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Table 1 Summary of available studies examining sustainability of health interventions implemented in sub-Saharan Africa

From: Toward the sustainability of health interventions implemented in sub-Saharan Africa: a systematic review and conceptual framework


Theory or framework


Definition of sustainability in frameworks used

Timeline of project (assessment year)

Analytical approach


1. Abbey et al. (2014) Ghana

Ecological behavior model

Community-based fever management

Retention of volunteer CHWs

2006–2009 (2010)

Mixed methods: CHW database of 660 CHW and 5 focus groups with 35 CHW

Attrition rate 21 % over 30 months; Attrition was comparatively higher in younger age groups (25.9 % in 15–25 years group, 18.2 % in 26–45 years group and 16.5 % in ≥46 years group). Community acceptance of program was positively associated with retention.

2. Ahluwalia et al. (2010) Tanzania


Community-Based Reproductive Health Project (CBRHP)

Post-project assessment on a community-supported emergency transport systems, retention of village health workers (VHWs), and potential impact on maternal health

2001–2006 (2007)

Document review, community assessment survey, volunteer health workers survey

1. Community-financed transport system continued in 6 villages.2: CBRHP-trained village health workers have continued to work for more than 5 years and report on their activities during village meetings3. Significant improvement in women seeking prenatal care <20 weeks gestation, identification of pregnancy-related danger signs and improved maternal and infant outcomes.

3. Ajayi et al. (2014) Nigeria


Home-based management of malaria Nigeria

The extent to which the program continued, the prospects and challenges encountered such as with retention of community medicine distributors (CMDs) and the way forward.

2005–2007 (2010)

Focus group and key informant interviews

Utilization of CMDs was said to be high when the project started but dwindled after the researchers left the community. Majority of the caregivers sought care at other alternative care providers or used herbs.

4. Akogun et al. (2001) Nigeria


Community-based onchocerciasis treatment, Nigeria

Treatment coverage, acceptability and effectiveness of a program-designed (PD) and community-designed (CD) treatment strategies in 37 villages. Features of the community that may facilitate acceptable and sustainable community-directed treatment.


37 villages divided into two groups: PD versus CD. A total of 1744 people were interviewed about their experiences after two treatment cycles using household surveys, observation notes, in-depth interviews and focus group discussions.

1: Mean total coverage was 37.7 % with a range between 0 and 100 %. 5 villages had coverage rates above 60 % and dosage was correct in most cases (87.5 %). Most frequent reason for non-treatment was drug shortage (50 %) and being under-age (31.3 %).

5. Amazigo et al. (2007) 41 projects with African Program for Onchocerciasis control: Cameroon. Chad, Democratic Republic of Congo, Ethiopia, Malawi, Nigeria, Sudan, Tanzania, and Uganda


Community-directed treatment with ivermectin (CDTI)

Community ownership in long-term project sustainability defined as: “evidence of the ability of the community to own and manage CDTI; participation of community members and their leadership in decision-making; initiating and supporting CDTI implementation”.

1997 (2002–2003)

Study included randomly selected 41 projects in 10 countries (total 492 communities); methods included interviews, documents review, and observations. Quantitative and qualitative scores were used to obtain individual community scores and an overall sustainability score for each project graded on a scale of 0–4.

Of the 41 projects evaluated, 70 % scored satisfactorily to highly on sustainable at the community level.

6. Amo-Adjei (2013) Ghana

Sustainability framework

TB control, Ghana

Sustainability is conceptualized as the perceived and actual ability of the NTP of Ghana to continuously seek and attract resources to improve or maintain the existing levels of diagnosis and treatment of tuberculosis


In-depth qualitative interviews with 19 stakeholders

The findings reveal two main strands of views about the sustainability of the current TB control programs: optimism and pessimism. The optimists revealed that the integration of TB into the generalized health system, integration of TB and HIV control services, the use of internally generated funds of health facilities, and a general improvement in socioeconomic conditions of the general population could provide positive pathways to sustainability. The pessimists on the other hand noted that the existing program was not likely to be sustainable so long as much of the operational funds were derived from external sources.

