Keywords

Sustainability is a multidisciplinary and multidimensional phenomenon. From the 1970s to the 1990s, studies on sustainability and sustainable development focused on the impact of human activity on the environment (Giovannoni & Fabietti, 2013). Only in the late 1980s did the perception of sustainability expand beyond ecology, nature conservation, and environmental degradation to include the social and economic aspects of this phenomenon (see Kidd, 1992). The 1987 “Our Common Future” report of the United Nations (UN) World Commission on Environment and Development (the Brundtland Report) and the 1992 Earth Summit in Rio manifested this multidimensionality, contributing to a “three-pillar” (environment, economic, and social) perspective of sustainability (see Purvis et al., 2019). Although the practical feasibility of this approach (Károly, 2011) and simultaneous attainment of all three dimensions to the same extent (Boussemart et al., 2020) remain unsettled, the three-pillar perspective manifested itself in the UN Sustainable Development Goals (SDGs 2015–2030). The SDGs, per se, embody the multidisciplinarity and multidimensionality of sustainability as a phenomenon.

At the same time, multidisciplinarity is among the main reasons for the ambiguity of the literature on sustainability. Following the Brundtland Report (1987), multiple authors discussed the interrelation, (in)compatibility, and balanced representation of the three pillars, along with the indicators and factors relevant to sustainability (e.g., Purvis et al., 2019). A multiplicity of studies contributed to the establishment of sustainability science—an interdisciplinary field aimed at identifying indicators and methods for sustainability research (Kajikawa, 2008). Nevertheless, the conceptual and theoretical underpinning behind the integrated approach toward sustainability remained weak, leading to difficulties in defining and characterizing sustainability (Purvis et al., 2019). This opacity is echoed in terminological inconsistency and conceptual ambiguity observed in the literature on the sustainability of development assistance to health care.

Sustainability is often used interchangeably with, among other terms, routinization, institutionalization, adaptability, resilience, and continuity (Gruen et al., 2008; Kiwanuka et al., 2015). However, if routinization and institutionalization focus on the standardization and integration of practices at organizational levels (Pluye et al., 2004; Scheirer & Dearing, 2011), sustainability refers to the integration of a practice or a change in the system as a whole. Similarly, the adaptability or flexibility of a program when faced with situational changes (Shigayeva & Coker, 2015) and the resilience or ability of the system (or a program) “to maintain” itself (Mayer, 2008, pp. 278–279) and continuity describe specific characteristics of sustainability but not the term itself. Depending on internal and external changes and challenges, interventions are likely to be adjusted or to retain certain features. However, it is not clear which aspects and to what extent they need to be continued for an intervention to be “sustainable” (Stirman et al., 2012, p. 10). Thus, all the terms mentioned above denote specific parts of sustainability but not the phenomenon as a whole.

Terminological inconsistency is an outcome of fragmentation of the literature on the sustainability of development assistance to health care. There is a prevalence of case studies contributing to context-specific knowledge but leaving the question of general implications unanswered. On reviewing the literature on the sustainability of health care programs in sub-Saharan Africa, Latin America, and Southeast Asia, it becomes clear that the research focuses on either systematic literature reviews or empirical analysis of interventions (i.e., case studies), often without any theoretical underpinning. This fragmentation and underdevelopment of the literature (Iwelunmor et al., 2016; Stirman et al., 2012) is reflected in the recommendations for further research on sustainability in health care, which emphasize, among other issues, the conceptual clarity and necessity for understanding the link between specific characteristics of interventions and contextual factors to the sustainability of interventions (Proctor et al., 2015).

A genuine understanding of sustainability and related factors also presupposes the awareness of biases behind this phenomenon. Sustainability is an “inherently political” phenomenon (Purvis et al., 2019, p. 692), which has a different meaning for different actors (Morgan, 2001). For donors, it implies the long-term financial costs of the program being taken over by the recipient, while for the recipient, sustainability refers to the freedom to make changes to enable the continuity of a program over time (Walsh et al., 2012). This dissimilarity in interpretation suggests that different actors are unlikely to have a similar understanding of what is sustainable and what is not. However, because of unequal power dynamics, the definition of sustainability and the factors associated with it may reflect the interests of stronger groups and not necessarily the recipients of health aid (see Murphy, 2012). The subsections below expand on the operational framework, which aims to overcome the terminological and conceptual ambiguity of sustainability in the context of health aid. Adapting and extending the existing analytical models, it intends to provide an equitable framework for analyzing various perspectives of sustainability and the factors related to it.

