Table 3 Summary of studies reporting on programs that were discontinued, illustrating common barriers of sustainability (n = 8)

Bond et al. [35]

49 community mental health sites (USA)

The National Implementing Evidence-Based Practices Project

2 years and 6 years

Eighteen sites (37%) discontinued the project, seven of which were discontinued ≤ 2 years. An additional eight sites (16%) discontinued the project then reinstated it after a lapse of time

• Financial barriers, e.g., state and national budgetary policies, agency finances/resources, and general economic trends

• Lack of support (prioritisation) from staff for the evidence-based practices

• Lack of training or appropriately credentialed practitioners and supervisory staff

• Workflow barriers such as documentation burden, physical environment, nonfinancial policies

Lean et al. [71]

Sample of ten inpatient mental health rehabilitation units, representing 50% of units that had received the intervention (UK)

Rehabilitation Effectiveness for Activities for Life (GetREAL): Staff training intervention to improve patient engagement in activities

1 year

Despite initial improvements in several workforce outcomes, the skills that staff members had gained and the agreed implemented processes and structures were not sustained after the implementation team left

• Insufficient preparation for the intervention in which there was a lack of information prior to the arrival of the training team

• Engagement with the intervention team was seen by staff to be too short to achieve its intervention goals

• Some staff members misunderstood the aims of the intervention, thinking the training was aimed at patients

• Lack of resources and time

• Staff members considered intervention activities to be outside their role responsibilities once the intervention team left

• Champions were signed up by management as opposed to volunteering, people were unaware who champions were, and the champion role was seen to carry additional burden with no rewards

• The prioritisation of mandatory paperwork competed with patient engagement

Olumide et al. [29]

10 of the NURHI-1 intervention facilities in Ilorin and six in Kaduna (Nigeria)

The Nigerian Urban Reproductive Health Initiative

3 years

The programme ended in Ilorin

• Frequently stock-out of family planning commodities and consumables

• Lack of funding to finance the program

• Lack of advertisements

• Non-existent of NURHI-type training (discontinued)

• Lack of trained staff due to turnover, retired, relocation

Peterson et al. [72]

49 sites that implemented Evidence-Based Practices (EBPs) (USA)

The National Implementing Evidence-Based Practices Project

2, 4, 8 years

Year 2: 10 sites discontinued

Year 4: 16 sites discontinued

Year 8: 8 sites discontinued

• EBPs implemented with high fidelity at sites engaged in agency-level strategies to support sustainability remained vulnerable to discontinuation

• Leadership/supervisor turnover

• External funding and supportive entities affect long-term survival

Pomey et al. [73]

Five Canadian health care organisations (Canada)

The Wait Time Management Strategies (WTMS) implementation

18 months

One of five cases was deemed non-sustainable because the WTMS failed to reduce waiting times to less than 26 weeks within 18 months (Case 1: Atlantic Canada)

• Lack of incentives to encourage staff engagement

• Cultural gap between senior and junior surgeons

• Lack of engagement among physicians

• Lack of standardisation of the referral process resulting in delays

• Nursing shortages due to budget constraints

• Physicians competing with other specialties for the operating rooms

• Lack of funding

Seppey et al. [74]

Six community health centres and two referral health centres (Mali)

A pilot project to improve demand and supply of health services through financing performance in targeted services

Unclear

The project was deemed to have a weak level of sustainability with many of the project activities being discontinued or diminished at the end of the project

• Insufficient and unstable resources (financial, human, material)

• A lack of supervision

• Distinction between the different roles (management vs. healthcare provision) led to a loss of contact between stakeholders

• Planning focused on potential scaling up and outcomes rather on the sustainability of the project/routines

• High rotation of personnel

• Lack of involvement of local authorities

• Insufficient time to integrate routines

Vidgen et al. [24]

16 study sites (eight per state) implementing PEACHQLD in Queensland and Go4Fun in NSW (Australia)

Childhood obesity management services within two Australian States (New South Wales and Queensland)

Queensland Department of Health ceased funding and coordinating in 2017. Data collection timeline was unclear

Three out of eight sites had discontinued implementation in NSW whereas one of five sites had discontinued in Queensland. Eventually, all local service providers decided to discontinue the program in 2017

Perceived negative influence:

Within-State: Queensland

• Complexity of implementing the program (the strongest factor)

• Acknowledgement of the need (tension) for change

• Alignment with external policy and incentives

• Program champions within the organisation

• Evaluation and feedback processes

• Leadership engagement

Discontinued sites in Queensland

• The high costs of delivering and participating in service in remote areas

• Compatibility and not meeting patient needs

• Geographic location

Discontinued sites in NSW

• Complexity, cost, patient needs and resources

• Identification by program delivery staff with the organisation

Zakumumpa et al. [75]

Six health facilities receiving donor support for implementing the ART program (Uganda)

Uganda National antiretroviral therapy (ART) scale-up program

6 years

Two (of six) sites selected for analysis had high sustainability, two had low sustainability, and two were ‘non-sustainers’

• Scale-up was at odds with organisational for-profit orientated goals

• Higher patient loads led to greater indirect costs, long waiting times and high workloads

• Staffing shortages were coupled with increased patient demand due to the introduction of donor-supported free ART services

• Irregular drug supplies

• High ART-proficient staff turnover

• Lack of staff motivation due to low salaries and dissatisfaction with rewards

• Remoteness of location associated with local infrastructure barriers, e.g., poor road network linkages and electricity supply