Table 4 Five examples describing programs sustained for 5 years or more and illustrating common facilitators of sustainability^a

Ament et al. [77]

Four hospitals, breast cancer surgery services (the Netherlands)

Short-stay program in breast cancer surgery care

5 years

The compliance with recommendations to facilitate short stay after breast cancer surgery increased from 65% after implementation to 78% 5 years post-implementation

• Normalization of short-stay breast cancer surgical protocols

• The organisational culture in early adopter hospitals may have facilitated the sustained results

• Adaptability of the new program and healthcare workers’ compliance with the key program recommendations

Casati and Bjugn [60]

One pathology department implementing a national initiative (Norway)

A national electronic template for histopathology reporting of colorectal carcinoma resections implemented into daily routine practice

5 years

The template was used in 91.8% of cases (n = 1186) and had significantly improved upon the reporting of parameters at 5 years post-implementation

• Template clarity and simplicity

• Health leaders as champions

• Culture of support for the template from staff members and peers

• Ongoing national funding

• Changes in individual long-term behaviour to refer to the national electronic template and include key parameters when writing reports

Magadzire et al. [78]

The Western Cape Department of Health (WCDoH) (South Africa)

Chronic Dispensing Unit (CDU)

10 years

Started with eight centres in 2005 and reached 216 centres by 2015

• Leadership and support from funders

• Engagement with clinical staff involved in developing the program

• Partnership between the WCDoH and the contractor (UTI Pharma)

• Adaptability and flexibility between involved stakeholders, e.g., adapting to policy changes

• Policy alignment at multiple organisational levels, and with the implementation team (health personnel and the contractor)

• Technological advancements (e.g., machines allowing the picking, packaging and labeling of medicines) that increased scope of program

• Funding for 5 years from government and contractors through political alignment

Oliveira et al. [76]

Primary care—over 39,000 family health units [FHUs]) (Brazil)

The Family Health Program (FHP) implemented in 1994 as national policy

12 years

Six critical events that allowed the program to evolve and change in response to its context, thus facilitating long-term sustainability

• The intervention was compatible with the government’s vision, allowing it to withstand policy and political changes occurring in local health management

• The change of municipal management by mobilising champions to rebuild alliances with other sectors for collaboration

• The involvement of staff as decision makers and negotiators to maintain the stability of the intervention

• Ongoing monitoring and adaptation of the program in response to critical events that occurred in the 11 years since the program’s inception, e.g., staff turnover and navigating different council approaches to healthcare

Zakumumpa et al. [25]

Four health facilities were purposively selected, with two sites with the highest institutionalisation scores and two the lowest institutionalisation scores. (Uganda)

Anti-retroviral therapy (ART) scale-up

Implementation history of between 8 and 11 years (sites with the highest scores)

Two sites with the highest institutionalisation had successfully transitioned to a more ‘permanent’ state in ART service delivery whereas the two sites with the lowest scores were in ‘pilot’ mode

• The availability of written procedures and manuals for ART service delivery and organisational strategic plans

• Adaptations to program models when needed

• Formally appointed roles

• The presence of program champions

• Service support from other departments

• ART program was embedded in daily organisational routines

• Deliberate strategies for training and retention of ART-proficient staff

• Salary support for key staff in the ART clinic