Rationale

Health systems are facing a battery of formidable challenges. Populations are ageing1–4; there is a rising prevalence of chronic conditions5–8; complex patients have multiple comorbidities9–12; new technologies are creating new models of care13 14; 20% or more of healthcare spending is wasteful15; the role of the patient is changing with a growing ‘consumer culture’ and demand for patient-centred healthcare models16–19; there is pressure to increase standards of patient safety and quality of care20–23; the costs of care are rising,24 25 driven in part by high prices for new cancer and orphan drugs26–28; and there are increased fiscal pressures to pay for everything medicine can do.29 30 Every health system is striving for solutions that find and deploy viable methods to meet growing demands while capitalising on new technologies and ensuring that core processes of care remain of high quality.31 However, the problem is complex. Health system sustainability—the capacity to deliver affordable, cost-effective outcomes over time—requires numerous stakeholders, multiple approaches and coordinated actions undertaken across various system components.32 33 Sustainable health systems are ones that have sufficient resources to meet their objectives and are able to adapt to a changing environment34; in short, they keep up with developments, or leap-frog hurdles. One way in which policymakers, decision-makers and healthcare management try to achieve the sustainability goal is through the implementation of improvements, interventions and change strategies.

While older reviews have been conducted on this topic,35–43 a synthesis of the more recent evidence, regarding how disparate programmes and interventions are achieving sustainability and how they might contribute to or help inform system sustainability, is absent. Therefore, we propose a systematic review with an in-depth focus on the sustainability of such improvement programmes.

Defining sustainability

Sustainability is poorly defined in the literature,35 42 43 which has hindered the development of a consensus, evidence-based, operational paradigm for research and evaluation.43 44 A seminal report released by the World Commission on Environment and Development in 1987 articulated ‘sustainable development’ as that which ‘meets the needs of the present without compromising the ability of future generations to meet their own needs’ and as a ‘process of change in which the exploitation of resources, the direction of investments, the orientation of technological development, and institutional change are all in harmony and enhance both current and future potential to meet human needs and aspiration’.45 This transdisciplinary conceptualisation of sustainability construes it as a multidimensional dynamic interplay of economic, social and ecological factors.42

Regarding the sustainability of improvement programmes in healthcare, a focus on innovation and organisational development has led to the conceptualisation of sustainability as the ‘ongoing delivery of health programmes, which may be measured by the longevity of independent projects, or how well programmes become institutionalised in organisations or health and social systems’ (p1580).44 This approach has been criticised for promoting the continuation and institutionalisation of health programmes with insufficient prioritisation of enduring health outcomes. Gruen et al44 suggest that sustainability instead requires ‘ongoing cycles of reflection, planning, and action’ (p1587).44 Hudson and Vissing43 argue that health benefits may be better achieved through alternate programmes or treatments, therefore requiring the constant evaluation and evolution of existing programmes and interventions.43 They contend that a blinkered adherence to programme maintenance may fail to promote population health.

Envisaging sustainable interventions as static tools fails to take into account the complex adaptive nature of healthcare systems.43 44 46 Within a complex adaptive system framework, sustainable interventions can be better seen as another variable47 that acts on, and responds to, the dynamic system. We can potentially refine and improve interventions over time, to sustainably meet contextual needs and maintain desirable patient outcomes.33

Earlier this decade, Wiltsey Stirman et al35 noted that the current body of sustainability research is limited by a lack of working definitions and models of sustainability to guide researchers.35 In their review of sustainable interventions, 65% of studies did not provide an operational definition of sustainability, whereas those that did frequently cited Scheirer’s (2005) definitions, which are based on earlier work of Shediac-Rizkallah and Bone.48 Scheirer49 describes three separate operational definitions for interventions that promote sustainability: (1) the continued health benefits for individuals beyond the initial funding period; (2) the continuation of programme activities within an organisation; and (3) the continued ability of a community to develop and deliver health promotion programmes.49 In a later paper, Scheirer and Dearing47 defined sustainability as ‘the continued use of program components and activities for the continued achievement of desirable program and population outcomes’ (p2060).47 In our review we will consider an amalgam of Scheirer’s49 and Scheirer and Dearing’s47 definitions. We have selected these characterisations of sustainability based on an understanding of health systems as complex adaptive systems and the prioritisation of health outcomes alongside the maintenance of programmes or programme elements.

Prior reviews of sustainable health interventions and programmes

Several reviews have investigated the sustainability of interventions and programmes and their effects on outcomes, typically looking at different areas or levels of the health sector.35–44 Some have focused on sustainability in specific regions, such as Canada and the USA,36 or sub-Saharan Africa.37 Others have looked at specific types of programmes or interventions, such as chronic disease programmes and interventions,38 39 medical professionals’ adherence to clinical practice guidelines,40 and the influence of interventions on sustaining culture change.41 Approaches to achieving programme sustainability have also been investigated, without examining outcomes.42 43

Gruen et al44 conducted a broader systematic review looking at both empirical studies and conceptual frameworks of health programme sustainability.44 They focused on health programmes assessed over a defined period. The authors identified factors they believed to be associated with the programmes’ sustainability. These factors include programme design elements (eg, stakeholder involvement), organisational setting characteristics (eg, favourable organisational culture) and environmental features (eg, community engagement). The authors developed a conceptual framework for sustainability planning grounded in sustainability science, which regards health programmes as complex systems.

Likewise, Wiltsey Stirman et al’s35 review took a more expansive approach to studying sustainable interventions, while maintaining a focus on empirical studies. Without limiting their review by context, the authors examined a broad scope of studies to assess the sustainability of interventions, the outcomes they provided, and their influences in a variety of countries and health settings.35 They revealed a ‘fragmented and underdeveloped’ body of research suffering from a lack of methodological rigour and definitional consensus (p13).35 The authors note that the absence of validated measures, of programme monitoring post implementation and of real-time observations has also affected the evidence base. Five years later, with growing pressure on health systems, and increased interest in sustainable healthcare, there is a need to establish the current state of the evidence.

Objectives

Following Wiltsey Stirman and colleagues,35 the objective of our review is to provide an account of the sustainability of interventions, improvement efforts and change strategies across health settings. We aim to analyse research conducted since Wiltsey Stirman et al’s 2012 review in order to provide an updated synthesis of the literature in the past 5 years. As figure 1 shows, considerable growth in publications focused on sustainability in healthcare has occurred between 2013 and 2016, supporting the need for an updated review of the evidence.

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Figure 1

Publication titles containing the words ‘health’ and ‘sustainability’, 1978–present. Adapted from Hudson and Vissing (2013), using data from Google Scholar.

Following Wiltsey Stirman et al, the review will be guided by the following research questions: (1) For the change strategy or intervention studied, has sustainability been defined and deployed in accordance with the evidence? (2) At what levels and units of analysis has it been studied? (3) What research methods have been used? (4) Over what time periods? (5) What outcomes have been reported in the empirical literature? (6) What were the findings? (7) What has research told us to date about influences on sustainability? (8) Were health outcomes sustained with continuation of the change strategy or intervention?

This systematic review will provide an essential contribution by synthesising the most relevant and up-to-date literature in this area. It seeks to provide important information for decision-makers, researchers, health professionals, clinicians and patients interested in collaborating on sustainable interventions, programmes and improvement efforts.