Conclusions
DM, NCD, HT
The clinical knowledge of HWs was sustained over 4 years after the end of the intervention project. This suggests that within similar primary care settings in LMICs, training effects resulting from the original intervention are likely to be maintained for some extended period, even as service availability and readiness decline in the absence of funding support. Nevertheless, we recommend that refresher training of health workers should be routinely provided within a public health care system until such a time when other elements of service readiness are sufficiently optimised.As expected, overall facility performance was negatively affected because of the interrupted supplies and a decline in regular supervision. Some intervention components declined more strongly in urban or rural than peri-urban settings; and we speculate that this depended on administrative impediments and supervision. Lastly, the availability of functioning patient clubs seemed to have a positive effect with regards to service availability and readiness.Surprisingly, although the overall quality of care received and experienced by HT and DM patients had declined, the proportion of those receiving adequate care according to national guidelines had not substantially changed even 4 years after the end of funding support to the intervention. District oversight was important to maintaining service quality.More research in similar primary care settings is needed to clarify the role of well-functioning patient clubs for the sustainability of NCD care: what is their mean time-to-full optimisation and how and when do they begin to affect the continuity of NCD or other chronic care services in the absence of any funding support.Sustainability or durability of an NCD intervention in similar primary care settings may remain achievable despite the funding instability and logistical challenges that follow withdrawal of research or programme support. Early during an intervention trial, health system managers and researchers should jointly plan how to sustain the intervention beyond the end of the project if the trial demonstrates its effectiveness.