the existing 66m bridge over the Sorbog River”.

10 September Date of site possession and the contractor mobilization

16 September Delivery of ambulance to SUB Navobod

30 September Delivery of medical equipment to SUB Navobod

15 – 24 October Training on Integrated Management of Childhood Illnesses

16 December Recruitment invitation for the Environmental Specialist (local)

16–30 December ADB midterm review mission

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Date Main Event

20 December Working Commission on acceptance of works for “Improvement of Diagnostic Center building of Rural Medical Facility in Jamoat Navobod (Rasht District)”

2015

13–18 February Campaign on behavior change communication

23 February Contract signing with the selected Environmental Specialist

18 March Recruitment invitation for the Monitoring & Evaluation Expert (local)

31 March Deadline of submitting expressing of interest

15 May Contract signing for supply of vertical blinds

15 May Contract signing for supply of table and chairs

15 May Contract signing for supply of hemoglobinmeter

14 May Repeated invitation for the Monitoring & Evaluation Expert (local)

1 June Deadline of submitting expressing of interest

22 May

Official opening ceremony of the building of the Diagnostic Centre of rural district hospital in Navobod Township, Rasht district. The presentation was attended by representatives of the Embassy of Japan, JICA, ADB Tajikistan, MoT, PIU RR and MHSPP

25–26 may Site visit and study on the situation related to the potential target Jamoats maintenance road

16 June The State Commission for acceptance of works to improve the Diagnostic Centre of rural district hospital in Navobod Township, Rasht district

3 July Contract signing with the selected Monitoring & Evaluation Specialist

5–13 August Training on "Interpersonal Relations"

17 August – 4 September ADB project review mission

14 September Contract reproduction of Poliaraphic Productions

16 September Procurement invitation for delivery of mini dump truck

21 September Deadline of submitting expressing of interest for mini dump truck

20 October Contract signing for delivery mini dump truck

28–31 October Training on the subject of “Strengthening of capacity in the technical and financial plan for the maintenance of the road and the bridge”

31 October–29 November Caravan of health in target jamoats

2016

7 January From the Ministry of Finance of the Republic of Tajikistan, the inquiry was sent to ADB for extension of grant closing date from March 31, 2016 to September 30, 2016 and use of the saved means

13 January

From the Ministry of transport of the Republic of Tajikistan, the inquiry was also sent to ADB for extension of date of closing of grant from March 31, 2016 to September 30, 2016, on extension of the contract for construction works till June 30, 2016 and use of the saved means

29 January – 3 February

Caravan of health in the five target jamoats, distributed information material among the female population, provided advisory care for women of childbearing age and newborns, performed preventive medical examination of women and babies using ultrasound

16 February Working commission on preliminary acceptance of the Rasht–Navobod Road and rehabilitation of an existing bridge over Sorbog River

18 February ADB approval on the extension of grant closing date from 31 March 2016 to 30 September 2016

28 Date Main Event

31 March Original grant closing date

25 April–10 May ADB project review mission

17 May Contract reproduction of Poliaraphic Productions

26-31 August 2016 Additional training on “Newborn care and reanimation” Final assessment survey and project closing seminar 30 September Revised grant closing date

2017

17 – 29 December ADB project implementation completion review mission

ADB = Asian Development Bank, JICA = Japan International Cooperation Agency, MOT = Ministry of Transport, PIU = project implementation unit, MHSPP = Ministry of Health and Social Protection of Population Source: the Project Implementation Unit

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Annex 8. PROJECT MAP