The ABCs For Designing Sustainable Public Health Initiatives: A Simple Framework For Program Planners

If there is anything the COVID-19 pandemic has taught us, it is the fact that the world is a global village with no country being completely immune from the effects of disease and pathogens. With migration across borders along with its attendant effects of disease dissemination, public health initiatives aimed at improving the health outcomes of populations must be designed with the target population in mind and long-term sustainability prioritized. The health of a community is dependent on the overall health of its people. Public health initiatives are often designed to modify health and disease patterns within groups of people. A key measure of success of any health initiative is its long-term sustainability. Therefore, a framework to guide program planners at the design stage of any public health program is critical to success. This framework can be summed up as the ABCs for designing sustainable public health initiatives.

Appraisal: Appraisal is defined as an act of assessing something or someone. It is an evaluation of a process, system, or population. An appraisal of any given situation or entity is carried out to give the full picture, without redundancy or superfluity. When a thorough appraisal is carried out, it elaborates the situation on the ground, and the best approaches to tackle any challenges. For an appraisal of a public health problem, the following key activities should be included in the program design.

  1. Root Cause Analysis: A Root Cause Analysis (RCA) is a term that describes techniques and tools used to uncover the causes of a problem or failure.1 A RCA is often carried out to get to the bottom of a problem, and not to only focus on the offshoot of the problem-the observable symptom. A thorough RCA defines the problem, answers all the ‘why’ questions, and proffers solutions that lend themselves to evaluations which address the problems.
  2. Social Determinants of health: What makes one community healthy, and the other unhealthy? What factors contribute to the well-being of communities? The social determinants of health are a consortium of factors apart from medical care that can be influenced by social policies and shape health in powerful ways.2 It is important to note that what may positively impact the health of one community, may negatively impact the health of another. Public health practitioners must be able to determine the most important influencers to health and diseases in any community, to potentiate the cost-effectiveness of any intervention. The social determinants of health can be summed up as the 3 G’s:
  3. Geography-The physical environment and all the elements of nature. These include access to clean drinking water, healthy food portions, climate change, global warming, etc.
  4. Goods-These includes the social and economic environment. People’s relationships, income levels, social status, education levels, etc.
  5. Genes-These includes a person’s genetic make-up, which has been shown to have a great impact on health and certain diseases.

Therefore, a thorough analysis and understanding by public health practitioners on the most important contributor to health, and targeting resources to such areas, will increase the likelihood of success of any health intervention or campaign.

  • Influence of Community Stakeholders: A stakeholder’s analysis is a process of systematically gathering and analyzing qualitative information to determine whose interests should be taken into account when developing and/or implementing a policy or program.3 The stakeholders in a process are actors (persons or organizations) with a vested interest in the policy or program being implemented.3 After conducting a stakeholder analysis of the key interest groups, it is imperative to determine the influence of community stakeholders on the proposed public health initiative. Community leaders have a great influence on their constituents. Therefore, the success or ultimate failure of a project depends in part on the role of these key community actors. Vital questions must be asked and answered including but not limited to: what is their interest in the project? What is their knowledge of the project? Do they have an adequate understanding of the major root causes of the problem? Do they proffer alternate ways to address the problem? What is their voting power in the decision-making process? These are some of the key factors that may be considered when trying to determine the influence of community stakeholders on the proposed health intervention.
  • The Role of health models on disease causation, interpretation, and outcomes: The role of the models of health on disease incidence and survival cannot be overlooked. At the crux of any public health problem is the answer to some ‘why’ questions. It is a well-known fact that models of health including the religious, biomedical, psychosomatic, humanistic, existential and transpersonal all have a role to play in disease incidence and survival to varying degrees.4 While one model may play a more significant role in one community, the same may not be the case in another community. For example, while infections and communicable diseases are still a huge burden in many developing countries5 due to environmental and biophysical concerns including limited access to immunizations, the same is not the case in developed countries. Developed countries tend to grapple more with chronic diseases6 such as obesity, diabetes, hypertension, cancers. It is therefore the responsibility of program planners to determine during the design stages of projects, the models with greater impacts on disease causation and outcome. This approach may increase the likelihood of success than the failure of the intervention.

Budget: A budget is a financial statement detailing the income and expenditure of an entity over a given period. Proper budgeting encompasses adequate planning, both for foreseeable and unforeseeable expenditures. A budget should also include the fixed assets and in-kind or monetary contributions of the program to the execution of any public health initiative. A comprehensive budget should take into account direct and indirect costs including but not limited to personnel costs, travel costs, equipment/supplies, consultants, printing/duplication costs, postage, staff training, rent, telephone expenses, heavy machinery, etc. A project with an insufficient budget would be more likely to encounter challenges that may pose as threats to its sustainability, than one which is adequately funded. Therefore, program planners must ensure that their budgets are sufficient enough to run through the entire lifecycle of the projects.

Community buy-in: It would be an effort in futility if after going through the planning and design phases of a project, you discover that a community is not interested in that line of intervention. This would amount to a humungous waste of time and valuable resources. Therefore, program planners must ensure during the design phase of any project, to get the community’s perspective on that particular line of program approach. This is imperative because apart from getting the community’s perspective on a particular proposal, they may also be able to provide valuable pieces of information that may enhance the sustainability of any project. Community buy-in works in tandem with the role of the community’s stakeholders. Successful programs are designed for the people and with the people. In summary, at the crux of any planned public health intervention is the issue of long-term sustainability. Program planners should become familiar with addressing fundamental elements of successful program interventions. A good place to start is ensuring


  2. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2(Suppl 2):19-31. doi:10.1177/00333549141291S206
  4. Tamm ME. Models of health and disease. Br J Med Psychol. 1993;66 ( Pt 3):213-228. doi:10.1111/j.2044-8341.1993.tb01745.x
  5. Tadesse GA, Javed H, Thanh NLN, et al. Multi-Modal Diagnosis of Infectious Diseases in the Developing World. IEEE J Biomed Health Inform. 2020;24(7):2131-2141. doi:10.1109/JBHI.2019.2959839
  6. Silvaggi F, Eigenmann M, Scaratti C, et al. Employment and Chronic Diseases: Suggested Actions for The Implementation of Inclusive Policies for The Participation of People with Chronic Diseases in the Labour Market. Int J Environ Res Public Health. 2020;17(3):820. Published 2020 Jan 28. doi:10.3390/ijerph17030820

-Evi Abada, MD, MS is a Resident Physician in anatomic and clinical pathology at the Wayne State University School of Medicine/Detroit Medical Center in Michigan. She earned her Masters of Science in International Health Policy and Management from Brandeis University in Massachusetts, and is a global health advocate. Dr. Abada has been appointed to serve on the ASCP’s Resident’s Council and was named one of ASCP’S 40 under Forty honorees for the year 2020. You can follow her on twitter @EviAbadaMD.

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