Can international health programmes be sustained after the end of international funding: the case of eye care interventions in Ghana

There is general agreement amongst major international policy makers that sustainability is a key component of health interventions in developing countries [1‐6]. The term "sustainability", defined in broad terms as the continuation of benefits [7], has become a buzzword in international development over the past two decades [8‐10]. It has generated rich, enthusiastic debates, and innovative theories beyond the sphere of international health, and has even led to the creation of "sustainability science" [11]. Everything must now be sustainable, not only the environment, but also cities, agriculture, livelihoods, and health. However, the concept of sustainability has been overused [12] and, as a result, means different things to different people [13‐15]. The absence of a clear and operational definition of sustainability has also generated ambiguous and vague methods for measuring sustainability in public health [15, 16]. A challenge for policy-makers and researchers is to translate the concept of sustainability into concrete indicators, and generate evidence on the factors constraining and enabling sustainability [13, 17].

The objective of the study carried out in Ghana, commencing eighteen months after the end of international funding provided by the Swiss Red Cross, was to identify sustainability factors, focusing on the characteristics of health activities implemented in district hospitals. For the first time in health systems research, the attributes of activities in a health programme implemented in a low or middle income country were described using diffusion of innovations theories; and a relationship was established between the level of continuation of activities (sustainability) and these attributes.

The definition of sustainability adopted in the study was based on how the eye care programme was designed and how the information system of the programme was structured [43]. Sustainability in the research was defined "as the level of continuation of activities after the end of international funding" (after Honadle and Sant [7]). Sustainability was measured by comparing the number of outputs per activity before and after the end of international funding (18 months after the international funding ceased) (e.g. ‘surgery activities’ were measured by the number of cataract surgeries performed).

The results indicated that differences in terms of sustainability varied in function of the type of activities and the attributes of these activities (i.e. observability, complexity, triability, and compatibility). Amongst the four district activities, facility-based activities (i.e. consultations and cataract surgeries) were maintained over time in a higher number of hospitals than cataract surgeries and outreach activities. School health screening was found to be the least sustained activity amongst the four district activities. School health activities were also scored as the most incompatible and most complex activity, and the least triable and observable activity amongst the four district activities. On the other hand, the facility-based consultations were more likely to be sustained because they were perceived by the hospital managers to be very compatible, and not complex, compared to the three other district activities. In other words, the four attributes of each eye care activity (i.e. incompatibility, complexity, triability, and observability) had an impact on their maintenance by hospital managers.

The relationships between attributes of activities and the continuation of these activities were explored in other studies. In terms of observability, Djellal and Gallouj [49] showed that the observable innovations such as new technology or new management systems determined the likelihood of their adoption by hospital staff. Innovation that showed visible benefits to its users were more likely to be adopted and maintained [30, 31, 50]. Singhal and Rogers [51] also showed that preventative health measures were less likely to be adopted and maintained than curative measures because they had less visible and immediate effects on an individual’s health than curative measures. Although all the studies mentioned above [30, 49‐51] were conducted in developed countries, their results were consistent with the results of the research presented here from a low income country, Ghana. Both school health and outreach activities were preventative. They had no direct impact on the health of the patient compared to consultations and cataract surgeries. From the patient and eye care staff perspectives, the observable effects of these two preventable activities were very limited. From the hospital managers’ perspective, school health and outreach activities had no financial observable added value. Both activities were delivered for free to the beneficiaries. Hospital managers were more likely to support facility-based consultations and cataract surgeries that had a positive observable impact on the population and the financial situation of the hospital.

In terms of complexity, past studies have shown that innovations were rejected by their health professionals if they were perceived by them, as users, as being too complicated to understand, use, or implement [28, 30, 52]. For example, the failure of the introduction of a shared electronic patient record system in the United Kingdom was explained by the high complexity of its utilisation [53]. Similar results were found in this study. In Ghana, the activities that were more likely to be stopped by hospital managers were those with the highest level of complexity: school health and outreach activities. These two activities involved a high number of actors and required efforts from the district hospital to inform and contact a wide range of actors who were for most of them from outside the health sphere (e.g. education authorities, school teachers, village leaders, sub-district nurses).

