From Pilot to Scale: What Sustainment Actually Requires

Global health is full of interventions that worked while a project team was watching closely. Pilots benefit from dedicated staff, troubleshooting support and unusually concentrated attention. Scale removes many of those protections. The question changes from whether an intervention can work to whether ordinary systems can keep it working after novelty and external support fade.

The m-mama sustainment study approached this directly: the emergency-transport model depended on government commitment, dispatch processes, community drivers, facilities and technical components that had to become routine responsibilities. Digital health shows the same gap. A review of maternal mHealth tools found many feasible and acceptable pilots but very little national-scale integration, interoperability or sustainability planning. Health-system resilience research adds the institutional layer: workforce, financing, procurement, quality improvement and learning capacity determine whether an intervention becomes service infrastructure.

Sustainment should therefore influence design from the beginning. Who will own the programme? Who pays recurring costs? Who maintains the technology? How does it enter routine data and procurement? What happens when the original champions leave?