Sustainability of health programs requires stakeholder at all levels to share the different meanings of sustainability and the responsibility for it, a paper recently published on Sustainability of Community Health Workers Program in Afghanistan.
To understand the various perspectives on sustainability, I interviewed 63 key informants and conducted 11 focus groups at policy, management and administration, and community levels between 2013 and 2014 in Afghanistan.
Speaking about sustainability, policymakers often refer to financial sustainability. They say the cost of health care is rising and thus it is not sustainable. Or they say the foreign aid is decreasing (or not enough) and thus the program is not sustainable.
Health managers have a slightly different understanding of sustainability. For them, the continuation of routine organizational activities such as receiving budgets on time, delivering training and supervisions, and supplying drugs and equipment are as important, if not more, as having enough money in the bank. These activities partly rely on the budget, but more on the capacity of the organization, the people who work in the organization, and the environment they are working in.
Community members as the recipients of the services have one main question in mind when they think of sustainability: will I receive the services when I need it? For community members, it is all about continuation of the services.
These different understandings of sustainability have implications. Since the voice of policymakers is the loudest, their perception of sustainability becomes appears to be more prominent. The focus on the financial aspect implicitly conveys the idea that there is a lack of money. Sometimes, it may be true and ensuring sufficient money for the program is important. Often, it is not. Often, how the money is spent can be a bigger challenge for sustainability than how much money should be spent. The focus on a lack of budget diverts the attention from other significant factors such as the contextual political economy, comprehensiveness of the services, the way services should be provided, and even who should provide what and to whom that have the potential to contribute to sustainability.
Understanding different perspectives among all levels may have advantages. When community members understand the challenges of policymakers in ensuring financial sustainability, they may become more accepting of the idea of community financing of some program or paying taxes. Managers could allocate organizational core budget to routine activities until next install of the national budget is approved and sent to the implementing organizations. In short, shared understanding may lead to shared responsibility.