Discussion
With regard to HW normalization, our study showed that there was generally good or adequate normalization strength (a median score of 4 (IQR; 3.9, 4.3) out of a maximum of 5) at all facility levels. This suggests that some aspects of the EACDRP intervention were well sustained, such that they were now embedded within routine practice. Normalisation scores were particularly high with respect to reflexive monitoring and cognitive participation.All facility levels showed good strength on cognitive participation which suggests that HWs internalised the intervention’s aims and processes. Evidence for reflexive monitoring was also strong suggesting an ability among HWs to consciously adapt their work to the dwindling support after the end of the trial. The domains of coherence (indicating intervention sense-making) and collective action (indicating ability to work as a team) were weak overall, but unexpectedly more so for higher level units which are usually less affected by absenteeism or the lack of mentors [Most of the respondents (74%) had been previously trained or were fully involved in the post-intervention phase, but this was much less the case at HCIVs than at lower-level HFs (HCIIs & HCIIIs-84% vs. HCIVs-44% - Table HCIIIs and HCIVs had more clinicians while HCIIs had none which is as expected per current MoH staffing norms. Compared to lower-level HFs, HCIVs had fewer staff who had been trained on NCDs during the trial (e.g., 35% vs. 71% – 80% Whilst we observed evidence for normalization that survived the end of the trial by 4 years, it was also obvious that for some domains, normalization strength was low, suggesting that it may have substantially declined since the end of research-related support in 2016.It is important to note that normalization is not irreversible, and good practices can be de-normalized over time [A South African study that examined implementation factors around provider-initiated HIV testing and counselling (PITC) after 2 years of embedding using the normalisation process model found that normalization was promoted by strong senior leadership, implementation support, appropriate accountability mechanisms, an intervention design that adapted to needs and practices, positive staff and patient perceptions, and a responsive organisational context [On intervention sustainability, we found that the overall sustainability capacity was low (median 3.1 (IQR 1.9,4.4) out of a maximum of 7). Higher level units performed better than lower-level ones. Their main strengths lay in communication, evaluation, adaptation and to a lesser extent the local environment or organisational capacity. In contrast, lower-level HFs performed rather weakly with respect to funding stability, forging partnerships, and strategic planning. The disparities between facility levels were particularly high for organisational capacity, evaluation, and strategic planning. This is likely due to differences in organisational capacity that affect strategic management [Obviously, some domains were better sustained than others. This applies in particular to domains that depended less on funding support and more on good organisation and management, or on staff qualities such as knowledge, confidence, and dedication. There was a paucity of findings within the NCD context in sub-Saharan Africa. However, our observations are similar to those from an NCD programme study in Malaysia, which also applied the PSAT [It is unclear whether the modest sustainability capacity that our study found will continue to be maintained in the long term. It will be important to identify ways in which the HFs can maintain or newly establish partnerships. Developing solutions to the lack of funding support will also be essential. The creation of patient clubs might be one option. The organisation of patients into an active and functional club directly impacts funding stability because essential drugs or other critical supplies would become available when freely provided supplies are low. Similar organisational or logistical benefits have been demonstrated with patient adherence clubs in HIV chronic care clinics [During the EACDRP intervention, deliberate efforts had been made to encourage sustainability through full engagement of MoH and district leadership in the design and revision of the programme, and by organising regular support supervision to HFs. This engagement, even though to varying extents, has largely continued even with other subsequent research projects.