3.1 Operationalizing Sustainability

Sustainability in empirical terms requires identifying a matter of interest, relevant actors, a timeframe, and the extent of sustainability—in other words, “what, how or by whom, how much and by when” to sustain (Iwelunmor et al., 2016, p. 2). This book focuses on development assistance for health care and the roles of multiple stakeholders in ensuring sustainability, which is not achieved by a single or limited number of actors (see Chap. 2). As indicated in the introduction to this book, the majority of health care programs are not sustained beyond the end of donor financing. Yet, sustainability does not automatically come along with the end of the financing; it is rather built throughout the realization of a health care aid. The case studies of health care programs selected for this book represent completed and ongoing projects (Table 3.1). Both types of projects are of equal value to understanding the sustainability of health care aid to the present day. Most data I have collected on selected projects range from 1991, when the Kyrgyz Republic gained its independence, to 2018, when I conducted the second fieldwork. The factual data were updated in 2022 to reflect the current state of organizations and selected programs in the face of the global coronavirus disease-19 (COVID-19) pandemic. Therefore, “up to the present day” in this book denotes the state of play at that specific point in time when data were collected (see Sztompka, 1993, p. 12). Last, sustainability is a “matter of degree rather than an all-or-none phenomenon” (Shediac-Rizkallah & Bone, 1998, p. 96). However, I refrain from assigning weak and strong or partial and full ranges to sustainability, as these measurements are inherently subjective (see Savaya et al., 2008). Instead, I define sustainability vis-à-vis the three perspectives described in the following subsection.

Table 3.1 Sustainability in empirical terms
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3.2 Conceptual Definition

This book adopts Shediac-Rizkallah and Bone’s (1998) conceptualization of sustainability as maintaining benefits, continuing program activities, and building the capacity of a recipient community. First, maintaining benefits refers to services or infrastructure provided within development assistance (Altman, 1995; Torpey et al., 2010). This book focuses on the services received by the population targeted by the assistance (i.e., the project beneficiaries) and, where relevant, on any use of hardware or infrastructure provided to the beneficiaries, continuing beyond the duration of the program. Second, in terms of continuity of project activities, it overviews the activities continued and discontinued by the end of the project. Self-evident in the cases of completed health care projects, these two aspects can, however, also be assessed in ongoing development programs. This book identifies arrangements made by aid recipients to maintain the services and continue project activities at their own expense or through financing from other donors as implications for the sustainability of these services and activities beyond the duration of the initial project funding. Third, community capacity-building presumes, among other issues, empowerment of a recipient community through a development program (see Shediac-Rizkallah & Bone, 1998).

Broad but nevertheless precise, Shediac-Rizkallah and Bone’s (1998) operationalization of sustainability is cited by multiple authors. However, studies largely concentrate on one or several of three aspects: maintenance of benefits (e.g., Chambers et al., 2013; Johnson et al., 2004), continuity of project activities (Cassidy et al., 2006; Schell et al., 2013), and community capacity-building (Alexander et al., 2003). This book incorporates all three aspects to characterize the sustainability of development assistance for health care. This ensures a comprehensiveness of the analysis and a balance of donors’ and recipients’ perspectives on this phenomenon. Some authors elaborate further on these three categories. Scheirer and Dearing (2011), for instance, assess the maintenance of procedures and policies promoted during project implementation, continued attention to the problem, and dissemination of program ideas and activities. Although useful for an in-depth analysis of specific aspects of the assistance, these indicators may be onerous for assessing the sustainability of development projects as a whole.

This book adheres to the original conceptualization by Shediac-Rizkallah and Bone (1998), although with further adaptations to resolve the ambiguity of the third aspect. Not as straightforward as the two others, it requires further consideration of nuances related to the operationalizations of “community” and “capacity-building.”