7. Aubel et al. (1996) Gambia


Community nutrition program

How can community nutrition programs be designed so as to favor sustainability involving the promotion of futu kanya, a traditional snack food made with millet, sugar and groundnut past as a dietary supplement for pregnant women.

1990 (1994)

Qualitative research using rapid assessment procedures involving in-depth interviews, semi-structured interviews, interviews with staff and document review.

Project was successful in terms of community involvement in the production and promotion of futu kanya which had a positive effect on the pregnant women who consumed it. Futu kanya was consumed at the recommended rate of 150 g daily.

8. Blanchet et al. (2014) Ghana

Sustainability framework based on diffusion of innovations; 5 components: health outcomes, service delivery, organizational capacity, viability, and community capacity; diffusion of innovations

An eye care program

Level of continuation of activities after the end of international funding in 11 of the 19 district hospitals. Measured by comparing the number of outputs per activity before and after the end of international funding (18 months after international funding ceased). It involved checking whether each eye care activity continued (i.e., outpatient consultation, cataract surgery, outreach, school health, and statistics) or was interrupted after the end of Swiss Red Cross funding

1996–2006 (2009)

Document reviews, in-depth interviews with 51 officers at the ministry of health, regional and district health authorities, district hospital managers, and health staff, Swiss Red Cross Officers, and community members.

School health screening was the least sustained activity after the end of international funding.

In contrast, compared to the three other district activities, facility-based consultations were more likely to be routinized.

9. Blanchet et al. (2014) Somaliland

Sustainability framework

Physical rehabilitation network

Sustainability analysis process which involves 5 steps which are as follows: (i) establish a common understanding of the rehabilitation system in the local context, (ii) define system boundaries, (iii) develop a common vision of sustainability, (iv) select measurable sustainability indicators for the local system, and (v) collect baseline indicator data

2010 (2012)

In-depth interviews and observations using analytic narrative approach

In Somaliland, the small, centralized stakeholder network suffered a critical rupture between the system’s two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was limited.

10. Burlew et al. (2014) Nigeria

In-service training (IST) improvement framework; 6 broad themes: strengthening training institutions and systems, coordination of training, continuum of learning from pre-service to in-service, design and delivery of training, support for learning, and evaluation and improvement of training

PEPAR-funded in-service training (IST)

How implementing partners collaborate with each other in the coordination and delivery of HIV/AIDS related IST and to what extent training is effective, efficient, sustainable, and aligned with national priorities

2004 (2007–2012)

Stakeholder survey

Recommendations: improve collaboration and coordination among implementing partners; apply a more diverse and cost-effective set of training modalities; allocate funding specifically for the evaluation of the effectiveness of training; improve links between IST and both continuing professional development and pre-service education; require implementing partners to create sustainability plans to transition training from PEPFAR funding to other funding sources; and develop a training information management system

11. Eliason (1999) Cameroon

Freire’s conscientization theory

Life Abundant Program (LAP), church sponsored primary health care project

Continuation of LAP defined as: active which refers to functioning health promoters and financially viable village primary health centers (PHCs). Closed refers to the locking of the medicine box and cessation of health promoter activities

1980–1997 (1980–1997)

Evaluation of the first 16 LAP-associated primary health centers.

81 % of the 16-LAP’s were active 9 years after the first PHC opened, and 87.5 % after 17 years.

12. Fonck et al. (2001), Kenya


Decentralized antenatal syphilis screening program

Effectiveness of screening and testing seroreactive pregnant women and their partners using rapid plasma regain (RPR) and formulate recommendation for future implementation

1992 (1997–1998)

Evaluated data from 10 primary health care clinics, quality control data from referral labs, with information on costs.

96 % of all pregnant women attending the 20 clinics were screened for syphilis. RPR prevalence was 3.4 %

13. Ghiron et al. (2014) East Africa (Uganda and Kenya)

WHO’s 12 recommended tools for beginning the end in mind

Health of People and the Environment Approach

Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up, which provide 12 recommendations to help ensure that a sustainable and scalable model is designed and tested, laying the groundwork for future success with scaling up

2003 (2011)

Participant observations, rural appraisal in project sites, key informant interviews, desk review of documents, in-depth interviews with 9 project team members and 13 project stakeholders

Previously funded PHE projects faced challenges of sustainability, and few reached beyond the confines of their original target communities. Rather than setting up parallel structures, the team has tried to work with, and within, existing personnel and systems.

