The sustainability of public health programs following donor transition: A comparative case study of HIV services and maternal and newborn care in Uganda

: Although there is emerging evidence on the impact of donor transition on health programs, there is little research comparing sustainability outcomes across health programs. We sought to compare drivers of health program sustainability concerning maternal and newborn care in Western Uganda after the end of the ‘Saving Mothers Giving Life’(SMGL) project and HIV services in eastern Uganda following loss of PEPFAR support. Methods: We report qualitative findings from a larger mixed-methods study. In-depth interviews were held with Ministry of Health officials (n = 11), district health teams (n = 27), facility in-charges (n = 39) and representatives of donor-implementing organizations (n = 22). Data were collected in eight districts in Western and Eastern Uganda. Data were analyzed by thematic approach based on the five themes proposed under the Integrated Sustainability Framework (ISF). Results: Our case studies identified several enablers and hindrances to the sustainment of public health gains across HIV and Maternal and Newborn Health (MNH). The recipient government appeared to assign a higher political priority to MNH relative to HIV following donor transition. MNH attracted multiple external funders after the end of SMGL support. In terms of donor transition processes, the MNH intervention was perceived as a ‘terminal’ project, while PEPFAR support was perceived as more ‘open-ended’. In contrast to districts in Eastern Uganda, which lost PEPFAR support, internal ‘program champions’ were identified in districts in Western Uganda. Differences in disease control approaches were identified; HIV was described as more ‘capital intensive’ with more ‘recurrent’ needs compared to MNH programming. The expanded MNH workforce (such as nurses and midwives) was transitioned to the public sector payroll, while PEPFAR-salaried officials were not. Participants perceived the SMGL project on MNH to have been more embedded in the local health system while PEPFAR support was perceived as more ‘vertical’. Conclusions: Our analysis suggests that variations in sustainability outcomes cross the two focus projects stem from differences in donor aid delivery mechanisms, transition processes and domestic political priorities. Our study suggests that donor transition is not a ‘one size fits all’ phenomenon regarding health programs, which has implications for planning for donor transition in Uganda and similar settings.