The romanticization of “community” and approaching it as a homogeneous unit is opposite to the success of community-oriented programs (Morgan, 1993, p. 44). Among other qualities, communities have nested hierarchies and power relations. Therefore, it is important to ask who the community is and whom it represents (Yeo, 1993). Men and women, the elderly, and marginalized groups, such as men who have sex with men and others, all have different social statuses. For instance, the status of men and the elderly in Central Asia, their access to resources and decision-making processes, is not comparable to the status of women (Earle et al., 2004). Without addressing these issues, development programs may simply reinforce existing hierarchies (Wells et al., 2012) instead of empowering the community as a whole. Acknowledging the hierarchies inherent in communities, this book focuses on community organizations, including community-based organizations (CBOs) and nongovernmental organizations (NGOs), which target or work with marginalized groups. This specific focus on community organizations, rather than on communities as a whole, contributes to and also assures the empirical feasibility of the assessment of capacity-building.

Capacity-building in this book refers to activities that contribute to the ability of a community organization to formulate and express its concerns and use internal and external resources to achieve its goals. This definition combines the operationalization provided by multiple scholars.Footnote 1 Internal resources in this definition include individual and organizational assets, such as skills, experience, and associations with other organizations; external resources refer to the physical assets (e.g., hospitals, social service institutions) that the organization can use in its activities (Mcknight & Kretzmann, 2012). The operationalization of capacity-building used in this book goes beyond Shediac-Rizkallah and Bone’s (1998) emphasis on training and its role in supporting the roles of community members as sources of information and expertise. In so doing, it amplifies (expands) the meaning of capacity-building and shifts the emphasis from health projects to the abilities and agency of community organizations.

To measure community organizations’ capacity-building, I adopt the model suggested by Laverack and focus on participation, leadership, and resource mobilization.Footnote 2 The emphasis on these three aspects corresponds to the agency of community organizations highlighted in the definition above. Engagement in problem-setting and the ability to influence decisions are inherent to participation (Labonte & Laverack, 2001a), which is critical to the responsiveness of development programs to local concerns. Although concomitant to participation, leadership refers to the ability of the community organization to define the problems, suggest solutions, critically assess the factors contributing to inequalities, and develop relevant strategies to address them (ibid.). Finally, resource mobilization is instrumental to the first two aspects. However, the ability of an organization to mobilize resources in addition to its own assets (ibid.) may take different forms.

This book focuses on development aid, state financing, community fundraising, and liaisons with other organizations as potential sources for resource mobilization. Donor funding is a typical source of financing for community organizations in developing countries. However, reductions in development assistance and unpredictability of funding flows make this source of financing unreliable. Inclusion of costs into the national state budget once the project has ended is another option, for instance, through state provision of services under social contracting, though budget deficits and government prioritization of other areas not targeted by community organizations may exclude this possibility. The third option is a mobilization of resources at the community level, for instance, through collecting donations and in-kind support, introducing membership fees (Paine-Andrews et al., 2000), or conducting income-generating activities (Walsh et al., 2012). However, there are some underwater stones here as well. For example, poverty may increase competition for limited resources (Roussos & Fawcett, 2000) or question the viability of fundraising activities at all.

Lastly, mobilization of resources also takes place through association with organizations that have similar objectives (Paine-Andrews et al., 2000). In addition to in-kind and political support, these alliances may contribute to strengthening human resources, also through the improvement of skills (Hirschhorn et al., 2013). Through collaboration with medical workers, community organizations working in health care may, for instance, gain supervisory support (Ajayi et al., 2012) and link their activities to existing health care services (WHO, 2008). However, the same organizations may be gatekeepers that are protective of their areas of interest. Thus, medical professionals at times oppose the involvement of community organizations in health care due to the lack of medical training and expertise of the latter (Morgan, 2001).

