The engagement and roles of leaders and participants.

The interviews depicted that when a project is implemented in the Vietnamese healthcare system (targeting commune or village level) it is commonly managed at provincial level where a project steering committee is established. The project stakeholders, that is, the elected leader and the members of that committee, may vary, depending on the focus of the project. A main task for a project leader is to direct and support project participants at the lower levels. However, project leaders are also in close contact with the higher levels of the healthcare system and sometimes need their approval for moving forward. The project steering committee is mainly active during the initiation phase, but continuously follows up on the project process, whereas project stakeholders and participants are expected to fulfil duties throughout the lifetime of a project.

“Project stakeholders stay engaged until the end of the project, except those who had to retire or were transferred. Each stakeholder has a particular responsibility, so they have to stay until the end to ensure a complete process.” (Interview 2, District level)

Projects are monitored.

According to study participants, healthcare projects in Vietnam are, in general, monitored. The monitoring is commonly established in a top-down manner involving many of the health system levels but to a various extent. The monitoring activities can be the responsibility of different project stakeholders, including researchers and funders. Also, regular follow-up is normally established using different methods (e.g. checklists, observations, and interviews), providing feedback to assure the quality of the performance and the fidelity of the planned actions. Sometimes project participants are informed of the planned follow-up visits while, in other cases, the visits are unannounced.

“By using a checklist or interviewing project participants, not only the project leader, a supervisor can collect information on how the project activities actually proceed.” (Interview 6, National level)

It was also conveyed that when finishing a project, a final report is produced and the results are disseminated among the relevant stakeholders.

Projects need tailoring to context.

Informants shared that when setting up a new project it is essential to assess the needs in order to understand the current situation. Also, choosing partners (project stakeholders and participants) who should partake in the project is an important step. These preparations are necessary in order to tailor the project to the setting.

Later, when the results from projects are available, stakeholders have to consider which results to disseminate and how. In the absence of this step, the diffusion of the project’s implementation is jeopardised, however, adopting effective strategies can still promote its sustainability.

“All successful projects in the community should, if possible, continue so that people, including children, can benefit from them and so that our efforts in implementing them are not in vain.” (Interview 1, District level)

Management of funding is somewhat flexible but requires transparency.

When a project budget is agreed and approved, one share of the budget is usually fixed, while other shares of the budget are more flexible and can be modified based on needs. Transparency of project budgets is deemed important, particularly in relation to sponsors. To establish an effective process, recurrent dialogue is the best approach. If the project steering committee, including the project leader, has a complete overview of the project, they can suggest minor budget adjustments, but approval for the execution of larger changes is commonly needed from higher levels.

“Usually we have to make requests to higher levels in the healthcare system for adjustments. However, for those items less than 5 million Vietnamese Dong [≈$250] we can make adjustments ourselves.” (Interview 2, District level)

Engagement, enthusiasm and commitment are important components among leaders and other stakeholders.

A key to sustainability in change is to have well informed leaders, project stakeholders and, not least, community members. When people are aware of why a project is conducted and what benefits it might have, the chances of succeeding are higher. The project leader is in a position where he/she can obtain an overview of the situation, which then allows him/her to ensure that activities comply with guidelines and regulations, and that plans are realistic and appropriate for the situation within a certain context. The project leader is commonly also the person responsible for engaging in a dialogue with other health system levels. In order to sustain project activities, the project leader is thus an important person. If the leader has an interest in a project, this will favor both its implementation and sustainability.

Providing generous information about the project and its benefits will secure the commitment of the committee members and project participants and increase their sense of ownership. However, it is important to reach stakeholders at all levels, that is to say, from those at grass-roots level to the decision makers at higher levels of the healthcare organisation. The characteristics of the project stakeholders are important, as they have influential positions and therefore need to be enthusiastic and have a genuine interest in implementing certain knowledge. While this is something that should already be considered when planning for a project, it was highlighted as being more important in a Vietnamese healthcare context as its people were depicted as being reluctant to join projects.

