by Altynay Shigayeva and Richard Coker
Substantial international funds are invested in programmes designed to control priority diseases, such as HIV/AIDS, tuberculosis and malaria. Tensions between the length of time donors’ funding is available and the time required to address public health problems have long been a concern in global health. Given the limits in international aid in the long run and the weaknesses of health systems, there are renewed concerns around the sustainability of donor-supported programmes.
But what do we mean by a sustainable health programme? How can we assess sustainability? There is currently no agreement. The concept of sustainability is complex and rooted in systems theories. Equity, effectiveness and efficiency are central concerns in the sustainability discourse. Sustainability is all about meeting future needs, and the uncertainty associated with this means that it is challenging to objectively determine if and when a programme is ‘sustainable’. Earlier this year, in a paper published in Health Policy and Planning, we proposed an approach to assess the sustainability of health programmes. Taking a system perspective, we defined a sustainable communicable disease programme as continuously effective in reducing a disease problem whilst being responsive and adaptive to changes in the nature of disease epidemics, population needs, or the contextual environment. We identified five characteristics (precursors of sustainability) that may suggest a potential for sustainability:
Leadership is central to programme sustainability, and concerns the capabilities and skills of stakeholders to lead, govern, and manage. It relates to the presence of individual charismatic leaders (champions) as well as the collective leadership’s competencies through collective efforts, norms and organisational culture. Leaders must have a clear and long-term vision for disease control efforts, gain political and financial support, build a programme’s credibility, build trust and engage with stakeholders, mobilise resources and implementation efforts, and take ownership of reforms and innovations.
This encompasses the managerial, technical, financial, physical (organisational structures), communication and human resources capabilities, which enable a programme to exist and function over time. While empirical evidence consistently demonstrates that sustainability of health programmes requires long-term funding and other resources, a critical feature of sustainable programmes is their efficient use of resources. The potential for sustainability is higher in programmes/organisations that use available funds efficiently, and frequently assess and plan present and future resources needs.
Health programmes do not exist in isolation. Building relationships both inside and outside an organisation is vital. For example functional and/or structural linkages or integration with primary health care (or other health programmes) are important in sustaining programmes. Integration may range from simply coordination of activities through to full integration of governance, financing, service delivery, and monitoring and evaluation. Collaborating, building alliances, gaining support and the inclusion of various stakeholders (both political and in communities), are all critical in achieving sustainability.
To help ensure sustainability, health programmes need to adapt continuously to societal changes, community needs, and population demands. There are two aspects. The first aspect is openness to learning, fostering new knowledge and orientation towards innovations. The second is the ability of actors to identify and recognise changes in the wider contextual environment in a health problem and its determinants, or in performance. In response, organisations need to be willing and able to change or modify strategies, priorities, or their functioning, whilst retaining their overall organisational mission. For example, in the case of funding cuts, reconfiguring services and staffing patterns or changing strategies to modify demand for services may be important. Longstanding practices, “we’ve always done it like this”, may need to be re-visited. Evidence should inform policy and practice in a timely manner.
Sustainability is not only about the maintenance of a programme. Programmes needs to operate effectively, equitably and efficiently. Robust monitoring and evaluation systems should provide sound measurements of a programme’s performance.
Programmes are components of health systems, and embedded within a broader socio-political context. The abovementioned programmatic characteristics are all interconnected and dynamic, and they each depend on several factors, such as political and institutional interests of stakeholders, health system arrangements, and broader context. For example, in the former Soviet Union, health system arrangements have historically supported highly specialised and organisationally isolated services for the management and control of TB. The generation of drug resistant TB and the collision of the HIV and TB epidemics threaten to overwhelm control efforts. There has been an increasing acknowledgement of the public health challenges. However, programmatic changes are very slow to address perverse financial incentives, entrenched professional interests and the broader social drivers of HIV and TB epidemics. The challenge is less epidemiological than it is organisational. Without systemic changes improvements in efficiency and equity are not likely, with limited prospects for sustainability.
To date, research to conceptualise and empirically assess programmatic sustainability has been limited. Given the very substantial sums being invested in priority health programmes, the conceptualisation and analysis of programme sustainability is important to support funding decisions as well as ensure lesson learning and knowledge dissemination of best programmatic practices.