14. Harpham et al. (2002) Tanzania


Urban Health Project

Capacity building and institutional strengthening

1990 (2000)

Key informant interviews, meetings with health management teams and health boards, document reviews, and surveys of users and community members

Project achieved improvements in capacity building and in structural and technical quality of care.

15. Humphries et al. (2011) Southern Africa (Botswana, Lesotho, Namibia, Southern Africa, Swaziland)

Johnson et al. (2004) sustainability planning model

NGO Training Institute to build capacity of NGO’s working to address HIV

Sustainability of (1) administrative structures, (2) innovation champions and leadership actions, (3) resources to support the innovation, (4) administrative policies and procedures, and (5) expertise to sustain the innovation and how these components were and were not incorporated into the NGOTI implementation

2004–2007 (2007)

Surveys and qualitative interviews to assess project outcomes: interviews with 44 internal stakeholders (trainers, managers, administrators, and technical advisors).

The NGOTI was able to develop the capacity of partner organizations in the area of AIDS NGO/CBO capacity building, as evidenced by the ability of these organizations to obtain additional funds to continue some of that work.

16. Hutchinson et al. (2010)


Obstetric case reviews, Benin

Adopting a multi-professional approach, engaging managers and key stakeholders, ensuring sufficient resources, and having an effective organizational structure with dynamic leadership


In-depth interviews

View that near-miss audits were valuable but that hospitals generally stopped performing them

17. Kachur et al. (1999) Kenya


Insecticide treatment material intervention

Whether community members had kept and continued to use their ITM, whether they had maintained and retreated them, and local attitudes toward ITM 3 years after the study ended

1990–1992 (1995 for follow-up)

Structured household questionnaire (QN) Focus groups

Participants identified malaria as a significant health problem in the community. Most noted that bednets were advantageous for preventing mosquito borne illness.

18. Katz et al. (2014) Benin, Kenya, Lesotho, Sierra Leone, and South Sudan

HIV/AIDS Programme Sustainability Analysis Tool (HAPSAT)

HIV program

Sustainability as characterized by the following: prioritization, efficiency improvement, and resource mobilization


Stakeholder interviews

The need to prioritize evidence-based interventions and apply efficiency measures is being accepted by countries. Five of the six countries in this study requested that the HAPSAT team prepare “prioritization” strategies. Three types of sustainability strategies were selected by stakeholders: prioritization, efficiency improvements and resource mobilization

19. Kuyini et al. (2011) Ghana

WHO model for community-based rehabilitation

Community-based rehabilitation program for people with disabilities

Sustainability depends on the balance of top-down versus bottom-up approaches to program implementation in a way that allows for meaningful grassroots participation, while at the same time attracting government support


Closed question survey with beneficiaries of disability service, local supervisors and social workers

Few CBR programs remained after funding ceased. Program officers had irregular contact with beneficiaries.

20. Le Gargasson et al. (2013) Congo


Public-private partnership to increase immunizations

Sustainability of routine immunization program performance and financing.


Review of published and gray literature, and interviews with stakeholders in Congo to assess allocation of funds

DTP3 coverage increased from 2002 (38 %) to 2007 (72 %) but had decreased to a level below 70 % in 2008 (68 %) and 2010 (63 %). The overall funding for vaccines increased from US$5.4 million in 2006 to US$30.5 million in 2010 (mostly from GAVI support for new vaccines). However, during the same period, the funding from national (government) and international (GAVI and other donors) sources for routine immunizationservices (except vaccines) decreased from US$36.4 million to US$24.4 million. This drop in overall funding (33 %) primarily affected surveillance, transport, and cold-chain equipment.