Overall, resource mobilization is one of the most important yet problematic components of community capacity-building. In addition to the knowledge and skills of community organizations (Sarriot et al., 2004a), it also largely depends on the overall political and economic situation in the relevant region or country. This interplay between organizational aspects and external factors brings to mind an indicator not included in the original model for analyzing capacity-building by Laverack (see Labonte & Laverack, 2001a, 2001b), namely, the survival of community organizations beyond the duration of the project funding.

Both the continuity of project activities and the maintenance of benefits largely depend on the survival of community organizations. For this reason, multiple stakeholders raised this issue during my fieldwork in the Kyrgyz Republic. Participation, leadership, and resource mobilization contribute to but do not necessarily guarantee the survival of a community organization. The organization may take part in the decision-making process, demonstrate leadership, have multiple sources of funding, and still discontinue its activities. For this reason, I include the survival of the organization beyond the duration of project funding as an additional indicator of community capacity-building (Table 3.2).

Table 3.2 Conceptual definition of sustainability
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3.3 Factors Influencing the Sustainability of Health Care Interventions

In addition to the empirical and conceptual definition, the accurate analysis encompasses the related factors, as sustainability does not materialize in a vacuum. Rather, it depends on several internal and external factors that are difficult to predict (Sarriot et al., 2004b). In the case of development assistance to health care, internal factors are technical or program-related elements, such as management, planning, implementation, and achievement of stated goals (Bossert, 1990; Shigayeva & Coker, 2015). External factors are the economic and political situations in the recipient country that shape the system in general, including the number of medical workers in the country, health care coverage (Iwelunmor et al., 2016), and political support for specific programs. All these factors contribute to the uncertainty associated with the sustainability of health care programs. This section summarizes the main factors associated with this phenomenon based on the literature on the sustainability of health care interventions (Table 3.3). Awareness of these factors is critical to the sustainability of health aid, although the prominence of each of these conditions may depend on a particular project and country setting.

Table 3.3 The factors relevant to sustainability
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First of all, donors provide the initial financing for projects, but at the end of the assistance period, or in the best-case scenario, at the beginning, the question of funding continuity arises. This continuity, as a rule, is ensured at the expense of aid recipients or through a mixture of funding mechanisms. A plan for program continuation, including evidence of the recipient’s contribution or evidence of a combination of the donor’s and recipients’ funding sources, is often a precondition for assistance (Schell et al., 2013). This requirement for the recipient’s contribution may increase the share of domestic funding to the areas targeted by development aid. UNAIDS (2015, p. 54) notes that in 2005, development assistance accounted for 69% of all HIV-related spending, but by 2014, contributions from domestic sources in low- and middle-income countries represented 57% of all HIV-related expenditure.

However, the recipient’s contribution may not be sufficient to cover the costs of all health care programs. For instance, in the case of projects combatting tuberculosis (TB), the course of treatment for drug-resistant forms of this disease ranges between US $1218 and $6313 per patient (Laurence et al., 2015; Ormerod, 2005). Depending on the burden of disease, these costs may be unaffordable to patients and governments in developing countries. Similarly, a recent study of development assistance for community health workers by Lu et al. (2020) suggests that in the context of low-income countries, domestic public spending alone cannot fully cover national community health worker programs. Nevertheless, the role of domestic resources remains imperative, notably as aid recipients transition from external assistance. As development aid to Eastern Europe, Central Asia, and Latin America is decreasing, national contribution becomes the key subject in sustainability discussions (Burrows et al., 2016).

Continuous financing of health care programs may also be provided through a combination of various other funding mechanisms. These are affordable procurement of medicines via large donors, optimization of spending, and adoption of “innovative” funding methods (Oberth & Whiteside, 2016, p. 3). As seen above, the cost of medicines is a key issue. Procurement via large organizations, such as the Global Drug Facility, provides access to affordable quality-assured TB medications and diagnostics because they purchase large quantities of health products (Stop TB Partnership, 2019). However, the price per item may be higher for individual countries since they procure considerably smaller quantities than these organizations. For this reason, the establishment of procurement mechanisms is essential to the sustainability of health projects involving diagnostic and treatment services (see Chap. 9). Another option for assuring additional funding is the optimization of spending on health care. Yet, given the limited amount of resources and budget deficits of the countries receiving development assistance, this measure may not guarantee significant savings to cover the costs of health care programs.

