Impact. Scale. Sustainability. As public health professionals, we are dedicated to high-impact and high-coverage interventions that significantly improve the health of large human populations. We also hope that the benefits become part of the timeless fabric of their families, communities, and the health system.
This triple expectation—impact, scale, and sustainability—has accompanied global health for decades and especially during the last generation. In 1990, Dr. Thomas Bossert reported that, among five US government-funded health programs in Africa and Central America, a project’s capacity to show results was the most important factor to ensure the sustainability of its benefits.
Recently, the Friedman School of Nutrition Science and Policy at Tufts University, as part of the US Agency for International Development (USAID)-funded FANTA III project, investigated the factors which enabled post-project sustainability (up to three years after project end) among USAID-funded food assistance projects in Kenya, Honduras, Bolivia, and India. These projects included maternal, newborn and child health (MNCH) interventions, such as maternal and child health, nutrition and water, sanitation and hygiene. Tufts found three factors critical to sustainability: (1) a sustained source of resources, (2) sustained technical and managerial capacity, and (3) sustained motivation (of beneficiaries and service providers). Linkages to governmental organizations and/or other entities, was considered a fourth factor that is central to sustainability in many circumstances. A gradual process of exit also contributed to sustainability.
WHAT DO THESE SUSTAINABILITY FINDINGS MEAN FOR GLOBAL HIGH-IMPACT, SCALABLE MNCH PROGRAMS?
- Results—and their measurement—matter. Host country governments and private providers appreciate significant impacts on lives saves and cases of disease prevented which are achieved at high coverage, quick speed, and at reasonable cost. MNCH programs must include a strategy to ensure accurate, complete, and timely collection; processing; and reporting of health information needed to reach a determination of program success. In Rwanda, MSH is assisting government stakeholders with the timely and accurate periodic reporting of its hundreds of health facilities into the web-based DHIS2 software. MSH is also assisting these stakeholders to produce easy-to-analyze reports and scorecards which will help local and national managers see the fruits of their work and also make programs decisions to improve it. This assistance has resulted in better decisions and improved allocation of local resources, which helps ensure better care for mothers, newborns, and children.
- Sustainable resources are required. Additional personnel, medicines and commodities, equipment and health infrastructure are needed (in most cases) to continue tangible benefits to a lot of people after a donor-funded MNCH project ends. User fees have the net effect of limiting access to health care. Therefore, projects need to engage national and subnational government, the private sector, and international donors to facilitate other types of sustainable funding (e.g. government taxation, commercial credits or microloans to private providers, health insurance) for the resources needed. In addition, MNCH projects should also support health leaders and managers to ensure the adequate deployment and use of these resources, and to report these findings to their key stakeholders. In Nigeria, MSH was successful in engaging the state governments of Niger, Kwara, and Sokoto to increase their domestic funding for prevention of mother-to-child transmission (PMTCT) of HIV and other HIV programs by $2.5 million. Thus, this initiative helped in the sustainability of initially funded USAID programs.
- Capacity building is a winner. It pays off to enhance local technical and management capacity during the project life, e.g., leadership, management and governance, quality improvement, pharmaceutical management, health information systems, human resource management, fundraising and financial management. The challenge is to identify, for each specific setting, the key topics and the best methods to provide training, supervision and technical assistance in a cost-effective way. Thus, this capacity building can be easily replicated by the institution sustaining the benefits of the MNCH program. Participatory planning at the local level, online training, mobile technology, and integrated supportive supervision are all steps in the right direction. In Afghanistan, MSH and other development partners assisted in the creation of provincial schools for the 18-month pre-service training of locally recruited community midwives. Studies by Dr. Linda Bartlett from Johns Hopkins University show that in provinces benefitting from these schools, approximately 90 percent of graduates worked in their assigned places and they contributed to a 39-percent increase in ANC and a 63-percent increase in delivery by a skilled attendant.
- Motivated health leaders, managers, and providers make a difference. Results-based funding—the provision of financial and material incentives to health workers if they meet agreed targets—is now commonplace. Project activities should facilitate communication and feedback between patients and providers. Social accountability can play a role here. Monitoring the behavior of health providers by population can provide an avenue for communication and feedback. Ultimately, all health providers hope to do their best for their patients; and all satisfied patients will duly thank their health provider and return to them if help is needed again.
In the Kasai Oriental Province of Democratic Republic of the Congo, MSH assisted local health providers to increase the access and quality of their maternal health services. In addition to facilitating training and supervision opportunities, plus providing material resources for the operation of the facilities, MSH and the government also implemented a performance-based funding activity. Through the latter, high-performing facilities received a periodic cash incentive if they met previously agreed targets of coverage and quality. In the first two years, maternal health indicators increased by 50 percent from baseline values (e.g. 54 percent of pregnant women had four antenatal care visits as compared with a baseline of 20 percent). With donor support, the government is planning to roll out a similar experience in other parts of the country. - Develop linkages. In MNCH projects, the most important linkages to develop and strengthen are: (a) the provision of a continuum of care, i.e. from the family and community health worker up to the referral hospital, (b) between communities and formal health services, and (c) between government and private health services. Sometimes we forget that these linkages need to work in both ways to be effective and sustainable, e.g., the community health worker receives training, supervision and supplies from the health facility, while referring patients and providing periodic information on his or her health production and epidemiological findings to the health facility.
In Madagascar, MSH supports local networks of more than 2,000 community volunteers who assist women or children (according to the volunteers’ government accreditation) with education and referral services. In a single quarter (October to December 2015), these volunteers referred to health facilities approximately 12,000 sick pregnant women, newborns, and children. In addition, nearly 6,500 pregnant women were referred by these volunteers to health facilities for antenatal care. Volunteers regularly meet with the facility staff to exchange information on the referred patients and to follow up in the community the patients discharged by the health facility (watch video).
Global health programs provide significant and sustained health benefits to the most vulnerable populations, including women, newborns, and children, in some of the most hard to reach, and conflict-ridden regions. We owe it to beneficiaries to help ensure that MNCH programs continue to make the most impact to the most people for many generations to come.
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