What Happens When the Project Ends? Rethinking Sustainability Under RBF 2.0

We rarely ask this question when launching a digital health project: what happens when the funding ends? During a project, things work with the help of a dedicated team, technical support, training sessions, and regular interviews. New software is introduced, dashboards are put up, and reports begin to flow. For a while, it does look as though the health system has changed. However, a few months later, when the project closes, the picture becomes totally different.

The one who helped the staff navigate the system is gone, and technical support is no longer available. Health workers return to their old registers, while the digital platform becomes one more thing they are expected to update. While the project may have delivered exactly what it promised, the change it was meant to bring about has not lasted.

And that is one of the biggest challenges facing digital health initiatives – deserving more attention in discussions around Results-based Financing .

A system that works only during a project isn't sustainable

Health workers have extremely demanding jobs. Apart from seeing patients, they also manage medicines, maintain records, and deal with staff shortages. If a digital platform needs them to enter the same information in two or three separate places, it is hardly surprising that they may see it as an additional burden. There is a lot of talk about adoption as though it is simply a matter of timing. Train the staff, explain the benefits, and the system will be used. However, in reality, people continue using tools that help them do their jobs. If a platform makes reporting easier, helps track patients or gives a facility manager useful information – there is a reason to return to it.

Digital-in-health: Unlocking the value for everyone

If it exists mainly to satisfy a project’s reporting requirements, that reason quickly disappears once the external support gets withdrawn.

Sustainability begins with usefulness, not with a handover document.

It means thinking beyond whether a digital system has been installed. So, does it fit into the way health workers operate? Does it connect with existing health information systems? Can the government maintain it? And will it continue to be useful when project funding is no longer available? These questions have to be considered at the beginning, not during the final months of implementation.

Where RBF 2.0 can make a difference

RBF offers an opportunity to approach this problem differently.

Traditionally, performance-based financing has focused on linking payments to specified results. RBF 2.0 can build on that principle by encouraging sustained performance and continuous improvement, rather than treating the achievement of a target as the end of the exercise.

For this to work, the underlying systems must be reliable and integrated into routine health service delivery. Take medicine availability – a project may introduce a digital tool to monitor stock levels and reward facilities or supply chains for keeping essential medicines available. The tool may generate useful information during the project – but what happens later? If stock information must still be entered separately into another government system, or if nobody is responsible for maintaining the platform, its value will diminish. The incentive mechanism may also struggle to function because the information needed to assess performance is no longer dependable.

The better approach is to build on systems that health workers and health authorities already use, strengthening them where necessary rather than creating parallel structures. Performance data should support day-to-day decisions as well as financing decisions. The same principle applies to immunisation, maternal health, HIV and TB programmes.

Design for the day after

Sustainability also requires clear ownership. Governments and health authorities need to be involved from the outset, with clarity on who will maintain the technology, support users, manage data, and meet recurring costs. There is little value in developing an impressive platform if nobody has budgeted for its upkeep, nor can a system survive on technology alone if staff do not trust its data or understand how the information can help them.

Under RBF 2.0, incentives should encourage not just immediate results but the continued ability to deliver services. That requires dependable data, practical verification mechanisms, and financing arrangements that reinforce routine health system functions.

It also means listening to health workers. They are often best placed to identify what is slowing them down, where information gets lost, and which changes would make a genuine difference. Their experience should shape the design of digital systems, rather than being considered only after implementation.

The real measure of success

A successful health project should leave something behind that continues to work - better processes, stronger institutions, [more reliable information and systems that people have a reason to use] (https://documents1.worldbank.org/curated/en/099062724112015857/pdf/P172504-38d59645-b673-4f1b-9c39-1943d8f68748.pdf).

The real test comes after the project team has left and the external funding has stopped. Are medicines still being tracked? Is performance data still being recorded accurately? Are health workers still using the system because it helps them provide better care?

These are the questions that matter.

RBF 2.0 has the potential to connect financing, data, and service delivery in ways that strengthen health systems over time. But that promise will remain limited if every project builds something new that disappears when its funding ends.

The aim should not be to build digital systems for projects. It should be to build systems that become part of healthcare itself.