The third option, introducing “innovative” funding methods, may take different forms, including specific tax mechanisms, fundraising activities, and recruitment of volunteers. For example, additional taxation on mining or cigarette companies for their contribution to the “risky environment and conditions” for the development of TB could be a supplementary source of financing for TB services (Amo-Adjei, 2013, pp. 4–5). Similarly, taxes on airlines, formally employed individuals and companies, and mobile phone usage could increase national spending on HIV/AIDS-related services (Oberth & Whiteside, 2016). However, there is no guarantee that gathered resources are actually going to be used for public health programs (ibid.). The sustainability of community organizations’ activities is associated with community support, volunteering, and local fundraising activities (Abdul Azeez & Anbu Selvi, 2019). Nevertheless, donor financing represents the largest share of funding for community health workers (see Saint-Firmin et al., 2021), and the actual contribution of “innovative” funding methods in economically weak countries remains ambivalent.

Furthermore, the economic, social, and political situation in the recipient country has implications for health care interventions, particularly in the long-term perspective (Bossert, 1990). During the project implementation period, these external factors are at best targeted by project implementers. By the end of the program, however, when the implementers withdraw, the influence of these factors on project outcomes increases. Economic crises or changes in the ruling party may alter domestic politics and government priorities, resulting in cuts to health care spending. Outcomes may also be impacted by issues in the local health care system, such as a shortage of health care professionals, their burn-out, an increased number of patients, and poor record-keeping systems (Harpham & Few, 2002; Iwelunmor et al., 2016). The prioritization of a program by the recipient country is also relevant to the continuity of outcomes. Thus, prevention programs are less likely to be sustained due to the lack of immediate visible effect (Shediac-Rizkallah & Bone, 1998). Short-term visibility of an intervention facilitates continuity of curative (e.g., treatment-oriented) programs over prevention programs. Similarly, the type of activity is also relevant to its continuity. Training programs, for example, offer continuity of outcomes at a low cost. Trained personnel disseminate knowledge further, also via “training of trainers” (ibid., p. 101). In this regard, Kiwanuka et al. (2015) suggest that training women may be particularly beneficial since they are more likely to stay in the community and train others than men. These are only a few examples of the external factors which are relevant to health care programs. Although program managers cannot foresee the influence of every possible aspect, they may nevertheless reflect on known factors during the project implementation/design phase in order to mitigate their impact by the end of the project.

Similarly, integration into the local context is essential for the sustainability of health care interventions. Sarriot et al. (2004a, p. 34) note that sustainability plans are “meaningless” out of context, and they are not alone in this assessment. A systematic evaluation of 125 studies identifies compliance with the local context as one of the most important factors for the sustainability of health care programs (Stirman et al., 2012). The significance of the context is equally acknowledged by practitioners. A vivid example thereof is the Paris Declaration on Aid Effectiveness (2005) and its emphasis on using “country systems and procedures” and “existing capacities” of the recipient country in development assistance (OECD, n.d., pp. 4–5). Although difficult to define, the context, in a general sense, refers to the setting broader than the intervention itself and the discussion of current politics and actors, including systemic, historical, and cultural factors (Andrews, 2013).

Systemic, historical, and cultural factors are reflected in institutional structures and actors’ preferences. Closely interrelated, these factors may hinder, promote, or contribute to the mixed results of a health care intervention, as demonstrated in the following examples of reforms targeting primary health care and decreased tea consumption.

Despite the broad acknowledgment and efforts made by domestic and external actors, funding for primary health care in post-Soviet countries remains small. In addition to the medical lobby behind hospital care and political, economic, and social hurdles (Kühlbrandt, 2014), the small funding also corresponds to the structure of the health care system inherited from the Soviet Union. The Semashko health care system emphasized a curative approach and little prevention or health care promotion. After the collapse of the Soviet Union, newly independent countries initiated multiple reforms to change this system (Isabekova, 2019). Nevertheless, the emphasis on treatment and curative approaches remained, often at the expense of prevention (Kazatchkine, 2017).

