TASC Russia: Maternal and Child Health Initiative (MCHI)

This 118-page report explores the impacts of, and advances lessons learned from, a communication-centred initiative to ensure the adoption of internationally recognised maternal and child health (MCH) standards and practices by targeted health facilities in Russia. In September 2003, the Russian Mission of the United States Agency for International Development (USAID/Russia) awarded a task order (TO) to John Snow, Inc. (JSI) under the Maternal and Child Health Technical Assistance and Support Contract (TASC I) to implement the 3-year Maternal and Child Health Initiative (MCHI).

The beginning sections of the document outline the project's key activities implemented to achieve 30 explicit tasks, which are listed with their relevant results in Section IV of the report. Appendix B: Result Indicators lists the 55 indicators that were originally specified in MCHI's December 2003 Three-Year Workplan and whose results are given in the main text of this report. To quantitatively assess the majority of the 55 specific Result Indicators, MCHI conducted a Baseline Facility-based Survey in 2004 and an Endline Facility-based Survey in 2006.

Here are some of the central findings:

• USAID's long-range aim in funding MCHI was to launch "a strong, credible, indigenous Russian 'legacy' organization with proven broad-range expertise" that could be self-sustaining as it carried on the promotion and provision of MCH innovations in Russia. This aim was actualised in the Institute for Family Health (IFH); for details, please visit their website.
• MCHI's focus on process as well as content and selection of strategies that not only stressed evidence-based medicine but that also offered a paradigm shift from focus on the provider to focus on the client led to changes in the way maternal and infant services were delivered. For example, at all the project institutions, births now take place in individual delivery rooms, which enables a significant other (according to the woman's choice: a husband, partner, parent, or friend) to be present during delivery. Postpartum units function according to the "‘mother and baby" principle, according to which the baby and the mother are not routinely separated from each other.
  
• Evaluators point out that "[t]he active involvement of a variety of stakeholders - health officials, policymakers responsible for decision making and resource allocation, and experts and providers from all levels of the health system - was cultivated from the very beginning. This helped establish full ownership for the...changes being introduced and helped motivate many to work towards the expansion and sustainability of the program."
• One tactic found to be helpful was the inter-linking of programme components and the multi-level focus, which organisers believe "gave the project's implementation strategies strength, breadth, adaptability and flexibility. By building on the successes of WIN [JSI's Women and Infants Health Project] and adapting additional materials from CDC [Centers for Disease Control and Prevention], WHO [World Health Organization], UNFPA [United Nations Population Fund], UNICEF [United Nations Children's Fund] and other CAs [cooperating agencies], MCHI was able to promote evidence-based interventions with efficiency....The evidence-based approach literally became a credo and supported the health care professionals in their roles as change agents as they introduced and implemented evidence-based practices."
• Reflecting on the capacity building that took place at the regional level, organisers explain that  participatory and interactive training techniques were used, and an interdisciplinary approach was modelled by the composition of the trainers as well as by the mix of participants in the courses. Course participants reportedly described the trainers as "kind, respectful, interactive, energetic, highly professional and accessible..." Throughout, efforts were made to carry out implementation in a participatory, transparent, low hierarchical manner. In effect, an effort was made to model with the regions the client-centered, mother-friendly, baby-friendly, youth-friendly, family-friendly approach that WIN/MCHI was striving to introduce..."
• Akin to these commitments, "[t]he requirement that the facilities chosen be an interrelated set of maternities, women's consultation clinics, children's polyclinics, family planning centers, and HIV/AIDS centers helped to horizontalize previously vertical institutions and to standardize the content and continuity of care."
• Evaluators note that the Inter-regional Working Group on Youth Reproductive Health which was formed was functional and appeared effective in that "useful Youth Programming Guidelines" were developed. However, "it is too early to assess the extent to which they were put into practice."
• MCHI focused on increasing active male participation and support at multiple junctures, leading organisers to assert that "[a]dult males and youth have visibly benefited from improved physical and emotional access to reproductive health care in MCHI facilities."
• A separate, but related, USAID-funded project called "Healthy Russia (HR) 2020" was made responsible for MCHI's IEC (information, education, and communication)/BCC (behaviour change communication) component. Organisers concede that - in general - collaboration can be valuable, pointing to the fact that "[c]oordination with donors and USAID-funded CAs was close and synergistic rather than pro-forma and perfunctory. Collaboration with Russian regional and municipal government partners and with the MOHSD [Ministry of Health and Social Development] has been strategic and successful..." However, in the case of the HR 2020 IEC/BCC collaboration, evaluators found that this approach did not work well because, "for maximum impact and efficiency, a project needs to be in control of its key components."
• While internationally recognised, evidence-based standards for selected MCH have been introduced into the pre-service and post-graduate curricula of training institutions for physicians, nurses, and midwives in all MCHI regions having such institutions, as well as in a major state medical academy in Moscow, the "move beyond these important first steps will require a much more focused and explicit program, to which Russian institutions would likely be highly receptive."
• "The small pilot component to extend family planning activities into rural rayons in two oblasts is still in its early implementation phase....The household survey carried out in Vologda has now provided some helpful information....A thorough evaluation and reassessment after at least a few more months of implementation would do much to inform future rural-focused activities."
• Although not a stated goal when initiating MCHI, the project "has become a major leader in Russia for PMTCT [prevention of mother-to-child transmission of HIV] policy development and service standards of care, as well as for the overall reproductive health needs of HIV+ women....The MCHI project design provided an excellent mechanism for humanizing, 'horizontalizing' and integrating the care of HIV+ women and their infants into the health care system..."
• According to the report, one of MCHI's strengths has been its attention to documentation and dissemination both nationally and internationally. For example, the project has created a set of "accessible and adaptable tools including IEC materials, a film and detailed replication packages. The MCHI website includes many of these tools in Russian and in English..."
• "MCHI exhibited strong leadership skills as well as strong management skills by continually revisiting both the content and the process of their interventions....MCHI conducted an internal mid-term evaluation which, among other actions, led to the decision to revise and update the family planning curriculum with counseling skills as its organizational backbone."

These findings lead the authors to conclude that MCHI was successful in helping regional and municipal government-supported health facilities adopt internationally recognised, client-centred, evidence-based maternal and child health standards and practices in areas ranging from antenatal care, family-centred maternity care, essential newborn care, exclusive breastfeeding, and family planning counselling and services, especially for postpartum and post-abortion clients. Based on their evaluation, they conclude that "[t]he design, content and implementation process of the MCHI Project is an excellent model for similar work in other countries."