21. Lindblade et al. (2004) Kenya


Malaria prevention

Continued surveillance of adherence

Phase 1: 1997–2000 and Phase 2: 1999–2002 (2002)

Community randomized control trial

The public health benefits of insecticide-treated bednets were sustained for up to 6 years. There is no evidence that bednet use from birth increases all-cause mortality in older children in an area of intense perennial transmission of malaria

22. Mbanefo et al. (2010) Nigeria


Community-directed treatment program for onchocerciasis (CDTI)

9 sustainability indicators: 5 of these indicators assessed the routine project activities and processes: planning, leadership, monitoring and supervision, Mectizan (ivermectin) supply and distribution, and training/health education/sensitization/advocacy/mobilization (TRHSAM). Three indicators assessed resources available to projects: financing human resources, and transport and material resources. The output indicator assessed the therapeutic coverage; 65 % being the threshold required to achieve control within 15 years

1997 (2008–2009)

Structured questionnaires and focus group discussions

Coverage: 90 % (adequate by WHO 65 % standard)

Planning: efficient but depended greatly on external resources and worker resilience

Leadership: rested on community leaders who are unable to accept financial responsibility

Finance: no organized system

Human resources: lack of motivation

Transport: logistics for transport of medication is not fully assumed by the communities. Overall, program can be sustained and disease eradicated, but efforts need to be intensified and strategies improved.

23. Mutale et al. (2015) Zambia

Sytems thinking-guided analysis framework

The BHOMA intervention (Better Health Outcome Through Mentorship and Assessment)

Improvement in service quality leading to increased service demand from the community

2011–2014 (2011–2012)

In-depth interview guides and focus group discussions

In the short term there was increased demand for services but the health worker capacity was not severely affected. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA

24. Osawa et al. (2010) Zimbabwe

Bennet et al. (2002) model of motivational processes

Community home-based HIV care program

Health worker motivation and satisfaction with workplace environment

1992 (2006)

Self-administered structure questionnaire for health workers

Motivation of workers linked with perception of family and community environment and perception toward organizational characteristics, specially managerial support, like attention from a manager, clear instruction, and goals, had an impact to CFs motivational outcome

25. Rashed et al. (1997) Benin

Participatory conceptual framework on sustainability

Participatory research program to develop local capacity to produce and market bednets

3 criteria:1. Participation of local human resources (program would be sustainable with existing local resources) 2. Self-financing 3. Appropriate action based on comprehensive knowledge of a local setting with enterprise adapted to local customs


Prevalence survey to establish rates of bednet utilization

Use of bednets increased, as well as sense of community pride for being able to address the problem. The mobilization of local human capacity, local financing of the purchase of bed nets in the rural setting and the participation of key local persons who produced tools adapted to the population, resulted in the development of an easy to produce and acceptable bed net.

26. Rassachert et al. (2014) Mozambique

Conceptual framework on sustainability based on previous literature

Community-based delivery of anti-retroviral—a process where patients take an active role in ART provision in the community

5 main components of sustainability: (1) design and implementation processes, (2) organizational capacity, (3) community embeddedness, (4) enabling environment, and (5) context

2008–2012 (2012)

In-depth interviews with: patients, nurses, lay counselors, health authorities, program implementers

The community embeddedness of the model, together with patient empowerment, high acceptability and progressive MoH involvement strongly favor the future sustainability of the CAG model. The high dependency on external resources for the model’s daily management, however, can potentially jeopardize its sustainability.

27. Rosenberg et al. (2008) Botswana, Lesotho, Namibia, South Africa, and Swaziland


Community-based orphans and children project

The continuation of benefits and activities achieved during the project after donors’ funding has ceased

1999 (2003–2006)

Site visits include document review and interviews with organization leaders, staff, partners from other organizations, and recipients of services. Focus groups with constituents are also conducted

For eight of the nine projects, evaluations provided evidence of the importance of the government partnership for sustainability. Government collaboration was important in projects designed to help families access government grants, initiate community-based solutions, and advocate for OVC rights through legislation. Government partnerships were also critical to the sustainability of two projects involved in placing children in foster care, but these showed signs of tension with government partners other factors included:organization, NGOs and donors should develop strong partnerships with local and national funding agencies.