Furthermore, an interplay of cultural and historical factors may contribute to the mixed outcomes of health care interventions. For example, excessive tea consumption is a problem in Central Asian countries. The Swiss health promotion program in the Kyrgyz Republic targeted, among other issues, child nutrition by promoting the use of a micronutrient powder and abstention from black tea consumption during meals. Although tea consumption among pregnant women and children did decrease (Schüth et al., 2014), the rate of anemia reduction among children was still lower than that in other countries (Lundeen et al., 2010). One of the main reasons was the continued tea consumption in the population (see Tobias Schüth, 2011).

Overall, the “context” has controversial implications for programs advocating for changes that are incompliant with mainstream norms. For example, a local population may be open to some projects but not to others. Thus, teachers may be reluctant to introduce sex education based on the belief that condoms could be perceived as an encouragement to have sex (Maticka-Tyndale et al., 2010). As Rashed et al. (1997) note, public attitudes toward bed nets and condoms differ because the first is culturally acceptable, while the second is not. Cultural values defining individual and collective behavior are highly relevant to health care programs (Airhihenbuwa, 1995). However, certain health care interventions, such as harm reduction programs—including needle exchange services and methadone substitution therapy for persons who inject drugs—access to condoms, sexually transmitted diseases for commercial sex workers and men who have sex with men, are controversial in the local context of many countries. Although these programs are also expected to address the context of the recipient country, the extent of their integration into a context that discriminates against the groups targeted by these projects may be limited.

(In)acceptability of specific practices and stigma and discrimination against certain groups is erroneously associated with the “morality” clause related to individual behavior, although it may, in fact, be the result of a reaction to the unknown or mere discrimination of marginalized groups. HIV/AIDS may be perceived as an outcome of or even a punishment for “immoral” behavior, not concomitant with “traditional” values, such as abstinence and fidelity (Hannon, 1990). Similarly, stigma is closely associated with degrading moral status (Goffman, 1963), leading to the discrimination of specific groups of the population affected by certain diseases. There, however, is a difference between persons affected and associated with diseases. Among persons living with HIV, commercial sex workers and men who have sex with men are more marginalized than children or pregnant women. This discrimination against certain groups also may materialize in the selectivity of the groups entitled to HIV/AIDS-related services (Oberth & Whiteside, 2016). For instance, following a significant reduction in financing from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the government may continue the prevention of mother-to-child transmission of HIV but cut these services for persons who inject drugs (OSF, 2015).

In both cases, (in)acceptability and stigma, the question of whether these two are parts of the moral system of a society or merely indicate the cultural variants remains open. Notably, a cultural variant is selected by an individual based on its popularity in a given environment, whereas the moral system encompasses a set of codes of conduct persisting over time due to its contribution to mutually beneficial social cooperation (Luco, 2014). In addition to the cultural meaning, stigma also may be the result of a “tactical response to perceived threats, real dangers, and fear of the unknown” (Yang et al., 2007, p. 1528). Thus, (in)acceptability of specific practices, stigma, and discrimination against some groups may be the outcome of cultural biases, response to the unknown, or even oppression of less powerful, often marginalized groups.

Elaborated analysis of moral systems and cultural biases goes beyond the scope of this book, but it nevertheless reasserts the necessity for going beyond the romanticized perspective of a “context.” Thus, integration into the local context presumes the awareness of power dimensions and hierarchies and considers perceptions of certain practices in the given context and beyond. This resonates with the distinction between the code of conduct followed by an individual or group (“descriptive”) against the one that, in certain conditions, would be supported by “all rational people” (“normative”) (Gert & Gert, 2002). In other words, a practice pursued in a given context does not necessarily represent a widespread norm or contribute to the benefit of people living in this context. The natural rights of persons, irrespective of their gender, nationality, or sexual orientation, are elaborated in the United Nations Universal Declaration of Human Rights (1948), the International Covenant on Civil and Political Rights (1966), and the International Covenant on Economic, Social, and Cultural Rights (1966) (see Office of the United Nations High Commissioner for Human Rights, 2023a, 2023b). Although the universal applicability of these documents is part of a continuous discussion, negative implications of stigma and discrimination on public health are evident. The social stigma and discrimination against marginalized groups, such as men who have sex with men and sex workers, jeopardize their access to health care (Oberth & Whiteside, 2016) and contribute to high HIV/AIDS prevalence among these groups (UNAIDS, 2014).

