{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T04:04:29Z","timestamp":1790741069034,"version":"4.1.0"},"reference-count":51,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T00:00:00Z","timestamp":1769990400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004423","name":"World Health Organization","doi-asserted-by":"publisher","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}],"id":[{"id":"10.13039\/100004423","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec102\">\n                    <jats:title\/>\n                    <jats:p>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 \u2018Saving Mothers Giving Life\u2019(SMGL) project and HIV services in eastern Uganda following loss of PEPFAR support.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec001\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We report qualitative findings from a larger mixed-methods study. In-depth interviews were held with Ministry of Health officials (n\u2009=\u200911), district health teams (n\u2009=\u200927), facility in-charges (n\u2009=\u200939) and representatives of donor-implementing organizations (n\u2009=\u200922). 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).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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 \u2018terminal\u2019 project, while PEPFAR support was perceived as more \u2018open-ended\u2019. In contrast to districts in Eastern Uganda, which lost PEPFAR support, internal \u2018program champions\u2019 were identified in districts in Western Uganda. Differences in disease control approaches were identified; HIV was described as more \u2018capital intensive\u2019 with more \u2018recurrent\u2019 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 \u2018vertical\u2019.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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 \u2018one size fits all\u2019 phenomenon regarding health programs, which has implications for planning for donor transition in Uganda and similar settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0341328","type":"journal-article","created":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T18:23:00Z","timestamp":1770056580000},"page":"e0341328","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["The sustainability of public health programs following donor transition: A comparative case study of HIV services and maternal and newborn care in Uganda"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8169-1151","authenticated-orcid":true,"given":"Henry","family":"Zakumumpa","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Ssegujja","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marjorie","family":"Kyomuhendo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beryl","family":"Maritim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timothy","family":"Musila","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Freddie","family":"Ssengooba","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,2,2]]},"reference":[{"key":"pone.0341328.ref001","author":"Centers for Diseases Control"},{"key":"pone.0341328.ref002","article-title":"Assessing PEPFAR\u2019s impact: analysis of mortality in PEPFAR countries","volume":"27","author":"J Kates","year":"2021","journal-title":"Global Health Policy"},{"issue":"3","key":"pone.0341328.ref003","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1016\/j.vaccine.2019.10.057","article-title":"Effect of donor funding for immunization from Gavi and other development assistance channels on vaccine coverage: evidence from 120 low and middle income recipient countries","volume":"38","author":"G Ikilezi","year":"2020","journal-title":"Vaccine"},{"key":"pone.0341328.ref004","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s41256-019-0118-y","article-title":"Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community","volume":"4","author":"H Zakumumpa","year":"2019","journal-title":"Glob Health Res Policy"},{"issue":"6","key":"pone.0341328.ref005","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002319","article-title":"The US President\u2019s Malaria Initiative and under-5 child mortality in sub-Saharan Africa: a difference-in-differences analysis","volume":"14","author":"A Jakubowski","year":"2017","journal-title":"PLoS Med"},{"key":"pone.0341328.ref006","article-title":"Dismantling US global health aid","author":"LO Gostin","year":"2025","journal-title":"Health Affairs Forefront"},{"issue":"4","key":"pone.0341328.ref007","doi-asserted-by":"crossref","first-page":"874","DOI":"10.1111\/twec.13336","article-title":"Economic costs of the Russia\u2010Ukraine war","volume":"46","author":"I Liadze","year":"2023","journal-title":"World Econ"},{"issue":"2","key":"pone.0341328.ref008","doi-asserted-by":"crossref","first-page":"274","DOI":"10.9745\/GHSP-D-14-00227","article-title":"PEPFAR transitions to country ownership: review of past donor transitions and application of lessons learned to the Eastern Caribbean","volume":"3","author":"A Vogus","year":"2015","journal-title":"Glob Health Sci Pract"},{"key":"pone.0341328.ref009","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1080\/17441692.2013.878957","article-title":"After the global fund: who can sustain the HIV\/AIDS response in Peru and how?","volume":"9","author":"AB Amaya","year":"2014","journal-title":"Glob Public Health"},{"issue":"2","key":"pone.0341328.ref010","doi-asserted-by":"crossref","first-page":"121","DOI":"10.2471\/BLT.16.179861","article-title":"Political commitment for vulnerable populations