28. Rourra et al. (2009) Tanzania

Socio-ecological framework

Community-based cohort study for ART

Factors underlying attendance at ART clinics


Semi-structured interviews with clients, service providers

Personal motivation and self-efficacy contribute to program retention, along with perceived health benefits and disease severity. However, these determinants are influenced by others’ opinions and beliefs in the community, and constrained by programmatic and structural barriers.

29. Sarriot et al. (2015) Rwanda

Sustainability framework

Integrated community-case management of malaria, pneumonia and diarrhea

The sustainability framework examines the maintenance of positive health outcomes, or their continued improvement, through social and institutional arrangements between stakeholders


Secondary data analysis and causal loop diagram

Financial, political and technical scenarios carry high probability for threatening the sustainability through: (1) reduction in performance-based financing resources, (2) political shocks and erosion of political commitment for community health, and (3) insufficient progress in resolving district health systems—“building blocks”—performance gaps

30. Sebotsa et al. (2007) Lesotho


Salt iodization program evaluation

WHO criteria for sustainable elimination of iodine-deficiency disorders such as: existence of an effective, functional national body responsible to the government for the national program for the elimination of iodine-deficiency disorders; appointment of a responsible executive officer for the iodine-deficiency disorders elimination program; legislation or regulations on universal salt iodization; cooperation from the salt industry in maintenance of quality control

2000 (2002)

Chemical analysis of urine samples and in-depth interviews with the chairperson of the iodinedeficiency disorders control program to assess indicators of sustainability.

Iodine deficiency was eliminated as a public health problem, as rates of deficiency were less than 10 %. But this elimination is not sustainable. Effective regular monitoring of salt iodine content at all levels, with special attention to iodization of coarse salt, is recommended, together with periodic evaluation of the iodization program.

31. Sharma et al. (2013) Kenya, Zambia, and Nigeria

Clinical Assessment for Systems Strengthening (ClASS) framework

Evaluate the role of Clinical Assessment for Systems Strengthening in building local partner capacity for HIV care

Building capacity of local partners to endure and adapt to changing financial and policy environments

2010–2011 (2011–2012)

Individual and group interviews with key stakeholders

Implementing the ClASS framework led to changes in policy and practice, continuous quality improvement initiatives, and consolidation of partnerships, all of which improved internal operations. CIASS had become part of the organization’s capacity building.

32. Somasse (2013) Burkina Faso

Community-based management of acute malnutrition (CMAM) of the Belgian Red Cross

Community-based management of acute malnutrition

Which activities of the program the community or the health system could continue to conduct even if the program funding stopped

2006 (2010)

Document analysis of program reports, individual interviews and focus groups

Recovery rates were about 87 %. The health district medical offices agreed that the program was effective and helped the communities to understand the problem of malnutrition and helped increase the use of antenatal care and health services

33. Swain et al. (2014) Rwanda


Collaboration between expatriate humanitarian cardiac surgery program and the National Health Foundations

Strengthen care on three levels: (1) expanding local capacity for cardiac surgery, (2) reinforcing registry-based secondary prophylaxis, and (3) enhancing treatment of streptococcal infections


Interviews with key personnel and review of administrative records; surgical cases completed and the resulting outcomes

86 patients have been seen with 123 valve replacements. Since 2008, the program is now treating patients with more complex diseases.

34. Teguete et al. (2012) Mali


Visual cervical screening

Improving cervical cancer control provision by health services and sustaining visual screening as part of routine health care in Bamako and surrounding areas after the completion of the research project


Routine visual screening and treatment services

Finding suggest that it is feasible to sustain good quality visual screening services in a low-income country such as Mali by maintaining and using the resources originally provided for a research project and by utilizing the resources available in government health services.

35. Torpey et al. (2011) Zambia

Sustainability conceptual framework

HIV services

Service sustainability, a complex concept that can be classified into four elements: technical, programmatic, social, and financial sustainability


Quality assurance and quality checklists through structured set of data collection tools, involving checklists, interviews by healthcare workers and patient record reviews.

Achieving operational sustainability in a resource-limited setting is practical and feasible. Developing and institutionalizing a quality assurance/quality improvement system is the basis of attaining graduation and sustainability of services.