“You see, when they [potential stakeholders] are asked to do something which differs from their daily routine, they tend to reject, saying it’s too difficult. But once they have engaged in doing it, they often find it easy and simple.” (Interview 5, National level)

If the targeted population do not understand the purpose of a project it will be hard to implement change and thus achieve sustainability. However, getting procedures integrated into regular routines can help both the targeted population and the project stakeholders to become more familiar with and actually apply various features of a strategy. To make this happen, a project should have a plan on how to sustain the effect of a beneficial change beyond the project period.

The health system’s impact on change.

As described above, project stakeholders and project leaders are key in community-based projects. However, participants emphasized that a common problem in the Vietnamese system is the lack of forums and/or time for where and when communication can take place. It was also suggested that poor communication can origin from a lack of interest in certain groups; for example, the district level organisations are not only nodes for information transfer with the provincial and community levels but also between the political/administrative system and the healthcare system. Thus, a lack of engagement at district level is a major barrier for communication.

“Every month, we host a work meeting with CHC heads. We have invited representatives from across the district level several times, according to the local regulation. However, they [the District Peoples Committee representatives] fail to attend every time. If they would attend the meetings, they would get information directly from CHC heads and it would be more adequate and accurate than getting it via us.” (Interview 3, District level)

Tailoring implementation strategy and format.

To achieve sustainability in the implementation of community-based strategies it was suggested that it is important to, early on in a project, establish strong relations with the “right” people, that is, stakeholders and individuals with authority as well as the recipients of the implementation.

Further, conducting a needs assessment and assessing who to engage early on in the project to ensure that they can have their say prior to the project launch is important. A thorough assessment should consider the current legislation, to assure that the projects are accurately performed. Further, policy advocacy can help a project to succeed; therefore, lobbying for a project before actually getting started may be worthwhile.

“If a foreigner wants to design a project for the health sector in Vietnam, it is important to analyse the needs before setting it up. You have to find out what the health sector needs, its capacity to meet the requirements, what problems it faces, and who can help solve such problems. … Another factor contributing to ensuring sustainability is dissemination in the community. Before the implementation of a project, dissemination of the project should be conducted to inform people in the community about it, its objectives, the approach, the benefits it will bring about, and what the requirements are for being entitled to benefits. This is essential for sustainability.” (Interview 6, National level)

Additionally, if the local authorities need to secure resources in order to sustain a change, for example, to keep people on the payroll once the project funds are withdrawn, it is less appealing than change with no or limited impact on the budget. Further, projects providing resources (e.g. equipment) or resulting in a visible change (e.g. a new building) are more easily accepted than more abstract projects (e.g. to increase knowledge or to empower staff). While the latter type of projects usually encounters more barriers, communities can become committed through the provision of substantial information and communication.

Funding implementation projects—before, during and after.

There was no common understanding among the informants with regards to the requirement of funding to sustain a project. Rather, some participants described that funding is necessary to sustain change beyond the project period, while others stressed that money is not that important and/or only has short-term effects. To them, including and engaging leaders, project stakeholders and the targeted population working with or being affected by the project is more important. Regardless of this inconsistency, all shared the notion that certain strategies to attain and manage funds are vital for a project, and that the original project plan should include how to hand over once external support ends.

“To sustain project activities after a project is over, we should act in the same way as we adjust medications; doses are gradually cut. Thus, for project activities, funding can be reduced gradually and the project sponsor should carefully consider the cuts, and communicate decisions to the head of the local authority.” (Interview 2, District level)

The NeoKIP project–in retrospect.

The project not only resulted in a substantial reduction of neonatal mortality but it also had implications for the healthcare system, from both a provider and a user perspective: study participants described that although the regular group meetings at commune level supported by a facilitator ended with the project, the healthcare system, particularly at primary level, focused more on maternal and newborn healthcare after the NeoKIP than before. According to the informants, this was, to some extent, caused by the endurance of NeoKIP: with the project running for three years, healthcare staff became aware that maternal and newborn care is important, and focused more on these aspects in their daily practice. Further, informants suggested that NeoKIP’s focus on maternal and newborn care had affected the population in a positive way; the population was considered to be more aware of different issues related to maternal and newborn healthcare, for example, an increased knowledge of the importance of immunization was noted, leading to increased health service utilization. In particular, NeoKIP was considered to have affected the ethnic minority groups in a positive way.

