Introduction: Sustainable service delivery is a major challenge in the HIV response that is often not adequately addressed in project implementation. Sustainable strategies must be built into project design and implementation to enable HIV efforts to continue long after donor-supported projects are completed.
Case description: This paper presents the experiences in operational sustainability of Family Health International's Zambia Prevention, Care and Treatment Partnership in Zambia, which is supported by the US President's Emergency Plan for AIDS Relief through United States Agency for International Development (October 2004 to September 2009). The partnership worked with Zambia's Ministry of Health to scale up HIV clinical services in five of the country's nine provinces, reaching 35 districts and 219 facilities. It provided technical and financial support from within the ministry's systems and structures. By completion of the project, 10 of the 35 districts had graduated beyond receiving ongoing technical support.
Discussion and evaluation: By working within the ministry's policies, structures and systems, the partnership was able to increase the ministry's capacity to add a comprehensive HIV service delivery component to its health services. Ministry structures were improved through renovations of health facilities, training of healthcare workers, procurement of essential equipment, and establishment of a quality assurance plan to ensure continued quality of care. The quality assurance tools were implemented by both the ministry and project staff as the foundation for technical graduation. Facilities that met all the quality criteria for more than six months were graduated from project technical support, as were districts where most supported facilities met the criteria. The district health offices then provided ongoing supervision of services. This predetermined "graduation" exit strategy, with buy in of the provincial and district health offices, set the stage for continued delivery of high-quality HIV services.
Conclusions: Achieving operational sustainability in a resource-limited setting is feasible. Developing and institutionalizing a quality assurance/quality improvement system is the basis on which facilities and districts can move beyond project support and, therefore, sustain services. Quality assurance/quality improvement tools should be based on national standards, and project implementation should use and improve existing health system structures.