Objectives to investigate the health managers perceived sustainability status of the health facilities institutional improvement projects and their experiences on factors that facilitated or constrained their maintenance, with intentions of informing relevant strategies or policies in Kenya's health sector.

Methods A qualitative study, nested within a quasi-experimental study. Thirty-three project-teams of health managers were purposively selected and interviewed based on their project implementation success rates post-training. The managers had previously undergone a 9-month leadership training, complimented with facility-based team coaching around the chosen projects. The training was funded by the USAID; however, the implementation of the projects was based on how the participants could innovatively utilize the existing resource to create a positive change. The projects were housed within 20 public, nine faith-based, and four private health facilities in 19 Counties in Kenya.  The interviews explored the manager’s experiences in sustaining the successfully implemented projects within the (24-60 months post-training period).  We asked Managers to describe factors they perceived enabled or hindered the sustainability of the successfully implemented institutional improvement project. The digitally audio-recorded interviews were transcribed verbatim.  Data on barriers and enablers were thematically analyzed.

Results Twenty-seven out of the 33 successfully implemented projects reported sustainability within periods ranging from 24-60 months post-training. Seven themes related to drivers of sustainability emerged, namely; program design, stakeholder's buy-in, board members, communication, coaching, presence of change champion, devolution and political good-will. Four sustainability inhibitors identified were; human resources constraints, policy implementation, misalignment of projects with daily operations, devolution and political interference.

Conclusions The sustainability of institutional improvement strategies such as projects implemented post-leadership training in public and private health facilities depends on the quality of board members, communication management and institutionalization of coaching culture. These findings are pertinent for planning and implementing similar health systems strengthening intervention in low-income countries.

This qualitative sub-study was nested within a quasi-experimental study on the “assessment of the impact of leadership training on health system performance in selected Counties in Kenya."  Among the issues examined in the larger study were leadership priority challenges at the health facility level, implementation status of priority challenge projects, factors influencing project implementation at the workplace, and impact of the institutional improvement projects on the selected outcome indicators. The 33 respondents who had successfully implemented their team projects constituted a sub-sample of 39 respondents in the larger study and participated in the study. We used a convenience sample approach, 33 facility and senior managers were contacted by email with an interview request. These were managers who had participated in the High-performing Healthcare Organisations (LeHHO) training program.

 In-depth interviews were conducted to discuss the health managers perceived status of their institutional improvement project implemented beyond the 24 months of leadership training.   In-depth interviews contributed to a profound understanding of participant’s perspectives and the relationship between the sustainability of the results and the contextual factors that could have influenced the sustainability of the institutional performance improvement initiative. Sustainability occurs when the positive implementation results are maintained 24-60 months post-training. A qualitative design was considered ideal for studying sustainability outcomes because in-depth interviews provide insight into why some projects were sustained while others were not, and promote understanding of differential processes occurring across context.

Data analysis: Data analysis was conducted by the first author (TC) and the second author (GK). The recorded interviews were then transcribed verbatim and verified for accuracy. The transcripts were then cross-checked with the field notes for consistency. The transcripts were clustered to public, private and faith-based facilities and then analyzed separately per sector. Analysis began with open coding to understand sustainability drivers and barriers from health managers' perspectives using the NVivo 11 software(34).  Each transcript was then read independently and the emerging codes and themes were analyzed by the co-authors. The emerging themes were subsequently analyzed against the sustainability of health innovations literature, and new emerging supplementary themes were also discerned, culminating in thematic analysis. To ease comparison, matrices of all identified codes were generated among the health managers, project type and across the health sectors. Illustrative quotes representing a range of health manager’s views were highlighted to elucidate each theme for reporting. Health managers also facilitated the dissemination of research findings through alumni breakfast forums and institutional breakfast series. Power-point slides were shared with respective institutions through the program alumni.

The proxy measure of the success of the leadership training was the completion of the implementation of the institutional improvement project as per the agreed team’s action plan. The project activities and the Desired Measurable Result (DMR) were agreed upon at the beginning of the training. Based on the preceding study by Chelagat et al. (2019), the end-line data were measured against the baseline and reported at the experience sharing workshop, marking the end of the 9-month leadership training and the end of any institutional support such as coaching from Strathmore Business School.  A project was considered sustained if the project indicators presented at the end of the 9-month period are maintained or improved within the 24-60 months period post-training