Employer-based programs in maternal and child health : Project HOPE"s strategy for attaining long-term sustainability of health promotion in Malawi

Project HOPE trained and supervised one employer-paid primary health care worker in each estate, with the estates covering much of the operational costs. The project was successful in improving living conditions and the availability of health services for the families of estate workers and probably contributed to increases in the coverage, practice, and knowledge of mothers essential to maternal and child health. Not only did the participating estates agree to continue the program with their own funds after the grant ended, but 19 other estates in the neighboring district asked to join the program. In 1996, Project HOPE, with USAID assistance, undertook a study to measure the extent of the improvements in health practices and conditions and to ascertain the reasons for the estates" decision to join the program and then continue it with their own funds. The primary reason given by the estates" management for joining the program was the potential benefit to their workers and their families at minimal cost to the estates. Their trust in Project HOPE"s ability to manage the program without putting additional burden on estate mangers or exposing the estates to risk of disruption or worker unrest was an additional reason. Confirmation of these views led them to continue the program after the grant ended. The potential for monetary or nonmonetary returns to the estates were viewed as unlikely and did not seem to be a factor in their decision. While other employer-based preventive health programs, especially in family planning, have also reported success in reaching low-income rural populations on a sustainable basis, sustaining employer commitment to them has been based on financial benefits to the employers from such programs and on the presence of internal champions. It remains to be seen whether the local NGOs established by Project HOPE and the Malawi estates to continue the technical support and championing roles played by Project HOPE will succeed and sustain. Nevertheless, the experience reported here shows that while collaboration with the private sector requires approaches different from those needed with the public sector, they hold the promise of sustainable improvements that are not dependent on tight and uncertain government budgets. (Author abstract, modified)