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Table 2 Summary of factors considered as facilitators and barriers toward sustainability of health interventions in sub-Saharan Africa

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

Facilitators Examples Barriers Examples
Community ownership 1. The highly centralized structure of the social network potential to help rapidly diffuse information between actors [34]
2. Community mobilization [66]
3. (a) Community involvement in meetings; (b) collective ownership; (c) inputs from professional in health system to include local economic concepts and values [67]
4. Community ownership, responsibility, and participation [33, 39, 44]
5. Regular dialogue with community; community ownership [40]
6. Engaging in participatory process with key stakeholders [41]
7. Builds on social and cultural values [38, 63]
8. Creating strong social links and networks with members; social support [38, 43]
9. Resource flow between members of social networks, [38, 66]
Weak health systems 1. Volunteer health workers need refresher training and proper supervision [66]
2. Limitations with assessment of sustainability over time [67, 68]
3. Severe shortage of drugs [67, 68]
4. Weaknesses with formal health systems with timing of distribution of medical services [33]
5. Lack of community-managed monitoring and supervision system [39]
6. Poor assessments [69]
7. Lack of collaboration and access to data
8. Lack of provider integrity [40]
9. Lack of comparable baseline data [17]
10. Lack of rigorous models evaluating sustainability of community health worker programs [61]
11. Lack of monitoring and reporting; no central database for recording [47]
12. (a) Need updated risk management, (b) lack of structure for decision-making, (c) need to improve referral and dissemination of results [50]
13. Lack of Ministry of Health recommendations on how to integrate the program activities into the daily planning and strong strategic plan [42]
14. (a) Fragile and understaffed health systems; b) lack of access to viral load monitoring [52]
15. Lack of disease registries; paper-based patient records [55]
Working within existing resources 1. Institutionalization and integrating within existing political and economic resources [66]
2. The use of a respected traditional authority (i.e., village heads) [33, 67]
3. Adaptation to cultural norms and values [33, 39, 67]; tailoring innovation to sociocultural and institutional settings [41]
4. Building on existing social units and roles such as traditional communicators, traditional birth attendants, and community management committees [39]
5. Consideration of the individual parts (e.g., activities) of a health program as it is to consider the program as a whole [34]
6. Continued dialogue with community members [41]
7. Building on pre-existing capacity of community-based organizations to organize themselves [57]
Lack of financial leadership 1. Lack of remuneration for caregivers [70]
2. (a) Lack of long-term planning [61, 71]
3. Reliance on external funds [40, 71, 72]
4. Lack of funds [4345, 69, 17]
5. Financial disbursements [43, 45]
6. Availability of resources [43, 7376]
7. Lack of motivation and incentives [70]
8. (a) Absence of functional financial institution to receive and transfer funds to sub-national levels; (b) incentives did not benefit staff; (c) lack of budget and accounting organization; (d) limited contribution of domestic resources [70]
9. (a) Constraints due to financing and vertical selection of programs; (b) free distribution approach weakens health system [35]
10. Conflict over fund allocations and patient difficulty paying fees [38]
11. Inability to guarantee continuity of future resources [72]
12. Lack of communication about funding termination [57]
13. Lack of medical equipment and uncertainty about securing future funds for equipment [32]
Community buy-in through volunteerism 1. Satisfaction of being able to contribute to community well-being [70]
2. Incentives/recognition by cardinal staff and community leaders [68, 70]
3. Supportive community environment [68]
4. Perceived benefit of intervention [33, 39]
5. Indirect benefits including happiness serving their people [33]
6. Support from key community leaders; motivation, training and supervision of community actors [39]
7. Strong community support [73]
8. Community acceptance [17]
9. Include stakeholders in discussion and planning [50]
10. Community volunteers perceived their role as close to that of a health worker in the community [42]
Health care worker shortage 1. Weak sense of social responsibility [70]
2. Staff workload; prolonged crisis in staffing [44]
3. Longer wait times due to overworked staff; staff working longer hours for less pay [31]
4. Volume of demand, equipment and staff shortages, inadequate management, limited supervision, high turnover, [77]
5. Health worker training in light of “brain drain” [48]
6. (a) High workload and patient volume, (b) limited resources and space [51]
7. Lack of staff [55]
Sound infrastructure 1. Community leadership support and administrative structures to foster supportive environment, efficiency, and commitment [33, 40, 45, 17, 57, 74, 76]
2. Resource contribution; resources to support innovations [33, 45, 46, 75, 51]
3. Record keeping and reporting; improved monitoring and reporting, quality improvement cycles initiated [33, 50]
4. Development and accreditation of standard training, education, and evaluation materials along with training and oversight [41, 45, 48, 63, 32]
5. Integrity in money management [40]
6. Promote learning and disseminate information [41]
7. Establishment of health facility board; development of community-based health care implementers; the community health boards monitored revenue collection and expenditure of cost-sharing funds; decentralized approach of services integral to health care with national supervision [44]
8. Good and well trained health care workers; consistent delivery of services [31, 37, 52]
9. Strategies based on key informants; (b) participation of non-governmental groups to provide experience with operationalization of a project [35]
10. Integration of staff, communication, political support, leadership, participation;[43]; integration of academic, government, and faith based organizations [77]
11. Strong political will to promote health; dynamic community health governance; systems approach to sustainability [61]
12. (a) existence of an effective, functional national body responsible to the government for the national health programs [47]
13. Several point-of-care services, with an in-built referral pathway for diagnosis and treatment [56]
14. (a) Enforcing use of standard guidelines; (b) staff training, mentorship, and technical support; (c) strengthening ministry’s supply and logistics for procuring and maintaining services; (d) quality assurance/quality improvement system provided basis for continuous assessment and monitoring of services [49]
15. (a) Social cash transfer scheme at national level; (b) coordination between health resources at district and community levels [57]
16. Capacity building through skill building [32]
17. (a) Open communication; (b) support from hospital administrators; (c) international partnerships [55]
Lack of education and awareness 1. Shortcomings in the knowledge and attitudes of members of the community concerning maternal health and nutrition [37, 39]
2. Weaknesses in medical skills training; lack of training for community engagement [44]
3. Lack of knowledge of disease risk or transmission [73]
4. Health education and community empowerment [36]
5. Social norms and misconceptions [38]
6. Insufficient public education and lack of awareness [47]
7. Lack of awareness and advocacy, need to mobilize resources [56]
8. Minimal community awareness [57]
9. Low literacy [52]
10. Poor knowledge retention [32]