during donor transition","volume":"95","author":"DC Rodr\u00edguez","year":"2017","journal-title":"Bulletin of the World Health Organization"},{"issue":"2","key":"pone.0341328.ref011","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1007\/s10488-010-0319-7","article-title":"Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda","volume":"38","author":"E Proctor","year":"2011","journal-title":"Adm Policy Ment Health"},{"key":"pone.0341328.ref012","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1146\/annurev-publhealth-040617-014731","article-title":"The sustainability of evidence-based interventions and practices in public health and health care","volume":"39","author":"RC Shelton","year":"2018","journal-title":"Annu Rev Public Health"},{"issue":"1","key":"pone.0341328.ref013","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1186\/s13012-021-01134-y","article-title":"Barriers and facilitators influencing the sustainment of health behaviour interventions in schools and childcare services: a systematic review","volume":"16","author":"A Shoesmith","year":"2021","journal-title":"Implement Sci"},{"issue":"1","key":"pone.0341328.ref014","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1186\/s13012-022-01252-1","article-title":"Evaluation of measures of sustainability and sustainability determinants for use in community, public health, and clinical settings: a systematic review","volume":"17","author":"A Hall","year":"2022","journal-title":"Implement Sci"},{"issue":"1","key":"pone.0341328.ref015","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1186\/s13012-023-01315-x","article-title":"Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review","volume":"18","author":"Y Zurynski","year":"2023","journal-title":"Implement Sci"},{"key":"pone.0341328.ref016","volume-title":"Health financing progress matrix assessment, Uganda 2023: summary of findings and recommendations","author":"World Health Organization","year":"2023"},{"issue":"1","key":"pone.0341328.ref017","doi-asserted-by":"crossref","first-page":"1919393","DOI":"10.1080\/16549716.2021.1919393","article-title":"Fitting health financing reforms to context: examining the evolution of results-based financing models and the slow national scale-up in Uganda (2003-2015)","volume":"14","author":"A Ssennyonjo","year":"2021","journal-title":"Glob Health Action"},{"issue":"1","key":"pone.0341328.ref018","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1186\/s12913-017-2009-6","article-title":"Alternative financing mechanisms for ART programs in health facilities in Uganda: a mixed-methods approach","volume":"17","author":"H Zakumumpa","year":"2017","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pone.0341328.ref019","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1186\/s12879-024-09748-5","article-title":"Long-acting injectable antiretroviral treatment: experiences of people with HIV and their healthcare providers in Uganda","volume":"24","author":"H Zakumumpa","year":"2024","journal-title":"BMC Infect Dis"},{"issue":"10","key":"pone.0341328.ref020","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0223426","article-title":"The impact of PEPFAR transition on HIV service delivery at health facilities in Uganda","volume":"14","author":"JA Wilhelm","year":"2019","journal-title":"PLoS One"},{"issue":"5","key":"pone.0341328.ref021","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2022-010499","article-title":"Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition","volume":"8","author":"L Paina","year":"2023","journal-title":"BMJ Glob Health"},{"key":"pone.0341328.ref022","doi-asserted-by":"crossref","DOI":"10.1093\/heapol\/czad096","article-title":"The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015\u201321)","volume":"39","author":"H Zakumumpa","year":"2024","journal-title":"Health Policy Plan"},{"key":"pone.0341328.ref023","author":"WHO\/Alliance for Health Policy and Systems Research","year":"2021"},{"issue":"1","key":"pone.0341328.ref024","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1186\/s13012-017-0637-1","article-title":"Developing a comprehensive definition of sustainability","volume":"12","author":"JE Moore","year":"2017","journal-title":"Implement Sci"},{"key":"pone.0341328.ref025","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/1748-5908-7-17","article-title":"The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research","volume":"7","author":"S Wiltsey Stirman","year":"2012","journal-title":"Implement Sci"},{"issue":"11","key":"pone.0341328.ref026","doi-asserted-by":"crossref","first-page":"2059","DOI":"10.2105\/AJPH.2011.300193","article-title":"An agenda for research on the sustainability of public health programs","volume":"101","author":"MA Scheirer","year":"2011","journal-title":"Am J Public Health"},{"issue":"1","key":"pone.0341328.ref027","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1093\/her\/13.1.87","article-title":"Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy","volume":"13","author":"MC Shediac-Rizkallah","year":"1998","journal-title":"Health Educ Res"},{"issue":"2","key":"pone.0341328.ref028","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1093\/heapol\/czv045","article-title":"A comparison of hierarchical cluster analysis and league table rankings as methods for analysis and presentation of district health system performance data in Uganda","volume":"31","author":"CK Tashobya","year":"2016","journal-title":"Health Policy Plan"},{"issue":"1","key":"pone.0341328.ref029","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1186\/s12992-023-00945-6","article-title":"The