Regarding triability, several authors [31‐33] found that innovations were adopted and maintained more easily if users could test them first before adopting them. Similar results were found in this study: activities that were the less triable (i.e., outreach activities and cataract surgeries) were more likely to be stopped as soon as the cessation of international funding.

In terms of compatibility, outreach activities raised numerous questions amongst hospital managers as to whether they should be run by hospitals or district authorities. The lack of clarification on this matter pushed most hospital managers to cease these activities as soon as funding stopped and check with the district authorities about who should run and fund these two activities. The mandate of district hospitals was to deliver facility-based services and serve the population living in their catchment area (i.e. the district). Every facility-based activity, such as consultations and cataract surgeries, was considered by hospital managers as fully compatible with the mandate of a Ghanaian district hospital. These two activities were fully in compliance with the mandate of district hospitals and no modification was required from the district hospitals to adjust their structure to deliver these activities. As such, facility-based consultations and cataract surgeries were perceived by hospital managers to be highly compatible innovations. The costs of these activities were included in the budget of the district hospital and were even refunded by National Health Insurance Scheme put in place by the Ministry of Health.

Hospital managers acknowledged that confusion existed over who should be responsible for the management and financing of outreach and school health activities. One hospital manager explained "Outreach activities should have been carried out the district authorities not by the hospitals. They are the ones in charge of all the health interventions that take place outside the walls of this hospital. However, they never took the initiative and our staff had to conduct the outreach consultations". As another hospital manager described it, "outreach activities and school health activities had never been seen as a problem as long as the costs of these activities were fully covered by the international organisation. As soon as the international organisation ceased its financial support, it became unclear for the health actors who should continue these activities, the hospital or the district authorities". The lack of clarity regarding the outreach activities and school health activities created conflicts between two distinct entities: the district health management teams (DHMTs) and the district hospital. In the Ghanaian health system, district hospitals are not accountable to the DHMTs. DHMTs are in charge of all the activities conducted at the primary health care level of the health system. Outreach consultations and school health activities were perceived as inconsistent with the mandate of the district hospitals. They also required slight adaptations from district hospital teams as described by one ophthalmic nurse: "outreach activities and school screening introduced new ways of working at the hospital. We had to contact headmasters or local authorities to offer our services. We then organised trips in collaboration with these people. This was very unusual for us. We were used to wait for the patient to come to the hospital. Now we had to do the inverse". Outreach and school activities were described as almost inconsistent with the mandate of hospitals and required adjustments from hospitals.

Several studies also showed that innovations that were compatible with individuals’ values [28‐30], and organisations’ mandates were more likely to be maintained, as corroborated in the work presented in this paper.

As shown earlier, the results of this study were consistent with the results found in past studies [28‐30, 49, 53‐59]). The study in Ghana, however, presented two novel features:

ii) Second, it is equally important to consider the individual parts (e.g., activities) of a health programme as it is to consider the programme as a whole. A health programme can be described as a set of activities. Disentangling projects into distinct activities allows sustainability to be assessed at a finer level, and helps identify which activities are likely to be maintained and which activities are more likely to stop.

This brings a new approach to evaluating sustainability, as well as providing new perspectives for implementing and funding agencies in their approaches to project implementation and sustainability. The implication is that the maintenance of health programmes can only be achieved through the introduction of customized strategies for each activity.

One limitation of the approach is that it does not capture the dynamics of health systems. The assessment at one point in time should be repeated over time to measure how the continuation of activities evolve and how the perception by health professionals in relation to attributes of innovations changes with the changing policy and finance environment. However, the utilisation of indicators validated by key informants was considered by the authors as appropriate way of describing the characteristics of innovations. Applications could be numerous in the field of international health to manage and predict implementation and scaling up of innovations (e.g. m-health, new drugs).

Eye care activities that were more likely to be dropped were the ones that had the least observable effects, were the most complex and the least compatible with the mandate and financing system of the hospital. In the case of the eye care programme in Ghana, the first activities to be stopped were school screening and outreach consultations. Using diffusion of innovations theories can help predict the sustainability of specific activities within a health programme. The study also highlighted the need for disentangling the various components of a health programme in order to identify which activities are more likely to be continued within a health system. The same methodology could be used in a different setting and could help predict which innovations are more likely to be adopted and maintained over time in a hospital setting in a Western country, for example.