36. Maticka-Tyndale et al. (2010) Kenya


Primary School Action for Better Health (PSABH) AIDS prevention

Program delivery and impacts of curriculum on student behavior


Surveys with teachers and students, focus groups with students and in-depth interviews with teachers.

Teachers continued to deliver program components three years after they were trained. Gains demonstrated in pupil knowledge, attitudes and risk-reducing sexual behaviors after one-and-a-half years of program implementation were replicated in the third year of the intervention with additional gains in attitudes related to condoms and girls’ reported use of condoms.

37. Vamos et al. (2014) Zambia

The “train the trainer” model

HIV risk reduction behavioral intervention for HIV seropositive and serodiscordant couples

Sustainability defined as retention of interventionists and clinic staff.


Data were collected from CHC sites on current employment status of participating CHC staff, and the reasons for discontinuing employment (e.g., transfer, study leave, retirement). The number of cohorts conducted by each interventionist was recorded, in addition to the continued provision of the intervention post-study completion at the CHC

High levels of clinic burden were identified; however, no increase in perceived clinic burden or staff burnout was associated with providing the intervention. The intervention was sustained at the majority of CHCs and also adopted at additional clinics.

38. Walsh et al. (2012) Zambia

Framework for the assessment of sustainable community-based organizations

Multi-country AIDS program

A contribution to the development of conditions enabling individuals, communities and local organizations to express their potential, improve local functionality, develop mutual relationships of support and accountability, and decrease dependency on insecure resources (financial, human, technical, informational) in order for local stakeholders to negotiate their respective roles in the pursuit of health and development, beyond a project intervention

2003–2008 (2010–2011)

In-depth interviews with district level representatives from community-based organizations

Funding opportunities for CBOs in Mumbwa in 2010 were scarce. Health services: While all CBOs were functioning in 2010, most reported reductions in service provision. Home visits had reduced due to a shortage of food to bring to people living with HIV/AIDS and scarcity of funding for transport, which reduced anti-retroviral treatment adherence support and transport of patients to clinics.

Organizational capacity and viability: Sustainability had been promoted during MAP through funding Income Generating Activities. However, there was a lack of infrastructure and training to make these sustainable. Links between health facilities and communities improved over time, however volunteers’ skills levels had reduced.

39. Wandeler et al. (2012) Zimbabwe, Mozambique, and Lesotho


ART retention program

Examined the importance of no follow-up after initiation of ART as well as mortality and loss to follow-up (LTFU) over three years of ART


Patient records from day 1 of ART treatment through follow-up; random quality checks for sites

A total of 9271 patients started ART during the study period. Overall 449 patients (5.8 %) were not seen after the ART initiation visit. Over 9575 person-years of follow-up 1319 patients (18.1 %) of the 7276 patients with at least one follow-up visit were LTFU and 698 patients (9.6 %) died. The crude mortality rate was 7.3 (95 % CI 6.8–7.9) deaths per 100 person-years.

40. Wilson et al. (2014) Ghana


Continuous positive airway pressure (CPAP) trial

The extent to which the skills and equipment necessary for CPAP use have been maintained.

2011 (2013)

Assessment of CPAP skills in first-generation and second-generation nurses who underwent training and equipment inventory

First-generation trainees scored significantly higher than second-generation trainees on both skills and knowledge assessments. Appropriate + technical support and training must be ensured to address equipment maintenance. Protocolization of the training program, in conjunction with skills and knowledge assessment, may improve acquisition and retention among second- and future-generation trainees.

41. Zulig et al. (2014) Tanzania

Weiner’s theory of organizational readiness to change

Cancer registry program

Weiner’s theory of organizational readiness to change provided the conceptual model was used to define sustainability. The key tenet is that organizational readiness is a multi-level, multi-faceted construct comprised of both organizational members’ shared resolve to implement a change


Interviews with administrative department heads and clinical stakeholders

Nearly half (45 %) of participants discussed change commitment, stating that the cancer registry would be of benefit to them and that they were committed to it. However, change efficacy was low—participants were not confident in their shared ability to sustain the registry. Most participants (73 %) discussed the importance of resource availability and administration support.

  1. n/a not available