Public health practitioners have little guidance around how to plan for the sustainability of donor sponsored programs after the donor withdraws. The literature is broad and provides no consensus on a definition of sustainability. This study used a mixed-methods methodology to assess program sustainability factors to inform donor-funded programs. Methods This study examined 61 health facilities in the Western Cape, South Africa, supported by four PEPFAR-funded non-governmental organizations

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... 2007 to 2012. Retention in care (RIC) was used to determine health facility performance. Sustainability was measured by comparing RIC during PEPFAR direct service (20072012), to RIC in the post PEPFAR period (2013 to 2015). Forty-three semi-structured in-depth interviews were conducted with key informants. The qualitative data were used to examine how predictor variables were operationalized at a health facility and NGO level. Results Our qualitative results suggest the following lessons for the sustainability of future programs: Sufficient and stable resources (i.e., financial, human resources, technical expertise, equipment, physical space) Investment in organizations that understand the local context and have strong relationships with local government. Strong leadership at a health facility level Joint planning/coordination and formalized skill transfer Local positive perceived value of the program Partnerships Conclusion Sustainability is complex, context dependent, and is reliant on various processes and outcomes. This study suggests additional health facility and community level staff should be employed in the health system to ensure RIC sustainability. Sustainability requires joint donor coordination with experienced local organizations with strong managers before during and after program implementation. If the program is as large as the South African HIV effort some dedicated additional resources in the long term would be required.