Elsevier

The Lancet

Volume 372, Issue 9649, 1–7 November 2008, Pages 1579-1589
The Lancet

Public Health
Sustainability science: an integrated approach for health-programme planning

https://doi.org/10.1016/S0140-6736(08)61659-1Get rights and content

Summary

Planning for programme sustainability is a key contributor to health and development, especially in low-income and middle-income countries. A consensus evidence-based operational framework would facilitate policy and research advances in understanding, measuring, and improving programme sustainability. We did a systematic review of both conceptual frameworks and empirical studies about health-programme sustainability. On the basis of the review, we propose that sustainable health programmes are regarded as complex systems that encompass programmes, health problems targeted by programmes, and programmes' drivers or key stakeholders, all of which interact dynamically within any given context. We show the usefulness of this approach with case studies drawn from the authors' experience.

Introduction

Policy makers, donors, programme managers, and communities often face challenges in sustaining seemingly worthwhile health programmes, especially in low-income and middle-income countries. The Mexico Statement on Health Research called on national governments to pursue sustainable programmes to support public health and health-care delivery systems.1 Most concerns about sustainability are related to premature discontinuation of programmes after an initial period of support. In addition to the needs left unmet, discontinued programmes are wasteful of human, monetary, and technical start-up investments, and can diminish community trust and support for future programmes.2

Ministers of health and other key stakeholders wanting to optimise health-programme sustainability would benefit from a practical framework derived from empirical research to support their approach to programme planning. Many studies of health programmes in low-income and middle-income countries have sought to identify factors associated with sustainability, but these data have not been systematically reviewed. Furthermore, several divergent conceptual approaches exist but their basis in empirical research has not always been articulated.

We aimed to review existing perspectives and empirical research about health-programme sustainability; to draw on the review to derive a practical framework for understanding health-programme sustainability; and to use this framework to propose an approach to planning for health-programme sustainability and developing a strong evidence base to support refinements to and implementation of the approach.

Section snippets

Procedures

We did a systematic review of both conceptual frameworks and empirical studies about health-programme sustainability. We searched Medline (1980 to June 18, 2008), EmBase (1950 to June 18, 2008), and the Cochrane library.

For the search strategy framework, we used words and MeSH and EMTREE headings that encompass programme sustainability, including synonyms such as “continuation”, “institutionalisation”, “resilience”, “durability”, “viability”, “stability”, “persistence”, and “maintenance”. We

Perspectives on health-programme sustainability

Our search yielded 1506 citations, from which we identified 145 articles about health-programme sustainability.

The simplest definition of sustainability is the ‘capability of being maintained at a certain rate or level’. As Greenhalgh et al3 showed in their review of diffusion of innovations in service organisations, and Shediac-Rizkallah and Bone2 articulated in a model of sustainability, different research traditions and perspectives may view complex concepts such as sustainability

Empirical assessments of health-programme sustainability

We identified 84 empirical assessments of programme sustainability, two-thirds of which reported a measure of sustainability over a discrete time. 24 reports were from low-income and middle-income countries, or disadvantaged populations in high-income countries (table 1). Studies from high-income countries that were sustained for 2 years or more after initial funding ended are reported in table 2. Four reviews that address sustainability of several programmes are included in table 3.

We found

Putting it together: an integrated approach for health-programme sustainability

In 1990, Bossert4 considered the factors that promote sustainability of American aid projects in Central America and Africa (table 3). Since Shediac-Rizkallah and Bone's aetiological model of programmatic, organisational, and environmental factors,2 Evashwick,59 Pluye,60 and Scheirer5 have made important contributions on the basis of their reviews of empirical research, although none included programmes in low-income and middle-income countries (table 3). These reviews have also emphasised the

Conclusions

Despite many differences between health and environmental science, we showed that a useful conceptual understanding of health-programme sustainability can be derived from a synthesis of existing conceptual approaches to health-programme sustainability and evidence of associated factors, informed by conceptual approaches developed within sustainability science. We propose that health-programme sustainability is the ultimate manifestation of a complex web of inter-relations between health

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