“In the past, ethnic minority people of my age [around 60] didn’t know at what point they had become pregnant and thus when they would give birth. But since the NeoKIP project, when all institutions in the commune jointly shared information on this [reproductive health], particularly the younger people have become more knowledgeable.” (FGD 3, Community level)

Engagement.

The NeoKIP project was depicted as a social intervention where people from various stakeholder groups became engaged in focusing on a common problem area. Communicating with women of reproductive age regarding different matters was considered a particularly key achievement that contributed to the success of NeoKIP. The level of engagement was rather high between group participants and the targeted population. However, the composition of the teams was highlighted as being a barrier. For example, more village health workers should have been included in the groups, and it would also have been appropriate to include other village representatives.

To have facilitators in NeoKIP from the Women’s Union, with the task of supporting people working with maternal and neonatal health, was not entirely appreciated. While the facilitators lacked knowledge in maternal and neonatal care (but were trained in facilitating knowledge implementation) the health professionals described that they wanted more up-to-date knowledge on pregnancy, childbirth, and neonatal care. Also, some facilitators were thought to lack skills in communication, which was considered a key feature in their role. The informants suggested that the group of facilitators in NeoKIP needed more training or to engage healthcare staff from the CHC as facilitators.

“I believe that the facilitator staff should live and work in the local setting and he or she must have [clinical] expertise to support others.” (FGD 1, Community level)

Project management.

The success of NeoKIP was partly attributed to its ability to engage various members of the healthcare system, particularly at commune level. However, a further integration of the project into the healthcare system, with the ownership being shared to the administrative and political part of the health system, would have sustained further success and sustainability. Further, increased engagement would also have helped to sustain facilitation of knowledge implementation as proposed in NeoKIP. The project was criticised for lacking the involvement of certain stakeholders, for example, those at district level (district hospitals, district centres and district People’s committees) and for providing opportunities for these parties to interact with project staff.

“When implementing a project like NeoKIP, to have a two-way communication between the health system levels is very important. Communes should communicate and report to the district level, who can evaluate and give advice.” (Interview 3, District level)

Tailoring.

NeoKIP was perceived to have been tailored to some extent, for example by including various stakeholders working together with maternal and neonatal health to increase people’s awareness and use of healthcare services. The strategies applied in NeoKIP were still affecting people in that manner after the NeoKIP intervention had ended, and, although no facilitators arranged further meetings beyond the project, the healthcare workers still applied the same approach, focusing on knowledge issues, and employing the means used in the intervention.

“Although there is no NeoKIP project now, the commune still continues its activities and we hold meetings with people from different organizations who interact with the population about perinatal health.” (FGD 4, Community level)

However, NeoKIP was not considered to be sufficiently tailored. For example, the facilitation strategy was deemed to be more suitable for targeting the most remote and difficult-to-reach areas of the province. Also, without a dialogue with the local population prior to the project and with key people at different levels of the healthcare system during the project, sustainability was jeopardised.

Funding.

Funding during the NeoKIP project was a common issue: with limited reimbursement (provided only as a monthly salary to the facilitators and travel expenses for village representatives to attend monthly group meetings), the informants recalled that there were people who should have been financially compensated during the NeoKIP intervention. Another point raised was the general lack of project funds available, restricting group members to mainly target the areas close by and not those in greatest need. Also, when having meetings at different places in a commune, it would have been appropriate to be able to attract people, which, in the Vietnamese context, necessitates a financial incentive.

“To tell you the truth, it takes them half a day to come all the way here to work for 10,000 Vietnamese Dong [about half a US dollar] which is just enough for a drink. As we work in the station here, it is not an issue for us to attend a meeting. But for other members of the board [e.g. village health workers], it was quite frustrating to do it without being reimbursed.” (FGD 6, Community level)

In addition, informants suggested that for future efforts within NeoKIP it was crucial to have funding for various activities and for supporting participants. When NeoKIP was compared with other projects, those with funding were described as having more satisfied participants. The lack of financial support when ending the project contributed to the threat to its sustainability.