Table 2.

Summary of factors considered as facilitators and barriers toward sustainability of health interventions in sub-Saharan Africa

Facilitators	Examples	Barriers	Examples
Community ownership	1. The highly centralized structure of the social network potential to help rapidly diffuse information between actors [34] 2. Community mobilization [66] 3. (a) Community involvement in meetings; (b) collective ownership; (c) inputs from professional in health system to include local economic concepts and values [67] 4. Community ownership, responsibility, and participation [33, 39, 44] 5. Regular dialogue with community; community ownership [40] 6. Engaging in participatory process with key stakeholders [41] 7. Builds on social and cultural values [38, 63] 8. Creating strong social links and networks with members; social support [38, 43] 9. Resource flow between members of social networks, [38, 66]	Weak health systems	1. Volunteer health workers need refresher training and proper supervision [66] 2. Limitations with assessment of sustainability over time [67, 68] 3. Severe shortage of drugs [67, 68] 4. Weaknesses with formal health systems with timing of distribution of medical services [33] 5. Lack of community-managed monitoring and supervision system [39] 6. Poor assessments [69] 7. Lack of collaboration and access to data 8. Lack of provider integrity [40] 9. Lack of comparable baseline data [17] 10. Lack of rigorous models evaluating sustainability of community health worker programs [61] 11. Lack of monitoring and reporting; no central database for recording [47] 12. (a) Need updated risk management, (b) lack of structure for decision-making, (c) need to improve referral and dissemination of results [50] 13. Lack of Ministry of Health recommendations on how to integrate the program activities into the daily planning and strong strategic plan [42] 14. (a) Fragile and understaffed health systems; b) lack of access to viral load monitoring [52] 15. Lack of disease registries; paper-based patient records [55]
Working within existing resources	1. Institutionalization and integrating within existing political and economic resources [66] 2. The use of a respected traditional authority (i.e., village heads) [33, 67] 3. Adaptation to cultural norms and values [33, 39, 67]; tailoring innovation to sociocultural and institutional settings [41] 4. Building on existing social units and roles such as traditional communicators, traditional birth attendants, and community management committees [39] 5. Consideration of the individual parts (e.g., activities) of a health program as it is to consider the program as a whole [34] 6. Continued dialogue with community members [41] 7. Building on pre-existing capacity of community-based organizations to organize themselves [57]	Lack of financial leadership	1. Lack of remuneration for caregivers [70] 2. (a) Lack of long-term planning [61, 71] 3. Reliance on external funds [40, 71, 72] 4. Lack of funds [43–45, 69, 17] 5. Financial disbursements [43, 45] 6. Availability of resources [43, 73–76] 7. Lack of motivation and incentives [70] 8. (a) Absence of functional financial institution to receive and transfer funds to sub-national levels; (b) incentives did not benefit staff; (c) lack of budget and accounting organization; (d) limited contribution of domestic resources [70] 9. (a) Constraints due to financing and vertical selection of programs; (b) free distribution approach weakens health system [35] 10. Conflict over fund allocations and patient difficulty paying fees [38] 11. Inability to guarantee continuity of future resources [72] 12. Lack of communication about funding termination [57] 13. Lack of medical equipment and uncertainty about securing future funds for equipment [32]
Community buy-in through volunteerism	1. Satisfaction of being able to contribute to community well-being [70] 2. Incentives/recognition by cardinal staff and community leaders [68, 70] 3. Supportive community environment [68] 4. Perceived benefit of intervention [33, 39] 5. Indirect benefits including happiness serving their people [33] 6. Support from key community leaders; motivation, training and supervision of community actors [39] 7. Strong community support [73] 8. Community acceptance [17] 9. Include stakeholders in discussion and planning [50] 10. Community volunteers perceived their role as close to that of a health worker in the community [42]	Health care worker shortage	1. Weak sense of social responsibility [70] 2. Staff workload; prolonged crisis in staffing [44] 3. Longer wait times due to overworked staff; staff working longer hours for less pay [31] 4. Volume of demand, equipment and staff shortages, inadequate management, limited supervision, high turnover, [77] 5. Health worker training in light of “brain drain” [48] 6. (a) High workload and patient volume, (b) limited resources and space [51] 7. Lack of staff [55]
Sound infrastructure	1. Community leadership support and administrative structures to foster supportive environment, efficiency, and commitment [33, 40, 45, 17, 57, 74, 76] 2. Resource contribution; resources to support innovations [33, 45, 46, 75, 51] 3. Record keeping and reporting; improved monitoring and reporting, quality improvement cycles initiated [33, 50] 4. Development and accreditation of standard training, education, and evaluation materials along with training and oversight [41, 45, 48, 63, 32] 5. Integrity in money management [40] 6. Promote learning and disseminate information [41] 7. Establishment of health facility board; development of community-based health care implementers; the community health boards monitored revenue collection and expenditure of cost-sharing funds; decentralized approach of services integral to health care with national supervision [44] 8. Good and well trained health care workers; consistent delivery of services [31, 37, 52] 9. Strategies based on key informants; (b) participation of non-governmental groups to provide experience with operationalization of a project [35] 10. Integration of staff, communication, political support, leadership, participation;[43]; integration of academic, government, and faith based organizations [77] 11. Strong political will to promote health; dynamic community health governance; systems approach to sustainability [61] 12. (a) existence of an effective, functional national body responsible to the government for the national health programs [47] 13. Several point-of-care services, with an in-built referral pathway for diagnosis and treatment [56] 14. (a) Enforcing use of standard guidelines; (b) staff training, mentorship, and technical support; (c) strengthening ministry’s supply and logistics for procuring and maintaining services; (d) quality assurance/quality improvement system provided basis for continuous assessment and monitoring of services [49] 15. (a) Social cash transfer scheme at national level; (b) coordination between health resources at district and community levels [57] 16. Capacity building through skill building [32] 17. (a) Open communication; (b) support from hospital administrators; (c) international partnerships [55]	Lack of education and awareness	1. Shortcomings in the knowledge and attitudes of members of the community concerning maternal health and nutrition [37, 39] 2. Weaknesses in medical skills training; lack of training for community engagement [44] 3. Lack of knowledge of disease risk or transmission [73] 4. Health education and community empowerment [36] 5. Social norms and misconceptions [38] 6. Insufficient public education and lack of awareness [47] 7. Lack of awareness and advocacy, need to mobilize resources [56] 8. Minimal community awareness [57] 9. Low literacy [52] 10. Poor knowledge retention [32]