Assessing Program Sustainability for Public Health in Low-Resource Setting

by Mahlet Gizaw

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Sustainability has increasingly become a key area of research in implementation science. A program's sustainability — the extent to which it can deliver its intended benefits over time after initial funding has ended — is crucial to and is indicative of whether the program will have real utility in the community for which it was designed. Assessing and planning for sustainability is particularly critical in low-resource settings where various programs are implemented with development assistance funding from external donors, which is nearly always time-limited. While there are several sustainability frameworks, the literature is limited with regards to availability of a validated tool with demonstrated quantifiable benefits for program implementation in low-resource settings. Low- and middle-income countries (LMICs) in Sub-Saharan Africa (SSA) are used to represent low-resource settings in this dissertation project. For the project, I explore the policy problem in the first three chapters and present a solution in the final two chapters. First, I use system maps of two programs to depict the current context for funding and implementation of public health programs in SSA. Next, I demonstrate the impact of shifts in funding on population outcomes by looking at antiretroviral treatment (ART) coverage for HIV in SSA. Then, I present a targeted literature review on determinants of sustainability in the SSA setting. Based on these findings, I identify the program sustainability assessment tool (PSAT) as an appropriate fit and adapt it to the SSA setting based on key informant interviews. Finally, I use psychometric assessments based on a broader pilot survey to evaluate the tool's quality in terms of reliability and validity.

Table of Contents

  • Chapter One

    The current system of funding and implementation for public health programs in SSA — Two case examples

  • Chapter Two

    The impact of strategic decrease in development assistance funding for HIV on Anti-retroviral (ART) coverage in SSA — an interrupted time series analysis

  • Chapter Three

    Determinants of sustainability within the current system of funding and implementation for public health programs implemented in SSA — a targeted literature review

  • Chapter Four

    Applying the Program Sustainability Assessment Tool (PSAT) to the SSA context — cognitive key informant interviews

  • Chapter Five

    Psychometric quality assessments of the modified PSAT

  • Appendix A

    Interrupted time series sensitivity analysis results

  • Appendix B

    PSAT tool and scoring instructions

  • Appendix C

    Key informant cognitive interview consent and interview protocol

  • Appendix D

    Survey consent and survey questions

  • Appendix E

    Exploratory factor analysis

Research conducted by

This document was submitted as a dissertation in May 2022 in partial fulfillment of the requirements of the doctoral degree in public policy analysis at the Pardee RAND Graduate School. The faculty committee that supervised and approved the dissertation consisted of Glen Wagner (Chair), Ryan McBain, and Indrani Saran.

This report is part of the RAND Corporation Dissertation series. Pardee RAND dissertations are produced by graduate fellows of the Pardee RAND Graduate School, the world's leading producer of Ph.D.'s in policy analysis. The dissertations are supervised, reviewed, and approved by a Pardee RAND faculty committee overseeing each dissertation.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.