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Lessons Learned (1999-2004)

The new state-of-the-art contributed by BASICS II is primarily in how to operationalize large-scale child health and nutrition programs with successful outcomes in the areas of immunization, timely and appropriate management of childhood illnesses, nutrition, and neonatal health. The specifics are provided in documents posted on the BASICS II website. The universal lessons across technical areas include: the importance of partnerships; the critical need to go beyond policies and guidelines to ensure field-level follow up and practice by front-line health workers; the need to engage local authorities with the power to affect change but who often sit outside the health sector; and the reiteration that families will respond enthusiastically to any reasonable opportunity to improve their children's health and well-being.

Lessons learned about the best use of technical assistance to expand child survival through a centrally managed "flagship" USAID project include the following. Some of these were reiterated by the external assessment team (Pielemeier et al, 2003):

  • A consistent strategic vision within USAID among various Missions and Bureaus, and a plan with projected resources that could lead to desired outcomes would have helped BASICS II achieve more results within the project period. As a performance-based contract with the Global Bureau, BASICS II started with a set of SO-level results developed centrally within USAID. However, a preponderance of field support funding led to a strong focus on meeting Mission needs and an effective but lower cost approach to global technical leadership. The USAID Missions did not always share the Global Bureau's vision and strategic direction. As BASICS II began, the USAID Missions had little knowledge about the results framework. Mission funds were programmed for systems strengthening, capacity building, and equipment in the traditional way–outside of a results framework. Initially designed as a 40% globally funded and 60% field funded project, BASICS II's field support funding in PY3, 4, and 5 was 76%, 72%, and 81%, respectively.
  • The expectation of meeting SO-level results at national scale was unrealistic in light of start-up delays and prolonged planning, and no adjustments were made in the Project's duration to accommodate this. There was a one- to two-year lag when programming shifted to the results frameworks that underlay USAID's new thinking. These planning and (on the PCHC, Inc. side) leadership problems were only resolved about halfway through the five-year program. The contract ended when countries were beginning to implement more results-oriented programs; USAID and the countries lost out in momentum and the payoffs from these revised, more scaled-up programs where investment had been carefully made.
  • The Project developed and applied an effective framework for working at scale that focused on engaging partner organizations already present in project areas, and supporting their efforts by strengthening, focusing, or adding child health and nutrition activities. The example of working with CARE in India illustrates this. With a modest budget and within a short period of time, the Project was able to support child health and nutrition interventions in a population of tens of millions. In the DR Congo, there was practically no movement in immunization indicators, and the Project filled gaps that no other agency was addressing and helped an interagency coordinating committee in better allocation of resources, resulting in scaled up impact.
  • Many prerequisites for achieving and maintaining scale include factors that are not under the direct control of a USAID project. These pro-scale conditions have not always been present in BASICS II countries, which threatened program expansion. The Project dealt with these factors in various ways. For example, the interventions in a country have to be tested and adapted to the satisfaction of the MOH, and the Project's SET function addressed this through documenting other country experiences and facilitating visits to other countries or meetings where these issues were discussed. Senior technical staff of the Project also maintained an ongoing dialogue with key stakeholders to gradually overcome barriers to change. The WARO team played a crucial role in overcoming these barriers in West Africa. Another prerequisite is that the MOH should provide strong program leadership and effective nationwide coordination. The Project often had to deal with changes in ministers and re-structured MOHs through alliances with other donors and strong district-level partnerships. (The role of the trust in and technical credibility of the Project field teams and in some countries of the USAID Mission was critical.) A reasonably effective health structure needs to be in place with trained staff, and the Project provided systems strengthening support, helped streamline interventions to fit local capacity, and identified local resources for additional support (e.g., NGOs). The Project also actively supported the use of interagency coordinating mechanisms for addressing many of these constraints.
  • Some important constraints to reaching scale included the availability of non–USAID donor funding for child health. This type of funding has gradually dwindled, even in Africa where child mortality and morbidity remains very high. Within USAID, the Africa Bureau's resources for child survival also declined. Although USAID funds were limited, the design assumed that funding could be obtained from other donors and the private sector for major expansion efforts. Despite some BASICS II successes, this assumption has not been widely validated. Host country budgets remain stagnant and are allocated primarily for curative care and to pay salaries. Although child health interventions are relatively inexpensive, local cost funding is needed at the health post and clinic levels and to pay for supervisory visits to outlying villages where community-based programs need periodic monitoring and restocking. Health reform and government decentralization efforts offer new options for local cost financing, but processes and frameworks for tapping these specifically for child survival remain to be developed and used routinely.
  • Learning from cross-country analysis of experiences is one of the main justifications for centrally managed projects. But systematic evaluations and analyses that have operational value take time. Country programs did not become fully operational at scale until PY 3 and 4 of the Project, and country and Mission interest in studies was not always high. In-country capacity was a limiting factor, and one that this Project was not geared up to address. However, the Project carried out several comprehensive studies, and critical assessments and analysis that highlighted important child survival issues.
