When we refer to the “sustainability of interventions” we often mean country leadership and ownership, quality, and effectiveness. While all of these elements are important to guarantee sustainability, a few equally as important, but not often mentioned, include fiscal space, managerial capacity, and available, well-trained human resources.
While the global community strives to ensure program sustainability, the sad reality is that only a few of these interventions will continue after donor support and technical assistance ends. In addition, many of these projects will end with limited evidence that only includes the impact on health outcomes within a finite number of facilities and districts. As the global community begins to support progress towards universal health coverage (UHC) in low- and middle-income countries, we should ask ourselves: who’s going to pay when the donor support and technical assistance have gone?
Too often, donors and implementers design interventions that even developed countries cannot afford. Some may argue that it is better to provide high-quality services to a reduced number of citizens, with the illusion that one day it can be scaled to provide an essential package of services to all citizens.
In reality, most low- and middle-income countries are currently working to ensure the provision of a defined benefits package to achieve UHC. Once the package of services has been defined, countries will need to build strong health systems that are capable of delivering the essential package of services without financial hardship. To strengthen the health systems in many countries, almost all programs will need to include cross-cutting health systems strengthening approaches.
However, understanding the interventions that are needed to strengthen national health systems has not always been coherent and cost-efficient across the diverse donor community. Lack of coordination among donors, disease-focused interventions, and implementation in selected provinces or districts makes some interventions appear successful, but health gains are quickly lost when oversight and management are transitioned to the local systems due to gaps in funding, management skills, and limited human resources. These gaps also prevent successful interventions from being scaled-up and institutionalized.
Geographically localized, or disease-focused approaches can only be effective if the interventions are developed within the context of a country’s policy framework and in consideration of its financial and technical constraints. As a matter of fact, the global health community agrees that the health-related Sustainable Development Goals can only be achieved if UHC is substantially improved in an integrated manner.
UHC will only become a reality if it includes a publically financed essential health benefits package, the systems are capable of delivering commodities and services equitably, and if new donor-funded programs are required to take into account a country’s legal framework and fiscal constraints.
With a significant decrease in financial support in the near future, it is more important than ever to leverage international support to implement the highest value interventions as well as support efforts to mobilize domestic resources to sustain health gains.