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Sustaining Health Promotion Efforts

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I Introduction

Sustainability refers to the continuation or persistence over time of
"something." Often, that "something" is a program or project,
particularly when there is a limited timeframe based on funding. 
However, it may be just as important to consider the sustainability of
health issues on the agendas of community members and decision makers,
the long-term viability of the partnerships that often develop when
working on projects, and the likelihood that changes made by
individuals and communities in support of improved health are
maintained over time.  Whether working by yourself or in a
coalition, at the local or national level, on promoting physical
activity or substance abuse, or with plentiful or scarce resources,
considering sustainability could, and I would suggest should, be a
fundamental component of planning and evaluation efforts.

In his article, "The Struggle for Sustainability," Mark Cabaj (2004)
states that sustainability goes beyond self-sufficiency, which he
defines as the ability to recover costs. He describes sustainability as
a project's ability to continue into the future, using a combination of
resources and strategies such as volunteers, grants, fundraising,
donations, and user fees.

This OHPE article builds on a previous one published in February 2000,
which had as its focus the specific approach developed and supported by
two members of the Ontario Health Promotion Resource System
( ) and introduces additional frameworks, resources,
tips and tools (please see the list of previous OHPE articles in this
issue's related resources list).

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II Why to Consider Sustainability

According to The Finance Project's "Sustaining Comprehensive Community Initiatives:  Key Elements for Success,"

"Many stakeholders involved in building community initiatives pursue
the answer to the above question by focusing solely on developing
fiscal resources that will continue to support their efforts.

"And although long-term sustainability planning must necessarily
include a focus on funding, it depends upon much more than just
maintaining sufficient fiscal resources. Sustaining an initiative over
time also requires a combination of non-fiscal resources from the
initiative itself and the broader community. Necessary internal
resources include: leadership from management and board members; access
to technical expertise from within the organization; and the existence
of strong administrative and financial management systems. Critical
external resources include support from policymakers, the public, or
other key stakeholders; access to technical expertise from outside the
organization; and engagement of community-based organizations, parents,
or other community members" (2002, 3).

Some specific examples are

  • Funders may require that it is addressed in a proposal.  For
    example, the application form for Ontario Trillium Foundation grants
    asks, "If part of the work you will undertake with OTF funding needs to
    the time covered by this grant, explain how it will be continued"
    (2006, 6).
  • Partners working on an initiative may expect that their
    developmental and implementation efforts will remain in place for some
    time. For example, the Wawa Healthy Lifestyles Coalition has been in
    place for over 15 years in northern Ontario.  Although their
    governance model has changed, and the specific activities have shifted
    to address emerging community issues such as methadone use in youth,
    and some specific partners have come and gone, the partnership has
    sustained its efforts for almost two decades because their work is
    simply not yet done (
  • The process of individual and system change can take a long time,
    requiring that efforts be sustained over many years often.  For
    example, in 1950 three important epidemiological studies provided the
    first powerful links between smoking and lung cancer and we are still
    fighting for stronger tobacco control initiatives in Canada some 55
    years later. Social norms do not change overnight

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III When to Consider Sustainability

"Sustaining Comprehensive Community Initiatives" further notes, "While
much attention is focused on sustainability planning as an activity set
apart from others, the work of sustainability planning is, in fact,
central to the management of a successful initiative. The key elements
of sustainability are the factors that contribute to the successful
development and day-to-day operation of an initiative. Yet, as anyone
running an initiative knows, success and sustainability do not happen
automatically. They are the result of a complex process and hard work"
(Finance Project, 4).

The following represent specific opportunities to consider:

  • When developing the proposal to initiate a program--this may be
    an internal process to secure commitment or aimed at external funders
    through a granting mechanism.
  • When creating strategic directions--often long-term planning
    looks three, five or even more years into the future.  Annual
    operational efforts often need to be identified within the plan as
    well.  The link between the short-term actions and the long-term
    outcomes requires that sustainability be considered.
  • When planning new programs or re-visiting existing
    plans--consider how this phase of the initiative will integrate the
    concepts of sustainability in order to increase the likelihood that
    there will be subsequent planning phases. Often, multi-year plans are
    necessary to achieve outcomes.
  • When a change in status is known--for instance, a grant is not
    being renewed, or the future status of funding is uncertain, or a
    participating partner organization is no longer involved, or a key
    individual has left the community, or competing health priorities are
    evident in the community.

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IV How to Address Sustainability

Three frameworks are presented here for consideration.

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A.  Achieving Sustainability: Eight Critical Elements for Success
The Finance Project

The Finance Project's eight-part sustainability framework is intended
to help policymakers, program developers and other stakeholders at both
state and community levels identify the basic resources needed and
address the strategic decisions necessary to sustain promising
comprehensive community initiatives. 

The eight key elements for success, geared to enhancing the health of
children in particular, are listed here. I have added a recommended
resource for each one to get you started; more information on each of
these, including where to find them, is in the related resources list
for this article.

1. Vision: Having a clear-cut objective that articulates how an
initiative's programs or activities will improve the lives of children,
families and communities is one of the most important and basic steps
involved in achieving sustainability. Without articulating these
objectives and developing a plan for achieving them, no initiative can
be truly viable.

