Life after PEPFAR’s direct service support: program sustainability among South African HIV/AIDS organizations funded by PEPFAR
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BACKGROUND: Public health practitioners have little guidance of how to plan for the sustainability of donor sponsored programs. The literature is broad and provides no consensus on a definition of sustainability. This study used a robust mixed-methods methodology to develop a list of program sustainability factors to inform donor-funded programs. METHODS: This study examined 61 health facilities in the Western Cape, South Africa, supported by four PEPFAR non-governmental organizations (NGOs) from 2007 to 2012. Retention in Care (RIC) was used to determine health facility performance. Sustainability was measured by comparing RIC during PEPFAR direct service, to RIC in the post PEPFAR period (2012 to 2015). Crude and adjusted risk differences were calculated to estimate the association between the type of government ownership, PEPFAR NGO support, ART treatment policy change, size of ART patient cohort, human resource transition and our outcome of RIC at 12 and 24 months on ART. Forty-three semi-structured in-depth interviews were conducted with key informants. The qualitative data were used to examine how predictor variables were operationalized at a health facility and NGO level. RESULTS AND DISCUSSION: Though the linear regression models showed no difference in RIC pre and post 2012, our graphed descriptive results showed a dip in RIC among the majority of the study facilities in 2012/2013. The RIC decrease was likely due to PEPFAR’s move from direct service to technical assistance: the decrease in the numbers of community health workers and a change in HIV treatment eligibility guidelines. Our qualitative results suggest the following lessons for the sustainability of future programs: • Sufficient and stable resources (i.e. financial, human resources, technical expertise, equipment, physical space) • Investment in organizations that understood the local context and have strong relationships with local government • Strong leadership at a health facility level. • Some disease specific staff (i.e. clinical, administrative, community) • Joint planning and formalized skill transfer: • Local positive perceived value of the program • Stable financial and political support for the program CONCLUSION: Sustainability is complex, context dependent, and reliant on various processes and outcomes. This study suggests additional health facility and community level staff should be employed in the health system to ensure RIC sustainability.