Demystifying Sustainability: Lessons from a Small Grants Global Health Program

Philanthropy has long grappled with a persistent challenge: how to ensure investments create lasting change rather than short-lived gains. For global health funders, this question has become even more urgent as funding in the field faces mounting pressures and deep cuts, making it critical for donors to ensure that local governments independently own and sustain as many programs as possible.

The Global Grants Program, a small grants program that is part of the Bloomberg Philanthropies Data for Health Initiative, recently carried out a qualitative assessment of sustainability to uncover fresh insights grounded in tangible experience. We conducted in-depth interviews with project leads from 17 teams across Africa and Latin America to understand what drives — and hinders — sustainability in strengthening public health data systems.

The findings hold valuable lessons for funders seeking to maximize the local ownership and long-term impact of their investments, not just in global health but in all areas of development.

Three Takeaways Funders Should Operationalize

1. It’s Never Too Early to Engage Stakeholders

Local government ownership and buy-in have long been promoted as a key measure for institutionalization and our assessment confirmed that this is the strongest predictor of sustainability. Across all projects, 48% of reported successes were directly attributed to senior-level government buy-in and prioritization of project activities. Conversely, 52% of reported challenges cited the lack of it as the main reason initial outcomes weren’t sustained.

While partners with the motivation and authority to carry out the work are a necessity, our results showed that it is also essential to have buy-in from other peers and leaders within and across stakeholder agencies. Not surprisingly, sustainability also hinged on engaging the right stakeholders, at the right levels, at the right time — which is usually from the very start. In Malawi, for example, a civil registration project succeeded because a future Secretary of Health had been part of early decision-making:

Many projects, including one in Argentina that developed a system of integrated health information, also demonstrated that the value of early stakeholder initiation and the key role that empowering them through decision-making plays in gaining buy-in:

Recommendations to promote buy-in include:

• Promote open calls for applications to ensure governments are motivated and propose priority activities. Encourage partners to map critical decision-makers and plan for their involvement early.
• Provide resources for stakeholder advocacy even before implementation begins.
• Cultivate champions at multiple levels. This also helps in times of inevitable staff turnovers.

2. Time Frames Matter

The Global Grants Program provides up to $100,000 over 12- to 15-month implementation timeframes. This was sufficient to deliver targeted results but, for many projects, insufficient for institutionalization. Pilot projects in particular struggled to sustain innovations without additional time to demonstrate value, secure adoption, and integrate costs into government budgets.

One respondent from Nigeria explained:

This pattern wasn’t isolated. Twenty-five separate instances across African projects cited “insufficient time for institutionalization” as a barrier to sustainability, and in Côte d’Ivoire, a promising new verbal autopsy tool never made it into the national health plan due to insufficient time beyond proof of concept:

For funders, unlimited multi-year grants may not be possible, but designing grantmaking with flexible timelines and the following recommendations in mind can be more doable, and is key to sustaining impact:

• Allow additional time and flexibility for pilot projects to both demonstrate results and achieve institutionalization or scale-up to sustain these results.
• Project closure can trigger a shift in attention. Consider leaving a project “active” for institutionalization activities even if no actual funding is associated.
• Plan ahead for any running costs such as internet, domains, office rent, etc. needed to maintain outcomes for reasonable timeframes until such payments can be formally adopted by the relevant agency.

3. Tangible Outcomes Drive Commitment

Global health systems-strengthening can feel abstract even to those who are champions of their importance, which makes visible, user-friendly outputs a critical driver of sustainability. Projects that produced something tangible, like dashboards, streamlined registration systems, or integrated data tools were significantly more successful at maintaining momentum than projects that produced a more abstract outcome.

For example, in Paraguay, a burden of disease study directly influenced national health insurance policies and led to a prioritized list of insurable conditions:

Similarly, in Gombe State, Nigeria, digitizing birth registration made day-to-day work simpler for registrars, increasing their enthusiasm for the work:

Clearly demonstrated value also helps defend against the challenges that occur when there are transitions in key staff and leadership that threaten buy-in and sustainability. If a process or outcome is benefiting a team and its value is clear, a new leader will more quickly embrace it rather than abandon or deprioritize it.

For funders, the takeaway is to demonstrate value early:

• Prioritize outputs that improve day-to-day efficiencies for system users.
• Encourage grantees to develop early-use cases that showcase impact within funding timelines.
• Share results and outcomes with those upstream of decision making, showcasing for them the importance of their work.

The Bottom Line for Funders

Sustainability in global health is complex, but not impossible. By combining trust-based grantmaking, adequate timelines, and investments in tangible, locally relevant solutions, funders can facilitate sustained ownership and impact. And in an era of shrinking global health budgets these lessons are not just useful, they are essential. Funders today must ensure that through country ownership, limited resources can deliver results that last.

We hope the insights from the Sustainability Assessment Report equip funders with the evidence and recommendations needed to strengthen sustainability efforts — in global health funding as well as other issue areas where these lessons apply. With significant upheaval already underway, we can turn today’s disruptions into an opportunity to secure strategies for lasting improvements.

Carlie Congdon is deputy director, Program Implementation for CRVS and the Global Grants Program at Vital Strategies, part of the Bloomberg Philanthropies Data for Health Initiative. Lara Tabac is the director of the Global Grants Program.

The authors would like to gratefully acknowledge the interviewees from 17 teams across government agencies and organizations working in Paraguay, Egypt, Tunisia, The Gambia, Argentina, Malawi, Burkina Faso, Nigeria (Lagos State and Gombe State), Peru, Côte d’Ivoire, and Ecuador, and the African Cancer Registry Network whose ideas and efforts inspired this article.