Nancy's Recommended Resource: Strategic Planning Model for Non-Profits and Public Sector Organizations. 

2. Results Orientation: Demonstrating program success through
measurable results (e.g., established indicators and performance
measures) is crucial for building support from key stakeholders in the
community. Stakeholder support, in turn, increases the likelihood of
program continuance.

Nancy's Recommended Resource: Measuring Program Outcomes: A Practical Approach.  United Ways of America

3. Strategic Financing Orientation: Developing a strategic financing
orientation is critical for program leaders. It enables them to
identify the resources they need to sustain their activities and then
develop strategies to bring these resources together to achieve their

Nancy's Recommended Resource: Basic Guide to Non-Profit Financial Management

4. Adaptability to Changing Conditions:
Adjusting to changing social, economic, and political trends in the
community enables initiatives to take advantage of various
opportunities that can help to achieve sustainability. Making these
adjustments also allows initiatives to identify and overcome any
external threats that could obstruct program continuance.

Nancy's Recommended Resource:  To assist in understanding what the
trends are in your community that might affect your direction,
undertake a PEESTDL Analysis (often referred to as a PEST Analysis)
with your key stakeholders.  This tool would call for input on the
Political, Economic, Environmental, Social, Technological, Demographic
and Legal trends to inform planning.  A sample strategic plan that
utilizes this framework as one input is the Rapid Risk Factor
Surveillance Survey (RRFSS) group within Ontario:

5. Broad Base of Community Support:
Achieving a broad base of community support means determining who
within the community loves an initiative, who needs it and who would
care if it were gone.  Often, when an initiative is able to build
a broad base of supporters who care about it and believe it is vital,
fiscal and non-fiscal support will follow.

Nancy's Recommended Resource:  Working in Partnership: Recipes for Success

6. Key Champions: Rallying leaders from businesses, faith-based
institutions, government and other parts of the community who are
committed to an initiative's vision and are willing to use their power
and prestige to generate support for that program will help to ensure
long-term stability.

Nancy's Recommended Resources:  Network Analysis builds on the
Theory of Diffusion of Innovations made popular by Rogers. This concept
identifies who the key influencers are in a community of practice so
that recruitment efforts can be focused on those most likely to affect
many others in the community. Thomas W. Valente's book, Network Models
of the Diffusion of Innovations, is recommended for those who want to
learn more about this topic.

7. Strong Internal Systems: Building strong internal systems, such as
fiscal management, accounting, information, personnel systems and
governance structures, enables an initiative to work effectively and
efficiently. Establishing these systems also allows initiatives to
document their results and demonstrate their soundness to potential

Nancy's Recommended Resources:  When "demonstrating soundness,"
one is trying to "make the case" to decision makers.  I recommend
Robert Cialdini's book Influence: The Psychology of Persuasion.

8. Sustainability Plan: Creating sustainability plans helps initiative
developers and managers clarify where they want their initiatives to go
in the future. They provide benchmarks for determining whether
initiatives are successfully reaching their goals. They also help
policymakers, opinion leaders and investors decide whether and how to
support certain initiatives. Collectively, these elements are key to
achieving a stable base of resources for community-based initiatives.

Nancy's Recommended Resources:  The Overview of Sustainability
Workbook from The Health Communication Unit offers a process to address
sustainability from four perspectives and a checklist for each all to
establish a Sustainability Plan for a project.

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B. Building Sustainable Non-Profits
Centre for Research and Education in Human Services/Social Planning Council of Cambridge and North Dumfries

The purpose of this manual is to provide non-profit organizations of
all types with practical strategies for building their capacity to
weather sustainability challenges. This manual on sustainability is
intended to be useful to non-profit organizations anywhere. At the same
time, it arises directly out of the experiences of non-profit
organizations in a particular community (Waterloo Region in
Ontario).  The manual explores four dimensions:

  1. Relationships and partnerships
  2. Organizational culture
  3. Planning and leadership
  4. Organizational relevance

In addition to the worksheets available in this manual, there is an
extensive reference list sorted by sub-topics related to sustainability
(such as "Funding"):

  1. Analyzing your current network  of relationships or partners
  2. Weighing the benefits and the drawbacks of partnerships
  3. Creating a structure for your volunteers
  4. Analyzing your leaders
  5. Reflecting on organizational values
  6. Needs assessment

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C. Overview of Sustainability
The Health Communication Unit

This resource was described extensively in the first OHPE feature
article on sustainability (2000).  In brief, the framework
addresses four aspects of a project that might benefit from an emphasis
on sustainability:

  • The Issue
  • The Program
  • The Partnership
  • The Behaviour Change.

A checklist is available for each aspect which organizations or
coalitions could use to assess the likelihood of sustainability with
their efforts.

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Cabaj, M. (2004). The struggle for sustainability: How to get the most out of grant funds by urban community groups.  Accessed October 27, 2006.

The Finance Project. (2002). Sustaining Comprehensive Community Initiatives:  Key Elements for Success. Accessed October 27, 2006.

Ontario Trillium Foundation. (2006). Application Form.  Accessed October 27, 2006.