Clearly, interventions based on “established values and practices” are better accepted (Aubel & Samba-Ndure, 1996, pp. 53–54), but what can be done with others who may not comply with the local but a general perception of morality? Awareness of stakeholders’ interests and societal hierarchies and going beyond the abstract notion of culture or context is the first step. It may be followed by strategies pursued by some community organizations that learned to build their discourse of providing access to HIV treatment to marginalized groups for the benefit of the general population (see Chap. 8).

In addition to the external factors mentioned above, the sustainability of health care programs is also influenced by internal factors, and this section focuses on two of them: the duration of the project and the capacity of the organization implementing it.

The duration of a project is inherent to its sustainability beyond the period of donor funding. There is a close correlation between time and change because change is closely related to time, and time is associated with change (Sztompka, 1993). Changes promoted by health care programs and their sustainability take time, particularly if these changes contradict the values or habits accepted in the recipient society. Projects with a duration of three to five years are often referred to as “seed funding” or “demonstration” projects that are expected to get financing from elsewhere by the end of those three to five years (Scheirer, 2005, p. 320). Nevertheless, both practitioners and researchers agree that, in practice, most interventions terminate before achieving maturity (Shediac-Rizkallah & Bone, 1998), and the majority of these “premature” projects are discontinued after the end of donor funding (Altman, 1995, p. 527). Nevertheless, donor organizations vary in their approaches to project duration. Swiss development assistance usually lasts longer than other average development programs. In contrast, organizations such as the Global Fund have a three-year project duration with the possibility of prolonging it; although uncertainty in regard to financing has its implications on relations between the actors (see Chap. 4).

Another factor inherent to the sustainability of health care interventions is the capacity of the organization implementing the relevant project. The OECD (2011, p. 2) defines capacity as the “ability of people, organizations, and society as a whole to manage their affairs successfully.” This book focuses on an organizational level. Capacity encompasses the managerial, financial, and structural characteristics of the organization and its human resources (Shigayeva & Coker, 2015). These attributes may suggest that larger organizations with developed structure, networking, and access to resources are preferred over their smaller counterparts. However, this is not necessarily the case. Although beneficial in some instances, increased professionalization may be counterproductive in other instances. Similarly, a large structure also may come with bureaucratization and rigidity of the organization, which decreases its flexibility and responsiveness to the local context. Furthermore, in relation to human resources, it should be noted that in the context of development programs, there is a continuous rotation of staff members on both sides, that is, the donor and the recipients. Human resources are particularly pressing for recipient state agencies and nongovernmental organizations, in contrast to donor institutions offering attractive employment conditions and recruiting the most qualified staff in aid-recipient countries (Swedlund, 2017).

Along with these general features of the organization, another significant factor to sustainability is the leadership and commitment of staff members to the health care program (Scheirer & Dearing, 2011; Shigayeva & Coker, 2015). Although difficult to measure, the dedication of staff members of implementing organizations was apparent in the two case studies covered in this book.

3.4 Summary

This section discussed the conceptual and empirical ambiguity of sustainability, and listed the factors relevant to it. As a concept, sustainability is defined in relation to the continuity of project activities once the project has ended, maintaining benefits offered to the targeted population, and building the capacity of the recipient community (Shediac-Rizkallah & Bone, 1998). In addition to conceptualization, this chapter also discussed the empirical operationalization of sustainability: defining what to sustain, by whom, to what extent, and for how long (Iwelunmor et al., 2016, p. 2). As sustainability analysis takes place in the context of uncertainty, this section also presented the factors related to sustainability of health care interventions, namely financing, accounting for general conditions, integration into local contexts, and organizational aspects. The impact of each of these factors is case-specific, though awareness of these conditions contributes to a better understanding of sustainability in health care interventions.