Sustainability: the elusive dimension of international health projects.

OBJECTIVE The Canada-China Yunnan Maternal and Child Health Project (1997-2003) sought to improve the quality of village life and promote development of productivity and social prosperity in Yunnan province, China. PARTICIPANTS The project targeted grassroots maternal and child health workers: new and in-service village doctors; traditional village midwives; doctors at township health centres; doctors at county maternal and child health hospitals; and provincial health staff. SETTING Ten impoverished counties (population 2.2 million) in Yunnan province with high proportions of ethnic minority populations. INTERVENTION There were three major innovations: training grassroots maternal and child health workers in participatory and community-based approaches and clinical skills; designing a model comprehensive referral system including provision of basic equipment; and introducing participatory monitoring and evaluation methods. Strategies to support sustainability were built into the project from the outset. OUTCOMES Over 4,000 village, township, and county health workers received training. Maternal, infant, and under-five mortality rates declined over 30% in project counties. Project innovations were disseminated throughout the province, into other donor-funded initiatives, and integrated into national health projects by local partners. CONCLUSION Maintaining the long-term benefits of international health interventions depends on sustaining innovations beyond short project timelines. Achieving sustainability poses a conundrum to implementing agencies. Three mechanisms influenced uptake in the Yunnan project: maintaining a good fit between core project elements and the existing health system; developing adequate organizational supports; and creating a handover plan from the outset. This project highlights some of the ways in which sustainability can be operationalized.