What happens after project funding ends? A qualitative study of sustainability and adaptation of a cardiovascular disease prevention intervention in Mukono and Buikwe districts in Uganda

Abstract Background Sustaining donor-funded public health interventions remains a persistent challenge in low- and middle-income countries. While implementation success is frequently documented, less is known about what persists after external funding ends. This study examined the post-funding sustainability and adaptation of a cardiovascular disease (CVD) prevention intervention implemented through the SPICES project in Uganda three years after project completion. Methods We conducted a qualitative descriptive study in Mukono and Buikwe districts involving 33 community health workers and 14 patients with hypertension and/or diabetes, participating in ten and three focus group discussions respectively, and 14 healthcare workers participating in key informant interviews. Data were analysed thematically and organised using Scheirer and Dearing’s conceptual framework for sustainability of public health programs, which examines continuation of benefits, program activities, organizational practices, partnerships, issue salience, and diffusion. Results Participants reported continued perceived patient-level benefits, including improved blood pressure control, healthier lifestyle practices, and more proactive care-seeking. Core clinical practices such as routine blood pressure screening and lifestyle counselling were described as integrated into everyday facility care, while partnerships between healthcare workers and community health workers remained active. Participants reported that CVD knowledge and health messages continued to spread informally beyond the original intervention sites. In contrast, structured activities, including community-based CVD screening, volunteer-supported facility triage, and use of the digital risk assessment tool, were reported to have declined because of resource constraints. Despite competing health priorities, participants also perceived continued institutional attention to CVD prevention, reflected in the integration of CVD services into chronic care clinics and inclusion of CVD-related activities in routine supervisory visits. Conclusions Findings suggest that, from participants’ perspectives, SPICES sustainability was characterized by adaptive continuity, with core intervention activities, perceived benefits, partnerships, attention to the health issue, and institutional practices persisting, often in modified forms and, in some cases, extending beyond the original implementation sites. However, sustainment was uneven across components, with some activities reportedly declining due to resource and system constraints. For future programs, sustainability planning should therefore distinguish between intervention components that can be feasibly integrated into routine systems and those that require continued dedicated resources or support.