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.