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Evaluation database

Evaluation report

2009 Serbia: Evaluation of the Baby Friendly Hospital Initiative in Serbia for the period 1995-2008

Executive summary


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The Baby-Friendly Hospital Initiative (BFHI) is a global initiative of the World Health Organisation and UNICEF that was launched in 1991. The Initiative aims to give every baby the best start in life by creating a health care environment that supports breastfeeding and appropriate health care practices as the norm. This Initiative began in the then FR of Yugoslavia in 1994.
A formative evaluation was carried out by external evaluations between the end of August and early October 2009. This aimed to review the Baby Friendly Hospital Initiative in Serbia 1995-2008 towards assisting the Special Working Group for Baby Friendly Hospital Initiative Plus to make recommendations for the future course of BFHI. The Terms of Reference for this evaluation were agreed by the Special Working Group.
Activities related to the BFHI in Serbia were very broad and had spanned many years including a period of political and social change. Responsibility for the implementation, monitoring and funding of BFHI activities had moved over time, which limited the data available to answer some of the questions within a business model of effectiveness and efficiency. The design was primarily exploratory focusing on what was the current situation, how past activities had influenced the present, and lessons for the future.
The stakeholders in the BFHI include the:
• service users: the current pregnant women, new mothers and their infants, and potential parents;
• service providers: the midwives, nurses, doctors and other staff, their managers, and those who provide staff training and public awareness activities;
• service funders: taxpayers, the ministry of health, budget holders and, in the past, UNICEF.


Formative evaluation to review the Baby Friendly Hospital Initiative (BFHI) in Serbia 1995-2008 towards assisting the Special Working Group for Baby Friendly Hospital Initiative Plus to make recommendations for the future course of BFHI.


Data was collected from a variety of sources to ensure its accuracy, validity and reliability, and that all affected people/stakeholders are considered. Instruments used for data collection at the facilities were based on the assessment and monitoring instruments of the global UNICEF/WHO Baby Friendly Hospital Initiative (revised 2006-8), adapted to the needs of the evaluation and the time available.
Documents and reports related to the establishment and implementation of the BFHI and associated activities, health indicator data, and other materials were acquired and reviewed. Five hospitals with maternity services and four associated primary health care facilities were visited taking into account geographic location and population served, their relevant documents reviewed and observations of practice carried out. Individual interviews were conducted with 17 managers of these facilities, 32 members of the staff of the facilities, plus discussions with 11 groups of staff. Individual interviews were conducted with 42 pregnant women and 71 postnatal women using the services in these facilities. Ten organisations including parent groups, NGOs and governmental organisations participated in interviews.
The choice of facilities and sampling of respondents attempted to ensure equal representation of population groups. The evaluation aimed to be conducted in a manner that was respectful and confidentiality for the people participating in interviews. Interview data was collected without individually identifiable information as far as possible and stored safely by the evaluators, then handed over to UNICEF to be securely kept until the evaluation report is accepted and then destroyed.

Findings and Conclusions:

Overview of findings
There were eight objectives of the evaluation provided to the evaluators in the Terms of Reference. The findings and specific recommendations for each objective are reported followed by a general recommendations section. An overview is presented here.
The BFHI is relevant to the needs of mothers, infants and the health service in Serbia, fits with national priorities and is generally acceptable. The BFHI was implemented as part of a wider programme of maternal and infant activity and raised awareness of breastfeeding and supportive practices. For the evaluation, it was not possible to separate out the specific BFHI activities from this broader programme. There are misperceptions of what is the BFHI by many mothers, staff and managers as well as the wider community. The Initiative had many activities and was moderately effective until about 2003 when support was reduced and activity curtailed. Low level activity continues in some areas due to the commitment of individuals. While some of the practices remain in place in some hospitals, the overall “Initiative” with its assessment and monitoring of standards has not been sustained. The WHO/UNICEF global BFHI was updated in 2006-8 and the updated standards and supporting materials are not part of the BFHI in Serbia at present.
The evaluation of the Baby Friendly Hospital Initiative (BFHI) in Serbia was carried out in accordance with the Terms of Reference.
Though there are difficulties due to the economic situation, this is also a time of opportunities for actions related to the BFHI in Serbia as improvements are made to health services. The evaluators recommend revitalisation of the BFHI starting with an effective and sustainable system of coordination of the Initiative that would raise awareness of the BFHI and work to link it with routine training of health workers as well as with other health service quality programmes. A health service model is also recommended that places the baby and mother needs at the centre of a supportive environment, including protection from marketing of breast milk substitutes.
The Special Working Group and others will need to develop a plan of action with realistic goals and measureable objectives and a suitable time frame. Bearing in mind economic realities, the evaluation report provides detailed recommendations and a suggested plan for action.


Overall recommendations
There are many recommendations presented with the findings for each objective of the evaluation (Section 5). Those recommendations are brought together in these overall recommendations from the evaluators to:
Place the baby and mother/parents at center of supportive healthcare environment and the reason for the service to exist, not merely as objects of the health care process.
Raise awareness of what are the practices and assessment process of the BFHI and why it is of value in Serbia.
Update and disseminate the updated information for parents and health workers related to breastfeeding and supportive practices.
Include up-to-date evidence based knowledge and skills related to breastfeeding and supportive practices, as the routine practice, in the pre-service training and continuing education of health workers through inclusion across the curriculum and in training materials. Ensure they know why the practices are important and can discuss this with parents, not only that the practices should occur.
 Link the BFHI to accreditation, quality assurance, health promotion and other health strategies to provide integrated processes rather than BFHI as an independent special project.
Remember that breastfeeding is not a medical or clinical problem to be treated but a normal health practice to be supported.
Enforce the protection of consumers as well as health workers from marketing practices that may undermine breastfeeding and optimal health for infants and their mothers. There is limited benefit in promoting breastfeeding if there is no protection from the much stronger promotion of breast milk substitutes.
Provide funding and thus time for the effective and sustainable coordination of the BFHI and related activities.
Recognise, reinforce and build on existing activities that are working well
Seek out key enthusiastic people in each health facility, institution for educating health workers, professional associations and community groups, support them in activities and assist them in developing skills to motivate and leaders those around them
Provide protective budgets for BFHI activities at individual facility and regional level as well as nationally.

Lessons Learned (Optional):

• The Baby Friendly Hospital Initiative was instigated as one aspect of a broad programme of breastfeeding promotion within mother and child health care and did not have measureable specific objectives or plans of its own. The practices of the BFHI were not integrated into pre-service education of health workers or routine maternity care processes. This combination of lack of identity and isolation from routine care made it difficult to sustain over the years, and particularly when funding support from UNICEF reduced.
• Particularly in more recent years, most of the coordination of the Initiative was left to a small group of people who frequently did this work in their own time and in addition to their regular employment. Lack of support for this work, for example by paid work time allocated to it, resulted in lack of recognition for the value of the BFHI and lack of awareness of its activities.
• Political and social changes in the country resulted in changes in the responsibility and funding for BFHI. A specific handover plan to increase national ownership, establish coordination, and assume funding responsibility when UNICEF reduced support might have assisted in maintaining the assessment and monitoring activities of the BFHI.

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