  • Initially perceived as too rigid, the performance indicators of increases in coverage and scale helped several of the technical areas focus their strategies. For example, nutrition programs with a tendency towards pilot projects were pushed to work at scale, neonatal interventions that have historically remained in facilities were encouraged to implement at community level, and C-IMCI was re-designed in the Project to focus on a few priority behaviors and aimed to make a measurable difference in household behaviors at scale. However, in the immunization technical area, the emphasis of project performance indicators on coverage alone tended to reinforce historically ineffective practices including insufficient emphasis on quality and sustainability. Ideally, to achieve important child health results in the field, a flexible, adaptive approach is needed, with performance indicators designed to address locally relevant constraints to public health impact, and mindful of differences across technical areas. Annual adjustments with the participation of national leaders in child health and nutrition would have helped program designs remain focused on priority issues in each country and technical area.
  • Effective approaches were developed by the Project both for the delivery of integrated services aimed at addressing multiple causes of mortality and co-morbidities, and for selective strengthening of key interventions within the context of comprehensive MCH services. Taking the lead from country-level needs assessments, the Project found that both strategies could work with careful planning and attention to follow-up. Integrated approaches are harder to implement and require a higher order of willingness to collaborate and compromise, and it takes time to form functioning linkages among technical domains. The short duration of BASICS II at the field level made this difficult.
  • Major transformations in the Project's lead technical arenas were taking place globally during 1999–2004. New global "initiatives" threatened to de-rail progress in the core elements of programming and systems strengthening. The technical leaders of the Project helped countries successfully navigate through these to maintain a focus on sustainable progress on the ground. Immunization was dealing with polio eradication and the danger of falling routine immunization coverage while injection safety became a concern; neonatal health was gaining recognition as one of the most critical areas, but field experience with large-scale programs and program frameworks and tools was in short supply; the IMCI initiative underwent review and re-thinking, emerging with more modest strategies and recognizing the many alternatives for community-oriented programming to produce results; in nutrition, new concerns and priorities emerged (e.g., zinc and HIV/AIDS) while the package of the most cost-effective and proven six essential interventions was far from scaled up beyond a handful of countries.
  • The Project was able to contribute substantially more due to the combination of global leadership and country support functions. Continued USAID leadership in child health is best served by a leadership project that combines global technical leadership and cutting edge, but practical, application in the field. BASICS II contributions to GAVI for immunizations and to operationalizing the global Infant and Young Child Feeding strategy are examples. Within countries, USAID Missions supported and encouraged the Project to engage in dialogue and policy discussions at the highest level. The Project's technical leadership was frequently invited to contribute in global forums, and closer teamwork between USAID and the Project would have been even more effective in bringing the funding and operational/technical insights to the table. Good examples of teamwork in global and regional forums are the Project Director's work with the USAID Global Health Bureau in establishing the global Child Survival Partnership (CSP) and taking initial steps in CSP focus country programming, and the Asia Bureau and Project neonatal health team leader working with WHO/SEARO in inaugurating the Southeast Asia neonatal initiative.
  • Based on BASICS II's experience, areas where more effort would produce stronger child survival and nutrition results in future include: more strategic use of communications to reach the 42 countries with the largest number of childhood deaths with effective tools and technical support to expand a core set of priority interventions; gap analysis and focus on critical missing operational elements needed for scale by country and technical intervention; transfer of experience from a small group of highly successful program sites to other countries through cross visits and dialogue; explicit strategies to build leadership in child survival programming in the 42 countries; and fostering interagency working groups at country and global levels for joint priority-setting, projections of future needs, and allocation of resources to assure that critical inputs for child survival are maintained. The value of performance monitoring on an annual basis to sustain momentum in reaching goals was validated. The need for focused, high coverage community approaches with explicit strategies to reach marginalized populations was highlighted. It was clear that systems support in the areas of performance and skills maintenance among front-line providers and their supervisors, supply and logistics systems, and information systems are critical even for community-oriented programs.

The Project reached the majority of its public health performance targets and exceeded them in several categories. The contributions made by BASICS II were widely acknowledged by other donors and countries as having advanced the state-of-the-art in child health and nutrition. The majority of its direct public health impact came from the DR Congo (immunization, vitamin A), Nigeria (breastfeeding and vitamin A), and India (nutrition and newborn care), illustrating the value of working in large countries with poor indicators and successfully engaging partners with a nationwide (or very broad) reach. Important activities with future payoffs included work in community-level newborn care, operational guidelines for the "reaching every district" initiative in immunization, community-level management of malaria and ARI including the role of private medicine vendors, and working at scale with a package of essential nutrition actions.

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