impact of donor transition on continuity of maternal and newborn health service delivery in Rwenzori sub-region of Uganda: a qualitative country case study analysis","volume":"19","author":"E Ssegujja","year":"2023","journal-title":"Global Health"},{"key":"pone.0341328.ref030","volume-title":"Case study research and applications: design and methods","author":"RK Yin","year":"2018","edition":"6"},{"issue":"8","key":"pone.0341328.ref031","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001079","article-title":"Building the field of health policy and systems research: social science matters","volume":"8","author":"L Gilson","year":"2011","journal-title":"PLoS Med"},{"key":"pone.0341328.ref032","author":"USAID"},{"key":"pone.0341328.ref033","volume-title":"Evaluating the impact of PEPFAR\u2019s geographic prioritization on centrally-supported health facilities","author":"DC Rodr\u00edguez","year":"2019"},{"key":"pone.0341328.ref034","year":"2023"},{"key":"pone.0341328.ref035"},{"key":"pone.0341328.ref036","volume-title":"Qualitative data analysis: An methods sourcebook","author":"MB Miles","year":"2019"},{"key":"pone.0341328.ref037","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1186\/1471-2288-13-117","article-title":"Using the framework method for the analysis of qualitative data in multi-disciplinary health research","volume":"13","author":"NK Gale","year":"2013","journal-title":"BMC Med Res Methodol"},{"issue":"1","key":"pone.0341328.ref038","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1177\/160940690600500107","article-title":"Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development","volume":"5","author":"J Fereday","year":"2006","journal-title":"Inter J Qual Methods"},{"key":"pone.0341328.ref039","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1186\/s12913-015-0894-0","article-title":"Management practices to support donor transition: lessons from Avahan, the India AIDS Initiative","volume":"15","author":"S Bennett","year":"2015","journal-title":"BMC Health Serv Res"},{"issue":"2","key":"pone.0341328.ref040","doi-asserted-by":"crossref","DOI":"10.9745\/GHSP-D-22-00430","article-title":"Stakeholders\u2019 perspectives on the financial sustainability of the HIV response in Nigeria: a qualitative study","volume":"11","author":"D Ogbuabor","year":"2023","journal-title":"Glob Health Sci Pract"},{"issue":"1","key":"pone.0341328.ref041","doi-asserted-by":"crossref","first-page":"35","DOI":"10.2989\/16085906.2016.1138976","article-title":"What does sustainability mean in the HIV and AIDS response?","volume":"15","author":"G Oberth","year":"2016","journal-title":"Afr J AIDS Res"},{"issue":"7","key":"pone.0341328.ref042","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1093\/heapol\/czw009","article-title":"Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level","volume":"31","author":"SA Luboga","year":"2016","journal-title":"Health Policy Plan"},{"issue":"2","key":"pone.0341328.ref043","doi-asserted-by":"crossref","DOI":"10.1136\/sextrans-2011-050303","article-title":"Health systems and HIV treatment in sub-Saharan Africa: matching intervention and programme evaluation strategies","volume":"88","author":"T B\u00e4rnighausen","year":"2012","journal-title":"Sex Transm Infect"},{"issue":"5","key":"pone.0341328.ref044","doi-asserted-by":"crossref","first-page":"796","DOI":"10.2105\/AJPH.2006.095455","article-title":"Generating political priority for maternal mortality reduction in 5 developing countries","volume":"97","author":"J Shiffman","year":"2007","journal-title":"Am J Public Health"},{"key":"pone.0341328.ref045","unstructured":"Shiffman J, Okonofua FE, Ved R. The state of political priority for maternal mortality reduction in Nigeria and India."},{"key":"pone.0341328.ref046","author":"N Gulrajani"},{"issue":"4","key":"pone.0341328.ref047","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1093\/fpa\/orx002","article-title":"Public goods and donor priorities: the political economy of development aid for infectious disease control","volume":"13","author":"CA Steele","year":"2017","journal-title":"Foreign Policy Analysis"},{"key":"pone.0341328.ref048","volume-title":"US foreign assistance in the age of strategic competition","author":"DF Runde","year":"2022"},{"issue":"9","key":"pone.0341328.ref049","doi-asserted-by":"crossref","first-page":"1188","DOI":"10.1093\/heapol\/czac063","article-title":"The impacts of donor transitions on health systems in middle-income countries: a scoping review","volume":"37","author":"HE Huffstetler","year":"2022","journal-title":"Health Policy Plan"},{"issue":"1","key":"pone.0341328.ref050","article-title":"Transitioning from donor aid for health: perspectives of national stakeholders in Ghana","volume":"6","author":"W Mao","year":"2021","journal-title":"BMJ Glob Health"},{"key":"pone.0341328.ref051","volume-title":"Transitions from donor funding to domestic reliance for HIV responses","author":"D Burrows","year":"2016"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0341328","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T18:23:08Z","timestamp":1770056588000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0341328"}},"subtitle":[],"editor":[{"given":"Daniel Chukwuemeka","family":"Ogbuabor","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,2,2]]},"references-count":51,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2,2]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0341328","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,2]]}}}