This report analyzes the findings of 12 PVO child survival (CS) project evaluations regarding the potential sustainability of project activities and of the gains made in CS indicators. Specific attention is paid to two sustainability strategies — a PUSH strategy, aimed at motivating the community to seek or demand health services; and a PULL strategy, aimed at strengthening existing services, particularly by training Ministry of Health (MOH) staff. The PVOs” projects reviewed included those of: Adventist Development and Relief Agency (ADRA), Indonesia; Andean Rural Health Care (ARHC), Bolivia; International Eye Foundation (IEF), Malawi; Minnesota International Health Volunteers (MIHV), Kenya; Project Concern International (PCI), Guatemala, Bolivia, Indonesia/Riau; PLAN, Mali; World Relief Corporation (WRC), Bangladesh; and World Vision (WV), Bangladesh, Mali, and Haiti. All projects had been operational through two cycles of CS funding (at least 6 years). The evaluations suggest that sustainable changes in community health behavior can be achieved with a significant investment of time at the community level. Leaving trained health workers and mothers in each community can create new community norms to protect children”s health, particularly in areas such as nutrition and oral rehydration, where minimal external service delivery is needed. Promoting related CS messages through the media has also been significantly supported. In sum, these projects have implemented the PUSH strategy for protective health services in a manner likely to be maintained. The evaluations also suggest that the projects have invested the time, training, and resources necessary to develop health services that will PULL individuals in for preventive care. The difficulties in maintaining this PULL once the external aid and props retreat are many: limited national budgets for health services in general; limited emphasis within health services on preventive rather than curative care; competing recurrent health crises (e.g., cholera or AIDS); frequent transfer of government health personnel; lack of focus on needs of already marginalized groups (urban poor, widely dispersed rural groups, indigenous peoples, etc.); lack of supervision and management techniques among public sector workers; and limited budgets for refresher training of workers. These problems can be ameliorated by CS projects only in part — by training MOH staff in technical and managerial issues, and by leaving a strong vocal community demand for services among the needy populations. Mentioned very little in the evaluations, and an oft-neglected area of PVO CS projects is national-level advocacy, or at least advocacy training of local people in this area.
